The biggest shift yet in U.S. vaccine policy

0:01Nola Jean Ernest is a pediatrician working in the Wiregrass region of Alabama. Which is the southeast corner of Alabama, where I like to say we don't have interstates and we don't have children's hospitals. So the pediatricians in this area really are the frontline experts in kids' health for all of the children. In her work, Dr. Ernest encounters a lot of skepticism around childhood vaccines. and she sees it as her job to convince her patients that vaccines are safe and effective. But recently, even in the last week, she has noticed a change in how some parents are thinking about the vaccine for hepatitis B, which for decades has been recommended for all newborns in the U.S.

0:51In the past, declining the hepatitis dose vaccine at birth was pretty rare. We would come up against it one or two times a year. In the last six months, it has become increasingly common. But this week, all of the newborns that I have seen this week in my clinic declined the birth dose of hepatitis B. It's no secret that Health Secretary Robert F. Kennedy Jr. is on a mission to reshape childhood immunization in the U.S. And so far, he's been pretty successful. He's directed the CDC to publish language suggesting that there might be a link between vaccines and autism. He's replaced every member of the vaccine advisory panel with his own picks.

1:41Now, that panel has recommended dropping the universal birth dose of the hepatitis B vaccine for newborns. Health reporter Lena Sun says that new leadership at the CDC are expected to approve that change. and that it could have major impacts on patients and doctors around the country. This will be a substantial change to the childhood immunization schedule, maybe the most substantial in decades. And it would just be the opening salvo for Robert F. Kennedy, who has always wanted to upend the childhood vaccination schedule, to continue going down this road next year.

2:29From the newsroom of The Washington Post, this is Post Reports. I'm Martine Powers. It's Thursday, December 11th. Today, why the U.S. government is poised to stop recommending the hepatitis B vaccine. Lena Sun talks through how this change came about and what the implications of it could be. Then, in the second half of the show, we talk more with Dr. Ernest about how, in the wake of these shifts, she is trying to make the case to patients that vaccines matter.

3:06Lena, thank you so much for being here. It's always a pleasure to be with you, Martine. So obviously we're here to talk about vaccines, which have been very top of mind for a lot of people during this first year of the Trump administration. President Trump has been elevating vaccine skeptics to positions of power. And there are clear consequences of that. As I understand it, last week, there was this massive development when it comes to kids and vaccines and Hep B. Can you explain to me what happened here? So we're talking about the childhood immunization schedule, which anybody who's had a kid or a grandchild knows, it's a schedule of when kids are supposed to get what vaccines, at what age, and there's a certain number of doses.

3:51And the current schedule is set up this way because it's designed to protect children from serious infectious disease as soon as possible and when they are most vulnerable. So that gives you optimal protection by spacing these vaccines effectively. Last week... Vicki Pebsworth, no conflicts of interest. I vote yes. Malone, no conflicts of interest. Yes. An influential vaccine advisory panel recommended that newborns no longer get the birth dose of hepatitis B vaccine. The DFO has transcribed eight votes yes and three votes no. The motion passes. And so this vote basically upended a longstanding practice for over 30 years that babies get this vaccine at birth.

4:45and the reason babies get it is that it offers decades of protection against this very contagious virus that can cause very serious illness. Yeah, I want to talk a little bit more about that just so people understand. I mean, it's funny that I just had a kid and I vaccinated my kid for Hep B and do not know what it is. And I think a lot of people don't know what it is. What is Hep B? How does it become contagious? What happens when people are infected? Hepatitis B is a virus and it's a blood-borne virus. And it's primarily transmitted in the blood. So when a mom gives birth to a baby, it's in the blood.

5:24It can pass to the baby. It also can be in the vaginal fluid. So the reason the birth dose is given is because that's like the primary way you can get it. And, you know, every child who is born, you know, gets the shot. That's been the current recommendation. But you can also get the virus through contact with just the teeniest tiny bit of blood on a toothbrush or a nail clipper because it's a sneaky virus. It can stay infectious on surfaces for up to seven days at room temperature. So transmission is more likely from an open sore or wound to open skin on the baby where blood can enter, you know, through cuts or sores on a caregiver's hand coming in contact with a baby's cut or a rash.

6:07So the reason you give the birth dose is sometimes moms don't get screened or tested for hepatitis B. Sometimes those tests are done too early in pregnancy, and then you might get infected later. And sometimes the results are not correct. So you miss some babies. And this way, this is the safety net to get the babies. And what happens if a baby does get hepatitis B? I mean, is it something that they can just, like, is there a cure for it? No. For babies who get infected, they're the most vulnerable for this virus that causes disease. As an adult, it's easier to fight it. But there's a 90 % chance if you get infected as a baby that you will go on to develop lifelong disease.

6:52And it can cause serious liver disease, liver transplant needed, cancer, death. and more than 2 million people in the United States have hepatitis B. About 50 % do not know they have it, which is why you want to give the baby the birth dose because if it's living in a household with other people who don't know they have Hep B, they can get infected with a caregiver or somebody else in the household. Well, then let's talk a little bit more about what's changing here. What is the argument from the folks in the federal government who are intending to change this recommendation and say that a birth dose is not necessary?

7:35What are they saying of their rationale here? Well, it's not a lot of data, and there's not really strong evidence behind their rationale, which is they think that there might be risk, and kids don't need that many shots, and let's take into account parents who have felt like their decisions have not been taken into account. Right now, the hepatitis B vaccine is recommended in three doses. At birth, the second one is, I think, one to two months. And the third dose is six to 18 months. It sort of depends as you get older because it's sometimes in a combination shot. The third dose is what gives you full protection, gives you 95 % protection.

8:25So what is it that they're proposing to change? So right now, it's very simple. Every baby gets a shot newborn, birth to 24 hours. What they're proposing to change is, well, we only just want to give this shot to babies who are high risk. So if the mother tests positive, in other words, if she has hepatitis B infection, obviously the baby should get the shot. And if we don't know what the status of the mom is, obviously we should give the baby the shot. Okay? That's clear. That doesn't change. What they're saying is, let's say the mom tests negative, doesn't have any sign of hepatitis B infection.

9:05They're saying those babies are not at risk. You don't have to get it. The parents can talk to their doctor. And if you decide to get it, you should wait until the baby's two months old. When you describe that to me, that sounds reasonable, right? Like if I'm about to give birth, if you know that I don't have hepatitis B, then why vaccinate my baby right when they're born? Like why not? Like what's the harm in waiting a couple months? The test may not be good. And somebody in your household may have hepatitis B and doesn't know it. Because they weren't tested because they weren't the person who was pregnant.

9:40Or they have hepatitis B or the baby comes in contact with a caregiver who lives in a different household and maybe she never got tested and she's carrying hepatitis B and is infected. So it's not a lot of kids. It's a small percentage, but that's why this is a safety net. And I should say that the CDC vaccine panel members, the ones who voted on this change, have argued that there's little evidence that there's widespread transmission in this way to justify vaccinating all newborns. What are the potential implications of this long term? If you have more families in the country choosing to delay their baby's hep B vaccine by a couple months or potentially not giving it at all?

10:25You risk the increase in hepatitis B infections and other serious consequences like death for the babies, for the most vulnerable segment of the population. The reason why the universal birth dose was put in place in 1991 was exactly to cover all babies. Because before that, women were screened and then they only gave the vaccine to kids who are at high risk. That didn't work because they still had infections. They put this universal birth dose policy in place in 1991. And if we could show a graph, it would show that the infections of hep B just plummeted. If you don't have that anymore, you're going back to the old days where kids are going to get infected.

11:12The more kids who get infected, the more kids are going to be getting serious disease, get hospitalized, and potentially die. Yeah, yeah. So the stakes here are... Very high. Yeah. Lina, thank you so much for explaining all this. Sure, anytime.

11:32After the break, we'll hear again from Dr. Nola Jean Ernest about what it's like right now for pediatricians on the ground and how she feels pushing back against the government's own messaging. We'll be right back.

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12:36Nola Jean Ernest, who practices in southeast Alabama and is also one of our reporter Lena Sun's sources. So after the news broke about this likely change to the vaccine recommendations, we called her up during her lunch break to get her reaction to this news. Hearing this news was rather frustrating. And the reason why it is frustrating is because it wasn't built on new data. So there was no new evidence presented that would clarify why we're making this change or how we would go about making this change. And instead, it shifts the burden of having these conversations about birth dose vaccination of hepatitis B to the pediatricians in the community.

13:24In our community, there are not enough birthing hospitals. And so we do not cover at all of the hospitals where children are being born. Instead, they're seen by hospitalists there or by the neonatologist that's on call. And so if those conversations aren't happening at the time of birth or if the family declines the vaccination at the time of birth, then the conversation gets pushed to the newborn visit, which increases the burden on community pediatricians. Well, I want to talk more about those conversations that are happening between doctors like yourself and new parents. So just to be clear, for you, are you still recommending to your patients that they get their babies the hep B vaccine at birth?

14:13Absolutely. And I've actually been working on a post for my own social media account today to be clear to my families that their doctor that they trust still recommends birth dose vaccination against hepatitis B. And how often are you coming up against skepticism from patients about this vaccine or people coming in and saying, well, you know, like, I feel like I've heard stuff and I don't know if I want to do this for my baby? In the past, declining the hepatitis dose vaccine at birth was pretty rare. We would come up against it one or two times a year. In the last six months, it has become increasingly common.

14:57But this week, all of the newborns that I have seen this week in my clinic declined the birth dose of hepatitis B. Really? Mm-hmm. Five newborn families that all refused. Wow. And they said it was in reaction to this most recent change? They did not actually say why. They just said, we don't understand why it's necessary, which is the rhetoric that the politicians are using. And so then we had a conversation about why it's necessary. and all but one chose to get it in my office, which is a little bit late. You know, I'd rather them got it in the hospital. But luckily, we were able to start all of those babies within the first week of life.

15:41I find that so fascinating. Like in those moments when you have new parents and they're saying, look, I don't think that I'm gonna give my baby the Hep B vaccine. What do you say to them then? Like, how does that conversation play out? So usually we ask, well, first of all, I always start the conversation with reminding parents that it is always their right to refuse medical advice or medical care for their child. I don't want parents to feel like they are being forced into something. But then I also try to explain that my role in our relationship is to give them the best advice possible for their child.

16:22And so I usually ask then for permission. So can I tell you why I strongly recommend that we start this hepatitis B series now, since you did not do it at birth. And then we talk about what hepatitis B is, why babies can still get it, even though they may not be having sex or sharing needles, which is one of the pieces of misinformation that families hear, and how horrible the disease can be for children. if they are exposed to it early in life. It's interesting because we have gotten a little perspective on this conversation from the other side. So as you know, earlier this year, reporter Lena Sun and one of our producers, they talked with patients of yours, specifically Andrews Barranco and Johanna Vargas Barranco, who have been seeing you for many years.

17:14And they talked about how they came to see you after their baby was born earlier this year, and that they were really worried about getting their newborn vaccinated. Our only concern was one of the vaccinations that we actually heard a lot of rumors about. There was a hepatitis B. Basically, I heard that they are linked to autism. And so they had these new worries they hadn't had with their older daughter. And they'd seen some videos on social media warning against vaccines. They talked about where they heard some of this stuff from. It was mostly social media, TikTok, YouTube, all that stuff.

17:54And it was in both Spanish and English. One of the main concerns about the hepatitis B was actually containing heavy metals and being a little bit too early to actually put that vaccine on a newborn, given the fact that that is a type of vaccination that can be taken later on in life, like when the kid reaches teenager years and stuff like that. So, yeah, that was our main concern. But then they said that they came to you about this and that they asked you about these vaccines. They asked if you could explain if vaccines are safe. And they decided to have their kid get this vaccine after talking to you.

18:30And this is how they remember that conversation. She actually explained us the concept of having heavy metals in the vaccine and the reason why it contains some type of metal in the vaccine. And she started by pulling her little laptop and she looked at the periodic table on Google and she showed us that the one metal that that vaccination has is aluminum. And aluminum is one of the lightest metals in the whole periodic chart. And the reason why that vaccine has that type of metal is to actually create an immune response in the blood. So that way the body can absorb and create the antibodies. Right.

19:03So that's the reason why it has. But she went in detail, explanation, you know, the research backed up by 20 years and all that stuff, you know, and the fact that, you know, it's safer in the smaller amounts. That's the reason why, you know, they give like small shots instead of the whole dosage in a spacing of months. Right. So, yeah, she did explain this in detail. So, Dr. Ernest, I'm curious what your reaction is hearing this and hearing what these patients were able to kind of take in from that conversation. It actually makes me very happy that the family remembered all of those details from our conversation.

19:47Sometimes you wonder if they are actually hearing what you're sharing. But the concern about heavy metals is not a new one. But at the same time, the concern, especially around hepatitis B vaccination, has been shifting. So one day it may be hepatitis B. One day it's exposing a baby too early. And another day it's simply that why do we give vaccines at all for something that is sexually transmitted? So a concern that this is not an infection they're going to be exposed to. And the conversation continues to change. And we have to be able to address all of those points. It's interesting for me hearing that tape because I think that it's easy in this moment to think of people as either pro-vaccine or anti-vaccine or that there are just like two camps in this country.

20:45But from at least what it sounds like here, there is an opportunity to persuade people or educate people or to like have real conversations that might influence people's actions about this kind of stuff. Absolutely. There is room for conversation with most families. Very few families present to our office entirely against vaccination for their child. They may have some misunderstanding about how the vaccine schedule is designed or what are the ingredients in the vaccine and their safety. And often if we address those concerns, we can convince a family to vaccinate a child, at least mostly on the normal schedules, sometimes with some minor changes, and protect their child early on against diseases that could cause them harm at an early age.

21:43So absolutely, we do see a lot of room for having conversations with families. What is it like for you in this moment to have to be the voice that is pushing back essentially against what the government is recommending? Yeah.

22:01As a professional in any career, it would be nice if the government had your back. And, you know, in the past, we could point to the CDC recommendations and say, you see, even our, you know, own government agrees with what I'm telling you. But the truth is, even without that, for our families, it's really my voice that matters the most. And And one of the hardest things for pediatricians is that, especially with birth dose vaccination, families don't hear my voice until they're already in my office after their child has been born. I see. Because when you're in the hospital giving birth, you're with your OB and that like the pediatrician doesn't come in until a little later past the point of when you would usually give this birth dose.

22:58Right. And in rural America, the pediatrician that comes in is usually not going to be your pediatrician because we can't all staff the few birthing hospitals we have. And so you may have a conversation with a pediatrician. But not the one you know and trust. Right. Not the one you know and trust. And so that kind of defers the responsibility to me. And if I try to put out information for my patients online, you know, where they might see that information before they have that baby, then that is often met with that larger, truly anti-vaccine community where you get flooded with anti-vaccine messages.

23:46And it's really hard for our voice to break through that noise. So, Dr. Ernest, when you think about the number of patients who are coming in with these kinds of concerns about the Hep B vaccine, about other vaccines, like what has this all been like for you? Seeing these concerns, talking through people with these concerns, and this kind of new question about hepatitis B in children. It's a little scary. You know, as pediatricians, we really are the experts in child health. But like any expert, you are most an expert in the things you do every day. And I take care of strep and flu and colds in kids every day.

24:32I diagnose rashes every day. I have never treated a case of hepatitis B. I know of one case in our community in a child, but I have never myself treated a case of hepatitis B. And so if I had a concern that a child had exposure or symptoms, I would have to rely heavily on our infectious disease colleagues. And remember, we practice in the wiregrass where there are no interstates and no children's hospitals. So our closest infectious disease colleagues are a three-hour drive for our families. Dr. Ernest, thank you so much for speaking with me. Absolutely.

25:19Dr. Nola Jean Ernest is a pediatrician in Alabama. Lena Sun covers public health for The Post. We are so grateful to have you as a listener. And now we want to learn more about your listening habits and how you think we can be better. We've got a new survey that we're running for a limited time, and we would love to hear from you. It shouldn't take more than 10 minutes to complete. And to do that, you go to WashingtonPost.com slash podcast survey. Again, that is WashingtonPost.com slash podcast survey. When you're done, you can enter to win a$100 gift card. So one more time, if that got your attention, that is WashingtonPost.com slash podcast survey.

26:03That's it for Post Reports. Thanks for listening. Today's episode was produced by Alana Gordon. It was mixed by Sam Baer and edited by Peter Bresnan. Thanks to editor Fennett Nierpil. I'm Martine Powers. We'll be back tomorrow with more stories from The Washington Post.

26:30Good journalism is even better when it's shared. With a premium subscription to The Washington Post, you get three extra accounts to share with friends and family, so they can stay informed too. Right now, you can get a premium subscription to The Post for$6 every four weeks. Just$6 unlocks trusted reporting to share with other people in your life. After your first six months, it'll cost$19 every four weeks. You can cancel anytime. Head over to WashingtonPost.com slash subscribe and get premium access to The Washington Post today. That's WashingtonPost.com slash subscribe.