Hepatitis B and vaccination of infants
The story that can have a happy ending
The debate that continues to flare up. RFK Jr. stated the hepatitis B vaccine at day one is unnecessary and suggested that giving it to newborns is “not justified” when the mother tests negative — arguing that immunity won’t last and that the real risk comes later in life.
This is personal for me as an Alaska Native physician, and someone exposed to hepatitis B as a medical student before we had vaccinations.
A friend of mine’s son died a few years ago. He was 23 years old, and had a liver transplant when he was in his late teens because of hepatitis B infection he did not get from his mother. He was in and out of the hospital multiple times, both in Alaska and in the lower 48. His death reminds us that even in an era where we have liver transplants, preventing the disease is much easier than dealing with the consequences.
You see in Alaska, we did not debate hepatitis B in theory. We lived it. We studied it. We saw it in our friends, families, and villages. And over the last four decades, we helped eliminate it in children. References are at the end for those who wish to follow this.
What Alaska Looked Like Before Vaccination
Before the vaccine program began in the early 1970s, hepatitis B was endemic in many Alaska Native communities. This was before I was a physician. I was a graduate student in virology at The University of Chicago, and was sent off to the CDC to collect some viral samples. In the middle of that work, we discussed the hepatitis B problem that caused:
Over 13% of the population showed evidence of infection
About 3% were chronic carriers
In some regions, that number climbed far higher
But numbers alone do not tell the story.
This was not a disease of needles, drugs, or sex in these communities. It spread in homes. Infants and children acquired hepatitis B from caregivers and siblings through everyday contact:
saliva
shared utensils
premastication of food
skin infections like impetigo
small breaks in the skin
The virus was found in saliva and even on environmental surfaces in homes. It could live outside the body for days.
This meant something critical:
You did not need “risk behavior” to get hepatitis B. You needed proximity
Why Newborn Infection Matters
Here is the piece critics consistently miss.
Hepatitis B behaves differently depending on when you get it.
Adults: less than 5% become chronically infected
Newborns: up to 90% become chronically infected
And chronic infection is not benign.
It is a decades-long setup for:
cirrhosis
liver failure
hepatocellular carcinoma
In Alaska, we saw liver cancer in young adults. In some cases, even in children.
This is not a hypothetical risk. It is observed reality. Imagine the young lady, first in her village, to go to college, having to have an operation because she had developed liver cancer at age 18. The first one in her community to ever go to college.
“But the Mother Tested Negative” — Why That Doesn’t End the Conversation
This sounds reassuring. It isn’t sufficient.
A negative maternal test is a snapshot, not a guarantee of safety over the next hours, days, and months when transmission can still occur.
Here is why relying on that alone fails in the real world:
1. Testing Is Good — Not Perfect
Screening can be missed, delayed, or improperly documented
Infection can occur late in pregnancy after testing
Lab error, while uncommon, is not zero
Public health decisions are not built on perfect conditions. They are built on what actually happens across millions of births.
The birth dose exists to close that gap.
2. Infants Do Not Play by Adult Rules
Adults typically acquire hepatitis B through:
blood exposure
sexual contact
shared needles
Infants do not need any of those.
Because their immune systems are immature, they are uniquely vulnerable to low-level, everyday exposure:
saliva from caregivers
shared utensils or pre-chewed food
contact with skin infections or small abrasions
contaminated household surfaces
In Alaska, hepatitis B was not primarily a disease of “risk behavior.” It was a disease of proximity.
3. The Immune System Changes the Outcome
This is the most important difference.
Adults: strong immune response → virus cleared in >95%
Newborns: tolerant immune response → virus persists in up to 90%
The infant immune system is designed to avoid overreaction. That is helpful for survival at birth. It is disastrous for hepatitis B.
Instead of clearing the virus, the infant often accepts it.
And that sets up decades of silent infection.
4. Early Infection Is the Dangerous Infection
When hepatitis B is acquired in infancy:
it is usually asymptomatic
it becomes chronic
it quietly increases the risk of cirrhosis and liver cancer
By the time it “matters” clinically, it is often too late to undo.
5. Vaccination Is About Timing, Not Just Exposure
The goal of the birth dose is simple:
Protect the infant before the first exposure occurs. Because in real life, exposure does not wait for adolescence, and does not ask permission.
A negative maternal test lowers risk. It does not eliminate it.
And in a newborn, even a small missed exposure is not a minor event — it is a lifelong infection waiting to happen. That is why we vaccinate at birth.
Not because we are careless with interventions, but because we have learned, over decades, what happens when we wait.
The Alaska Hepatitis B Study: One of the Longest in the World
The Alaska Hepatitis B cohort is one of the longest-running population studies of any infectious disease.
We followed over a thousand chronic carriers for decades.
What we learned:
HBeAg clearance occurred in ~72% within 10 years
Chronic infection persisted in many, with ongoing cancer risk
Liver cancer incidence was measurable and real
Certain viral genotypes dramatically increased cancer risk
With extended follow-up over 35 years, genotype F — common in Alaska Native populations — showed some of the highest liver cancer rates ever recorded for hepatitis B.
This is not a mild infection that you “deal with later.”
This is a virus that sets the stage for cancer early in life.
Then We Vaccinated
Beginning in 1983–1984, Alaska implemented one of the most comprehensive hepatitis B vaccination programs in the world:
universal newborn vaccination
catch-up vaccination for children and adults
aggressive screening programs
The results were not subtle. They were extraordinary.
Acute hepatitis B incidence dropped from 215 to 14 per 100,000
No new cases of acute hepatitis B in children since 1992
No liver cancer cases in people under 20 since 1999
HBsAg-positive children fell from 657 to 2 over two decades
Read that again.
We eliminated a cancer in children.
This inspired me to become a physician. I liked people better than Petri dishes, but I wanted to be a doctor who helped directly. Oddly, I ended up in surgery, far from virology - or so I thought.
The Long-Term Question: Does the Vaccine Last?
This is the second claim often made: that immunity “wears off.”
We did not guess at this.
We followed vaccinated individuals for 30 to 35 years.
About 47–51% still had measurable antibodies decades later
74–88% mounted a strong response to a booster
~86% showed ongoing protection overall
No breakthrough chronic infections were observed
Immunity is not just a number on a lab test.
It is immune memory.
And in this case, it works.
Why Give It on Day One?
Because the window we are trying to close is immediate.
Even if a mother tests negative:
testing is not perfect
infection can occur late in pregnancy
household transmission begins early
In a place like Alaska, we learned the hard way that waiting is not neutral.
Waiting means risk.
And risk in a newborn carries lifelong consequences.
This Is What Long-Term Science Looks Like
There are many things in medicine where we argue from short-term data.
This is not one of them.
We have:
40 years of follow-up
population-level data
cancer outcomes
real-world elimination of disease
This is not pharma marketing.
This is epidemiology, public health, and time.
The Autism Claim — Let’s Deal With It Directly
Now we get to the part that always shows up.
It doesn’t matter if we are talking about measles, hepatitis B, or anything else. The word “autism” gets dropped like a trump card.
So let’s deal with it.
Because in Alaska, we did not just track hepatitis B.
We tracked outcomes. Long-term. Carefully. Repeatedly.
And here is what we found.
There is no increase in autism, developmental delay, or neurologic disease in children who received the hepatitis B vaccine — including in the Alaska Native population that has been followed for over 35 years.
None.
What the Large Data Actually Show
When you step away from anecdotes and look at actual population data:
A meta-analysis of over 1.2 million children shows no association between vaccines and autism
No signal for thimerosal. No signal for mercury
No signal for hepatitis B vaccination specifically
Multiple independent reviews — including large systematic analyses — come to the same conclusion:
If there were a link, we would have seen it by now.
We have not.
The Alaska Data Matters Here
This is not theoretical.
We vaccinated entire populations of Alaska Native children starting in the early 1980s.
We followed them for decades.
We published about infection rates, antibody persistence, liver cancer outcomes. And if there had been a signal for neurodevelopmental harm, it would have shown up in one of the most closely studied public health cohorts in the world. It did not.
What About the “Studies” That Say Otherwise?
Yes, a few small papers get circulated online.
They share a pattern:
small sample sizes
parental self-report of autism
poorly defined control groups
selection bias
results that cannot be reproduced
And most importantly:
They collapse when tested against large, well-designed studies.
That is how science works.
Not by finding one paper you like, but by seeing what holds up when the sample size hits a million.
The Real Tradeoff
This is the part that gets lost in the noise.
We are not choosing between:
vaccine vs nothing
We are choosing between:
vaccination against a virus that causes lifelong infection and liver cancer when acquired in infancy. In Alaska, we watched what happened before and after.
Before: chronic infection, cirrhosis, cancer
After: elimination of hepatitis B in children, elimination of liver cancer in children
And no increase in autism.
FINALLY
The autism claim persists not because the evidence supports it, but because it is emotionally powerful and endlessly repeated.
But repetition is not evidence.
And after decades of data, across millions of children, in one of the longest-running cohorts we have:
The hepatitis B vaccine prevents disease. It prevents cancer. And it does not cause autism.
That is what the data say.
The Bottom Line
The idea that the hepatitis B vaccine at birth is unnecessary is not a bold new insight. It is a dismissal of one of the most successful long-term public health interventions ever conducted.
We did not theorize this in Alaska. We measured it. And we watched a generation grow up without a virus that once defined entire communities.
And that mother whose child died–I see her two or three times a year. And every time we talk about her son. She is thankful for the care he received, and works hard in healthcare to ensure that no other mom has to suffer as she did, and no other child has to suffer as her son did.
And that story, and many others, inspired me to become a physician.
References
1. McMahon BJ, Holck P, Bulkow L, Snowball M. Serologic and clinical outcomes of Alaska Native patients with chronic hepatitis B virus infection. Ann Intern Med. 2001.
2. McMahon BJ, Nolen LD, Snowball M, et al. Hepatitis B virus genotype and risk of hepatocellular carcinoma. Hepatology. 2021.
3. Gounder PP, Bulkow LR, Snowball M, et al. Hepatocellular carcinoma risk in Alaska Native children and young adults with hepatitis B. J Pediatr. 2016.
4. Hayashi S, Khan A, Simons BC, et al. Core mutations and hepatocellular carcinoma in hepatitis B genotype F1b. Hepatology. 2019.
5. McMahon BJ, Rhoades ER, Heyward WL, et al. A comprehensive program to reduce hepatitis B virus infection in Alaska Natives. Lancet. 1987.
6. McMahon BJ, Bulkow LR, Singleton RJ, et al. Elimination of hepatocellular carcinoma and acute hepatitis B in children 25 years after immunization. Hepatology. 2011.
7. Harpaz R, McMahon BJ, Margolis HS, et al. Elimination of new chronic hepatitis B virus infections in Alaska. J Infect Dis. 2000.
8. Bruce MG, Bruden D, Hurlburt D, et al. Antibody levels and protection after hepatitis B vaccination: 30-year follow-up. J Infect Dis. 2016.
9. Bruce MG, Bruden D, Hurlburt D, et al. Protection and antibody levels 35 years after hepatitis B vaccination. Hepatology. 2022.
10. McMahon BJ, Schoenberg S, Bulkow L, et al. Seroprevalence of hepatitis B virus markers in Alaska Natives. Am J Epidemiol. 1993.
11. Taylor LE, Swerdfeger AL, Eslick GD. Vaccines are not associated with autism: an evidence-based meta-analysis. Vaccine. 2014.
12. Dudley MZ, Halsey NA, Omer SB, et al. The state of vaccine safety science: systematic reviews of the evidence. Lancet Infect Dis. 2020.
13. Larson HJ, Gakidou E, Murray CJL. The vaccine-hesitant moment. N Engl J Med. 2022.
14. Schillie S, Vellozzi C, Reingold A, et al. Prevention of hepatitis B virus infection in the United States: ACIP recommendations. MMWR Recomm Rep. 2018.
15. Haber P, Moro PL, Ng C, et al. Safety of hepatitis B vaccines in the United States (VAERS 2005–2015). Vaccine. 2018.
16. McMahon BJ, Bulkow LR, Singleton RJ, et al. Elimination of hepatocellular carcinoma and acute hepatitis B in children after immunization. Hepatology. 2011.
17. Dentinger CM, McMahon BJ, Butler JC, et al. Persistence of antibody and protection after hepatitis B vaccination in Alaska Natives. Pediatr Infect Dis J. 2005.
18. Bruce MG, Bruden D, Hurlburt D, et al. Protection and antibody levels 35 years after hepatitis B vaccination. Hepatology. 2022.
19. Ulrich AK, Fleming DF, Smith EA, et al. Hepatitis B vaccination at birth: safety and effectiveness. Pediatrics. 2026.
20. Gallagher CM, Goodman MS. Hepatitis B vaccination of male neonates and autism diagnosis. J Toxicol Environ Health A. 2010.
21. Geier DA, Kern JK, Homme KG, Geier MR. Hepatitis B vaccine exposure and special education services. Int J Environ Res Public Health. 2018.
22. Yang J, Qi F, Yang Y, et al. Neonatal hepatitis B vaccination and transient neurobehavioral effects in mice. Psychoneuroendocrinology. 2016.
If you are going to argue against a vaccine, at least argue against the data.
Because in this case, the data are not subtle — they are definitive.