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Neonatal Hepatitis B Vaccination: Acceptance In Israel

By: Dr. F. Edward Yazbak

An excellent article was just published in the March issue of Vaccine: To vaccinate or not to vaccinate-that is the question: why are some mothers opposed to giving their infants hepatitis B vaccine? (1)

The article was authored by Drs. Ayala Maayan-Metzger, Peri Kedem-Friedrich and Jacob Kuint. Doctors Maayan-Metzger and Kuint are affiliated with the Department of Neonatology at the Edmund and Lily Safra Children’s Hospital, Sheba Medical Center, Ramat-Gan and Dr. Kedem-Friedrich is at the Psychology Department, Bar-Ilam University also in Ramat-Gan, Israel. Doctors Maayan-Metzger and Kedem-Friedrich contributed equally to the manuscript, as first authors from different disciplines.

Testing pregnant women for hepatitis B is recommended "“ but not always done - in Israel and in the United States.

Previously, only infants born to mothers who had hepatitis B "“ or tested positive for hepatitis B surface antigen "“ received prophylactic treatment: Hepatitis B immune globulin immediately after birth, followed by the first of three dose of hepatitis B vaccine. Two hepatitis B vaccines produced by recombinant DNA technology are licensed in the United States. The original plasma-derived vaccine is no more available.

Starting in 1991, 3 doses of recombinant Hepatitis B vaccine have been recommended for administration to all newborns in the United States and Israel, regardless of their mothers' history, findings or immune status. The first dose was to be given during the nursery stay, the second one month later and the third at the age of 6 months. An accelerated schedule was also possible for special circumstances. Until 1999, each dose contained 12.5 µg of mercury. 

Informed consent is required in the United States though not invariably obtained. No consent for the Hepatitis B vaccination and routine nursery medications is needed in Israel. When Israeli parents refuse to have them administered, the medical and nursing staffs will respect their wishes.

Many Israeli mothers have refused (or are refusing) the hepatitis B vaccination for their newborns. Unlike mothers in the United States, who simply just do not sign the permit, Israeli mothers, who do not wish to have their infants vaccinated, must approach the hospital staff and formally decline the vaccination.

The purpose of the study was to identify the characteristics and reasons of those mothers and to compare them to the mothers who allow their infants to be vaccinated.

Mothers included in the study delivered healthy term babies born between January and September 2003 in a large tertiary hospital. The mothers had to complete the questionnaire before their discharge. Mothers of twins were not included.

During the study period, 71 mothers out of 6,665 refused the vaccine. Of these, 51 were included in the study. I will refer to that group as Group A. The control group consisted of 153 women whose infants were vaccinated (Group B).

The mothers' opinions were closely related to their actions: 94.1% of moms in group A were totally convinced and were anti-vaccine. Only 71.9% of moms in group B were definitive about their opinion and 22.9% had no opinion.

Sixty percent of Group B was knowledgeable about the vaccine.

The study compared three groups:

  • Prevent (Group A): 51 mothers (25%)
  • Comply-Know (Group B1): 91 mothers (44.6%)
  • Comply-Do not Know (Group B2): 62 mothers (30.4%)


Reasons for decision

82.4% of mothers in group A gave at least one reason for refusing the vaccine.

The listed reasons were:
Baby too young: 55%
Doctors vaccinate without differentiation: 20%
Vaccines are dangerous: 18%
It causes trauma to the baby: 14%
The mother was vaccinated: 10%

61.5% of mothers in Group B1 and 44.5% of those in Group B2 mentioned at least one reason why they complied.

Their listed reasons were:

Group B1  
Group B2
I trust the doctors
Vaccines protect the baby  


Source of information

  Group A   Group B1
Pre-labor courses 45% 17%
Magazines/News media 32% 17%
Medical literature 28% 13%
Internet 23% 8%
Alternative Medicine Literature   11% 2%
Alternative physician 9% 0
Previous birth 9% 37%
Friends 20% 10%

Pediatricians and obstetricians were rarely mentioned as the source of information; Family members, including mothers not at all.


Group characteristics

Mothers from Group A came from a higher income group. They tended to be older and overall more educated. More of them were in the health professions.

Mothers in the B1 group were better educated and had a higher income than those in the B2 group,  

Before birth, a higher percentage of mothers in Group A were opposed to epidural anesthesia.



There were significant differences in intention variables between Group A and B.

A higher percentage of mothers from Group A intended to breastfeed and for a longer period and a much lower percentage intended to comply and allow all the recommended vaccinations. 


FEY Comments

This is the best review of its type I have ever seen.

The authors should be congratulated.

The following are the strengths that impressed me:

  • The two principal investigators who contributed equally, were from different disciplines (Neonatology and Psychology)
  • None of the authors was a vaccine epidemiologist or a health department employee
  • The study was superbly designed and carried out
  • The questionnaire was constructed specifically for the study
  • The questionnaire included several categories to provide a wide array of aspects to be compared
  • The mothers completed the questionnaire while they were still in the hospital
  • There were no extraneous causes that could have affected the decision not to vaccinate and that are often encountered after discharge: Lack of baby sitters for the other children, lack of funds or insurance coverage, lack of time etc

Of particular note is the fact that the authors - in the title and in the article - referred to "vaccination" and not "immunization". The administration of a dose of hepatitis B vaccine in the nursery is a vaccination indeed because it certainly will NOT provide immunity in the later years of risky behavior.

Also notable is the fact that almost half of the mothers who declined vaccination had made their decision based on information obtained during their pre-labor courses. One can only imagine the turmoil if this happened in the US. 

One third of the Group A mothers reported that their decision was based on information they obtained in magazines and from news media. This is unlikely to ever happen in the United States were vaccine and drug manufacturers so heavily advertise.

Similarly, it is unlikely that the "medical literature", a factor in 28% of the refusals in Israel, would play any role in the United States. Few dare to break ranks here.

On the other hand, it is very possible that the Internet plays a more substantial role in the decision of mothers who decline vaccinations in the United States.

The abstract of the Israeli paper can be found here

It is well-worth reading.


For comparison, let us look at a US study published in the November 2000 issue of Pediatrics: "Do Parents Understand Immunizations? A National Telephone Survey". (2)

This study did not deal with neonatal routine Hepatitis B vaccination specifically.

The principal author, Bruce Gellin MD was the director of the National Network for Immunization Information. He is presently the Director of the National Vaccine Program Office in the US Department of Health and Human Services.

The investigators conducted a study to "assess parents’ understanding of vaccine-preventable diseases, vaccines, immunization practices, and policies." They interviewed "a nationally representative sample of parents with children under 6 and expectant parents in April and May 1999".

Sixteen hundred interviews were conducted.

  • Of the respondents, 87% felt that immunization is an extremely important action that parents can take to keep theirchildren well.
  • Respondents overall rating of immunizationsafety was high.
  • A substantial minority held "misconceptions":
    1. 25% believed that the child’s immune system couldbecome weakened
    2. 23%believed that children get more immunizations than are good forthem.
  • Children’s health care providers were cited as the mostimportant source of information on immunizations.

The authors concluded that a systematic educational effort was needed to address common misconceptions and that health care providers are the most important source of information.

Continuing medical education (CME) sessions are often provided by health departments and vaccine manufacturers.

The investigators in this 2000 Study seem to presume that parents, who do not vaccinate their children, do so because they lack understanding or knowledge of the subject. "Do Parents Understand Immunizations?"

Certainly in 2005 and with increased access to the Internet, this is not so. Most parents who refuse to have their children vaccinated or who vaccinate them selectively are usually educated and very well informed on the subject.

Starting with the title, the authors mention "immunizations" exclusively thus intimating that long-lasting immunity invariably follows the administration of a vaccine. This is not always true.

The CDC program dealing with vaccines is the "National Immunization Program".

The abstract of the US paper can be found here


Italian authors use both terms: vaccination and "immunization", interchangeably.

In an article entitled: "Factors influencing vaccine uptake in Italy",(3) Bonanni and  Bergamini, of the Department of Public Health and Epidemiology, University of Florence, write:

"In Italy, vaccination of children is regulated by a dual system, that is a certain number of compulsory immunisations, and a number of other facultative vaccinations. This has resulted in a different coverage against infections under the two regimens. While the percentage of immunised children against polio, diphtheria, tetanus and hepatitis B is around 95%, until recently the average coverage with facultative vaccinations was no >50%.".

In the report, published in the journal Vaccine in October 2001, the authors added:

"The preliminary results on 300 questionnaires show a generally favourable attitude towards vaccines of 80% of mothers. Only 7% of them would not immunise at all their children if vaccinations were not mandatory. Measles and mumps vaccines are considered important by 92% of mothers."

Interestingly, according to the CDC (4): "In early 2002, measles incidence increased sharply; the area most affected was Campania"¦In 2001, estimated measles vaccination coverage for the 1998 Campania birth cohort was 65%. "¦ A coordinated effort is needed to interrupt measles transmission in Italy A total of 1,571 measles cases were reported, resulting in an annual incidence of 3,750 cases per 100,000 children aged <15 years. The majority (1,543 (98%)) of cases occurred during January--July, with a peak in May."


One can only imagine how many cases of measles did indeed occur during that outbreak (1,571 were reported) that started within three months of the publication of the paper.

The value of telephone surveys in general seems limited.



Over the years, many excellent medical articles have been published in Israel.

The latest by Maayan-Metzger, Kedem-Friedrich and Kuint is certainly among the best.



  1. Maayan-Metzger A, Kedem-Friedrich P, Kuint J. - To vaccinate or not to vaccinate-that is the question: why are some mothers opposed to giving their infants hepatitis B vaccine? Vaccine. 2005 Mar 14;23(16):1941-8.
  2. Gellin B, Maibach E, Marcuse, E: Do Parents Understand Immunizations? A National Telephone Survey. Pediatrics Vol. 106 No. 5 November 2000, pp.1097-1102
  3. Bonanni P, Bergamini M. Factors influencing vaccine uptake in Italy. Vaccine. 2001 Oct 15;20 Suppl 1:S8-12; discussion S1.
  4. link

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