Disclaimer: This paper represents the views of the author and not of his institutions

 

Competing Interests: Dr. Zimmerman is primarily funded by federal research grants but also receives vaccine industry grants, consulting, teaching and patient care revenues; none of these are directly related to this topic.

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In 2025, and in contrast to previous precedent, all members of the Advisory Committee on Immunization Practices (ACIP) at the U.S. Centers for Disease Control and Prevention (CDC) were replaced, and many new members were known to express vaccine hesitancy. In December 2025, in a split vote, the ACIP voted to change the recommendations on routine infant hepatitis B vaccination.

 

Biblical and Theological Foundations

 

God’s truth in Scripture and creation extends to scientific truths via common grace. The speech of God, which is always truthful, results in Scripture, creation and providence. The idea of eliminating a disease that causes suffering, such as hepatitis B, flows directly from the promotion of human flourishing based on the cultural mandate in Genesis 1:26-8. Theologian Bavinck wrote: “Science, art, moral, domestic, and societal life…were derived from that common grace and acknowledged and commended with gratitude.”¹ Indeed, the CMDA Ethics Statement on Vaccines and Immunizations notes: “Vaccines have significantly reduced the incidence of life-threatening infections and have saved lives. Vaccines are an important part of maintaining health, especially in children.”²

 

Sanctity of Life. Humans are made in God’s image (imago dei, Genesis 1:27) and we are to protect life. Prevention has a biblical basis, as shown by the need for railings when people stayed on a flat roof for the cool of night in an arid area: “When you build a new house, be sure to put a railing around the edge of the roof. Then you will not be responsible if someone falls off and is killed” (Deuteronomy 22:8, GNT).

 

Altruism and Love of Neighbor. The “love one another” passages in the New Testament support caring for another, with direct attention to caring for physical needs: “…our love should not be just words…shows itself in action” (1 John 3:18, GNT). Being vaccinated dramatically reduces the risk that one will contract hepatitis B and, thus, the risk of transmission to others.

 

Medical and Public Health Evidence

 

Hepatitis B Virus (HBV) Transmission. HBV can be contracted via parenteral or mucosal exposure and is present in the blood for one to two months before the onset of symptoms. Innocuous transmission can also occur, particularly among households in which a member is chronically infected. Indeed, the source of infection is not identified for 24 percent of hepatitis B cases.³ These cases may result from (1) underreporting of injection drug use and sexual activity, and (2) inapparent contamination of skin lesions or mucosal surfaces, since hepatitis B surface antigen (HBsAg) is found in impetigo lesions and saliva of persons chronically infected with HBV, and on toothbrush racks and coffee cups in their homes.⁴ HBV is infectious for at least seven days on environmental surfaces and can be transmitted even in the absence of visible blood.⁵ Thus, epidemiological studies show HBV can be transmitted in households with hepatitis B carriers or between preschool-aged children.^6-8

 

Importance of Age at Infection on Development of Chronic Infection and Premature Death

Persons infected early in life are much more likely to become chronically infected than those infected during adulthood. Chronic HBV infection develops in up to 90 percent of those infected as infants, 30 percent to 50 percent of those infected between one and five years and 5 percent of those infected as adults.⁵ One-quarter of infected infants and one-eighth of infected adults will die prematurely ⁵ from cirrhosis or liver cancer. Although most acute infections in the United States occur in adulthood, one-third (36 percent) of all persons chronically infected contract HBV during early childhood.⁹ About half of the adults who are acutely infected are asymptomatic. In the U.S., an estimated 850,000 to 2.2 million persons are chronically infected with HBV⁵ and, therefore, are contagious.

 

Hepatitis B Vaccine

Preexposure vaccination results in protective antibody levels in almost all (more than 90 percent) infants and healthy adults less than 40 years old. However, immunogenicity declines with age, dropping to 75 percent for recipients 60 years old. Although antibody levels slowly diminish following vaccination, most persons remain protected for more than 30 years.⁵ This immunologic memory and long HBV incubation period allow most immunized persons with low titers to mount an anamnestic response. Acute HBV infection rates dropped about 90 percent from 9.6 per 100,000 in 1982 to one case per 100,000 in 2018, following the introduction of hepatitis B vaccines.⁵

 

No links to severe adverse events have been proven other than anaphylaxis. A controlled study of neonatal hepatitis B vaccination found “no evidence that newborn hepatitis B vaccination is associated with an increase in the number of febrile episodes, sepsis evaluations or allergic or neurologic events.”¹⁰ Another study of newborn deaths found no association with hepatitis B birth immunization.¹¹

 

U.S. Public Health Policy: Advisory Committee on Immunization Practices (ACIP) Votes in December 2025

 

Advisory Committee on Immunization Practices (ACIP) Issue 1 – Delaying birth dose until two months in those proven to be born to mothers who are not infected with Hepatitis B

Pros: The pros of delaying the birth dose are the increased maturity of the infant’s immune system and the potential to reduce the number of injections, because two infant combination vaccines contain hepatitis B vaccine. Although fever only occurs in 1 percent to 6 percent of vaccinees, it has the potential to create confusion in the newborn nursery about perinatal infection risk.

 

Cons: Some women might become infected with hepatitis B after their prenatal test was drawn and thereby place their infant at risk, particularly during delivery. Another concern is that hepatitis B virus may be prevalent in households that contain a person chronically infected, placing the newborn at risk before the vaccine at two months of age. A third con is the birth dose strategy worked well¹² and is a safety net when human communication systems fail.

 

Conclusion: I feel neutral because there are pros and cons. ACIP continues to recommend that women born to mothers with hepatitis B infection should have the vaccination and immunoglobulin.

 

Advisory Committee on Immunization Practices (ACIP) Issue 2 – Changing the existing recommendation for vaccination to an individual decision-making discussion

Pros: Individual clinical decision-making is useful when the pros and cons are relatively balanced and when preferences might be debated.

 

Cons:

1. The goal of elimination of hepatitis B follows the creation mandate by promoting health. Jesus taught to love one another; isolated decisions that do not consider the benefit to both the individual and others do not meet this (Mark 12:31).
2. No parent of an infant can know the occupation, medical illnesses, lifestyle of their children or lifestyle of their children’s eventual partners. Postponing the vaccination decision until the child reaches adulthood to make their own decision leaves windows of vulnerability for accidental or occupational exposure.
3. The vaccine is more effective when given to children than to older adults, particularly if they develop immunocompromising diseases.
4. Multiple needlesticks have been a concern of many parents, and removing use of existing hepatitis B-containing combination vaccines would likely increase the number of injections. Such a disruption may result in inadequate windows of protection against several vaccine-preventable diseases.
5. Furthermore, many clinics would need to stock more vaccines if each parent tailors the immunization schedule to their own design preference.
6. The comprehensive policy of hepatitis B vaccination, of which infant vaccination is a part, overall has been successful with a 90 percent drop in rates; the burden of proof falls on those wishing a policy change to show that it is unlikely to harm.

 

Conclusion: I continue to recommend routine hepatitis B vaccination of infants. Consider the analogy of other preventive services: we recommend colon and breast cancer screening, although most persons will never develop these cancers. Both these preventive services have a low but measurable risk in themselves, but overall protection is greater in those screened. It is similar with hepatitis B vaccination, and the existing paradigm of infant vaccination has worked. Nonetheless, according to the CMDA Ethics Statement on Healthcare Right of Conscience, “Patients with decision-making capacity have the right to refuse treatment, even when such refusal would bring them harm. When a patient’s refusal of treatment threatens the lives of others, the patient’s right to refuse treatment should be subordinate to the protection of others….”¹³

 

Advisory Committee on Immunization Practices (ACIP) Issue 3 – Allowing titers to be used to guide the number of infant doses in the vaccine series

Pros: This might reduce the number of doses of hepatitis B vaccine and might reduce needlesticks, although the use of combination vaccines makes a reduction less likely.

 

Cons: Most parents do not tolerate venipuncture in infants unless absolutely necessary, and venipuncture in infants is technically challenging. The tracking of results and the need to stock individual vaccines instead of combination vaccines makes this burdensome for primary care offices. Whether or not a dose of vaccine provides lifelong immunity is unknown and untested. Initially, plasma cells make Immunoglobulin G antibodies (IgG), but most are not long-lived and neither is their IgG. What is crucial is the development of memory B-cells that are imprinted for hepatitis B surface antigen and whether one dose will suffice to do this is unknown.

 

Summary

In summary, I am neutral on the first ACIP vote but oppose the second and third votes. I believe that elimination of hepatitis B virus through a comprehensive program that includes childhood vaccination will promote human flourishing toward the fulfillment of the creation mandate. 

 

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References

1. Bavinck H, Bolt J, Vriend J. Reformed dogmatics. Grand Rapids, Mich.: Baker Academic, 2003.
2. Christian Medical & Dental Associations. Vaccines and Immunizations. (https://cmda.org/policy-issues-home/position-statements/).
3. Iqbal K, Klevens RM, Kainer MA, et al. Epidemiology of Acute Hepatitis B in the United States From Population-Based Surveillance, 2006-2011. Clin Infect Dis 2015;61(4):584-92. DOI: 10.1093/cid/civ332.
4. Petersen NJ, Barrett DH, Bond WW, et al. Hepatitis B surface antigen in saliva, impetiginous lesions, and the environment in two remote Alaskan villages. Appl Environ Microbiol 1976;32(4):572-4. DOI: 10.1128/aem.32.4.572-574.1976.
5. Centers for Disease Control and Prevention. Hepatitis B. In: Hall E. WAP, Hamborsky J., et al., eds, ed. Epidemiology and Prevention of Vaccine-Preventable Diseases. 14th ed. Washington, D.C.: Public Health Foundation; 2021.
6. Craxi A, Tine F, Vinci M, et al. Transmission of hepatitis B and hepatitis delta viruses in the households of chronic hepatitis B surface antigen carriers: a regression analysis of indicators of risk. Am J Epidemiol 1991;134(6):641-50. DOI: 10.1093/oxfordjournals.aje.a116136.
7. Franks AL, Berg CJ, Kane MA, et al. Hepatitis B virus infection among children born in the United States to Southeast Asian refugees. N Engl J Med 1989;321(19):1301-5. DOI: 10.1056/NEJM198911093211905.
8. Hurie MB, Mast EE, Davis JP. Horizontal transmission of hepatitis B virus infection to United States-born children of Hmong refugees. Pediatrics 1992;89(2):269-73. (https://www.ncbi.nlm.nih.gov/pubmed/1734395).
9. Margolis HS, Alter MJ, Hadler SC. Hepatitis B: evolving epidemiology and implications for control. Semin Liver Dis 1991;11(2):84-92. DOI: 10.1055/s-2008-1040427.
10. Lewis E, Shinefield HR, Woodruff BA, et al. Safety of neonatal hepatitis B vaccine administration. Pediatr Infect Dis J 2001;20(11):1049-54. DOI: 10.1097/00006454-200111000-00009.
11. Eriksen EM, Perlman JA, Miller A, et al. Lack of association between hepatitis B birth immunization and neonatal death: a population-based study from the vaccine safety datalink project. Pediatr Infect Dis J 2004;23(7):656-62. DOI: 10.1097/01.inf.0000130953.08946.d0.
12. Wasley A, Kruszon-Moran D, Kuhnert W, et al. The prevalence of hepatitis B virus infection in the United States in the era of vaccination. J Infect Dis 2010;202(2):192-201. DOI: 10.1086/653622.
13. Christian Medical & Dental Associations. Healthcare Right of Conscience Statement. (https://cmda.org/policy-issues-home/position-statements/).