Some clarifications on Hepatitis B transmissibility

In case people were feeling misled by how transmissible Hep B is, here is a clarification.

Motto: If you wanna fix smth that ain't broke, you should have a good reason & a plan. Exactly how it would be implemented in the context of the US healthcare system, how it would work differently from previous risk based approaches that in the US context weren't very successful.

I recently wrote an article about how the universal newborn vaccination policy for Hepatitis B did not originate, as many of its critics claim, out of a desire to not offend liberal sensibilities and that if it became more widespread due to low vaccination, it could end up affecting people beyond those they call “degenerates”. Now, to be clear, I do not the children (!) of these so-called “degenerates” deserve to get chronic liver issues because of their parents’ actions (what happened to the whole “luxury beliefs”/Christian morality thing?), but since this was framed explicitly as a matter of responsibility of said “degenerate” parents, I felt like I had to clarify that even assuming one does not care about these children, the disease could end up affecting a larger proportion of the population IF it starts being more common in these groups of people.

The main purpose of the post was not even to argue this is the best policy that could be envisioned in an ideal world: I acknowledged that it might not be “the platonic ideal of a policy”, but given that we know it has reduced rates of Hepatitis B induced liver damage and cancer massively and has no known downside after decades of it being implemented, my principle is: “If it ain’t broken, don’t fix it”. It’s also important to remind everyone that here we are debating whether to vaccinate a newborn or a few months old baby (unless you actually want to advocate for no vaccination whatsoever). Overall, to assume that this difference in a few months might have any negative impact, in the absence of any evidence, seems weird to me.

The other notable thing here is that the US did try a “selective vaccination” policy before 1991, whereby only the newborns of mothers at risk and mothers who tested positive for hepatitis B were vaccinated. For some reason, this did not work very well (maybe miscommunications between hospitals?), and this is why in 1991 CDC recommended universal newborn vaccination. I am not sure exactly why this happened, because I do not fully understand the logistics of US hospitals.

If someone wants to investigate this further and can come up with a better policy that works within the US healthcare system and its logistics and models the Hepatitis B spread arising from it in a credible way, they should do that, instead of screaming about degeneracy on X. I personally think this is a low EV area to focus on, as I cannot possibly imagine how vaccinating your kid at a few months old versus as a newborn could possibly make a difference to the supposed risk from this vaccine, but if someone is passionate about the topic, they should propose a better framework, taking into account all the trade-offs and real life practicalities of how the US healthcare system works. Something to also consider for this hypothetical new policy proposal are the changing demographic patterns versus pre-1991 US, since I keep getting messages like this (and no, I do not think anti-vaxx sentiment is a good reason to be against high-skill immigration from China). On the pro side, I guess we might have better tech to test mothers/data infrastructure to communicate information. Again, things to be researched.

Anyway, because I have been accused of misrepresenting how transmissible Hepatitis B can be, and apparently that’s how the edifice of Science gets destroyed, I have edited my original article to make it clear that spread via saliva in toddlers is not a common occurrence. New section included here in a block quote. You can also see the entire debate here.

What I learned from this experience is that certain institutional failures, which I have written about before, have created a low trust environment. However, they have given rise to nihilists that endlessly criticize the system and who will not build something better: they prefer being mad at degenerates & trolling on twitter. If they cared about public health, they’d discuss the new Florida vaccination rules that will mean that mandatory vaccination for polio and measles (!!) is removed or write the better policy memo I discussed, taking into consideration all the existing real-world constraints and all the trade-offs. Overall, I have been very critical of how public health officials handled Covid in the past, but if the only alternative is being overridden by plagues and crank medicine, then I will pray at the altar of Dr. Fauci.

I will discuss this more at length in a future post, but since I have other things to do (including writing and researching biotech policy) and I do not want to have another sentence taken out of context and used improperly, I cannot do it now. This underscores a deeper problem: people with full-time jobs who know about this stuff do not have the time to endlessly argue against the barrage of bad information for free, only to be “owned” by those with endless time on their hands to take any possible thing out of context. And it’s not just this. Some influencer with a gazillion followers told me I belong in prison because of the tweet in which I explained this is much more transmissible than HIV. She has 810k followers!!!! With this following she can probably live off posting anti-vaxx nonsense all day long. Not sure what the solution to this is: paying people to research this full-time and refute these points?

You might think refuting this stuff is not consequential, but given that now everything related to vaccines is taken to be some conspiracy, and the spread of ideas like “if I vaccinate my dog they might get autism”, it does seem quite consequential to me.

The new part of the article:

Edit: It was claimed that an initial version of this post was misleading people into thinking that Hepatitis B is more transmissible than it is. You can see the back and forth here. I have amended my article to make sure that no misunderstanding might take place. All in all, the premise on X was that this was as hard to transmit as HIV, which is not true. Hepatitis B is a virus that transmits via bodily fluids and is much more likely to affect “at risk” populations that engage in risky behaviour. Nonetheless, it is considered one of the most contagious viruses in its class and, as I show below, can affect ~ large parts of non at risk people.

“What is your body count?” — asks the doctor attending to your birth, looming over you. You are stressed, in pain, and can barely think: but this is an important part of defeating wokeness via “whoreness score” pre-screening for Hepatitis B. Now, some might really, really want to embed incel internet discourse into medical practice and instantiate such a reality (would they get the whoreness score qualified as a biomarker under the Biomarker Qualification Program?)

Fine. But even then, I want to explain to these people that this might be bad for THEM, since uncontained Hepatitis B can be bad in the long-run for everyone, not just high-risk populations.

While hepatitis B infections may be concentrated in certain high-risk populations NOW (or those high in degeneracy score), due to widespread vaccination, the virus may NOT stay confined to those groups in the long run. In the end, hepatitis B, given its high rate of infectiousness, might not be something that can be kept neatly contained within a few groups we label as “high risk” if it becomes prevalent enough in the “high risk” groups. And if your “high risk” population is large enough, which in the U.S. it might very well be, it might become an actual widespread problem. Viruses don’t respect categories. They move in quiet, ordinary ways: through families, through partners, through the accidents and medical encounters that touch all of our lives.

Before the universal vaccination recommendations in 1991, a study from 1986 found that 1.5% of white heterosexual students with less than 3 recent sexual partners were Hepatitis B infected. Given that college attendance rates were even lower in 1986 than now, this is a quite highly selected group. In a larger cohort, including those from lower socioeconomic backgrounds, 30% of those with Hepatitis B infection had no known risk factor. In Communist China, a country hardly known for its degeneracy, Hepatitis B used to be endemic, with 10% of the population being infected. This led to the government mandating vaccination at birth. It is hard to estimate exactly how Hepatitis B prevalence would look like in the US today if mothers were tested at birth before vaccinating: changing demographics, transmissibility of the virus, healthcare system logistics and so on, would have to be taken into consideration to propose a better policy. But none of the critics of the current system, which works, is doing this exercise.

A Chinese follower of mine, Dr Dale Wen, who is hardly woke (look at her tweets!), summarized her experience in a tweet copied below:

“And she is totally wrong scientifically. Hepatitis B is highly highly transmissible, at least before the vaccine. In 1980s, about 10% of Chinese were carriers. Even though drug use and prostitution were almost unexistent under the communists. My father died from Hepatitis B at age 53. He got it by eating with my uncle, a known patient. When he got diagnosed, my whole family got tested and everyone of us tested positive for antibodies. Meaning we all got exposed but fortunately our immune system fought it off successfully . But my father was not so lucky. There are also academic papers showing toddlers transmit hepatitis B to each other, by sharing saliva. It is the vaccine that changed the tragic situation in China. Today only 3 % Chinese are carriers, despite the fact there are much more drug use and prostitution in China today than in 1980s. Hepatitis B is only transmissable through sex and drug use is a lie pushed by patient activists, because they don't want to be discriminated. Fortunately it has largely become true because most people are vaccinated. If most people are no longer vaccinated, it will no longer be true, as the case in 1980s China.”

She also provided some links to papers showing how easily transmissible hepatitis B can be: one study found a case of transmission between toddlers biting each other in daycare, and another one found horizontal transmission within a family with everyone getting hepatitis B. Because I have been accused of misrepresenting these studies, I want to make it clear these are not the most common ways of spreading the virus: risk increases massively for those who engage in high levels of sexual activity with many partners and so on. But it’s much more contagious than HIV and we probably do not fully know all the ways in which it can spread.

As an anecdotal story, I know of a family in Romania (where baseline rates were higher in the 90s) who was upper middle class and where everyone ended up with Hepatitis B. One of the parents died in his 50s due to cirrhosis.