In the United States, there are three ways to acquire Hepatitis B virus (HBV):

1) Be born to a mother with active HBV infection.

2) Have your skin punctured with a sharp object, accidentally or on purpose, that has been previously contaminated with the blood of someone who has active HBV infection.

3) Have sex with someone who has active HBV infection.

It is virtually impossible to acquire HBV by being born to a HBV surface antigen-negative mother. And yet, universal Hep B vaccination is included in standard newborn nursery orders throughout Massachusetts.

Flea recently asked Dr. Nebish why all newborns of HBsAg-negative mothers needed the immunization in the hospital prior to discharge. After all, the state-supplied vaccine schedule includes Pediarix, which includes Hep B vaccine, given at 2, 4, and 6 months. Full vaccination requires only 3 shots. Why needlessly apply a fourth? Dr. Nebish refused to answer, as is his custom. As a result, Flea needs to write orders to ask nurses not to give Hep B vaccine to babies of HBsAg-negative mothers. He is the only flea at his hospital that does so.

Hepatitis B vaccination is required by Massachusetts state law for all children entering kindergarten. It is also required by most state-licensed child-care facilities. The reasoning for this is two-fold: In high-prevalence areas, transmission of HBV between children accounts for a measurable number of cases. The other is that kids are known to bite one another.

Massachusetts is not a high-prevalence area for HBV. And though children do indeed bite one another, cases of horizontal transmission in child-care centers and schools is exceedingly rare. It makes far more sense to screen mothers prior to birth and to transfer this information to child-care centers and schools prior to admission. If the mother is HBsAg-positive, or her status is unknown, the child is immediately immunized and given Hepatitis B Immune Globulin to boot.

Having said all that, HBV is a terrible disease and it's preventable. The vaccine is highly effective and safe. Some of the complications of the disease, on the other hand, include cirrhosis of the liver and hepatocellular carcinoma (liver cancer).

If it were up to Flea, all Americans would be vaccinated against HBV in adolescence, prior to achieving age when they begin engaging in the activities that transmit HBV in the U.S.