In an unprecedented change, the Centers for Disease Control and Prevention reduced the number of vaccines recommended for all children on Monday. One of them is the hepatitis B vaccine, a three-dose series first given at birth that protects against a dangerous virus that relentlessly attacks the liver.
Health Secretary Robert F. Kennedy Jr. has long questioned the safety and efficacy of the newborn dose, even linking an ingredient long used in the shot to autism without citing any evidence.
Last month, Kennedy called the U.S. a "high outlier" in the number of immunizations recommended for all children, a rationale used by the secretary to scrap the hepatitis B newborn vaccine. But according to a memo released by the Department of Health and Human Services last Friday, 20 peer nations — except Denmark and Finland — recommend that all kids receive the hepatitis B vaccine, either at birth or later in life.
In the U.S. alone, public health experts attribute more than 1,800 deaths to hepatitis B each year.
"It's just really sad," says Dr. Samuel So, a surgeon specializing in hepatitis B at Stanford Medicine. He treats patients with liver cancer, which the virus can cause. "This has done so much damage to the reputation of the CDC."
Health experts agree that the ultimate result will be a decrease in the number of children who are vaccinated.
Other countries face a different situation: They're making a great effort to secure the life-saving vaccine vials.
The West African nation of Ghana is among the countries racing to obtain them. But the journey to a national immunization program has been a rocky path for the country — and a famous Ghanaian rapper has even stepped in to help.
The toll of hepatitis B in Ghana
Nearly one in ten Ghanaians has chronic hepatitis B, and about 10,000 new infections are reported each year in the country of 35 million. In the U.S., the CDC estimates 20,700 new infections annually.
The risks associated with the virus — cirrhosis and liver cancer, among others — can be deadly. Since 2015, deaths from complications of the virus have risen in Ghana, with 14,000 people dying in 2022.
"The cost that it brings onto the patient themselves, their family and then the health system is quite huge," says Charles Adjei, the executive director of the Hepatitis Alliance of Ghana. He noted that his country still requires patients to pay out of pocket for treatment.
The virus' ancient roots — stretching back millennia — explain why it hits certain regions of the world harder than others. Over time, the virus has become especially efficient at spreading across entire communities. That spread intensifies when newborn protection is absent or delayed.
While unprotected sex and injection drug use are the main drivers of transmission in the U.S., Ghana is a different story. "It's a big misconception that you only get hepatitis B from using drugs or unprotected sex," So explains.
When infants in countries like Ghana miss out on the birth dose, that allows for a particularly dangerous route — mother-to-child transmission — to keep going unchecked. Risk of transmission to babies ranges from anywhere between 10% to 90%, depending on how severe the mom's infection is.
And about 95% of infants are infected with the virus for life. "It's a life-long stigma," So says. "And when the virus flares up, it could cause life-threatening liver disease."
Vaccines given at birth offer hope in Ghana
Reducing the spread from mom to child is simple. All it takes is a jab in the thigh within 24 hours of birth, with two additional pokes later in childhood for long-term protection. That first shot is the most cost-effective way to prevent transmission — and the numbers show it.
"The pillar of prevention of mother-to-child transmission is that timely birth dose," So says. "That will protect most of the newborns born to infected mothers." About 75% to 95% effective, in fact, and roughly a quarter of infants gain lifelong protection from a single shot alone, and follow-up doses strengthen that shield. The second dose confers long-term protection to about two-thirds of babies, and the third raises that figure to 95%.
However, that life-saving intervention isn't widely available in Ghana, despite a 2009 World Health Organization recommendation to all countries to administer the vaccine at birth, updating previous guidance from five years earlier.
In fact, Ghana has mounted a national hepatitis B vaccination effort since 2002, achieving coverage as high as 95% — just not with the newborn vaccine that matters most. The vaccine currently used, which protects against hepatitis B and four other infections, is called the pentavalent vaccine and is free to all citizens. It's first given at about one month of age.
But that's often too late to prevent infection, which typically occurs during birth or in the uterus. Studies estimate that even a seven-day delay in vaccination can increase the risk of infection ninefold.
"That baby has to be protected right when they're born," says Dr. Yvonne Ayerki Nartey, a physician based in Cape Coast, Ghana, who conducts research with So. "We don't want to leave that gap open."
While researchers agree that the pentavalent vaccine is somewhat helpful in reducing transmission, it's nowhere close to perfect. For instance, more than half of children with hepatitis B had received the three-dose pentavalent series yet still got infected, according to a study from Sierra Leone.
And unfortunately, it's not safe to give the pentavalent vaccine at birth.
The only other available intervention for little ones is a shot of concentrated hepatitis B antibodies that gives the baby instant protection, temporarily, with a quarter of infants eventually becoming infected.
But that shot costs patients about $50 because health programs don't widely cover it, according to Adjei, who works with hepatitis patients. That's an insurmountable expense for Ghanaians who earn an average of $240 per month.
Complicating matters, many mothers don't even know they're infected because testing is hard to come by, and hepatitis B sometimes causes no symptoms. Even when testing is available, some pregnant women, Adjei says, are forced to pay for the service, which is supposed to be free.
Ghana's uphill battle to give all babies a poke
In recent years, Ghana's economy has struggled with rampant inflation and debt, squeezing its health budget. The country has one of the lowest levels of health spending as a share of GDP worldwide — about $82 per person.
Those few dollars that are available for health spending weren't enough to cover the cost of a newborn vaccination program for hepatitis B.
"We haven't taken that bold step yet," Adjei says. "The reality is, until Gavi comes in, forget it, you won't have the budgetary support."
Gavi, the organization that funds immunizations for lower-income countries, helps Ghana fund the pentavalent vaccine. However, the newborn vaccine was never funded.
That's because Gavi co-finances vaccines, a process where countries are generally asked to pay at least 20 cents per dose, and Gavi covers the rest.
But the newborn vaccine once cost just 20 cents, meaning countries would've had to pay the full price regardless — without any aid from Gavi.
The organization put the vaccine on hold, and Ghana was left to fend for itself. By 2014, Gavi said it would "focus its limited resources on other high-impact vaccines."
Without Gavi's negotiating power, the shot would cost patients $3.50 per dose, according to Adjei. As a result, the free pentavalent shot remained the standard.
Implementing the newborn vaccine would also be logistically challenging. The poke has to be given to babies within 24 hours of birth, but in Ghana, more than one-fifth of births happen outside the hospital.
These challenges didn't stop groups from publicly pressuring Gavi, though.
"We started amplifying our voices to get this on the priority list," Adjei recalls, noting his organization's advocacy efforts were launched in 2015. "We started making noise."
Enter Rap Doctor
The public push in Ghana also involved an unlikely character: a famous rapper.
Kwame Nsiah-Apau, who goes by his stage names Okyeame Kwame and Rap Doctor, has captivated Ghanaian audiences for nearly three decades with his "hiplife" style of music. For much of that time, he has also been a vocal advocate for people living with hepatitis B.
The 49-year-old partnered with groups to raise awareness about the plight of hepatitis B patients and the stigma they face. He says he often visits college campuses to promote the vaccine and sat down with vaccine researchers at the University of Ghana in July.
"It's a coalition of people working together," he says. "We curate one message and keep pushing it so that we will be able to achieve our goal. We must all hold hands and push hepatitis into the deep blue ocean."
The noise they made eventually reached Gavi. By 2018, the organization's board agreed to start supporting hepatitis B birth doses in 2021. But yet another setback — the pandemic — stalled those efforts.
"It was silent for a while," Adjei, who leads a hepatitis advocacy group, recalls.
The activist, who was drawn to the field after seeing the impact of the virus on pregnant women, started working with hepatitis B patients nearly two decades ago. Adjei says he began by administering shots. Each shot he gave was meticulously noted in a notebook. "Whenever I looked at that book, I could see the number of lives that I could save," he says.
The virus continued to spread, and Ghana's Ministry of Health rated its performance at keeping the virus at bay as "poor" in a report published in 2023. Adjei kept pushing, and it didn't take long to reenergize public pressure.
The news finally came in 2024, when Gavi announced it would help cover the cost of newborn vaccines, providing a framework for Ghana to co-purchase mass quantities of the vaccine.
Roadblocks ahead
Despite the announcement, Adjei says the Ghanaian government's push to make the immunization campaign official didn't come until last year, when the government said it would introduce the vaccine in September and receive help from partners to facilitate the new program.
But September came and went — and the rollout never did. An official from the Ghana Health Service declined to speak with NPR for this story.
Though Adjei says he's "sure" the campaign will launch in 2026, uncertainty remains.
"It was very unpleasant, and at a point it was very irritating, especially when you have the figures and you're showing how many people are dying as a result of a vaccine-preventable condition," Adjei says. "You keep on reminding the government almost every day about the need to have this on the priority table. Obviously, at some point, we were just exhausted — even mad."
"It's been a very, very, very long fight. They just keep on assuring us that it will happen very soon. It's an unending battle, but we are sure and optimistic that one day it will be over."
Nsiah-Apau shares that sense of hope. He says he's even ready for the call — the one when the government calls on him to help out with the new campaign.
But Nartey, the doctor who treats patients with hepatitis, warns that even countries that have rolled out national birth-dose programs continue to struggle. Even those 14 countries in sub-Saharan Africa — including the Gambia and Nigeria — have reached birth dose coverage rates of only about 17%, according to a report published Saturday.
Another worry hovering over Adjei is Gavi's future. With funding dollars already cut, he worries the newborn hepatitis B vaccine might be on the chopping block. Gavi, though, is thinking ahead.
Adjei is too, and he says his global community of hepatitis advocates keeps him going. "Even though they are not in Africa, they still extend their helping hand."
Nartey continues to see those glimmers of hope and tries to imagine a Ghana that will one day be hepatitis B-free.
"It's a good feeling to see that you are doing something to try to reduce the burden of the largest cause of cancer mortality in your country," Nartey says. "I see their future when I see that they've been vaccinated. At least I know that they're not going to die."
Michal Ruprecht is a Stanford Global Health Media Fellow and a fourth-year medical student.
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