What’s at stake when the Hep B birth dose is skipped?

Clinical takeaway: Recommend hepatitis B vaccination at birth for all newborns; a new modeling study projects that delaying vaccination or adopting shared decision making would increase chronic infections acquired by age 20.

Infants infected with hepatitis B virus (HBV) face a particularly high risk of lifelong infection, with potential complications including cirrhosis and liver cancer. Universal birth-dose vaccination provides a safety net against missed maternal infections and exposure through household or community contacts.

Researchers modeled a single U.S. birth cohort of 3.6 million infants through age 20, comparing universal birth-dose vaccination with two alternatives for infants whose mothers tested negative for HBV: starting vaccination at 2 months or offering it at that age through shared decision making. All strategies retained birth-dose vaccination for infants whose mothers had positive or unknown HBV status.

Universal birth-dose vaccination was projected to result in 255 chronic infections by age 20, compared with 303 with delayed vaccination (a 19% increase) and 467 with shared decision making (an 83% increase). These represent 48 and 212 additional chronic infections, respectively, within one birth cohort.

Shared decision making also left approximately 1.8 million people susceptible to HBV at age 20 (about half the cohort) compared with 232,000 under universal birth-dose vaccination.

The projections assumed vaccine-series completion of approximately 91% with universal birth-dose vaccination, 87% with delayed vaccination, and 50% with shared decision making. Uncertainty about future uptake and household or community transmission limits the estimates; the model did not capture subsequent transmission or lifetime liver complications.

“Even a small number of additional infections in childhood could have large clinical, public health, and economic effects, given that most childhood infections are asymptomatic and may persist to be lifelong infections,” the authors wrote.

Source: Mohareb AM, et al. (2026 Oct 19) Ann Intern Med. Projected Effect of 2026 Federal Changes to the Childhood Immunization Schedule on Chronic Hepatitis B Virus Infections in the United States