JAMA Pediatr
Delaying newborn hep B vaccine may increase infections, costs
Clinical takeaway: Universal hepatitis B screening and birth-dose vaccination provide overlapping protection for newborns. Moving to delayed or targeted vaccination may leave more infants exposed, especially when maternal screening is incomplete or vaccine series completion falls.
The Advisory Committee on Immunization Practices (ACIP) voted last December to replace universal birth-dose hepatitis B vaccination with shared decision-making for infants born to mothers who test negative for hepatitis B surface antigen. Two modeling studies examined what that change could mean for infant infections, long-term outcomes, and costs.
In one study, investigators modeled a U.S. birth cohort of about 3.7 million infants, matching expected births in 2021. At the current 86% maternal screening rate, universal birth-dose vaccination was projected to result in 1,292 neonatal hepatitis B infections.
Switching to a targeted approach increased infections, with the magnitude depending largely on vaccination coverage among infants of unscreened mothers. If coverage stayed near current levels at 80%, the model projected 69 additional neonatal infections. If coverage fell to 10%, as occurred after a 1999 recommendation to delay the birth dose for some infants, the model projected 628 additional neonatal infections and 565 additional chronic infections.
Preventing those excess infections would require unusually high screening or vaccination coverage. The model estimated that more than 100,000 additional pregnant women would need screening if birth-dose coverage among infants of unscreened mothers stayed at 80%, and more than 400,000 would need screening if coverage fell to 10%.
The other study modeled 3.6 million infants born in 2025 and found that any delay in the first hepatitis B vaccine dose led to more infections, deaths, and costs than vaccination at birth.
Even delaying the first dose to 2 months among infants of hepatitis B-negative parents was projected to add 90 acute infections, 76 chronic infections, 29 hepatitis B-related deaths, and $16.4 million in lifetime health care costs. Delaying until age 12 was projected to add 190 acute infections, 50 hepatitis B-related deaths, and nearly $30 million in costs, with worse outcomes when parental hepatitis B status was unknown or children missed later doses.
About 90% of newborns who acquire hepatitis B develop chronic infection, which can later lead to cirrhosis, liver failure, liver cancer, and premature death.
“Even small drops in birth dose vaccination can increase HBV infection risk, especially for infants of unscreened mothers,” said Rachel Epstein, MD, MSCE, pediatric and adult infectious disease clinician-scientist at Boston Medical Center and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine. “This study highlights the importance of consistent prevention strategies to protect newborns and reduce hepatitis B nationwide.”
Sources: Lind ML. JAMA Pediatr. 2026 Apr 27. Impact of Removing the Universal Hepatitis B Birth-Dose Vaccination in the US; Hall EW. JAMA Pediatr. 2026 Apr 27. Economic Impact of Delaying the Infant Hepatitis B Vaccination Schedule