Universal hepatitis B birth-dose removal could increase neonatal infections, modeling study finds

A modeling study published in JAMA Pediatrics estimated that replacing universal hepatitis B birth-dose vaccination with a targeted recommendation could increase neonatal hepatitis B virus (HBV) infections in the United States, particularly if vaccination rates decline among infants born to unscreened mothers.^1,

Investigators modeled outcomes following the December 2025 Advisory Committee on Immunization Practices (ACIP) vote to replace universal hepatitis B birth-dose vaccination with shared clinical decision-making for infants born to mothers who screen negative for hepatitis B surface antigen (HBsAg).²

The analysis simulated a US birth cohort of 3,659,289 infants under 2 strategies: universal birth-dose vaccination and a targeted recommendation in which birth-dose vaccination remains recommended only for infants born to HBsAg-positive or unscreened mothers.

Researchers found that under current maternal HBV screening rates of 86%, the universal recommendation resulted in a median of 1292 neonatal HBV infections. In comparison, the targeted recommendation was associated with 628 additional neonatal infections when birth-dose vaccination coverage among infants of unscreened mothers declined to 10%, reflecting historical declines observed after a prior temporary removal of universal recommendations in 1999.

Even when vaccination coverage among infants of unscreened mothers remained at 80%, similar to current universal vaccination levels, the targeted recommendation was associated with 69 additional neonatal infections.

The authors wrote, “Findings from this study indicate that the targeted birth-dose vaccine recommendation will likely increase neonatal infections unless maternal screening rises substantially or vaccination coverage among infants of unscreened mothers exceeds current levels.”

Why does maternal hepatitis B screening remain important?

Investigators noted that approximately 12% to 16% of pregnant women in the US remain unscreened for HBV despite CDC recommendations for screening during every pregnancy. They emphasized that neonatal HBV infection carries substantial long-term risks because approximately 90% of infected infants progress to chronic infection.

The study also examined what level of maternal screening would be required to offset excess infections under the targeted recommendation. At birth-dose vaccination coverage levels of 10% and 50% among infants of unscreened mothers, maternal screening rates would need to increase to 98% and 96%, respectively, to achieve infection numbers comparable to universal vaccination.

When vaccination coverage among infants of unscreened mothers remained at 80%, maternal screening rates still needed to reach at least 90% to achieve similar outcomes.

Researchers further estimated that more than 100,000 additional pregnant individuals would need to be screened to offset excess infections if vaccination coverage among infants of unscreened mothers remained at 80%. If coverage fell to 10%, more than 400,000 additional pregnant individuals would require screening.

Which populations could be most affected by targeted hepatitis B vaccination recommendations?

The burden of increased infections was not evenly distributed across populations. The model estimated the highest number of neonatal infections among infants born to mothers from East Asia, despite that group representing approximately 1.7% of the modeled birth cohort.

The authors also highlighted broader public health concerns related to reduced vaccine uptake. “By shifting birth vaccination from a default practice at birth to an opt-in decision, overall HBV vaccine coverage will likely decline and, in turn, increase long-term population infection and disease risk,” the investigators wrote.

They added that receipt of the hepatitis B birth dose has previously been associated with higher uptake of other routine childhood immunizations.

In their conclusion, the authors stated, “Results of this study highlight that the built-in redundancy of universal HBV screening in pregnancy and vaccination in newborns offers robust protection against neonatal HBV transmission, protection that will be difficult to replicate under the targeted recommendation.”

References

1. Lind ML, Hitchings MDT, Singh RP, et al. Impact of removing the universal hepatitis B birth-dose vaccination in the US. JAMA Pediatr. Published online April 27, 2026. doi:10.1001/jamapediatrics.2026.1226

2. Fitch J, Ebert M. ACIP votes to update hepatitis B vaccine recommendation for infants. Contemporary Pediatrics. December 5, 2025. Accessed May 7, 2026. https://www.contemporarypediatrics.com/view/acip-votes-to-update-hepatitis-b-vaccine-recommendation-for-infants