The global impact of the coronavirus pandemic cannot be underestimated and highlights the vast societal benefits afforded by vaccinations over the past century. Sadly, during this unprecedented time, we have observed a steep reduction in routine pediatric vaccine administrations nationally.1  Now, more than ever, we must work to ensure timely receipt of all currently available recommended vaccines, especially in vulnerable populations. These efforts must extend beyond primary care settings, beginning with the first vaccine on the childhood immunization schedule: the hepatitis B birth dose.

Approximately 1000 US infants are perinatally infected with the hepatitis B virus (HBV) each year.2,3  HBV infection can cause chronic liver disease, with high morbidity and mortality, particularly among those infected as infants. To address this public health concern, the US Department of Health and Human Services set a goal of “zero” perinatal hepatitis B transmission by 2020.4  Hepatitis B vaccination, along with hepatitis B immune globulin when indicated, is the most effective means of preventing perinatal HBV transmission.2,5  In October 2016, the US Advisory Committee on Immunization Practices voted to recommend hepatitis B vaccination of all medically stable infants born weighing ≥2000 g to hepatitis B surface antigen (HBsAg)–negative mothers within the first 24 hours of birth.5  In 2017, the American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborn endorsed this recommendation.2 

Timing of the hepatitis B birth dose is critical because the vaccine is 75% effective (94% effective when given with hepatitis B immune globulin) in preventing perinatal hepatitis B transmission when given within 24 hours of birth.2,5  It serves as an important safety net, providing postexposure prophylaxis to infants born to HBV-infected mothers not identified at birth for a variety of reasons, including lack of maternal HBsAg testing, seroconversion after testing, errors in testing, and delayed reporting to the newborn care team.6  The hepatitis B birth dose also offers protection against postnatal horizontal transmission7  and in cases in which unexpected surgery or blood transfusions are needed. In addition, timely receipt of the hepatitis B birth dose is associated with timely completion of the 3-dose hepatitis B vaccine series and other early childhood vaccines.8 

National data suggest that only two-thirds of infants receive their first hepatitis B vaccine dose within 1 day of birth.9  Several factors may hinder timely hepatitis B vaccination. Parents may not understand the importance of hepatitis B vaccination, may perceive their infant to be low risk, may have specific or general vaccine concerns, or may prefer to receive the vaccine in the outpatient setting.10  Hospital staff and providers may not effectively address these views or may offer resistance themselves. For example, some community pediatricians prefer vaccinating newborns in their office.10  In addition, hospital staff and providers often face competing priorities during the newborn hospitalization, particularly when the hospital stay is brief, when patient census is high, and in challenging times, such as during the coronavirus pandemic. Systems-based barriers, including lack of a standardized protocol, could also contribute to missed opportunities for timely hepatitis B vaccination.

To achieve our national goal of zero perinatal hepatitis B transmission, states, delivery hospitals, and birthing facilities should establish case-management programs and develop appropriate laws, policies, procedures, and/or regulations to ensure that all pregnant women are tested for HBsAg to identify at-risk infants and that all infants weighing ≥2000 g receive the hepatitis B vaccine within 24 hours of birth. In a nationally representative study, it was found that the strongest predictors of newborn hepatitis B vaccination were the presence of a written hospital policy for hepatitis B vaccine administration at birth and the hospital’s location in a state with a universal birth dose policy.11 

Delivery hospitals and birthing facilities should implement evidenced-based strategies that incorporate maternal screening and timely hepatitis B vaccination of newborns into their standard workflow. Provider prompts and standing vaccine orders in the electronic health record, effective approaches that have been used in diverse health care settings,12  may address some of the aforementioned challenges. They could be integrated with other standard newborn practices performed immediately after birth (ie, erythromycin ophthalmic and vitamin K administration).

It is critical that delivery hospitals and birthing facilities educate staff and providers, including community pediatricians, regarding the importance of timely hepatitis B vaccination. In addition, they should offer training in effective vaccine communication strategies, such as use of a presumptive vaccine recommendation and motivational interviewing.13,14  Providers report that these approaches are easy to use, save time, and increase self-efficacy in discussing vaccines with hesitant parents.1416  Given the variability in parental knowledge, beliefs, and intentions with respect to hepatitis B vaccination, vaccine conversations should also be tailored to meet the unique needs of each family. They should begin early and occur across disciplines and settings, including at prenatal visits with obstetric providers, in prenatal classes with nursing staff, and after delivery with the newborn care team or community pediatrician. Because parental refusal of hepatitis B vaccination has been associated with refusal of other standard newborn practices,17,18  addressing these preventive measures collectively with repeated and consistent messaging throughout the pregnancy and early newborn period may be valuable.

Multimodal interventions have shown particular promise with respect to improving hepatitis B vaccination in the hospital setting. In their recent quality improvement study published in Hospital Pediatrics, Bradshaw et al19  implemented standardized workflow processes and enhanced education of parents, nurses, and providers, resulting in marked increases in birth hospitalization hepatitis B vaccination rates. In an earlier study, the authors performed educational outreach and incorporated the hepatitis B vaccine within the postdelivery order set, demonstrating sustained improvement in timely hepatitis B birth dose receipt.20  Efforts that engage multidisciplinary teams in this work are critical.

We emphasize the importance of timely administration of the hepatitis B birth dose to achieve our national goal of zero perinatal hepatitis B transmission in the near future. In addition, greater awareness of and adherence to all US Advisory Committee on Immunization Practices recommendations, including for the hepatitis B vaccine, are critical. The necessity of capturing vaccination opportunities in diverse health care settings, including delivery hospitals and birthing facilities, is clearly evident during the coronavirus pandemic. In the wake of this pandemic, a refocus on preventive public health efforts is imperative, and it starts with the birth dose of the hepatitis B vaccine.

Dr Hofstetter is supported by a Mentored Clinical Scientist Research Career Development Award from the Agency for Healthcare Research and Quality (K08HS025470).

Drs Chabra and Hofstetter conceptualized and drafted this work and approved the final manuscript as submitted.

FUNDING: No external funding.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.