Objective:

To estimate how replacing universal hepatitis B vaccination at birth with delayed vaccination or shared clinical decision-making could affect childhood HBV infections and susceptibility.

Approach:

• Model: Investigators used a Markov cohort model to simulate 3.6 million US-born infants through age 20 years.
• Strategies: The model compared universal birth-dose vaccination, universal vaccination beginning at age 2 months, and vaccination through shared clinical decision-making.
• Analyses: Scenario and sensitivity analyses examined vaccine uptake, maternal HBV prevalence, childhood exposure risks, and later vaccine initiation.

Key Findings:

• Projected chronic infections by age 20 were 255 with universal birth-dose vaccination, 303 with vaccination deferred to 2 months (19% higher), and 467 with shared decision-making (83% higher).
• Projected numbers susceptible at age 20 were approximately 232,000, 474,000, and 1.8 million, respectively; under shared decision-making, about half the cohort remained susceptible.
• With lower vaccine uptake, projected chronic infections rose to 357 under deferred vaccination and 575 under shared decision-making.
• In a higher-risk scenario, projected infections were 1,700 with deferred vaccination and 2,192 with shared decision-making, compared with 255 under the base-case birth-dose strategy.
• Across 1,000 probabilistic sensitivity simulations, universal birth-dose vaccination consistently produced fewer projected chronic infections than the alternatives.

Interpretation:

The model projected more childhood chronic HBV infections and greater susceptibility by age 20 when universal vaccination at birth was replaced by delayed vaccination or shared clinical decision-making.

Limitations:

• Household and community transmission risks were uncertain, and the model did not distinguish risks by setting.
• The model did not account for partial immunity after incomplete vaccination, subsequent liver disease, mortality, onward transmission, or economic consequences.
• Projections assuming broad implementation of federal policy changes may not apply where state health departments or medical societies continue to recommend universal birth-dose vaccination.

Conclusion:

The authors noted that even a small number of additional childhood infections could have substantial clinical, public health, and economic effects.

Sources:

• Annals of Internal Medicine