Liver Lineup: Navigating Hepatitis B Prevention After ACIP’s Birth Dose Shift

In this episode of Liver Lineup: Updates & Unfiltered Insights, hosts Nancy Reau, MD, and Kim Brown, MD, take on a recent consequential and controversial public health decision: the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices’ (ACIP) vote to remove the universal birth-dose hepatitis B vaccine recommendation for infants born to mothers who test negative for HBV.

The conversation centers around the December 5, 2025, ACIP recommendation, which shifts the long-standing universal birth dose to an individual-based decision when maternal testing is documented as negative. While newborns of mothers with positive or unknown HBV status should still receive the vaccine within 24 hours of birth, the committee’s vote effectively eliminates universal coverage for the broader infant population.

As transplant physicians who routinely manage the downstream consequences of chronic hepatitis B, Reau and Brown say this update is a reversal of decades of data and public health success. Reau begins by reflecting on the dramatic decline in HBV prevalence and chronic infection rates following the introduction of the universal birth dose in the 1990s. The vaccine, she notes, has functioned as one of the earliest and most effective “anti-cancer vaccines,” cutting the risk of hepatocellular carcinoma in populations around the world.

Brown adds a clinical lens drawn from transplantation, recounting the striking shift over her career: before widespread HBV vaccination, chronic HBV infection was a leading indication for liver transplantation. Today, thanks to vaccination and effective antiviral therapy, HBV-related transplants are rare and largely driven by hepatocellular carcinoma, not liver failure itself. For her, the new ACIP decision raises concern about reintroducing preventable infections into the population.

A key theme throughout the discussion is the danger of relying on perfect systems. While ACIP’s updated guidance assumes universal maternal screening and accurate documentation, Reau explains that real-world data do not align. In practice, HBV screening during pregnancy is inconsistently captured, results are not always transferred across systems, and as many as 1 in 5 pregnant individuals may have no documented HBV test. This creates a major vulnerability if the universal birth dose is no longer routine.

Reau and Brown also highlight the unique epidemiology of HBV: early-life exposure, not adult behavioral risk, is the primary driver of chronic infection. Household transmission, caregiver exposure, and contact with unscreened adults remain key pathways, even when maternal status is known. Delaying vaccination until 2 months of age offers no protection during this highest-risk window.

Brown underscores the lifelong consequences of early HBV acquisition. Even in the era of effective antivirals, chronic HBV infection remains a major cause of hepatocellular carcinoma and carries the risk of reactivation during immunosuppression. For these reasons, both hepatologists view prevention, not treatment, as the cornerstone of HBV control.

Despite ACIP’s intent to give parents and clinicians more individualized decision-making power, both experts worry about widening disparities in vaccine uptake, eroding decades of progress, and placing infants, especially those in under-resourced settings, at avoidable risk.

The episode closes with a call for continued education and advocacy. Reau and Brown encourage clinicians to remain clear-eyed about the evidence, discuss the implications of delayed vaccination with families, and work to uphold the public health gains that universal hepatitis B immunization has delivered for over 30 years.

Editors’ note: Relevant Disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal.

References

1. Brooks A. CDC Changes Infant Hepatitis B Vaccine Recommendation. HCPLive. December 5, 2025. Accessed December 10, 2025. https://www.hcplive.com/view/cdc-changes-infant-hepatitis-b-vaccine-recommendation

2. CDC. Achievements in Public Health: Hepatitis B Vaccination --- United States, 1982--2002. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5125a3.htm