Downward Trends in Neonatal Hepatitis B Vaccine Uptake: 2021 to 2025

Hepatitis B virus (HBV) is a leading cause of pediatric liver disease.1 Following the recommendation for universal neonatal HBV vaccination, acute pediatric HBV in the United States decreased by 99%.2 The safety and efficacy of HBV vaccination are well established3,4; however, recent public debate has questioned the need for neonatal administration.1 A recent study of US electronic health records identified decreasing neonatal HBV vaccination rates after a peak in February 2023.5 Noting a decline in HBV vaccine uptake at a university hospital, we aimed to quantify the magnitude and timing of this trend.We performed a descriptive analysis of HBV vaccine uptake among neonates admitted to a tertiary academic medical center on Long Island, New York from 2021 to 2025. Stony Brook University Hospital Level 1 Well Newborn Nursery (NBN) has approximately 3000 annual admissions and requires parental consent for HBV vaccination.A monthly report identified neonates discharged from the NBN. We calculated the proportion who received HBV vaccine within 2 days of birth (birth date counted as day 0). We excluded infants discharged from the neonatal intensive care unit (NICU) and with birth weight greater than 2000 g, for whom HBV vaccination may not be indicated at birth. The data abstraction protocol was unchanged throughout the study period. Aside from one educational refresher for NBN staff in 2023, no quality improvement interventions or policy changes occurred during the study. This work was exempt from institutional review board review because data were collected for quality improvement purposes.All statistical analyses were performed using R statistical software (v.4.2.0). Segmented regression analysis using the segmented package (v.2.1–4) identified an optimal breakpoint in the monthly vaccination rate. A generalized linear model with a binomial family and logit link function was used to model the relationship between time (month) and the log odds of vaccination. Once the breakpoint was established, separate logistic regression models were fitted to the 2 resulting periods to compare the temporal trend of the vaccination rate. Regression structural stability was validated by sensitivity analysis (Supplemental Material). A P value less than .05 was considered statistically significant.During the 58-month period, 11 854 (78.3%) of 15 130 neonates discharged from the NBN received HBV vaccine by 2 days old. We identified June 2024 plus or minus 1 month as the point of maximum change in monthly HBV vaccination rate (Figure 1). The data were subsequently divided into 2 distinct periods: period 1 (January 2021 to June 2024, 42 months) and period 2 (July 2024 to October 2025, 16 months). The average HBV vaccination rate in period 1 was 81.5% ± 0.4 (SE) but decreased to 70.0% ± 1.9 (SE) during period 2, a highly statistically significant shift (P < .001).The vaccination rate remained stable from winter 2021 to summer 2024; the logistic regression model showed no statistically significant temporal trend during this period (β = −0.001 log odds per month; P = .699). After summer 2024, the HBV vaccination rate steeply declined (β = −0.074 log odds per month; P < .001), reaching a nadir of 56% in October 2025, a decrease of 25 percentage points compared with the period 1 average.We identified a striking decrease in neonatal HBV vaccine uptake after years of stability. Vaccine hesitancy rates have increased since the COVID-19 pandemic and may have contributed to our findings.6,7 Parents may prefer fewer preventive injections, potentially prioritizing respiratory syncytial virus (RSV) over HBV,8 although the breakpoint we identified predated seasonal availability of the RSV monoclonal antibody. Alternatively, HBV vaccination may be declined at birth but accepted during early pediatric visits, although series completion becomes substantially less likely.9 Rothman et al5 reported a smaller 10 percentage point decrease, likely reflecting differences in data sources, scale, and cohort definitions. Although neonatal HBV vaccination is safe,3,4 the perception of vaccines as unsafe or unnecessary is associated with decreased uptake.6 In a time of increasing public health skepticism,1,6,7,10 it is important to avoid messaging that reinforces scientifically unsupported vaccine misinformation.We did not investigate why vaccination rates decreased and did not evaluate NICU or outpatient vaccinations. We measured vaccine delivery, rather than consent rates. The findings of this single-center study are impacted by local context, including birthing hospital type, consent practices, patient demographics, and institutional culture, limiting generalizability. Additional limitations include the lack of demographic data and short post-breakpoint follow-up period.Identification of HBV vaccination barriers and evidence-based interventions are urgently needed to limit future cases of this preventable disease.10