The economic and health consequences of shared clinical decision-making for hepatitis B birth dose vaccination

In December 2025, the Advisory Committee on Immunization Practices recommended individual-based decision-making-termed shared clinical decision-making (SCDM) on CDC schedules-for hepatitis B (HepB) birth-dose vaccination in infants of mothers documented as HBsAg-negative at delivery. We evaluated projected economic, health, and distributional consequences for the 2026 US birth cohort.

A hybrid decision tree-Markov cohort model took the societal perspective over a lifetime horizon for 3.6 million 2026 US births, under three coverage-decline scenarios (10-, 20-, and 30-percentage-point). Costs (2026 US dollars) and outcomes were discounted 3% annually. Outcomes included costs, infections, deaths, quality-adjusted life years (QALYs), and equity impacts by insurance, race/ethnicity, hospital type, and geography. Probabilistic sensitivity analysis used 10,000 iterations; reporting followed CHEERS 2022.

Under the base-case 20-percentage-point decline, SCDM was projected to produce approximately 44 additional acute infections, 8 additional chronic HBV cases, 2 additional HBV-related deaths (incomplete-linkage scenario), and 56 discounted QALYs lost per cohort. Assuming incremental counseling time for all policy-sensitive births, SCDM generated approximately $301 million in net societal cost-driven principally by provider counseling opportunity cost, not disease treatment-and was dominated by universal vaccination. With counseling time assigned zero cost, SCDM remained less effective but less costly, implying approximately $0.7 million per QALY to retain universal vaccination. Modeled burdens concentrated among Medicaid/CHIP and safety-net populations.

This early assessment used scenario-based coverage-decline, counseling-time, mortality, and completion assumptions as post-policy data were unavailable; results are projections, not observations.

Moving from universal birth-dose vaccination to SCDM was projected to reduce timely vaccination and increase preventable infections across all scenarios. The societal-cost conclusion hinged on whether SCDM imposed counseling-time burden at scale, whereas the unfavorable health-effect direction was robust. Postimplementation evidence on coverage, counseling, completion, and linkage to care is needed before treating SCDM as low-cost or low-risk.