What vaccinations should be administered to a newborn when the mother is Hepatitis B surface antigen (HBsAg) positive, including Hepatitis B (Hep B), Bacillus Calmette-Guérin (BCG), and Polio vaccines?

Vaccination for Newborns of HBsAg-Positive Mothers

Yes, when the mother is HBsAg-positive, give hepatitis B vaccine and HBIG within 12 hours of birth; BCG and polio vaccines can be administered according to standard schedules without interference from hepatitis B immunoprophylaxis. 1

Hepatitis B Immunoprophylaxis (Critical - Within 12 Hours)

All infants born to HBsAg-positive mothers must receive both hepatitis B vaccine AND hepatitis B immune globulin (HBIG) within 12 hours of birth, administered at different injection sites (e.g., separate limbs). 1

Specific Dosing:

• Hepatitis B vaccine: Single-antigen formulation only for birth dose (10 mcg for infants) 1
• HBIG: 0.5 mL administered intramuscularly at a separate site from the vaccine 1, 2
• Timing is critical: Efficacy decreases markedly if treatment is delayed beyond 48 hours 2

Complete Vaccine Series:

• Second dose at 1-2 months of age 1
• Third dose at 6 months of age 1
• Final dose should not be administered before 24 weeks (164 days) of age 1

Special Consideration for Preterm Infants:

• For infants weighing <2,000 grams, the birth dose does NOT count toward the vaccine series 1
• These infants require 4 total doses (birth dose plus 3 additional doses starting at 1 month of age) 1

BCG and Polio Vaccines - Safe to Administer

Hepatitis B immune globulin administered at birth does not interfere with oral polio vaccine or other routine childhood vaccines administered at 2 months of age. 2

Key Points:

• BCG vaccine can be given according to your local immunization schedule 2
• Polio vaccine (whether oral or inactivated) can be administered per routine schedule 2
• No delay or modification of standard childhood immunizations is required 2

Post-Vaccination Testing (Mandatory)

All infants born to HBsAg-positive mothers require postvaccination serologic testing at 9-12 months of age (or 1-2 months after completing the vaccine series). 1, 3

Testing Protocol:

• Test for both HBsAg and anti-HBs 1
• Do NOT test before 9 months of age to avoid detecting passive anti-HBs from HBIG 1
• Protective level is anti-HBs ≥10 mIU/mL 1

Management Based on Results:

• HBsAg-negative with anti-HBs ≥10 mIU/mL: Protected, no further management needed 1
• HBsAg-negative with anti-HBs <10 mIU/mL: Revaccinate with single dose and retest 1-2 months later; if still inadequate, complete second 3-dose series 1
• HBsAg-positive: Infant is infected, refer for appropriate hepatitis B management 1

Common Pitfalls to Avoid

Critical Timing Error:

• Never delay hepatitis B vaccine and HBIG beyond 12 hours of birth - this significantly increases infection risk 1, 4
• The 12-hour window is absolute for maximum protection 1

Vaccine Selection Error:

• Only use single-antigen hepatitis B vaccine for the birth dose - combination vaccines (like Pediarix) are NOT appropriate at birth 1
• Combination vaccines may be used for subsequent doses after 6 weeks of age 1

Testing Timing Error:

• Do not test before 9 months of age - this will detect passive antibody from HBIG rather than vaccine response 1

Breastfeeding Misconception:

• Breastfeeding is safe and can begin immediately after birth once the infant receives appropriate immunoprophylaxis 1

Evidence Quality Note

The recommendations are based on high-quality ACIP guidelines from 2018 1, which represent the most current and authoritative guidance. These guidelines supersede earlier 2005 recommendations 1 but maintain the same core principles. Research evidence consistently demonstrates that combined passive-active immunoprophylaxis prevents perinatal transmission in >95% of cases when administered properly 5, 6.