Missed children’s Hepatitis B vaccinations - case study


The Screening and Immunisation Team operate a failsafe designed to ensure that children born to Hepatitis B positive mothers are appropriately vaccinated in a timely fashion to reduce the risk of them contracting chronic Hepatitis B.


Whilst CHIS schedule these children, there are still occasions when children miss vital early vaccinations . Practice reception/admin staff play a key role in noting these children when hospital discharge notes come in and when movers in register.  Hence the Screening and Immunisation Team delivered a WebEx training session in the summer for admin staff.


  • One of the practices who participated in the WebEx implemented recommendations and ran searches to check records of patients coded as female, pregnant and Hep B positive. This brought up a family whose 4 children had not completed the post exposure vaccination schedule or been tested for Hepatitis B surface antigen – HBsAg.  
  • Further searches identified another family with 5 children born to Hep B positive mother with incomplete vaccinations.
  • The practice is now running regular searches to anticipate the need for infants coming in requiring off schedule post exposure vaccines and expedited registration to facilitate this.

Recommended Practice failsafe procedures to ensure child receives timely Hep B vaccinations:

1.     Weekly searches for pregnant women who are diagnosed with Hepatitis B linking to their delivery date.

2.     All newborn baby hospital discharge documents to be thoroughly reviewed (regardless of registration) and, where Hepatitis B vaccination indicated, link with mother and call for vaccination at 4 weeks

3.     When infant registered, check if 4 week dose has been given/is scheduled

4.     6-8 week infant check – has infant received 4 week vaccination?

For more information re the vaccination pathway for children born to Hepatitis B positive mothers see: https://www.england.nhs.uk/south/info-professional/public-health/immunisations/hepatitis-b/