Abstract
Despite three decades of recommendations, hepatitis B birth dose vaccination coverage remains suboptimal at 81.5% nationally, falling short of other routine immunizations and public health targets. This study examined implementation practices across five Washington, DC birthing hospitals through semi-structured interviews with 36 healthcare workers representing professional roles. While providers demonstrated strong support for vaccination, with 94% routinely recommending the birth dose for newborns, significant system-level barriers emerged that impede optimal delivery. Only 69% consistently recommended vaccination for premature infants, revealing concerning practice variability and knowledge gaps regarding weight-based guidelines. Critical infrastructure deficiencies included widespread unawareness of vaccination tracking systems (64% uncertain), complete absence of designated vaccine champions, minimal leadership engagement, and severely limited provider training - with only 19% receiving regular education on birth dose importance and 86% lacking training to address vaccine hesitancy. Electronic reminder systems were absent (17% utilization), despite proven effectiveness. Although parent education showed better implementation with literacy-appropriate materials and multi-modal communication strategies, the disconnect between robust provider support and weak institutional systems represents a fundamental implementation failure. Addressing these modifiable barriers through systematic quality improvement initiatives, enhanced monitoring infrastructure, and comprehensive workforce development could substantially improve vaccination coverage and advance perinatal hepatitis B elimination goals.