A vaccine emergency-when to overrule parental refusal of vaccination at birth for prevention of vertical transmission of hepatitis B virus?

Hepatitis B virus (HBV) is a potentially chronic infection that can be transmitted from mother to child with the risk of developing cirrhosis, liver failure and hepatocellular carcinoma. There is a safe and effective vaccine to prevent vertical transmission that is recommended to be given as soon as possible after birth and within 24 hours.When a woman with HBV refuses the birth dose of HBV vaccine for her baby, infectious diseases and safeguarding teams are asked to provide urgent opinions on whether this crosses the threshold for triggering child protection mechanisms.We consider a low-infectivity HBV vertical transmission scenario where there is parental refusal of HBV vaccination and focus on ethical arguments for and against overruling parental refusal in the child's best interests. As an additional resource for clinical and safeguarding teams, we also include the anonymised transcript of the only available UK court judgement to our knowledge that addresses the issue of decline of HBV vaccine to prevent vertical transmission.We propose a dialogue process for managing scenarios where a pregnant woman with HBV has concerns about vaccinating her baby when born, which is the basis of the current UK Health Security Agency guidance.