What hepatitis B (HBV) vaccine is recommended for an adult undergoing chemotherapy?

Hepatitis B Vaccination for Adults Undergoing Chemotherapy

Adults undergoing chemotherapy should receive standard-dose hepatitis B vaccine (Engerix-B 20 μg or Recombivax HB 10 μg) in a 3-dose series at 0,1, and 6 months, with post-vaccination antibody titers checked 1-2 months after completion to ensure adequate seroprotection (anti-HBs ≥10 mIU/mL). 1

Vaccine Selection and Dosing

Use standard adult formulations during chemotherapy:

• Engerix-B: 20 μg at 0,1, and 6 months 1
• Recombivax HB: 10 μg at 0,1, and 6 months 1

The German Society for Hematology and Medical Oncology (DGHO) guidelines specifically state that hepatitis B vaccination is safe and immunogenic in patients younger than 60 years undergoing chemotherapy, with patients showing appropriate antibody responses during maintenance treatment and upon completion. 1

Critical Timing Considerations

Vaccination can be administered during chemotherapy cycles without waiting for specific timing within the cycle. 1 The ASCO 2024 guidelines emphasize there is no recommended optimal timing during treatment cycles for hepatitis B vaccination, unlike some other vaccines. 1

Key timing principles:

• Simultaneous administration of vaccination and chemotherapy is possible 1
• Earlier vaccination during chemotherapy is safe and may provide benefits 1
• Do not delay appropriate chemotherapy to complete vaccination series 1

Vaccines NOT Recommended for Immunocompromised Patients

Avoid Heplisav-B and PreHevbrio in cancer patients undergoing chemotherapy. 1 The 2022 ACIP guidelines explicitly state that safety and effectiveness of these newer vaccines have not been established in immunocompromised adults, and providers should use Engerix-B, Recombivax HB, or Twinrix for patients needing hepatitis B vaccination during cancer treatment. 1

Post-Vaccination Monitoring Protocol

Mandatory antibody testing is essential in this population:

• Check anti-HBs titers 1-2 months after completing the 3-dose series 1
• Protective level is anti-HBs ≥10 mIU/mL 1, 2
• If non-responsive (anti-HBs <10 mIU/mL), administer a second complete 3-dose series 1
• Recheck titers 1-2 months after the second series 1

The ASCO guidelines specifically note that hepatitis B surface antibody concentrations can be lower in patients who receive vaccine during chemotherapy, making post-vaccination testing particularly important. 1

Special Circumstances

For patients on hemodialysis with cancer:

• Use high-dose formulations: Recombivax HB 40 μg or Engerix-B 40 μg 1, 2
• Follow 0,1,6-month schedule (Engerix-B may use 0,1,2,6-month schedule) 1, 2
• Annual anti-HBs monitoring is recommended 2

Post-stem cell transplant patients:

• Wait 6-12 months after autologous stem cell transplantation before initiating hepatitis B vaccination 1
• Administer 3-dose series at that time 1

Common Pitfalls to Avoid

Do not use newer adjuvanted vaccines (Heplisav-B, PreHevbrio) in immunocompromised patients as they lack safety and efficacy data in this population. 1

Do not skip post-vaccination antibody testing in cancer patients, as response rates are lower than in healthy individuals and many will require revaccination. 1

Do not assume protection without serologic confirmation since chemotherapy significantly impairs vaccine responses. 1

Do not delay vaccination indefinitely waiting for "optimal" timing—vaccination during chemotherapy is safe and preferable to remaining unprotected. 1