What is the recommended hepatitis A and B vaccination schedule?

Hepatitis B Vaccination Schedule

For most populations, administer hepatitis B vaccine at 0,1, and 6 months, which achieves >90% seroprotection after the third dose. 1, 2

Infants and Children

Newborns

• All infants should receive the first dose within 12 hours of birth, before hospital discharge 2
• For infants born to HBsAg-negative mothers: administer doses at birth, 1-2 months, and 6 months 2
• For infants born to HBsAg-positive mothers: give the first dose within 12 hours of birth PLUS hepatitis B immune globulin (HBIG), then at 1-2 months and 6 months 2, 3
• Delaying the birth dose beyond 12 hours in HBsAg-positive mothers significantly increases infection risk 2, 3
• The final dose must not be given before 24 weeks of age, regardless of when earlier doses were administered 3, 4

Children and Adolescents (Previously Unvaccinated)

• Standard schedule: 3 doses at 0,1, and 6 months 2, 4
• Alternative 2-dose schedule for adolescents aged 11-15 years: adult formulation of Recombivax HB (10 μg) at 0 and 4-6 months 1, 2, 4

Adults

Standard Adult Schedule

• Three doses at 0,1, and 6 months for adults ≥18 years 2, 3, 4
• After dose 1: 30-55% achieve protective antibody levels 1, 3
• After dose 2: 75% achieve protection 1, 3
• After dose 3: >90% achieve protection 1, 3

Alternative Adult Schedules

• Accelerated schedule: 0,1,2, and 12 months (Engerix-B) for rapid protection 3, 4
• Alternative schedules at 0,2, and 4 months produce similar seroprotection rates 3
• Longer intervals between the last two doses (≥4 months) result in higher final antibody titers 3, 5

Heplisav-B (2-Dose Schedule)

• Adults ≥18 years: two doses (20 μg each) separated by 1 month 1
• Achieves approximately 90% seroprotection compared to 70.5-90.2% with Engerix-B 1, 3
• Do not use in infants, children, adolescents, pregnant women, or hemodialysis patients 1, 3

Special Populations

Hemodialysis and Immunocompromised Patients

• Administer higher doses: 40 μg of Recombivax HB or 40 μg of Engerix-B (two 1.0-mL doses at one site) 1, 3, 4
• Schedule: 0,1, and 6 months (Recombivax HB) or 0,1,2, and 6 months (Engerix-B) 1, 4
• Perform annual anti-HBs testing with booster doses when levels fall below 10 mIU/mL 2, 3, 4
• Post-vaccination testing recommended 1-2 months after completing the series 2, 4

Pregnant Women

• Use only Engerix-B, Recombivax HB, or Twinrix 3
• Do not use Heplisav-B or PreHevbrio due to insufficient safety data in pregnancy 3

Minimum Dosing Intervals

Critical timing requirements to ensure adequate immune response:

• Minimum interval between doses 1 and 2: 4 weeks 2, 3, 4
• Minimum interval between doses 2 and 3: 8 weeks 2, 3, 4
• Minimum interval between doses 1 and 3: 16 weeks 2, 3, 4
• Doses given ≤4 days before the minimum interval are considered valid 3, 4

Interrupted Schedules

If the vaccination series is interrupted, do not restart—simply continue where you left off 3, 4

• If interrupted after dose 1: give dose 2 as soon as possible, then dose 3 at least 8 weeks after dose 2 3
• Increasing intervals between doses has little effect on final immunogenicity 3
• Vaccine-induced immunity persists for >30 years 1, 3

Combined Hepatitis A and B Vaccine (Twinrix)

Indications

• Use Twinrix only for patients requiring protection against both hepatitis A and B 3
• Appropriate for international travelers to endemic regions, men who have sex with men at risk for both infections, and persons with chronic liver disease 3

Twinrix Schedules

• Standard schedule: 3 doses at 0,1, and 6 months 3, 6
• Accelerated schedule for rapid protection: 4 doses at days 0,7, and 21-30, followed by a booster at 12 months 3
• At month 2, >99% are seropositive for anti-HAV and 84% are protected against hepatitis B 6
• After completion, nearly all vaccinees have protective titers against both viruses 6

Post-Vaccination Testing

Routine testing after vaccination is unnecessary for immunocompetent persons 1

Testing Recommended For:

• Infants born to HBsAg-positive mothers (test at 9-15 months for HBsAg and anti-HBs) 2, 3
• Healthcare personnel 2
• Hemodialysis patients 2
• HIV-infected persons 2
• Other immunocompromised persons 2
• Perform testing 1-2 months after completing the vaccination series 2
• Anti-HBs level ≥10 mIU/mL indicates adequate protection 2

Common Pitfalls to Avoid

• Never restart the series if interrupted—this wastes doses and delays protection 3, 4
• Do not give the third dose before 16 weeks from the first dose, even if 8 weeks have passed since the second dose 3, 4
• Do not give the final infant dose before 24 weeks of age, as this may compromise long-term immunity 3, 4
• Do not use standard adult doses in hemodialysis patients—they require 40 μg doses 1, 3, 4
• Do not use Twinrix simply for hepatitis B vaccination when the patient has no indication for hepatitis A protection 3
• Do not administer doses at shorter-than-recommended intervals, as this results in suboptimal immune response 4