What are the Hepatitis B (Hep B) vaccine options and schedules?

Hepatitis B Vaccine Options and Schedules

For adults aged 19-59 years, the CDC now recommends universal hepatitis B vaccination, with multiple vaccine options available including traditional 3-dose series (Recombivax HB, Engerix-B, PreHevbrio) or the more convenient 2-dose Heplisav-B series. 1

Available Vaccine Products for Adults (≥18 years)

Standard 3-Dose Vaccines

• Recombivax HB: 10 μg (1.0 mL) administered at 0,1, and 6 months for adults ≥20 years 1, 2
• Engerix-B: 20 μg (1.0 mL) administered at 0,1, and 6 months for adults ≥20 years 1, 2, 3
• PreHevbrio: 10 μg (1.0 mL) administered at 0,1, and 6 months (ACIP-recommended in 2022) 1, 2

Accelerated 2-Dose Option

• Heplisav-B: 20 μg (0.5 mL) administered at 0 and 1 month for adults ≥18 years 1, 2
• This vaccine achieves approximately 90% seroprotection compared to 70.5-90.2% with Engerix-B, making it the preferred choice for rapid protection and improved compliance 4, 5

Combination Vaccine

• Twinrix (HepA-HepB): 20 μg HBsAg (1.0 mL) for adults ≥18 years 1
  • Standard schedule: 0,1, and 6 months 1, 4
  • Accelerated schedule: 0 days, 7 days, 21-30 days, and 12 months 1, 4
  • Reserve Twinrix only for patients requiring both hepatitis A and B protection (travelers to endemic regions, men who have sex with men, chronic liver disease patients) 4

Adolescent Vaccination Options (Ages 11-19 years)

• Recombivax HB for ages 11-15: 10 μg (0.5 mL) in either a 2-dose schedule (0 and 4-6 months) OR 3-dose schedule (0,1, and 6 months) 1, 2
• Engerix-B for ages 11-19: 10 μg (0.5 mL) at 0,1, and 6 months 1, 2, 3
• For ages ≥16: Switch to adult formulations if the 2-dose adolescent series was started 1

Special Populations

Hemodialysis and Immunocompromised Adults (≥20 years)

• Recombivax HB: 40 μg (1.0 mL) at 0,1, and 6 months (3-dose series) 1, 2, 4
• Engerix-B: 40 μg (2.0 mL) at 0,1,2, and 6 months (4-dose series) 1, 2, 3
• Annual anti-HBs testing is mandatory with booster doses when levels fall below 10 mIU/mL 4
• Do not use Heplisav-B or PreHevbrio as safety and effectiveness have not been established in hemodialysis patients 1, 2

Pregnant Women

• Use only Engerix-B, Recombivax HB, or Twinrix for pregnant women requiring hepatitis B vaccination 1, 2
• Avoid Heplisav-B and PreHevbrio due to insufficient data on vaccine-associated risks in pregnancy 1, 2

Critical Scheduling Principles

Interrupted Series Management

• Never restart the series if interrupted—simply continue where you left off 2, 4
• If interrupted after dose 1: give dose 2 as soon as possible, then dose 3 at least 8 weeks after dose 2 2, 4
• If only dose 3 is delayed: administer as soon as possible 1

Minimum Intervals

• Dose 1 to Dose 2: minimum 4 weeks 1, 4
• Dose 2 to Dose 3: minimum 8 weeks 1, 2, 4
• Dose 1 to Dose 3: minimum 16 weeks 1, 4
• Doses given ≤4 days before the minimum interval are considered valid 1, 2, 4

Alternative Accelerated Schedules

For Rapid Protection (Post-Exposure, Recent Exposure, High-Risk Travel)

• Engerix-B: 0,1,2, and 12 months 4, 3
• Twinrix: 0,7, and 21-30 days, followed by 12 months 1, 4
• These schedules achieve 99% seroprotection by month 3 3

Prevaccination Testing Considerations

• Testing is not required before vaccination, and lack of access to serologic testing should not be a barrier 1
• When performed, prevaccination testing includes HBsAg, anti-HBs, and anti-HBc 1
• In populations difficult to reach, proceed with vaccination without testing 1

Common Pitfalls to Avoid

• Do not restart an interrupted series—this wastes doses and delays protection 2, 4
• Do not give dose 3 before 16 weeks from dose 1, even if 8 weeks have passed since dose 2 4
• Do not use standard adult doses in hemodialysis patients—they require 40 μg doses 2, 4
• Do not use Heplisav-B or PreHevbrio in pregnant women, children, or hemodialysis patients 1, 2
• Do not use Twinrix for hepatitis B-only indications—this exposes patients to unnecessary hepatitis A antigen 4
• Do not administer in the gluteal region—use deltoid in adults or anterolateral thigh in infants, as gluteal injections result in suboptimal response 3

Age-Related Response Considerations

• Adults over 40 years have lower seroprotection rates (88% vs. >96% in younger adults) and lower GMTs (610 mIU/mL vs. higher titers in younger adults) 3
• After the standard 3-dose series, >90% of adults under 40 achieve protective antibody response, but this declines with advancing age 4
• For older adults and vaccine non-responders, consider Heplisav-B due to its superior immunogenicity 5