What is the recommended hepatitis B vaccination schedule for a healthy adult patient with no significant past medical history?

Hepatitis B Vaccination for Healthy Adults

All healthy adults aged 19-59 years should receive hepatitis B vaccination using one of several approved schedules, with the standard 3-dose series (0,1, and 6 months) being most common, or the 2-dose Heplisav-B series (0 and 1 month) offering a faster completion option. 1, 2

Universal Recommendation for Adults

The Advisory Committee on Immunization Practices (ACIP) issued updated 2022 guidelines establishing universal hepatitis B vaccination for all adults aged 19-59 years, eliminating the previous requirement for risk factor assessment. 1 This represents a major shift from risk-based vaccination to a universal approach, removing barriers related to risk factor screening and disclosure. 1

Standard Vaccination Schedules

Three-Dose Regimens

For adults ≥18 years, several 3-dose options are available: 2

• Recombivax HB: 10 μg (1.0 mL) at 0,1, and 6 months 2
• Engerix-B: 20 μg (1.0 mL) at 0,1, and 6 months 2, 3
• PreHevbrio: 10 μg (1.0 mL) at 0,1, and 6 months 2

The standard 0,1, and 6-month schedule produces seroprotection rates of 96-99% one month after the third dose, with geometric mean titers (GMTs) ranging from 2,204 to 4,023 mIU/mL depending on the vaccine and population. 3, 4

Two-Dose Regimen

Heplisav-B offers a streamlined 2-dose schedule: 20 μg (0.5 mL) at 0 and 1 month. 2 This vaccine demonstrates superior seroprotection rates of approximately 90% compared to 70.5-90.2% with Engerix-B in clinical trials, making it an excellent choice for faster series completion. 5

Accelerated Schedules

For individuals requiring rapid protection, an accelerated 4-dose schedule can be used: 0,1,2, and 12 months. 2, 3 This provides earlier seroconversion (99% by month 3) but requires the fourth dose at 12 months for long-term protection. 3 The Twinrix combined hepatitis A and B vaccine can also be given on an accelerated schedule of 0 days, 7 days, 21-30 days, and 12 months. 2

Important Clinical Considerations

Interrupted Schedules

If the vaccination schedule is interrupted, never restart the series—simply continue where you left off. 2, 5 The second and third doses should be separated by at least 8 weeks, with the final dose administered at least 8 weeks after the second dose and at least 16 weeks after the first dose. 2 Vaccine doses administered ≤4 days before the minimum interval are considered valid. 2

Pregnancy Considerations

Pregnant women requiring hepatitis B vaccination should receive only Engerix-B, Recombivax HB, or Twinrix, as Heplisav-B and PreHevbrio have insufficient safety data in pregnancy. 2

Pre-Vaccination Testing

Pre-vaccination serologic testing is not required and should not be a barrier to vaccination. 2 However, in populations with high rates of previous HBV infection, testing for HBsAg, anti-HBs, and anti-HBc can be performed concomitantly with the first dose to identify those already immune and reduce costs. 1

Documentation Requirements

Providers should only accept dated records as evidence of prior hepatitis B vaccination. 1 Persons who have completed a vaccination series at any point or who have a history of HBV infection should not receive additional vaccination, although receiving additional doses is not harmful. 1

Common Pitfalls to Avoid

• Do not restart the series if interrupted—this is the most common error in practice. 2, 5
• Do not use Heplisav-B or PreHevbrio in pregnant women, hemodialysis patients, or children due to insufficient safety data or lack of approval. 2
• Do not delay vaccination while attempting to assess risk factors in adults aged 19-59 years, as universal vaccination is now recommended. 1
• Do not assume lack of documentation means lack of immunity—consider serologic testing in uncertain cases rather than automatically revaccinating. 1

Expected Immunologic Response

With the standard 0,1, and 6-month schedule using Engerix-B 20 μg, seroprotection rates reach 79% at month 6 and 96% at month 7, with a GMT of 2,204 mIU/mL among seroconverters. 3 The timing of the third dose significantly impacts antibody response—longer intervals between the second and third doses produce higher GMTs and more robust long-term immunity. 6, 7