What is the recommended hepatitis A and hepatitis B (HBV) vaccine schedule for adults, including those with impaired liver function or weakened immune system?

Hepatitis B Vaccination Schedule for Adults

All adults aged 19-59 years should receive hepatitis B vaccination using a standard 3-dose schedule at 0,1, and 6 months (Recombivax HB, Engerix-B, PreHevbrio, or Twinrix) or a 2-dose schedule at 0 and 1 month (Heplisav-B only), with special high-dose regimens required for hemodialysis patients and immunocompromised individuals. 1

Standard Adult Vaccination Schedules

The 2022 ACIP guidelines represent a major shift by recommending universal hepatitis B vaccination for all adults aged 19-59 years, eliminating the previous risk-based approach that resulted in suboptimal coverage 1. For adults ≥60 years, vaccination may be given but is not universally recommended 1.

Standard-Dose Options for Immunocompetent Adults

Three-dose schedules (0,1,6 months):

• Recombivax HB: 10 μg (1.0 mL) per dose for adults ≥20 years 1, 2
• Engerix-B: 20 μg (1.0 mL) per dose for adults ≥20 years 1, 2
• PreHevbrio: 10 μg (1.0 mL) per dose for adults ≥18 years 1, 2
• Twinrix (combined HepA-HepB): 20 μg HBV component (1.0 mL) per dose for adults ≥18 years 1, 2

Two-dose schedule (0,1 month):

• Heplisav-B: 20 μg (0.5 mL) per dose for adults ≥18 years, achieving approximately 90% seroprotection compared to 70.5-90.2% with Engerix-B 1, 3, 2

Special Populations Requiring Modified Dosing

Hemodialysis Patients and Immunocompromised Adults

These patients require significantly higher doses and cannot use standard formulations. 1

High-dose regimens:

• Recombivax HB: 40 μg (1.0 mL) per dose on a 3-dose schedule at 0,1, and 6 months 1, 2
• Engerix-B: 40 μg (2.0 mL—administered as two 20 μg injections) per dose on a 4-dose schedule at 0,1,2, and 6 months 1, 2

Critical monitoring: Annual anti-HBs testing is recommended with booster doses when levels fall below 10 mIU/mL 3

Important limitation: Heplisav-B and PreHevbrio have not established safety and effectiveness in hemodialysis patients and should not be used in this population 1, 2, 4

Pregnant Women

Pregnant women requiring hepatitis B vaccination must receive only Engerix-B, Recombivax HB, or Twinrix. 1, 3, 2, 4

Heplisav-B and PreHevbrio have insufficient data on vaccine-associated risks in pregnancy and should be avoided 1, 3, 2, 4. Data on effects on breastfed infants and milk production are also lacking for these newer formulations 1.

Patients with Chronic Liver Disease

Adults with impaired liver function (including cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, or ALT/AST >2× upper limit of normal) should receive standard-dose hepatitis B vaccination 1. These patients are specifically identified as a priority group for vaccination due to increased risk of severe outcomes from HBV infection 1.

Accelerated Schedules for Rapid Protection

When faster protection is needed (e.g., imminent travel, recent exposure risk):

Twinrix accelerated schedule: 4 doses at 0 days, 7 days, 21-30 days, and 12 months 1, 3, 2

Engerix-B accelerated schedule: 4 doses at 0,1,2, and 12 months 3, 2

The accelerated schedules provide earlier seroprotection but require the final dose at 12 months for long-term protection 2. With traditional 3-dose vaccines, 30-55% achieve protection after dose 1,75% after dose 2, and >90% after dose 3 3.

Critical Dosing Intervals and Interrupted Schedules

Minimum Intervals Between Doses

These intervals must be respected to ensure adequate immune response: 1, 3, 4

• Minimum 4 weeks between doses 1 and 2
• Minimum 8 weeks between doses 2 and 3
• Minimum 16 weeks between doses 1 and 3

Doses administered ≤4 days before the minimum interval are considered valid 1, 3, 2. However, this 4-day grace period does not apply to the first 3 doses of Twinrix due to its unique accelerated schedule 1.

Managing Interrupted Series

If the vaccination schedule is interrupted, never restart the series—simply continue where you left off. 1, 3, 2, 4 This is one of the most important principles to avoid wasting doses and delaying protection.

Specific guidance for interrupted 3-dose series: 1, 3

• If interrupted after dose 1: Give dose 2 as soon as possible, then dose 3 at least 8 weeks after dose 2
• If only dose 3 is delayed: Give it as soon as possible
• The final dose must be administered ≥8 weeks after dose 2 AND ≥16 weeks after dose 1

There is no maximum interval between doses—longer intervals do not compromise final immunogenicity and may actually result in higher antibody titers 3, 5.

Hepatitis A Vaccination Considerations

While the question asks about hepatitis vaccines broadly, hepatitis A vaccination follows different principles and is not universally recommended for all adults like hepatitis B 1.

Use Twinrix (combined HepA-HepB) only when both vaccines are indicated: 3, 2

• International travelers to endemic regions
• Men who have sex with men at risk for both infections
• Persons with chronic liver disease needing both vaccines
• Injection drug users

Do not use Twinrix solely for hepatitis B protection when hepatitis A is not indicated, as this exposes patients to unnecessary hepatitis A antigen 3.

Pre-Vaccination Testing

Pre-vaccination serologic testing for HBsAg, anti-HBs, and anti-HBc can identify those already immune but is not required 1, 2. Lack of access to serologic testing should never be a barrier to vaccination, especially in hard-to-reach populations 1. The presence of anti-HBs indicates immunity from either vaccination or prior infection 1.

Common Pitfalls to Avoid

• Never restart an interrupted series—this wastes doses and delays protection 1, 3, 2, 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 use standard adult doses in hemodialysis patients—they require 40 μg doses 1, 3, 2
• Do not use Heplisav-B or PreHevbrio in pregnant women, hemodialysis patients, or children 1, 3, 2, 4
• Do not use Twinrix when only hepatitis B protection is needed 3
• Do not assume testing is required before vaccination—proceed with vaccination if testing is not feasible 1, 2

Long-Term Protection

Vaccine-induced immunity persists for >30 years in immunocompetent individuals 3. The standard 0,1,6-month schedule produces protective antibody response in >90% of adults under 40 years, though response rates decline with age 3. Schedules with longer intervals between the last two doses (4-6 months) result in higher final antibody titers compared to shorter intervals 3, 5.