What is the recommended Hepatitis B (HBV) vaccine timeline for infants and high-risk adults?

Hepatitis B Vaccine Timeline

For infants, administer the first dose within 12 hours of birth, the second dose at 1-2 months, and the third dose at 6 months; for adults, use the standard 0,1, and 6-month schedule. 1

Infant Vaccination Schedule

Standard Schedule for Infants Born to HBsAg-Negative Mothers

• First dose: At birth (before hospital discharge) 2
• Second dose: 1-2 months of age 1
• Third dose: 6 months of age (not before 24 weeks of age) 1

High-Risk Infants: Born to HBsAg-Positive Mothers

For infants ≥2,000 g birthweight:

• First dose + HBIG: Within 12 hours of birth (at separate anatomical sites) 1, 3
• Second dose: 1-2 months 1
• Third dose: 6 months 1
• Post-vaccination testing: At 9-15 months for HBsAg and anti-HBs 4

For infants <2,000 g birthweight:

• First dose + HBIG: Within 12 hours of birth 1
• Second dose: 1 month 1
• Third dose: 2-3 months 1
• Fourth dose: 6 months (the birth dose does not count toward the series for low birthweight infants) 1

Critical Timing for High-Risk Infants

Delaying the birth dose beyond 12 hours in infants born to HBsAg-positive mothers dramatically increases infection risk. 2, 4 HBIG efficacy decreases markedly if treatment is delayed beyond 48 hours. 3

Adult Vaccination Schedule

Standard Adult Schedule

• First dose: Day 0 1, 5
• Second dose: 1 month later 1, 5
• Third dose: 6 months after the first dose 1, 5

This schedule achieves >90% seroprotection in adults under 40 years. 4

Alternative Adult Schedules

Alternative schedules (0,1,4 months or 0,2,4 months) produce similar seroprotection rates to the standard schedule. 1, 4 However, longer intervals between the last two doses (e.g., 11 months) result in higher final antibody levels. 1

Accelerated Schedule for Rapid Protection

For individuals requiring immediate protection:

• Doses: 0,1,2, and 12 months 5, 4
• This provides earlier seroprotection while maintaining long-term immunity 4

Twinrix (Combined Hepatitis A and B) Accelerated Schedule

• Standard: 0,1, and 6 months 4
• Accelerated: 0,7, and 21-30 days, followed by a booster at 12 months 1, 5

Note: The 4-day grace period for early vaccine administration does not apply to the first 3 doses of Twinrix on the accelerated schedule. 1

Special Populations

Hemodialysis Patients and Immunocompromised Adults

• Dose: 40 μg (double the standard dose) 1, 5
• Schedule: 0,1, and 6 months with Recombivax HB OR 0,1,2, and 6 months with Engerix-B 1
• Monitoring: Annual anti-HBs testing with booster doses when levels fall below 10 mIU/mL 1, 4

Adolescents (11-15 Years)

A 2-dose schedule using adult formulation Recombivax HB at 0 and 4-6 months is an acceptable alternative. 1

Critical Minimum Intervals

Never restart the series if interrupted—simply continue where you left off. 1, 5, 4

• Between doses 1 and 2: Minimum 4 weeks 1, 5, 4
• Between doses 2 and 3: Minimum 8 weeks 1, 5, 4
• Between doses 1 and 3: Minimum 16 weeks 1, 5, 4
• Final infant dose: Not before 24 weeks of age 1, 4

Doses administered ≤4 days before the minimum interval are considered valid. 1, 4

Interrupted Schedules: Management Algorithm

If interrupted after dose 1:

• Give dose 2 as soon as possible 1, 4
• Give dose 3 at least 8 weeks after dose 2 and at least 16 weeks after dose 1 1, 4

If only dose 3 is delayed:

• Give dose 3 as soon as possible 1
• No maximum interval exists between doses 5, 4

Post-Vaccination Testing

Populations Requiring Testing

Testing should be performed 1-2 months after completing the series for: 1, 2

• Infants born to HBsAg-positive mothers (test for both HBsAg and anti-HBs at 9-15 months) 1, 4
• Healthcare personnel and public safety workers 1
• Hemodialysis patients 1
• HIV-infected persons 1
• Other immunocompromised persons 1
• Sex partners of HBsAg-positive persons 1

Interpretation

An anti-HBs level ≥10 mIU/mL indicates adequate protection. 1, 2

Common Pitfalls to Avoid

• Never restart the series if doses are delayed—there is no maximum interval between doses, and restarting wastes doses and delays protection 1, 5, 4
• Do not give the third dose before 16 weeks from the first dose, even if 8 weeks have passed since the second dose 1, 5, 4
• Do not give the final infant dose before 24 weeks of age, as this may compromise long-term immunity 1, 4
• Do not use standard adult doses in hemodialysis patients—they require 40 μg doses 1, 5, 4
• Do not use Heplisav-B or PreHevbrio in pregnant women, hemodialysis patients, or children due to insufficient safety data 5, 4
• Do not delay the birth dose beyond 12 hours for infants born to HBsAg-positive mothers, as this significantly increases infection risk 2, 4