What is the recommended hepatitis B (HBV) vaccination schedule for adults, particularly those at high risk of exposure, such as healthcare workers, individuals with high-risk sexual behavior, chronic liver disease, or human immunodeficiency virus (HIV) infection?

Hepatitis B Vaccination for Adults

All adults aged 19-59 years should receive hepatitis B vaccination, and adults ≥60 years with risk factors should also be vaccinated, using either a 2-dose Heplisav-B series (0,1 month) or a 3-dose series with traditional vaccines (0,1,6 months). 1

Universal Vaccination Recommendations

The Advisory Committee on Immunization Practices (ACIP) updated recommendations in 2022 to eliminate risk-based screening requirements for adults aged 19-59 years, making hepatitis B vaccination universal in this age group. 1 This shift removes barriers related to risk factor disclosure and is expected to increase vaccination coverage and decrease hepatitis B cases. 1

For adults ≥60 years:

• Vaccination is recommended if any risk factors are present 1
• Vaccination may be offered to those without known risk factors, with providers encouraged to proactively offer rather than wait for patient requests 1

High-Risk Groups Requiring Vaccination

Adults ≥60 years with the following risk factors should receive hepatitis B vaccination: 1

Sexual exposure risks:

• Sex partners of HBsAg-positive persons 1
• Sexually active persons not in long-term mutually monogamous relationships (>1 partner in previous 6 months) 1
• Persons seeking STI evaluation or treatment 1
• Men who have sex with men 1

Percutaneous/blood exposure risks:

• Current or recent injection drug use 1
• Household contacts of HBsAg-positive persons 1
• Healthcare and public safety workers with blood exposure risk 1
• Hemodialysis patients (in-center, home, peritoneal, or predialysis) 1

Medical conditions:

• HIV infection 1
• Hepatitis C infection 1
• Chronic liver disease (cirrhosis, fatty liver, alcoholic liver disease, autoimmune hepatitis, ALT/AST >2× upper limit of normal) 1
• Diabetes (at clinician's discretion) 1

Other populations:

• International travelers to countries with HBsAg prevalence ≥2% 1
• Incarcerated persons 1
• Residents and staff of developmental disability facilities 1

Standard Vaccination Schedules

Immunocompetent Adults ≥18 Years

Heplisav-B (preferred for efficiency): 1, 2

• 20 μg (0.5 mL) at 0 and 1 month
• Demonstrates superior seroprotection rates (~90%) compared to Engerix-B (70.5%-90.2%) 3, 4
• Do not use in pregnant women, hemodialysis patients, or children 2, 5

Recombivax HB: 1, 2

• 10 μg (1.0 mL) at 0,1, and 6 months

Engerix-B: 1, 2

• 20 μg (1.0 mL) at 0,1, and 6 months

PreHevbrio: 1, 2

• 10 μg (1.0 mL) at 0,1, and 6 months
• Do not use in pregnant women, hemodialysis patients, or children 2, 5

Twinrix (combined HepA-HepB): 1, 2

• Standard: 20 μg HepB component (1.0 mL) at 0,1, and 6 months
• Accelerated: 4 doses at 0 days, 7 days, 21-30 days, and 12 months 1, 2

Hemodialysis and Immunocompromised Adults ≥20 Years

Recombivax HB: 1, 2

• 40 μg (1.0 mL) at 0,1, and 6 months

Engerix-B: 1, 2, 6

• 40 μg (2.0 mL) at 0,1,2, and 6 months
• The 4-dose regimen produces 67% seroprotection in hemodialysis patients 6

Pregnant Women

Only use Engerix-B, Recombivax HB, or Twinrix for pregnant women requiring hepatitis B vaccination, as Heplisav-B and PreHevbrio lack sufficient pregnancy safety data. 1, 2, 5

Interrupted Vaccination Series

Critical principle: Never restart the series if interrupted. 1, 2, 5 Simply continue where you left off with the following minimum intervals:

• Between doses 1 and 2: ≥4 weeks 1, 2
• Between doses 2 and 3: ≥8 weeks 1, 2
• Between doses 1 and 3: ≥16 weeks 1, 2
• Doses administered ≤4 days before minimum interval are considered valid 1, 2

Pre-Vaccination Testing

Pre-vaccination serologic testing is not required and should not be a barrier to vaccination. 1 However, in populations with high rates of previous HBV infection, testing for HBsAg, anti-HBs, and anti-HBc may reduce costs by avoiding vaccination of already immune persons. 1

Testing interpretation: 1

• HBsAg positive = current infection
• Anti-HBs positive = immunity from vaccination or past infection
• Anti-HBc positive = previous or ongoing infection

Post-Vaccination Serologic Testing

Routine post-vaccination testing is not recommended for most adults. 2 However, testing for anti-HBs 1-2 months after series completion is recommended for: 2, 3

• Healthcare and public safety workers with blood exposure risk
• Hemodialysis patients
• Immunocompromised persons
• Sex partners of HBsAg-positive persons

Protective level: Anti-HBs ≥10 mIU/mL 2, 3

Management of Non-Responders

For adults who fail to achieve anti-HBs ≥10 mIU/mL after the initial series: 3

First-line approach:

• Administer Heplisav-B 2-dose series (if not previously used), which achieves ~90% seroprotection in non-responders 3

Alternative approach:

• High-dose Engerix-B: 40 μg at 0,1,2, and 6 months 3

After revaccination:

• Test anti-HBs 1-2 months after completing the series 3
• If still non-responsive after 6 total doses, consider the person a true non-responder 3
• True non-responders require counseling about susceptibility and need for HBIG prophylaxis after future exposures 3

Age-Related Considerations

Vaccine response declines with age: 2, 6

• Adults <40 years: >90% achieve protective antibody levels 2
• Adults ≥40 years: 88% achieve protective levels 6
• By age 60 years: only 75% achieve protection even after completing the full series 2

Other factors reducing vaccine response include smoking, obesity, and immunosuppression. 2

Common Pitfalls to Avoid

• Do not restart interrupted series—there is no maximum interval between doses 2, 5
• Do not use Heplisav-B or PreHevbrio in pregnant women, hemodialysis patients, or children 2, 5
• Do not assume serologic testing is mandatory—lack of testing should never delay vaccination 1
• Do not administer routine booster doses to immunocompetent persons who initially responded—immunologic memory persists even when anti-HBs levels decline 1