What is the recommended hepatitis B vaccination schedule for adults?

Adult Hepatitis B Vaccination Schedule

For adults aged 18 years and older, use either the 2-dose Heplisav-B series (0 and 1 month) or the traditional 3-dose series with Engerix-B or Recombivax HB (0,1, and 6 months). 1, 2

Standard Vaccination Options

Two-Dose Schedule (Preferred for Completion Rates)

• Heplisav-B: 20 μg (0.5 mL) at 0 and 1 month for adults ≥18 years provides rapid seroprotection and significantly higher series completion rates (60.5% vs 32.3% at 1 year) compared to 3-dose vaccines 2, 3
• The minimum interval between the two Heplisav-B doses is 4 weeks 2
• Do not use Heplisav-B in pregnant women due to insufficient safety data 1, 2

Three-Dose Schedules

• Engerix-B: 20 μg (1.0 mL) at 0,1, and 6 months for adults ≥20 years achieves 96% seroprotection at month 7 with GMT of 2,204 mIU/mL 4
• Recombivax HB: 10 μg (1.0 mL) at 0,1, and 6 months for adults ≥20 years 2
• PreHevbrio: 10 μg (1.0 mL) at 0,1, and 6 months for adults ≥18 years, but avoid in pregnancy 2

Alternative Schedules for Specific Situations

Accelerated Schedule for Rapid Protection

• Administer doses at 0,1,2, and 12 months when immediate protection is needed (e.g., recent exposure, imminent travel to endemic areas) 2, 5
• This provides 99% seroprotection by month 3, but the fourth dose at month 12 is essential for long-term protection 4, 5
• The GMT after the fourth dose (9,163 mIU/mL) is substantially higher than after three doses alone 4

Alternative Intervals

• 0,1, and 4 months OR 0,2, and 4 months produce similar seroprotection rates to the standard 0,1,6-month schedule 2
• Longer intervals between doses (0,1,12 months) result in higher antibody titers (GMT 345.78 mIU/mL) compared to shorter intervals 6, 5

Special Populations

Hemodialysis and Immunocompromised Patients

• Engerix-B: 40 μg (2.0 mL) at 0,1,2, and 6 months achieves 67% seroprotection with GMT of 93 mIU/mL 2, 4
• Recombivax HB: 40 μg (1.0 mL) at 0,1, and 6 months using the high-dose formulation 2
• These patients have substantially lower response rates than healthy adults, reflecting impaired immune response 2

Pregnant Women

• Use only Engerix-B, Recombivax HB, or Twinrix during pregnancy 1, 2, 7
• Heplisav-B and PreHevbrio lack safety data in pregnancy and should be avoided 1, 2

HIV-Infected Adults

• Either 40 μg Recombivax HB (3-dose schedule) OR 40 μg Engerix-B (4-dose schedule at 0,1,2,6 months) 2
• Test for anti-HBs response 1-2 months after the third dose 2

Managing Interrupted Series

Critical Principle: Never Restart

• If the vaccination schedule is interrupted, continue where you left off—never restart the series 2, 8, 7
• There is no maximum interval between doses 8

Minimum Intervals

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

Switching Between Vaccine Products

• When feasible, use the same manufacturer's vaccine to complete the series 1
• However, vaccination should not be delayed if the original vaccine is unavailable 1
• For Heplisav-B specifically: a valid 2-dose series requires 2 doses of Heplisav-B with at least 4 weeks between them—it cannot be substituted mid-series 1

Post-Vaccination Testing

Who Needs Testing

• Routine post-vaccination serologic testing is NOT recommended for most adults 7
• Test anti-HBs 1-2 months after series completion for: 2, 7
  • Healthcare and public safety workers with blood exposure risk
  • Hemodialysis patients
  • Immunocompromised persons
  • Sex partners of HBsAg-positive persons
• Protective level is anti-HBs ≥10 mIU/mL 2

Managing Non-Responders

• If anti-HBs <10 mIU/mL after the first complete series, administer a second complete series (either 2-dose Heplisav-B or high-dose Engerix-B) and retest 7

Age-Related Considerations

• Adults <40 years achieve >90% protective antibody levels after completing the series 2, 7
• Adults ≥40 years achieve 88% protective levels, with declining response rates and lower GMTs (610 mIU/mL vs higher titers in younger adults) 4
• By age 60, only 75% achieve protective antibody levels even after completing the full series 2

Universal Vaccination Recommendations

• All adults aged 19-59 years should receive hepatitis B vaccination regardless of risk factors, per 2022 ACIP guidelines 7
• Adults ≥60 years with risk factors (sexual exposure, percutaneous/blood exposure, chronic liver disease, diabetes, healthcare workers, etc.) should be vaccinated 7

Common Pitfalls to Avoid

• Do not restart an interrupted series—this is the most common error; simply continue from where you stopped 2, 8
• Do not use Heplisav-B in pregnant women, hemodialysis patients, or children due to lack of safety data or approval 2
• Do not delay vaccination if the original vaccine brand is unavailable; use what is available 1
• Do not require pre-vaccination serologic testing—this should not be a barrier to vaccination 7
• Do not assume all 2-dose schedules are equivalent—only Heplisav-B is approved for a 2-dose adult schedule; traditional vaccines require 3 doses 1, 2