What are the recommended hepatitis B vaccination schedules for adults, including the standard (0‑1‑6 months) and accelerated (0, 7, 21 days with a 12‑month booster) regimens, and how should they be modified for patients with chronic kidney disease (CKD), on dialysis, who are immunocompromised, or have unknown or incomplete vaccination status?

Hepatitis B Vaccination Schedules for Adults

Standard Adult Schedules

For most adults ≥18 years, use either the 2-dose Heplisav-B schedule (0,1 month) or a 3-dose traditional vaccine schedule (0,1,6 months), with Heplisav-B offering faster completion and equivalent long-term protection. 1

Traditional 3-Dose Vaccines

• Recombivax HB: 10 μg (1.0 mL) at 0,1, and 6 months for adults ≥20 years 1
• Engerix-B: 20 μg (1.0 mL) at 0,1, and 6 months for adults ≥20 years 1
• PreHevbrio: 10 μg (1.0 mL) at 0,1, and 6 months for adults ≥18 years 1

2-Dose Option

• Heplisav-B: 20 μg (0.5 mL) at 0 and 1 month (minimum 4-week interval), with both doses required to be Heplisav-B 1

Accelerated Schedules for Rapid Protection

When immediate protection is needed (e.g., occupational exposure, travel), use the 4-dose accelerated schedule at 0,1,2, and 12 months—this provides earlier seroprotection while the 12-month booster ensures long-term immunity. 1, 2

• The accelerated schedule achieves higher early seroconversion rates (70% at 1 month after dose 3) compared to standard schedules, though the fourth dose at 12 months is essential to achieve equivalent long-term antibody levels 3, 4
• Twinrix (combined hepatitis A/B): Can be given on a super-accelerated schedule at 0 days, 7 days, 21-30 days, and 12 months 1, 2
• The usual 4-day grace period does not apply to the first three doses of Twinrix on the accelerated schedule 5

Special Populations

Chronic Kidney Disease and Dialysis Patients

For hemodialysis patients and immunocompromised adults ≥20 years, use high-dose formulations: either Recombivax HB 40 μg (1.0 mL) in 3 doses OR Engerix-B 40 μg (2.0 mL) in 4 doses at 0,1,2, and 6 months. 1

• Engerix-B for dialysis patients achieves only 67% seroprotection with significantly lower antibody titers (GMT 93 mIU/mL) compared to healthy adults, reflecting impaired immune response 1
• Do not use Heplisav-B or PreHevbrio in hemodialysis patients—safety and efficacy data are insufficient 5, 2
• Mandatory post-vaccination testing: Check anti-HBs 1-2 months after series completion; protective level is ≥10 mIU/mL 1
• Annual anti-HBs monitoring is required for dialysis patients to assess durability of protection 1
• Administer a booster dose when anti-HBs falls below 10 mIU/mL 1

HIV-Infected and Immunocompromised Adults

• Use either 40 μg Recombivax HB (3-dose schedule) OR 40 μg Engerix-B administered as two simultaneous 20 μg injections (4-dose schedule at 0,1,2,6 months) 1
• Test anti-HBs 1-2 months after the third dose or at the next clinic visit 1
• Annual serologic surveillance is recommended to monitor antibody persistence 1, 2

Pregnant Women

Pregnant women requiring hepatitis B vaccination must receive only Engerix-B, Recombivax HB, or Twinrix—never use Heplisav-B or PreHevbrio due to insufficient pregnancy safety data. 5, 1, 2

Managing Interrupted or Unknown Vaccination Status

Interrupted Series

Never restart a hepatitis B series regardless of time elapsed—simply continue where you left off. 5, 1, 2

• If interrupted after dose 1: Give dose 2 as soon as possible, then separate doses 2 and 3 by ≥8 weeks 5
• If only dose 3 is delayed: Administer it immediately when the patient returns 5, 6
• Minimum intervals: 4 weeks between doses 1-2; 8 weeks between doses 2-3; 16 weeks between doses 1-3 1, 2
• No maximum interval exists between doses 2
• Switching vaccine brands mid-series is acceptable and does not require restarting 1

Unknown or Incomplete Vaccination History

• Pre-vaccination serologic testing (HBsAg, anti-HBs, anti-HBc) is not required and should never delay vaccination 1
• If testing is performed in high-risk populations, administer the first vaccine dose immediately after blood collection without awaiting results 1
• For individuals with uncertain vaccination history, simply begin or complete the series—there is no harm in revaccinating 1

Post-Vaccination Testing and Non-Responders

Who Requires Testing

Mandatory anti-HBs testing 1-2 months after series completion is required for: 1

• Healthcare personnel with blood exposure risk
• Public safety workers
• Hemodialysis patients
• Immunocompromised individuals

Managing Non-Responders

• If anti-HBs <10 mIU/mL after the first complete series, administer a second full series (6 total doses) and retest 1-2 months after the final dose 1, 2
• After a booster dose, repeat anti-HBs testing is not required 1

Critical Pitfalls to Avoid

• Do not restart interrupted series—there is no maximum interval between doses 5, 1, 2
• Do not use Heplisav-B or PreHevbrio in pregnant women, dialysis patients, or children 5, 1, 2
• Do not delay the fourth dose at 12 months when using accelerated schedules—it is essential for long-term protection 1, 3
• Do not assume standard-dose vaccines are adequate for dialysis or immunocompromised patients—high-dose formulations are required 1
• Doses given ≤4 days before the minimum interval are valid, except for the first three doses of Twinrix on the super-accelerated schedule 5, 1