What are the recommended hepatitis B vaccine dosages and schedules for healthy adults, infants, and patients with chronic renal failure or on dialysis, and when should hepatitis B surface antibody titers be measured?

Hepatitis B Vaccine Dosing Guidelines

Standard Dosing for Healthy Adults

For healthy adults aged ≥20 years, administer 10 μg of Recombivax HB or 20 μg of Engerix-B intramuscularly at 0,1, and 6 months, which achieves >95% seroprotection rates. 1

• The deltoid muscle is the preferred injection site for adults, as buttock administration substantially reduces immunogenicity 1
• After the complete 3-dose series, 96% of adults achieve protective antibody levels (anti-HBs ≥10 mIU/mL) by month 7 2
• Alternative schedules of 0,1,4 months or 0,2,4 months produce similar seroprotection rates but are not classified as "accelerated" 3, 4

Dosing for Infants and Children

For infants born to HBsAg-negative mothers, administer 5 μg of Recombivax HB or 10 μg of Engerix-B at 0,1-2, and 6 months of age. 1, 4

• The first dose should be given at birth or within the first 2 months of life 1
• The anterolateral thigh is the preferred injection site for neonates and infants 1, 5
• The final dose must not be administered before 24 weeks of age, regardless of when earlier doses were given 3
• For infants born to HBsAg-positive mothers, the first dose (10 μg Engerix-B) plus HBIG must be given within 12 hours of birth, followed by doses at 1-2 months and 6 months 1, 3

For children and adolescents aged 11-19 years, administer 5 μg of Recombivax HB or 10 μg of Engerix-B at 0,1, and 6 months. 1, 4

• An alternative 2-dose schedule using adult formulation Recombivax HB (10 μg) at 0 and 4-6 months is approved for adolescents aged 11-15 years 1
• Pediatric doses are 50-75% lower than adult doses 1

Dosing for Hemodialysis and Chronic Kidney Disease Patients

For adult hemodialysis patients aged ≥20 years, administer 40 μg of Recombivax HB at 0,1, and 6 months OR 40 μg of Engerix-B (given as two 20 μg doses at one site) at 0,1,2, and 6 months. 1, 6

• Standard adult doses (10-20 μg) are inadequate for dialysis patients and result in only 50% seroprotection compared to 67% with the 40 μg regimen 1, 6, 2
• The 4-dose Engerix-B schedule (0,1,2,6 months) achieves 67% seroprotection with a GMT of 93 mIU/mL 2
• For pediatric dialysis patients, use 5 μg Recombivax HB or 10 μg Engerix-B at 0,1, and 6 months 6

For pre-dialysis CRF patients (eGFR <30 mL/min), vaccinate early with standard adult doses: 10 μg Recombivax HB or 20 μg Engerix-B at 0,1, and 6 months. 6, 7

• Pre-dialysis patients achieve 100% seroprotection with standard doses, compared to only 64-94% once on dialysis 7
• Vaccinate before progression to end-stage renal disease whenever possible 7

Post-Vaccination Antibody Testing

For hemodialysis and immunocompromised patients, measure anti-HBs titers 1-2 months after completing the vaccine series to confirm protective levels (≥10 mIU/mL). 1, 3, 6

• Hemodialysis patients require annual anti-HBs monitoring with booster doses when levels fall below 10 mIU/mL 3, 6
• For non-responders (anti-HBs <10 mIU/mL), administer a complete second 3-dose series using the same high-dose regimen 6
• Immunocompetent adults with documented adequate response do not require routine antibody testing or boosters 3

For infants born to HBsAg-positive mothers, test for HBsAg and anti-HBs at 9-15 months of age. 3

Minimum Dosing Intervals

The minimum interval between doses 1 and 2 is 4 weeks, between doses 2 and 3 is 8 weeks, and between doses 1 and 3 is 16 weeks. 1, 3, 4

• Doses administered ≤4 days before the minimum interval are considered valid 1, 3, 4
• Longer intervals between the last two doses (4-12 months) result in higher final antibody titers 1

Management of Interrupted Schedules

If the vaccination series is interrupted, do not restart—simply continue where you left off. 1, 3, 4

• If interrupted after dose 1, give dose 2 as soon as possible, then dose 3 at least 8 weeks after dose 2 and at least 16 weeks after dose 1 1, 3
• If only dose 3 is delayed, administer it when convenient 1

Alternative Accelerated Schedules

For rapid protection against both hepatitis A and B in adults ≥18 years, use Twinrix at 0,7, and 21-30 days, followed by a booster at 12 months. 1, 3

• No CDC-approved accelerated schedule exists for monovalent hepatitis B vaccines 3
• Do not use Twinrix solely for hepatitis B protection when hepatitis A vaccination is not indicated 3

Common Pitfalls to Avoid

• Never restart the vaccine series if interrupted—this wastes doses and delays protection 1, 3, 4
• Never use standard adult doses (10-20 μg) in hemodialysis patients—they require 40 μg doses 1, 6
• Never administer the third dose before 16 weeks from the first dose, even if 8 weeks have passed since the second dose 1, 3, 4
• Never give the final infant dose before 24 weeks of age—this may compromise long-term immunity 3
• Never delay the birth dose beyond 12 hours in infants born to HBsAg-positive mothers—this significantly increases infection risk 3
• Never use buttock injection in adults—immunogenicity is substantially lower than deltoid administration 1
• Never fail to check post-vaccination antibody titers in dialysis patients—this may leave them unprotected 3, 6