Hepatitis B

Vaccination is the best way to prevent infection, and universal infant vaccination programmes are the cornerstone of prevention.[32]Centers for Disease Control and Prevention. Clinical overview of hepatitis B. Aug 2025 [internet publication]. https://www.cdc.gov/hepatitis-b/hcp/clinical-overview/index.html ​ Tailored screening and vaccine programmes are also useful. Primary prevention can be via passive immunisation with hepatitis B immunoglobulin (HBIG) or via active immunisation with hepatitis B vaccination (recombinant inactive hepatitis B surface antigen [HBsAg]).

Infants, children, and adolescents ≤18 years

• The World Health Organization (WHO) recommends that all infants should receive a hepatitis B vaccine series, with the first dose given as soon as possible after birth, preferably within 24 hours, followed by two or three doses administered according to national routine immunisation schedules.​[75]World Health Organization. Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection. Mar 2024 [internet publication]. https://www.who.int/publications/i/item/9789240090903 ​​

  • The monovalent vaccine should be used for the birth dose, while monovalent or combined vaccines can be used in infants aged >6 weeks.

• In the US, the Centers for Disease Control and Prevention (CDC) recommends babies receive a first dose of hepatitis B vaccine within 24 hours of birth, with a second dose at 1-2 months (minimum interval after first dose of 4 weeks), and a third dose at 6-18 months (at least 8 weeks after the second dose and at least 16 weeks after the first dose). If no dose is given at birth, then three doses of a hepatitis B-containing vaccine should be given on a schedule of 0, 1-2, and 6 months, starting as soon as possible. A four-dose series is permitted when a combination vaccine containing hepatitis B is administered after the birth dose. The final (third or fourth) dose should be administered no earlier than the age of 24 weeks. The monovalent vaccine should be used for doses administered before age 6 weeks.[76]Centers for Disease Control and Prevention. Child and adolescent immunization schedule by age: recommendations for ages 18 years or younger - United States, 2025. Oct 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/child-adolescent-age.html ​​​

  • Babies born to HBsAg-positive mothers should receive both hepatitis B vaccine (monovalent vaccine only) and HBIG (in separate limbs) within 12 hours of birth, regardless of birth weight. Babies <2000 g should receive three additional doses of vaccine (total of four doses), beginning at age 1 month. Babies should be tested for HBsAg and antibody to hepatitis B surface antigen (anti-HBs) at age 9-12 months, or if vaccination is delayed, at 1-2 months after completion of hepatitis B vaccine series.

  • Babies born to mothers with an unknown HBsAg status should receive hepatitis B vaccine within 12 hours of birth regardless of birth weight, and those weighing <2000 g should also receive HBIG (in separate limbs) and three additional doses of vaccine (total of four doses), beginning at age 1 month. For babies weighing ≥2000 g, the mother’s HBsAg status should be determined as soon as possible and, if positive, HBIG given to the baby as soon as possible and within 7 days. If there is evidence to suggest maternal hepatitis B infection, manage infants as if the mother is HBsAg-positive.

  • Babies born to HBsAg-negative mothers should receive one dose of hepatitis B vaccine within 24 hours of birth if medically stable and birth weight is ≥2000 g. Babies <2000 g should receive one dose at chronological age 1 month or hospital discharge (whichever is earlier, even if weight is still <2000 g).

  • Catch-up vaccination: children and adolescents who have not previously received the hepatitis B vaccine should receive the standard schedule of three vaccinations at 0, 1-2, and 6 months. Adolescents aged 11-15 years may receive an alternative two-dose series of adult Recombivax HB® with at least 4 months between doses. Adolescents aged ≥18 years may receive a two-dose series of Heplisav-B® at least 4 weeks apart, a three-dose series of PreHevbrio® at 0, 1, and 6 months, or the combined hepatitis A and hepatitis B vaccine (Twinrix®) as a three- or four-dose series.

• The American College of Obstetricians and Gynecologists (ACOG) supports the recommendation that neonates of HBsAg-positive mothers (or whose status is unknown at the time of delivery), receive both hepatitis B vaccination and HBIG within 12 hours of birth.[77]American College of Obstetricians and Gynecologists. Clinical practice guideline no. 6: viral hepatitis in pregnancy. Sep 2023 [internet publication]. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/09/viral-hepatitis-in-pregnancy

• In the UK, the routine childhood immunisation programme includes hepatitis B in the hexavalent combination vaccine for diphtheria, tetanus, pertussis, polio, and Haemophilus influenzae type B (DTaP/IPV/Hib/HepB).[78]Public Health England. Hepatitis B: the green book, chapter 18. Jun 2025 [internet publication]. https://www.gov.uk/government/publications/hepatitis-b-the-green-book-chapter-18

  • Vaccination with a hexavalent DTaP/IPV/Hib/HepB vaccine is recommended at 8 weeks, 12 weeks, and 16 weeks of age. Children born on or after 1 July 2024 should receive an additional dose of the hexavalent Hib-containing vaccine at 18 months of age. Children born on or before 30 June 2024 should continue to be offered a dose of a monovalent hepatitis B vaccine alongside HBsAg testing on or after their first birthday (an 18-month dose is not required in these children). The primary schedule can be given from age 6 weeks to 10 years if not completed in the first year of life.

  • Babies born to hepatitis B-infected mothers should receive an accelerated immunisation schedule with a dose of a monovalent hepatitis B vaccine given at birth (within 24 hours) and at 4 weeks of age, followed by a hexavalent vaccine at 8, 12, and 16 weeks of age. Babies are tested for HBsAg between 12 and 18 months of age. Children who are born on or before 30 June 2024 should be offered a dose of monovalent hepatitis B vaccine on or after their first birthday. Children who are born on or after 1 July 2024 will instead receive a routine hexavalent vaccine dose at 18 months of age.

  • Babies born to hepatitis B-infected mothers should also receive HBIG ideally within 24 hours of the birth dose of the hepatitis B vaccine and within 7 days following birth, unless the mother is HBsAg-positive and antibody to hepatitis B e antigen (anti-HBe)-positive and hepatitis B e antigen (HBeAg)-negative, or the mother is HBsAg-positive and the baby also weighs >1500 g at birth.

  • Children born from 1 August 2017 and aged under 10 years of age who have completed their course of immunisations for diphtheria, tetanus, pertussis and polio, but have not received hepatitis B vaccination should opportunistically be offered a hepatitis B vaccine course, while those who are exposed to hepatitis B virus (HBV) or who are in a high-risk group should proactively be offered a hepatitis B vaccine course.

  • Consult the UK immunisation schedule for more detailed information on hepatitis B vaccination.

• The global coverage with the third dose of hepatitis B vaccine was between 82% and 85% between 2016 and 2020. Coverage was ≥90% for both the birth dose and the 3-dose series in 41% of countries with data available in 2020.[20]Khetsuriani N, Lesi O, Desai S, et al. Progress toward the elimination of mother-to-child transmission of hepatitis B virus - worldwide, 2016-2021. MMWR Morb Mortal Wkly Rep. 2022 Jul 29;71(30):958-63. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9345178 http://www.ncbi.nlm.nih.gov/pubmed/35900928?tool=bestpractice.com

• Immunisation schedules differ between countries. Consult your local immunisation protocols for more information.

Adults

• In the US, ACIP recommends universal vaccination in adults aged 19-59 years with a two-, three-, or four-dose series. Adults ≥60 years of age with known risk factors for infection (see below) should receive a complete vaccine series. Adults ≥60 years of age without known risk factors may receive a complete vaccine series if they choose to or request it. The dose schedule depends on the vaccine used (e.g., Engerix-B®, Recombivax HB®, Heplisav-B®, Twinrix®, PreHevbrio®). Consult the immunisation schedule for more detailed information. Adults ≥60 years of age with diabetes should receive vaccination based on shared clinical decision-making.[79]Centers for Disease Control and Prevention. Adult immunization schedule by age: recommendations for ages 19 years or older - United States, 2025. Oct 2025 [internet publication]. https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html ​​​

• At-risk populations include:

  • People with chronic liver disease (e.g., hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice upper limit of normal)

  • People living with HIV or current or recent injection drug use

  • People with a sexual exposure risk (e.g., sex partners of HBsAg-positive people, sexually active people not in mutually monogamous relationships, men who have sex with men, people seeking evaluation or treatment of sexually transmitted infection)

  • People with percutaneous or mucosal risk for exposure to blood (e.g., patients with diabetes, dialysis patients, household contacts of HBsAg-positive people, healthcare personnel)

  • Incarcerated people

  • People travelling to countries with high or intermediate endemic hepatitis B

• ACOG supports the use of the hepatitis B vaccine with an appropriate vaccine during pregnancy for recommended patient groups.[77]American College of Obstetricians and Gynecologists. Clinical practice guideline no. 6: viral hepatitis in pregnancy. Sep 2023 [internet publication]. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/09/viral-hepatitis-in-pregnancy

• In the UK, an accelerated schedule is given in most risk groups, with the vaccine given at 0, 1, 2, and 12 months, or alternatively, at 0, 1, and 6 months where rapid protection isn’t required and adherence is likely.​[78]Public Health England. Hepatitis B: the green book, chapter 18. Jun 2025 [internet publication]. https://www.gov.uk/government/publications/hepatitis-b-the-green-book-chapter-18 ​ Consult the UK immunisation schedule for more detailed information on hepatitis B vaccination.

• Immunisation schedules differ between countries. Consult your local immunisation protocols for more information.

The CDC provides useful guidance pages on hepatitis B vaccination.

• CDC: ​hepatitis B vaccine administration Opens in new window

• CDC: hepatitis B perinatal vaccine information Opens in new window

The following general secondary prevention measures are recommended:[2]Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018 Apr;67(4):1560-99. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5975958 http://www.ncbi.nlm.nih.gov/pubmed/29405329?tool=bestpractice.com [29]European Association for the Study of the Liver. EASL clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol. 2025 Aug;83(2):502-83. https://www.journal-of-hepatology.eu/article/S0168-8278(25)00174-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/40348683?tool=bestpractice.com

• Screen pregnant women for HBsAg. Encourage pregnant women to discuss the need for maternal antiviral therapy, as well as newborn hepatitis B vaccination and HBIG, with their obstetrician to prevent perinatal transmission.

• Advise healthcare workers with hepatitis B virus (HBV) infection who perform exposure-prone procedures to seek counselling and advice from an expert review panel, as antiviral prophylaxis may be indicated.

• Initiate antiviral prophylaxis in patients who are starting on immunosuppressive therapy (including chemotherapy or immunotherapy), based on a risk assessment, in order to prevent HBV reactivation. See Complications.

The following secondary prevention measures are recommended in liver transplant recipients:[29]European Association for the Study of the Liver. EASL clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol. 2025 Aug;83(2):502-83. https://www.journal-of-hepatology.eu/article/S0168-8278(25)00174-6/fulltext http://www.ncbi.nlm.nih.gov/pubmed/40348683?tool=bestpractice.com

• Initiate lifelong antiviral prophylaxis with a nucleoside/nucleotide analogue (with or without HBIG) in all patients with chronic HBV infection undergoing liver transplantation. An individualised approach to HBIG use is recommended.

• Initiate long-term antiviral therapy in patients who are HBsAg-negative and receiving livers a liver transplantation from a donor with evidence of past HBV infection (antibody to hepatitis B core antigen-positive [anti-HBc]) to prevent HBV reactivation. Detailed guidance on the management of patients who are HBsAg-negative and who receive an organ from an anti-HBc-positive donor is beyond the scope of this topic, and consultation with a transplantation specialist is required.

• Initiate antiviral therapy with a nucleoside/nucleotide analogue in all patients who receive a liver transplantation from a donor who is HBsAg-positive. Liver transplantation from a donor who is HBsAg-positive is not recommended in patients with chronic hepatitis D virus (HDV) infection.

• Initiate antiviral therapy with a nucleoside/nucleotide analogue plus HBIG in all patients who receive any other organ transplantation (e.g., kidney, heart, pancreas, lung, stem cell) from a donor who is HBsAg-positive. The donor should also be treated with antiviral therapy as soon as possible before transplantation in the case of stem cell transplant or living donation of a solid organ.