Adult vaccinations

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Recommendations

Recommended schedule of vaccination for adults aged 19 and older, by age group, in the United States:

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Vaccine	Age in Years
	19-21	22-26	27-59	60-64	>65
Influenza	1 dose annualy
Td/Tdap	Substitute Tdap for Td once, then give Td booster evry 10 years
MMR	1 or 2 doses depending on indication
VAR	2 doses
HZV				1 dose
HPV-Female	3 doses
HPV-Male	3 doses	3 doses
PCV13	1 dose				1 dose
PPSV23	1 or 2 doses depending on indication				1 dose
HepA	2 or 3 doses depending on vaccine
HepB	3 doses
MenACWY or MPSV4	1 or 3 doses depending on indication
MenB	2 or 3 doses depending on vaccine
Hib	1 or 3 doses depending on indication

Color Scheme
	Recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection
	Recommended for adults with additional medical conditions or other indications
	No recommendation

• Recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection
• Recommended for adults with additional medical conditions or other indications
• No recommendation

Recommended schedule of vaccination for adults aged 19 and older, by medical condition and other indications, in the United States:

Vaccine	Pregnancy	Immunocompromised (except HIV)	HIV infection CD4+ count (cells/uL)		Asplenia, persistent complement deficiencies	Kidney failure, End stage renal disease on hemodialysis	Heart of Lung disease, chronic alcoholism	Chronic liver disease	Diabetes	Healthcare Personnel	Men who have sex with men
			<200	>200
Influenza	1 dose annualy
Td/Tdap	1 dose Tdap each pregnancy	Substitute Tdap for Td once, then Td booster every 10 years
MMR	Contraindicated			1 or 2 doses depending on indication
VAR	Contraindicated			2 doses
HZV	Contraindicated				1 dose
HPV-Female		3 doses through age 26 years
HPV-Male		3 doses through age 26 years			3 doses through age 21 years						3 doses through age 26 years
PCV13		1 dose					1 dose
PPSV23	1 to 3 doses depending on indication	1 to 3 doses depending on indication								1 to 3 doses depending on indication
Hep A	2 or 3 doses depending on vaccine							2 or 3 doses depending on vaccine	2 or 3 doses depending on vaccine		2 or 3 doses depending on vaccine
Hep B	3 doses		3 doses		3 doses	3 doses	3 doses	3 doses
MenACWY or MPSV4	1 or more doses depending on indication		1 or more doses depending on indication			1 or more doses depending on indication
MenB		2-3 doses depending on vaccine			2-3 doses depending on vaccine	2-3 doses depending on vaccine
Hib		3 doses post-HSCT recipients only	1 dose		1 dose	1 dose

Color Scheme
	Recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection
	Recommended for adults with additional medical conditions or other indications
	Contraindicated
	No recommendation

Recommendations for Special Populations

Vaccine	Special populations		Recommendation
Influenza	History of egg allergy with only hives after exposure		Should receive age-appropriate IIV* or RIV*
	History of egg allergy other than hives e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis OR who required epinephrine or another emergency medical intervention		May receive age-appropriate IIV or RIV, under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions.
Td/Tdap	Pregnant women		1 dose of Tdap during each pregnancy, preferably during the early part of gestational weeks 27–36, regardless of prior history of receiving Tdap.
MMR	Pregnant women who do not have evidence of immunity to rubella		1 dose of MMR upon completion or termination of pregnancy and before discharge from the healthcare facility.
	Non-pregnant women of childbearing age without evidence of rubella immunity		1 dose of MMR.
	Adults with primary or acquired immunodeficiency including malignant conditions affecting the bone marrow or lymphatic system, systemic immunosuppressive therapy, or cellular immunodeficiency		Should NOT recieve MMR.
	Adults with human immunodeficiency virus (HIV) infection and CD4+ T-lymphocyte count ≥200 cells/µl for at least 6 months who do not have evidence of measles, mumps, or rubella immunity		Should receive 2 doses of MMR at least 28 days apart.
	Adults with HIV infection and CD4+ T-lymphocyte count <200 cells/µl		Should not receive MMR.
	Adults who work in healthcare facilities		Should receive 2 doses of MMR at least 28 days apart.
	Healthcare personnel born before 1957 who are unvaccinated or lack laboratory evidence of measles, mumps, or rubella immunity, or laboratory confirmation of disease		Should be considered for vaccination with 2 doses of MMR at least 28 days apart for measles or mumps, or 1 dose of MMR for rubella.
	Adults who are students in postsecondary educational institutions or plan to travel internationally		Should receive 2 doses of MMR at least 28 days apart.
	Adults who received inactivated (killed) measles vaccine or measles vaccine of unknown type during years 1963–1967		Should be revaccinated with 1 or 2 doses of MMR.
	Adults who were vaccinated before 1979 with either inactivated mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection, e.g., work in a healthcare facility		Should be considered for revaccination with 2 doses of MMR at least 28 days apart.
VAR	Pregnant women who do not have evidence of immunity		Should receive the first dose of VAR upon completion or termination of pregnancy and before discharge from the healthcare facility, and the second dose 4–8 weeks after the first dose.
	Healthcare personnel		Healthcare institutions should assess and ensure that all healthcare personnel have evidence of immunity to varicella.
	Adults with malignant conditions, including those that affect the bone marrow or lymphatic system or who receive systemic immunosuppressive therapy		Should NOT receive VAR.
	Adults with human immunodeficiency virus (HIV) infection and CD4+ T-lymphocyte count ≥200 cells/µl		May receive 2 doses of VAR 3 months apart.
	Adults with HIV infection and CD4+ T-lymphocyte count <200 cells/µl		Should NOT receive VAR.
HZV	Adults aged 60 years or older with chronic medical conditions		May receive HZV unless they have a medical contraindication, e.g., pregnancy or severe immunodeficiency.
	Adults with malignant conditions, including those that affect the bone marrow or lymphatic system or who receive systemic immunosuppressive therapy		Should not receive HZV.
	Adults with human immunodeficiency virus (HIV) infection and CD4+ T-lymphocyte count <200 cells/µl		Should not receive HZV.
HPV	Adult females and males through age 26 years with immunocompromising conditions (described below), including those with human immunodeficiency virus (HIV) infection.		Should receive a 3-dose series of HPV vaccine at 0, 1–2, and 6 months.
	Pregnant women		Not recommended to receive HPV vaccine, although there is no evidence that the vaccine poses harm. If a woman is found to be pregnant after initiating the HPV vaccination series, delay the remaining doses until after the pregnancy. No other intervention is needed. Pregnancy testing is not needed before administering HPV vaccine.
	Men who have sex with men through age 26 years who have not received any HPV vaccine.		Should receive a 3-dose series of HPV vaccine at 0, 1–2, and 6 months.
	Pathologies including primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity like: B-lymphocyte antibody deficiencies Complete or partial T-lymphocyte defects HIV infection Malignant neoplasm Transplantation Autoimmune disease Immunosuppressive therapy		3-dose series of HPV vaccine is indicated.
Pneumococcal vaccination	Adults aged 19 through 64 years with chronic heart disease including congestive heart failure and cardiomyopathies (excluding hypertension); chronic lung disease including chronic obstructive lung disease, emphysema, and asthma; chronic liver disease including cirrhosis; alcoholism; or diabetes mellitus; or who smoke cigarettes		Should receive PPSV23. At age 65 years or older, they should receive PCV13 and another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after the most recent dose of PPSV23.
	Adults aged 19 years or older with immunocompromising conditions or anatomical or functional asplenia		Should receive PCV13 and a dose of PPSV23 at least 8 weeks after PCV13, followed by a second dose of PPSV23 at least 5 years after the first dose of PPSV23. If the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.
	Adults aged 19 years or older with cerebrospinal fluid leak or cochlear implant		Should receive PCV13 followed by PPSV23 at least 8 weeks after PCV13. If the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.
	Indications for Pneumococcal vaccination Congenital or acquired immunodeficiency including B- or T-lymphocyte deficiency Complement deficiencies Phagocytic disorders excluding chronic granulomatous disease Human immunodeficiency virus (HIV) infection Chronic renal failure and nephrotic syndrome Leukemia Lymphoma Hodgkin disease Generalized malignancy Multiple myeloma Solid organ transplant Iatrogenic immunosuppression including: Long-term systemic corticosteroid Radiation therapy Anatomical or functional asplenia that are indications for pneumococcal vaccination are: Sickle cell disease Other hemoglobinopathies Congenital or acquired asplenia Splenic dysfunction, and splenectomy		Pneumococcal vaccination should be given. Pneumococcal vaccines should be given at least 2 weeks before immunosuppressive therapy or an elective splenectomy, and as soon as possible to adults who are diagnosed with HIV infection.
HepA	Adults with any of the following indications: Chronic liver disease Receive clotting factor concentrates Men who have sex with men Use of injection or non-injection drugs Working with hepatitis A virus-infected primates or in a hepatitis A research laboratory setting		Should receive a HepA series.
	Adults who: Travel in countries with high or intermediate levels of endemic hepatitis A infection or Anticipate close personal contact with an international adoptee, from a country with high or intermediate level of endemic hepatitis A infection within the first 60 days of arrival in the United States e.g., Reside in the same household or Regularly babysit		Should receive a HepA series.
HepB	Adults at risk for hepatitis B virus infection by sexual exposure, including: Sex partners of hepatitis B surface antigen (HBsAg)-positive persons Sexually active persons who are not in a mutually monogamous relationship Persons seeking evaluation or treatment for a sexually transmitted infection Men who have sex with men (MSM)		Should receive a HepB series.
	Adults at risk for hepatitis B virus infection by percutaneous or mucosal exposure to blood, including: Adults who are recent or current users of injection drugs Household contacts of HBsAg-positive persons Residents and staff of facilities for developmentally disabled persons Incarcerated Healthcare and public safety workers at risk for exposure to blood or blood-contaminated body fluids Younger than age 60 years with diabetes mellitus Age 60 years or older with diabetes mellitus at the discretion of the treating clinician		Should receive a HepB series.
	Adults with chronic liver disease including, but not limited to: Hepatitis C virus infection Cirrhosis Fatty liver disease Alcoholic liver disease Autoimmune hepatitis An alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level greater than twice the upper limit of normal		Should receive a HepB series.
	Adults with end-stage renal disease including those on Pre-dialysis care Hemodialysis Peritoneal dialysis Home dialysis		Should receive a HepB series. Adults on hemodialysis should receive a 3-dose series of 40 µg Recombivax HB at 0, 1, and 6 months or a 4-dose series of 40 µg Engerix-B at 0, 1, 2, and 6 months.
	Adults with human immunodeficiency virus (HIV) infection		Should receive a HepB series.
	Pregnant women who are at risk for hepatitis B virus infection during pregnancy, like Having more than one sex partner during the previous six months History of evaluation or treatment for a sexually transmitted infection Recent or current injection drug use Had an HBsAg-positive sex partner		Should receive a HepB series.
	International travelers to regions with high or intermediate levels of endemic hepatitis B virus infection		Should receive a HepB series.
	Adults in the following settings Hexually transmitted disease treatment facilities HIV testing and treatment facilities Facilities providing drug-abuse treatment and prevention services Healthcare settings targeting services to persons who inject drugs Correctional facilities Healthcare settings targeting services to MSM Hemodialysis facilities and end-stage renal disease programs Institutions and nonresidential day care facilities for developmentally disabled persons		Should receive a HepB series as adults in these settings are assumed to be at risk for hepatitis B virus infection.
Meningococcal vaccination	Adults with anatomical or functional asplenia or persistent complement component deficiencies		Should receive a 2-dose primary series of serogroups A, C, W, and Y meningococcal conjugate vaccine (MenACWY) at least 2 months apart and revaccinate every 5 years. They should also receive a series of serogroup B meningococcal vaccine (MenB) with either a 2-dose series of MenB-4C (Bexsero) at least 1 month apart or a 3-dose series of MenB-FHbp (Trumenba) at 0, 1–2, and 6 months.
	Adults with human immunodeficiency virus (HIV) infection	Not previously vaccinated	Should receive a 2-dose primary series of MenACWY at least 2 months apart and revaccinate every 5 years.
		Previously received 1 dose of MenACWY	Should receive a second dose at least 2 months after the first dose.
		Adults with HIV infection are not routinely recommended to receive MenB because meningococcal disease in this population is caused primarily by serogroups C, W, and Y.
	Microbiologists who are routinely exposed to isolates of Neisseria meningitidis		Should receive 1 dose of MenACWY and revaccinate every 5 years if the risk for infection remains, and either a 2-dose series of MenB-4C at least 1 month apart or a 3-dose series of MenB-FHbp at 0, 1–2, and 6 months.
	Adults at risk because of a meningococcal disease outbreak		Should receive 1 dose of MenACWY if the outbreak is attributable to serogroup A, C, W, or Y, OR Either a 2-dose series of MenB-4C at least 1 month apart OR A 3-dose series of MenB-FHbp at 0, 1–2, and 6 months if the outbreak is attributable to serogroup B.
	Adults who travel to or live in countries with hyperendemic or epidemic meningococcal disease		Should receive 1 dose of MenACWY and revaccinate every 5 years if the risk for infection remains. MenB is not routinely indicated because meningococcal disease in these countries is generally not caused by serogroup B.
	Military recruits		Should receive 1 dose of MenACWY and revaccinate every 5 years if the increased risk for infection remains.
	First-year college students aged 21 years or younger who live in residence halls		Should receive 1 dose of MenACWY if they have not received MenACWY at age 16 years or older.
	Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) who are healthy and not at increased risk for serogroup B meningococcal disease		May receive either a 2-dose series of MenB-4C at least 1 month apart OR A 2-dose series of MenB-FHbp at 0 and 6 months for short-term protection against most strains of serogroup B meningococcal disease.
	For adults aged 56 years or older depending on previous vaccination and required dosing	Who have not previously received serogroups A, C, W, and Y meningococcal vaccine and need only 1 dose	Meningococcal polysaccharide serogroups A, C, W, and Y vaccine (MPSV4) is preferred.
		Who previously received MenACWY or anticipate receiving multiple doses of serogroups A, C, W, and Y meningococcal vaccine	MenACWY is preferred.
	General		MenB-4C and MenB-FHbp are not interchangeable, i.e., the same vaccine should be used for all doses to complete the series. There is no recommendation for MenB revaccination at this time. MenB may be administered at the same time as MenACWY but at a different anatomic site, if feasible.
Hib	Adults who have Anatomical or functional asplenia OR Sickle cell disease OR Are undergoing elective splenectomy		Should receive 1 dose of Haemophilus influenzae type b conjugate vaccine (Hib) if they have not previously received Hib. Hib should be administered at least 14 days before splenectomy.
	Adults with a hematopoietic stem cell transplant (HSCT)		Should receive 3 doses of Hib in at least 4 week intervals 6–12 months after transplant regardless of their Hib history.
	General		Hib is not routinely recommended for adults with human immunodeficiency virus infection because their risk for Haemophilus influenzae type b infection is low.

*IIV-Inactivated influenza vaccine

*RIV-Recombinant influenza vaccine

Contraindications and Precautions for Adult Vaccinations

Vaccine	Contraindications	Precautions
All vaccines routinely recommended for adults	Severe reaction, e.g., anaphylaxis, after a previous dose or to a vaccine component	Moderate or severe acute illness with or without fever
IIV		History of Guillain-Barré Syndrome within 6 weeks after previous influenza vaccination Egg allergy other than hives, e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis; or required epinephrine or another emergency medical intervention (IIV may be administered in an inpatient or outpatient medical setting and under the supervision of a healthcare provider who is able to recognize and manage severe allergic conditions)
RIV		History of Guillain-Barré Syndrome within 6 weeks after previous influenza vaccination
LAIV	LAIV should not be used during 2016–2017 influenza season	LAIV should not be used during 2016–2017 influenza season
Tdap/Td	For pertussis-containing vaccines: encephalopathy, e.g., coma, decreased level of consciousness, or prolonged seizures, not attributable to another identifiable cause within 7 days of administration of a previous dose of a vaccine containing tetanus or diphtheria toxoid or acellular pertussis	Guillain-Barré Syndrome within 6 weeks after a previous dose of tetanus toxoid-containing vaccine History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine. Defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine For pertussis-containing vaccine, progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy (until a treatment regimen has been established and the condition has stabilized)
MMR	Severe immunodeficiency e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy3, human immunodeficiency virus (HIV) infection with severe immunocompromise Pregnancy	Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) History of thrombocytopenia or thrombocytopenic purpura Need for tuberculin skin testing
VAR	Severe immunodeficiency e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy3, HIV infection with severe immunocompromise Pregnancy	Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)4 Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
HZV	Severe immunodeficiency e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy3, HIV infection with severe immunocompromise Pregnancy	Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
HPV vaccine		Pregnancy
PCV13	Severe allergic reaction to any vaccine containing diphtheria toxoid