Immunization Schedule for Adults

Special situations

• Anatomical or functional asplenia (including sickle cell disease): 1 dose if previously did not receive Hib; if elective splenectomy, 1 dose, preferably at least 14 days before splenectomy
• Hematopoietic stem cell transplant (HSCT): 3-dose series 4 weeks apart starting 6–12 months after a successful transplant, regardless of Hib vaccination history

Routine vaccination

• Not at risk but want protection from hepatitis A
  (identification of risk factor not required): 2-dose series HepA (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum interval: 6 months]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 5 months])

Special situations

• At risk for hepatitis A virus infection: 2-dose series HepA or 3-dose series HepA-HepB as above
  • Chronic liver disease (e.g., persons with hepatitis B, hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
  • HIV infection
  • Men who have sex with men
  • Injection or non-injection drug use
  • Persons experiencing homelessness
  • Work with hepatitis A virus in a research laboratory or with nonhuman primates with hepatitis A virus infection
  • Travel in countries with high or intermediate endemic hepatitis A (HepA-HepB [Twinrix] may be administered on an accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster dose at 12 months)
  • Close, personal contact with international adoptee (e.g., household or regular babysitting) in the first 60 days after arrival from a country with high or intermediate endemic hepatitis A (administer dose 1 as soon as adoption is planned, at least 2 weeks before adoptee’s arrival)
  • Pregnancy is at risk for infection or severe outcome from infection during pregnancy
  • Settings for exposure, including health care settings targeting services to injection or non-injection drug users or group homes and nonresidential daycare facilities for developmentally disabled persons (individual risk factor screening not required)

Routine vaccination

• Not at risk but want protection from hepatitis B
  (identification of risk factor not required): 2- or 3-dose series (2-dose series Heplisav-B at least 4 weeks apart [2-dose series HepB only applies when 2 doses of Heplisav-B are used at least 4 weeks apart] or 3-dose series Engerix-B or Recombivax HB at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks/dose 2 to dose 3: 8 weeks/dose 1 to dose 3: 16 weeks]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks/dose 2 to dose 3: 5 months])

Special situations

• At risk for hepatitis B virus infection: 2-dose (Heplisav-B) or 3-dose (Engerix-B, Recombivax HB) series or 3-dose series HepA-HepB (Twinrix) as above
  • Chronic liver disease (e.g., persons with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
  • HIV infection
  • Sexual exposure risk (e.g., sex partners of hepatitis B surface antigen [HBsAg]-positive persons; sexually active persons not in mutually monogamous relationships; persons seeking evaluation or treatment for a sexually transmitted infection; men who have sex with men)
  • Current or recent injection drug use
  • Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAg-positive persons; residents and staff of facilities for developmentally disabled persons; health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids; hemodialysis, peritoneal dialysis, home dialysis, and predialysis patients; persons with diabetes mellitus age younger than 60 years, shared clinical decision-making for persons age 60 years or older)
  • Incarcerated persons
  • Travel in countries with high or intermediate endemic hepatitis B
  • Pregnancy if at risk for infection or severe outcome from infection during pregnancy. Heplisav-B not currently recommended due to lack of safety data in pregnant women

Routine vaccination

• HPV vaccination recommended for all persons through age 26 years: 2- or 3-dose series depending on age at initial vaccination or condition:
  • Age 15 years or older at initial vaccination: 3-dose series at 0, 1–2 months, 6 months (minimum intervals: dose 1 to dose 2: 4 weeks/dose 2 to dose 3: 12 weeks/dose 1 to dose 3: 5 months; repeat dose if administered too soon)
  • Age 9–14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart: 1 additional dose
  • Age 9–14 years at initial vaccination and received 2 doses at least 5 months apart: HPV vaccination series complete, no additional dose needed
• Interrupted schedules: If the vaccination schedule is interrupted, the series does not need to be restarted
• No additional dose recommended after completing the series with recommended dosing intervals using any HPV vaccine

Shared clinical decision-making

• Some adults age 27–45 years: Based on shared clinical decision-making, 2- or 3-dose series as above

Special situations

• Age ranges recommended above for routine and catch-up vaccination or shared clinical decision-making also apply in special situations
• Immunocompromising conditions, including HIV infection: 3-dose series as above, regardless of age at initial vaccination
• Pregnancy: HPV vaccination not recommended until after pregnancy; no intervention needed if vaccinated while pregnant; pregnancy testing not needed before vaccination

Routine vaccination

• Persons age 6 months or older: 1 dose any influenza vaccine appropriate for age and health status annually
• For additional guidance, see www.cdc.gov/flu/professionals/index.htm

Special situations

• Egg allergy, hives only: 1 dose any influenza vaccine appropriate for age and health status annually
• Egg allergy–any symptom other than hives (e.g., angioedema, respiratory distress): 1 dose any influenza vaccine appropriate for age and health status annually. If using an influenza vaccine other than RIV4 or ccIIV4, administer in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions.
• Severe allergic reactions to any vaccine can occur even in the absence of a history of previous allergic reaction. Therefore, all vaccine providers should be familiar with the office emergency plan and certified in cardiopulmonary resuscitation.
• A previous severe allergic reaction to any influenza vaccine is a contraindication to future receipt of the vaccine.
• LAIV4 should not be used in persons with the following conditions or situations:
  • History of severe allergic reaction to any vaccine component (excluding egg) or to a previous dose of any influenza vaccine
  • Immunocompromised due to any cause (including medications and HIV infection)
  • Anatomic or functional asplenia
  • Close contacts or caregivers of severely immunosuppressed persons who require a protected environment
  • Pregnancy
  • Cranial CSF/oropharyngeal communications
  • Cochlear implant
• Received influenza antiviral medications oseltamivir or zanamivir within the previous 48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days
• Adults 50 years or older
• History of Guillain-Barré syndrome within 6 weeks after the previous dose of influenza vaccine: Generally, should not be vaccinated unless vaccination benefits outweigh risks for those at higher risk for severe complications from influenza

Routine vaccination

• No evidence of immunity to measles, mumps, or rubella: 1 dose
  • Evidence of immunity: Born before 1957 (health care personnel, see below), documentation of receipt of MMR vaccine, laboratory evidence of immunity or disease (diagnosis of disease without laboratory confirmation is not evidence of immunity)

Special situations

• Pregnancy with no evidence of immunity to rubella: MMR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose
• Nonpregnant women of childbearing age with no evidence of immunity to rubella: 1 dose
• HIV infection with CD4 count ≥200 cells/mm³ for at least 6 months and no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart; MMR contraindicated for HIV infection with CD4 count <200 cells/mm³
• Severe immunocompromising conditions: MMR contraindicated
• Students in postsecondary educational institutions, international travelers, and household or close, personal contacts of immunocompromised persons with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart if previously did not receive any doses of MMR or 1 dose if previously received 1 dose MMR
• Health care personnel:
  • Born in 1957 or later with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart for measles or mumps or at least 1 dose for rubella
  • Born before 1957 with no evidence of immunity to measles, mumps, or rubella: Consider 2-dose series at least 4 weeks apart for measles or mumps or 1 dose for rubella

Special situations for MenACWY

• Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use: 2-dose series MenACWY-D (Menactra, Menveo or MenQuadfi) at least 8 weeks apart and revaccinate every 5 years if risk remains
• Travel in countries with hyperendemic or epidemic meningococcal disease, microbiologists routinely exposed to Neisseria meningitidis: 1 dose MenACWY (Menactra, Menveo or MenQuadfi) and revaccinate every 5 years if risk remains
• First-year college students who live in residential housing (if not previously vaccinated at age 16 years or older) and military recruits: 1 dose MenACWY (Menactra, Menveo or MenQuadfi)
• For MenACWY booster dose recommendations for groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm

Shared clinical decision-making for MenB

• Adolescents and young adults age 16–23 years (age 16–18 years preferred) not at increased risk for meningococcal disease: Based on shared clinical decision-making, 2-dose series MenB-4C (Bexsero) at least 1 month apart or 2-dose series MenB-FHbp (Trumenba) at 0, 6 months (if dose 2 was administered less than 6 months after dose 1, administer dose 3 at least 4 months after dose 2); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series)

Special situations for MenB

• Anatomical or functional asplenia (including sickle cell disease), persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use, microbiologists routinely exposed to Neisseria meningitidis: 2-dose primary series MenB-4C (Bexsero) at least 1 month apart or 3-dose primary series MenB-FHbp (Trumenba) at 0, 1–2, 6 months (if dose 2 was administered at least 6 months after dose 1, dose 3 not needed); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2–3 years if risk remains
• Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweigh potential risks
• For MenB booster dose recommendations for groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov
  mmwr/volumes/69/rr/rr6909a1.htm

Routine vaccination

• Age 65 years or older (immunocompetent—see www.cdc.gov/mmwr/volumes/68/wr/mm6846a5.htm): 1 dose PPSV23
  • If PPSV23 was administered prior to age 65 years, adminster 1 dose PPSV23 at least 5 years after previous dose

Shared clinical decision-making

• Age 65 years or older (immunocompetent): 1 dose PCV13 based on shared clinical decision-making if previously not administered.
  • PCV13 and PPSV23 should not be administered during the same visit
  • If both PCV13 and PPSV23 are to be administered, PCV13 should be administered first
  • PCV13 and PPSV23 should be administered at least 1 year apart

Special situations

(https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm)

• Age 19–64 years with chronic medical conditions (chronic heart [excluding hypertension], lung, or liver disease, diabetes), alcoholism, or cigarette smoking: 1 dose PPSV23
• Age 19 years or older with immunocompromising conditions (congenital or acquired immunodeficiency [including B- and T-lymphocyte deficiency, complement deficiencies, phagocytic disorders, HIV infection], chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression [e.g., drug or radiation therapy], solid organ transplant, multiple myeloma) or anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies): 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later, then another dose PPSV23 at least 5 years after previous PPSV23; at age 65 years or older, administer 1 dose PPSV23 at least 5 years after most recent PPSV23 (note: only 1 dose PPSV23 recommended at age 65 years or older)
• Age 19 years or older with cerebrospinal fluid leak or cochlear implant: 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later; at age 65 years or older, administer another dose PPSV23 at least 5 years after PPSV23 (note: only 1 dose PPSV23 recommended at age 65 years or older)

Routine vaccination

• Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then Td or Tdap every 10 years

Special situations

• Previously did not receive primary vaccination series for tetanus, diphtheria, or pertussis: At least 1 dose Tdap followed by 1 dose Td or Tdap at least 4 weeks after Tdap and another dose Td or Tdap 6–12 months after last Td or Tdap (Tdap can be substituted for any Td dose, but preferred as first dose); Td or Tdap every 10 years thereafter
• Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part of gestational weeks 27–36
• Wound management: Persons with 3 or more doses of tetanus-toxoid-containing vaccine: For clean and minor wounds, administer Tdap or Td if more than 10 years since last dose of tetanus-toxoid-containing vaccine; for all other wounds, administer Tdap or Td if more than 5 years since last dose of tetanus-toxoid-containing vaccine. Tdap is preferred for persons who have not previously received Tdap or whose Tdap history is unknown. If a tetanus-toxoid-containing vaccine is indicated for a pregnant woman, use Tdap. For detailed information, see www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm

Routine vaccination

• No evidence of immunity to varicella: 2-dose series 4–8 weeks apart if previously did not receive varicella-containing vaccine (VAR or MMRV [measles-mumps-rubella-varicella vaccine] for children); if previously received 1 dose varicella-containing vaccine, 1 dose at least 4 weeks after first dose
  • Evidence of immunity: U.S.-born before 1980 (except for pregnant women and health care personnel [see below]), documentation of 2 doses varicella-containing vaccine at least 4 weeks apart, diagnosis or verification of history of varicella or herpes zoster by a health care provider, laboratory evidence of immunity or disease

Special situations

• Pregnancy with no evidence of immunity to varicella: VAR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose if previously received 1 dose varicella-containing vaccine or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
• Health care personnel with no evidence of immunity to varicella: 1 dose if previously received 1 dose varicella-containing vaccine; 2‑dose series 4–8 weeks apart if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
• HIV infection with CD4 count ≥200 cells/mm³ with no evidence of immunity: Vaccination may be considered (2 doses 3 months apart); VAR contraindicated for HIV infection with CD4 count <200 cells/mm³
• Severe immunocompromising conditions: VAR contraindicated

Routine vaccination

• Age 50 years or older: 2-dose series RZV (Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon), regardless of previous herpes zoster or history of zoster vaccine live (ZVL, Zostavax) vaccination (administer RZV at least 2 months after ZVL)

Special situations

• Pregnancy: Consider delaying RZV until after pregnancy if RZV is otherwise indicated.
• Severe immunocompromising conditions (including HIV infection with CD4 count <200 cells/mm³): Recommended use of RZV under review