Recommended Immunization Schedule for Adults Aged 19 Years or Older by Medical Conditions and Other Indications, United States, 2017

General information

• All persons aged 6 months or older who do not have a contraindication should receive annual influenza vaccination with an age-appropriate formulation of inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV).
• In addition to standard-dose IIV, available options for adults in specific age groups include: high-dose or adjuvanted IIV for adults aged 65 years or older, intradermal IIV for adults aged 18 through 64 years, and RIV for adults aged 18 years or older.
• Notes: Live attenuated influenza vaccine (LAIV) should not be used during the 2016–2017 influenza season. A list of currently available influenza vaccines is available at www.cdc.gov/flu/protect/vaccine/vaccines.htm.

Special populations

• Adults with a history of egg allergy who have only hives after exposure to egg should receive age-appropriate IIV or RIV.
• Adults with a 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. The selected vaccine should 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.
• Pregnant women and women who might become pregnant in the upcoming influenza season should receive IIV.

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General information

• Adults who have not received tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) or for whom pertussis vaccination status is unknown should receive 1 dose of Tdap followed by a tetanus and diphtheria toxoids (Td) booster every 10 years. Tdap should be administered regardless of when a tetanus or diphtheria toxoid-containing vaccine was last received.
• Adults with an unknown or incomplete history of a 3-dose primary series with tetanus and diphtheria toxoid-containing vaccines should complete the primary series that includes 1 dose of Tdap. Unvaccinated adults should receive the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second dose.
• Notes: Information on the use of Td or Tdap as tetanus prophylaxis in wound management is available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.

Special populations

• Pregnant women should receive 1 dose of Tdap during each pregnancy, preferably during the early part of gestational weeks 27–36, regardless of prior history of receiving Tdap.

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General information

• Adults born in 1957 or later without acceptable evidence of immunity to measles, mumps, or rubella (defined below) should receive 1 dose of measles, mumps, and rubella vaccine (MMR) unless they have a medical contraindication to the vaccine, e.g., pregnancy or severe immunodeficiency.
• Notes: Acceptable evidence of immunity to measles, mumps, or rubella in adults is: born before 1957, documentation of receipt of MMR, or laboratory evidence of immunity or disease. Documentation of healthcare provider-diagnosed disease without laboratory confirmation is not acceptable evidence of immunity.

Special populations

• Pregnant women who do not have evidence of immunity to rubella should receive 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 should receive 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 receive 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.

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General information

• Adults without evidence of immunity to varicella (defined below) should receive 2 doses of single-antigen varicella vaccine (VAR) 4–8 weeks apart, or a second dose if they have received only 1 dose.
• Persons without evidence of immunity for whom VAR should be emphasized are: adults who have close contact with persons at high risk for serious complications, e.g., healthcare personnel and household contacts of immunocompromised persons; adults who live or work in an environment in which transmission of varicella zoster virus is likely, e.g., teachers, childcare workers, and residents and staff in institutional settings; adults who live or work in environments in which varicella transmission has been reported, e.g., college students, residents and staff members of correctional institutions, and military personnel; non-pregnant women of childbearing age; adolescents and adults living in households with children; and international travelers.
• Notes: Evidence of immunity to varicella in adults is: U.S.-born before 1980 (for pregnant women and healthcare personnel, U.S.-born before 1980 is not considered evidence of immunity); documentation of 2 doses of VAR at least 4 weeks apart; history of varicella or herpes zoster diagnosis or verification of varicella or herpes zoster disease by a healthcare provider; or laboratory evidence of immunity or disease.

Special populations

• Pregnant women should be assessed for evidence of varicella immunity. 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 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.

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General information

• Adults aged 60 years or older should receive 1 dose of herpes zoster vaccine (HZV), regardless of whether they had a prior episode of herpes zoster.

Special populations

• 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.

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General information

• Adult females through age 26 years and adult males through age 21 years who have not received any human papillomavirus (HPV) vaccine should receive a 3-dose series of HPV vaccine at 0, 1–2, and 6 months. Males aged 22 through 26 years may be vaccinated with a 3-dose series of HPV vaccine at 0, 1–2, and 6 months.
• Adult females through age 26 years and adult males through age 21 years (and males aged 22 through 26 years who may receive HPV vaccination) who initiated HPV vaccination series before age 15 years and received 2 doses at least 5 months apart are considered adequately vaccinated and do not need an additional dose of HPV vaccine.
• Adult females through age 26 years and adult males through age 21 years (and males aged 22 through 26 years who may receive HPV vaccination) who initiated HPV vaccination series before age 15 years and received only 1 dose, or 2 doses less than 5 months apart, are not considered adequately vaccinated and should receive 1 additional dose of HPV vaccine.
• Notes: HPV vaccination is routinely recommended for children at age 11 or 12 years. For adults who had initiated but did not complete the HPV vaccination series, consider their age at first HPV vaccination (described above) and other factors (described below) to determine if they have been adequately vaccinated.

Special populations

• 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.
• 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 are 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.
• Notes: Immunocompromising conditions for which a 3-dose series of HPV vaccine is indicated are primary or secondary immunocompromising conditions that might reduce cell-mediated or humoral immunity, e.g., B-lymphocyte antibody deficiencies, complete or partial T-lymphocyte defects, HIV infection, malignant neoplasm, transplantation, autoimmune disease, and immunosuppressive therapy.

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General information

• Adults who are immunocompetent and aged 65 years or older should receive 13-valent pneumococcal conjugate vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least 1 year after PCV13.
• Notes: Adults are recommended to receive 1 dose of PCV13 and 1, 2, or 3 doses of PPSV23 depending on indication. When both PCV13 and PPSV23 are indicated, PCV13 should be administered first; PCV13 and PPSV23 should not be administered during the same visit. If PPSV23 has previously been administered, PCV13 should be administered at least 1 year after PPSV23. When two or more doses of PPSV23 are indicated, the interval between PPSV23 doses should be at least 5 years. Supplemental information on pneumococcal vaccine timing for adults aged 65 years or older and adults aged 19 years or older at high risk for pneumococcal disease (described below) is available at www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf [4 pages]. No additional doses of PPSV23 are indicated for adults who received PPSV23 at age 65 years or older. When indicated, PCV13 and PPSV23 should be administered to adults whose pneumococcal vaccination history is incomplete or unknown.

Special populations

• 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 (described below) 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.
• Notes: Immunocompromising conditions that are indications for pneumococcal vaccination are congenital or acquired immunodeficiency including B- or T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders excluding chronic granulomatous disease; human immunodeficiency virus (HIV) infection; chronic renal failure and nephrotic syndrome; leukemia, lymphoma, Hodgkin disease, generalized malignancy, and multiple myeloma; solid organ transplant; and iatrogenic immunosuppression including long-term systemic corticosteroid and radiation therapy. Anatomical or functional asplenia that are indications for pneumococcal vaccination are sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, and splenectomy. 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.

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General information

• Adults who seek protection from hepatitis A virus infection may receive a 2-dose series of single antigen hepatitis A vaccine (HepA) at either 0 and 6–12 months (Havrix) or 0 and 6–18 months (Vaqta). Adults may also receive a combined hepatitis A and hepatitis B vaccine (HepA-HepB) (Twinrix) as a 3-dose series at 0, 1, and 6 months. Acknowledgment of a specific risk factor by those who seek protection is not needed

Special populations

• Adults with any of the following indications should receive a HepA series: have chronic liver disease, receive clotting factor concentrates, men who have sex with men, use injection or non-injection drugs, or work with hepatitis A virus-infected primates or in a hepatitis A research laboratory setting.
• Adults who travel in countries with high or intermediate levels of endemic hepatitis A infection or anticipate close personal contact with an international adoptee, e.g., reside in the same household or regularly babysit, from a country with high or intermediate level of endemic hepatitis A infection within the first 60 days of arrival in the United States should receive a HepA series.

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General information

• Adults who seek protection from hepatitis B virus infection may receive a 3-dose series of single-antigen hepatitis B vaccine (HepB) (Engerix-B, Recombivax HB) at 0, 1, and 6 months. Adults may also receive a combined hepatitis A and hepatitis B vaccine (HepA-HepB) (Twinrix) at 0, 1, and 6 months. Acknowledgment of a specific risk factor by those who seek protection is not needed.

Special populations

• Adults at risk for hepatitis B virus infection by sexual exposure should receive a HepB series, 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, and men who have sex with men (MSM).
• Adults at risk for hepatitis B virus infection by percutaneous or mucosal exposure to blood should receive a HepB series, 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, and age 60 years or older with diabetes mellitus at the discretion of the treating clinician.
• Adults with chronic liver disease including, but not limited to, hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and 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, and 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, e.g., having more than one sex partner during the previous six months, been evaluated or treated for a sexually transmitted infection, recent or current injection drug use, or 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 are assumed to be at risk for hepatitis B virus infection and should receive a HepB series: sexually 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, and institutions and nonresidential day care facilities for developmentally disabled persons.

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Special populations

• 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 who have not been previously vaccinated should receive a 2-dose primary series of MenACWY at least 2 months apart and revaccinate every 5 years. Those who 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 (described above) 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 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. For adults who previously received MenACWY or anticipate receiving multiple doses of serogroups A, C, W, and Y meningococcal vaccine, MenACWY is preferred.
• Notes: 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.

Special populations

• 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.
• Notes: Hib is not routinely recommended for adults with human immunodeficiency virus infection because their risk for Haemophilus influenzae type b infection is low.

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