Footnotes: Recommended Immunization Schedule for Adults Aged 19 Years and Older — United States, 2013

1. Additional information

• Additional guidance for the use of the vaccines described in this supplement is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.

• Information on vaccination recommendations when vaccination status is unknown and other general immunization information can be found in the General Recommendations on Immunization at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6002a1.htm.

• Information on travel vaccine requirements and recommendations (e.g., for hepatitis A and B, meningococcal, and other vaccines) are available at http://wwwnc.cdc.gov/travel/page/vaccinations.htm.

2. Influenza vaccination

• Annual vaccination against influenza is recommended for all persons aged 6 months and older.

• Persons aged 6 months and older, including pregnant women, can receive the inactivated influenza vaccine (IIV).

• Healthy, nonpregnant persons aged 2–49 years without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (LAIV) (FluMist), or IIV. Health-care personnel who care for severely immunocompromised persons (i.e., those who require care in a protected environment) should receive IIV rather than LAIV.

• The intramuscularly or intradermally administered IIV are options for adults aged 18–64 years.

• Adults aged 65 years and older can receive the standard dose IIV or the high-dose IIV (Fluzone High-Dose).

3. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination

• Administer one dose of Tdap vaccine to pregnant women during each pregnancy (preferred during 27–36 weeks' gestation), regardless of number of years since prior Td or Tdap vaccination.

• Administer Tdap to all other adults who have not previously received Tdap or for whom vaccine status is unknown. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-toxoid containing vaccine.

• Adults with an unknown or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete a primary vaccination series including a Tdap dose.

• For unvaccinated adults, administer the first 2 doses at least 4 weeks apart and the third dose 6–12 months after the second.

• For incompletely vaccinated (i.e., less than 3 doses) adults, administer remaining doses.

• Refer to the Advisory Committee on Immunization Practices (ACIP) statement for recommendations for administering Td/Tdap as prophylaxis in wound management (see footnote #1).

4. Varicella vaccination

• All adults without evidence of immunity to varicella (as defined below) should receive 2 doses of single-antigen varicella vaccine or a second dose if they have received only 1 dose.

• Special consideration for vaccination should be given to those who have close contact with persons at high risk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers).

• Pregnant women should be assessed for evidence of varicella immunity. Women who do not have evidence of immunity should receive the first dose of varicella vaccine upon completion or termination of pregnancy and before discharge from the health-care facility. The second dose should be administered 4–8 weeks after the first dose.

• Evidence of immunity to varicella in adults includes any of the following:

• documentation of 2 doses of varicella vaccine at least 4 weeks apart;
• U.S.-born before 1980 except health-care personnel and pregnant women;
• history of varicella based on diagnosis or verification of varicella disease by a health-care provider;
• history of herpes zoster based on diagnosis or verification of herpes zoster disease by a health-care provider; or
• laboratory evidence of immunity or laboratory confirmation of disease.

5. Human papillomavirus (HPV) vaccination

• Two vaccines are licensed for use in females, bivalent HPV vaccine (HPV2) and quadrivalent HPV vaccine (HPV4), and one HPV vaccine for use in males (HPV4).

• For females, either HPV4 or HPV2 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years, and for those aged 13 through 26 years, if not previously vaccinated.

• For males, HPV4 is recommended in a 3-dose series for routine vaccination at age 11 or 12 years, and for those aged 13 through 21 years, if not previously vaccinated. Males aged 22 through 26 years may be vaccinated.

• HPV4 is recommended for men who have sex with men (MSM) through age 26 years for those who did not get any or all doses when they were younger.

• Vaccination is recommended for immunocompromised persons (including those with HIV infection) through age 26 years for those who did not get any or all doses when they were younger.

• A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should be administered 1–2 months after the first dose; the third dose should be administered 6 months after the first dose (at least 24 weeks after the first dose).

• HPV vaccines are not recommended for use in pregnant women. However, pregnancy testing is not needed before vaccination. If a woman is found to be pregnant after initiating the vaccination series, no intervention is needed; the remainder of the 3-dose series should be delayed until completion of pregnancy.

• Although HPV vaccination is not specifically recommended for health-care personnel (HCP) based on their occupation, HCP should receive the HPV vaccine as recommended (see above).

6. Zoster vaccination

• A single dose of zoster vaccine is recommended for adults aged 60 years and older regardless of whether they report a prior episode of herpes zoster. Although the vaccine is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends that vaccination begins at age 60 years.

• Persons aged 60 years and older with chronic medical conditions may be vaccinated unless their condition constitutes a contraindication, such as pregnancy or severe immunodeficiency.

• Although zoster vaccination is not specifically recommended for HCP, they should receive the vaccine if they are in the recommended age group.

7. Measles, mumps, rubella (MMR) vaccination

• Adults born before 1957 generally are considered immune to measles and mumps. All adults born in 1957 or later should have documentation of 1 or more doses of MMR vaccine unless they have a medical contraindication to the vaccine, or laboratory evidence of immunity to each of the three diseases. Documentation of provider-diagnosed disease is not considered acceptable evidence of immunity for measles, mumps, or rubella.

Measles component:

• A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who

• are students in postsecondary educational institutions;
• work in a health-care facility; or
• plan to travel internationally.

• Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown type during 1963–1967 should be revaccinated with 2 doses of MMR vaccine.

Mumps component:

• A routine second dose of MMR vaccine, administered a minimum of 28 days after the first dose, is recommended for adults who

• are students in a postsecondary educational institution;
• work in a health-care facility; or
• plan to travel internationally.

• Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of unknown type who are at high risk for mumps infection (e.g., persons who are working in a health-care facility) should be considered for revaccination with 2 doses of MMR vaccine.

Rubella component:

• For women of childbearing age, regardless of birth year, rubella immunity should be determined. If there is no evidence of immunity, women who are not pregnant should be vaccinated. Pregnant women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility.

HCP born before 1957:

• For unvaccinated health-care personnel born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval for measles and mumps or 1 dose of MMR vaccine for rubella.

8. Pneumococcal polysaccharide (PPSV23) vaccination

• Vaccinate all persons with the following indications:

• all adults aged 65 years and older;
• adults younger than age 65 years with chronic lung disease (including chronic obstructive pulmonary disease, emphysema, and asthma); chronic cardiovascular diseases; diabetes mellitus; chronic renal failure; nephrotic syndrome; chronic liver disease (including cirrhosis); alcoholism; cochlear implants; cerebrospinal fluid leaks; immunocompromising conditions; and functional or anatomic asplenia (e.g., sickle cell disease and other hemoglobinopathies, congenital or acquired asplenia, splenic dysfunction, or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]);
• residents of nursing homes or long-term care facilities; and
• adults who smoke cigarettes.

• Persons with immunocompromising conditions and other selected conditions are recommended to receive PCV13 and PPSV23 vaccines. See footnote #10 for information on timing of PCV13 and PPSV23 vaccinations.

• Persons with asymptomatic or symptomatic HIV infection should be vaccinated as soon as possible after their diagnosis.

• When cancer chemotherapy or other immunosuppressive therapy is being considered, the interval between vaccination and initiation of immunosuppressive therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided.

• Routine use of PPSV23 is not recommended for American Indians/Alaska Natives or other persons younger than age 65 years unless they have underlying medical conditions that are PPSV23 indications. However, public health authorities may consider recommending PPSV23 for American Indians/Alaska Natives who are living in areas where the risk for invasive pneumococcal disease is increased.

• When indicated, PPSV23 should be administered to patients who are uncertain of their vaccination status and there is no record of previous vaccination. When PCV13 is also indicated, a dose of PCV13 should be given first (see footnote #10).

9. Revaccination with PPSV23

• One-time revaccination 5 years after the first dose is recommended for persons aged 19 through 64 years with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocompromising conditions.

• Persons who received 1 or 2 doses of PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose.

• No further doses are needed for persons vaccinated with PPSV23 at or after age 65 years.

10. Pneumococcal conjugate 13-valent vaccination (PCV13)

• Adults aged 19 years or older with immunocompromising conditions (including chronic renal failure and nephrotic syndrome), functional or anatomic asplenia, CSF leaks or cochlear implants, and who have not previously received PCV13 or PPSV23 should receive a single dose of PCV13 followed by a dose of PPSV23 at least 8 weeks later.

• Adults aged 19 years or older with the aforementioned conditions who have previously received one or more doses of PPSV23 should receive a dose of PCV13 one or more years after the last PPSV23 dose was received. For those that require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years since the most recent dose of PPSV23.

• When indicated, PCV13 should be administered to patients who are uncertain of their vaccination status history and there is no record of previous vaccination.

• Although PCV13 is licensed by the Food and Drug Administration (FDA) for use among and can be administered to persons aged 50 years and older, ACIP recommends PCV13 for adults aged 19 years and older with the specific medical conditions noted above.

11. Meningococcal vaccination

• Administer 2 doses of meningococcal conjugate vaccine quadrivalent (MCV4) at least 2 months apart to adults with functional asplenia or persistent complement component deficiencies.

• HIV-infected persons who are vaccinated also should receive 2 doses.

• Administer a single dose of meningococcal vaccine to microbiologists routinely exposed to isolates of Neisseria meningitidis, military recruits, and persons who travel to or live in countries in which meningococcal disease is hyperendemic or epidemic.

• First-year college students up through age 21 years who are living in residence halls should be vaccinated if they have not received a dose on or after their 16th birthday.

• MCV4 is preferred for adults with any of the preceding indications who are aged 55 years and younger; meningococcal polysaccharide vaccine (MPSV4) is preferred for adults aged 56 years and older.

• Revaccination with MCV4 every 5 years is recommended for adults previously vaccinated with MCV4 or MPSV4 who remain at increased risk for infection (e.g., adults with anatomic or functional asplenia or persistent complement component deficiencies).

12. Hepatitis A vaccination

• Vaccinate any person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications:

• men who have sex with men and persons who use injection or noninjection illicit drugs;
• persons working with HAV-infected primates or with HAV in a research laboratory setting;
• persons with chronic liver disease and persons who receive clotting factor concentrates;
• persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A; and
• unvaccinated persons who anticipate close personal contact (e.g., household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity. (See footnote #1 for more information on travel recommendations). The first dose of the 2-dose hepatitis A vaccine series should be administered as soon as adoption is planned, ideally 2 or more weeks before the arrival of the adoptee.

• Single-antigen vaccine formulations should be administered in a 2-dose schedule at either age 0 and 6–12 months (Havrix), or age 0 and 6–18 months (Vaqta). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose schedule may be used, administered on days 0, 7, and 21–30, followed by a booster dose at month 12.

13. Hepatitis B vaccination

• Vaccinate persons with any of the following indications and any person seeking protection from hepatitis B virus (HBV) infection:

• sexually active persons who are not in a long-term, mutually monogamous relationship (e.g., persons with more than one sex partner during the previous 6 months); persons seeking evaluation or treatment for a sexually transmitted disease (STD); current or recent injection-drug users; and men who have sex with men;
• health-care personnel and public-safety workers who are potentially exposed to blood or other infectious body fluids;
• persons with diabetes younger than age 60 years as soon as feasible after diagnosis; persons with diabetes who are age 60 years or older at the discretion of the treating clinician based on increased need for assisted blood glucose monitoring in long-term care facilities, likelihood of acquiring hepatitis B infection, its complications or chronic sequelae, and likelihood of immune response to vaccination;
• persons with end-stage renal disease, including patients receiving hemodialysis; persons with HIV infection; and persons with chronic liver disease;
• household contacts and sex partners of hepatitis B surface antigen-positive persons; clients and staff members of institutions for persons with developmental disabilities; and international travelers to countries with high or intermediate prevalence of chronic HBV infection; and
• all adults in the following settings: STD treatment facilities; HIV testing and treatment facilities; facilities providing drug-abuse treatment and prevention services; health-care settings targeting services to injection-drug users or men who have sex with men; correctional facilities; end-stage renal disease programs and facilities for chronic hemodialysis patients; and institutions and nonresidential daycare facilities for persons with developmental disabilities.

• Administer missing doses to complete a 3-dose series of hepatitis B vaccine to those persons not vaccinated or not completely vaccinated. The second dose should be administered 1 month after the first dose; the third dose should be given at least 2 months after the second dose (and at least 4 months after the first dose). If the combined hepatitis A and hepatitis B vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6 months; alternatively, a 4-dose Twinrix schedule, administered on days 0, 7, and 21–30 followed by a booster dose at month 12 may be used.

• Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 µg/mL (Recombivax HB) administered on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 µg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months.

14. Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used

• 1 dose of Hib vaccine should be considered for persons who have sickle cell disease, leukemia, or HIV infection, or who have anatomic or functional asplenia if they have not previously received Hib vaccine.

15. Immunocompromising conditions

• Inactivated vaccines generally are acceptable (e.g., pneumococcal, meningococcal, and influenza [inactivated influenza vaccine]), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.

See footnotes on page 18.

Advisory Committee on Immunization Practices

Membership List, October 2012

Chair: Jonathan Temte, MD, PhD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

Executive Secretary: Larry Pickering, MD, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia.

Members: Nancy Bennett, MD, University of Rochester School of Medicine and Dentistry, Rochester, New York; Joseph Bocchini, Jr., MD, Louisiana State University Health Sciences Center, Shreveport, Louisiana; Douglas Campos-Outcalt, MD, University of Arizona College of Medicine, Phoenix, Arizona; Tamera Coyne-Beasley, MD, University of North Carolina, Chapel Hill, North Carolina; Jeffrey Duchin, MD, University of Washington, Seattle, Washington; Kathleen Harriman, PhD, California Department of Public Health, Richmond, CA; Lee Harrison, MD, University of Pittsburgh, Pittsburgh, Pennsylvania; Renée Jenkins, MD, Howard University School of Medicine, District of Columbia; Ruth Karron, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Wendy Keitel, MD, Baylor College of Medicine, Houston, Texas; Sara Rosenbaum, JD, Georgetown University, District of Columbia; Lorry Rubin, MD, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York; Mark Sawyer, MD, University of California at San Diego, California; Marietta Vázquez, MD, Yale University School of Medicine, New Haven, Connecticut.

Ex Officio Members: Vito Caserta, MD, MPH, Health Resources and Services Administration, Rockville, Maryland; Jesse Geibe, MD, Department of Defense, CDC, Atlanta, Georgia; Bruce Gellin, MD, National Vaccine Program Office, District of Columba; Richard Gorman, MD, National Institutes of Health, Bethesda, Maryland; Amy Groom, MPH, Indian Health Service, Albuquerque, New Mexico; Mary Beth Hance, Centers for Medicare and Medicaid Services, Baltimore, Maryland; Linda Kinsinger, MD, Department of Veterans Affairs, Durham, North Carolina; Wellington Sun, MD, Food and Drug Administration, Bethesda, Maryland.

Liaison Representatives: American Academy of Family Physicians, Jamie Loehr, MD, Cayuga Family Medicine, Ithaca, New York; American Academy of Pediatrics, Michael Brady, MD, Ohio State University, Columbus, Ohio, David Kimberlin, MD, University of Alabama School of Medicine, Birmingham, Alabama; American Academy of Physician Assistants, Marie-Michèle Léger, MPH, Alexandria, Virginia; American College Health Association, James C. Turner, MD, University of Virginia School of Medicine, Charlottesville, Virginia; American College of Obstetricians and Gynecologists, Laura Riley, MD, Harvard Medical School, Boston, Massachusetts; American College of Physicians, Gregory Poland, MD, Mayo Clinic, Rochester, Minnesota; American College of Physicians, Sandra Fryhofer, MD, Emory University School of Medicine, Atlanta, Georgia; American Geriatrics Society, Kenneth Schmader, MD, Duke University and Durham VA Medical Centers, Durham, North Carolina; America›s Health Insurance Plans, Mark Netoskie, MD, CIGNA, Houston, Texas; American Medical Association, Litjen Tan, PhD, Chicago, Illinois; American Nurses Association, Katie Brewer, MSN, Silver Springs, Maryland; American Osteopathic Association, Stanley Grogg, DO, Oklahoma State University-Center for Health Sciences, Tulsa, Oklahoma; American Pharmacists Association, Stephan L. Foster, PharmD, University of Tennessee Health Sciences Center, College of Pharmacy, Memphis, Tennessee; Association of Immunization Managers, Kelly Moore, MD, Tennessee Department of Health, Nashville, Tennessee; Association for Prevention Teaching and Research, W. Paul McKinney, MD, University of Louisville School of Public Health and Information Sciences, Louisville, Kentucky; Association of State and Territorial Health Officials, José Montero, MD, New Hampshire Department of Health and Human Services, Concord, New Hampshire; Biotechnology Industry Organization, Clement Lewin, PhD, Novartis Vaccines and Diagnostics, Cambridge, Massachusetts; Canadian National Advisory Committee on Immunization, Bryna Warshawsky, MDCM, Middlesex-London Health Unit, London, Ontario, Canada; Council of State and Territorial Epidemiologists, Christine Hahn, MD, Idaho Department of Health and Welfare, Boise, Idaho; Department of Health, United Kingdom, David M. Salisbury, MD, London, United Kingdom; Healthcare Infection Control Practices Advisory Committee, Alexis Elward, MD, Washington University School of Medicine, St Louis, Missouri; Infectious Diseases Society of America, Kathleen Neuzil, MD, University of Washington School of Medicine, Seattle, Washington; Infectious Diseases Society of America, Carol Baker, MD, Baylor College of Medicine, Houston, Texas; National Association of County and City Health Officials, Matthew Zahn, MD, Orange County Health Care Agency, Santa Ana, California; National Association of Pediatric Nurse Practitioners, Patricia Stinchfield, MPH, Children's Hospitals and Clinics of Minnesota, St Paul, Minnesota; National Foundation for Infectious Diseases, William Schaffner, MD, Vanderbilt University School of Medicine, Nashville, Tennessee; National Medical Association, Patricia Whitley-Williams, MD, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; National Vaccine Advisory Committee, Walter Orenstein, MD, Emory University School of Medicine, Atlanta, Georgia; Pharmaceutical Research and Manufacturers of America, Damian A. Braga, Swiftwater, Pennsylvania; Society for Adolescent Health and Medicine, Amy Middleman, MD, Baylor College of Medicine, Houston, Texas; Society for Healthcare Epidemiology of America, Harry Keyserling, MD, Emory University School of Medicine, Atlanta, Georgia.