2020 Vaccination Schedule: Adults

 1. Influenza vaccination

• Give 1 dose of age-appropriate formulation of inactivated influenza vaccine (IIV), recombinant influenza vaccine (RIV), or live attenuated influenza vaccine (LAIV) annually.

• Persons with hives-only allergy to eggs should receive age-appropriate IIV, RIV, or LAIV. If allergy more severe than hives, administer in a medical setting under supervision of healthcare provider.

• LAIV is not recommended in persons with immunocompromising conditions (including HIV), asplenia, cerebrospinal fluid leak, cochlear implant, pregnant women, close contacts/caregivers of severely immunocompromised persons, use of influenza antivirals in previous 48hrs.

 2. Tetanus, diphtheria, and acellular pertussis (Tdap or Td) vaccination

• Persons who previously did not receive a dose of Tdap at or after age 11yrs should receive 1 dose of Tdap vaccine, followed by Td or Tdap booster every 10yrs.

• Persons who previously did not receive primary series for tetanus, diphtheria, and pertussis should receive at least 1 dose of Tdap, followed by 1 dose Td or Tdap ≥4wks after, and another Td or Tdap dose 6–12mos after last Td or Tdap (Tdap can be substituted for any Td dose, but preferred as first dose); Td or Tdap booster every 10yrs thereafter.

• Give 1 dose of Tdap vaccine to pregnant women during each pregnancy (preferred during the early part of gestational weeks 27−36).

• Refer to the ACIP statement for recommendations on Tdap/Td use as prophylaxis in wound management (see footnote 12).

 3. Measles, mumps, rubella (MMR) vaccination

• Adults with no evidence of immunity to measles, mumps, or rubella should receive 1 dose of MMR vaccine.

• Evidence of immunity includes any of the following:

— Born before 1957 (except healthcare personnel)

— Documentation of receipt of MMR vaccine

— Lab evidence of immunity or disease (documentation of provider-diagnosed disease without lab confirmation is not considered evidence of immunity)

• Healthcare personnel born in 1957 or later with no evidence of immunity to measles, mumps, or rubella should receive 2-dose series ≥4wks apart for measles or mumps, or ≥1 dose for rubella. If born before 1957 with no evidence of immunity, consider 2-dose series.

• MMR is contraindicated during pregnancy. Give 1 dose after birth and before hospital discharge. Nonpregnant women of childbearing age with no evidence of immunity to rubella should receive 1 dose of MMR.

• Give 2-dose series ≥4wks apart to persons with HIV and CD4 count ≥200cells/μL for ≥6mos with no evidence of immunity. MMR is contraindicated in HIV with CD4 count <200 cells/µL and other severe immunocompromising conditions.

• Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons should receive 2 doses ≥4wks apart (or 1 dose if previously received 1 MMR dose).

 4. Varicella vaccination

• All adults without evidence of immunity to varicella should receive 2 doses of VAR vaccine 4–8wks apart. If previously received 1 dose of varicella-containing vaccine, give the 2nd dose at least 4wks after the 1st dose.

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

— documentation of 2 doses of varicella vaccine at least 4wks apart;

— U.S.-born before 1980, except HCPs and pregnant women

— diagnosis or verification of history of varicella or herpes zoster by a HCP;

— lab evidence of immunity or disease.

• VAR is contraindicated during pregnancy. Pregnant women without evidence of immunity should receive the first of 2 doses (4–8wks apart) or the 2nd dose, if previously received 1 dose, after birth and before hospital discharge.

• HCP without evidence of immunity should receive 2 doses 4–8wks apart or the 2nd dose if previously received 1 dose.

• Persons with HIV and CD4 count ≥200cells/μL with no evidence of immunity may consider 2 doses 3mos apart. VAR is contraindicated in HIV with CD4 count <200 cells/μL and other severe immunocompromising conditions.

 5. Zoster (recombinant zoster vaccine [RZV] and zoster vaccine live [ZVL]) vaccination

• Adults ≥50yrs regardless of past episode of herpes zoster or receipt of ZVL should receive 2 doses of RZV 2–6mos apart (repeat dose if given <4wks apart).

• Adults ≥60yrs should receive either 2 doses of RZV (preferred) or 1 dose of ZVL if not previously vaccinated.

• Persons who previously received ZVL should receive 2 doses of RZV at least 2mos after ZVL.

• ZVL is contraindicated during pregnancy and in severe immunodeficiency (including HIV with CD4 count <200 cells/μL). Consider delaying RZV until after pregnancy if RZV is otherwise indicated. RZV use in severe immunocompromising conditions is under review.

 6. Human papilloma virus (HPV) vaccination

• Vaccinate all adults through age 26yrs. Can vaccinate adults age 27–45yrs based on shared clinical decision-making.

• If initiated vaccination at ≥15yrs, give a 3-dose series at 0, 1–2, and 6mos; the 1st and 2nd doses should be at least 4wks apart, the 2nd and 3rd doses at least 12wks apart, and the 1st and 3rd doses at least 5mos apart; repeat doses if given too soon.

• If initiated vaccination at 9–14yrs and received 1 dose or 2 doses <5mos apart, give 1 dose. No additional dose is needed if initiated vaccination at 9–14yrs and received 2 doses at least 5mos apart.

• No additional doses needed if valid vaccination series completed with any HPV vaccine.

• HPV vaccination is not recommended until after pregnancy. However, pregnancy testing is not needed before vaccination. If a woman is vaccinated while pregnant, no intervention is needed.

 7. Pneumococcal (13-valent pneumococcal conjugate vaccine [PCV13] and 23-valent pneumococcal polysaccharide vaccine [PPSV23]) vaccination

• All immunocompetent adults ≥65yrs should receive 1 dose of PPSV23. If given before age 65yrs, give additional dose of PPSV23 at age ≥65yrs, ≥5yrs after previous dose.

• Immunocompetent adults ≥65yrs may receive 1 dose of PCV13 based on shared clinical decision-making. If both PCV13 and PPSV23 are indicated, give PCV13 first (do not give both during the same visit). PCV13 and PPSV23 should be given ≥1yr apart.

• Adults 19−64yrs with chronic heart disease (excluding hypertension), chronic lung or liver disease, alcoholism, diabetes, or cigarette smokers should receive 1 dose of PPSV23.

• Adults ≥19yrs with immunocompromising conditions (eg, immunodeficiency including B- and T-lymphocyte deficiency, complement deficiencies, phagocytic disorders, HIV, chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression [drug or radiation therapy], solid organ transplant, multiple myeloma) or anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies) should receive 1 dose of PCV13 followed by 1 dose of PPSV23 at least 8wks after, and a 2nd dose of PPSV23 at least 5yrs after the previous PPSV23 dose. At age ≥65yrs, give another dose of PPSV23 at least 5yrs after the last PPSV23 dose (only 1 dose PPSV23 recommended at age ≥65yrs).

• Adults ≥19yrs with cerebrospinal fluid leak or cochlear implant should receive 1 dose of PCV13 followed by 1 dose of PPSV23 at least 8wks after. At age ≥65yrs, give another dose of PPSV23 at least 5yrs after the last PPSV23 dose (only 1 dose PPSV23 recommended at age ≥65yrs).

 8. Hepatitis A vaccination

• Vaccinate any not at risk person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications:

— chronic liver disease (hepatitis B/C, cirrhosis, fatty or alcoholic liver disease, autoimmune hepatitis, ALT/AST >2xULN);

— HIV infection;

— men who have sex with men;

— injection or non-injection drug use;

— homelessness;

— work with HAV in research lab or nonhuman primates with HAV infection;

— travel to countries with high or intermediate endemic hepatitis A;

— close personal contact with international adoptee (eg, household, regular babysitting) in 1st 60 days after arrival from country with high or intermediate endemic hepatitis A (give 1st dose as soon as adoption is planned, at least 2wks before adoptee’s arrival);

— Pregnancy (if at risk for infection or severe outcome);

— Settings for exposure (eg, drug use clinics, group homes, day care facilities for persons with developmental disabilities)

• Give either a 2-dose series of the single antigen HepA vaccine (Havrix 6–12mos apart or Vaqta 6–18mos apart), or a 3-dose series of the HepA-HepB vaccine combination (Twinrix at 0, 1, and 6mos; the 1st and 2nd doses should be ≥4wks apart, and the 2nd and 3rd doses ≥5mos apart).

 9. Hepatitis B vaccination

• Vaccinate any not at risk person seeking protection from hepatitis B virus (HBV) infection and persons with any of the following indications:

— HCV infection or chronic liver disease (cirrhosis, fatty or alcoholic liver disease, autoimmune hepatitis, ALT/AST >2xULN);

— HIV-infection;

— sexual exposure risk (eg, sex partners of HBsAg-­positive persons, sexually active persons who are not in a mutually monogamous relationship, persons seeking evaluation or treatment for an STD, men who have sex with men);

— current or recent injection drug use;

— percutaneous or mucosal risk for blood exposure (eg, household contacts of HBsAg-positive persons, residents/staff of facilities for persons with developmental disabilities, HCPs and public safety workers who are exposed to blood or blood-contaminated body fluids, dialysis patients, patients <60yrs with diabetes [≥60yrs at the discretion of the treating clinician]);

— incarcerated;

— travel to countries with high or intermediate hepatitis B endemicity

— pregnancy (if at risk for infection or severe outcome. Heplisav-B not currently recommended due to lack of safety data in pregnant women)

• Give a 2-dose series with Heplisav-B at least 4wks apart (2-dose series HepB only applies when 2 doses of Heplisav-B are used) or a 3-dose series with either Engerix-B, Recombivax HB or Twinrix. 3-dose series with single-antigen HepB vaccines (Engerix-B, Recombivax HB) are given at 0, 1 and 6mos; the 1st and 2nd doses should be at least 4wks apart, and the 2nd and 3rd doses at least 8wks apart. If the combined HepA and HepB vaccine (Twinrix) is used, administer 3 doses at 0, 1, and 6mos; the 1st and 2nd doses should be at least 4wks apart, and the 2nd and 3rd doses at least 5mos apart.

10. Meningococcal (Serogroups A, C, W, and Y [MenACWY] or serogroup B [MenB]) vaccination

• MenACWY vaccination (Menactra, Menveo):

— Adults with anatomical or functional asplenia, HIV, persistent complement component deficiency, or on eculizumab or ravulizumab therapy should receive 2 doses of MenACWY at least 8wks apart. Revaccinate with 1 dose every 5yrs if risk remains.

— microbiologists routinely exposed to N. meningitidis and persons traveling in countries where meningococcal ­disease is hyperendemic or epidemic should receive 1 dose of MenACWY; revaccinate every 5yrs if risk remains

— first-year college students in residential housing (if not received vaccine at ≥16yrs) and military recruits should receive 1 dose of MenACWY.

• MenB vaccination (Bexsero, Trumenba):

— young adults 16–23yrs (16–18yrs preferred) not at increased risk may receive, based on shared clinical decision making, 2 doses of Bexsero at least 1 month apart, or 2 doses of Trumenba at least 6mos apart (if 2nd dose given too soon, give 3rd dose at least 4mos after 2nd dose).

— adults with anatomic or functional asplenia, persistent complement component deficiency, on eculizumab or ravulizumab therapy, or microbiologists routinely exposed to N. meningitidis should receive 2 doses of Bexsero at least 1 month apart, or 3 doses of Trumenba at 0, 1–2, and 6mos (3rd dose is not needed if 2nd dose was given at least 6mos after 1st dose). Give 1 dose of MenB booster 1yr after primary series and revaccinate every 2–3yrs if risk remains.

— delay MenB until after pregnancy unless at increased risk and benefit outweighs potential risks.

— The two MenB vaccines are not interchangeable.

11. Haemophilus influenzae type b (Hib) vaccination

• 1 dose of Hib vaccine should be administered to persons with functional or anatomic asplenia, sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib should be administered ≥14 days before splenectomy.

• Recipients of a hematopoietic stem cell transplant should be vaccinated with a 3-dose regimen 6–12mos after a successful transplant, regardless of vaccination history; at least 4wks should separate doses.

12. Additional information

• Immunocompromising conditions: Inactivated vaccines generally are acceptable (eg, pneumococcal, meningococcal, and inactivated influenza vaccine), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html.

• Information on travel vaccine requirements and recommendations (eg, for hepatitis A and B, meningococcal, and other vaccines) available at http://wwwnc.cdc.gov/travel/destinations/list.

• The table columns for ages 19–21 and 22–26 years have been combined due to the change made to recommended catch-up HPV vaccination for all adults through age 26yrs.

• A shaded box has been added to the table to indicate that shared clinical decision-making is recommended regarding vaccination. This impacts HPV, PCV13, and meningococcal rows.

• The HepA footnote has been revised to include minor changes to chronic liver disease definition, pregnancy indication, vaccination in settings of exposure, and removal of clotting factor disorders as an indication.

• The HepB footnote has been revised to include minor changes to chronic liver disease definition and pregnancy indication.

• The HPV footnote has been revised to recommend vaccination for all persons through age 26yrs and for persons 27–45yrs based on shared clinical decision-making.

• The MMR footnote has been revised to clarify recommendations for healthcare personnel.

• The MenB footnote added the use of ravulizumab as an indication for MenB administration. Use in not at risk persons aged 16–23yrs is based on shared clinical decision-making. For adults with special situations, a booster is recommended 1yr after primary series, and revaccination every 2–3 years if risk remains.

• The pneumococcal footnote has been updated for immunocompetent persons ≥65yrs; 1 dose of PPSV23 is still recommended and use of PCV13 is now based on shared clinical decision-making.

• Td or Tdap may be used in situations where only Td vaccine is indicated for the decennial booster, prophylaxis for wound management, and catch-up vaccination.

• The VAR footnote has been updated to indicate that vaccination may be considered for persons with HIV and CD4 count ≥200cells/μL with no evidence of immunity.