Recommended Adult Immunization Schedule -- United States, 2011

Abstract

Each year, the Advisory Committee on Immunization Practices (ACIP) reviews the recommended adult immunizationschedule to ensure that the schedule reflects current recommendations for the licensed vaccines. In October 2010, ACIP approved the adult immunization schedule for 2011, which includes several changes. The
notation for influenza vaccination in the figure and footnotes was changed to reflect the expanded recommendation for annual influenza vaccination for all persons aged 6 months and older, which was approved
by ACIP in February 2010. In October 2010, ACIP issued a permissive recommendation for use of tetanus, diphtheria, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older, approved the recommendation that Tdap vaccine be administered regardless of how much time has elapsed since the most recent tetanus and diphtheria toxoids (Td)--containing vaccine, and approved a recommendation for a 2-dose series of meningococcal vaccine in adults with certain high-risk medical
conditions. The vaccines listed in the figures have been reordered to keep all universally recommended vaccines together (e.g., influenza, Td/Tdap, varicella, human papillomavirus [HPV], and zoster vaccines).
Clarifications were made to the footnotes for measles, mumps, and rubella (MMR) vaccination; HPV vaccine; revaccination with pneumococcal polysaccharide vaccine (PPSV), and Haemophilus influenza type b
(Hib) vaccine. Finally, a statement has been added to the box at the bottom of the footnotes to clarify that a vaccine series does not need to be restarted, regardless of the time that has elapsed between doses.
Additional information is available as follows: schedule (in English and Spanish) at http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm; information about adult vaccination at http://www.cdc.gov/vaccines/default.htm; ACIP statements for specific vaccines at http://www.cdc.gov/vaccines/pubs/acip-list.htm; and reporting adverse events at http://www.vaers.hhs.gov or by telephone, 800-822-7967.

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Figure 1. Recommended adult immunization schedule, by vaccine and age group --- United States, 2011 The figure above shows the recommended adult immunization schedule, by vaccine and age group for the United States in 2011.

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Figure 2. Vaccines that might be indicated for adults, based on medical and other indications --- United States, 2011 The figure above shows vaccines that might be indicated for adults, based on medical and other indications in the United States for 2011.

1. Influenza Vaccination

Annual vaccination against influenza is
recommended for all persons aged 6 months and older, including all adults. Healthy, nonpregnant adults aged less than 50 years without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (FluMist), or inactivated vaccine. Other persons should receive the inactivated vaccine. Adults aged 65 years and older can receive the standard
influenza vaccine or the high-dose (Fluzone) influenza vaccine. Additional information about influenza vaccination is available at http://www.cdc.gov/vaccines/vpd-vac/flu/default.htm.


Changes for 2011
The influenza vaccination footnote (#1) is revised
and shortened to reflect a recommendation for vaccination of all personsaged 6 months and older, including all adults. The high-dose influenza
vaccine (Fluzone), licensed in 2010 for adults aged 65 years and older, is mentioned as an option for this age group.

2. Tetanus, Diphtheria, and Acellular Pertussis (Td/Tdap) Vaccination

Administer a one-time dose of Tdap to adults
aged less than 65 years who have not received Tdap previously or for whom vaccine status is unknown to replace one of the 10-year Td boosters, and as soon as feasible to all 1) postpartum women, 2) close
contacts of infants younger than age 12 months (e.g., grandparents and child-care providers), and 3) health-care personnel with direct patient
contact. Adults aged 65 years and older who have not previously receivedTdap and who have close contact with an infant aged less than 12 months
also should be vaccinated. Other adults aged 65 years and older may receive Tdap. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-containing vaccine.Adults with uncertain or incomplete history of completing a 3-dose primary vaccination series with Td-containing vaccines should begin or complete a primary vaccination series. For
unvaccinated adults, administer the first 2 doses at least 4 weeks apartand the third dose 6--12 months after the second. If incompletely vaccinated (i.e., less than 3 doses), administer remaining doses.
Substitute a one-time dose of Tdap for one of the doses of Td, either inthe primary series or for the routine booster, whichever comes first.
If a woman is pregnant and received the most
recent Td vaccination 10 or more years previously, administer Td during the second or third trimester. If the woman received the most recent Td
vaccination less than 10 years previously, administer Tdap during the immediate postpartum period. At the clinician's discretion, Td may be deferred during pregnancy and Tdap substituted in the immediate
postpartum period, or Tdap may be administered instead of Td to a pregnant woman after an informed discussion with the woman.The ACIP statement for recommendations for administering Td as prophylaxis in wound management is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.

Changes for 2011

The Td/Tdap vaccination footnote (#2) has language
added to indicate that persons aged 65 years and older who have close contact with an infant aged less than 12 months should get vaccinated
with Tdap; the additional language notes that all persons aged 65 years and older may get vaccinated with Tdap. Also added is the recommendation
to administer Tdap regardless of interval since the most recent Td-containing vaccine.
3. Varicella Vaccination

All adults without evidence of immunity to
varicella should receive 2 doses of single-antigen varicella vaccine if not previously vaccinated or a second dose if they have received only 1 dose, unless they have a medical contraindication. Special consideration
should be given to those who 1) have close contact with persons at highrisk for severe disease (e.g., health-care personnel and family contacts of persons with immunocompromising conditions) or 2) 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).Evidence of immunity to varicella in adults
includes any of the following: 1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for health-care personnel and pregnant women, birth before 1980 should not
be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health-care provider (for a patient reporting a history of or having an atypical case, a mild case, or both, health-care providers should seek either an epidemiologic link with a typical varicella case or to a laboratory-confirmed case or evidence of laboratory confirmation, if it was performed at the time of
acute disease); 4) history of herpes zoster based on diagnosis or verification of herpes zoster by a health-care provider; or
5) laboratory evidence of immunity or laboratory confirmation of disease.
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
4. Human Papillomavirus (HPV) Vaccination




HPV vaccination with either quadrivalent
(HPV4) vaccine or bivalent vaccine (HPV2) is recommended for females at
age 11 or 12 years and catch-up vaccination for females aged 13 through
26 years.
Ideally, vaccine should be administered
before potential exposure to HPV through sexual activity; however,
females who are sexually active should still be vaccinated consistent
with age-based recommendations. Sexually active females who have not
been infected with any of the four HPV vaccine types (types 6, 11, 16,
and 18, all of which HPV4 prevents) or any of the two HPV vaccine types
(types 16 and 18, both of which HPV2 prevents) receive the full benefit
of the vaccination. Vaccination is less beneficial for females who have
already been infected with one or more of the HPV vaccine types. HPV4 or
HPV2 can be administered to persons with a history of genital warts,
abnormal Papanicolaou test, or positive HPV DNA test, because these
conditions are not evidence of previous infection with all vaccine HPV
types.
HPV4 may be administered to males aged 9
through 26 years to reduce their likelihood of genital warts. HPV4 would
be most effective when administered before exposure to HPV through
sexual contact.
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.
Although HPV vaccination is not specifically
recommended for persons with the medical indications described in Figure
2, "Vaccines that might be indicated for adults based on medical and
other indications," it may be administered to these persons because the
HPV vaccine is not a live-virus vaccine. However, the immune response
and vaccine efficacy might be less for persons with the medical
indications described in Figure 2 than in persons who do not have the
medical indications described or who are immunocompetent.




Changes for 2011

The HPV vaccination footnote (#4) has language added
to the introductory sentences to indicate that either quadrivalent
vaccine or bivalent vaccine is recommended for females.
5. Herpes Zoster Vaccination




A single dose of zoster vaccine is
recommended for adults aged 60 years and older regardless of whether
they report a previous episode of herpes zoster. Persons with chronic
medical conditions may be vaccinated unless their condition constitutes a
contraindication.6. 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, laboratory evidence of
immunity to each of the three diseases, or documentation of
provider-diagnosed measles or mumps disease. For rubella, documentation
of provider-diagnosed disease is not considered acceptable evidence of
immunity.
Measles component: A second dose of MMR
vaccine, administered a minimum of 28 days after the first dose, is
recommended for adults who 1) have been recently exposed to measles or
are in an outbreak setting; 2) are students in postsecondary educational
institutions; 3) work in a health-care facility; or 4) 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 second dose of MMR
vaccine, administered a minimum of 28 days after the first dose, is
recommended for adults who 1) live in a community experiencing a mumps
outbreak and are in an affected age group; 2) are students in
postsecondary educational institutions; 3) work in a health-care
facility; or 4) 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 revaccinated 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.
Health-care personnel 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 1) consider
routinely vaccinating personnel with 2 doses of MMR vaccine at the
appropriate interval (for measles and mumps) and 1 dose of MMR vaccine
(for rubella), and 2) recommend 2 doses of MMR vaccine at the
appropriate interval during an outbreak of measles or mumps, and 1 dose
during an outbreak of rubella. Complete information about evidence of
immunity is available at http://www.cdc.gov/vaccines/recs/provisional/default.htm.




Changes for 2011

The MMR vaccination footnote (#6) has been revised
mainly by consolidating common language that previously had been part of
each of the three vaccine component sections into one introductory
statement.

7. Pneumococcal Polysaccharide (PPSV) Vaccination




Vaccinate all persons with the following indications:
Medical: Chronic lung disease
(including asthma); chronic cardiovascular diseases; diabetes mellitus;
chronic liver diseases; cirrhosis; chronic alcoholism; functional or
anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective
splenectomy is planned, vaccinate at least 2 weeks before surgery]);
immunocompromising conditions (including chronic renal failure or
nephrotic syndrome); and cochlear implants and cerebrospinal fluid
leaks. Vaccinate as close to HIV diagnosis as possible.
Other: Residents of nursing homes
or long-term care facilities and persons who smoke cigarettes. Routine
use of PPSV is not recommended for American Indians/Alaska Natives or
persons aged less than 65 years unless they have underlying medical
conditions that are PPSV indications. However, public health authorities
may consider recommending PPSV for American Indians/Alaska Natives and
persons aged 50 through 64 years who are living in areas where the risk
for invasive pneumococcal disease is increased.8. Revaccination with PPSV




One-time revaccination after 5 years 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. For persons aged 65 years and older,
one-time revaccination is recommended if they were vaccinated 5 or more
years previously and were aged less than 65 years at the time of primary
vaccination.




Changes for 2011

The revaccination with PPSV footnote (#8) clarifies
that one-time revaccination after 5 years only applies to persons with
indicated chronic conditions who are aged 19 through 64 years.9. Meningococcal Vaccination




Meningococcal vaccine should be administered to persons with the following indications:
Medical: A 2-dose series of
meningococcal conjugate vaccine is recommended for adults with anatomic
or functional asplenia, or persistent complement component deficiencies.
Adults with HIV infection who are vaccinated should also receive a
routine 2-dose series. The 2 doses should be administered at 0 and 2
months.
Other: A single dose of
meningococcal vaccine is recommended for unvaccinated first-year college
students living in dormitories; 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 (e.g., the "meningitis belt" of
sub-Saharan Africa during the dry season [December through June]),
particularly if their contact with local populations will be prolonged.
Vaccination is required by the government of Saudi Arabia for all
travelers to Mecca during the annual Hajj.
Meningococcal conjugate vaccine, quadrivalent
(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).




Changes for 2011

The meningococcal vaccination footnote (#9) has
language added to indicate that a 2-dose series of meningococcal
conjugate vaccine is recommended for adults with anatomic or functional
asplenia, or persistent complement component deficiencies, as well
adults with human immunodeficiency (HIV) virus infection who are
vaccinated. Language has been added that a single dose of meningococcal
vaccine is still recommended for those with other indications. Also,
language has been added to clarify that quadrivalent meningococcal
conjugate vaccine (MCV4) is a quadrivalent vaccine.10. Hepatitis A Vaccination




Vaccinate persons with any of the following
indications and any person seeking protection from hepatitis A virus
(HAV) infection:
Behavioral: Men who have sex with men and persons who use injection drugs.
Occupational: Persons working with HAV-infected primates or with HAV in a research laboratory setting.
Medical: Persons with chronic liver disease and persons who receive clotting factor concentrates.
Other: Persons traveling to or
working in countries that have high or intermediate endemicity of
hepatitis A (a list of countries is available at http://wwwn.cdc.gov/travel/contentdiseases.aspx).
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 should
be vaccinated. 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 0 and 6--12 months
(Havrix), or 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 12.11. Hepatitis B Vaccination




Vaccinate persons with any of the following
indications and any person seeking protection from hepatitis B virus
(HBV) infection:
Behavioral: 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.
Occupational: Health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids.
Medical: Persons with end-stage
renal disease, including patients receiving hemodialysis; persons with
HIV infection; and persons with chronic liver disease.
Other: Household contacts and sex
partners of persons with chronic HBV infection; 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 (a list of countries is available at
http://wwwn.cdc.gov/travel/contentdiseases.aspx).
Hepatitis B vaccination is recommended for
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
day-care 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,
administer 3 doses at 0, 1, and 6 months; alternatively, a 4-dose
Twinrix schedule, administered on days 0, 7, and 21 to 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 or 2 doses of 20 µg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months.12. 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 had a splenectomy, if they have not previously received Hib
vaccine.




Changes for 2011

The language for the selected conditions for the Hib
footnote (#12) has been shortened to clarify which persons at high risk
may receive 1 dose of Hib vaccine.13. Immunocompromising Conditions




Inactivated vaccines generally are acceptable
(e.g., pneumococcal, meningococcal, 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.