What vaccinations are recommended for adult immunization?

Adult Immunization Recommendations

All adults should receive annual influenza vaccination, one-time Tdap followed by Td boosters every 10 years, and age-appropriate pneumococcal, zoster, and other vaccines based on specific risk factors and medical conditions. 1, 2

Universal Vaccinations for All Adults

Influenza Vaccination

• Annual influenza vaccination is recommended for all adults aged ≥19 years, regardless of health status 3, 1, 2
• Adults aged ≥65 years should preferentially receive high-dose inactivated influenza vaccine, recombinant influenza vaccine, or adjuvanted inactivated influenza vaccine for enhanced protection 1, 2
• Pregnant women should receive inactivated influenza vaccine during any trimester of pregnancy 4, 2
• Live attenuated influenza vaccine (LAIV) is contraindicated in pregnancy 4

Tetanus, Diphtheria, and Pertussis (Tdap/Td)

• All adults should receive one dose of Tdap if not previously received, followed by Td or Tdap booster every 10 years 3, 1, 2
• Pregnant women should receive Tdap during each pregnancy, preferably between 27-36 weeks gestation, regardless of interval since prior Td or Tdap 4, 2
• Adults with uncertain vaccination histories should complete a 3-dose primary series: first 2 doses at least 4 weeks apart, third dose 6-12 months after the second 2

COVID-19 Vaccination

• COVID-19 vaccination is recommended for all adults with a primary series (2-3 doses) plus boosters 2
• Moderately or severely immunocompromised individuals may require 3 doses for the primary series 2

Age-Based Vaccination Recommendations

Ages 19-26 Years

• HPV vaccination: 2-3 dose series depending on age at initial vaccination 3, 1, 2
• Measles, mumps, rubella (MMR): 1-2 doses for adults born in 1957 or later without evidence of immunity 3, 1
• Varicella: 2 doses for adults born in 1980 or later without evidence of immunity 3, 1

Ages 27-45 Years

• HPV vaccination based on shared clinical decision-making 3, 1, 2
• Hepatitis A: 2-3 doses depending on vaccine for those at risk 3, 1, 2
• Hepatitis B: 2-3 doses depending on vaccine for those at risk 3, 1, 2

Ages 50-64 Years

• Recombinant zoster vaccine (RZV): 2 doses, 2-6 months apart (preferred over live zoster vaccine) 3, 1, 2

Ages ≥65 Years

• Pneumococcal vaccination: PCV13 based on shared clinical decision-making, followed by PPSV23 3, 1
• For immunocompetent adults ≥65 years who previously did not receive PCV13: 1 dose PCV13 followed by 1 dose PPSV23 at least 1 year after PCV13 and at least 5 years after last dose PPSV23 3
• PPSV23 is recommended for all adults ≥65 years 3, 1

Medical Condition-Based Recommendations

Immunocompromising Conditions

• Pneumococcal vaccination is strongly recommended with both PCV13 and PPSV23 3, 1, 2
• For adults aged 19+ years with immunocompromising conditions: 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later, then another dose PPSV23 at least 5 years after previous PPSV23 3
• Live vaccines (MMR, varicella, LAIV, live zoster vaccine) are contraindicated 3, 1, 4, 2
• 2-dose primary series of MenACWY for adults with HIV 3, 1, 2
• Hepatitis B vaccination recommended for adults with HIV infection 2

Chronic Medical Conditions

• Pneumococcal vaccination (PPSV23) recommended for adults aged 19-64 years with chronic heart disease (excluding hypertension), chronic lung disease (including asthma), diabetes mellitus, chronic liver disease, or alcoholism 3, 1, 2
• Hepatitis B vaccination recommended for adults with chronic liver disease, including hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and elevated liver enzymes 3, 1, 2
• For adults with end-stage renal disease/hemodialysis: special high-dose hepatitis B formulation (40 µg/mL Recombivax HB or 2 doses of 20 µg/mL Engerix-B administered simultaneously) 2

Asplenia and Complement Deficiencies

• Pneumococcal, meningococcal (both MenACWY and MenB), and Haemophilus influenzae type b vaccines recommended 3, 1, 2
• For MenB: 2-dose series MenB-4C (Bexsero) at least 1 month apart, or 3-dose series MenB-FHbp (Trumenba) at 0,1-2,6 months 3
• MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series) 3

Risk Factor-Based Recommendations

Occupational Indications

• Healthcare personnel: hepatitis B vaccination, annual influenza vaccination, MMR (2-dose series for those born in 1957 or later), and varicella (2-dose series if no evidence of immunity) 3, 2
• Microbiologists routinely exposed to Neisseria meningitidis: meningococcal vaccination 3, 2
• Persons working with hepatitis A virus in laboratory settings: hepatitis A vaccination 3, 2

Behavioral Risk Factors

• Men who have sex with men: hepatitis A and hepatitis B vaccination 3, 2
• Current or recent injection drug users: hepatitis A and hepatitis B vaccination 3, 2
• Sexually active persons not in long-term monogamous relationships: hepatitis B vaccination 2

Travel Indications

• Hepatitis A vaccination for persons traveling to countries with high or intermediate endemicity 3, 2
• Administer hepatitis A vaccine at least 2 weeks prior to expected exposure 5

Special Populations

Pregnancy

• Tdap during each pregnancy (27-36 weeks gestation) and inactivated influenza vaccine during any trimester are universally recommended 4, 2
• Live vaccines (MMR, varicella, LAIV, live zoster vaccine) are absolutely contraindicated 3, 4
• HPV vaccine should be delayed until postpartum, but if inadvertently given during pregnancy, no intervention is needed 4
• Recombinant zoster vaccine (RZV) should be delayed until after pregnancy 4
• MenB should be deferred unless the pregnant woman is at increased risk for serogroup B meningococcal disease 4
• Heplisav-B (2-dose hepatitis B vaccine) should not be used in pregnancy due to lack of safety data 3

Healthcare Personnel

• 2-dose series MMR for those born in 1957 or later with no evidence of immunity; consider 2-dose series even for those born before 1957 3
• 2-dose varicella series if no evidence of immunity, regardless of birth year 3
• Annual influenza vaccination 3
• Hepatitis B vaccination 2

Key Implementation Considerations

Vaccine Administration Principles

• Vaccine series do not need to be restarted regardless of time elapsed between doses 1, 2
• A 2-dose hepatitis B vaccine series (Heplisav-B) can be administered at least 4 weeks apart for adults ≥18 years 1, 2
• Hepatitis A vaccine: 2-dose schedule at 0 and 6-12 months (Havrix) or 0 and 6-18 months (Vaqta) 3

Common Pitfalls to Avoid

• Do not delay Tdap in pregnancy due to recent Td vaccination; Tdap should be given during each pregnancy 4, 2
• Do not assume adults born before 1980 are immune to varicella if they are healthcare personnel or pregnant women 2
• Do not use live vaccines in immunocompromised patients 2
• Do not restart vaccine series if doses are delayed; continue where left off 1, 2
• Do not withhold MenACWY vaccine in pregnancy if indicated, unlike MenB which should be deferred unless risk factors are present 4

Strategies to Improve Coverage

• Assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines 6
• Implementation of reminder-recall systems 6
• Use of standing-order programs for vaccination 6
• Assessment of practice-level vaccination rates with feedback to staff members 6