What vaccinations are recommended for adults?

Adult Vaccination Recommendations

All adults should receive annual influenza vaccination, Tdap (if not previously given), and age-appropriate vaccines including pneumococcal, zoster, HPV, and hepatitis vaccines based on specific criteria outlined below. 1

Universal Vaccinations for All Adults

Influenza Vaccine

• Administer annually to all adults aged 19 years and older, regardless of age or health status 2
• High-dose and adjuvanted formulations are available for adults aged 65 years and older to improve immune response 3
• No contraindication for egg allergy presenting only as hives; more severe egg allergies can still receive appropriate formulations 2

Tetanus, Diphtheria, and Pertussis (Tdap/Td)

• Tdap should replace a single dose of Td for all adults who have not previously received Tdap 1
• Administer Td booster every 10 years after the initial Tdap dose 2
• For adults never vaccinated against tetanus and diphtheria, initiate a 3-dose primary series 1
• Pregnant women should receive Tdap during the third trimester of each pregnancy (between 27-36 weeks) to prevent 50-90% of pertussis infections in infants 3

Age-Based Vaccinations

Human Papillomavirus (HPV)

• Females aged 19-26 years: Administer 3-dose series (0,1-2, and 6 months) if not previously vaccinated 2
• Males aged 19-21 years: Administer 3-dose series if not previously vaccinated 2
• Males aged 22-26 years: May be vaccinated based on individual discussion 2
• Men who have sex with men through age 26 years: Strongly recommended 2
• Either HPV4 (quadrivalent) or HPV2 (bivalent) for females; only HPV4 for males 2

Zoster (Shingles) Vaccine

• Administer a single dose of recombinant zoster vaccine (Shingrix) to all adults aged 60 years or older, regardless of prior herpes zoster episodes 2, 1
• Although FDA-approved for ages 50 and older, ACIP recommends starting at age 60 2
• Recombinant zoster vaccine (Shingrix) is strongly preferred over the older live vaccine 1, 3
• Can be administered to adults with chronic medical conditions unless severely immunodeficient 2
• If patient has had recent herpes zoster, wait at least 2 months after complete resolution before vaccinating 4

Pneumococcal Vaccines

PPSV23 (Pneumococcal Polysaccharide)

• All adults aged 65 years or older: Administer PPSV23 2
• Adults aged 19-64 years with specific conditions:
  • Chronic lung disease (COPD, emphysema, asthma) 2
  • Chronic cardiovascular disease 2
  • Diabetes mellitus 2
  • Chronic liver disease (cirrhosis, alcoholism) 2
  • Chronic renal failure or nephrotic syndrome 2
  • Immunocompromising conditions 2
  • Functional or anatomic asplenia (including sickle cell disease) 2
  • Cochlear implants or CSF leaks 2
  • Cigarette smokers 2
  • Residents of nursing homes or long-term care facilities 2

PCV13 (Pneumococcal Conjugate)

• Adults aged 19 years or older with immunocompromising conditions, functional/anatomic asplenia, CSF leaks, or cochlear implants:
  • If no prior pneumococcal vaccination: Give PCV13 first, then PPSV23 at least 8 weeks later 2
  • If previously received PPSV23: Give PCV13 at least 1 year after last PPSV23 dose 2

Revaccination with PPSV23

• One-time revaccination 5 years after first dose for adults aged 19-64 years with:
  • Chronic renal failure or nephrotic syndrome 2
  • Functional or anatomic asplenia 2
  • Immunocompromising conditions 2
• Adults who received PPSV23 before age 65: Give another dose at age 65 or later if at least 5 years have passed 2
• No further doses needed after vaccination at or after age 65 2

Measles, Mumps, Rubella (MMR)

• Adults born before 1957 are generally considered immune (exception: healthcare personnel and pregnant women should have documented immunity) 2
• Adults born in 1957 or later: Require documentation of at least 1 dose of MMR or laboratory evidence of immunity 1
• Two doses required for:
  • Healthcare personnel 2
  • Students in postsecondary educational institutions 2
  • International travelers 2
• Women of childbearing age without evidence of rubella immunity: Vaccinate if not pregnant; if pregnant, vaccinate immediately postpartum before hospital discharge 2

Varicella (Chickenpox)

• All adults without evidence of immunity: Administer 2 doses of varicella vaccine 4-8 weeks apart 2, 1
• Evidence of immunity includes:
  • Documentation of 2 doses of varicella vaccine at least 4 weeks apart 2
  • U.S.-born before 1980 (except healthcare personnel and pregnant women) 2
  • Healthcare provider-verified history of varicella or herpes zoster 2
  • Laboratory evidence of immunity 2
• Priority groups for vaccination:
  • Healthcare personnel 2
  • Family contacts of immunocompromised persons 2
  • Teachers and childcare employees 2
  • College students 2
  • Military personnel 2
  • Nonpregnant women of childbearing age 2
  • International travelers 2
• Pregnant women without immunity: Vaccinate immediately postpartum before hospital discharge 2

Risk-Based Vaccinations

Hepatitis A

Vaccinate any adult seeking protection and those with the following indications: 2

• Men who have sex with men 2
• Persons who use injection or non-injection illicit drugs 2
• Persons with chronic liver disease 2
• Persons who receive clotting factor concentrates 2
• Persons working with HAV-infected primates or HAV in research laboratories 2
• Travelers to countries with high or intermediate HAV endemicity 2
• Household contacts of international adoptees from endemic countries (first 60 days after arrival) 2

Dosing schedules: 2

• Havrix: 2 doses at 0 and 6-12 months 2
• Vaqta: 2 doses at 0 and 6-18 months 2
• Twinrix (combined hepatitis A and B): 3 doses at 0,1, and 6 months OR 4 doses at 0,7,21-30 days, and 12 months 2

Hepatitis B

Vaccinate any adult seeking protection and those with the following indications: 2

• Sexually active persons not in long-term mutually monogamous relationships (>1 sex partner in previous 6 months) 2
• Persons seeking evaluation or treatment for sexually transmitted diseases 2
• Current or recent injection drug users 2
• Men who have sex with men 2
• Healthcare personnel and public safety workers exposed to blood or body fluids 2
• Persons with end-stage renal disease including hemodialysis patients 2
• Persons with HIV infection 2
• Persons with chronic liver disease 2
• Persons with diabetes mellitus (consider for those aged 19-59 years; strongly recommended for those aged 60 years and older) 2
• Household contacts and sex partners of HBsAg-positive persons 2
• Residents and staff of facilities for developmentally disabled persons 2
• Inmates of correctional facilities 2
• International travelers to countries with high or intermediate HBV prevalence 2

Standard dosing: 3-dose series at 0,1, and 6 months 2, 5 Accelerated schedule with Twinrix: 4 doses at 0,7,21-30 days, and 12 months 2 Special formulations for hemodialysis patients: Higher doses (40 µg Recombivax HB or double dose of 20 µg Engerix-B) 2

Meningococcal Vaccines

MenACWY (Conjugate Vaccine)

Administer 2 doses at least 2 months apart to adults with: 2

• Functional or anatomic asplenia 2
• Persistent complement component deficiencies 2
• HIV infection 2

Administer single dose to: 2

• Microbiologists routinely exposed to Neisseria meningitidis 2
• Military recruits 2
• Travelers to or residents of countries with hyperendemic or epidemic meningococcal disease 2
• First-year college students through age 21 living in residence halls (if not vaccinated on or after 16th birthday) 2

Revaccinate every 5 years if risk remains 2 Preferred for adults aged 55 years or younger; MPSV4 preferred for adults aged 56 years or older 2

MenB (Serogroup B Vaccine)

Administer to adults with: 2

• Anatomic or functional asplenia 2
• Persistent complement component deficiencies 2
• Eculizumab use 2
• Microbiologists routinely exposed to Neisseria meningitidis 2

Dosing: 2

• MenB-4C (Bexsero): 2 doses at least 1 month apart 2
• MenB-FHbp (Trumenba): 3 doses at 0,1-2, and 6 months (if dose 2 given at least 6 months after dose 1, dose 3 not needed) 2
• Products are not interchangeable 2

Special Populations

Healthcare Personnel

• Must have documented evidence of immunity to measles, mumps, rubella, and varicella 2
• Healthcare personnel born before 1957: Consider 2 doses of MMR for measles/mumps or 1 dose for rubella if lacking laboratory evidence of immunity 2
• Annual influenza vaccination mandatory 2
• Hepatitis B vaccination series required 2

Immunocompromised Adults

• Inactivated vaccines generally acceptable; live vaccines generally contraindicated 2
• PCV13 followed by PPSV23 for those with immunocompromising conditions 2
• HPV vaccination recommended through age 26 years if not previously vaccinated 2
• MenACWY: 2-dose series with revaccination every 5 years 2
• Avoid live vaccines including MMR, varicella, and live zoster vaccine 2
• Recombinant zoster vaccine (Shingrix) can be administered as it is not live 6

Pregnant Women

• Tdap during third trimester (27-36 weeks) of each pregnancy 3
• Influenza vaccine during any trimester 2
• Assess for rubella and varicella immunity; if lacking, vaccinate immediately postpartum 2
• HPV, MMR, varicella, and live zoster vaccines contraindicated during pregnancy 2
• Delay MenB until after pregnancy unless at increased risk 2

Common Pitfalls to Avoid

• Not checking vaccination history leads to missed opportunities 1, 7
• Assuming birth before 1957 confers immunity to measles/mumps for healthcare personnel and pregnant women—it does not 2
• Administering only Td boosters without ever giving Tdap—all adults need at least one Tdap dose 1
• Delaying vaccination because "the patient is healthy"—many vaccines are age-based, not risk-based 8
• Not stocking vaccines in specialty practices, creating barriers to vaccination 9
• Forgetting that vaccine series do not need to be restarted regardless of time elapsed between doses 1
• Administering live vaccines to immunocompromised patients 2, 6
• Not documenting vaccines in immunization information systems 9
• Waiting too long after herpes zoster to give Shingrix—vaccinate at 2 months post-resolution, not 1 year 4