What vaccine should be given to a patient without an immunization record?

Vaccination Approach for Adults Without Immunization Records

Adults without documentation of vaccination should be assumed unvaccinated and receive all age-appropriate vaccines according to the current immunization schedule, as administering vaccines to previously immunized individuals poses no additional risk. 1

Core Principle for Unknown Vaccination Status

When vaccination records are unavailable, the standard approach is straightforward:

• Administer indicated vaccines rather than attempting serologic testing for most vaccines, as giving an extra dose to someone already immune is safe and avoids delays in protection 1
• The only exceptions where serologic testing may be considered are for MMR and varicella, though revaccination remains the preferred approach 1
• Military service history can be assumed to include vaccines recommended at time of service entry, but without specific records, proceed with age-appropriate vaccination 1

Essential Vaccines for All Adults (Age-Independent)

Tetanus-Diphtheria-Pertussis (Td/Tdap)

• Administer a complete 3-dose primary series if no documentation exists: first two doses at least 4 weeks apart, third dose 6-12 months after the second 1
• Substitute one dose of Tdap for Td (preferably the first dose), then continue with Td every 10 years 1
• Uncertain vaccination history should be treated as unvaccinated 1

Influenza

• Annual vaccination is recommended for all adults regardless of age 1
• Standard-dose inactivated vaccine for adults 18-64 years; high-dose or adjuvanted formulations for those ≥65 years 1

Hepatitis B

• Universal vaccination is now recommended for all adults aged 19-59 years 1
• HEPLISAV-B: 2-dose series at 0 and 1 month (preferred for efficiency) 1
• Alternative: 3-dose series (ENGERIX-B, Recombivax HB, or PreHevbrio) at 0,1, and 6 months 1

Age-Specific Vaccine Recommendations

Adults 19-49 Years

• MMR: 1-2 doses if born in 1957 or later without documentation of vaccination, physician-diagnosed disease, or laboratory immunity 1
  • Healthcare workers and other high-risk adults require 2 doses regardless of birth year 1
• Varicella: 2-dose series (at least 4 weeks apart) if no evidence of immunity 1
• HPV: 3-dose series (0,1-2, and 6 months) for adults through age 26; shared decision-making for ages 27-45 1

Adults 50-64 Years

• Pneumococcal vaccination if high-risk conditions present (chronic lung/heart disease, diabetes, immunocompromising conditions, smoking, alcoholism) 1
• Continue all core vaccines listed above

Adults ≥65 Years

• Pneumococcal vaccines: PCV15, PCV20, or PCV21 followed by PPSV23 based on specific sequencing guidelines 1
• Recombinant zoster vaccine (Shingrix): 2-dose series at 0 and 2-6 months 1
  • For immunocompetent adults: 8-12 weeks apart
  • For immunocompromised adults: 4-8 weeks apart 1
• High-dose or adjuvanted influenza vaccine preferred over standard dose 1
• RSV vaccine: single dose for adults ≥75 years or ages 60-74 with high-risk conditions 1

Additional Risk-Based Vaccines

Hepatitis A

• 2-dose series for: men who have sex with men, injection drug users, chronic liver disease, travel to endemic areas, close contact with international adoptees 1

Meningococcal

• MCV4 (2 doses, 2 months apart) for: functional/anatomic asplenia, complement deficiencies, HIV infection, microbiologists, travelers to endemic areas 1

Haemophilus influenzae type b (Hib)

• 1 or 3 doses for adults with anatomic/functional asplenia or hematopoietic stem cell transplant 1

Critical Implementation Points

When vaccines are indicated but status is uncertain, administer them immediately without waiting for records or serologic confirmation 1. This approach prioritizes protection over theoretical concerns about redundant vaccination.

For patients with immunocompromising conditions, complete all indicated vaccines at least 2 weeks before starting immunosuppressive therapy when possible 1. Live vaccines (MMR, varicella, zoster) should be given at least 4 weeks before immunosuppression or deferred until immune function recovers 1.

Intervals between doses longer than recommended do not require restarting the series—simply continue from where the patient left off to complete the total number of doses 1.