What are the recommended vaccination schedule and indications for adults?

Adult Vaccination Recommendations

All adults should receive annual influenza vaccination, Tdap (replacing one Td dose), and follow age-based schedules for pneumococcal, zoster, HPV, hepatitis A/B, meningococcal, and MMR vaccines based on specific age cutoffs and risk factors. 1, 2

Universal Vaccinations for All Adults

Influenza

• Annual vaccination required for all adults regardless of age or health status 3, 1
• Inactivated or recombinant vaccine for all adults
• Live attenuated vaccine (LAIV) only for healthy, non-pregnant adults <50 years without high-risk conditions and not contacts of severely immunocompromised persons 4

Tetanus, Diphtheria, Pertussis (Td/Tdap)

• One-time Tdap dose to replace Td for all adults 19-64 years who haven't received it previously 4
• Complete primary series (3 doses at 0,4 weeks, 6-12 months) if vaccination history uncertain 4
• Td or Tdap booster every 10 years after primary series 4
• Pregnant women: Tdap during second or third trimester if last Td ≥10 years ago, or Tdap immediately postpartum if last Td <10 years ago 4

Age-Based Vaccination Schedule

Ages 19-26 Years

• HPV vaccine: 2-3 doses depending on age at initiation (2 doses if started before age 15; 3 doses if started at 15 or later) 3
• May continue through age 26 for those not previously vaccinated 4

Ages 27-49 Years

• HPV: Shared clinical decision-making for ages 27-45 3
• Pneumococcal: Risk-based vaccination (see special situations below) 1

Ages 50-64 Years

• Pneumococcal PCV21 or PCV20: Universal recommendation starting at age 50 1
• Zoster (Shingles): 2 doses of recombinant zoster vaccine (RZV/Shingrix) starting at age 50 3

Ages 65+ Years

• Pneumococcal: One dose PPSV23 for all adults ≥65 years 3
  • If previously vaccinated with PPSV23 before age 65, give one-time revaccination if ≥5 years since first dose 4
• Zoster: 2 doses RZV if not previously vaccinated 3
• RSV: Universal vaccination for all adults ≥75 years 1
• RSV: Risk-based for ages 60-74 years with chronic heart/lung disease, diabetes, or other risk factors 1

Risk-Based and Indication-Specific Vaccinations

Pneumococcal (Ages 19-49)

Vaccinate if any of the following 4:

• Chronic lung disease (including asthma)
• Chronic cardiovascular disease
• Diabetes mellitus
• Chronic liver disease, cirrhosis, chronic alcoholism
• Chronic renal failure or nephrotic syndrome
• Functional or anatomic asplenia (vaccinate ≥2 weeks before elective splenectomy)
• Immunocompromising conditions (vaccinate HIV patients as close to diagnosis as possible)
• Cochlear implants or CSF leaks
• Cigarette smoking
• Nursing home residents

Revaccination: One-time after 5 years for chronic renal failure, asplenia, or immunocompromising conditions 4

Hepatitis A

Two-dose series (0 and 6-12 months for Havrix; 0 and 6-18 months for Vaqta) for 4:

• Chronic liver disease
• Clotting factor concentrate recipients
• Men who have sex with men
• Injection drug users
• Laboratory workers with HAV exposure
• Travelers to high/intermediate endemicity countries
• Anyone seeking protection

Hepatitis B

Three-dose series (0,1,6 months) for 4:

• End-stage renal disease/hemodialysis patients (use special high-dose formulation: 40 µg/mL Recombivax or double 20 µg/mL Engerix-B) 4
• HIV infection
• Chronic liver disease
• Healthcare personnel and public safety workers exposed to blood
• Sexually active persons not in long-term monogamous relationships (>1 partner in 6 months)
• STD evaluation/treatment seekers
• Current or recent injection drug users
• Men who have sex with men
• Household contacts/sex partners of HBV-infected persons
• Travelers to high/intermediate HBV prevalence countries
• Anyone seeking protection

Settings requiring universal vaccination: STD clinics, HIV testing facilities, drug treatment programs, correctional facilities, hemodialysis centers, developmental disability institutions 4

Meningococcal

MCV4 (conjugate vaccine preferred for age ≤55) for 4:

• Anatomic or functional asplenia
• Terminal complement component deficiencies
• HIV infection (2 doses at least 2 months apart) 5
• Microbiologists exposed to N. meningitidis
• Military recruits
• Travelers to hyperendemic/epidemic areas (e.g., sub-Saharan Africa "meningitis belt" December-June, Hajj pilgrims)
• First-year college students ≤21 years in dormitories (if not vaccinated after 16th birthday)

Revaccination: Every 5 years for those with ongoing risk 5

MMR (Measles, Mumps, Rubella)

• 1-2 doses for adults born in 1957 or later without evidence of immunity 3
• Healthcare personnel: 2 doses regardless of birth year 4
• Women of childbearing age: Verify rubella immunity; vaccinate if non-immune upon pregnancy completion/termination before hospital discharge 4
• Outbreak settings: Consider second dose for previously one-dose recipients 4

Varicella

• 2 doses for adults born in 1980 or later without evidence of immunity 3
• Evidence of immunity: documented 2-dose vaccination, laboratory confirmation, or healthcare provider-diagnosed/verified history of disease

COVID-19

• Follow current CDC recommendations for primary series and boosters based on age and immunocompromise status 2

Mpox

• Risk-based vaccination for specific exposures; not routinely recommended for healthcare personnel 1

Special Populations

Immunocompromised Patients

• Inactivated vaccines generally acceptable (pneumococcal, meningococcal, influenza inactivated) 4
• Live vaccines generally avoided (MMR, varicella, zoster live, LAIV) 4
• Vaccinate ≥2 weeks before starting immunosuppressive therapy when possible 5

Pregnant Women

• Tdap: Second or third trimester (or immediately postpartum) 4
• Influenza: Inactivated vaccine during any trimester 4
• RSV: Universal recommendation during pregnancy 1
• Avoid live vaccines (MMR, varicella, LAIV)

Healthcare Personnel

• Required: Influenza (annual), Tdap (one-time), hepatitis B (series) 4
• Verify immunity: MMR (2 doses), varicella (2 doses or evidence of immunity)

Common Pitfalls to Avoid

1. Don't delay Tdap waiting for 10-year Td interval - can give as short as 2 years after last Td 4
2. Don't skip pneumococcal vaccination in smokers or asthmatics - these are clear indications regardless of age <65 4
3. Don't use live vaccines in immunocompromised patients - includes LAIV, live zoster, MMR, varicella 4
4. Don't forget hepatitis B for diabetics <60 years - vaccinate as soon as feasible after diagnosis 5
5. Don't assume prior disease = immunity - verify with laboratory testing or documented vaccination for MMR, varicella, hepatitis A/B

The most recent 2025 guidelines 1 represent the current standard, with key updates including universal pneumococcal vaccination at age 50 (lowered from 65), universal RSV vaccination for adults ≥75 years and pregnant persons, and addition of PCV21 as a pneumococcal vaccine option.