Practice Guidelines

The 2005 Recommended Adult Immunization Schedule, United States, October 2004–September 2005

Am Fam Physician. 2004 Dec 15;70(12):2372-2375.

Cooperation continues between the American Academy of Family Physicians (AAFP), the Advisory Committee on Immunization Practices (ACIP), and the American College of Obstetricians and Gynecologists (ACOG) with the publication of the Recommended Adult Immunization Schedule by Age Group, Medical, and other Conditions, United States, October 2004–September 2005 (Figures 1 and 2). The age-based schedule is similar to the 2004 schedule, but there are two changes for medical conditions: (1) the addition of vaccines indicated for health care workers and (2) a change in color coding to differentiate vaccines when there is lack of documentation of immunity (green) and vaccines for persons at risk because of medical or exposure indications (lavender). The following examples may make this more clear.

Under the pregnancy column in Figure 2, influenza vaccine and tetanus and diphtheria (Td) boosters are indicated (as shown by the yellow bar). Hepatitis B vaccine is only indicated in women who are pregnant if they have a medical or exposure indication, such as sexually transmitted diseases or multiple sexual partners (as shown by the lavender bar). Measles, mumps, rubella (MMR), and varicella vaccines are contraindicated during pregnancy (as is shown in red).

Under the chronic disease column that includes diabetes and chronic pulmonary disease (Figure 2), influenza and pneumococcal polysaccharide vaccines are indicated (as shown in yellow). Because the influenza and pneumococcal mortality rates primarily are determined by the number of high-risk medical conditions, vaccination of high-risk persons is particularly important. Hepatitis A and B vaccines (as shown by the lavender bars) are only indicated for those with medical or exposure indications; footnote I (Figure 2) clarifies that all persons with chronic liver disease should be vaccinated against hepatitis A unless already immune. MMR and varicella vaccines are indicated if the person lacks documentation of previous vaccination or evidence of disease (as shown by the green bar).

Under the column for health care workers, vaccination is indicated against influenza (as is shown in yellow). Indeed, the best predictor of influenza attack rates in long-term care facilities is vaccination rates of the staff, not vaccination rates of patients. Pneumococcal polysaccharide vaccine is only indicated if the worker has a personal medical or exposure indication (as shown in lavender). Health care workers should have documented immunity or prior immunization to MMR, varicella, Td, and hepatitis B (as shown by the green bars and explained in detail in the footnotes on the last page of the schedule).

This fall, there has been a major shortage of inactivated influenza vaccine, as all clinicians are undoubtedly aware. The Centers for Disease Control and Prevention (CDC) is a good source of information about the shortage (http://www.cdc.gov/flu). One way to save inactivated influenza vaccine for high-risk groups is for health care workers and parents of infants less than six months of age to receive live, attenuated influenza vaccine (LAIV; FluMist). It is licensed for healthy persons five to 49 years of age. LAIV contains cold-adapted viruses that do not replicate well in the lower airways. LAIV can be given to health care workers as long as they are not in units with the most severely immunocompromised persons during the time that the patient needs reverse (protective) isolation (such as, bone marrow transplant unit); health care workers who are around persons infected with human immunodeficiency virus (HIV) and patients who are on dialysis can receive LAIV (see CDC publications1 for details). Although the optimal influenza vaccination season is October and November, influenza vaccine can be given December through March in persons who were not vaccinated during the fall.

Recommended adult immunization schedule, by vaccine and age group—United States, October 2004–September 2005.

Figure 1.

*—Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons aged ≥19 years. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. Providers should consult manufacturers’ package inserts for detailed recommendations. Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by telephone, 800-822-7967, or from the VAERS Website at http://www.vaers.hhs.gov. Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/osp/vicp or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place NW, Washington, DC 20005, telephone 202-219-9657. Additional information about the vaccines listed above and contraindications for immunization is available at http://www.cdc.gov/nip or from the National Immunization Hotline, 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP).

1. Tetanus and diphtheria (Td). Adults, including pregnant women with uncertain history of a complete primary vaccination series, should receive a primary series of Td. A primary series for adults is 3 doses; administer the first 2 doses at least 4 weeks apart and the 3rd dose 6–12 months after the second. Administer 1 dose if the person received the primary series and if the last vaccination was received ≥ 10 years previously. Consult recommendations for administering Td as prophylaxis in wound management (see MMWR 1991;40[RR-10]). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster.

2. Influenza vaccination. The Advisory Committee on Immunization Practices (ACIP) recommends inactivated influenza vaccination for the following indications, when vaccine is available. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]); and pregnancy during the influenza season. Occupational indications: health care workers and employees of long-term–care and assisted living facilities. Other indications: residents of nursing homes and other long-term–care facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home caregivers to persons with medical indications, household/close contacts and out-of-home caregivers of children aged 0–23 months, household members and caregivers of elderly persons and adults with high-risk conditions); and anyone who wishes to be vaccinated. For healthy persons aged 5–49 years without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, either the inactivated vaccine or the intranasally administered influenza vaccine (FluMist) may be administered (see MMWR 2004;53[RR-6]).note: Because of the vaccine shortage for the 2004–05 influenza season, CDC has recommended that vaccination be restricted to the following priority groups, which are considered to be of equal importance: all children aged 6–23 months; adults aged ≥ 65 years; persons aged 2–64 years with underlying chronic medical conditions; all women who will be pregnant during the influenza season; residents of nursing homes and long-term–care facilities; children aged 6 months–18 years on chronic aspirin therapy; health-care workers involved in direct patient care; and out-of-home caregivers and household contacts of children aged <6 months. For the 2004–05 season, intranasally administered, live, attenuated influenza vaccine, if available, should be encouraged for healthy persons who are aged 5–49 years and are not pregnant, including health-care workers (except those who care for severely immunocompromised patients in special care units) and persons caring for children aged <6 months (see MMWR 2004;53:923–4).

3. Pneumococcal polysaccharide vaccination.Medical indications: chronic disorders of the pulmonary system (excluding asthma); cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids; or cochlear implants. Geographic/other indications: Alaska Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term–care facilities (see MMWR 1997;46[RR-8] and MMWR 2003;52:739–40).

4. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons aged ≥ 65 years, one-time revaccination if they were vaccinated ≥ 5 years previously and were aged <65 years at the time of primary vaccination (see MMWR 1997;46[RR-8]).

5. Hepatitis B vaccination.Medical indications: hemodialysis patients or patients who receive clotting factor concentrates. Occupational indications: health care workers and public safety workers who have exposure to blood in the workplace; and persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injection-drug users; persons with more than one sex partner during the previous 6 months; persons with a recently acquired sexually transmitted disease (STD); all clients in STD clinics; and men who have sex with men. Other indications: household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for the developmentally disabled; inmates of correctional facilities; or international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for >6 months (http://www.cdc.gov/travel/diseases/hbv.htm) (see MMWR 1991;40[RR-13]).

6. Hepatitis A vaccination.Medical indications: persons with clotting factor disorders or chronic liver disease. Behavioral indications: men who have sex with men or users of illegal drugs. Occupational indications: persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. If the combination hepatitis A and hepatitis B vaccine is used, administer 3 doses at 0, 1, and 6 months (http://www.cdc.gov/travel/diseases/hav. htm) (see MMWR 1999;48[RR-12]).

7. Measles, mumps, rubella (MMR) vaccination.Measles component: adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive ≥ 1 dose of MMR unless they have a medical contraindication, documentation of ≥ 1 dose, or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who: (1) were recently exposed to measles or in an outbreak setting, (2) were previously vaccinated with killed measles vaccine, (3) were vaccinated with an unknown vaccine during 1963–1967, (4) are students in postsecondary educational institutions, (5) work in health care facilities, or (6) plan to travel internationally. Mumps component: 1 dose of MMR vaccine should be adequate for protection. Rubella component: Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1998;47[RR-8] and MMWR 2001;50:1117).

8. Varicella vaccination. Recommended for all persons lacking a reliable clinical history of varicella infection or serologic evidence of varicella zoster virus (VZV) infection who might be at high risk for exposure or transmission. This includes health care workers and family contacts of immunocompromised persons; persons who live or work in environments where transmission is likely (e.g., teachers of young children, child care employees, and residents and staff members in institutional settings); persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates, and staff members of correctional institutions, and military personnel); adolescents aged 11–18 years and adults living in households with children; women who are not pregnant but who might become pregnant; and international travelers who are not immune to infection. NOTE: Approximately 95% of U.S.-born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1999;48 [RR-6]).

9. Meningococcal vaccine (quadrivalent polysaccharide for sero-groups A, C, Y, and W 135).Medical indications: adults with terminal complement component deficiencies or those with anatomic or functional asplenia. Other indications: travelers to countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa and Mecca, Saudi Arabia). Revaccination after 3–5 years might be indicated for persons at high risk for infection (e.g., persons residing in areas where disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and availability of the vaccine to enable them to make an educated decision about receiving the vaccination (see MMWR 2000;49[RR-7]). The American Academy of Family Physicians recommends that colleges should take the lead on providing education on meningococcal infection and availability of vaccination and offer it to students who are interested. Physicians need not initiate discussion of meningococcal quadrivalent polysaccharide vaccine as part of routine medical care.

View Large

Recommended adult immunization schedule, by vaccine and age group—United States, October 2004–September 2005.


Figure 1.

*—Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons aged ≥19 years. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. Providers should consult manufacturers’ package inserts for detailed recommendations. Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by telephone, 800-822-7967, or from the VAERS Website at http://www.vaers.hhs.gov. Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/osp/vicp or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place NW, Washington, DC 20005, telephone 202-219-9657. Additional information about the vaccines listed above and contraindications for immunization is available at http://www.cdc.gov/nip or from the National Immunization Hotline, 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP).

1. Tetanus and diphtheria (Td). Adults, including pregnant women with uncertain history of a complete primary vaccination series, should receive a primary series of Td. A primary series for adults is 3 doses; administer the first 2 doses at least 4 weeks apart and the 3rd dose 6–12 months after the second. Administer 1 dose if the person received the primary series and if the last vaccination was received ≥ 10 years previously. Consult recommendations for administering Td as prophylaxis in wound management (see MMWR 1991;40[RR-10]). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster.

2. Influenza vaccination. The Advisory Committee on Immunization Practices (ACIP) recommends inactivated influenza vaccination for the following indications, when vaccine is available. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]); and pregnancy during the influenza season. Occupational indications: health care workers and employees of long-term–care and assisted living facilities. Other indications: residents of nursing homes and other long-term–care facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home caregivers to persons with medical indications, household/close contacts and out-of-home caregivers of children aged 0–23 months, household members and caregivers of elderly persons and adults with high-risk conditions); and anyone who wishes to be vaccinated. For healthy persons aged 5–49 years without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, either the inactivated vaccine or the intranasally administered influenza vaccine (FluMist) may be administered (see MMWR 2004;53[RR-6]).note: Because of the vaccine shortage for the 2004–05 influenza season, CDC has recommended that vaccination be restricted to the following priority groups, which are considered to be of equal importance: all children aged 6–23 months; adults aged ≥ 65 years; persons aged 2–64 years with underlying chronic medical conditions; all women who will be pregnant during the influenza season; residents of nursing homes and long-term–care facilities; children aged 6 months–18 years on chronic aspirin therapy; health-care workers involved in direct patient care; and out-of-home caregivers and household contacts of children aged <6 months. For the 2004–05 season, intranasally administered, live, attenuated influenza vaccine, if available, should be encouraged for healthy persons who are aged 5–49 years and are not pregnant, including health-care workers (except those who care for severely immunocompromised patients in special care units) and persons caring for children aged <6 months (see MMWR 2004;53:923–4).

3. Pneumococcal polysaccharide vaccination.Medical indications: chronic disorders of the pulmonary system (excluding asthma); cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids; or cochlear implants. Geographic/other indications: Alaska Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term–care facilities (see MMWR 1997;46[RR-8] and MMWR 2003;52:739–40).

4. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons aged ≥ 65 years, one-time revaccination if they were vaccinated ≥ 5 years previously and were aged <65 years at the time of primary vaccination (see MMWR 1997;46[RR-8]).

5. Hepatitis B vaccination.Medical indications: hemodialysis patients or patients who receive clotting factor concentrates. Occupational indications: health care workers and public safety workers who have exposure to blood in the workplace; and persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injection-drug users; persons with more than one sex partner during the previous 6 months; persons with a recently acquired sexually transmitted disease (STD); all clients in STD clinics; and men who have sex with men. Other indications: household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for the developmentally disabled; inmates of correctional facilities; or international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for >6 months (http://www.cdc.gov/travel/diseases/hbv.htm) (see MMWR 1991;40[RR-13]).

6. Hepatitis A vaccination.Medical indications: persons with clotting factor disorders or chronic liver disease. Behavioral indications: men who have sex with men or users of illegal drugs. Occupational indications: persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. If the combination hepatitis A and hepatitis B vaccine is used, administer 3 doses at 0, 1, and 6 months (http://www.cdc.gov/travel/diseases/hav. htm) (see MMWR 1999;48[RR-12]).

7. Measles, mumps, rubella (MMR) vaccination.Measles component: adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive ≥ 1 dose of MMR unless they have a medical contraindication, documentation of ≥ 1 dose, or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who: (1) were recently exposed to measles or in an outbreak setting, (2) were previously vaccinated with killed measles vaccine, (3) were vaccinated with an unknown vaccine during 1963–1967, (4) are students in postsecondary educational institutions, (5) work in health care facilities, or (6) plan to travel internationally. Mumps component: 1 dose of MMR vaccine should be adequate for protection. Rubella component: Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1998;47[RR-8] and MMWR 2001;50:1117).

8. Varicella vaccination. Recommended for all persons lacking a reliable clinical history of varicella infection or serologic evidence of varicella zoster virus (VZV) infection who might be at high risk for exposure or transmission. This includes health care workers and family contacts of immunocompromised persons; persons who live or work in environments where transmission is likely (e.g., teachers of young children, child care employees, and residents and staff members in institutional settings); persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates, and staff members of correctional institutions, and military personnel); adolescents aged 11–18 years and adults living in households with children; women who are not pregnant but who might become pregnant; and international travelers who are not immune to infection. NOTE: Approximately 95% of U.S.-born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1999;48 [RR-6]).

9. Meningococcal vaccine (quadrivalent polysaccharide for sero-groups A, C, Y, and W 135).Medical indications: adults with terminal complement component deficiencies or those with anatomic or functional asplenia. Other indications: travelers to countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa and Mecca, Saudi Arabia). Revaccination after 3–5 years might be indicated for persons at high risk for infection (e.g., persons residing in areas where disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and availability of the vaccine to enable them to make an educated decision about receiving the vaccination (see MMWR 2000;49[RR-7]). The American Academy of Family Physicians recommends that colleges should take the lead on providing education on meningococcal infection and availability of vaccination and offer it to students who are interested. Physicians need not initiate discussion of meningococcal quadrivalent polysaccharide vaccine as part of routine medical care.

Recommended adult immunization schedule, by vaccine and age group—United States, October 2004–September 2005.


Figure 1.

*—Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons aged ≥19 years. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components are not contraindicated. Providers should consult manufacturers’ package inserts for detailed recommendations. Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by telephone, 800-822-7967, or from the VAERS Website at http://www.vaers.hhs.gov. Information on how to file a Vaccine Injury Compensation Program claim is available at http://www.hrsa.gov/osp/vicp or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place NW, Washington, DC 20005, telephone 202-219-9657. Additional information about the vaccines listed above and contraindications for immunization is available at http://www.cdc.gov/nip or from the National Immunization Hotline, 800-232-2522 (English) or 800-232-0233 (Spanish). Approved by the Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP).

1. Tetanus and diphtheria (Td). Adults, including pregnant women with uncertain history of a complete primary vaccination series, should receive a primary series of Td. A primary series for adults is 3 doses; administer the first 2 doses at least 4 weeks apart and the 3rd dose 6–12 months after the second. Administer 1 dose if the person received the primary series and if the last vaccination was received ≥ 10 years previously. Consult recommendations for administering Td as prophylaxis in wound management (see MMWR 1991;40[RR-10]). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster.

2. Influenza vaccination. The Advisory Committee on Immunization Practices (ACIP) recommends inactivated influenza vaccination for the following indications, when vaccine is available. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus [HIV]); and pregnancy during the influenza season. Occupational indications: health care workers and employees of long-term–care and assisted living facilities. Other indications: residents of nursing homes and other long-term–care facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home caregivers to persons with medical indications, household/close contacts and out-of-home caregivers of children aged 0–23 months, household members and caregivers of elderly persons and adults with high-risk conditions); and anyone who wishes to be vaccinated. For healthy persons aged 5–49 years without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, either the inactivated vaccine or the intranasally administered influenza vaccine (FluMist) may be administered (see MMWR 2004;53[RR-6]).note: Because of the vaccine shortage for the 2004–05 influenza season, CDC has recommended that vaccination be restricted to the following priority groups, which are considered to be of equal importance: all children aged 6–23 months; adults aged ≥ 65 years; persons aged 2–64 years with underlying chronic medical conditions; all women who will be pregnant during the influenza season; residents of nursing homes and long-term–care facilities; children aged 6 months–18 years on chronic aspirin therapy; health-care workers involved in direct patient care; and out-of-home caregivers and household contacts of children aged <6 months. For the 2004–05 season, intranasally administered, live, attenuated influenza vaccine, if available, should be encouraged for healthy persons who are aged 5–49 years and are not pregnant, including health-care workers (except those who care for severely immunocompromised patients in special care units) and persons caring for children aged <6 months (see MMWR 2004;53:923–4).

3. Pneumococcal polysaccharide vaccination.Medical indications: chronic disorders of the pulmonary system (excluding asthma); cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids; or cochlear implants. Geographic/other indications: Alaska Natives and certain American Indian populations. Other indications: residents of nursing homes and other long-term–care facilities (see MMWR 1997;46[RR-8] and MMWR 2003;52:739–40).

4. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkins disease, generalized malignancy, or organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or long-term systemic corticosteroids. For persons aged ≥ 65 years, one-time revaccination if they were vaccinated ≥ 5 years previously and were aged <65 years at the time of primary vaccination (see MMWR 1997;46[RR-8]).

5. Hepatitis B vaccination.Medical indications: hemodialysis patients or patients who receive clotting factor concentrates. Occupational indications: health care workers and public safety workers who have exposure to blood in the workplace; and persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injection-drug users; persons with more than one sex partner during the previous 6 months; persons with a recently acquired sexually transmitted disease (STD); all clients in STD clinics; and men who have sex with men. Other indications: household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff members of institutions for the developmentally disabled; inmates of correctional facilities; or international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for >6 months (http://www.cdc.gov/travel/diseases/hbv.htm) (see MMWR 1991;40[RR-13]).

6. Hepatitis A vaccination.Medical indications: persons with clotting factor disorders or chronic liver disease. Behavioral indications: men who have sex with men or users of illegal drugs. Occupational indications: persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A. If the combination hepatitis A and hepatitis B vaccine is used, administer 3 doses at 0, 1, and 6 months (http://www.cdc.gov/travel/diseases/hav. htm) (see MMWR 1999;48[RR-12]).

7. Measles, mumps, rubella (MMR) vaccination.Measles component: adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive ≥ 1 dose of MMR unless they have a medical contraindication, documentation of ≥ 1 dose, or other acceptable evidence of immunity. A second dose of MMR is recommended for adults who: (1) were recently exposed to measles or in an outbreak setting, (2) were previously vaccinated with killed measles vaccine, (3) were vaccinated with an unknown vaccine during 1963–1967, (4) are students in postsecondary educational institutions, (5) work in health care facilities, or (6) plan to travel internationally. Mumps component: 1 dose of MMR vaccine should be adequate for protection. Rubella component: Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable and counsel women to avoid becoming pregnant for 4 weeks after vaccination. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1998;47[RR-8] and MMWR 2001;50:1117).

8. Varicella vaccination. Recommended for all persons lacking a reliable clinical history of varicella infection or serologic evidence of varicella zoster virus (VZV) infection who might be at high risk for exposure or transmission. This includes health care workers and family contacts of immunocompromised persons; persons who live or work in environments where transmission is likely (e.g., teachers of young children, child care employees, and residents and staff members in institutional settings); persons who live or work in environments where VZV transmission can occur (e.g., college students, inmates, and staff members of correctional institutions, and military personnel); adolescents aged 11–18 years and adults living in households with children; women who are not pregnant but who might become pregnant; and international travelers who are not immune to infection. NOTE: Approximately 95% of U.S.-born adults are immune to VZV. Do not vaccinate pregnant women or those planning to become pregnant during the next 4 weeks. For women who are pregnant and susceptible, vaccinate as early in the postpartum period as possible (see MMWR 1999;48 [RR-6]).

9. Meningococcal vaccine (quadrivalent polysaccharide for sero-groups A, C, Y, and W 135).Medical indications: adults with terminal complement component deficiencies or those with anatomic or functional asplenia. Other indications: travelers to countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa and Mecca, Saudi Arabia). Revaccination after 3–5 years might be indicated for persons at high risk for infection (e.g., persons residing in areas where disease is epidemic). Counsel college freshmen, especially those who live in dormitories, regarding meningococcal disease and availability of the vaccine to enable them to make an educated decision about receiving the vaccination (see MMWR 2000;49[RR-7]). The American Academy of Family Physicians recommends that colleges should take the lead on providing education on meningococcal infection and availability of vaccination and offer it to students who are interested. Physicians need not initiate discussion of meningococcal quadrivalent polysaccharide vaccine as part of routine medical care.

Recommended adult immunization schedule, by vaccine and medical and other indications—United States, October 2004–September 2005.

Figure 2.

*—Covered by the Vaccine Injury Compensation Program.

—Cerebrospinal fluid.

§—Human immunodeficiency virus.

Special Notes for Medical and Other Indications

A. Although chronic liver disease and alcoholism are not indications for influenza vaccination, administer 1 dose annually if the patient is aged ≥ 50 years, has other indications for influenza vaccine, or requests vaccination.

B. Asthma is an indication for influenza vaccination but not for pneumococcal vaccination.

C. No data exist specifically on the risk for severe or complicated influenza infections among persons with asplenia. However, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia.

D. For persons aged <65 years, revaccinate once after ≥ 5 years have elapsed since initial vaccination.

E. Administer meningococcal vaccine and consider Haemophilus influenzae type B vaccine.

F. For persons undergoing elective splenectomy, vaccinate ≥ 2 weeks before surgery. G. Vaccinate as soon after diagnosis as possible.

H. For hemodialysis patients, use special formulation of vaccine (40 μg/mL) or two 20 μg/mL doses administered at one body site. Vaccinate early in the course of renal disease. Assess antibody titers to hepatitis B surface antigen (anti-HB) levels annually. Administer additional doses if anti-HB levels decline to <10 mIU/mL.

I. For all persons with chronic liver disease.

J. Withhold MMR or other measles-containing vaccines from HIV-infected persons with evidence of severe immunosuppression (see MMWR 1998;47 [RR-8]:21–2 and MMWR 2002;51[RR-2]:22–4).

K. Persons with impaired humoral immunity but intact cellular immunity may be vaccinated (see MMWR 1999;48[RR-6]).

View Large

Recommended adult immunization schedule, by vaccine and medical and other indications—United States, October 2004–September 2005.


Figure 2.

*—Covered by the Vaccine Injury Compensation Program.

—Cerebrospinal fluid.

§—Human immunodeficiency virus.

Special Notes for Medical and Other Indications

A. Although chronic liver disease and alcoholism are not indications for influenza vaccination, administer 1 dose annually if the patient is aged ≥ 50 years, has other indications for influenza vaccine, or requests vaccination.

B. Asthma is an indication for influenza vaccination but not for pneumococcal vaccination.

C. No data exist specifically on the risk for severe or complicated influenza infections among persons with asplenia. However, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia.

D. For persons aged <65 years, revaccinate once after ≥ 5 years have elapsed since initial vaccination.

E. Administer meningococcal vaccine and consider Haemophilus influenzae type B vaccine.

F. For persons undergoing elective splenectomy, vaccinate ≥ 2 weeks before surgery. G. Vaccinate as soon after diagnosis as possible.

H. For hemodialysis patients, use special formulation of vaccine (40 μg/mL) or two 20 μg/mL doses administered at one body site. Vaccinate early in the course of renal disease. Assess antibody titers to hepatitis B surface antigen (anti-HB) levels annually. Administer additional doses if anti-HB levels decline to <10 mIU/mL.

I. For all persons with chronic liver disease.

J. Withhold MMR or other measles-containing vaccines from HIV-infected persons with evidence of severe immunosuppression (see MMWR 1998;47 [RR-8]:21–2 and MMWR 2002;51[RR-2]:22–4).

K. Persons with impaired humoral immunity but intact cellular immunity may be vaccinated (see MMWR 1999;48[RR-6]).

Recommended adult immunization schedule, by vaccine and medical and other indications—United States, October 2004–September 2005.


Figure 2.

*—Covered by the Vaccine Injury Compensation Program.

—Cerebrospinal fluid.

§—Human immunodeficiency virus.

Special Notes for Medical and Other Indications

A. Although chronic liver disease and alcoholism are not indications for influenza vaccination, administer 1 dose annually if the patient is aged ≥ 50 years, has other indications for influenza vaccine, or requests vaccination.

B. Asthma is an indication for influenza vaccination but not for pneumococcal vaccination.

C. No data exist specifically on the risk for severe or complicated influenza infections among persons with asplenia. However, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia.

D. For persons aged <65 years, revaccinate once after ≥ 5 years have elapsed since initial vaccination.

E. Administer meningococcal vaccine and consider Haemophilus influenzae type B vaccine.

F. For persons undergoing elective splenectomy, vaccinate ≥ 2 weeks before surgery. G. Vaccinate as soon after diagnosis as possible.

H. For hemodialysis patients, use special formulation of vaccine (40 μg/mL) or two 20 μg/mL doses administered at one body site. Vaccinate early in the course of renal disease. Assess antibody titers to hepatitis B surface antigen (anti-HB) levels annually. Administer additional doses if anti-HB levels decline to <10 mIU/mL.

I. For all persons with chronic liver disease.

J. Withhold MMR or other measles-containing vaccines from HIV-infected persons with evidence of severe immunosuppression (see MMWR 1998;47 [RR-8]:21–2 and MMWR 2002;51[RR-2]:22–4).

K. Persons with impaired humoral immunity but intact cellular immunity may be vaccinated (see MMWR 1999;48[RR-6]).

Information on immunizations by family physician leaders for family physicians can be found at the Group on Immunization Education of the Society of Teachers of Family Medicine’s Web site at http://www.immunizationed.org, which includes free handheld personal digital assistant software in both Palm and Windows formats. Materials for offices about adult immunization can be found at the National Partnership for Immunization’s Web site (http://www.partnersforimmunization.org), the Immunization Action Coalition Web site (http://www.immunize.org), the CDC National Immunization Program Web site (http://www.cdc.gov/nip), the National Coalition for Adult Immunization Web site (http://www.nfid.org/ncai), the National Network for Immunization Information Web site (http://www.immunizationinfo.org), and the AAFP Web site (http://www.aafp.org/x10615.xml).

The Author

RICHARD K. ZIMMERMAN, M.D., M.P.H., is associate professor in the Department of Family Medicine and Clinical Epidemiology at the University of Pittsburgh (Pa.) School of Medicine. Dr. Zimmerman acted as chair of the Influenza Working Group of the ACIP during the development of the Recommended Adult Immunization Schedule, United States, 2004–2005.

REFERENCES

1. Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB, Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP) [Published correction in MMWR Recomm Rep 2004;53:743]. MMWR Recomm Rep. 2004;53(RR-6):1–40.


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