Practice Guidelines

The 2006 Adult Immunization Schedule: Improving Immunization Rates



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Am Fam Physician. 2005 Dec 15;72(12):2545-2548.

In a recent survey by the American Academy of Family Physicians (AAFP), active members overwhelmingly identified American Family Physician as their single most used source of clinical immunization information (81 percent; AAFP Immunization Survey, unpublished data, 2005). The 2006 Recommended Adult Immunization Schedule—as approved by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, the AAFP, and the American College of Obstetricians and Gynecologists—provides a concise tool to help family physicians identify who to vaccinate, when to vaccinate, and which vaccine to use.

The 2006 schedule has been simplified and is depicted in two charts (Figures 1 and 2). The first chart provides age-based recommendations for two categories of patients: (1) those who meet age requirements and lack evidence of immunity, and (2) those in whom some other risk factor is present. The second chart provides guidance for seven risk groups comprised of pregnant women; immunocompromised persons; health care professionals; and persons with chronic medical conditions, asplenia, renal failure, and human immunodeficiency virus infection.

The benefits of immunization often extend well beyond individual patients. For example, a recent systematic review1 of pneumococcal vaccination in adults 55 years and older demonstrated 53 percent effectiveness in reducing rates of invasive pneumococcal disease. Beyond this protection, immunization of children with 7-valent pneumococcal conjugate vaccine (PNC7; Prevnar) has been associated with a 55 percent decrease in invasive pneumococcal disease in adults 50 years and older between 1998 and 2003, thus demonstrating the role of herd immunity.2

Recent examples of a measles outbreak in Indiana3 and of polio infections in Minnesota,4 both occurring in undervaccinated communities, serve as testimony to the ongoing role of vaccination when highly contagious diseases are only an airplane ride away. One of the patients with measles was hospitalized with pneumonia and required six days of ventilator support.

Effective, evidence-based methods to improve immunization rates in ambulatory practice include reminder systems, assessment and feedback to vaccine providers, and standing orders.5 Despite their known effectiveness, these tools are underused by family physicians and have estimated use rates of 46, 31, and 67 percent, respectively (AAFP Immunization Survey, unpublished data, 2004). Such interventions can be implemented easily by primary care physicians.

Family physicians are encouraged to review the 2006 adult immunization schedule and the accompanying footnotes. To maximize the patient-centered benefits, however, this schedule should be coupled with clinical interventions that have been shown to effectively increase immunization rates.

Recommended Adult Immunization Schedule

Figure 1.

Recommended adult immunization schedule by vaccine and age group, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons 19 years and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated. For detailed recommendations, consult the manufacturers' package inserts and the complete statements from the Advisory Committee on Immunization Practices (http://www.cdc.gov/nip/publications/acip-list.htm). 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) and from the VAERS Web site (http://www.vaers.hhs.gov). Information on how to file a Vaccine Injury Compensation Program claim is available online 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, N.W., Washington, DC 20005 (telephone: 202–357–6400). Additional information about the vaccines listed above and contraindications for vaccination are also available at http://www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (232–4636) in English and Spanish, 24 hours per day, seven days per week.

View Large

Recommended Adult Immunization Schedule


Figure 1.

Recommended adult immunization schedule by vaccine and age group, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons 19 years and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated. For detailed recommendations, consult the manufacturers' package inserts and the complete statements from the Advisory Committee on Immunization Practices (http://www.cdc.gov/nip/publications/acip-list.htm). 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) and from the VAERS Web site (http://www.vaers.hhs.gov). Information on how to file a Vaccine Injury Compensation Program claim is available online 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, N.W., Washington, DC 20005 (telephone: 202–357–6400). Additional information about the vaccines listed above and contraindications for vaccination are also available at http://www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (232–4636) in English and Spanish, 24 hours per day, seven days per week.

Recommended Adult Immunization Schedule


Figure 1.

Recommended adult immunization schedule by vaccine and age group, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons 19 years and older. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine's other components are not contraindicated. For detailed recommendations, consult the manufacturers' package inserts and the complete statements from the Advisory Committee on Immunization Practices (http://www.cdc.gov/nip/publications/acip-list.htm). 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) and from the VAERS Web site (http://www.vaers.hhs.gov). Information on how to file a Vaccine Injury Compensation Program claim is available online 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, N.W., Washington, DC 20005 (telephone: 202–357–6400). Additional information about the vaccines listed above and contraindications for vaccination are also available at http://www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (232–4636) in English and Spanish, 24 hours per day, seven days per week.

Recommended Adult Immunization Schedule

Figure 2.

Recommended adult immunization schedule by vaccine and medical and other indications, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

1. Tetanus and diphtheria (Td) vaccination. Adults with uncertain histories of a complete primary vaccination series with diphtheria and tetanus-toxoid–containing vaccines should receive a primary series using combined Td toxoid. A primary series for adults is three doses; administer the first two doses at least four weeks apart and the third dose six to 12 months after the second. Administer one dose if the person received the primary series and if the last vaccination was received more than 10 years previously. Consult the Advisory Committee on Immunization Practices (ACIP) recommendations for administering Td as prophylaxis in wound management (http://www.cdc.gov/mmwr/preview/mmwrhtml/00041645.htm). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at 50 years of age for persons who have completed the full pediatric series, including the teenage/young-adult booster. A newly licensed tetanus-diphtheria-acellular pertussis vaccine is available for adults; ACIP recommendations for its use will be published.

2. 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 at least one dose of MMR unless they have a medical contraindication, documentation of receipt of one or more doses, history of measles based on health care professional diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who (1) recently were exposed to measles or were in an outbreak setting, (2) previously were vaccinated with killed measles vaccine, (3) were vaccinated with an unknown type of measles vaccine from 1963 to 1967, (4) are students in postsecondary educational institutions, (5) work in a health care facility, or (6) plan to travel internationally. Withhold MMR or other measles-containing vaccines from persons infected with human immunodeficiency virus (HIV) and those with severe immunosuppression. Mumps component: one dose of MMR vaccine should be adequate protection for persons born during or after 1957 who lack a history of mumps based on health care professional diagnosis or who lack laboratory evidence of immunity. Rubella component: administer one dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility.

3. Varicella vaccination. Varicella vaccination is recommended for nearly all adults without evidence of immunity to varicella. Special consideration should be given to those who (1) have close contact with persons at high risk for severe disease (e.g., health care professionals, family contacts of immunocompromised persons) and (2) are at high risk for exposure or transmission (e.g., teachers of young children; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; international travelers). Evidence of immunity to varicella in adults includes any of the following: (1) documented age-appropriate varicella vaccination (i.e., receipt of one dose before 13 years of age or receipt of two doses [administered at least four weeks apart] after 13 years of age); (2) born in the United States before 1966; (3) history of varicella disease based on health care professional diagnosis or self- or parental report of typical varicella disease for non–U.S.-born persons born before 1966 and all persons born during 1966 to 1997 (for a patient reporting a history of an atypical, mild case, health care professionals should seek an epidemiologic link with a typical varicella case or evidence of laboratory confirmation, if it was performed at the time of acute disease); (4) history of herpes zoster based on health care professional diagnosis; or (5) laboratory evidence of immunity. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive dose 1 of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. Dose 2 should be given four to eight weeks after dose 1.

4. Influenza vaccination. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, and immunosuppression (including immunosuppression caused by medications or HIV infection); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, seizure disorder, other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: health care professionals and employees of long-term care and assisted-living facilities. Other indications: residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home household contacts and caregivers of children from birth through 23 months of age, or persons of all ages with high-risk conditions); and anyone who wishes to be vaccinated. For healthy, nonpregnant persons five to 49 years of age without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, intranasally administered influenza vaccine (FluMist) may be administered in lieu of inactivated vaccine.

5. 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, splenectomy [if elective splenectomy is planned, vaccinate at least two weeks before surgery]); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection [vaccinate as close to diagnosis as possible when CD4+ cell counts are highest], leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids; and cochlear implants. Other indications: Alaskan Natives and certain American Indian populations; residents of nursing homes and other long-term care facilities.

6. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after five years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease, splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids. For persons 65 years or older, onetime revaccination if they were vaccinated at least five years previously and were younger than 65 years at the time of primary vaccination.

7. 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 (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa), as well as any person wishing to obtain immunity. Current vaccines should be given in a two-dose series at either zero and six to 12 months, or zero and six to 18 months. If the combined hepatitis A and hepatitis B vaccine is used, administer three doses at zero, one, and six months.

8. Hepatitis B vaccination. Medical indications: patients on hemodialysis (use special formulation [40 mcg per mL] or two 20-mcg-per-mL doses) or patients who receive clotting factor concentrates. Occupational indications: health care professionals and public safety workers who are exposed to blood in the workplace; and persons 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 in the previous six months; persons with a recently acquired sexually transmitted disease (STD); 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 of institutions for the developmentally disabled; all clients of STD clinics; inmates of correctional facilities; and international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than six months (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa).

9. Meningococcal vaccination. Medical indications: adults with anatomic or functional asplenia, or terminal complement component deficiencies. Other indications: college students living in dormitories for the first time; microbiologists who are exposed routinely to isolates of Neisseria meningitidis; military recruits; and persons who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December through June]), particularly if contact with the local population will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine is preferred for adults meeting any of the above indications who are 55 years or younger, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Revaccination after five years may be indicated for adults previously vaccinated with MPSV4 who remain at high risk for infection (e.g., persons residing in areas in which disease is epidemic).

10. Selected conditions for which Haemophilus influenzae type B (Hib) vaccine may be used. H. influenzae type B conjugate vaccines are licensed for children six weeks to 71 months of age. No efficacy data are available on which to base a recommendation about the use of Hib vaccine in older children and adults with chronic conditions associated with an increased risk of disease. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection, or who have had splenectomies; vaccination of these patients is not contraindicated.

View Large

Recommended Adult Immunization Schedule


Figure 2.

Recommended adult immunization schedule by vaccine and medical and other indications, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

1. Tetanus and diphtheria (Td) vaccination. Adults with uncertain histories of a complete primary vaccination series with diphtheria and tetanus-toxoid–containing vaccines should receive a primary series using combined Td toxoid. A primary series for adults is three doses; administer the first two doses at least four weeks apart and the third dose six to 12 months after the second. Administer one dose if the person received the primary series and if the last vaccination was received more than 10 years previously. Consult the Advisory Committee on Immunization Practices (ACIP) recommendations for administering Td as prophylaxis in wound management (http://www.cdc.gov/mmwr/preview/mmwrhtml/00041645.htm). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at 50 years of age for persons who have completed the full pediatric series, including the teenage/young-adult booster. A newly licensed tetanus-diphtheria-acellular pertussis vaccine is available for adults; ACIP recommendations for its use will be published.

2. 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 at least one dose of MMR unless they have a medical contraindication, documentation of receipt of one or more doses, history of measles based on health care professional diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who (1) recently were exposed to measles or were in an outbreak setting, (2) previously were vaccinated with killed measles vaccine, (3) were vaccinated with an unknown type of measles vaccine from 1963 to 1967, (4) are students in postsecondary educational institutions, (5) work in a health care facility, or (6) plan to travel internationally. Withhold MMR or other measles-containing vaccines from persons infected with human immunodeficiency virus (HIV) and those with severe immunosuppression. Mumps component: one dose of MMR vaccine should be adequate protection for persons born during or after 1957 who lack a history of mumps based on health care professional diagnosis or who lack laboratory evidence of immunity. Rubella component: administer one dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility.

3. Varicella vaccination. Varicella vaccination is recommended for nearly all adults without evidence of immunity to varicella. Special consideration should be given to those who (1) have close contact with persons at high risk for severe disease (e.g., health care professionals, family contacts of immunocompromised persons) and (2) are at high risk for exposure or transmission (e.g., teachers of young children; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; international travelers). Evidence of immunity to varicella in adults includes any of the following: (1) documented age-appropriate varicella vaccination (i.e., receipt of one dose before 13 years of age or receipt of two doses [administered at least four weeks apart] after 13 years of age); (2) born in the United States before 1966; (3) history of varicella disease based on health care professional diagnosis or self- or parental report of typical varicella disease for non–U.S.-born persons born before 1966 and all persons born during 1966 to 1997 (for a patient reporting a history of an atypical, mild case, health care professionals should seek an epidemiologic link with a typical varicella case or evidence of laboratory confirmation, if it was performed at the time of acute disease); (4) history of herpes zoster based on health care professional diagnosis; or (5) laboratory evidence of immunity. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive dose 1 of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. Dose 2 should be given four to eight weeks after dose 1.

4. Influenza vaccination. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, and immunosuppression (including immunosuppression caused by medications or HIV infection); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, seizure disorder, other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: health care professionals and employees of long-term care and assisted-living facilities. Other indications: residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home household contacts and caregivers of children from birth through 23 months of age, or persons of all ages with high-risk conditions); and anyone who wishes to be vaccinated. For healthy, nonpregnant persons five to 49 years of age without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, intranasally administered influenza vaccine (FluMist) may be administered in lieu of inactivated vaccine.

5. 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, splenectomy [if elective splenectomy is planned, vaccinate at least two weeks before surgery]); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection [vaccinate as close to diagnosis as possible when CD4+ cell counts are highest], leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids; and cochlear implants. Other indications: Alaskan Natives and certain American Indian populations; residents of nursing homes and other long-term care facilities.

6. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after five years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease, splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids. For persons 65 years or older, onetime revaccination if they were vaccinated at least five years previously and were younger than 65 years at the time of primary vaccination.

7. 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 (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa), as well as any person wishing to obtain immunity. Current vaccines should be given in a two-dose series at either zero and six to 12 months, or zero and six to 18 months. If the combined hepatitis A and hepatitis B vaccine is used, administer three doses at zero, one, and six months.

8. Hepatitis B vaccination. Medical indications: patients on hemodialysis (use special formulation [40 mcg per mL] or two 20-mcg-per-mL doses) or patients who receive clotting factor concentrates. Occupational indications: health care professionals and public safety workers who are exposed to blood in the workplace; and persons 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 in the previous six months; persons with a recently acquired sexually transmitted disease (STD); 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 of institutions for the developmentally disabled; all clients of STD clinics; inmates of correctional facilities; and international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than six months (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa).

9. Meningococcal vaccination. Medical indications: adults with anatomic or functional asplenia, or terminal complement component deficiencies. Other indications: college students living in dormitories for the first time; microbiologists who are exposed routinely to isolates of Neisseria meningitidis; military recruits; and persons who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December through June]), particularly if contact with the local population will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine is preferred for adults meeting any of the above indications who are 55 years or younger, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Revaccination after five years may be indicated for adults previously vaccinated with MPSV4 who remain at high risk for infection (e.g., persons residing in areas in which disease is epidemic).

10. Selected conditions for which Haemophilus influenzae type B (Hib) vaccine may be used. H. influenzae type B conjugate vaccines are licensed for children six weeks to 71 months of age. No efficacy data are available on which to base a recommendation about the use of Hib vaccine in older children and adults with chronic conditions associated with an increased risk of disease. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection, or who have had splenectomies; vaccination of these patients is not contraindicated.

Recommended Adult Immunization Schedule


Figure 2.

Recommended adult immunization schedule by vaccine and medical and other indications, United States, October 2005 to September 2006.

note: These recommendations must be read along with the footnotes.

*— Covered by the Vaccine Injury Compensation Program.

1. Tetanus and diphtheria (Td) vaccination. Adults with uncertain histories of a complete primary vaccination series with diphtheria and tetanus-toxoid–containing vaccines should receive a primary series using combined Td toxoid. A primary series for adults is three doses; administer the first two doses at least four weeks apart and the third dose six to 12 months after the second. Administer one dose if the person received the primary series and if the last vaccination was received more than 10 years previously. Consult the Advisory Committee on Immunization Practices (ACIP) recommendations for administering Td as prophylaxis in wound management (http://www.cdc.gov/mmwr/preview/mmwrhtml/00041645.htm). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at 50 years of age for persons who have completed the full pediatric series, including the teenage/young-adult booster. A newly licensed tetanus-diphtheria-acellular pertussis vaccine is available for adults; ACIP recommendations for its use will be published.

2. 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 at least one dose of MMR unless they have a medical contraindication, documentation of receipt of one or more doses, history of measles based on health care professional diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who (1) recently were exposed to measles or were in an outbreak setting, (2) previously were vaccinated with killed measles vaccine, (3) were vaccinated with an unknown type of measles vaccine from 1963 to 1967, (4) are students in postsecondary educational institutions, (5) work in a health care facility, or (6) plan to travel internationally. Withhold MMR or other measles-containing vaccines from persons infected with human immunodeficiency virus (HIV) and those with severe immunosuppression. Mumps component: one dose of MMR vaccine should be adequate protection for persons born during or after 1957 who lack a history of mumps based on health care professional diagnosis or who lack laboratory evidence of immunity. Rubella component: administer one dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility.

3. Varicella vaccination. Varicella vaccination is recommended for nearly all adults without evidence of immunity to varicella. Special consideration should be given to those who (1) have close contact with persons at high risk for severe disease (e.g., health care professionals, family contacts of immunocompromised persons) and (2) are at high risk for exposure or transmission (e.g., teachers of young children; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; international travelers). Evidence of immunity to varicella in adults includes any of the following: (1) documented age-appropriate varicella vaccination (i.e., receipt of one dose before 13 years of age or receipt of two doses [administered at least four weeks apart] after 13 years of age); (2) born in the United States before 1966; (3) history of varicella disease based on health care professional diagnosis or self- or parental report of typical varicella disease for non–U.S.-born persons born before 1966 and all persons born during 1966 to 1997 (for a patient reporting a history of an atypical, mild case, health care professionals should seek an epidemiologic link with a typical varicella case or evidence of laboratory confirmation, if it was performed at the time of acute disease); (4) history of herpes zoster based on health care professional diagnosis; or (5) laboratory evidence of immunity. Do not vaccinate women who are pregnant or who might become pregnant within four weeks of receiving the vaccine. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive dose 1 of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. Dose 2 should be given four to eight weeks after dose 1.

4. Influenza vaccination. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, and immunosuppression (including immunosuppression caused by medications or HIV infection); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, seizure disorder, other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: health care professionals and employees of long-term care and assisted-living facilities. Other indications: residents of nursing homes and other long-term care and assisted-living facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home household contacts and caregivers of children from birth through 23 months of age, or persons of all ages with high-risk conditions); and anyone who wishes to be vaccinated. For healthy, nonpregnant persons five to 49 years of age without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, intranasally administered influenza vaccine (FluMist) may be administered in lieu of inactivated vaccine.

5. 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, splenectomy [if elective splenectomy is planned, vaccinate at least two weeks before surgery]); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection [vaccinate as close to diagnosis as possible when CD4+ cell counts are highest], leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids; and cochlear implants. Other indications: Alaskan Natives and certain American Indian populations; residents of nursing homes and other long-term care facilities.

6. Revaccination with pneumococcal polysaccharide vaccine. Onetime revaccination after five years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease, splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin's disease, generalized malignancy, organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids. For persons 65 years or older, onetime revaccination if they were vaccinated at least five years previously and were younger than 65 years at the time of primary vaccination.

7. 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 (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa), as well as any person wishing to obtain immunity. Current vaccines should be given in a two-dose series at either zero and six to 12 months, or zero and six to 18 months. If the combined hepatitis A and hepatitis B vaccine is used, administer three doses at zero, one, and six months.

8. Hepatitis B vaccination. Medical indications: patients on hemodialysis (use special formulation [40 mcg per mL] or two 20-mcg-per-mL doses) or patients who receive clotting factor concentrates. Occupational indications: health care professionals and public safety workers who are exposed to blood in the workplace; and persons 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 in the previous six months; persons with a recently acquired sexually transmitted disease (STD); 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 of institutions for the developmentally disabled; all clients of STD clinics; inmates of correctional facilities; and international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for more than six months (a list of countries is available online at http://www.cdc.gov/travel/diseases.htm#hepa).

9. Meningococcal vaccination. Medical indications: adults with anatomic or functional asplenia, or terminal complement component deficiencies. Other indications: college students living in dormitories for the first time; microbiologists who are exposed routinely to isolates of Neisseria meningitidis; military recruits; and persons who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December through June]), particularly if contact with the local population will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine is preferred for adults meeting any of the above indications who are 55 years or younger, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Revaccination after five years may be indicated for adults previously vaccinated with MPSV4 who remain at high risk for infection (e.g., persons residing in areas in which disease is epidemic).

10. Selected conditions for which Haemophilus influenzae type B (Hib) vaccine may be used. H. influenzae type B conjugate vaccines are licensed for children six weeks to 71 months of age. No efficacy data are available on which to base a recommendation about the use of Hib vaccine in older children and adults with chronic conditions associated with an increased risk of disease. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection, or who have had splenectomies; vaccination of these patients is not contraindicated.

The Author

JONATHAN L. TEMTE, M.D., PH.D., is associate professor of family medicine at the University of Wisconsin Medical School, Madison. He also serves as the American Academy of Family Physicians' liaison to the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices.

Address correspondence to Jonathan L. Temte, M.D., Ph.D., University of Wisconsin Medical School, Department of Family Medicine, 777 S. Mills St., Madison, WI 53715 (e-mail: jon.temte@fammed.wisc.edu). Reprints are not available from the author.

REFERENCES

1. Dear K, Holden J, Andrews R, Tatham D. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2003;(4):CD000422.

2. Lexau CA, Lynfield R, Danila R, Pilishvili T, Facklam R, Farley MM, et al. Changing epidemiology of invasive pneumococcal disease among older adults in the era of pediatric pneumococcal conjugate vaccine. JAMA. 2005;294:2043–51.

3. Centers for Disease Control and Prevention. Import-associated measles outbreak—Indiana, May-June 2005. MMWR Weekly Rep. 2005;54:1073–5. Accessed online November 16, 2005, at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5442a1.htm.

4. Centers for Disease Control and Prevention. Poliovirus infections in four unvaccinated children—Minnesota, August-October 2005. MMWR Weekly Rep. 2005;54:1053–5. Accessed online November 16, 2005, at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5441a6.htm.

5. Centers for Disease Control and Prevention. Vaccine-preventable diseases: improving vaccination coverage in children, adolescents and adults. Atlanta: CDC, 2000. Accessed online November 16, 2005, at: http://www.guideline.gov/summary/summary.aspx?doc_id=2107&nbr=1333.



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