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Am Fam Physician. 2019;99(4):264-265

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• The 2018–2019 influenza vaccination recommendations include inactivated influenza vaccines, recombinant influenza vaccine, and live attenuated influenza vaccine to be administered without preference in age-appropriate patients without contraindications.

• HepB-CpG is recommended for use in nonpregnant people 18 years and older.

• Hepatitis A vaccine is recommended for people experiencing homelessness.

From the AFP Editors

The 2019 adult and childhood/adolescent immunization schedules have been approved by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) and are accessible at The new look includes fewer colors, improved readability, and harmonization between schedules, with several edits to tables. Footnotes will now be called notes and printed in a larger font. Content changes to the notes for hepatitis A; hepatitis B; inactivated polio; measles, mumps, and rubella; meningococcal; and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines will be incorporated.

Influenza Vaccines

Following a particularly severe 2017–2018 influenza season with a record-breaking estimated 900,000 hospitalizations and more than 80,000 deaths in the United States, the National Foundation for Infectious Diseases, with other public health and medical organizations, presented the benefits of influenza vaccination and urged the public and health care professionals to follow the CDC recommendation that everyone six months and older get vaccinated each year.1

The most notable change for the 2019 influenza vaccine recommendations is the addition of quadrivalent live attenuated influenza vaccine to the list of licensed, recommended, and age-appropriate vaccines, including inactivated influenza vaccines, recombinant influenza vaccine, and live attenuated influenza vaccine, to be given without preference for those who do not have contraindications.

In January 2018, the U.S. Food and Drug Administration approved an expanded age indication for Fluarix Quadrivalent. Previously licensed for people three years and older, Fluarix Quadrivalent is now licensed for people six months and older. Children six through 35 months of age may receive Fluarix Quadrivalent at the same 0.5 mL per dose that is used for older children and adults. This licensure creates a third option for inactivated influenza vaccines for children six through 35 months, in addition to the previously available 0.5 mL per dose of Flulaval Quadrivalent and 0.25 mL per dose of Fluzone Quadrivalent.

Viruses included in the 2018–2019 U.S. trivalent influenza vaccines are A/Michigan/45/2015 (H1N1) pdm09–like virus, an A/Singapore/INFIMH-16-0019/2016 (H3N2)–like virus, and a B/Colorado/06/2017–like virus (Victoria lineage). Quadrivalent vaccines contain these three viruses and an additional influenza B virus, a B/Phuket/3073/2013–like virus (Yamagata lineage).2

Hepatitis Vaccines

A new hepatitis B vaccine has been recommended. HepB-CpG is recommended in a two-dose series (0, 1 month) for people 18 years and older.3 Data are limited on the safety and immunogenicity effects when HepB-CpG is interchanged with hepatitis B vaccines from other manufacturers. When feasible, the same manufacturer's vaccines should be used to complete the series.4 However, vaccination should not be deferred when the manufacturer of the previously administered vaccine is unknown or when the vaccine from the same manufacturer is unavailable. There are no clinical studies of HepB-CpG in pregnant women. Available human data on HepB-CpG administered to pregnant women are insufficient to inform assessment of vaccine-associated risks in pregnancy. Until safety data are available for HepB-CpG, health care professionals should continue to vaccinate pregnant women needing hepatitis B vaccination with a vaccine from a different manufacturer.4

People experiencing homelessness has been added to the list of groups that should receive the hepatitis A vaccine. All children should receive two doses of the vaccine: at 12 through 23 months of age for the first dose, and at two through four years of age for the second dose (or earlier as long as it is six to 18 months after the first dose). All adults at increased risk of hepatitis A should receive two doses given six to 18 months apart including5:

  • Those who travel to places where hepatitis A is common

  • Men who have sex with men

  • Those who use drugs (with or without needles)

  • Patients getting treatment for certain bleeding disorders (e.g., hemophilia)

  • Parents adopting a child from a country where hepatitis A is common

  • People working with animals that have hepatitis A, or who work in a hepatitis A research laboratory

  • People who are homeless.

Editor's Note: The author serves as liaison to ACIP for the AAFP. The AAFP's recommendations for live attenuated influenza vaccine (LAIV) differ from ACIP's (see Although LAIV is an option this season for age-appropriate patients who might not otherwise be vaccinated, the AAFP's preference is for the inactivated vaccine.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, Assistant Medical Editor.

A collection of Practice Guidelines published in AFP is available at

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