Am Fam Physician. 2022;106(5):534-542
Author disclosure: No relevant financial relationships.
Adult vaccination rates are low in the United States, despite clear benefits for reducing morbidity and mortality. Vaccine science is evolving rapidly, and family physicians must maintain familiarity with the most recent guidelines. The recommended adult immunization schedule is updated annually by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. All eligible patients should receive SARS-CoV-2 vaccines according to the current guidelines. Adults without contraindications should also receive an annual influenza vaccine. Hepatitis A vaccine is recommended for adults with specific risk factors. All pregnant patients, adults younger than 60 years, and those 60 years and older who have risk factors should receive a hepatitis B vaccine. A 15- or 20-valent pneumococcal conjugate vaccine is recommended for all patients who are 65 years and older. Patients who receive 15-valent pneumococcal conjugate vaccine should receive a dose of 23-valent pneumococcal polysaccharide vaccine one year later. Adults 19 to 64 years of age should receive a pneumococcal vaccination if they have medical risk factors. A single dose of measles, mumps, and rubella vaccine is recommended for adults without presumptive immunity, and additional doses are recommended for patients with HIV and postdelivery for pregnant patients who are not immune to rubella. A tetanus and diphtheria toxoids booster is recommended every 10 years. For pregnant patients and those in close contact with young infants, a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine should be administered. The human papillomavirus vaccine is recommended for all people through 26 years of age. Herpes zoster vaccine is indicated for all adults 50 years and older. .
Vaccination rates for adults in the United States have not met public health goals; consequently, vaccine-preventable diseases are widespread. Less than optimal vaccination rates may be attributed to variations in perspectives about vaccinations based on cultural and religious beliefs, race, and socioeconomic status.1 Family physicians can positively influence vaccination uptake by educating, reassuring, and recommending vaccination to patients.2 Patient education is important because of the growth of the antivaccination movement.3
| Two doses of a SARS-CoV-2 vaccine decreases the need for hospital care by up to 77% in patients who are immunocompromised and 90% in patients who are immunocompetent. A booster (third) dose provides an additional reduction in severe disease symptoms, and a fourth dose further reduces the short-term risk of disease-related complications. |
| All pregnant patients and adults younger than 60 years should routinely receive hepatitis B vaccination. |
| The Advisory Committee on Immunization Practices recommends recombinant zoster vaccine (Shingrix) for the prevention of herpes zoster and related complications for adults 50 years and older who are immunocompetent. Because of the recombinant zoster vaccine’s greater effectiveness, a full two-dose vaccination series is recommended for adults who previously received the discontinued zoster vaccine live (Zostavax). |
| Primary human papillomavirus vaccination can be administered at as young as nine years of age, before onset of sexual contact, because most new human papillomavirus infections are acquired in adolescence or early adulthood. Catch-up vaccination is now recommended for all people through 26 years of age. |
| Recommendation | Sponsoring organization |
|---|---|
| Do not routinely avoid influenza vaccination in patients who are allergic to eggs. | American Academy of Allergy, Asthma, and Immunology |
Vaccines work by introducing a weakened or inactive bacterial or viral antigen to the body, which starts an immune response through the production of immunoglobulin G and A antibodies. These antibodies bind to the antigen, triggering CD8 T cells to clear infected cells and begin the development of memory CD8 T cells.
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) vaccination schedule provides updated guidance on vaccine recommendations. Table 1 summarizes the recommendations for vaccines discussed in this article.4 The full CDC vaccination schedule is available at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html.
| Vaccine | Indications | Frequency |
|---|---|---|
| SARS-CoV-2 | Protection from SARS-CoV-2, age ≥ 6 months | Refer to current Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommendations; dosing depends on agent used |
| Influenza | Prevention of influenza A and B, age ≥ 6 months | Annually |
| Hepatitis A | Prevention of hepatitis A virus in adults at risk Postexposure prevention | Havrix, Vaqta: 2-dose series: 0 and 6 to 12 months Twinrix (combination hepatitis A and hepatitis B vaccine): 3-dose series: 0, 1, and 6 months |
| Hepatitis B | Protection against hepatitis B virus in previously unvaccinated patients younger than 60 years without prior hepatitis B infection or in those 60 years and older who have medical, environmental, or work-related risk factors Postexposure prevention | Heplisav-B: 2-dose series at least 4 weeks apart Engerix-B, Recombivax HB: 3-dose series: 0, 1, and 6 months (4 weeks minimum between dose 1 and 2, 8 weeks minimum between 2 and 3, and 16 weeks between 1 and 3) Twinrix (combination hepatitis A and hepatitis B vaccine): 3-dose series: 0, 1, and 6 months (4 weeks minimum between dose 1 and 2, and 5 months between 2 and 3) |
| Pneumococcal | Prevention of pneumococcal disease in all adults, especially those who are immunocompromised or have chronic medical conditions, cerebrospinal fluid leak, or cochlear implant | Age 19 to 64 years with chronic conditions (chronic heart, lung, or liver disease, diabetes mellitus, alcoholism, cigarette smoking), or a high-risk condition (chronic renal failure, nephrotic syndrome, leukemia, immunocompromised, lymphoma, Hodgkin disease, generalized malignancy, chemotherapy, radiation, solid organ transplant, multiple myeloma, or asplenia, cerebrospinal fluid leak, cochlear implant): 1 dose of PCV15 (Vaxneuvance) or PCV20 (Prevnar); if PCV15 used, follow with a dose of PPSV23 (Pneumovax 23) with a minimal interval of 8 weeks Age 65 years and older, no previous PCV: administer PCV15 or PCV20; if PCV15 used, follow with a dose of PPSV23 after one year Age 65 years and older, previous PCV13: administer PPSV23 Age ≥ 19 years, previous PPSV23: may administer PCV15 or PCV20 ≥ 1 year after the last PPSV23 dose; does not need to be followed by another PPSV23 dose, even if PCV15 used |
| MMR | Protection against MMR in adults with no evidence of immunity to measles, nonpregnant patients of childbearing age with no immunity to rubella, and patients who are immunocompromised or have environmental risk Postexposure prevention | 1 dose for those born in 1957 or later who have no evidence of immunity and for patients of childbearing age who are nonimmune to rubella 2 doses at least 28 days apart in patients at high risk |
| Td and Tdap | Prevention of tetanus, diphtheria, and pertussis in adults in close contact with infants younger than 12 months; pregnant people; adults who have never received Tdap previously; prophylaxis for tetanus-prone wound (if at least 5 years since the last tetanus toxoid-containing vaccine received) Postexposure prevention | Td every 10 years, 1-dose Tdap (Adacel, Boostrix) during pregnancy between 27 to 36 weeks’ gestation, and if Tdap not previously received; 1 dose if administered for wound prophylaxis and > 5 years since the last booster |
| HPV | Prevention of HPV infections, including HPV-related cancers; recommended for all people 9 through 26 years of age who have not been vaccinated previously; for people 27 to 45 years of age, consider who is most likely to benefit | 3-dose series: 0, 1 to 2, and 6 months if started at > 16 years of age, otherwise 2-dose series: 0 and 6 to 12 months |
| Herpes zoster | Prevention of herpes zoster in all adults ≥ 50 years | Zoster vaccine recombinant, adjuvanted: 2-dose series (Shingrix; 2 to 6 months apart) |
Insurance coverage for vaccines differs by payor. Beginning in January 2023, all Medicare Part D plans will be required to cover adult vaccines recommended by ACIP with no cost sharing, even if the beneficiary is in the deductible phase of benefits. Medicaid will implement a similar requirement beginning in October 2023.
SARS-CoV-2 Vaccine (COVID-19 Vaccine)
Three SARS-CoV-2 vaccines have been developed and approved in the United States. The Pfizer and Moderna vaccines contain a single-stranded messenger RNA (mRNA) molecule, which is transcribed by white blood T cells into a protein antigen that triggers an immune response.5 This type of SARS-CoV-2 vaccine was developed based on mRNA technology used in vaccines for Zika virus infections, HIV-1, influenza, and solid organ tumors.6 The Johnson & Johnson (Janssen) COVID-19 vaccine is a viral vector vaccine. Due to the risk of adverse events, including thrombosis and thrombocytopenia, the Johnson & Johnson (Janssen) COVID-19 vaccine is no longer preferred.7
The Pfizer and Moderna vaccines have shown high effectiveness. Clinicians should administer an mRNA SARSCoV-2 vaccine to eligible patients to decrease the risk of hospitalization and death.8,9 Two doses of a COVID-19 vaccine decreases the need for hospital care by up to 77% in patients who are immunocompromised and up to 90% in patients who are immunocompetent.10
As a result of the emergence of the Omicron strain, the U.S. Food and Drug Administration (FDA) no longer authorizes booster doses of the original monovalent Pfizer and Moderna vaccines for adults. New bivalent Pfizer and Moderna booster vaccines have received emergency use authorization from the FDA. As of September 8, 2022, the CDC recommends that a single booster dose of either of the new bivalent COVID-19 vaccines be administered to adults at least two months after completing a primary two-dose vaccine series with either of the original monovalent vaccines or having received a booster dose with one of the monovalent vaccines.11
As a result of the evolution in the timing and frequency of additional boosters and potential changes in antigen components when different COVID-19 variants emerge, clinicians should monitor updates on the CDC and the FDA websites about these and other vaccines (Table 2).
| Topic | Website | Description |
|---|---|---|
| Adult vaccine schedule | https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html | Recommendations for vaccine use in the United States, updated annually |
| Advisory Committee on Immunization Practices vaccine recommendations and guidelines | https://www.cdc.gov/vaccines/hcp/acip-recs/index.html | Detailed vaccine guidelines and references |
| Vaccine for travelers | https://wwwnc.cdc.gov/travel | Updated regularly based on disease surveillance and risk |
| Vaccine news and updates | https://www.cdc.gov/vaccines/news/related.html | Reliable source of new information and updates |
| Adverse events | https://vaers.hhs.gov | Where to report vaccine-associated adverse events |
| U.S. Food and Drug Administration | https://www.fda.gov/vaccines-blood-biologics/vaccines | Licensing and safety information for vaccines in the United States |
Influenza Vaccines
Influenza vaccines can be classified as inactivated, live attenuated, or recombinant (Table 3).12 The latter is produced with an influenza DNA sequence inserted into a baculovirus (rather than using chicken eggs).12 That virus then produces the antigen for the vaccine. All influenza vaccines are quadrivalent vaccines designed to protect against two influenza A and two influenza B viruses.13
| Influenza vaccine | Vaccine type | Contraindications | Age range |
|---|---|---|---|
| Live attenuated (Flumist) | Nasal spray | Severe allergy to vaccine or component People 2 to 17 years of age who receive aspirin or salicylate-containing medications Children 2 to 4 years of age with asthma or wheezing in past 12 months Immunosuppressed People who care for severely immunocompromised persons People without a spleen Pregnancy Cerebrospinal fluid leak Cochlear implant Use of influenza antiviral agent within certain amount of time (48 hours for oseltamivir [Tamiflu] and zanamivir [Relenza]; 5 days for peramivir [Rapivab]; 17 days for baloxavir [Xofluza]) | 2 to 49 years |
| Quadrivalent (Afluria, Fluarix, Flulaval, Fluzone) | Inactivated | Severe allergy to vaccine or component | ≥ 6 months |
| Quadrivalent cell-based (Flucelvax) | Inactivated | Severe allergy to vaccine or component | ≥ 6 months |
| Quadrivalent (Flucelvax) | Recombinant | Severe allergy to vaccine or component | ≥ 18 years |
| Quadrivalent high-dose (Fluzone) | Inactivated | Severe allergy to vaccine or component | ≥ 65 years |
| Quadrivalent with adjuvant (Fluad) | Inactivated | Severe allergy to vaccine or component | ≥ 65 years |
The CDC provides guidance about which type of vaccine should be used based on age and contraindications. Therefore, one vaccine may be preferred over others for individual patients.14 People with an egg allergy of any severity can receive any licensed, age-appropriate influenza vaccine. People with severe reactions can be vaccinated under the supervision of a health care professional.15
Subscribe
From $145- Immediate, unlimited access to all AFP content
- More than 130 CME credits/year
- AAFP app access
- Print delivery available
Issue Access
$59.95- Immediate, unlimited access to this issue's content
- CME credits
- AAFP app access
- Print delivery available
Article Only
$25.95- Immediate, unlimited access to just this article
- CME credits
- AAFP app access
- Print delivery available
