2023 Vaccination Schedule: Adults

 1. Influenza vaccination

• For persons ≥19yrs, give 1 dose of any age and health status-appropriate influenza vaccine annually.

• For persons ≥65yrs, give 1 dose of high-dose IIV4 (HD-IIV4), RIV4, or adjuvanted llV4 (aIIV4) influenza vaccine annually. Give any age-appropriate vaccine if none of these are available.

• Persons with hives-only allergy to eggs should receive 1 dose of any appropriate vaccine. For allergy other than hives (eg, angioedema, respiratory distress), give in a medical setting under supervision of healthcare provider if using a vaccine other than RIV4 or ccIIV4. Persons with a previous severe allergic reaction to any influenza vaccine is contraindicated for future vaccination.

• Do not give if person has a history of Guillain-Barre syndrome within 6wks after previous influenza vaccine dose, unless benefits outweigh risks.

 2. Tetanus, diphtheria, and acellular pertussis (Tdap or Td) vaccination

• Persons who previously did not receive a dose of Tdap at or after age 11yrs should receive 1 dose of Tdap vaccine, followed by Td or Tdap booster every 10yrs.

• Persons who previously did not receive primary series for tetanus, diphtheria, and pertussis should receive at least 1 dose of Tdap, followed by 1 dose Td or Tdap ≥4wks after, and another Td or Tdap dose 6–12mos after last Td or Tdap (Tdap can be substituted for any Td dose, but preferred as first dose); Td or Tdap booster every 10yrs thereafter.

• Give 1 dose of Tdap vaccine to pregnant women during each pregnancy (preferred during the early part of gestational weeks 27−36).

• For wound management in persons with ≥3 doses of tetanus-toxoid-containing vaccine, give Tdap or Td for clean and minor wounds if >10yrs since last dose of tetanus-toxoid-containing vaccine. For all other wounds, give Tdap or Td if >5yrs since last dose of tetanus vaccine. Tdap is preferred if no or unknown history of Tdap vaccination, or in pregnancy.

 3. Measles, mumps, rubella (MMR) vaccination

• Adults with no evidence of immunity to measles, mumps, or rubella should receive 1 dose of MMR vaccine.

• Evidence of immunity includes any of the following:

— Born before 1957 (except healthcare personnel)

— Documentation of receipt of MMR vaccine

— Lab evidence of immunity or disease (documentation of provider-diagnosed disease without lab confirmation is not considered evidence of immunity)

• Healthcare personnel born in 1957 or later with no evidence of immunity to measles, mumps, or rubella should receive 2-dose series ≥4wks apart for measles or mumps, or ≥1 dose for rubella. If born before 1957 with no evidence of immunity, consider 2-dose series ≥4wks apart for measles or mumps, or 1 dose for rubella.

• MMR is contraindicated during pregnancy. Give 1 dose after birth and before hospital discharge. Nonpregnant women of childbearing age with no evidence of immunity to rubella should receive 1 dose of MMR.

• Give 2-dose series ≥4wks apart to persons with HIV and CD4 percentages ≥15% and CD4 count ≥200cells/μL for ≥6mos with no evidence of immunity. MMR is contraindicated in HIV with CD4 percentage <15%, CD4 count <200 cells/µL, or other severe immunocompromising conditions.

• Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons should receive 2 doses ≥4wks apart (or 1 dose if previously received 1 MMR dose).

• In mumps outbreak settings, see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7.htm for guidelines about additional doses of MMR, including 3rd dose.

 4. Varicella vaccination

• All adults without evidence of immunity to varicella should receive 2 doses of VAR vaccine 4–8wks apart. If previously received 1 dose of varicella-containing vaccine, give the 2nd dose at least 4wks after the 1st dose.

• Evidence of immunity to varicella in adults includes any of the following:

— documentation of 2 doses of varicella vaccine at least 4wks apart;

— U.S.-born before 1980, except HCPs and pregnant women

— diagnosis or verification of history of varicella or herpes zoster by a HCP;

— lab evidence of immunity or disease.

• VAR is contraindicated during pregnancy. Pregnant women without evidence of immunity should receive the first of 2 doses (4–8wks apart) or the 2nd dose, if previously received 1 dose, after birth and before hospital discharge.

• HCP without evidence of immunity should receive 2 doses 4–8wks apart or the 2nd dose if previously received 1 dose.

• Persons with HIV and CD4 percentages ≥15% and CD4 count ≥200cells/μL with no evidence of immunity may consider 2 doses 3mos apart. VAR is contraindicated in HIV with CD4 percentage <15%, CD4 count <200 cells/µL, or other severe immunocompromising conditions.

 5. Zoster (recombinant zoster vaccine [RZV]) vaccination

• All persons ≥50yrs and those 19–49yrs with immunocompromising conditions (including HIV regardless of CD4 count) should receive 2 doses of RZV 2–6mos apart (repeat dose if given <4wks apart).

• Serologic evidence of prior varicella is not necessary for RZV vaccination. If evidence of varicella susceptibility becomes available, ACIP guidelines for varicella vaccination should be followed first.

• If there is no documented history of varicella, varicella vaccination, or herpes zoster in persons ≥19yrs with immunocompromising conditions, refer to www.cdc.gov/mmwr/volumes71/wr/mm7103a2.htm for further guidance.

• Consider delaying RZV until after pregnancy, if indicated.

 6. Human papilloma virus (HPV) vaccination

• Vaccinate all adults through age 26yrs. Can vaccinate adults age 27–45yrs based on shared clinical decision-making.

• If initiated vaccination at ≥15yrs, give a 3-dose series at 0, 1–2, and 6mos; the 1st and 2nd doses should be at least 4wks apart, the 2nd and 3rd doses at least 12wks apart, and the 1st and 3rd doses at least 5mos apart; repeat doses if given too soon.

• If initiated vaccination at 9–14yrs and received 1 dose or 2 doses <5mos apart, give 1 dose. No additional dose is needed if initiated vaccination at 9–14yrs and received 2 doses at least 5mos apart.

• Persons with immunocompromising conditions, including HIV, should get a 3-dose series, even if initiated vaccination at 9–14yrs.

• Series does not need to be restarted if vaccination schedule is interrupted.

• No additional doses needed if valid vaccination series completed with any HPV vaccine.

• HPV vaccination is not recommended until after pregnancy. However, pregnancy testing is not needed before vaccination. If a woman is vaccinated while pregnant, no intervention is needed.

 7. Pneumococcal (15-valent and 20-valent pneumococcal conjugate vaccines [PCV15, PCV20] and 23-valent pneumococcal polysaccharide vaccine [PPSV23]) vaccination

• All adults ≥65yrs and those 19–64yrs with certain underlying medical conditions or risk factors who have not previously received a dose of PCV13, PCV15, or PCV20, have previously received only PCV7, or whose previous vaccination history is unknown should receive 1 dose PCV15 or 1 dose PCV20. If PCV15 is used, 1 dose of PPSV23 should be given ≥1yr after PCV15 (≥8wks between doses of PCV15 and PPSV23 can be considered for immunocompromising conditions, cochlear implant, or cerebrospinal fluid leak).

• Adults ≥65yrs and those 19–64yrs with certain underlying medical conditions or risk factors who previously received only PCV13 should receive 1 dose PCV20 ≥1yr after PCV13 dose or complete the recommended PPSV23 series.

• Adults ≥65yrs and those 19–64yrs with certain underlying medical conditions or risk factors who previously received only PPSV23 should receive 1 dose PCV15 or 1 dose PCV20 ≥1yr after PPSV23. PCV15 dose does not need to be followed by another PPSV23 dose.

• If previously received both PCV13 and PPSV23 but PPSV23 was given at age <65yrs, give 1 dose PCV20 ≥5yrs after the last pnuemococcal vaccine dose or complete the recommended PPSV23 series.

• If previously received both PCV13 and PPSV23 and PPSV23 was given at age ≥65yrs, can give 1 dose PCV20 ≥5yrs after the last pneumococcal vaccine dose based on shared clinical decision- making.

• Adults 19–64yrs with certain underlying medical conditions or risk factors who previously received both PCV13 and PPSV23 but have not completed the recommended series should receive 1 dose PCV20 ≥5yrs after the last pneumococcal vaccine dose or complete the recommended PPSV23 series.

• Immunocompromising conditions and underlying medical conditions or other risk factors include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, HIV, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, other hemoglobinopathies, alcoholism, chronic heart/liver/lung disease, cigarette smoking, cochlear implant, CSF leak, diabetes.

 8. Hepatitis A vaccination

• Vaccinate any not at risk person seeking protection from hepatitis A virus (HAV) infection and persons with any of the following indications:

— chronic liver disease (hepatitis B/C, cirrhosis, fatty or alcoholic liver disease, autoimmune hepatitis, ALT/AST >2xULN);

— HIV infection;

— men who have sex with men;

— injection or non-injection drug use;

— homelessness;

— work with HAV in research lab or nonhuman primates with HAV infection;

— travel to countries with high or intermediate endemic hepatitis A;

— close personal contact with international adoptee (eg, household, regular babysitting) in 1st 60 days after arrival from country with high or intermediate endemic hepatitis A (give 1st dose as soon as adoption is planned, at least 2wks before adoptee’s arrival);

— Pregnancy (if at risk for infection or severe outcome);

— Settings for exposure (eg, drug use clinics, group homes, day care facilities for persons with developmental disabilities)

• Give either a 2-dose series of the single antigen HepA vaccine (Havrix 6–12mos apart or Vaqta 6–18mos apart), or a 3-dose series of the HepA-HepB vaccine combination (Twinrix at 0, 1, and 6mos; the 1st and 2nd doses should be ≥4wks apart, and the 2nd and 3rd doses ≥5mos apart).

• For travel in highly or intermediately endemic countries, Twinrix may be given on an accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster at 12mos.

 9. Hepatitis B vaccination

• Vaccinate any person age 19–59yrs and those ≥60yrs with known HBV risk factors with a 2-, 3- or 4-dose series. Persons ≥60yrs without known risk factors may be vaccinated. Risk factors for HBV infection include:

— HCV infection or chronic liver disease (cirrhosis, fatty or alcoholic liver disease, autoimmune hepatitis, ALT/AST >2xULN);

— HIV-infection;

— sexual exposure risk (eg, sex partners of HBsAg-­positive persons, sexually active persons who are not in a mutually monogamous relationship, persons seeking evaluation or treatment for an STD, men who have sex with men);

— current or recent injection drug use;

— percutaneous or mucosal risk for blood exposure (eg, household contacts of HBsAg-positive persons, residents/staff of facilities for persons with developmental disabilities, HCPs and public safety workers who are exposed to blood or blood-contaminated body fluids, dialysis patients, patients <60yrs with diabetes [shared clinical decision-making for ≥60yrs]);

— incarcerated;

— travel to countries with high or intermediate hepatitis B endemicity

— pregnancy (if at risk for infection or severe outcome. Heplisav-B and PreHevbrio are not recommended due to lack of safety data in pregnant persons)

• Give the 2-dose series with Heplisav-B at least 4wks apart (2-dose series HepB only applies when 2 doses of Heplisav-B are used).

• Give the 3-dose series with single-antigen HepB vaccines (Engerix-B, PreHevbrio, Recombivax HB) at 0, 1 and 6mos; the 1st and 2nd doses should be ≥4wks apart, the 2nd and 3rd doses ≥8wks apart, and the 1st and 3rd doses ≥16wks apart. If the combined HepA and HepB vaccine (Twinrix) is used, give 3 doses at 0, 1, and 6mos; the 1st and 2nd doses should be ≥4wks apart, and the 2nd and 3rd doses at least ≥5mos apart.

• Give the 4-dose series of Twinrix on an accelerated schedule of 3 doses at 0, 7, and 21-30 days, followed by a booster at 12mos.

• Dialysis patients should complete a 3-dose series with Recombivax HB at 0, 1, and 6mos or a 4-dose series with Engerix-B at 0, 1, 2 and 6mos.

10. Meningococcal (Serogroups A, C, W, and Y [MenACWY] or serogroup B [MenB]) vaccination

• MenACWY vaccination (Menactra, Menveo, MenQuadfi):

— Adults with anatomical or functional asplenia, HIV, persistent complement component deficiency, or on eculizumab or ravulizumab therapy should receive 2 doses of MenACWY at least 8wks apart. Revaccinate with 1 dose every 5yrs if risk remains.

— microbiologists routinely exposed to N. meningitidis and persons traveling in countries where meningococcal disease is hyperendemic or epidemic should receive 1 dose of MenACWY; revaccinate every 5yrs if risk remains

— first-year college students in residential housing (if not received vaccine at ≥16yrs) and military recruits should receive 1 dose of MenACWY.

• MenB vaccination (Bexsero, Trumenba):

— young adults 16–23yrs (16–18yrs preferred) not at increased risk may receive, based on shared clinical decision making, 2 doses of Bexsero at least 1 month apart, or 2 doses of Trumenba at least 6mos apart (if 2nd dose given too soon, give 3rd dose at least 4mos after 2nd dose).

— adults with anatomic or functional asplenia, persistent complement component deficiency, on eculizumab or ravulizumab therapy, or microbiologists routinely exposed to N. meningitidis should receive 2 doses of Bexsero at least 1 month apart, or 3 doses of Trumenba at 0, 1–2, and 6mos (3rd dose is not needed if 2nd dose was given ≥6mos after 1st dose; if 3rd dose was given <4mos after 2nd dose, a 4th dose should be given ≥4 mos after 3rd dose). Give 1 dose of MenB booster 1yr after primary series and revaccinate every 2–3yrs if risk remains.

— delay MenB until after pregnancy unless at increased risk and benefit outweighs potential risks.

— The two MenB vaccines are not interchangeable.

• Additional information on MenACWY and MenB booster doses in special situations is available at https://www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm.

11. Haemophilus influenzae type b (Hib) vaccination

• 1 dose of Hib vaccine should be administered to persons with functional or anatomic asplenia, sickle cell disease or are undergoing elective splenectomy if they have not previously received Hib vaccine. Hib should be administered ≥14 days before splenectomy.

• Recipients of a hematopoietic stem cell transplant should be vaccinated with a 3-dose regimen 6–12mos after a successful transplant, regardless of vaccination history; at least 4wks should separate doses.

12. Covid-19 vaccination

• All unvaccinated adults and those who previously received only monovalent vaccine doses should receive 1 bivalent mRNA vaccine dose. Adults ≥65yrs may receive 1 additional bivalent mRNA vaccine dose ≥4mos after the first bivalent dose. Bivalent dose should be given ≥8wks after the last monovalent dose.

• The monovalent Novavax vaccine remains authorized for use as a 2-dose primary series and as a booster in certain limited situations to adults who previously completed primary vaccination with any FDA authorized vaccine and have not received a previous booster dose, are unable or unwilling to receive an mRNA booster and would otherwise not receive a booster dose.

• Monovalent formulations of mRNA vaccines should no longer be used for vaccination. The Janssen vaccine is no longer available in the US.

• For a list of currently available COVID-19 vaccines and other recommendations for COVID-19 vaccination including dosing for immunocompromised adults, see https://www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html.

13. Polio vaccination

• Routine polio vaccination is not recommended.

• In adults at increased risk of exposure with no evidence of a complete polio series (eg, ≥3 doses), give remaining doses to complete the series. If has evidence of completed series, may give one lifetime IPV booster.

14. Additional information

• Immunocompromising conditions: Inactivated vaccines generally are acceptable (eg, pneumococcal, meningococcal, and inactivated influenza vaccine), and live vaccines generally are avoided in persons with immune deficiencies or immunocompromising conditions. Information on specific conditions is available at https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html.

• Information on travel vaccine requirements and recommendations (eg, for hepatitis A and B, meningococcal, and other vaccines) available at http://wwwnc.cdc.gov/travel/destinations/list.

• The HepB footnote was updated to add the 3-dose series for PreHevbrio. Recommendations for age ≥60yrs with or without known risk factors were also added.

• The influenza footnote was updated to note the preferred vaccines for those age ≥65yrs and that live attenuated vaccine should not be administered to close contacts of immunosuppressed persons.

• The MMR footnote was updated to include recommendations for additional doses in a mumps outbreak.

• The meningococcal B footnote was updated to add guidance regarding a 4th dose of Trumenba.

• The pneumococcal footnote has been substantially updated with recommendations for PCV15 and PCV20.

• A poliovirus footnote was added to address adults who are at increased risk for exposure.

• The zoster footnote was updated to provide guidance for those with evidence of prior varicella susceptibility and those with immunocompromising conditions.