Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017*

David K. Kim; Laura E. Riley; Kathleen H. Harriman; Paul Hunter; Carolyn B. Bridges

doi:10.7326/M16-2936

In October 2016, the Advisory Committee on Immunization Practices (ACIP) voted to approve the Recommended Adult Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017. The 2017 adult immunization schedule summarizes ACIP recommendations in 2 figures, footnotes for the figures, and a table of contraindications and precautions for vaccines recommended for adults (Figure). These documents can also be found at www.cdc.gov/vaccines/schedules. The full ACIP recommendations for each vaccine can be found at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The 2017 adult immunization schedule was also reviewed and approved by the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.

Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017.

Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017.

Figure 1.

Recommended immunization schedule for adults aged 19 years or older by age group, United States, 2017

Figure 2.

Recommended immunization schedule for adults aged 19 years or older by medical condition and other indications, United States, 2017

Footnotes.

Footnotes.

Footnotes continued.

Footnotes continued.

Table.

Contraindications and precautions for vaccines recommended for adults aged 19 years or older*

Newly added to the 2017 adult immunization schedule is a cover page that contains information on select general principles pertinent to the adult immunization schedule, additional CDC resources, instructions for reporting adverse events related to vaccination and suspected cases of reportable vaccine-preventable diseases, and an ACIP-approved list of standardized acronyms for vaccines recommended for adults. In addition, the table of contraindications and precautions for vaccines routinely recommended for adults that was formerly a standalone document has been incorporated into the adult immunization schedule. Changes in the 2017 adult immunization schedule from the previous year's schedule include new or revised ACIP recommendations on influenza, human papillomavirus, hepatitis B, and meningococcal vaccinations.

Influenza vaccination (1). Changes are related to concerns regarding low effectiveness of the live attenuated influenza vaccine (LAIV) (FluMist, MedImmune) against influenza A(H1N1)pdm09 in the United States during the 2013–2014 and 2015–2016 influenza seasons and revised recommendations on the use of the influenza vaccine among patients with egg allergy. These changes are reflected in the 2017 adult immunization schedule as:

• LAIV should not be used during the 2016–2017 influenza season.

• Adults with a history of egg allergy who have only hives after exposure to egg should receive age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV).

• Adults with a history of egg allergy with symptoms other than hives (e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis, or who required epinephrine or another emergency medical intervention) may receive age-appropriate IIV or RIV. The selected vaccine should be administered in an inpatient or outpatient medical setting and supervised by a health care provider who is able to recognize and manage severe allergic conditions.

Human papillomavirus vaccination (2). Healthy adolescents who start their human papillomavirus vaccine (HPV) series before age 15 years are recommended to receive 2 doses of HPV. However, the recommendation remains at 3 doses for adults and adolescents who did not start their vaccination series before age 15 years. Changes in recommendations in the adult immunization schedule include updates regarding HPV vaccination for adults who did not complete HPV series as adolescents. These changes are described in the 2017 adult immunization schedule as:

• Women through age 26 years and men through age 21 years who have not received any HPV should receive a 3-dose series of HPV at 0, 1-2, and 6 months. Men aged 22 through 26 years may be vaccinated with a 3-dose series of HPV at 0, 1-2, and 6 months.

• Women through age 26 years and men through age 21 years (and men aged 22 through 26 years who may receive HPV) who initiated HPV series before age 15 years and received 2 doses at least 5 months apart are considered adequately vaccinated and do not need an additional dose of HPV.

• Women through age 26 years and adult males through age 21 years (and men aged 22 through 26 years who may receive HPV) who initiated HPV series before age 15 years and received only 1 dose, or 2 doses less than 5 months apart, are not considered adequately vaccinated and should receive 1 additional dose of HPV.

Hepatitis B vaccination (3). The ACIP updated chronic liver disease conditions for which a hepatitis B vaccine (HepB) series is recommended. This change is described in the 2017 adult immunization schedule as:

• Adults with chronic liver disease, including, but not limited to, hepatitis C virus infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an alanine aminotransferase (ALT) or aspartate aminotransferase (AST) level greater than twice the upper limit of normal, should receive a HepB series.

Meningococcal vaccination (4, 5). There are 2 changes in meningococcal vaccination recommendations for 2017. First, the ACIP recommended that adults with HIV infection should receive a 2-dose primary series of serogroups A, C, W, and Y meningococcal conjugate vaccine (MenACWY). Second, the ACIP provided updated dosing guidance for one of the serogroup B meningococcal vaccine (MenB)—MenB-FHbp (Trumenba, Pfizer). For adults who are at increased risk for meningococcal disease and for use during serogroup B meningococcal disease outbreaks, 3 doses of MenB-FHbp should be administered at 0, 1-2, and 6 months. When MenB-FHbp is given to healthy adolescents and young adults who are not at increased risk for meningococcal disease, 2 doses of MenB-FHbp should be administered at 0 and 6 months (MenB-FHbp was previously recommended as a 3-dose series at 0, 2, and 6 months, consistent with the original vaccine licensure for this population). Note that the dosing frequency and interval for the other MenB, MenB-4C (Bexsero, GlaxoSmithKline), have not changed; MenB-4C remains a 2-dose series administered at least 1 month apart. Either MenB can be used when indicated. The change in ACIP recommendations on the use of MenB-FHbp does not imply a preference for one MenB over the other. These updates in meningococcal vaccination are reflected in the 2017 adult immunization schedule as:

• Adults with anatomical or functional asplenia or persistent complement component deficiencies should receive a 2-dose primary series of MenACWY at least 2 months apart and revaccinate every 5 years. They should also receive a series of MenB with either a 2-dose series of MenB-4C at least 1 month apart or a 3-dose series of MenB-FHbp at 0, 1-2, and 6 months.

• Adults with HIV infection who have not been previously vaccinated should receive a 2-dose primary series of MenACWY at least 2 months apart and revaccinate every 5 years. Those who previously received 1 dose of MenACWY should receive a second dose at least 2 months after the first dose. Adults with HIV infection are not routinely recommended to receive MenB because meningococcal disease in this population is caused primarily by serogroups C, W, and Y.

• Microbiologists who are routinely exposed to isolates of Neisseria meningitidis should receive 1 dose of MenACWY and revaccinate every 5 years if the risk for infection remains, and either a 2-dose series of MenB-4C at least 1 month apart or a 3-dose series of MenB-FHbp at 0, 1-2, and 6 months.

• Adults at risk because of a meningococcal disease outbreak should receive 1 dose of MenACWY if the outbreak is attributable to serogroup A, C, W, or Y, or either a 2-dose series of MenB-4C at least 1 month apart or a 3-dose series of MenB-FHbp at 0, 1-2, and 6 months if the outbreak is attributable to serogroup B.

• Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) who are healthy and not at increased risk for serogroup B meningococcal disease may receive either a 2-dose series of MenB-4C at least 1 month apart or a 2-dose series of MenB-FHbp at 0 and 6 months for short-term protection against most strains of serogroup B meningococcal disease.

Notable changes in Figures 1 and 2 are:

• In Figures 1 and 2, standardized acronyms for vaccines are used to promote simplicity and consistency, and their listing has been reordered. Ancillary information previously contained in the figures have been consolidated and moved to the cover page. Colored blocks instead of colored bars are used to denote indications. These figures must be read with the footnotes that contain important information for each vaccine and considerations for special populations.

• In Figure 2, the columns for medical condition and other indications have been reordered to keep medical conditions together and special populations together. Additional footnotes mark appropriate columns of medical conditions and other indications to refer the reader to view relevant vaccine-specific information.

• In Figure 2, the color of the indication block for MenACWY for HIV infection has been changed to yellow (recommended for adults who meet the age requirement, lack documentation of vaccination, or lack evidence of past infection) from purple (recommended for adults with additional medical conditions or other indications).

Significant changes in the 2017 adult immunization schedule footnotes include the following:

• Footnotes are limited to the information that pertains to the vaccines listed in Figures 1 and 2 and organized by vaccine-specific information and considerations for special populations (e.g., pregnant women and adults with HIV infection). The footnote on “additional information,” contained in previous iterations of the adult immunization schedule, has been moved to the cover page. The footnote on “immunocompromising conditions” has been removed but vaccine-specific information on immunocompromising conditions has been added to appropriate footnotes, e.g., the footnote for pneumococcal vaccination.

• The format for the footnotes has been condensed, simplified, and standardized. The format for pneumococcal; human papillomavirus; meningococcal; varicella; and measles, mumps, and rubella vaccination footnotes have undergone significant revision.

Lastly, the table of contraindications and precautions for vaccines routinely recommended for adults, previously a standalone document, has been incorporated into the adult immunization schedule. The content of the table has been consolidated and simplified.

The ACIP-recommended use of each vaccine is developed after in-depth reviews of vaccine-related data, including disease epidemiology, vaccine efficacy and effectiveness, vaccine safety, feasibility of program implementation, and economic aspects of immunization policy (6). As a result, some vaccination recommendations are complex and their implementation can be challenging. The adult immunization schedule summarizes the current ACIP recommendations and is designed to help health care providers implement those recommendations. In preparing the 2017 adult immunization schedule, the ACIP made a concerted effort to simplify, consolidate, and standardize its graphics, language, and format. Additional efforts are under way to continue to improve its usability by health care providers and to evaluate its usefulness.

The utility of the adult immunization schedule is ultimately dependent on the efforts of health care providers and health care systems to apply it in the care of their adult patients and implement the standards for adult immunization practice (7). The incorporation of ACIP recommendations into clinical practice and reducing missed opportunities to vaccinate adult patients remain a challenge (8). Barriers for vaccination for adults cited by health care providers include competing priorities with management of patients' acute and chronic health conditions, lower prioritization of immunization for adults compared with other preventive services, and financial barriers to providing vaccination services to adults (9, 10). These and other challenges (e.g., limited awareness for adult vaccinations by adult patients, difficulties maintaining complete vaccination records for adult patients, and complexities of adult vaccine insurance coverage) contribute to low immunization coverage rates for adults in the United States (9–11).

The 2014 National Health Interview Survey (NHIS) found that influenza vaccination coverage among adults aged ≥19 years was 43.2%; pneumococcal vaccination coverage among adults aged 19 through 64 years who are at high risk for pneumococcal disease was 20.3% and among adults aged ≥65 years was 61.3%; tetanus and diphtheria toxoids and acellular pertussis vaccination (Tdap) coverage among adults aged ≥19 years was 20.1%; and herpes zoster vaccination coverage among adults aged ≥60 years was 27.9% (8). These low immunization coverage rates have generally not changed significantly over the past several years. In addition, racial and ethnic disparities—with whites generally having higher adult immunization coverage than blacks, Hispanics, and Asians—were prevalent across vaccines recommended for adults (8, 12).

Not surprisingly, adults who have health insurance have higher vaccination coverage than those who do not have health insurance (8). Overall, immunization coverage in 2014 was 2 to 5 times higher among adults with public or private health insurance than among those without health insurance for influenza vaccination for adults aged ≥19 years (48.0% vs. 15.9%); pneumococcal vaccination for adults aged 19 through 64 years at high risk (22.5% vs. 11.0%) and adults aged ≥65 years (61.7% vs. 24.3%); Tdap for adults aged ≥19 years (21.5% vs. 11.5%); and herpes zoster vaccine for adults aged ≥60 years (28.7% vs. 5.6%). While adults with health insurance are more likely to receive vaccines than are those without, substantial proportions of adults with health insurance who reported having had at least 10 physician contacts within the past year reported missing vaccinations. For example, 23.8% of adults aged ≥65 years did not report having received influenza vaccination, 61.4% of high-risk adults aged 19 through 64 years did not report having received pneumococcal vaccination, and 64.8% of adults aged 19 through 59 years with diabetes did not report having received hepatitis B vaccination (8).

Missed opportunities for vaccinating adults may result in part from limited familiarity or challenges with the complexity of the adult immunization schedule among health care providers. In a recent survey, 25.3% (149 of 588) of general internists and family physicians reported that the age-based vaccination recommendations for adults were difficult to follow and 29.3% (172 of 587) reported that medical condition–based recommendations were difficult to follow (9). Additional data are needed to assess health care providers' range of familiarity with the adult immunization schedule and identify ways to improve its utility and usability.

To improve overall adult vaccination rates, health care providers and health care systems can use a systematic approach to adult immunization and implement evidence-based strategies, such as use of standing orders, patient reminders, recall for patients with missing vaccinations, and provider reminders through electronic medical record alerts and other means (13). These proven amplifiers for adult vaccination, along with the implementation of the adult immunization practice standards, should help health care providers and health care systems reduce racial and ethnic disparities in vaccination levels for adults and reduce their risk for illness, disability, and death from vaccine-preventable diseases.

Appendix

Recommendations for routine use of vaccines in adults, and children and adolescents are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is chartered as a federal advisory committee to provide expert external advice and guidance to the Director of the Centers for Disease Control and Prevention (CDC) on use of vaccines and related agents for the control of vaccine-preventable diseases in the civilian population of the United States. Recommendations for routine use of vaccines in adults are harmonized with recommendations of the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the American College of Nurse-Midwives (ACNM). Recommendations for routine use of vaccines in children and adolescents are harmonized to the greatest extent possible with recommendations made by the American Academy of Pediatrics (AAP), AAFP, and ACOG. ACIP recommendations adopted by the CDC Director become agency guidelines on the date published in the Morbidity and Mortality Weekly Report (MMWR). Additional information on ACIP is available at www.cdc.gov/vaccines/acip.

Members of the ACIP

Nancy Bennett, MD, MS, University of Rochester School of Medicine and Dentistry, Rochester, New York (Chair); Amanda Cohn, MD, Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases, Atlanta, Georgia (Executive Secretary); Robert L. Atmar, MD, Baylor College of Medicine, Houston, Texas; Edward Belongia, MD, Marshfield Clinic Research Foundation, Marshfield, Wisconsin; Echezona Ezeanolue, MD, MPH, University of Nevada, Las Vegas, Nevada; Paul Hunter, MD, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI; Allison Kempe, MD, MPH, University of Colorado School of Medicine, Denver, Colorado; Grace M. Lee, MD, MPH, Harvard Medical School, Boston, Massachusetts; Kelly Moore, MD, MPH, Tennessee Department of Health, Nashville, Tennessee; Cynthia Pellegrini, March of Dimes, Washington, DC; Arthur L. Reingold, MD, University of California School of Public Health, Berkeley, California; Laura E. Riley, MD, Harvard Medical School, Boston, Massachusetts; José R. Romero, MD, University of Arkansas for Medical Sciences, Little Rock, Arkansas; David Stephens, MD, Emory University School of Medicine, Atlanta, Georgia; Peter Szilagyi, MD, MPH, University of California, Los Angeles, Los Angeles, California; Emmanuel (Chip) Walter Jr., MD, MPH, Duke University School of Medicine, Durham, North Carolina. A list of current ACIP members is available at www.cdc.gov/vaccines/acip/committee/members.html.

ACIP Adult Immunization Work Group

Work Group Chair: Laura E. Riley, MD, Cambridge, Massachusetts.

Work Group Members: John Epling, MD, MSEd, Syracuse, New York; Stephan Foster, Nashville, Tennessee; Sandra Fryhofer, MD, Atlanta, Georgia; Robert H. Hopkins Jr., MD, Little Rock, Arkansas; Paul Hunter, MD, Milwaukee, WI; Jane Kim, MD, Durham, North Carolina; Laura Pinkston Koenigs, MD, Springfield, Massachusetts; Maria Lanzi, ANP, MPH, Hamilton, New Jersey; Marie-Michele Leger, MPH, PA-C, Alexandria, Virginia; Susan M. Lett, MD, Boston, Massachusetts; Robert Palinkas, MD, Urbana, Illinois; Gregory Poland, MD, Rochester, Minnesota; Joni Reynolds, MPH, Denver, Colorado; Charles Rittle, DNP, MPH, RN, Pittsburgh, Pennsylvania; William Schaffner, MD, Nashville, Tennessee; Kenneth Schmader, MD, Durham, North Carolina; Angela Shen, PhD, Washington, DC; Rhoda Sperling, MD, New York, New York.

Work Group Contributors: Carolyn B. Bridges, MD, Atlanta, Georgia; Elizabeth Briere, MD, MPH, Atlanta, Georgia; Lisa Grohskopf, MD, MPH, Atlanta, Georgia; Rafael Harpaz, MD, MPH, Atlanta, Georgia; Charles LeBaron, MD, Atlanta, Georgia; Jennifer L. Liang, DVM, MPVM, Atlanta, Georgia; Jessica MacNeil, MPH, Atlanta, Georgia; Mona Marin, MD, Atlanta, Georgia; Lauri Markowitz, MD, Atlanta, Georgia; Noele Nelson, MD, PhD, Atlanta, Georgia; Tamara Pilishvili, MPH, Atlanta, Georgia; Mona Saraiya, MD, MPH, Atlanta, Georgia; Sarah Schillie, MD, Atlanta, Georgia; Raymond A. Strikas, MD, MPH, Atlanta, Georgia; Walter W. Williams, MD, MPH, Atlanta, Georgia.

Work Group Consultants: Tamera Coyne-Beasley, MD, MPH, Chapel Hill, North Carolina; Kathleen H. Harriman, PhD, MPH, RN, Richmond, California; Molly Howell, MPH, Bismarck, North Dakota; Linda Kinsinger, MD, MPH, Durham, North Carolina; Diane Peterson, St. Paul, Minnesota; Litjen Tan, PhD, Chicago, Illinois.

Work Group Secretariat: David K. Kim, MD, MA, Atlanta, Georgia.