Dear Clinician,
Recommended Adult Immunization Schedule
- United States
October 2007--September 2008
EXCERPT
The Recommended Adult Immunization Schedule has been approved by the
Advisory Committee on Immunization Practices, the American Academy of
Family Physicians, the American College of Obstetricians and
Gynecologists, and the American College of Physicians. The standard
MMWR footnote format has been modified for publication of this
schedule.
NOTE: These recommendations must be read along with the footnotes,
which are on pages Q2--Q4 of this schedule.
Approved by the Advisory Committee on Immunization Practices (ACIP),
the
Obstetricians and Gynecologists, and the
Physicians.
Complete statements from ACIP are available at
http://www.cdc.gov/vaccines/pubs/acip-list.htm.
1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination
Tdap should replace a single dose of Td for adults aged <65 years who
have not previously received a dose of Tdap. Only one of two Tdap
products (Adacel® [Sanofi Pasteur]) is licensed for use in adults.
Adults with uncertain histories of a complete primary vaccination
series with tetanus and diphtheria toxoid--containing vaccines should
begin or complete a primary vaccination series. A primary series for
adults is 3 doses of tetanus and diphtheria toxoid--containing
vaccines; administer the first 2 doses at least 4 weeks apart and the
third dose 6--12 months after the second. However, Tdap can substitute
for any one of the doses of Td in the 3-dose primary series. The
booster dose of tetanus and diphtheria toxoid--containing vaccine
should be administered to adults who have completed a primary series
and if the last vaccination was received greater than or equal to 10
years previously. Tdap or Td vaccine may be used, as indicated.
If the person is pregnant and received the last Td vaccination greater
than or equal to 10 years previously, administer Td during the second
or third trimester; if the person received the last Td vaccination in
<10 years, administer Tdap during the immediate postpartum period. A
one-time administration of 1 dose of Tdap with an interval as short as
2 years from a previous Td vaccination is recommended for postpartum
women, close contacts of infants aged <12 months, and all health-care
workers with direct patient contact. In certain situations, Td can be
deferred during pregnancy and Tdap substituted in the immediate
postpartum period, or Tdap can be administered instead of Td to a
pregnant woman after an informed discussion with the woman.
Consult the ACIP statement for recommendations for administering Td as
prophylaxis in wound management.
2. Human papillomavirus (HPV) vaccination
HPV vaccination is recommended for all females aged less than or equal
to 26 years who have not completed the vaccine series. History of
genital warts, abnormal Papanicolaou test, or positive HPV DNA test is
not evidence of prior infection with all vaccine HPV types; HPV
vaccination is still recommended for these persons.
Ideally, vaccine should be administered before potential exposure to
HPV through sexual activity; however, females who are sexually active
should still be vaccinated. Sexually active females who have not been
infected with any of the HPV vaccine types receive the full benefit of
the vaccination. Vaccination is less beneficial for females who have
already been infected with one or more of the HPV vaccine types.
A complete series consists of 3 doses. The second dose should be
administered 2 months after the first dose; the third dose should be
administered 6 months after the first dose.
Although HPV vaccination is not specifically recommended for females
with the medical indications described in Figure 2, "Vaccines that
might be indicated for adults based on medical and other indications,"
it is not a live-virus vaccine and can be administered. However, immune
response and vaccine efficacy might be less than in persons who do not
have the medical indications described or who are immunocompetent.
3. 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 greater than
or equal to 1 dose of MMR unless they have a medical contraindication,
documentation of greater than or equal to1 dose, history of measles
based on health-care provider diagnosis, or laboratory evidence of
immunity.
A second dose of MMR is recommended for adults who 1) have been
recently exposed to measles or are in an outbreak setting; 2) have been
previously vaccinated with killed measles vaccine; 3) have been
vaccinated with an unknown type of measles vaccine during 1963--1967;
4) are students in postsecondary educational institutions; 5) work in a
health-care facility; or 6) plan to travel internationally.
Mumps component: adults born before 1957 can generally be considered
immune to mumps. Adults born during or after 1957 should receive 1 dose
of MMR unless they have a medical contraindication, history of mumps
based on health-care provider diagnosis, or laboratory evidence of
immunity.
A second dose of MMR is recommended for adults who 1) are in an age
group that is affected during a mumps outbreak; 2) are students in
postsecondary educational institutions; 3) work in a health-care
facility; or 4) plan to travel internationally. For unvaccinated
health-care workers born before 1957 who do not have other evidence of
mumps immunity, consider administering 1 dose on a routine basis and
strongly consider administering a second dose during an outbreak.
Rubella component: administer 1 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. Women who do not have evidence
of immunity should receive MMR vaccine on completion or termination of
pregnancy and before discharge from the health-care facility.
4. Varicella vaccination
All adults without evidence of immunity to varicella should receive 2
doses of single-antigen varicella vaccine unless they have a medical
contraindication. Special consideration should be given to those who 1)
have close contact with persons at high risk for severe disease (e.g.,
health-care personnel and family contacts of immunocompromised persons)
or 2) are at high risk for exposure or transmission (e.g., teachers;
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; and international
travelers).
Evidence of immunity to varicella in adults includes any of the
following: 1) documentation of 2 doses of varicella vaccine at least 4
weeks apart; 2) U.S.-born before 1980 (although for health-care
personnel and pregnant women, birth before 1980 should not be
considered evidence of immunity); 3) history of varicella based on
diagnosis or verification of varicella by a health-care provider (for a
patient reporting a history of or presenting with an atypical case, a
mild case, or both, health-care providers should seek either an
epidemiologic link with a typical varicella case or to a
laboratory-confirmed 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 provider diagnosis; or 5) laboratory
evidence of immunity or laboratory confirmation of disease.
Assess pregnant women for evidence of varicella immunity. Women who do
not have evidence of immunity should receive the first dose of
varicella vaccine upon completion or termination of pregnancy and
before discharge from the health-care facility. The second dose should
be administered 4--8 weeks after the first dose.
5. Influenza vaccination
Medical indications: chronic disorders of the cardiovascular or
pulmonary systems, including asthma; chronic metabolic diseases,
including diabetes mellitus, renal or hepatic dysfunction,
hemoglobinopathies, or immunosuppression (including immunosuppression
caused by medications or human immunodeficiency virus [HIV]); 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, or seizure disorder
or 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 personnel 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 (e.g., in-home household contacts and caregivers
of children aged 0--59 months, or persons of all ages with high-risk
conditions); and anyone who would like to be vaccinated. Healthy,
nonpregnant adults aged less than or equal to 49 years without
high-risk medical conditions who are not contacts of severely
immunocompromised persons in special care units can receive either
intranasally administered live, attenuated influenza vaccine (FluMist®)
or inactivated vaccine. Other persons should receive the inactivated
vaccine.
6. Pneumococcal polysaccharide vaccination
Medical indications: chronic pulmonary disease (excluding asthma);
chronic cardiovascular diseases; diabetes mellitus; chronic liver
diseases, including liver disease as a result of alcohol abuse (e.g.,
cirrhosis); chronic alcoholism, chronic renal failure, or nephrotic
syndrome; functional or anatomic asplenia (e.g., sickle cell disease or
splenectomy [if elective splenectomy is planned, vaccinate at least 2
weeks before surgery]); immunosuppressive conditions; and cochlear
implants and cerebrospinal fluid leaks. Vaccinate as close to HIV
diagnosis as possible.
Other indications:
populations and residents of nursing homes or other long-term--care
facilities.
7. Revaccination with pneumococcal polysaccharide vaccine
One-time revaccination after 5 years for persons with chronic renal
failure or nephrotic syndrome; functional or anatomic asplenia (e.g.,
sickle cell disease or splenectomy); or immunosuppressive conditions.
For persons aged greater than or equal to 65 years, one-time
revaccination if they were vaccinated greater than or equal to 5 years
previously and were aged <65 years at the time of primary vaccination.
8. Hepatitis A vaccination
Medical indications: persons with chronic liver disease and persons who
receive clotting factor concentrates.
Behavioral indications: men who have sex with men and persons who use
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 at
http://wwwn.cdc.gov/travel/contentdiseases.aspx) and any
person seeking
protection from HAV infection.
Single-antigen vaccine formulations should be administered in a 2-dose
schedule at either 0 and 6--12 months (Havrix®), or 0 and 6--18 months
(Vaqta®). If the combined hepatitis A and hepatitis B vaccine
(Twinrix®) is used, administer 3 doses at 0, 1, and 6 months.
9. Hepatitis B vaccination
Medical indications: persons with end-stage renal disease, including
patients receiving hemodialysis; persons seeking evaluation or
treatment for a sexually transmitted disease (STD); persons with HIV
infection; and persons with chronic liver disease.
Occupational indications: health-care personnel and public-safety
workers who are exposed to blood or other potentially infectious body
fluids.
Behavioral indications: sexually active persons who are not in a
long-term, mutually monogamous relationship (e.g., persons with more
than one sex partner during the previous 6 months); current or recent
injection-drug users; 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 members of
institutions for persons with developmental disabilities; international
travelers to countries with high or intermediate prevalence of chronic
HBV infection (a list of countries is available at
http://wwwn.cdc.gov/travel/contentdiseases.aspx); and any adult
seeking
protection from HBV infection.
Settings where hepatitis B vaccination is recommended for all adults:
STD treatment facilities; HIV testing and treatment facilities;
facilities providing drug-abuse treatment and prevention services;
health-care settings targeting services to injection-drug users or men
who have sex with men; correctional facilities; end-stage renal disease
programs and facilities for chronic hemodialysis patients; and
institutions and nonresidential day care facilities for persons with
developmental disabilities.
Special formulation indications: for adult patients receiving
hemodialysis and other immunocompromised adults, 1 dose of 40 μg/mL
(Recombivax HB®) or 2 doses of 20 μg/mL (Engerix-B®), administered
simultaneously.
10. Meningococcal vaccination
Medical indications: adults with anatomic or functional asplenia or
terminal complement component deficiencies.
Other indications: first-year college students living in dormitories;
microbiologists who are routinely exposed to isolates of Neisseria
meningitidis; military recruits; and persons who travel to or live in
countries in which meningococcal disease is hyperendemic or epidemic
(e.g., the "meningitis belt" of sub-Saharan Africa during the dry
season [December--June]), particularly if their contact with local
populations will be prolonged. Vaccination is required by the
government of
Hajj.
Meningococcal conjugate vaccine is preferred for adults with any of the
preceding indications who are aged less than or equal to 55 years,
although meningococcal polysaccharide vaccine (MPSV4) is an acceptable
alternative. Revaccination after 3--5 years might be indicated for
adults previously vaccinated with MPSV4 who remain at increased risk
for infection (e.g., persons residing in areas in which disease is
epidemic).
11. Herpes zoster vaccination
A single dose of zoster vaccine is recommended for
adults aged greater
than or equal to 60 years regardless of whether they report a prior
episode of herpes zoster. Persons with chronic medical conditions may
be vaccinated unless a contraindication or precaution exists for their
condition.
12. Selected conditions for which Haemophilus influenzae type b (Hib)
vaccine may be used
Hib conjugate vaccines are licensed for children aged 6 weeks--71
months. No efficacy data are available on which to base a
recommendation concerning use of Hib vaccine for older children and
adults with the chronic conditions associated with an increased risk
for Hib disease. However, studies suggest good immunogenicity in
patients who have sickle cell disease, leukemia, or HIV infection or
who have had splenectomies; administering vaccine to these patients is
not contraindicated.
13. Immunocompromising conditions
Inactivated vaccines generally are acceptable (e.g., pneumococcal,
meningococcal, and influenza [trivalent inactivated influenza vaccine])
and live vaccines generally are avoided in persons with immune
deficiencies or immune suppressive conditions. Information on specific
conditions is available at
http://www.cdc.gov/vaccines/pubs/acip-list.htm.
REFERENCE:
Centers for Disease Control and Prevention. Recommended Adult
Immunization Schedule---
MMWR 2007;56:Q1--Q4. [Link to free full text
publication online]
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm
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