Adult Immunization Schedule 2023

• Anatomical or functional asplenia (including sickle cell disease): 1 dose if previously did not receive Hib; if elective splenectomy, 1 dose, preferably at least 14 days before splenectomy
• Hematopoietic stem cell transplant (HSCT): 3-dose series 4 weeks apart starting 6–12 months after successful transplant, regardless of Hib vaccination history

• Not at risk but want protection from hepatitis A
  (identification of risk factor not required): 2-dose series HepA (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum interval: 6 months]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 5 months])

• At risk for hepatitis A virus infection: 2-dose series HepA or 3-dose series HepA-HepB as above
  • Chronic liver disease (e.g., persons with hepatitis B, hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal)
  • HIV infection
  • Men who have sex with men
  • Injection or noninjection drug use
  • Persons experiencing homelessness
  • Work with hepatitis A virus in research laboratory or with nonhuman primates with hepatitis A virus infection
  • Travel in countries with high or intermediate endemic hepatitis A (HepA-HepB [Twinrix] may be administered on an accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster dose at 12 months)
  • Close, personal contact with international adoptee (e.g., household or regular babysitting) in first 60 days after arrival from country with high or intermediate endemic hepatitis A (administer dose 1 as soon as adoption is planned, at least 2 weeks before adoptee’s arrival)
  • Pregnancy if at risk for infection or severe outcome from infection during pregnancy
  • Settings for exposure, including health care settings targeting services to injection or noninjection drug users or group homes and nonresidential day care facilities for developmentally disabled persons (individual risk factor screening not required)

• Age 19 through 59 years: complete a 2- or 3- or 4-dose series
  • 2-dose series only applies when 2 doses of Heplisav-B* are used at least 4 weeks apart
  • 3-dose series Engerix-B, PreHevbrio*, or Recombivax HB at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose 1 to dose 3: 16 weeks])
  • 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 5 months])
  • 4-dose series HepA-HepB (Twinrix) accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster dose at 12 months
• *Note: Heplisav-B and PreHevbrio are not recommended in pregnancy due to lack of safety data in pregnant persons.
• Age 60 years or older with known risk factors for hepatitis B virus infection should complete a HepB vaccine series.
• Age 60 years or older without known risk factors for hepatitis B virus infection may complete a HepB vaccine series.
  • Risk factors for hepatitis B virus infection include:
    • Chronic liver disease (e.g., persons with hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice upper limit of normal)
    • HIV infection
    • Sexual exposure risk (e.g., sex partners of hepatitis B surface antigen [HBsAg]-positive persons; sexually active persons not in mutually monogamous relationships; persons seeking evaluation or treatment for a sexually transmitted infection; men who have sex with men)
    • Current or recent injection drug use
    • Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAg-positive persons; residents and staff of facilities for developmentally disabled persons; health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids; persons on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis, and persons who are predialysis; patients with diabetes)
    • Incarceration
    • Travel in countries with high or intermediate endemic hepatitis B

• Patients on dialysis: complete a 3- or 4-dose series
  • 3-dose series Recombivax HB at 0, 1, 6 months (note: use Dialysis Formulation 1 mL = 40 mcg)
  • 4-dose series Engerix-B at 0, 1, 2, and 6 months (note: use 2 mL dose instead of the normal adult dose of 1 mL)

• HPV vaccination recommended for all persons through age 26 years: 2- or 3-dose series depending on age at initial vaccination or condition:
  • Age 15 years or older at initial vaccination: 3-dose series at 0, 1–2 months, 6 months (minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 12 weeks / dose 1 to dose 3: 5 months; repeat dose if administered too soon)
  • Age 9–14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart: 1 additional dose
  • Age 9–14 years at initial vaccination and received 2 doses at least 5 months apart: HPV vaccination series complete, no additional dose needed
• Interrupted schedules: If vaccination schedule is interrupted, the series does not need to be restarted
• No additional dose recommended when any HPV vaccine series has been completed using the recommended dosing intervals.

• Some adults age 27–45 years: Based on shared clinical decision-making, 2- or 3-dose series as above

• Age ranges recommended above for routine and catch-up vaccination or shared clinical decision-making also apply in special situations
  • Immunocompromising conditions, including HIV infection: 3-dose series, even for those who initiate vaccination at age 9 through 14 years.
  • Pregnancy: Pregnancy testing is not needed before vaccination; HPV vaccination is not recommended until after pregnancy; no intervention needed if inadvertently vaccinated while pregnant.

• Age 19 years or older: 1 dose any influenza vaccine appropriate for age and health status annually
• Age 65 years or older: Any one of quadrivalent high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4) is preferred. If none of these three vaccines is available, then any other age-appropriate influenza vaccine should be used.
• For the 2022–2023 season, see www.cdc.gov/mmwr/volumes/71/rr/rr7101a1.htm
• For the 2023–2024 season, see the 2023–2024 ACIP influenza vaccine recommendations.

• Egg allergy, hives only: any influenza vaccine appropriate for age and health status annually
• Egg allergy–any symptom other than hives (e.g., angioedema, respiratory distress or required epinephrine or another emergency medical intervention): Any influenza vaccine appropriate for age and health status may be administered. If using egg-based IIV4 or LAIV4, administer in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions.
• Close contacts (e.g., caregivers, healthcare workers) of severely immunosuppressed persons who require a protected environment: these persons should not receive LAIV4. If LAIV4 is given, they should avoid contact with/caring for such immunosuppressed persons for 7 days after vaccination.
• Severe allergic reaction (e.g., anaphylaxis) to a vaccine component or a previous dose of any influenza vaccine: see Appendix listing contraindications and precautions
• History of Guillain-Barré syndrome within 6 weeks after previous dose of influenza vaccine: Generally, should not be vaccinated unless vaccination benefits outweigh risks for those at higher risk for severe complications from influenza

• No evidence of immunity to measles, mumps, or rubella: 1 dose
  • Evidence of immunity: Born before 1957 (health care personnel, see below), documentation of receipt of MMR vaccine, laboratory evidence of immunity or disease (diagnosis of disease without laboratory confirmation is not evidence of immunity)

• Pregnancy with no evidence of immunity to rubella: MMR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose
• Nonpregnant persons of childbearing age with no evidence of immunity to rubella: 1 dose
• HIV infection with CD4 percentages ≥15% and CD4 count ≥200 cells/mm3 for at least 6 months and no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart; MMR contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm³
• Severe immunocompromising conditions: MMR contraindicated
• Students in postsecondary educational institutions, international travelers, and household or close, personal contacts of immunocompromised persons with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart if previously did not receive any doses of MMR or 1 dose if previously received 1 dose MMR
• In mumps outbreak settings, for information about additional doses of MMR (including 3rd dose of MMR), see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7. htm
• Health care personnel:
  • Born before 1957 with no evidence of immunity to measles, mumps, or rubella: Consider 2-dose series at least 4 weeks apart for protection against measles or mumps or 1 dose for protection against rubella
  • Born in 1957 or later with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart for protection against measles or mumps or at least 1 dose for protection against rubella

• Anatomical or functional asplenia (including sickle cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use: 2-dose series MenACWY-D (Menactra, Menveo, or MenQuadfi) at least 8 weeks apart and revaccinate every 5 years if risk remains
• Travel in countries with hyperendemic or epidemic meningococcal disease, or microbiologists routinely exposed to Neisseria meningitidis: 1 dose MenACWY (Menactra, Menveo, or MenQuadfi) and revaccinate every 5 years if risk remains
• First-year college students who live in residential housing (if not previously vaccinated at age 16 years or older) or military recruits: 1 dose MenACWY (Menactra, Menveo, or MenQuadfi)
• For MenACWY booster dose recommendations for groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm

• Adolescents and young adults age 16–23 years (age 16–18 years preferred) not at increased risk for meningococcal disease: Based on shared clinical decision-making, 2-dose series MenB-4C (Bexsero) at least 1 month apart or 2-dose series MenB-FHbp (Trumenba) at 0, 6 months (if dose 2 was administered less than 6 months after dose 1, administer dose 3 at least 4 months after dose 2); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series)

• Anatomical or functional asplenia (including sickle cell disease), persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use, or microbiologists routinely exposed to Neisseria meningitidis: 2-dose primary series MenB-4C (Bexsero) at least 1 month apart or 3-dose primary series MenB-FHbp (Trumenba) at 0, 1–2, 6 months (if dose 2 was administered at least 6 months after dose 1, dose 3 not needed; if dose 3 is administered earlier than 4 months after dose 2, a fourth dose should be administered at least 4 months after dose 3); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2–3 years if risk remains
• Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweigh potential risks
• For MenB booster dose recommendations for groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm

• Note: MenB vaccines may be administered simultaneously with MenACWY vaccines if indicated, but at a different anatomic site, if feasible.

• Age 65 years or older who have:
  • Not previously received a dose of PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups.
  • Previously received only PCV7: follow the recommendation above.
  • Previously received only PCV13: 1 dose PCV20 at least 1 year after the PCV13 dose OR complete the recommended PPSV23 series as described here: www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
  • Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23.
  • Previously received both PCV13 and PPSV23 but NO PPSV23 was received at age 65 years or older: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here: www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
  • Previously received both PCV13 and PPSV23, AND PPSV23 was received at age 65 years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose.
  • For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app which can be downloaded here: www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html

• Age 19–64 years with certain underlying medical conditions or other risk factors** who have
  • Not previously received a PCV13, PCV15, or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak
  • Previously received only PCV7: follow the recommendation above
  • Previously received only PCV13: 1 dose PCV20 at least 1 year after the PCV13 dose OR complete the recommended PPSV23 series as described here:
    www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
  • Previously received only PPSV23: 1 dose PCV15 OR 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23
  • Previously received both PCV13 and PPSV23 but have not completed the recommended series: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here:
    www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf
• For guidance on determining which pneumococcal vaccines a patient needs and when, please refer to the mobile app which can be downloaded here: www.cdc.gov/vaccines/vpd/pneumo/hcp/pneumoapp.html

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

• Previously did not receive Tdap at or after age 11 years: 1 dose Tdap, then Td or Tdap every 10 years

• Previously did not receive primary vaccination series for tetanus, diphtheria, or pertussis: 1 dose Tdap followed by 1 dose Td or Tdap at least 4 weeks later, and a third dose of Td or Tdap 6–12 months later (Tdap can be substituted for any Td dose, but preferred as first dose), Td or Tdap every 10 years thereafter
• Pregnancy: 1 dose Tdap during each pregnancy, preferably in early part of gestational weeks 27–36
• Wound management: Persons with 3 or more doses of tetanus-toxoid-containing vaccine: For clean and minor wounds, administer Tdap or Td if more than 10 years since last dose of tetanus-toxoid-containing vaccine; for all other wounds, administer Tdap or Td if more than 5 years since last dose of tetanus-toxoid-containing vaccine. Tdap is preferred for persons who have not previously received Tdap or whose Tdap history is unknown. If a tetanus-toxoid-containing vaccine is indicated for a pregnant woman, use Tdap. For detailed information, see www.cdc.gov/mmwr/volumes/69/wr/mm6903a5.htm

• No evidence of immunity to varicella: 2-dose series 4–8 weeks apart if previously did not receive varicella-containing vaccine (VAR or MMRV [measles-mumps-rubella-varicella vaccine] for children); if previously received 1 dose varicella-containing vaccine, 1 dose at least 4 weeks after first dose
  • Evidence of immunity: U.S.-born before 1980 (except for pregnant persons and health care personnel [see below]), documentation of 2 doses varicella-containing vaccine at least 4 weeks apart, diagnosis or verification of history of varicella or herpes zoster by a health care provider, laboratory evidence of immunity or disease

• Pregnancy with no evidence of immunity to varicella: VAR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose if previously received 1 dose varicella-containing vaccine or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
• Health care personnel with no evidence of immunity to varicella: 1 dose if previously received 1 dose varicella-containing vaccine; 2-dose series 4–8 weeks apart if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980
• HIV infection with CD4 percentages ≥15% and CD4 count ≥200 cells/mm³ with no evidence of immunity: Vaccination may be considered (2 doses 3 months apart); VAR contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm³
• Severe immunocompromising conditions: VAR contraindicated

• Age 50 years or older*: 2-dose series recombinant zoster vaccine (RZV, Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon), regardless of previous herpes zoster or history of zoster vaccine live (ZVL, Zostavax) vaccination.

• *Note: Serologic evidence of prior varicella is not necessary for zoster vaccination. However, if serologic evidence of varicella susceptibility becomes available, providers should follow ACIP guidelines for varicella vaccination first. RZV is not indicated for the prevention of varicella, and there are limited data on the use of RZV in persons without a history of varicella or varicella vaccination.

• Pregnancy: There is currently no ACIP recommendation for RZV use in pregnancy. Consider delaying RZV until after pregnancy.
• Immunocompromising conditions (including persons with HIV regardless of CD4 count)**: 2-dose series recombinant zoster vaccine (RZV, Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon). For detailed information, see www.cdc.gov/shingles/vaccination/immunocompromised-adults.html

• **Note: If there is no documented history of varicella, varicella vaccination, or herpes zoster, providers should refer to the clinical considerations for use of RZV in immunocompromised adults aged ≥19 years and the ACIP varicella vaccine recommendations for further guidance: www.cdc.gov/mmwr/volumes/71/wr/mm7103a2.htm