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## Complete Summary

#### GUIDELINE TITLE

Recommended adult immunization schedule: United States, October
2007-September 2008.

#### BIBLIOGRAPHIC SOURCE(S)

Advisory Committee on Immunization Practices. Recommended adult
immunization schedule: United States, October 2007-September 2008. Ann
Intern Med 2007 Nov 20;147(10):725-9. \[1 reference\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17947396)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Vaccine-preventable diseases:

-   Diphtheria

-   Hepatitis A

-   Hepatitis B

-   Herpes Zoster

-   Human Papillomavirus (HPV) infection

-   Influenza

-   Measles

-   Meningococcal disease

-   Mumps

-   Pertussis

-   Pneumonia

-   Rubella

-   Tetanus

-   Varicella

#### GUIDELINE CATEGORY

Prevention

#### CLINICAL SPECIALTY

Family Practice\
Geriatrics\
Infectious Diseases\
Internal Medicine\
Nursing\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Health Care Providers\
Nurses\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

To update the Adult Immunization Schedule to reflect current
recommendations for the licensed vaccines

#### TARGET POPULATION

Adults 18 years or older

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Vaccination with the following:

    -   Tetanus, diphtheria, and acellular pertussis vaccine (Td/Tdap)

    -   Human papillomavirus (HPV) vaccine

    -   Measles, mumps, and rubella (MMR) vaccine

    -   Varicella vaccine

    -   Influenza vaccine

    -   Intramuscular trivalent inactivated influenza vaccine (TIV)

    -   Live-attenuated influenza vaccine (LAIV)

    -   Pneumococcal polysaccharide vaccine (PPV)

    -   Hepatitis A vaccine

    -   Hepatitis B vaccine

    -   Meningococcal vaccine

    -   Meningococcal conjugate vaccine (MCV4)

    -   Meningococcal polysaccharide vaccine (MPSV4)

    -   Herpes zoster vaccine

2.  Special consideration of immunization needs for adults based on
    medical and other conditions

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

In June 2007, the Advisory Committee on Immunization Practices (ACIP)
approved the Adult Immunization Schedule for October 2007 -- September
2008. This schedule has also been approved by the American Academy of
Family Physicians, American College of Obstetricians and Gynecologists,
and American College of Physicians.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

***Note**: The Advisory Committee on Immunization Practices (ACIP)
annually reviews the recommended Adult Immunization Schedule to ensure
that the schedule reflects current recommendations for the licensed
vaccines.*

**[Changes in the Schedule for October 2007 -- September
2008]{.underline}**

The 2007--2008 schedule differs from the previous schedule as follows:

-   The yellow bar for varicella has been extended through all age
    groups on the age-based schedule (see figure below), indicating that
    varicella vaccine is recommended for all adults without evidence of
    immunity to varicella.

-   Zoster vaccine has been added to the age-based schedule, with a
    yellow bar indicating that the vaccine is recommended for persons
    age 60 years or older.

-   The title of the medical and other indications schedule (see figure,
    below) has been changed to \"Vaccines That May Be Indicated for
    Adults Based on Medical and Other Indications,\" which indicates
    that not all of the vaccines are recommended on the basis of medical
    indications.

-   The word *contraindicated* has been added to the red bars in the
    medical and other indications schedule and is removed from the
    legend, simplifying the presentation.

-   The immunocompromising conditions column heading in the medical and
    other indications schedule has been shortened by removing the list
    of specific immunocompromising conditions.

-   The human immunodeficiency virus (HIV) infection column in the
    medical and other indications schedule has been moved next to the
    immunocompromising conditions column.

-   The HIV column in the medical and other indications schedule has
    been split into CD4^+^ T lymphocyte count less than 200
    cells/microliters and 200 cells/microliters or greater to highlight
    vaccine indications based on CD4^+^ T lymphocyte counts.

-   The indication \"recipients of clotting factor concentrates\" has
    been removed from the chronic liver disease column heading because
    only 1 vaccine has this recommendation. The indication remains in
    the hepatitis A vaccine footnote.

-   The yellow bar for varicella vaccine in the medical and other
    indications schedule has been extended to include HIV-infected
    persons with CD4^+^ T lymphocyte counts of 200 cells/microliters or
    greater.

-   Text has been added to the influenza vaccine yellow bar for the
    health care personnel indication in the medical and other
    indications schedule to indicate that health care workers can
    receive either trivalent inactivated influenza vaccine (TIV) or
    live, attenuated influenza vaccine (LAIV).

-   The yellow bar for influenza vaccine has been extended to include
    the asplenia risk group in the medical and other indications
    schedule.

-   The bar for meningococcal vaccine in the medical and other
    indications schedule has been revised to indicate that 1 or more
    doses of vaccine may be indicated.

-   Zoster vaccine has been added to the medical and other indications
    schedule with a yellow bar to indicate that zoster vaccine is
    recommended for all indications except pregnancy, immunocompromising
    conditions, and HIV. A red bar, indicating a contraindication, has
    been inserted for pregnancy, immunocompromising conditions, and HIV
    infection with a CD4^+^ T lymphocyte count less than 200
    cells/microliters.

-   The footnotes have been reformatted into paragraphs to make them
    easier to read.

-   Language on vaccine contraindications in pregnancy has been removed
    from the footnotes of human Papillomavirus (HPV) (footnote 2);
    measles, mumps, rubella (MMR) vaccine (footnote 3); and varicella
    vaccine (footnote 4) to be consistent with the intent of the
    footnotes to summarize the indications for vaccine use. Pregnancy
    contraindications are given on the medical and other conditions
    schedule with a red bar.

-   The HPV footnote (footnote 2) has been revised to clarify evidence
    of prior infection and that the HPV vaccine is not specifically
    indicated on the basis of medical conditions and to indicate that
    the efficacy and immunogenicity may be lower in immunocompromised
    persons or persons with certain medical conditions.

-   The varicella footnote (footnote 4) has been revised to clarify that
    birth before 1980 in immunocompromised persons is not considered
    evidence of immunity and to add an epidemiologic link to a
    laboratory-confirmed case as a requirement for evidence of immunity
    in a health care provider diagnosis of a mild or atypical case.

-   The pneumococcal (polysaccharide) vaccine footnote (footnote 6) has
    been revised to make it consistent with the column heading in the
    medical and other indications schedule by adding chronic alcoholism.
    The list of specific immunocompromising conditions has been deleted.
    The indication of \"cerebrospinal fluid (CSF) leaks\" has been moved
    from the immunocompromising condition column heading to the footnote
    text.

-   The hepatitis A vaccine footnote (footnote 8) has been revised to
    clarify the dose schedule.

-   The hepatitis B vaccine footnote (footnote 9) has been revised to
    delete persons who receive clotting factor concentrates as a risk
    group and to clarify the dose for special formulation indications.

-   The meningococcal vaccine footnote (footnote 10) has been revised to
    clarify that persons who remain at increased risk for infection may
    be indicated for revaccination.

-   A footnote (footnote 11) has been added to reflect ACIP
    recommendations for herpes zoster vaccination for persons age 60
    years or older.

-   A footnote (footnote 13) has been added to provide a reference for
    the use of vaccines in persons with immunocompromising conditions.

**Recommended Adult Immunization Schedule: United States, October
2007---September 2008**

Note: These recommendations must be read with the footnotes that follow.

**Recommended Schedule for Adult Immunization, by Vaccine and Age
Group**

  ---------------------------- -------------------- ------------ --- ---------- ------ --------------------
  **Vaccine**                  **Age Group**        **19-49          **50-64           **[\>]{.underline}
                                                    years**          years**           65 years**

  **Tetanus, diphtheria,                            1 dose of Td                       
  pertussis                                         booster                            
  (Td/Tdap)^1,\ \*^**                               every 10 y                         

                                                    Substitute 1                        
                                                    dose of Tdap                       
                                                    for Td                             

  **Human papillomavirus                            3 doses for\                        
  (HPV)^2,\ \*^**                                   females\                           
                                                    (0, 2, 6 mo)                       

  **Measles, mumps, rubella                         1 or 2 doses     1 dose            
  (MMR)^3,\ \*^**                                                                      

  **Varicella^4,\ \*^**                             2 doses (0,                        
                                                    4-8 wk)                            

  **Influenza^5,\ \*^**                                              1 dose            
                                                                     annually          

  **Pneumococcal                                    1-2 doses                          1 dose
  (polysaccharide)^6,\ 7^**                                                            

  **Hepatitis A^8,\ \*^**                           2 doses (0,                        
                                                    6-12 mo or                         
                                                    0, 6-18 mo)                        

  **Hepatitis B^9,\ \*^**                           3 doses (0,                        
                                                    1-2, 4-6 mo)                       

  **Meningococcal^10,\ \*^**                        1 or more                          
                                                    doses                              

  **Zoster^11^**                                                                       1 dose
  ---------------------------- -------------------- ------------ --- ---------- ------ --------------------

  ---------------- --- -------------------------- --- ----------------------
  ^\*^Covered by       For all persons in this        Recommended if some
  the Vaccine          category who meet the age      other risk factor is
  Injury               requirements and who lack      present (e.g., on the
  Compensation         evidence of immunity           basis of medical,
  Program.             (e.g., lack documentation      occupational,
                       of vaccination or have no      lifestyle, or other
                       evidence of prior              indications)
                       infection)                     

                                                      
  ---------------- --- -------------------------- --- ----------------------

 

  -----------------------------------------------------------------------------
  Report all clinically significant postvaccination reactions to the Vaccine
  Adverse Event Reporting System (VAERS). Reporting forms and instructions on
  filing a VAERS report are available at
  [www.vaers.hhs.gov](http://www.vaers.hhs.gov/) or by telephone,
  800-822-7967.\
  Information on how to file a Vaccine Injury Compensation Program claim is
  available at
  [www.hrsa.gov/vaccinecompensation](http://www.hrsa.gov/vaccinecompensation)
  or by telephone, 800-338-2382. To file a claim for vaccine injury, contact
  the U.S. Court of Federal Claims, 717 Madison Place, NW, Washington, DC
  20005; telephone, 202-357-6400.\
  Additional information about the vaccines in this schedule, extent of
  available data, and contraindications for vaccination is also available at
  [www.cdc.gov/vaccines](http://www.cdc.gov/vaccines) or from the CDC-INFO
  Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24
  hours a day, 7 days a week.

  -----------------------------------------------------------------------------

**Vaccines That May Be Indicated for Adults Based on Medical and Other
Conditions**

  ---------------------------- ---------------- ----------------- ----------------------- ------------------------- ----------------------- -------------- ----------------- ----------- ---------------- ------------- -- -- --
  ** **                        **Indication**   **Pregnancy**     **Immuno-compromising   **Human immunodeficiency                          **Diabetes,    **Asplenia^12^    **Chronic   **Kidney         **Health care       
                                                                  conditions (excluding   virus (HIV)                                       heart disease, (including        liver       failure,         personnel**         
                                                                  HIV), medications,      infection^3,\ 12,\ 13^\                           chronic        elective          disease**   end-stage renal                      
                                                                  radiation^13^**         CD4\* T lymphocyte                                pulmonary      splenectomy and               disease,                             
                                                                                          count**                                           disease,       terminal                      recipients of                        
                                                                                                                                            chronic        complement                    hemodialysis**                       
                                                                                                                                            alcoholism**   component                                                          
                                                                                                                                                           deficiencies)**                                                    

  **Vaccine**                                                                             **\<200 cells/μL**        **[\>]{.underline}200                                                                                     
                                                                                                                    cells/μL**                                                                                                

  **Tetanus, diphtheria,                        1 dose of Td                                                                                                                                                                  
  pertussis                                     booster every 10                                                                                                                                                              
  (Td/Tdap)^1,\ \*^**                           y                                                                                                                                                                             

                                                                  Substitute 1 dose of                                                                                                                                        
                                                                  Tdap for Td                                                                                                                                                 

  **Human papillomavirus                                          3 doses for females age                                                                                                                                     
  (HPV)^2,\ \*^**                                                 26 y (0, 2, 6 mo)                                                                                                                                           

  **Measles, mumps, rubella                     Contraindicated                                                     1 or 2 doses                                                                                              
  (MMR)^3,\ \*^**                                                                                                                                                                                                             

  **Varicella^4,\ \*^**                         Contraindicated                                                     2 doses (0, 4-8 wk)                                                                                       

  **Influenza^5,\ \*^**                         1 dose annually                                                                                                                                           1 dose of TIV       
                                                                                                                                                                                                          or LAIV             
                                                                                                                                                                                                          annually            

  **Pneumococcal                                                  1-2 doses                                                                                                                                                   
  (polysaccharide)^6,\ 7^**                                                                                                                                                                                                   

  **Hepatitis A^8,\ \*^**                       2 doses (0, 6-12                                                                                                                                                              
                                                mo or 0, 6-18 mo)                                                                                                                                                             

  **Hepatitis B^9,\ \*^**                                                                                                                   3 doses (0,                                                                       
                                                                                                                                            1-2, 4-6 mo)                                                                      

  **Meningococcal^10,\ \*^**                    1 or more doses                                                                                                                                                               

  **Zoster^11^**                                Contraindicated                                                                             1 dose                                                                            
  ---------------------------- ---------------- ----------------- ----------------------- ------------------------- ----------------------- -------------- ----------------- ----------- ---------------- ------------- -- -- --

  ---------------- --- -------------------------- --- ----------------------
  ^\*^Covered by       For all persons in this        Recommended if some
  the Vaccine          category who meet the age      other risk factor is
  Injury               requirements and who lack      present (e.g., on the
  Compensation         evidence of immunity           basis of medical,
  Program.             (e.g., lack documentation      occupational,
                       of vaccination or have no      lifestyle, or other
                       evidence of prior              indications)
                       infection)                     

                                                      
  ---------------- --- -------------------------- --- ----------------------

 

  ----------------------------------------------------------------------------------------------
  These schedules indicate the recommended age groups and medical indications for which
  administration of currently licensed vaccines are commonly indicated for adults age 19 years
  or older as of 1 October 2007. Licensed combination vaccines may be used whenever any
  components of the combination are indicated and when the vaccine\'s other components are not
  contraindicated. For detailed recommendations on all vaccines, including those used primarily
  for travelers or that are issued during the year, consult the manufacturers\' package inserts
  and the complete statements from the Advisory Committee on Immunization Practices
  ([www.cdc.gov/vaccines/pubs/acip-list.htm](http://www.cdc.gov/vaccines/pubs/acip-list.htm)).

  ----------------------------------------------------------------------------------------------

**[Footnotes]{.underline}**

1.  **Tetanus, diphtheria, and acellular pertussis (Td/Tdap)
    vaccination**

    -   Tetanus, diphtheria, and acellular pertussis vaccine (Tdap)
        should replace a single dose of tetanus and diphtheria vaccine
        (Td) for adults age \<65 years who have not previously received
        a dose of Tdap (either in the primary series, as a booster, or
        for wound management). Only 1 of 2 Tdap products (Adacel, Sanofi
        Pasteur) is licensed for use in adults.

    -   Adults with uncertain histories of a complete primary
        vaccination series with diphtheria and tetanus
        toxoid--containing vaccines should begin or complete a primary
        vaccination series. A primary series for adults is 3 doses;
        administer the first 2 doses at least 4 weeks apart and the
        third dose 6 to 12 months after the second dose. Administer a
        booster dose to adults who have completed a primary series and
        if the last vaccination was received [\>]{.underline}10 years
        previously. Tdap or Td vaccine may be used, as indicated.

    -   If the person is pregnant and received the last Td vaccination
        [\>]{.underline}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 1-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 age \<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 given instead of Td to a
        pregnant woman after an informed discussion with the woman.

    -   Consult the National Guideline Clearinghouse (NGC) summary of
        the ACIP statement on [Preventing tetanus, diphtheria, and
        pertussis among
        adults](http://www.guideline.gov/summary/summary.aspx?doc_id=10332&nbr=005421)
        for recommendations for administering Td as prophylaxis in wound
        management.

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2.  **Human papillomavirus (HPV) vaccination**

    -   Human papillomavirus vaccination is recommended for all women
        age [\<]{.underline}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 women.

    -   Ideally, vaccine should be administered before potential
        exposure to HPV through sexual activity; however, women who are
        sexually active should still be vaccinated. Sexually active
        women who have not been infected with any of the HPV vaccine
        types receive the full benefit of the vaccination. Vaccination
        is less beneficial for women who have already been infected with
        1 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 the table
        titled \"Vaccines May Be Indicated for Adults Based on Medical
        and Other Conditions\" (see above), it can be administered
        because it is not a live-virus vaccine. However, immune response
        and vaccine efficacy might be less than that in persons who do
        not have the medical indications described or who are
        immunocompetent.

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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 [\>]{.underline}1 dose of MMR unless they have a medical
        contraindication, documentation of [\>]{.underline}1 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 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 giving 1 dose on
        a routine basis and strongly consider giving 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
        upon completion or termination of pregnancy and before discharge
        from the health care facility.

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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 dose 1 of
        varicella vaccine upon completion or termination of pregnancy
        and before discharge from the health care facility. The second
        dose should be administered 4 to 8 weeks after the first dose.

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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; immunosuppression (including
        immunosuppression caused by medications or HIV); any condition
        that compromises respiratory function or the handling of
        respiratory secretions or that can increase the risk for
        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 age 0 to 59
        months, or persons of all ages with high-risk conditions); and
        anyone who would like to be vaccinated. Healthy, nonpregnant
        adults age [\<]{.underline}49 years without high-risk medical
        conditions who are not contacts of severely immunocompromised
        persons in special care units can receive either intranasally
        administered influenza vaccine (FluMist, MedImmune Vaccines,
        Gaithersburg, Maryland) or inactivated vaccine. Other persons
        should receive the inactivated vaccine.

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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*: Alaska Natives and certain American Indian
        populations and residents of nursing homes or other long-term
        care facilities.

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7.  **Revaccination with pneumococcal polysaccharide vaccine**

    -   One-time revaccination after 5 years for persons with chronic
        renal failure or the nephrotic syndrome; functional or anatomic
        asplenia (e.g., sickle cell disease or splenectomy); or
        immunosuppressive conditions. For persons age [\>]{.underline}65
        years, 1-time revaccination if they were vaccinated
        [\>]{.underline}5 years previously and were age \<65 years at
        the time of primary vaccination.

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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 who would like to obtain immunity.

    -   Single-antigen vaccine formulations should be administered in a
        2-dose schedule at either 0 and 6 to 12 months (Havrix,
        GlaxoSmithKline), or 0 and 6 to 18 months (Vaqta, Merck & Co.).
        If the combined hepatitis A and hepatitis B vaccine (Twinrix,
        GlaxoSmithKline) is used, administer 3 doses at 0, 1, and 6
        months.

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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 \>1 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
        micrograms/mL (Recombivax HB, Merck & Co.) or 2 doses of 20
        micrograms/mL (Engerix-B, GlaxoSmithKline), administered
        simultaneously.

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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 Saudi Arabia for all travelers to Mecca during the
        annual Hajj).

    -   Meningococcal conjugate vaccine is preferred for adults with any
        of the preceding indications who are age [\<]{.underline}55
        years, although meningococcal polysaccharide vaccine (MPSV4) is
        an acceptable alternative. Revaccination after 3 to 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).

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11. **Herpes zoster vaccination**

    -   A single dose of zoster vaccine is recommended for adults 60
        years of age or older 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.

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12. **Selected conditions for which *Haemophilus influenza* type b (Hib)
    vaccine may be used**

    -   Hib conjugate vaccines are licensed for children age 6 weeks to
        71 months. No efficacy data are available on which to base a
        recommendation concerning the use of the 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.

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13. **Immunocompromising conditions**

    -   Inactivated vaccines are generally acceptable (e.g.,
        pneumococcal, meningococcal, influenza \[trivalent inactivated
        influenza vaccine\]) and live vaccines are generally avoided
        when there are immune deficiencies or immunosuppressive
        conditions. For guidance related to specific conditions, refer
        to the NGC summary of the Centers for Disease Control and
        Prevention\'s [General recommendations on
        immunization](http://www.guideline.gov/summary/summary.aspx?doc_id=12325&nbr=006390).

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Effective and age-appropriate administration of vaccines to adults

-   Decline in vaccine-preventable diseases among adults

#### POTENTIAL HARMS

Adverse reactions to vaccination

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Refer to the Major Recommendations field for the table titled \"Vaccines
that May Be Indicated for Adults Based on Medical and Other Conditions\"
for contraindications to recommended vaccines.

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Additional vaccines may be licensed and recommended during the year.
Licensed combination vaccines may be used whenever any components of the
combination are indicated and other components of the vaccine are not
contraindicated and if approved by the U.S. Food and Drug Administration
(FDA). Providers should consult the respective Advisory Committee on
Immunization Practices (ACIP) statements for detailed recommendations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Foreign Language Translations\
Patient Resources\
Quick Reference Guides/Physician Guides\
Resources\
Slide Presentation\
Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Advisory Committee on Immunization Practices. Recommended adult
immunization schedule: United States, October 2007-September 2008. Ann
Intern Med 2007 Nov 20;147(10):725-9. \[1 reference\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17947396)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2007 Nov 20

#### GUIDELINE DEVELOPER(S)

Centers for Disease Control and Prevention - Federal Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

United States Government

#### GUIDELINE COMMITTEE

Advisory Committee on Immunization Practices

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Jon S. Abramson, MD (*Chairman*), Wake Forest
University School of Medicine, Winston--Salem, North Carolina; Larry K.
Pickering, MD (*Executive Secretary*), Centers for Disease Control and
Prevention, Atlanta, Georgia; Ban Mishu Allos, MD, Vanderbilt University
School of Medicine, Nashville, Tennessee; Carol Baker, MD, Baylor
College of Medicine, Houston, Texas; Robert L. Beck, JD, Palmyra,
Virginia; Janet R. Gilsdorf, MD, University of Michigan, Ann Arbor,
Michigan; Harry Hull, MD, St. Paul, Minnesota; Susan Lett, MD, MPH,
Massachusetts Department of Public Health, Jamaica Plain, Massachusetts;
Tracy Lieu, MD, MPH, Harvard Pilgrim Health Care and Harvard Medical
School, Boston, Massachusetts; Gina T. Mootrey, DO, MPH (Lead Staff,
ACIP Adult Immunization Working Group), Centers for Disease Control and
Prevention, Atlanta, Georgia; Julia Morita, MD, Chicago Department of
Public Health, Chicago, Illinois; Dale L. Morse, MD, New York State
Department of Health, Albany, New York; Kathleen Neuzil, MD, MPH,
University of Washington, Seattle, Washington; Patricia Stinchfield, NP,
Children\'s Hospitals and Clinics of Minnesota, St. Paul, Minnesota;
Ciro Valent Sumaya, MD, MPH, Texas A&M University System Health Science
Center, College Station, Texas; John J. Treanor, MD, University of
Rochester School of Medicine and Dentistry, Rochester, New York; and
Robin J. Womeodu, MD, Methodist Healthcare University Hospital, Memphis,
Tennessee

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

To assure the integrity of the Advisory Committee on Immunization
Practices (ACIP), the U.S. Department of Health and Human Services has
taken steps to assure that there is technical compliance with ethics
statutes and regulations regarding financial conflicts of interest.
Concerns regarding the potential for the appearance of a conflict are
addressed, or avoided altogether, through both pre- and postappointment
considerations. Individuals with particular vaccine-related interests
will not be considered for appointment to the committee. Potential
nominees are screened for conflicts of interest, and if any are found,
they are asked to divest or forgo certain vaccine-related activities. In
addition, at the beginning of each ACIP meeting, each member is asked to
declare his or her conflicts.

Members with conflicts are not permitted to vote if a conflict involves
the vaccine or biologic being voted upon. Members of the ACIP have
disclosed the following: *Consultancies*: C. Baker (Novartis); J.J.
Treanor (AlphaVax, Dynavax, Toyama Chemical). *Honoraria*: C. Baker
(Merck & Co. Inc., Sanofi Pasteur, Inhibitex, GlaxoSmithKline, Chiron).
*Stock ownership or options* (other than mutual funds): R.L. Beck
(Applera, Gilead Sciences, GlaxoSmithKline, Merck & Co. Inc., Novartis,
Pfizer Inc., Bristol-Myers Squibb, Wyeth). *Grants received*: J.J.
Treanor (Glaxo-SmithKline, Merck & Co. Inc., Protein Sciences Corp.,
Sanofi, Wyeth).

*Institutional conflicts of interest*: J.R. Gilsdorf (University of
Michigan, whose School of Public Health received royalties for the live,
attenuated influenza vaccine); J.J. Treanor (University of Rochester,
which has a patent for an HPV vaccine and receives licensing payment
from Merck & Co. Inc. and GlaxoSmithKline).

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the Centers for Disease Control and
Prevention (CDC) Web site:

-   [HTML
    Format](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm)

-   [Portable Document Format
    (PDF)](http://www.annals.org/cgi/reprint/147/10/725.pdf)

Print copies: Available from the Centers for Disease Control and
Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased
from the Superintendent of Documents, U.S. Government Printing Office,
Washington, DC 20402-9325; (202) 783-3238.

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Recommended Adult Immunization Schedule: United States, October 2007
    -- September 2008. Available in PowerPoint format from the [*[Annals
    of Internal Medicine]{.underline}* Web
    site](http://www.annals.org/cgi/content/full/0000605-200711200-00187v1/F1).

-   Poland GA, Schaffner W. Adult immunization guidelines: a patient
    safety and quality-of-care issue. Ann Intern Med. 2007 Nov
    20;147(10):735-7. Epub 2007 Oct 18. Electronic copies: Available
    from the [*[Annals of Internal Medicine]{.underline}* Web
    site](http://www.annals.org/cgi/reprint/147/10/735.pdf).

-   A Continuing Medical Education (CME) activity is available from [the
    *[Annals of Internal Medicine]{.underline}* Web
    site](http://cme.annals.org/cgi/hierarchy/annintcme_course;M07-1907).

-   An audio interview with one of the authors of the guideline is
    available as a podcast from the [*[Annals of Internal
    Medicine]{.underline}* Web
    site](http://www.annals.org/cgi/content/full/0000605-200711200-00187/DC1 target=)

-   The Adult Immunization Schedule is available in English and Spanish
    in a variety of formats and as Personal Digital Assistant (PDA)
    download from the [Centers for Disease Control and Prevention (CDC)
    Web
    site](http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm).
    See the related QualityTool summary on the [Health Care Innovations
    Exchange Web
    site](http://innovations.ahrq.gov/content.aspx?id=1020).

-   General information about adult vaccinations, including
    recommendations on vaccination of persons with HIV and other
    immunosuppressive conditions is available from the [Centers for
    Disease Control and Prevention (CDC) Web
    site](http://www.cdc.gov/vaccines/default.htm)

#### PATIENT RESOURCES

Vaccine Information Statements for individual vaccines are available in
Portable Document Format (PDF) in a variety of languages from the
[Centers for Disease Control and Prevention (CDC) Web
site](http://www.cdc.gov/vaccines/pubs/vis/default.htm).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This NGC summary was completed by ECRI Institute on February 20, 2008.

#### COPYRIGHT STATEMENT

No copyright restrictions apply.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008