CDC announced the availability of the 2018 adult immunization schedule in the Morbidity and Mortality Weekly Report (MMWR). 1 The schedule is published in its entirety in the Annals of Internal Medicine. 2 The adult immunization schedule consists of figures that summarize routinely recommended vaccines for adults by age groups and medical conditions and other indications, footnotes for the figures, and a table of vaccine contraindications and precautions. Note the following when reviewing the adult immunization schedule:#
- The figures in the adult immunization schedule should be reviewed with the accompanying footnotes. - The figures and footnotes display indications for which vaccines, if not previously administered, should be administered unless noted otherwise. - The table of contraindications and precautions identifies populations and situations for which vaccines should not be used or should be used with caution. - When indicated, administer recommended vaccines to adults whose vaccination history is incomplete or unknown. - Increased interval between doses of a multidose vaccine series does not diminish vaccine effectiveness; it is not necessary to restart the vaccine series or add doses to the series because of an extended interval between doses. - Combination vaccines may be used when any component of the combination is indicated and when the other components of the combination are not contraindicated. - The use of trade names in the adult immunization schedule is for identification purposes only and does not imply endorsement by the ACIP or CDC.
Special populations that need additional considerations include:
- Pregnant women. Pregnant women should receive the tetanus, diphtheria, and acellular pertussis vaccine (Tdap) during pregnancy and the influenza vaccine during or before pregnancy. Live vaccines (e.g., measles, mumps, and rubella vaccine ) are contraindicated. - Asplenia. Adults with asplenia have specific vaccination recommendations because of their increased risk for infection by encapsulated bacteria. Anatomical or functional asplenia includes congenital or acquired asplenia, splenic dysfunction, sickle cell disease and other hemoglobinopathies, and splenectomy. - Immunocompromising conditions. Adults with immunosuppression should generally avoid live vaccines. Inactivated vaccines (e.g., pneumococcal vaccines) are generally acceptable. High-level immunosuppression includes HIV infection with a CD4 cell count <200 cells/L, receipt of daily corticosteroid therapy with 20 mg of prednisone or equivalent for 14 days, primary immunodeficiency disorder (e.g., severe combined immunodeficiency or complement component deficiency), and receipt of cancer chemotherapy. Other immunocompromising conditions and immunosuppressive medications to consider when vaccinating adults can be found in IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host. 3 Additional information on vaccinating immunocompromised adults is in General Best Practice Guidelines for Immunization. 4 Additional resources for health care providers include: This figure should be reviewed with the accompanying footnotes. This figure and the footnotes describe indications for which vaccines, if not previously administered, should be administered unless noted otherwise.
Vaccine Pregnancy  Immunocompromised (excluding HIV infection) 11 HIV infection CD4+ count (cells/L) 3-7,9-10 Asplenia, complement deficiencies 7,10,11 End-stage renal disease, on hemodialysis 7,9 Heart or lung disease, alcoholism 7 Chronic liver disease 7-9 Diabetes 7,9
Health care personnel 3,4,9 Men who have sex with men 6,8,9 <200 200

# General information
- Administer to adults who previously did not receive a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) as an adult or child (routinely recommended at age 11-12 years) 1 dose of Tdap, followed by a dose of tetanus and diphtheria toxoids (Td) booster every 10 years - Information on the use of Tdap or Td as tetanus prophylaxis in wound management is available at www.cdc.gov/mmwr/ preview/mmwrhtml/rr5517a1.htm

# Special populations
- Pregnant women: Administer 1 dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27-36 - History of Guillain-Barre syndrome within 6 weeks after previous influenza vaccination - Egg allergy other than hives, e.g., angioedema, respiratory distress, lightheadedness, or recurrent emesis; or required epinephrine or another emergency medical intervention (IIV may be administered in an inpatient or outpatient medical setting and under the supervision of a health care provider who is able to recognize and manage severe allergic conditions) RIV 1 - History of Guillain-Barre syndrome within 6 weeks after previous influenza vaccination Tdap, Td
- For pertussis-containing vaccines: encephalopathy, e.g., coma, decreased level of consciousness, or prolonged seizures, not attributable to another identifiable cause within 7 days of administration of a previous dose of a vaccine containing tetanus or diphtheria toxoid or acellular pertussis
- Guillain-Barre syndrome within 6 weeks after a previous dose of tetanus toxoid-containing vaccine - History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine. Defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine - For pertussis-containing vaccine, progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy (until a treatment regimen has been established and the condition has stabilized) MMR 2 - Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy 3 , human immunodeficiency virus (HIV) infection with severe immunocompromise - Pregnancy
- Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 4 - History of thrombocytopenia or thrombocytopenic purpura - Need for tuberculin skin testing 5 VAR 2 - Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy 3 , HIV infection with severe immunocompromise - Pregnancy
- Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product) 4 - Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination) ZVL 2 - Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy 3 , HIV infection with severe immunocompromise - Pregnancy - Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
HPV vaccine - Pregnancy PCV13
- Severe allergic reaction to any vaccine containing diphtheria toxoid 1. For additional information on use of influenza vaccines among persons with egg allergy, see: CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices-United States, 2016-17 influenza season. MMWR. 2016;65(RR-5):1-54. Available at www.cdc.gov/mmwr/volumes/65/rr/rr6505a1.htm. 2. MMR may be administered together with VAR or ZVL on the same day. If not administered on the same day, separate live vaccines by at least 28 days. 3. Immunosuppressive steroid dose is considered to be daily receipt of 20 mg or more prednisone or equivalent for 2 or more weeks. Vaccination should be deferred for at least 1 month after discontinuation of immunosuppressive steroid therapy. Providers should consult ACIP recommendations for complete information on the use of specific live vaccines among persons on immune-suppressing medications or with immune suppression because of other reasons. 4. Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered. See: Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html. 5. Measles vaccination may temporarily suppress tuberculin reactivity. Measles-containing vaccine may be administered on the same day as tuberculin skin testing, or should be postponed for at least 4 weeks after vaccination.

# Table. Contraindications and precautions for vaccines recommended for adults aged 19 years or older*
The Advisory Committee on Immunization Practices (ACIP) recommendations and package inserts for vaccines provide information on contraindications and precautions related to vaccines. Contraindications are conditions that increase chances of a serious adverse reaction in vaccine recipients and the vaccine should not be administered when a contraindication is present. Precautions should be reviewed for potential risks and benefits for vaccine recipients.

# Vaccine(s) Contraindications Precautions
All vaccines routinely recommended for adults
- Severe reaction, e.g., anaphylaxis, after a previous dose or to a vaccine component - Moderate or severe acute illness with or without fever

# Additional contraindications and precautions for vaccines routinely recommended for adults
Contraindications and precautions for vaccines routinely recommended for adults

# Abbreviations of vaccines