CS310021-C

Report

y Suspected cases of reportable vaccine-preventable diseases or outbreaks to 

the local or state health department

y Clinically significant postvaccination reactions to the Vaccine Adverse Event 

Reporting System at www.vaers.hhs.gov or 800-822-7967

Injury claims

All vaccines included in the adult immunization schedule except PPSV23, RZV, 

and COVID-19 vaccines are covered by the National Vaccine Injury Compensation 

Program (VICP). COVID-19 vaccines that are authorized or approved by the FDA are 

covered by the Countermeasures Injury Compensation Program (CICP). For more 

information, see www.hrsa.gov/vaccinecompensation or www.hrsa.gov/cicp.

Questions or comments

Contact www.cdc.gov/cdc-info or 800-CDC-INFO (800-232-4636), in English or 

Spanish, 8 a.m.–8 p.m. ET, Monday through Friday, excluding holidays.

Helpful information

y Complete Advisory Committee on Immunization Practices (ACIP) recommendations: 

www.cdc.gov/vaccines/hcp/acip-recs/index.html

y General Best Practice Guidelines for Immunization

(including contraindications and precautions):

www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html

y Vaccine information statements: www.cdc.gov/vaccines/hcp/vis/index.html

y Manual for the Surveillance of Vaccine-Preventable Diseases 

(including case identification and outbreak response): 

www.cdc.gov/vaccines/pubs/surv-manual 

y Travel vaccine recommendations: www.cdc.gov/travel

y Recommended Child and Adolescent Immunization Schedule, United States, 2023: 

www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html

y ACIP Shared Clinical Decision-Making Recommendations:

www.cdc.gov/vaccines/acip/acip-scdm-faqs.html

Recommended Adult Immunization Schedule

for ages 19 years or older

How to use the adult immunization schedule

1 Determine 

recommended 

vaccinations 

by age 

(Table 1)

2 Assess need 

for additional 

recommended 

vaccinations 

by medical 

condition or 

other indication 

(Table 2)

3 Review vaccine 

types, dosing 

frequencies and 

intervals, and

considerations for 

special situations 

(Notes)

4 Review 

contraindications 

and precautions 

for vaccine types 

(Appendix)

5 Review new 

or updated 

ACIP guidance

(Addendum)

Recommended by the Advisory Committee on Immunization Practices 

(www.cdc.gov/vaccines/acip) and approved by the Centers for Disease 

Control and Prevention (www.cdc.gov), American College of Physicians 

(www.acponline.org), American Academy of Family Physicians (www.aafp.org), 

American College of Obstetricians and Gynecologists (www.acog.org), 

American College of Nurse-Midwives (www.midwife.org), American Academy of 

Physician Associates (www.aapa.org), American Pharmacists Association 

(www.pharmacist.com), and Society for Healthcare Epidemiology of America 

(www.shea-online.org).

UNITED STATES

2023

Vaccines in the Adult Immunization Schedule*

Vaccine Abbreviation(s) Trade name(s)

COVID-19 vaccine† 1vCOV-mRNA Comirnaty®/Pfizer-BioNTech COVID-19 Vaccine

SPIKEVAX®/Moderna COVID-19 Vaccine

2vCOV-mRNA Pfizer-BioNTech COVID-19 Vaccine, Bivalent

Moderna COVID-19 Vaccine, Bivalent

1vCOV-aPS Novavax COVID-19 Vaccine

Haemophilus influenzae type b vaccine Hib ActHIB®

Hiberix®

PedvaxHIB®

Hepatitis A vaccine HepA Havrix®

Vaqta®

Hepatitis A and hepatitis B vaccine HepA-HepB Twinrix®

Hepatitis B vaccine HepB Engerix-B®

Heplisav-B®

PreHevbrio®

Recombivax HB®

Human papillomavirus vaccine HPV Gardasil 9®

Influenza vaccine (inactivated)† IIV4 Many brands

Influenza vaccine (live, attenuated)† LAIV4 FluMist® Quadrivalent

Influenza vaccine (recombinant)† RIV4 Flublok® Quadrivalent

Measles, mumps, and rubella vaccine MMR M-M-R II®

Priorix®

Meningococcal serogroups A, C, W, Y vaccine MenACWY-D

MenACWY-CRM

MenACWY-TT

Menactra®

Menveo®

MenQuadfi®

Meningococcal serogroup B vaccine MenB-4C

MenB-FHbp

Bexsero®

Trumenba®

Pneumococcal conjugate vaccine PCV15

PCV20

VaxneuvanceTM

Prevnar 20TM

Pneumococcal polysaccharide vaccine PPSV23 Pneumovax 23®

Poliovirus vaccine† IPV IPOL®

Tetanus and diphtheria toxoids Td Tenivac®

TdvaxTM

Tetanus and diphtheria toxoids and acellular 

pertussis vaccine

Tdap Adacel®

Boostrix®

Varicella vaccine VAR Varivax®

Zoster vaccine, recombinant RZV Shingrix

New vaccines added to the Schedule since February 2023 (See Addendum)

Respiratory Syncytial Virus vaccine RSV Arexvy®

ABRYSVOTM

*Administer recommended vaccines if vaccination history is incomplete or unknown. Do not restart or add doses to vaccine series 

if there are extended intervals between doses. The use of trade names is for identification purposes only and does not imply 

endorsement by the ACIP or CDC.

†

 COVID-19, Poliovirus, and Influenza vaccines have new or updated ACIP recommendations. Please see Addendum for more details.

Download the CDC Vaccine Schedules app for providers at 

www.cdc.gov/vaccines/schedules/hcp/schedule-app.html.

Scan QR code 

for access to 

online schedule

See Addendum for new or updated ACIP vaccine recommendations
Vaccine 19–26 years 27–49 years 50–64 years ≥65 years

COVID-19 2- or 3- dose primary series and booster (See Notes)

Influenza inactivated (IIV4) or 

Influenza recombinant (RIV4) 1 dose annually

Influenza live, attenuated

(LAIV4) 1 dose annually

Tetanus, diphtheria, pertussis 

(Tdap or Td)

1 dose Tdap each pregnancy; 1 dose Td/Tdap for wound management (see notes)

1 dose Tdap, then Td or Tdap booster every 10 years

Measles, mumps, rubella 

(MMR)

 1 or 2 doses depending on indication 

 (if born in 1957 or later)

For healthcare personnel, 

see notes

Varicella 

(VAR)

2 doses

(if born in 1980 or later) 2 doses

Zoster recombinant 

(RZV) 2 doses for immunocompromising conditions (see notes) 2 doses

Human papillomavirus (HPV) 2 or 3 doses depending on age at 

initial vaccination or condition 27 through 45 years

Pneumococcal

(PCV15, PCV20, PPSV23)

1 dose PCV15 followed by PPSV23

OR

1 dose PCV20 (see notes)

See Notes

See Notes

Hepatitis A 

(HepA) 2, 3, or 4 doses depending on vaccine

Hepatitis B 

(HepB) 2, 3, or 4 doses depending on vaccine or condition

Meningococcal A, C, W, Y 

(MenACWY) 1 or 2 doses depending on indication, see notes for booster recommendations

Meningococcal B 

(MenB)

Haemophilus influenzae type b 

(Hib) 1 or 3 doses depending on indication

or or

 Recommended vaccination for adults who meet age requirement, lack documentation of vaccination, or lack evidence of past infection  Recommended vaccination for adults with an additional risk factor or another indication  Recommended vaccination based on shared 

clinical decision-making  No recommendation/

Not applicable

2 or 3 doses depending on vaccine and indication, see notes for booster recommendations

19 through 23 years

2, 3, or 4 doses depending on vaccine or condition

Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2023

See Addendum for new or updated ACIP vaccine recommendations Table 1
Vaccine Pregnancy

Immunocompromised 

(excluding HIV 

infection)

HIV infection CD4 

percentage and count Asplenia, 

complement 

deficiencies

End-stage 

renal 

disease, or on 

hemodialysis

Heart or 

lung disease; 

alcoholisma

Chronic liver 

disease Diabetes Health care personnelb

Men who 

have sex 

<15% or with men

<200 mm3

≥15% and 

≥200 mm3

COVID-19 See Notes

IIV4 or RIV4 1 dose annually

LAIV4 Contraindicated Precaution 1 dose annually

Tdap or Td 1 dose Tdap each 

pregnancy 1 dose Tdap, then Td or Tdap booster every 10 years

MMR Contraindicated* Contraindicated 1 or 2 doses depending on indication

VAR Contraindicated* Contraindicated 2 doses

RZV 2 doses at age ≥19 years 2 doses at age ≥50 years

HPV Not

Recommended* 3 doses through age 26 years 2 or 3 doses through age 26 years depending on age at initial vaccination or condition

Pneumococcal 

(PCV15, PCV20, 

PPSV23)

HepA

HepB 3 doses

(see notes) 2, 3, or 4 doses depending on vaccine or condition

MenACWY

MenB Precaution

Hib 3 doses HSCTc

recipients only 1 dose

1 or 2 doses depending on indication, see notes for booster recommendations

2 or 3 doses depending on vaccine and indication, see notes for booster recommendations

2, 3, or 4 doses depending on vaccine

Table 2 Recommended Adult Immunization Schedule by Medical Condition or Other Indication, United States, 2023

 Recommended vaccination for adults who meet 

age requirement, lack 

documentation of 

vaccination, or lack 

evidence of past infection

 Recommended vaccination 

for adults with an additional 

risk factor or another 

indication

 Recommended vaccination 

based on shared clinical 

decision-making

 Precaution–vaccination might be indicated if 

benefit of protection 

outweighs risk of adverse 

reaction

 Contraindicated or not 

recommended–vaccine 

should not be administered. 

*Vaccinate after pregnancy.

 No recommendation/Not applicable

or or

a. Precaution for LAIV4 does not apply to alcoholism. b. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations. c. Hematopoietic stem cell transplant.

1 dose PCV15 followed by PPSV23 OR 1 dose PCV20 (see notes)
Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2023

See Addendum for new or updated ACIP vaccine recommendations Notes

For vaccine recommendations for persons 18 years 

of age or younger, see the Recommended Child and 

Adolescent Immunization Schedule.

COVID-19 vaccination

Routine vaccination

y Primary series: 2-dose series at 0, 4-8 weeks 

(Moderna) or 2-dose series at 0, 3-8 weeks 

(Novavax, Pfizer-BioNTech)

y Booster dose: see www.cdc.gov/vaccines/covid-19/

clinical-considerations/interim-considerations-us.html

Special situations

Persons who are moderately or severely 

immunocompromised

y Primary series

- 3-dose series at 0, 4, 8 weeks (Moderna) or 

3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech)

- 2-dose series at 0, 3 weeks (Novavax)

y Booster dose: see www.cdc.gov/vaccines/covid-19/

clinical-considerations/interim-considerations-us.html

y Pre-exposure prophylaxis (e.g., monoclonal 

antibodies) may be considered to complement 

COVID-19 vaccination. See www.cdc.gov/

vaccines/covid-19/clinical-considerations/interimconsiderations-us.html#immunocompromised

For Janssen COVID-19 Vaccine recipients see 

COVID-19 schedule at www.cdc.gov/vaccines/covid-19/

clinical-considerations/interim-considerations-us.html. 

Note: Current COVID-19 schedule available at www.

cdc.gov/vaccines/covid-19/downloads/COVID-19-

immunization-schedule-ages-6months-older.pdf. 

For more information on Emergency Use Authorization 

(EUA) indications for COVID-19 vaccines, please visit 

www.fda.gov/emergency-preparedness-and-response/

coronavirus-disease-2019-covid-19/covid-19-vaccines

Haemophilus influenzae type b vaccination

Special situations

yAnatomical 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

yHematopoietic stem cell transplant (HSCT): 

3-dose series 4 weeks apart starting 6–12 months 

after successful transplant, regardless of 

Hib vaccination history

Hepatitis A vaccination

Routine vaccination

yNot 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]) 

Special situations

yAt 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)

Hepatitis B vaccination

Routine vaccination

yAge 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.
Notes Recommended Adult Immunization Schedule, United States, 2023

yAge 60 years or older with known risk factors for 

hepatitis B virus infection should complete a 

HepB vaccine series.

yAge 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 HBsAgpositive 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

Special situations

y 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)

Human papillomavirus vaccination

Routine vaccination

yHPV 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

y Interrupted schedules: If vaccination schedule is 

interrupted, the series does not need to be restarted

yNo additional dose recommended when any HPV 

vaccine series has been completed using the 

recommended dosing intervals.

Shared clinical decision-making

y Some adults age 27–45 years: Based on shared 

clinical decision-making, 2- or 3-dose series as above

Special situations

yAge ranges recommended above for routine and 

catch-up vaccination or shared clinical decisionmaking 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

Influenza vaccination

Routine vaccination

yAge 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.

y For the 2022–2023 season, see www.cdc.gov/mmwr/

volumes/71/rr/rr7101a1.htm

y For the 2023–2024 season, see the 2023–2024 ACIP 

influenza vaccine recommendations.

Special situations

y Egg allergy, hives only: any influenza vaccine 

appropriate for age and health status annually

y 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.

y 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.

y Severe allergic reaction (e.g., anaphylaxis) 

to a vaccine component or a previous dose 

of any influenza vaccine: see Appendix listing 

contraindications and precautions
Notes Recommended Adult Immunization Schedule, United States, 2023

yHistory 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

Measles, mumps, and rubella vaccination

Routine vaccination

yNo 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)

Special situations

y Pregnancy with no evidence of immunity to 

rubella: MMR contraindicated during pregnancy; 

after pregnancy (before discharge from 

health care facility), 1 dose

yNonpregnant persons of childbearing age with no 

evidence of immunity to rubella: 1 dose

yHIV 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

y Severe immunocompromising conditions: 

MMR contraindicated

y 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

y 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

yHealth 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

Meningococcal vaccination

Special situations for MenACWY

yAnatomical 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

y 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

y 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)

y 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

Shared clinical decision-making for MenB

yAdolescents 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)

Special situations for MenB

yAnatomical 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

y Pregnancy: Delay MenB until after pregnancy unless 

at increased risk and vaccination benefits outweigh 

potential risks

y 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.
Notes Recommended Adult Immunization Schedule, United States, 2023

Pneumococcal vaccination

Routine vaccination

yAge 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.

y 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

Special situations 

yAge 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.

y 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: Immunocompromising conditions 

include chronic renal failure, nephrotic syndrome, 

immunodeficiency, iatrogenic immunosuppression, 

generalized malignancy, human immunodeficiency 

virus, Hodgkin disease, leukemia, lymphoma, multiple 

myeloma, solid organ transplants, congenital or 

acquired asplenia, sickle cell disease, or other 

hemoglobinopathies.

**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.

Polio vaccination

Routine vaccination 

Routine poliovirus vaccination of adults residing in the 

United States is not necessary. 

Special situations 

yAdults at increased risk of exposure 

to poliovirus with:

-No evidence of a complete polio vaccination series 

(i.e., at least 3 doses): administer remaining doses 

(1, 2, or 3 doses) to complete a 3-dose series 

- Evidence of completed polio vaccination series 

(i.e., at least 3 doses): may administer one lifetime 

IPV booster

For detailed information, see: www.cdc.gov/vaccines/

vpd/polio/hcp/recommendations.html
9/27/2023 Centers for Disease Control and Prevention | Recommended Adult Immunization Schedule, United States, 2023

Notes Recommended Adult Immunization Schedule, United States, 2023

Tetanus, diphtheria, and pertussis vaccination

Routine vaccination

y Previously did not receive Tdap at or after age 

11 years: 1 dose Tdap, then Td or Tdap every 10 years

Special situations

y 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

y Pregnancy: 1 dose Tdap during each pregnancy, 

preferably in early part of gestational weeks 27–36

y 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-toxoidcontaining 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

Varicella vaccination

Routine vaccination

yNo evidence of immunity to varicella: 2-dose series 

4–8 weeks apart if previously did not receive varicellacontaining vaccine (VAR or MMRV [measles-mumpsrubella-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

Special situations

y 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 varicellacontaining 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

yHealth 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

yHIV 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

y Severe immunocompromising conditions: 

VAR contraindicated

Zoster vaccination

Routine vaccination 

yAge 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.

Special situations 

y Pregnancy: There is currently no ACIP 

recommendation for RZV use in pregnancy. 

Consider delaying RZV until after pregnancy. 

y 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
Appendix Recommended Adult Immunization Schedule, United States, 2023

Vaccine Contraindicated or Not Recommended1 Precautions2

Influenza, egg-based, 

inactivated injectable (IIV4)

• Severe allergic reaction (e.g., anaphylaxis) after previous dose of any influenza vaccine 

(i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency) 

• Severe allergic reaction (e.g., anaphylaxis) to any vaccine component3 (excluding egg)

• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of 

influenza vaccine

• Moderate or severe acute illness with or without fever

Influenza, cell culture-based 

inactivated injectable 

[(ccIIV4), Flucelvax® 

Quadrivalent]

• Severe allergic reaction (e.g., anaphylaxis) to any ccIIV of any valency, or to any 

component3 of ccIIV4

• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of 

influenza vaccine

• Persons with a history of severe allergic reaction (e.g., anaphylaxis) after a previous 

dose of any egg-based IIV, RIV, or LAIV of any valency. If using ccIV4, administer in 

medical setting under supervision of health care provider who can recognize and 

manage severe allergic reactions. May consult an allergist.

• Moderate or severe acute illness with or without fever

Influenza, recombinant 

injectable [(RIV4), Flublok® 

Quadrivalent]

• Severe allergic reaction (e.g., anaphylaxis) to any RIV of any valency, or to any component3

of RIV4

• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of 

influenza vaccine

• Persons with a history of severe allergic reaction (e.g., anaphylaxis) after a previous 

dose of any egg-based IIV, ccIIV, or LAIV of any valency. If using RIV4, administer in 

medical setting under supervision of health care provider who can recognize and 

manage severe allergic reactions. May consult an allergist.

• Moderate or severe acute illness with or without fever

Influenza, live attenuated 

[LAIV4, Flumist® 

Quadrivalent]

• Severe allergic reaction (e.g., anaphylaxis) after previous dose of any influenza vaccine 

(i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency) 

• Severe allergic reaction (e.g., anaphylaxis) to any vaccine component3 (excluding egg)

• Anatomic or functional asplenia

• Immunocompromised due to any cause including, but not limited to, medications and 

HIV infection

• Close contacts or caregivers of severely immunosuppressed persons who require a 

protected environment

• Pregnancy

• Cochlear implant

• Active communication between the cerebrospinal fluid (CSF) and the oropharynx, 

nasopharynx, nose, ear, or any other cranial CSF leak

• Received influenza antiviral medications oseltamivir or zanamivir within the previous 

48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days.

• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of 

influenza vaccine

• Asthma in persons aged 5 years old or older

• Persons with underlying medical conditions (other than those listed under 

contraindications) that might predispose to complications after wild-type influenza 

virus infection [e.g., chronic pulmonary, cardiovascular (except isolated hypertension), 

renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes 

mellitus)]

• Moderate or severe acute illness with or without fever

1. When a contraindication is present, a vaccine should NOT be administered. Kroger A, Bahta L, Hunter P. ACIP General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/

contraindications.html

2. When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction. Kroger A, Bahta L, Hunter P. 

ACIP General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html

3. Vaccination providers should check FDA-approved prescribing information for the most complete and updated information, including contraindications, warnings, and precautions. Package inserts for U.S.-

licensed vaccines are available at www.fda.gov/vaccines-blood-biologics/approved-products/vaccines-licensed-use-united-states.

Guide to Contraindications and Precautions to Commonly Used Vaccines

Adapted from Table 4-1 in Advisory Committee on Immunization Practices (ACIP) General Best Practice Guidelines for Immunization: Contraindication and Precautions available at www.cdc.

gov/vaccines/hcp/acip-recs/general-recs/contraindications.html and ACIP’s Recommendations for the Prevention and Control of 2022-23 Seasonal Influenza with Vaccines available at 

www.cdc.gov/mmwr/volumes/71/rr/rr7101a1.htm

For COVID-19 vaccine contraindications and precautions see

www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#contraindications
Appendix Recommended Adult Immunization Schedule, United States, 2023

Vaccine Contraindicated or Not Recommended1 Precautions2

Haemophilus influenzae type b 

(Hib) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• For Hiberix, ActHib, and PedvaxHIB only: History of severe allergic reaction to dry natural latex

• Moderate or severe acute illness with or without fever

Hepatitis A (HepA) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 including 

neomycin

• Moderate or severe acute illness with or without fever

Hepatitis B (HepB) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 including yeast

• Pregnancy: Heplisav-B and PreHevbrio are not recommended due to lack of safety data in pregnant persons. 

Use other hepatitis B vaccines if HepB is indicated4

• Moderate or severe acute illness with or without fever

Hepatitis A- Hepatitis B vaccine 

[HepA-HepB, (Twinrix®)] • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

 including 

neomycin and yeast • Moderate or severe acute illness with or without fever

Human papillomavirus (HPV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• Pregnancy: HPV vaccination not recommended

• Moderate or severe acute illness with or without fever

Measles, mumps, rubella (MMR) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• Severe immunodeficiency (e.g., hematologic and solid tumors, receipt of chemotherapy, congenital 

immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are severely 

immunocompromised)

• Pregnancy 

• Family history of altered immunocompetence, unless verified clinically or by laboratory testing as 

immunocompetent

• Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on 

product)

• History of thrombocytopenia or thrombocytopenic purpura

• Need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing

• Moderate or severe acute illness with or without fever

Meningococcal ACWY (MenACWY)

[MenACWY-CRM (Menveo®); 

MenACWY-D (Menactra®); 

MenACWY-TT (MenQuadfi®)]

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• For MenACWY-D and MenACWY-CRM only: severe allergic reaction to any diphtheria toxoid–or CRM197–

containing vaccine

• For MenACWY-TT only: severe allergic reaction to a tetanus toxoid-containing vaccine

• Moderate or severe acute illness with or without fever

Meningococcal B (MenB)

[MenB-4C (Bexsero); MenB-FHbp 

(Trumenba)]

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Pregnancy

• For MenB-4C only: Latex sensitivity 

• Moderate or severe acute illness with or without fever

Pneumococcal conjugate 

(PCV15, PCV20)

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• Severe allergic reaction (e.g., anaphylaxis) to any diphtheria-toxoid–containing vaccine or to its vaccine 

component3

• Moderate or severe acute illness with or without fever

Pneumococcal polysaccharide 

(PPSV23)

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever

Tetanus, diphtheria, and acellular 

pertussis (Tdap) 

Tetanus, diphtheria (Td) 

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• For Tdap only: Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures), not 

attributable to another identifiable cause, within 7 days of administration of previous dose of DTP, DTaP, or 

Tdap

• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus-toxoid–containing 

vaccine

• History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid– 

containing or tetanus-toxoid–containing vaccine; defer vaccination until at least 10 years have elapsed 

since the last tetanus-toxoid–containing vaccine

• Moderate or severe acute illness with or without fever

• For Tdap only: Progressive or unstable neurological disorder, uncontrolled seizures, or progressive 

encephalopathy until a treatment regimen has been established and the condition has stabilized

Varicella (VAR) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3

• Severe immunodeficiency (e.g., hematologic and solid tumors, receipt of chemotherapy, congenital 

immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are severely 

immunocompromised)

• Pregnancy

• Family history of altered immunocompetence, unless verified clinically or by laboratory testing as 

immunocompetent

• Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on 

product)

• Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination 

(avoid use of these antiviral drugs for 14 days after vaccination)

• Use of aspirin or aspirin-containing products

• Moderate or severe acute illness with or without fever

Zoster recombinant vaccine (RZV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever

• Current herpes zoster infection

1. When a contraindication is present, a vaccine should NOT be administered. Kroger A, Bahta L, Hunter P. ACIP General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html

2. When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction. Kroger A, Bahta L, Hunter P. ACIP General Best 

Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html

3. Vaccination providers should check FDA-approved prescribing information for the most complete and updated information, including contraindications, warnings, and precautions. Package inserts for U.S.-licensed vaccines are 

available at www.fda.gov/vaccines-blood-biologics/approved-products/vaccines-licensed-use-united-states.

4. For information on the pregnancy exposure registries for persons who were inadvertently vaccinated with Heplisav-B or PreHevbrio while pregnant, please visit heplisavbpregnancyregistry.com/ or www.prehevbrio.com/#safety.
Addendum Recommended Adult Immunization Schedule, United States, 2023

Vaccines Recommendations Effective Date of

Recommendation*

Meningococcal Vaccines

Pfizer’s MenABCWY vaccine may be used when both MenACWY and MenB are indicated at the same visit.*

*1) Healthy individuals aged 16–23 years (routine schedule) when shared clinical decision-making favors administration of MenB vaccination, 

2) individuals aged 10 years and older at increased risk of meningococcal disease (e.g., due to persistent complement deficiencies, complement 

inhibitor use, or functional or anatomic asplenia) due for both vaccines.

October 26, 2023

Mpox Vaccines

ACIP recommends vaccination* with the 2-dose§ JYNNEOS vaccine series for persons aged 18 years and older at risk for mpox¶

*This is an interim recommendation that ACIP will revisit in 2-3 years

§

Dose 2 administered 28 days after dose 1

¶

Persons at risk:

• Gay, bisexual, and other men who have sex with men, transgender or nonbinary people who in the past 6 months have had one of the following:

ɦ A new diagnosis of ≥1 sexually transmitted disease

ɦ More than one sex partner

ɦ Sex at a commercial sex venue

ɦ Sex in association with a large public event in a geographic area where mpox transmission is occurring

• Sexual partners of persons with the risks described in above

• Persons who anticipate experiencing any of the above

October 26, 2023

Respiratory syncytial virus 

(RSV)

• Maternal Respiratory Syncytial Virus (RSV) vaccine (ABRYSVOTM) is recommended for pregnant people during 32 through 36 weeks gestation, using 

seasonal administration, to prevent RSV lower respiratory tract infection in infants. September 22, 2023

COVID-19 (Moderna,

Pfizer-BioNTech)

• All persons ≥6 months of age should receive 2023–2024 (monovalent, XBB containing) COVID-19 vaccines as authorized under EUA or approved by BLA.

• Bivalent mRNA COVID-19 vaccines are no longer recommended in the United States

• For detailed information, see: www.cdc.gov/covidschedule

September 12, 2023

Respiratory syncytial

virus (RSV)

• Adults 60 years of age and older may receive a single dose of Respiratory Syncytial Virus (RSV) vaccine, using shared clinical decision-making.

• For detailed information, see: www.cdc.gov/mmwr/volumes/72/wr/mm7229a4.htm?s_cid=mm7229a4_w

June 27, 2023

Poliovirus (IPV)

• Adults who are known or suspected to be unvaccinated or incompletely vaccinated against polio should complete a primary 

vaccination series with inactivated polio vaccine (IPV).

• Adults who have received a primary series of trivalent oral polio vaccine (tOPV) or IPV in any combination and who are at increased risk of poliovirus 

exposure may receive another dose of IPV. Available data do not indicate the need for more than a single lifetime booster dose with IPV for adults.

June 27, 2023

Influenza (IIV4, ccIV4,

RIV4, LAIV4)

• All persons ages ≥6 months with egg allergy should receive influenza vaccine. Any influenza vaccine (egg based or non-egg based) 

that is otherwise appropriate for the recipient’s age and health status can be used.

• Affirm the updated MMWR Recommendations and Reports, “Prevention and Control of Seasonal Influenza with Vaccines: 

Recommendations of the Advisory Committee on Immunization Practices—United States, 2023-24 Influenza Season” 

www.cdc.gov/mmwr/volumes/72/rr/rr7202a1.htm

June 27, 2023

In addition to the recommendations presented in the previous sections of this Immunization Schedule, ACIP has approved the following recommendations by majority vote since

October 20, 2022. The following recommendations have been adopted by the CDC Director and are now official. Links are provided if these recommendations have been published in

Morbidity and Mortality Weekly Report (MMWR).

*The effective date is the date when the CDC director adopted the recommendation and when the ACIP recommendation became official.