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Recommended Adult Schedule for ages 19 years or older 2021 Recommended by the Advisory Committee on Immunization Practices How to use the adult immunization schedule (www.cdc.gov/vaccines/acip) and approved by the Centers for Determine recommended Assess need for additional Review types, Control and Prevention (www.cdc.gov), American College of Physicians 1 by age 2 recommended vaccinations 3 frequencies, and intervals (www.acponline.org), American Academy of Family Physicians (www.aafp. (Table 1) by medical condition and and considerations for org), American College of Obstetricians and Gynecologists (www.acog.org), other indications (Table 2) special situations (Notes) American College of Nurse-Midwives (www.midwife.org), and American Academy of Physician Assistants (www.aapa.org).

Vaccines in the Adult Immunization Schedule* Report y Vaccines Abbreviations Trade names Suspected cases of reportable vaccine-preventable or outbreaks to the local or state department type b vaccine Hib ActHIB® y Clinically significant postvaccination reactions to the Hiberix® Reporting System at www.vaers.hhs.gov or 800‑822‑7967 PedvaxHIB® A vaccine HepA Havrix® Injury claims Vaqta® All vaccines included in the adult immunization schedule except pneumococcal 23-valent polysaccharide (PPSV23) and zoster (RZV) vaccines are covered by the and vaccine HepA-HepB Twinrix® Vaccine Injury Compensation Program. Information on how to file a vaccine injury HepB Engerix-B® claim is available at www.hrsa.gov/vaccinecompensation. Recombivax HB® Heplisav-B® Questions or comments Contact www.cdc.gov/cdc-info or 800-CDC-INFO (800-232-4636), in English or papillomavirus vaccine HPV 9® Spanish, 8 a.m.–8 p.m. ET, Monday through Friday, excluding holidays. vaccine (inactivated) IIV Many brands Download the CDC Vaccine Schedules app for providers at (live, attenuated) LAIV4 FluMist® Quadrivalent www.cdc.gov/vaccines/schedules/hcp/schedule-app.html. Influenza vaccine (recombinant) RIV4 Flublok® Quadrivalent Helpful information , , and vaccine MMR M-M-R II® y Complete ACIP recommendations: Meningococcal serogroups A, C, W, Y vaccine MenACWY-D Menactra® www.cdc.gov/vaccines/hcp/acip-recs/index.html MenACWY-CRM Menveo® y General Best Practice Guidelines for Immunization MenACWY-TT MenQuadfi® (including contraindications and precautions): Meningococcal serogroup B vaccine MenB-4C Bexsero® www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html MenB-FHbp Trumenba® y Vaccine information statements: www.cdc.gov/vaccines/hcp/vis/index.html Pneumococcal 13-valent PCV13 Prevnar 13® y Manual for the Surveillance of Vaccine-Preventable Diseases (including case identification and ): Pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23® www.cdc.gov/vaccines/pubs/surv-manual and Td Tenivac® y Travel vaccine recommendations: www.cdc.gov/travel Tdvax™ y Recommended and Adolescent Immunization Schedule, United States, 2021: Tetanus and diphtheria toxoids and acellular Tdap Adacel® www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html Boostrix® y ACIP Shared Clinical Decision-Making Recommendations VAR Varivax® www.cdc.gov/vaccines/acip/acip-scdm-faqs.html , recombinant RZV Shingrix *Administer recommended vaccines if 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.

CS310021-B Table 1 Recommended Adult Immunization Schedule by Age Group, United States, 2021

Vaccine 19–26 years 27–49 years 50–64 years ≥65 years

Influenza inactivated (IIV) or 1 dose annually Influenza recombinant (RIV4) or or Influenza live, attenuated 1 dose annually (LAIV4)

Tetanus, diphtheria, pertussis 1 dose Tdap each ; 1 dose Td/Tdap for wound management (see notes) (Tdap or Td) 1 dose Tdap, then Td or Tdap booster every 10 years Measles, mumps, rubella 1 or 2 doses depending on indication (MMR) (if born in 1957 or later)

Varicella 2 doses (if born in 1980 or later) 2 doses (VAR)

Zoster recombinant 2 doses (RZV)

2 or 3 doses depending on age at Human papillomavirus (HPV) 27 through 45 years initial vaccination or condition

Pneumococcal conjugate 1 dose (PCV13) 1 dose Pneumococcal polysaccharide 1 or 2 doses depending on indication 1 dose (PPSV23)

Hepatitis A 2 or 3 doses depending on vaccine (HepA)

Hepatitis B 2 or 3 doses depending on vaccine (HepB)

Meningococcal A, C, W, Y 1 or 2 doses depending on indication, see notes for booster recommendations (MenACWY)

Meningococcal B 2 or 3 doses depending on vaccine and indication, see notes for booster recommendations (MenB) 19 through 23 years Haemophilus influenzaetype b 1 or 3 doses depending on indication (Hib)

Recommended vaccination for adults who meet age requirement, Recommended vaccination for adults with an Recommended vaccination based on shared No recommendation/  lack documentation of vaccination, or lack evidence of past  additional risk factor or another indication  clinical decision-making  Not applicable Table 2 Recommended Adult Immunization Schedule by Medical Condition and Other Indications, United States, 2021

Immuno- HIV infection End-stage , Heart or compromised CD4 count renal Chronic Men who have Vaccine Pregnancy complement lung disease, (excluding HIV disease; or on disease personnel2 sex with men <200 ≥200 deficiencies alcoholism1 infection) mm3 mm3 hemodialysis

IIV or RIV4 1 dose annually or or LAIV4 Not Recommended Precaution 1 dose annually

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

Not MMR Not Recommended 1 or 2 doses depending on indication Recommended* Not VAR Not Recommended 2 doses Recommended*

RZV 2 doses at age ≥50 years

Not HPV 3 doses through age 26 years 2 or 3 doses through age 26 years depending on age at initial vaccination or condition Recommended*

PCV13 1 dose

PPSV23 1, 2, or 3 doses depending on age and indication

HepA 2 or 3 doses depending on vaccine

<60 years HepB 2, 3, or 4 doses depending on vaccine or condition >60 years

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

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

3 doses HSCT3 Hib recipients only 1 dose

Recommended vaccination Recommended vaccination Precaution—vaccination Recommended vaccination Not recommended/ No recommendation/  for adults who meet  for adults with an additional  might be indicated if benefit  based on shared clinical  contraindicated—vaccine  Not applicable age requirement, lack risk factor or another of protection outweighs risk decision-making should not be administered. documentation of indication of adverse reaction *Vaccinate after pregnancy. vaccination, or lack evidence of past infection

1. Precaution for LAIV4 does not apply to . 2. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations.3. Hematopoietic stem transplant. Notes Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2021

For vaccine recommendations for persons 18 years - Persons experiencing homelessness - Current or recent use of age or younger, see the Recommended Child/ - Work with hepatitis A in research laboratory or with - Percutaneous or mucosal risk for exposure to Adolescent Immunization Schedule. nonhuman primates with hepatitis A virus infection (e.g., household contacts of HBsAg-positive persons; - Travel in countries with high or intermediate residents and staff of facilities for developmentally Additional Information hepatitis A (HepA-HepB [Twinrix] may be administered on disabled persons; health care and public safety personnel an accelerated schedule of 3 doses at 0, 7, and 21–30 days, with reasonably anticipated risk for exposure to blood or followed by a at 12 months) blood-contaminated body fluids; hemodialysis, peritoneal COVID-19 Vaccination - Close, personal contact with international adoptee , home dialysis, and predialysis patients; persons (e.g., household or regular babysitting) in first 60 days after with diabetes mellitus age younger than 60 years, shared ACIP recommends use of COVID-19 vaccines within arrival from country with high or intermediate endemic clinical decision-making for persons age 60 years or older) the scope of the Emergency Use Authorization or hepatitis A (administer dose 1 as soon as adoption is - Incarcerated persons Biologics License Application for the particular planned, at least 2 weeks before adoptee’s arrival) - Travel in countries with high or intermediate endemic vaccine. Interim ACIP recommendations for the use - Pregnancy if at risk for infection or severe outcome from hepatitis B of COVID-19 vaccines can be found at www.cdc.gov/ infection during pregnancy - Pregnancy if at risk for infection or severe outcome from vaccines/hcp/acip-recs/vacc-specific/covid-19.html - Settings for exposure, including health care settings infection during pregnancy (Heplisav-B not currently targeting services to injection or noninjection drug users recommended due to lack of safety data in pregnant or group homes and nonresidential day care facilities for women) Haemophilus influenzae type b vaccination developmentally disabled persons (individual risk factor screening not required) Human papillomavirus vaccination Special situations y Anatomical or functional asplenia (including sickle cell Hepatitis B vaccination Routine vaccination disease): 1 dose if previously did not receive Hib; if elective y HPV vaccination recommended for all persons through splenectomy, 1 dose, preferably at least 14 days before Routine vaccination age 26 years: 2- or 3-dose series depending on age at initial splenectomy y Not at risk but want protection from hepatitis B vaccination or condition: y Hematopoietic transplant (HSCT): 3-dose (identification of risk factor not required): 2- or 3-dose - Age 15 years or older at initial vaccination: 3-dose series series 4 weeks apart starting 6–12 months after successful series (2-dose series Heplisav-B at least 4 weeks apart [2- at 0, 1–2 months, 6 months (minimum intervals: dose 1 to transplant, regardless of Hib vaccination history dose series HepB only applies when 2 doses of Heplisav-B dose 2: 4 weeks / dose 2 to dose 3: 12 weeks / dose 1 to are used at least 4 weeks apart] or 3-dose series Engerix-B dose 3: 5 months; repeat dose if administered too soon) Hepatitis A vaccination or Recombivax HB at 0, 1, 6 months [minimum intervals: - Age 9–14 years at initial vaccination and received 1 dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose or 2 doses less than 5 months apart: 1 additional Routine vaccination dose 1 to dose 3: 16 weeks]) or 3-dose series HepA-HepB dose y Not at risk but want protection from hepatitis A (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to - Age 9–14 years at initial vaccination and received 2 (identification of risk factor not required): 2-dose series dose 2: 4 weeks / dose 2 to dose 3: 5 months]) doses at least 5 months apart: HPV vaccination series HepA (Havrix 6–12 months apart or Vaqta 6–18 months Special situations complete, no additional dose needed apart [minimum interval: 6 months]) or 3-dose series HepA- y At risk for hepatitis infection: 2-dose (Heplisav-B) y Interrupted schedules: If is HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 or 3-dose (Engerix-B, Recombivax HB) series or 3-dose interrupted, the series does not need to be restarted to dose 2: 4 weeks / dose 2 to dose 3: 5 months]) series HepA-HepB (Twinrix) as above y No additional dose recommended after completing Special situations - Chronic (e.g., persons with hepatitis series with recommended dosing intervals using any y At risk for hepatitis A virus infection: 2-dose series HepA C, , fatty liver disease, alcoholic liver disease, HPV vaccine or 3-dose series HepA-HepB as above autoimmune hepatitis, alanine aminotransferase [ALT] or Shared clinical decision-making - (e.g., persons with hepatitis B, aspartate aminotransferase [AST] level greater than twice y Some adults age 27–45 years: Based on shared clinical , cirrhosis, fatty liver disease, alcoholic liver upper limit of normal) decision-making, 2- or 3-dose series as above disease, autoimmune hepatitis, alanine aminotransferase - HIV infection Special situations [ALT] or aspartate aminotransferase [AST] level greater - Sexual exposure risk (e.g., sex partners of hepatitis B y Age ranges recommended above for routine and catch- than twice the upper limit of normal) surface [HBsAg]-positive persons; sexually active up vaccination or shared clinical decision-making also - HIV infection persons not in mutually monogamous relationships; apply in special situations - Men who have sex with men persons seeking evaluation or treatment for a sexually - Injection or noninjection drug use transmitted infection; men who have sex with men) Notes Recommended Adult Immunization Schedule, United States, 2021

- Immunocompromising conditions, including HIV - Received influenza antiviral medications or - Born before 1957 with no evidence of to infection: 3-dose series as above, regardless of age at within the previous 48 hours, within measles, mumps, or rubella: Consider 2-dose series at initial vaccination the previous 5 days, or baloxavir within the previous 17 least 4 weeks apart for measles or mumps or 1 dose for - Pregnancy: HPV vaccination not recommended until days rubella after pregnancy; no intervention needed if vaccinated - Adults 50 years or older while pregnant; pregnancy testing not needed before y History of Guillain-Barré syndrome within 6 weeks after Meningococcal vaccination vaccination previous dose of influenza vaccine:Generally, should not be vaccinated unless vaccination benefits outweigh Special situations for MenACWY Influenza vaccination risks for those at higher risk for severe complications from y Anatomical or functional asplenia (including sickle influenza cell disease), HIV infection, persistent complement Routine vaccination component deficiency, complement inhibitor (e.g., y Persons age 6 months or older: 1 dose any influenza Measles, mumps, and rubella vaccination eculizumab, ravulizumab) use: 2-dose series MenACWY-D vaccine appropriate for age and health status annually (Menactra, Menveo or MenQuadfi) at least 8 weeks apart y For additional guidance, see www.cdc.gov/flu/ Routine vaccination and revaccinate every 5 years if risk remains professionals/index.htm y No evidence of immunity to measles, mumps, or y Travel in countries with or Special situations rubella: 1 dose meningococcal disease, microbiologists routinely y allergy, hives only: 1 dose any influenza vaccine - Evidence of immunity: Born before 1957 (health care exposed to : 1 dose MenACWY appropriate for age and health status annually personnel, see below), documentation of receipt of MMR (Menactra, Menveo or MenQuadfi) and revaccinate every 5 y –any symptom other than hives (e.g., vaccine, laboratory evidence of immunity or disease years if risk remains angioedema, respiratory distress): 1 dose any influenza (diagnosis of disease without laboratory confirmation is y First-year college students who live in residential vaccine appropriate for age and health status annually. not evidence of immunity) housing (if not previously vaccinated at age 16 years or If using an influenza vaccine other than RIV4 or ccIIV4, Special situations older) and military recruits: 1 dose MenACWY (Menactra, administer in medical setting under supervision of health y Pregnancy with no evidence of immunity to rubella: Menveo or MenQuadfi) y For MenACWY booster dose recommendations for care provider who can recognize and manage severe MMR contraindicated during pregnancy; after pregnancy allergic reactions. groups listed under “Special situations” and in an outbreak (before discharge from health care facility), 1 dose y Severe allergic reactions to any vaccine can occur even setting (e.g., in community or organizational settings y Nonpregnant women of childbearing age with no in the absence of a history of previous allergic reaction. and among men who have sex with men) and additional evidence of immunity to rubella: 1 dose Therefore, all vaccine providers should be familiar with the meningococcal vaccination information, see www.cdc.gov/ y HIV infection with CD4 count ≥200 cells/mm3 for at least office emergency plan and certified in cardiopulmonary mmwr/volumes/69/rr/rr6909a1.htm resuscitation. 6 months and no evidence of immunity to measles, Shared clinical decision-making for MenB mumps, or rubella: 2-dose series at least 4 weeks apart; y A previous severe allergic reaction to any influenza vaccine y Adolescents and young adults age 16–23 years (age MMR contraindicated for HIV infection with CD4 count is a contraindication to future receipt of the vaccine. 16–18 years preferred) not at increased risk for 3 y LAIV4 should not be used in persons with the following <200 cells/mm meningococcal disease: Based on shared clinical decision- conditions or situations: y Severe immunocompromising conditions: MMR making, 2-dose series MenB-4C (Bexsero) at least 1 month - History of severe allergic reaction to any vaccine contraindicated apart or 2-dose series MenB-FHbp (Trumenba) at 0, 6 component (excluding egg) or to a previous dose of any y Students in postsecondary educational institutions, months (if dose 2 was administered less than 6 months influenza vaccine international travelers, and household or close, after dose 1, administer dose 3 at least 4 months after dose - Immunocompromised due to any cause (including personal contacts of immunocompromised persons 2); MenB-4C and MenB-FHbp are not interchangeable (use medications and HIV infection) with no evidence of immunity to measles, mumps, or same product for all doses in series) - Anatomic or functional asplenia rubella: 2-dose series at least 4 weeks apart if previously Special situations for MenB - Close contacts or of severely did not receive any doses of MMR or 1 dose if previously y Anatomical or functional asplenia (including sickle cell immunosuppressed persons who require a protected received 1 dose MMR disease), persistent complement component deficiency, environment y Health care personnel: complement inhibitor (e.g., eculizumab, ravulizumab) - Pregnancy - Born in 1957 or later with no evidence of immunity use, microbiologists routinely exposed to Neisseria - Cranial CSF/oropharyngeal communications to measles, mumps, or rubella: 2-dose series at least 4 meningitidis: 2-dose primary series MenB-4C (Bexsero) at - Cochlear implant weeks apart for measles or mumps or at least 1 dose for least one month apart or rubella Notes Recommended Adult Immunization Schedule, United States, 2021 y MenB-4C (Bexsero) at least 1 month apart or 3-dose y Age 19 years or older with immunocompromising Varicella vaccination primary series MenB-FHbp (Trumenba) at 0, 1–2, 6 months conditions (congenital or acquired (if dose 2 was administered at least 6 months after dose [including B- and T-lymphocyte deficiency, complement Routine vaccination y No evidence of immunity to varicella: 2-dose series 4–8 1, dose 3 not needed); MenB-4C and MenB-FHbp are not deficiencies, phagocytic disorders, HIV infection], weeks apart if previously did not receive varicella-containing interchangeable (use same product for all doses in series); chronic renal failure, , , vaccine (VAR or MMRV [measles-mumps-rubella-varicella 1 dose MenB booster 1 year after primary series and , Hodgkin disease, generalized malignancy, vaccine] for children); if previously received 1 dose varicella- revaccinate every 2–3 years if risk remains iatrogenic [e.g., drug or ], solid organ transplant, multiple myeloma) or containing vaccine, 1 dose at least 4 weeks after first dose y Pregnancy: Delay MenB until after pregnancy unless at - Evidence of immunity: U.S.-born before 1980 (except for increased risk and vaccination benefits outweigh potential anatomical or functional asplenia (including and other hemoglobinopathies): 1 dose PCV13 pregnant women and health care personnel [see below]), risks documentation of 2 doses varicella-containing vaccine followed by 1 dose PPSV23 at least 8 weeks later, then y For MenB booster dose recommendations for groups at least 4 weeks apart, diagnosis or verification of history another dose PPSV23 at least 5 years after previous PPSV23; listed under “Special situations” and in an outbreak of varicella or herpes zoster by a health care provider, at age 65 years or older, administer 1 dose PPSV23 at least setting (e.g., in community or organizational settings laboratory evidence of immunity or disease 5 years after most recent PPSV23 (note: only 1 dose PPSV23 and among men who have sex with men) and additional recommended at age 65 years or older) Special situations meningococcal vaccination information, see www.cdc.gov/ y Age 19 years or older with cerebrospinal fluid leak or y Pregnancy with no evidence of immunity to varicella: mmwr/volumes/69/rr/rr6909a1.htm cochlear implant: 1 dose PCV13 followed by 1 dose PPSV23 VAR contraindicated during pregnancy; after pregnancy at least 8 weeks later; at age 65 years or older, administer (before discharge from health care facility), 1 dose if Pneumococcal vaccination another dose PPSV23 at least 5 years after PPSV23 (note: previously received 1 dose varicella-containing vaccine or only 1 dose PPSV23 recommended at age 65 years or older) dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously Routine vaccination did not receive any varicella-containing vaccine, regardless y Age 65 years or older (immunocompetent— of whether U.S.-born before 1980 see www.cdc.gov/mmwr/volumes/68/wr/mm6846a5. Tetanus, diphtheria, and pertussis vaccination y Health care personnel with no evidence of immunity htm?s_ cid=mm6846a5_w): 1 dose PPSV23 Routine vaccination to varicella: 1 dose if previously received 1 dose varicella- - If PPSV23 was administered prior to age 65 years, y Previously did not receive Tdap at or after age 11 years: 1 containing vaccine; 2-dose series 4–8 weeks apart if administer 1 dose PPSV23 at least 5 years after previous dose Tdap, then Td or Tdap every 10 years previously did not receive any varicella-containing vaccine, dose Special situations regardless of whether U.S.-born before 1980 y 3 Shared clinical decision-making y Previously did not receive primary vaccination series HIV infection with CD4 count ≥200 cells/mm with no y Age 65 years or older (immunocompetent): 1 dose PCV13 for tetanus, diphtheria, or pertussis: At least 1 dose Tdap evidence of immunity: Vaccination may be considered (2 doses 3 months apart); VAR contraindicated for HIV infection based on shared clinical decision-making if previously followed by 1 dose Td or Tdap at least 4 weeks after Tdap and with CD4 count <200 cells/mm3 not administered. another dose Td or Tdap 6–12 months after last Td or Tdap y Severe immunocompromising conditions: VAR - PCV13 and PPSV23 should not be administered during (Tdap can be substituted for any Td dose, but preferred as contraindicated the same visit first dose), Td or Tdap every 10 years thereafter - If both PCV13 and PPSV23 are to be administered, PCV13 y Pregnancy: 1 dose Tdap during each pregnancy, preferably Zoster vaccination should be administered first in early part of gestational weeks 27–36 - PCV13 and PPSV23 should be administered at least 1 year y Wound management: Persons with 3 or more doses of Routine vaccination apart tetanus--containing vaccine: For clean and y Age 50 years or older: 2-dose series RZV (Shingrix) 2–6 Special situations wounds, administer Tdap or Td if more than 10 years since months apart (minimum interval: 4 weeks; repeat dose if last dose of tetanus-toxoid-containing vaccine; for all other administered too soon), regardless of previous herpes zoster (www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. wounds, administer Tdap or Td if more than 5 years since last htm) or history of zoster vaccine live (ZVL, Zostavax) vaccination dose of tetanus-toxoid-containing vaccine. Tdap is preferred (administer RZV at least 2 months after ZVL) y Age 19–64 years with chronic medical conditions for persons who have not previously received Tdap or whose Special situations (chronic heart [excluding hypertension], lung, or liver Tdap history is unknown. If a tetanus-toxoid-containing disease, diabetes), alcoholism, or cigarette smoking: 1 y Pregnancy: Consider delaying RZV until after pregnancy if vaccine is indicated for a pregnant , use Tdap. For RZV is otherwise indicated. dose PPSV23 detailed information, see www.cdc.gov/mmwr/volumes/69/ y Severe immunocompromising conditions (including HIV wr/mm6903a5.htm infection with CD4 count <200 cells/mm3): Recommended use of RZV under review 2/11/2021 Centers for Disease Control and Prevention | Recommended Adult Immunization Schedule, United States, 2021