Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2016* FREE
In
October 2015, the Advisory Committee on Immunization Practices (ACIP)
approved the Recommended Adult Immunization Schedule: United States,
2016. This schedule summarizes ACIP recommendations for the use of
vaccines routinely recommended for adults in 2 figures (Figures 1 and 2), footnotes for each vaccine, and a table that describes primary contraindications and precautions for commonly used vaccines for adults (Table). Details on these updates and information on other vaccines recommended for adults can be found at www.cdc.gov/vaccines/schedules.
The full ACIP recommendations for each vaccine are not included in the
schedule owing to space limitations but can be found at www.cdc.gov/vaccines/hcp/acip-recs/index.html.
The 2016 adult immunization schedule was reviewed and approved by the
American College of Physicians, American Academy of Family Physicians,
American College of Obstetricians and Gynecologists, and American
College of Nurse-Midwives.
Changes in the 2016 adult immunization schedule from the 2015 schedule include the following new ACIP recommendations:
•
Interval change for 13-valent pneumococcal conjugate vaccine (PCV13)
followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23) from
“6 to 12 months” to “at least 1 year” for immunocompetent adults aged
≥65 years (1).
Adults aged ≥19 years with anatomical or functional asplenia,
cerebrospinal fluid leak, or cochlear implant or who are
immunocompromised should receive PPSV23 at least 8 weeks after PCV13.
•
Serogroup B meningococcal (MenB) vaccine series should be administered
to persons aged ≥10 years who are at increased risk for serogroup B
meningococcal disease (2).
Those at increased risk include persons with anatomical or functional
asplenia or persistent complement component deficiencies,
microbiologists who are routinely exposed to isolates of Neisseria meningitidis,
and persons identified at increased risk because of a serogroup B
meningococcal disease outbreak. MenB vaccine series may be administered
to adolescents and young adults aged 16 through 23 years (preferred age
is 16 through 18 years) to provide short-term protection against most
strains of serogroup B meningococcal disease (3).
•
Nine-valent human papillomavirus (HPV) vaccine (9vHPV) was added to the
2016 adult immunization schedule. This vaccine can be used for routine
vaccination against HPV as 1 of 3 HPV vaccines (bivalent HPV vaccine
[2vHPV], quadrivalent HPV vaccine [4vHPV], and 9vHPV) recommended for
females and 1 of 2 HPV vaccines (4vHPV and 9vHPV) recommended for males (4).
•
The row for “Meningococcal” was retitled to “Meningococcal 4-valent
conjugate (MenACWY) or polysaccharide (MPSV4)” to indicate that there
are 2 types of serogroup A, C, W, and Y meningococcal vaccines available
for adults.
•
Additional text was added in several indication bars to describe
reasons for alternate dosing schedules for vaccines where such
designations were appropriate; for example, in the “Measles, mumps, and
rubella (MMR)” indication bar that states “1 or 2 doses,” the clause
“depending on indication” was added.
•
The text in the “Hepatitis A” indication bar was revised from “2 doses”
to “2 or 3 doses depending on vaccine” to account for the hepatitis A
and hepatitis B combination vaccine that is administered in a 3-dose
series.
Additional clarifying changes in Figure 2 include:
•
The text in the consolidated “Influenza” indication bar was simplified
to “one dose annually”; readers should refer to the footnotes for
additional information regarding which influenza vaccine types are
recommended for different age and risk groups.
•
The text in the “Pneumococcal polysaccharide (PPSV23)” indication bar
was revised from “1 or 2 doses” to “1, 2, or 3 doses depending on
indication” to account for the recommendation that adults aged ≥19 years
with immunocompromising conditions or anatomical or functional asplenia
can receive up to 3 doses of PPSV23.
• The text in the “Haemophilus influenzae
type b (Hib)” indication bar was revised from “1 or 3 doses” to “3
doses, post-HSCT [hemapoietic stem cell transplant] recipients only” as
these adults are the only group for whom a 3-dose series of Hib
vaccination is recommended; for adults in other groups for whom Hib
vaccination is recommended, the text in the indication bar was revised
to “1 dose.”
The
influenza, pneumococcal, meningococcal, and HPV vaccination sections
are revised in the footnotes. The 2016 ACIP recommendations on influenza
vaccination reiterate that all persons aged ≥6 months are recommended
to receive annual vaccination against influenza (5).
Persons aged ≥18 years with egg allergy of any severity may receive the
recombinant influenza vaccine (RIV) because it does not contain any egg
protein. Persons with hives-only allergy to eggs may receive the
inactivated influenza vaccine (IIV) with additional safety measures.
The 2016 schedule footnotes correct 2 errata on pneumococcal vaccination that were in the 2015 schedule footnotes:
•
“Adults aged ≥19 years” replaced “adults aged 19 through 64 years” as
the age group for pneumococcal vaccination recommendations for persons
with immunocompromising conditions, anatomical or functional asplenia,
cerebrospinal fluid leak, or cochlear implant (6).
The interval from PCV13 vaccination to PPSV23 vaccination is at least 8
weeks for adults aged ≥19 years with these conditions. For adults aged
≥65 years without these conditions, the interval from PCV13 vaccination
to PPSV23 vaccination is at least 1 year.
•
“Adults aged 19 through 64 years who are residents of nursing homes and
other long-term care facilities” was removed from those for whom PPSV23
is recommended. These adults should be assessed for pneumococcal
vaccination status and receive pneumococcal vaccines recommended based
on their health condition(s) or age (6).
The
footnotes in the 2016 schedule for meningococcal vaccination include
new recommendations on the use of MenB vaccine, in addition to the
information on the use of MenACWY and MPSV4 vaccines. Certain groups of
persons known to be at increased risk for meningococcal disease are
recommended to be routinely vaccinated with a MenACWY vaccine, which
protects against meningococcal serogroups A, C, W, and Y (7).
Although the epidemiology for meningococcal serogroup B is different
from serogroups A, C, W, and Y, persons who are at increased risk for
serogroup A, C, W, and Y meningococcal disease may also be at increased
risk for serogroup B meningococcal disease. The footnotes for
meningococcal vaccination in the 2016 schedule include the following
general information:
•
MenACWY vaccine is preferred over MPSV4 vaccine for adults with
meningococcal vaccine indications who are aged ≤55 years, and for adults
aged ≥56 years who were vaccinated previously with MenACWY vaccine and
are recommended for revaccination or for whom multiple doses of vaccine
are anticipated; MPSV4 vaccine is preferred for adults aged ≥56 years
who have not received MenACWY vaccine previously and who require a
single dose only (for example, persons at risk because of an outbreak).
•
Revaccination with MenACWY vaccine every 5 years is recommended for
adults previously vaccinated with MenACWY or MPSV4 vaccine who remain at
increased risk for infection (for example, adults with anatomical or
functional asplenia or persistent complement component deficiencies and
microbiologists who are routinely exposed to isolates of Neisseria meningitidis).
•
MenB vaccine is available as a 2-dose series of MenB-4C or a 3-dose
series of MenB-FHbp vaccine; the 2 MenB vaccines are not
interchangeable, that is, the same MenB vaccine product must be used for
all doses.
• MenB vaccine may be administered concomitantly with MenACWY vaccine, but at a different anatomical site, if feasible.
•
HIV infection is not an indication for routine vaccination with MenACWY
or MenB vaccine; if an HIV-infected person of any age is to be
vaccinated, administer 2 doses of MenACWY vaccine at least 2 months
apart.
•
MenB vaccines are approved by the U.S. Food and Drug Administration for
use in persons aged 10 through 25 years; however, because there is no
theoretical difference in safety for persons aged >25 years compared
with those aged 10 through 25 years, MenB vaccine is recommended by the
ACIP for routine use in persons aged ≥10 years who are at increased risk
for serogroup B meningococcal disease.
The
meningococcal vaccination footnotes provide an algorithm for groups of
persons known to be at increased risk for meningococcal disease:
•
Adults with anatomical or functional asplenia or persistent complement
component deficiencies: administer 2 doses of MenACWY vaccine at least 2
months apart and revaccinate every 5 years; in addition, administer
either a 2-dose series of MenB-4C or a 3-dose series of MenB-FHbp
vaccine.
• Microbiologists who are routinely exposed to isolates of Neisseria meningitidis:
administer a single dose of MenACWY vaccine; revaccinate with MenACWY
vaccine every 5 years if they remain at increased risk for infection; in
addition, administer either a 2-dose series of MenB-4C or a 3-dose
series of MenB-FHbp vaccine.
•
Persons at risk because of a meningococcal disease outbreak: administer
a single dose of MenACWY vaccine if the outbreak is attributable to
serogroup A, C, W, or Y; if the outbreak is attributable to serogroup B,
administer either a 2-dose series of MenB-4C or a 3-dose series of
MenB-FHbp vaccine.
•
Persons who travel to or live in countries in which meningococcal
disease is hyperendemic or epidemic: administer a single dose of MenACWY
vaccine and revaccinate with MenACWY vaccine every 5 years if they
remain at increased risk for infection; MenB vaccine is not recommended
because meningococcal disease in these countries is generally not caused
by serogroup B.
•
First-year college students aged ≤21 years who live in residence halls:
administer a single dose of MenACWY vaccine if they have not received a
dose on or after their 16th birthday.
•
Young adults aged 16 through 23 years (preferred age range is 16
through 18 years) may be vaccinated with either a 2-dose series of
MenB-4C or a 3-dose series of MenB-FHbp vaccine to provide short-term
protection against most strains of serogroup B meningococcal disease.
•
Three HPV vaccines are licensed for use in females (2vHPV, 4vHPV, and
9vHPV) and two are licensed for use in males (4vHPV and 9vHPV).
•
For females, 2vHPV, 4vHPV, or 9vHPV is recommended in a 3-dose series
for routine vaccination at age 11 or 12 years and for those aged 13
through 26 years if not previously vaccinated.
•
For males, 4vHPV or 9vHPV is recommended in a 3-dose series for routine
vaccination at age 11 or 12 years and for those aged 13 through 21
years, if not previously vaccinated. Males aged 22 through 26 years may
be vaccinated.
•
HPV vaccination is recommended for men who have sex with men through
age 26 years who did not get any or all doses when they were younger.
•
Vaccination is recommended for immunocompromised persons (including
those with HIV infection) through age 26 years who did not get any or
all doses when they were younger.
•
A complete HPV vaccination series consists of 3 doses. The second dose
should be administered 4 to 8 weeks (minimum interval of 4 weeks) after
the first dose; the third dose should be administered 24 weeks after the
first dose and 16 weeks after the second dose (minimum interval of 12
weeks).
•
HPV vaccines are not recommended for use in pregnant women. However,
pregnancy testing is not needed before vaccination. If a woman is found
to be pregnant after initiating the HPV vaccination series, no
intervention is needed; the remainder of the 3-dose series should be
delayed until completion or termination of pregnancy.
Lastly,
a row for MenACWY/MPSV4 vaccine and a separate row for MenB vaccine
replace the single row for meningococcal vaccine in the 2015 schedule
table of contraindications and precautions to commonly used vaccines in
adults. The text “Severe allergic reaction (e.g., anaphylaxis) after a
previous dose or to a vaccine component” was added as a contraindication
and “Moderate or severe acute illness with or without fever” was added
as a precaution for both MenACWY/MPSV4 and MenB rows.
The
adult immunization schedule describes certain conditions that might
cause altered immunocompetence, such as anatomical or functional
asplenia and the use of immunosuppressive drugs, as indications or
contraindications for specific vaccines. It also describes certain
high-risk conditions for which specific vaccines are recommended. For
example, before all adults were recommended to receive yearly influenza
vaccine—a recommendation since the 2010–2011 influenza season—the ACIP
recommended that adults who are at increased risk for severe
complications from influenza or at higher risk for influenza-related
outpatient, emergency department, or hospital visits receive annual
influenza vaccine, including those with chronic pulmonary (including
asthma) or cardiovascular (except isolated hypertension), renal,
hepatic, neurologic, hematologic, or metabolic disorders (including
diabetes mellitus), and HIV infection (8).
The ACIP also recommends that women who are or will be pregnant during
the influenza season be vaccinated to protect themselves and their
newborns (5, 8).
In addition, tetanus–diphtheria–acellular pertussis (Tdap) vaccination
is recommended for pregnant women during each pregnancy, preferably
during 27 to 36 weeks' gestation, regardless of her history of receiving
tetanus–diphtheria (Td) or Tdap vaccines (9).
Thus, obstetrician-gynecologists, pulmonologists, nephrologists,
cardiologists, and other clinical specialists who provide care for these
at-risk adult populations have the responsibility, as do their primary
care colleagues, to assess for and recommend vaccines their patients
need, and either administer the needed vaccines or refer them to a place
where they can get the recommended vaccines. Recently, the authors of 2
published meta-analyses described an association between influenza
vaccination and lower risk for cardiovascular events among patients with
existing cardiovascular disease. They concluded that physicians should
be aware of the need to offer influenza vaccination to patients with
cardiovascular disease and that cardiologists should offer vaccination
to their patients as “a simple once-annual protective therapy to reduce
cardiovascular events” (10, 11).
Despite
the long-standing ACIP recommendations and continued emphasis on
vaccinating adults who are at increased risk for complications from
influenza, influenza vaccination coverage rates among high-risk adults
have remained low (12, 13).
The overall influenza vaccination coverage for the 2012–2013 season
among adults 18 through 64 years of age with at least 1 high-risk
condition was only 49.5% and those with at least 2 high-risk conditions
was only 59.5% (13).
Influenza vaccination rates were low among those with lung disease
(46.2%), heart disease (50.5%), diabetes (58.0%), renal disease (62.5%),
and cancer (56.4%). In 2012–2013, out of an estimated 40 million adults
18 through 64 years of age with medical conditions that increase the
risk for severe illness from influenza, approximately 90% of those who
were unvaccinated may have missed at least 1 potential opportunity to
receive the influenza vaccine through their health care provider (13).
Coverage rates for other vaccines indicated for adults 18 through 64
years of age who have high-risk conditions are likewise low (14).
For adults ≥19 years of age with chronic liver conditions, only 13.3%
reported that they received hepatitis A vaccinations and 34.0% reported
that they received hepatitis B vaccinations. Hepatitis B vaccination
coverage among adults aged 19 through 59 years and ≥60 years with
diabetes was 26.3% and 13.9%, respectively.
Although
vaccination coverage estimates for adults with high-risk conditions are
low, almost all general internists and family physicians feel
responsible to ensure that patients receive recommended vaccines (15).
But only 29% of general internists and 32% of family physicians assess
their adult patients' vaccination status at every visit (15).
In addition, some adult patients may rely on the specialists they see
for primary care, including vaccination. A recommendation by an adult
patient's health care provider for needed vaccines is a strong predictor
of the patient receiving recommended vaccines (16).
The health care provider is clearly the central figure in promoting
vaccination among adults with high-risk conditions and adults in
general.
Several
tools are available to assist primary care and specialty health care
providers in assessing for and recommending needed vaccines for their
adult patients (17–19).
Health care providers also have at their disposal proven methods for
improving vaccination rates, such as the use of standing orders, patient
reminder and recall notices, provider feedback, and immunization
information systems (commonly known as vaccine registries, which are
available in most states) (20).
In addition, electronic health record management systems can include
adult immunization and clinical decision-support systems to prompt
providers to assess their patients' immunization needs and recommend
appropriate vaccinations. Because only 31% of family physicians and 20%
of general internists reported stocking all vaccines routinely
recommended for adults (15),
many providers will need to refer some of their patients to other
providers for vaccination. Online tools, such as Vaccine Finder (www.vaccines.gov/more_info/features/healthmapvaccinefinder.html), can be useful for providers to identify vaccination service providers in their area.
Primary
care providers and specialty providers, such as
obstetrician-gynecologists, cardiologists, and other clinical
specialists, have the responsibility to help ensure that their patients
are protected from vaccine-preventable diseases and their sequelae. The
use of proven, existing strategies can lead to improvements in
immunization coverage rates and reduced illness and disability from
vaccine-preventable diseases among adults in the United States.
Recommendations
for routine use of vaccines in children, adolescents, and adults are
developed by the Advisory Committee on Immunization Practices (ACIP).
ACIP is chartered as a federal advisory committee to provide expert
external advice and guidance to the Director of the Centers for Disease
Control and Prevention (CDC) on use of vaccines and related agents for
the control of vaccine-preventable diseases in the civilian population
of the United States. Recommendations for routine use of vaccines in
children and adolescents are harmonized to the greatest extent possible
with recommendations made by the American Academy of Pediatrics (AAP),
the American Academy of Family Physicians (AAFP), and the American
College of Obstetricians and Gynecologists (ACOG). Recommendations for
routine use of vaccines in adults are harmonized with recommendations of
AAFP, ACOG, and the American College of Physicians (ACP). ACIP
recommendations adopted by the CDC Director become agency guidelines on
the date published in the Morbidity and Mortality Weekly Report (MMWR). Additional information on ACIP is available at www.cdc.gov/vaccines/acip.
Nancy Bennett, MD, MS, University of Rochester School of Medicine and Dentistry, Rochester, New York (Chair);
Raymond A. Strikas, MD, MPH, Centers for Disease Control and
Prevention, National Center for Immunization and Respiratory Diseases,
Atlanta, Georgia (Acting Executive Secretary); Edward Belongia,
MD, Marshfield Clinic Research Foundation, Marshfield, Wisconsin;
Echezona Ezeanolue, MD, MPH, University of Nevada, Las Vegas, Nevada;
Kathleen H. Harriman, PhD, MPH, RN, California Department of Public
Health, Richmond, California; Lee H. Harrison, MD, University of
Pittsburgh, Pittsburgh, Pennsylvania; Ruth A. Karron, MD, Center for
Immunization Research, Johns Hopkins Bloomberg School of Public Health,
Baltimore, Maryland; Allison Kempe, MD, MPH, University of Colorado
School of Medicine, The Children's Hospital of Denver, Denver, Colorado;
Kelly Moore, MD, MPH, Tennessee Department of Health, Vanderbilt
University School of Medicine, Nashville, Tennessee; Cynthia Pellegrini,
March of Dimes, Washington, DC; Arthur L. Reingold, MD, University of
California School of Public Health, Berkeley, California; Laura E.
Riley, MD, Harvard Medical School, Massachusetts General Hospital,
Boston, Massachusetts; José R. Romero, MD, University of Arkansas for
Medical Sciences and Arkansas Children's Hospital, Arkansas Children's
Hospital Research Institute, Little Rock, Arkansas; Lorry Rubin, MD,
Steven and Alexandra Cohen Children's Medical Center of New York, North
Shore–Long Island Jewish Health System, New Hyde Park, New York; and
David Stephens, MD, Emory University School of Medicine, Atlanta,
Georgia. A list of current ACIP members is available at www.cdc.gov/vaccines/acip/committee/members.html.
Work Group Members:
John Epling, MD, MSEd, Syracuse, New York; Sandra Fryhofer, MD,
Atlanta, Georgia; Robert H. Hopkins Jr., MD, Little Rock, Arkansas; Jane
Kim, MD, Durham, North Carolina; Laura Pinkston Koenigs, MD,
Springfield, Massachusetts; Maria Lanzi, ANP, MPH, Hamilton, New Jersey;
Marie-Michele Leger, MPH, PA-C, Alexandria, Virginia; Susan M. Lett,
MD, Boston, Massachusetts; Robert Palinkas, MD, Urbana, Illinois;
Gregory Poland, MD, Rochester, Minnesota; Joni Reynolds, MPH, Denver,
Colorado; Laura E. Riley, MD, Boston, Massachusetts; Charles Rittle,
DNP, MPH, RN, Pittsburgh, Pennsylvania; William Schaffner, MD,
Nashville, Tennessee; Kenneth Schmader, MD, Durham, North Carolina;
Rhoda Sperling, MD, New York, New York; and Richard Zimmerman, MD, MPH,
Pittsburgh, Pennsylvania.
Work Group Contributors:
Anna Acosta, MD, Atlanta, Georgia; Carolyn B. Bridges, MD, Atlanta,
Georgia; Elizabeth Briere, MD, MPH, Atlanta, Georgia; Lisa Grohskopf,
MD, MPH, Atlanta, Georgia; Rafael Harpaz, MD, MPH, Atlanta, Georgia;
Charles LeBaron, MD, Atlanta, Georgia; Jennifer L. Liang, DVM, MPVM,
Atlanta, Georgia; Jessica MacNeil, MPH, Atlanta, Georgia; Mona Marin,
MD, Atlanta, Georgia; Lauri Markowitz, MD, Atlanta, Georgia; Matthew
Moore, MD, MPH, Atlanta, Georgia; Tamara Pilishvili, MPH, Atlanta,
Georgia; Mona Saraiya, MD, MPH, Atlanta, Georgia; Sarah Schillie, MD,
Atlanta, Georgia; Raymond A. Strikas, MD, MPH, Atlanta, Georgia; and
Walter W. Williams, MD, MPH, Atlanta, Georgia.
Work Group Consultants:
Tamera Coyne-Beasley, MD, MPH, Chapel Hill, North Carolina; Molly
Howell, MPH, Bismarck, North Dakota; Linda Kinsinger, MD, MPH, Durham,
North Carolina; Terri Murphy, RN, MSN, Durham, North Carolina; Diane
Peterson, Saint Paul, Minnesota; and Litjen Tan, PhD, Chicago, Illinois.
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