Morbidity and Mortality Weekly Report
QuickGuide / Vol. 60 / No. 4 February 4, 2011
The recommended adult immunization schedule has been approved
by the Advisory Committee on Immunization Practices, the American
Academy of Family Physicians, the American College of Obstetricians and
Gynecologists, and the American College of Physicians.
Suggested citation: Centers for Disease Control and Prevention.
Recommended adult immunization schedule—United States, 2011.
MMWR 2011;60(4).
Recommended Adult Immunization Schedule — United States, 2011
Each year, the Advisory Committee on Immunization Practices
(ACIP) reviews the recommended adult immunization schedule to
ensure that the schedule reflects current recommendations for the
licensed vaccines. In October 2010, ACIP approved the adult immuni-
zation schedule for 2011, which includes several changes. The notation
for influenza vaccination in the figure and footnotes was changed to
reflect the expanded recommendation for annual influenza vaccina-
tion for all persons aged 6 months and older, which was approved by
ACIP in February 2010. In October 2010, ACIP issued a permissive
recommendation for use of tetanus, diphtheria, and acellular pertus-
sis (Tdap) vaccine in adults aged 65 years and older, approved the
recommendation that Tdap vaccine be administered regardless of how
much time has elapsed since the most recent tetanus and diphtheria
toxoids (Td)–containing vaccine, and approved a recommendation
for a 2-dose series of meningococcal vaccine in adults with certain
high-risk medical conditions. The vaccines listed in the figures have
been reordered to keep all universally recommended vaccines together
(e.g., influenza, Td/Tdap, varicella, human papillomavirus [HPV], and
zoster vaccines). Clarifications were made to the footnotes for measles,
mumps, and rubella (MMR) vaccination; HPV vaccine; revaccination
with pneumococcal polysaccharide vaccine (PPSV), and Haemophilus
influenza type b (Hib) vaccine. Finally, a statement has been added to
the box at the bottom of the footnotes to clarify that a vaccine series
does not need to be restarted, regardless of the time that has elapsed
between doses.
Additional information is available as follows: schedule (in English
and Spanish) at http://www.cdc.gov/vaccines/recs/schedules/adult-
schedule.htm; information about adult vaccination at http://www.
cdc.gov/vaccines/default.htm; ACIP statements for specific vaccines at
http://www.cdc.gov/vaccines/pubs/acip-list.htm; and reporting adverse
events at http://www.vaers.hhs.gov or by telephone, 800-822-7967.
Changes for 2011
Footnotes (Figures 1 and 2)
• The influenza vaccination footnote (#1) is revised and shortened
to reflect a recommendation for vaccination of all persons aged 6
months and older, including all adults. The high-dose influenza
vaccine (Fluzone), licensed in 2010 for adults aged 65 years and
older, is mentioned as an option for this age group.
• The Td/Tdap vaccination footnote (#2) has language added to
indicate that persons aged 65 years and older who have close
contact with an infant aged less than 12 months should get
vaccinated with Tdap; the additional language notes that all
persons aged 65 years and older may get vaccinated with Tdap.
Also added is the recommendation to administer Tdap regardless
of interval since the most recent Td-containing vaccine.
• The HPV vaccination footnote (#4) has language added to the
introductory sentences to indicate that either quadrivalent vac-
cine or bivalent vaccine is recommended for females.
• The MMR vaccination footnote (#6) has been revised mainly
by consolidating common language that previously had been
part of each of the three vaccine component sections into one
introductory statement.
• The revaccination with PPSV footnote (#8) clarifies that one-
time revaccination after 5 years only applies to persons with
indicated chronic conditions who are aged 19 through 64
years.
• The meningococcal vaccination footnote (#9) has language
added to indicate that a 2-dose series of meningococcal conjugate
vaccine is recommended for adults with anatomic or functional
asplenia, or persistent complement component deficiencies, as
well adults with human immunodeficiency (HIV) virus infec-
tion who are vaccinated. Language has been added that a single
dose of meningococcal vaccine is still recommended for those
with other indications. Also, language has been added to clarify
that quadrivalent meningococcal conjugate vaccine (MCV4) is
a quadrivalent vaccine.
• The language for the selected conditions for the Hib footnote
(#12) has been shortened to clarify which persons at high risk
may receive 1 dose of Hib vaccine.
QuickGuide
2 MMWR / February 4, 2011 / Vol. 60 / No. 4
NOTE: The above recommendations must be read along with the footnotes on pages 3–4 of this schedule.
* Covered by the Vaccine
Injury Compensation
Program
For all persons in this category who meet the age
requirements and who lack evidence of immunity
(e.g., lack documentation of vaccination or have
no evidence of previous infection)
Recommended if some other risk
factor is present (e.g., based on
medical, occupational, lifestyle,
or other indications)
No recommendation
VACCINE AGE GROUP 19–26 years 27–49 years 50–59 years 60–64 years ≥65 years
Influenza1,*
Tetanus, diphtheria, pertussis (Td/Tdap)2,*
Varicella3,*
Human papillomavirus (HPV)4,*
Zoster5
Measles, mumps, rubella (MMR)6,*
Pneumococcal (polysaccharide)7,8
Meningococcal9,*
Hepatitis A10,*
Hepatitis B11,*
FIGURE 1. Recommended adult immunization schedule, by vaccine and age group — United States, 2011
1 dose annually
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 years Td booster every 10 years
2 doses
3 doses (females)
1 dose
1 or 2 doses 1 dose
1 dose1 or 2 doses
1 or more doses
2 doses
3 doses
INDICATION
Pregnancy
Immunocompro-
mising conditions
(excluding hu-
man immuno-
deficiency virus
[HIV])3,5,6,13
HIV infection3,6,12,13
CD4+ T
lymphocyte count
Diabetes,
heart disease,
chronic lung
disease, chron-
ic alcoholism
Asplenia12 (including
elective splenectomy)
and persistent
complement
component
deficiencies
Chronic
liver
disease
Kidney failure,
end-stage
renal disease,
receipt of
hemodialysis
Health-care
personnelVACCINE
<200
cells/µL
≥200
cells/µL
Influenza1,*
Tetanus, diphtheria, per-
tussis (Td/Tdap)2,*
Varicella3,*
Human
papillomavirus (HPV)4,*
Zoster5 1 dose
Measles, mumps,
rubella6,*
1 or 2 doses
Pneumococcal
(polysaccharide)7,8
1 of 2 doses
Meningococcal9,*
Hepatitis A10,*
Hepatitis B11,*
1 dose TIV annually
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 years
2 doses
Contraindicated 1 dose
1 or 2 doses
1 or 2 doses
1 or more doses
FIGURE 2. Vaccines that might be indicated for adults, based on medical and other indications — United States, 2011
* Covered by the Vaccine
Injury Compensation
Program
For all persons in this category who meet the age
requirements and who lack evidence of immunity
(e.g., lack documentation of vaccination or have no
evidence of previous infection)
Recommended if some other risk
factor is present (e.g., on the basis
of medical, occupational, lifestyle,
or other indications)
No recommendation
Td
Contraindicated
2 doses
Contraindicated
3 doses
1 dose TIV or
LAIV annually
3 doses through age 26 years
QuickGuide
MMWR / February 4, 2011 / Vol. 60 / No. 4 3
1. Influenza vaccination
Annual vaccination against influenza is recommended for all persons aged 6 months
and older, including all adults. Healthy, nonpregnant adults aged less than 50 years
without high-risk medical conditions can receive either intranasally administered live,
attenuated influenza vaccine (FluMist), or inactivated vaccine. Other persons should
receive the inactivated vaccine. Adults aged 65 years and older can receive the standard
influenza vaccine or the high-dose (Fluzone) influenza vaccine. Additional information
about influenza vaccination is available at http://www.cdc.gov/vaccines/vpd-vac/flu/
default.htm.
2. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination
Administer a one-time dose of Tdap to adults aged less than 65 years who have not
received Tdap previously or for whom vaccine status is unknown to replace one of the
10-year Td boosters, and as soon as feasible to all 1) postpartum women, 2) close contacts
of infants younger than age 12 months (e.g., grandparents and child-care providers), and
3) health-care personnel with direct patient contact. Adults aged 65 years and older who
have not previously received Tdap and who have close contact with an infant aged less
than 12 months also should be vaccinated. Other adults aged 65 years and older may
receive Tdap. Tdap can be administered regardless of interval since the most recent tetanus
or diphtheria-containing vaccine.
Adults with uncertain or incomplete history of completing a 3-dose primary vac-
cination series with Td-containing vaccines should begin or complete a primary vac-
cination series. For unvaccinated adults, administer the first 2 doses at least 4 weeks
apart and the third dose 6–12 months after the second. If incompletely vaccinated
(i.e., less than 3 doses), administer remaining doses. Substitute a one-time dose of
Tdap for one of the doses of Td, either in the primary series or for the routine booster,
whichever comes first.
If a woman is pregnant and received the most recent Td vaccination 10 or more years
previously, administer Td during the second or third trimester. If the woman received the
most recent Td vaccination less than 10 years previously, administer Tdap during the imme-
diate postpartum period. At the clinician’s discretion, Td may be deferred during pregnancy
and Tdap substituted in the immediate postpartum period, or Tdap may be administered
instead of Td to a pregnant woman after an informed discussion with the woman.
The ACIP statement for recommendations for administering Td as prophylaxis in
wound management is available at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
3. Varicella vaccination
All adults without evidence of immunity to varicella should receive 2 doses of single-
antigen varicella vaccine if not previously vaccinated or a second dose if they have
received only 1 dose, unless they have a medical contraindication. Special consideration
should be given to those who 1) have close contact with persons at high risk for severe
disease (e.g., health-care personnel and family contacts of persons with immunocom-
promising conditions) or 2) are at high risk for exposure or transmission (e.g., teachers;
child-care employees; residents and staff members of institutional settings, including
correctional institutions; college students; military personnel; adolescents and adults
living in households with children; nonpregnant women of childbearing age; and
international travelers).
Evidence of immunity to varicella in adults includes any of the following: 1) docu-
mentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980
(although for health-care personnel and pregnant women, birth before 1980 should
not be considered evidence of immunity); 3) history of varicella based on diagnosis
or verification of varicella by a health-care provider (for a patient reporting a history
of or having an atypical case, a mild case, or both, health-care providers should seek
either an epidemiologic link with a typical varicella case or to a laboratory-confirmed
case or evidence of laboratory confirmation, if it was performed at the time of acute
disease); 4) history of herpes zoster based on diagnosis or verification of herpes zoster
by a health-care provider; or 5) laboratory evidence of immunity or laboratory confir-
mation of disease.
Pregnant women should be assessed for evidence of varicella immunity. Women who
do not have evidence of immunity should receive the first dose of varicella vaccine upon
completion or termination of pregnancy and before discharge from the health-care
facility. The second dose should be administered 4–8 weeks after the first dose.
4. Human papillomavirus (HPV) vaccination
HPV vaccination with either quadrivalent (HPV4) vaccine or bivalent vaccine (HPV2)
is recommended for females at age 11 or 12 years and catch-up vaccination for females
aged 13 through 26 years.
Ideally, vaccine should be administered before potential exposure to HPV through
sexual activity; however, females who are sexually active should still be vaccinated
consistent with age-based recommendations. Sexually active females who have not
been infected with any of the four HPV vaccine types (types 6, 11, 16, and 18, all of which
HPV4 prevents) or any of the two HPV vaccine types (types 16 and 18, both of which
HPV2 prevents) receive the full benefit of the vaccination. Vaccination is less beneficial
for females who have already been infected with one or more of the HPV vaccine types.
HPV4 or HPV2 can be administered to persons with a history of genital warts, abnormal
Papanicolaou test, or positive HPV DNA test, because these conditions are not evidence
of previous infection with all vaccine HPV types.
HPV4 may be administered to males aged 9 through 26 years to reduce their likelihood
of genital warts. HPV4 would be most effective when administered before exposure to
HPV through sexual contact.
A complete series for either HPV4 or HPV2 consists of 3 doses. The second dose should
be administered 1–2 months after the first dose; the third dose should be administered
6 months after the first dose.
Although HPV vaccination is not specifically recommended for persons with the medical
indications described in Figure 2, “Vaccines that might be indicated for adults based on medi-
cal and other indications,” it may be administered to these persons because the HPV vaccine
is not a live-virus vaccine. However, the immune response and vaccine efficacy might be less
for persons with the medical indications described in Figure 2 than in persons who do not
have the medical indications described or who are immunocompetent.
5. Herpes zoster vaccination
A single dose of zoster vaccine is recommended for adults aged 60 years and older
regardless of whether they report a previous episode of herpes zoster. Persons with
chronic medical conditions may be vaccinated unless their condition constitutes a
contraindication.
6. Measles, mumps, rubella (MMR) vaccination
Adults born before 1957 generally are considered immune to measles and mumps.
All adults born in 1957 or later should have documentation of 1 or more doses of MMR
vaccine unless they have a medical contraindication to the vaccine, laboratory evidence
of immunity to each of the three diseases, or documentation of provider-diagnosed
measles or mumps disease. For rubella, documentation of provider-diagnosed disease
is not considered acceptable evidence of immunity.
Measles component: A second dose of MMR vaccine, administered a minimum of
28 days after the first dose, is recommended for adults who 1) have been recently
exposed to measles or are in an outbreak setting; 2) are students in postsecondary edu-
cational institutions; 3) work in a health-care facility; or 4) plan to travel internationally.
Persons who received inactivated (killed) measles vaccine or measles vaccine of unknown
type during 1963–1967 should be revaccinated with 2 doses of MMR vaccine.
Mumps component: A second dose of MMR vaccine, administered a minimum of 28 days
after the first dose, is recommended for adults who 1) live in a community experiencing
a mumps outbreak and are in an affected age group; 2) are students in postsecondary
educational institutions; 3) work in a health-care facility; or 4) plan to travel internationally.
Persons vaccinated before 1979 with either killed mumps vaccine or mumps vaccine of
unknown type who are at high risk for mumps infection (e.g. persons who are working in a
health-care facility) should be revaccinated with 2 doses of MMR vaccine.
Rubella component: For women of childbearing age, regardless of birth year, rubella
immunity should be determined. If there is no evidence of immunity, women who are
not pregnant should be vaccinated. Pregnant women who do not have evidence of
immunity should receive MMR vaccine upon completion or termination of pregnancy
and before discharge from the health-care facility.
Health-care personnel born before 1957: For unvaccinated health-care personnel born
before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity
or laboratory confirmation of disease, health-care facilities should 1) consider routinely
vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval (for measles
and mumps) and 1 dose of MMR vaccine (for rubella), and 2) recommend 2 doses of MMR
vaccine at the appropriate interval during an outbreak of measles or mumps, and 1 dose
during an outbreak of rubella. Complete information about evidence of immunity is avail-
able at http://www.cdc.gov/vaccines/recs/provisional/default.htm.
7. Pneumococcal polysaccharide (PPSV) vaccination
Vaccinate all persons with the following indications:
Medical: Chronic lung disease (including asthma); chronic cardiovascular diseases;
diabetes mellitus; chronic liver diseases; cirrhosis; chronic alcoholism; functional or
anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is
planned, vaccinate at least 2 weeks before surgery]); immunocompromising condi-
tions (including chronic renal failure or nephrotic syndrome); and cochlear implants
and cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible.
Other: Residents of nursing homes or long-term care facilities and persons who
smoke cigarettes. Routine use of PPSV is not recommended for American Indians/
Alaska Natives or persons aged less than 65 years unless they have underlying
medical conditions that are PPSV indications. However, public health authorities may
consider recommending PPSV for American Indians/Alaska Natives and persons aged
50 through 64 years who are living in areas where the risk for invasive pneumococcal
disease is increased.
8. Revaccination with PPSV
One-time revaccination after 5 years is recommended for persons aged 19 through
64 years with chronic renal failure or nephrotic syndrome; functional or anatomic
asplenia (e.g., sickle cell disease or splenectomy); and for persons with immunocom-
promising conditions. For persons aged 65 years and older, one-time revaccination is
recommended if they were vaccinated 5 or more years previously and were aged less
than 65 years at the time of primary vaccination.
9. Meningococcal vaccination
Meningococcal vaccine should be administered to persons with the following
indications:
Medical: A 2-dose series of meningococcal conjugate vaccine is recommended for
adults with anatomic or functional asplenia, or persistent complement component
deficiencies. Adults with HIV infection who are vaccinated should also receive a routine
2-dose series. The 2 doses should be administered at 0 and 2 months.
Other: A single dose of meningococcal vaccine is recommended for unvaccinated
first-year college students living in dormitories; microbiologists routinely exposed
to isolates of Neisseria meningitidis; military recruits; and persons who travel to or
live in countries in which meningococcal disease is hyperendemic or epidemic
(e.g., the “meningitis belt” of sub-Saharan Africa during the dry season [December
through June]), particularly if their contact with local populations will be prolonged.
Vaccination is required by the government of S
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