Immunization Schedule, Adults

A significant number of adults in the United States die of complications of influenza, pneumococcal infections, and hepatitis B each year. Vaccines to prevent these diseases are very effective, but underused.

Some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives. This is true for certain diseases, such as polio. However, some adults were never vaccinated as children. New vaccines such as the chickenpox vaccination were not available when many adults were children. And vaccinations for certain diseases must be repeated periodically to maintain immunity. In addition, certain vaccines are given to adults but not children. This is because with aging, we become more susceptible to serious diseases caused by common infections (such as flu or pneumonia).

The Advisory Committee on Immunization Practices of the Department of Health and Human Services through the U.S. Centers for Disease Control and Prevention (CDC) made the following recommendations about vaccines needed by all adults:

Vaccines needed for all adults:

• Varicella (chickenpox) vaccine
• Hepatitis B vaccines (adults at risk)
• Measles-mumps-rubella (MMR) vaccine
• Tetanus-diphtheria-pertussis (Td/Tdap) vaccine
  • Vaccines needed for those aged 50 years and older: influenza vaccine (for the flu)
  • Vaccines needed for those aged 60 years and older: shingles vaccine
  • Vaccines needed for those aged 65 years and older: pneumococcal vaccine
  • Vaccines needed for all health-care workers: influenza vaccine (for the flu)

Annual updates are made each year by the CDC.

• A complete Adult Immunization Schedule is available from the CDC's National Immunization Program.
• Recommended immunizations for children are also updated annually by the CDC and the American Academy of Pediatrics.
• A Quick Reference Vaccines Chart summarizes the requirements for children and adults and includes information about additional protection for diseases such as Lyme disease, anthrax, and polio.
  • Side effects: A reaction to a vaccine such as trouble breathing or a seizure is a medical emergency. Call 911 immediately. For more minor side effects such as a fever or soreness at the site of the shot, call your doctor. After any reaction, tell your doctor what happened, the date and time it happened, and when the vaccination was given. You may need to avoid similar vaccinations in the future.

Tetanus is disease caused by bacteria. These bacteria live in all outdoor environments, most commonly in soil. Any open injury to the skin (for example, from a dirty cut, puncture wound, or animal bite) can produce a port of entry into the body. Once inside, the bacteria may germinate and produce a poisonous substance that interferes with nerve conduction. This can result in uncontrolled muscle spasms and may be fatal. Adults younger than 65 years may receive the tetanus, reduced diphtheria, and pertussis vaccine (Tdap) as a one-time alternative to tetanus and diphtheria (Td) if the pertussis component is indicated. The combination vaccine (Tdap) is composed of vaccines against diphtheria, tetanus (lockjaw), and pertussis, another bacterial disease (whooping cough). This vaccine is given routinely to children and is recommended for adults under 65 years of age who have never received a dose of Tdap.

• The incubation period (time from exposure to the bacteria to symptoms) is 48 hours to three or more weeks, with a median of seven days. With such a long incubation period, it is not surprising that the victim may not even remember the wound. The most common symptom is stiffness of the jaw (that's why tetanus is also called lockjaw). Neck stiffness and difficulty swallowing are also common. Complications include airway obstruction, respiratory arrest, heart failure, urinary retention, and constipation due to spasms of the muscles that control the release of urine and bowel.
• In the United States, most tetanus cases occur in those who are unvaccinated. Elderly people, newborns, immigrant workers, and injection drug users are at a greater risk.
• The CDC recommends that adults get a TD booster every 10 years. Pregnant women should get a Tdap vaccine to protect the baby.

Diphtheria is an infection caused by bacteria. The bacteria usually attack the respiratory tract, especially the throat. Toxins produced by the bacteria cause damage to nerve fibers and to the heart that can result in an irregular or very slow heartbeat or heart failure.

• Who gets the vaccine: Children are given the standard vaccine for tetanus and diphtheria plus protection against pertussis (whooping cough). The first Tdap is recommended from age 15-18 months. For adults, a booster shot of just tetanus and diphtheria (Td) is needed every 10 years after the primary series in childhood. Because tetanus can cause death, a shot should be given within the first three days of a suspicious injury whenever you cannot remember when you had your last tetanus shot or if more than five years has passed since your last booster shot. The vaccine is for all adolescents and adults.
• When given: A booster dose is needed every 10 years after the primary doses given during childhood. The CDC recommends one shot of Tdap at age 11 or 12 years. Pregnant women should get a Tdap vaccine to protect the baby.
• For people with suspicious wounds, boosters are given if the last shot was more than five years before the injury. Certain clean, minor wounds may not require a booster if the last booster was within 10 years.
• Side effects: Pain, redness, swelling may occur at the site of the shot. Fever, drowsiness, anxiousness, and loss of appetite occur frequently.
• The vaccine should not be given to people who have had major reactions to the vaccine or any of its components in the past. Pregnant or breastfeeding women should receive the vaccine.

Many bacteria can cause respiratory tract infections such as pneumonia. Pneumococcal organisms (Streptococcus pneumoniae) are the most common bacteria causing pneumonia. Pneumonia is especially dangerous for people with other serious medical conditions. Each year, about 1 million people are hospitalized for pneumonia.

The pneumonia vaccine Pneumovax, or PPSV23, immunizes against the 23 most common strains of the Pneumococcus bacteria. It does not contain any live bacteria. The pneumonia vaccine Prevnar 13, or PCV13, immunizes against 13 common Streptococcus pneumoniae strains. The healthier the immune system of the vaccine recipient, the better their immunity after the vaccine. Healthy young people have an excellent response compared to those who are older or those with a weakened immune system (such as people with diabetes, alcoholism, or cancer).

• Who gets the vaccine: The immunization is recommended for adults 65 years and older; for anyone aged 2-64 years who has a chronic illness or other risk factors such as diabetes, lung, heart, or liver disease; for Alaska Natives, certain American Indian populations; for people who had their spleen removed; for people with sickle cell disease; for those with weakened immune systems (HIV, cancer, chronic kidney failure, organ transplantation); and for people receiving chemotherapy for cancer.
• When given: The shot is routinely given as a onetime dose. It gives lifelong immunity. It can be given to someone who doesn't know if he or she has had the vaccine before. If the first dose was given before the age of 65 years and it has been more than five years since, another shot can be given. For those at highest risk, a onetime revaccination after five years is recommended.
• Side effects: There may be joint aches and tenderness and redness at the injection site. Fever can occur.
• The shot is not for anyone who has had an allergic reaction to the vaccine in the past. Pregnant or breastfeeding women may take the vaccine.

Influenza is commonly called the flu and is caused by a virus. The illness usually goes away by itself without complications, but elderly people or those with serious illnesses may be less able to fight off the disease, resulting in complications. A rare complication known as Reye syndrome can occur with influenza and other viral diseases. It consists of rapid liver failure and brain function abnormalities and can cause death. It is more common in children and is associated with the use of aspirin during these viral infections. This is the reason why doctors warn parents not to give children aspirin for any illness.

Widespread cases of flu (called pandemics) can occur when new strains appear in a population that lacks immunity. According to the CDC, the 1957 and 1968 pandemics caused one-fourth or more of the U.S. population to be infected in a period of two to three months.

There are two major types of influenza viruses, called A and B. Influenza A viruses tend to change over time and become more resistant to the vaccine developed the previous season. Influenza B viruses exhibit fewer changes. Therefore, the development of a flu vaccine is based on the commonest strains of the year before. A new vaccine must be developed each year. To be protected against the most likely strains of virus in an upcoming flu season, a new shot must be taken each year.

Although they are not substitutes for the vaccine, antiviral medicines such as zanamivir (Relenza) and oseltamivir (Tamiflu) can reduce the symptoms or prevent influenza A. These drugs can decrease the chance of infection in someone exposed to influenza A if they have not already been vaccinated. The medicine must be started immediately after exposure and continued for 10 days. During an outbreak, a recently vaccinated person may also need to take these medications while allowing time for the immunity to develop from the shot. Other antiviral drugs, such as amantadine (Symmetrel) and rimantadine (Flumadine), have been previously recommended. As of January 2006, the Centers for Disease Control and Prevention (CDC) no longer recommend amantadine and rimantadine due to the development of resistance of these antivirals for influenza prophylaxis. For more information, see Recalls and Alerts, Jan. 17, 2006.

• Who gets the vaccine: The flu vaccine is recommended yearly for all adults. All adults 50 years or older; anyone 6 months to 50 years of age with chronic diseases (such as heart, lung, kidney, diabetes, asthma, or blood diseases); anyone living in chronic care facilities, such as nursing homes; those 6 months of age or older living with at-risk individuals; children 6 months to 5 years of age (because of the high risk of hospitalization); pregnant women beyond the third month of pregnancy during influenza season; health-care workers exposed to at-risk individuals; travelers to countries where there are influenza activities; and anyone who would like to reduce the chances of becoming ill should get a flu vaccine.
• When given: anytime during influenza season (November through March). October through November is the best time, offering highest protection. Individuals at higher risk should receive their flu vaccine as early as possible. Children younger than 9 years receive two doses (one month apart) if they have not previously received influenza vaccine.
• Side effects: soreness at injection site for one to two days. Some people have a reaction to the virus protein in the vaccine that causes flu-like symptoms such as mild fatigue and muscle aches. They occur six to 12 hours after vaccination and last up to two days. Pregnant and breastfeeding women may take the vaccine.
• Egg allergy is no longer a risk factor for getting a flu shot per a 2017-2018 update published in the Annals of Allergy, Asthma & Immunology.
• Influenza vaccine is also available as a nasal spray (FluMist) for healthy children 5 years of age or older, adolescents, and adults 49 years of age or younger.

Hepatitis is inflammation of the liver. It may be caused by medications, toxins, alcohol, or viruses. The inflammation results in injury to liver cells. The injured liver may be unable to perform functions such as toxin removal, processing of nutrients, removal of old red blood cells, or production of bile to aid in fat digestion.

Viral hepatitis is caused by the hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), hepatitis E virus (HEV), and hepatitis G virus (HGV). However, the only vaccines available are for hepatitis A and B.

Some people with viral hepatitis may have no symptoms. Others have a severe form that leads to death in a few days. Many are somewhere in between. Initially, fatigue, muscle and joint aches, upper respiratory tract symptoms (nasal discharge or sore throat), and loss of appetite occur. Nausea and vomiting are frequent. A slight fever generally is present. Pain is usually present in the upper right part of the abdomen. Five to 10 days later, jaundice (yellowing of the skin and whites of the eyes) may be present. Hepatitis can last just a short time, with symptoms going away after two to three weeks, or it can become a chronic, lifelong disease.

Hepatitis A: Also known as infectious hepatitis, hepatitis A does not become a long-term illness. Transmission occurs via a fecal-oral route due to such things as contaminated food or water or improper hand washing. The virus is in the stool of infected persons and if swallowed by another person may cause disease. This is more likely in crowded or unsanitary conditions. Close contact with infected people is also a mode of transmission. Death seldom occurs from hepatitis A. Especially in children, hepatitis A tends to show no symptoms. Symptoms are often more severe in adults.

• Who gets the vaccine: travelers outside the United States (except for Western Europe, New Zealand, Australia, Canada, Japan); food handlers; people with chronic liver disease; illicit drug users; men who have sex with men; certain laboratory workers; and health-care workers.
• When given: Two doses are required, given at least six months apart. It is recommended that children get their first hepatitis A vaccine starting from 12-24 months.
• Side effects: The vaccine is very safe and effective, but mild allergies may occur. Anyone who has had a previous reaction should avoid the vaccine. Safety for pregnant women has not been determined. Breastfeeding women may take the vaccine.

Hepatitis B and D: Also known as serum hepatitis, this form can be found in blood, saliva, semen, and vaginal secretions. The virus is transmitted via blood transfusions, sexual contact, or contaminated needles. It is common in homosexual men and IV drug users. Infected mothers can also pass it on to their babies at the time of delivery. Some people with this form of hepatitis will develop chronic hepatitis. These people have a 25-40% greater risk of developing cirrhosis and liver cancer. Hepatitis D can only occur when there is also infection with Hepatitis B. Hepatitis D is uncommon in the United States, except in those requiring multiple transfusions or in IV drug users.

• Who gets the vaccine: Primary vaccination now takes place during infancy from ages 6 to 18 months. If not immunized during childhood, the following at-risk people should receive the vaccine: all adolescents; and high-risk adults (those who have household contact with infected people; sex partners of infected people; heterosexuals with multiple sex partners in less than six months; IV drug users; people with recently diagnosed sexually transmitted diseases; people on hemodialysis for kidney failure; health-care workers exposed to blood products; inmates of correctional facilities).
• When given: Three doses are needed. After the first dose, four weeks are needed between doses #1 and #2 and eight weeks needed between doses #2 and #3.
• Side effects: Soreness at the site of injection is common. There have been reports of nerve inflammation.

Measles: In the past, measles was a common childhood disease. It was a major worldwide cause of illness and death. Measles is a viral infection transmitted through the air. Symptoms similar to upper respiratory infections (nasal congestion, sneezing, sore throat) and high fevers lasting five to seven days mark the initial stage. Tiny white spots appear on the inside of the cheeks two days before the appearance of a rash. The rash first appears on the face and behind the ears. It then spreads to the trunk, followed by the extremities, including the palms and soles. It fades in the order of appearance. Complications include inflammation of the brain (encephalitis), seizures, and death.

• According to the CDC, before the development of the live vaccine in 1963, about 500,000 cases of measles and 500 associated deaths were reported annually in the United States.
• By 1983, the development and implementation of the measles vaccine decreased the annual number of reported cases to 3,600.

Mumps: Mumps is caused by the mumps virus. Usual symptoms include fever, weakness, and body aches. The most distinctive feature of mumps is swelling of one or both parotid glands (salivary glands). The illness generally runs its course without complications, but meningitis (inflammation of the lining of the brain) may appear in some cases. Although swelling of the testicles may occur in some males, sterility is rare. Some cases will suffer deafness in one ear.

• The incubation period is generally 14-18 days. Most cases occur in the spring. The virus is spread through infected salivary or urinary secretions.
• The introduction of the vaccine in the late 1960s dramatically decreased the occurrence of mumps over the next 20 years.

Rubella: Rubella is a viral disease caused by inhalation of virus-containing droplets in the air. It is characterized by rash, fever, and painful swollen lymph nodes. There may be a variety of other symptoms. The most devastating complication is infection of the fetus during the first trimester of pregnancy. This usually leads to development of congenital rubella. Exposed babies can later develop a variety of disorders such as cataracts at a young age, glaucoma, hearing loss, retardation, and heart defects. Pregnant women may also have an increased rate of miscarriage. In 1967, the licensing of the vaccine dramatically decreased the number of reported cases.

Who gets the vaccine: The measles, mumps, and rubella vaccines contain live viruses. They are usually combined into a single vaccine (MMR) given as a first dose to children aged 12-15 months; the second dose is given prior to kindergarten (or the first opportunity thereafter). In adults, the MMR vaccine is recommended for these groups:

• Adults born in 1957 or later and who are older than 18 years should receive one dose.
• High-risk groups, such as health-care workers, college entrants, and international travelers, should receive two doses total.
• Adults born before 1957 are typically considered immune to mumps and measles if proof is provided.
• Females of childbearing age (regardless of age and year of birth) without evidence of immunity should be immunized. Women should not receive an MMR vaccination while pregnant or if they may become pregnant within four weeks of receiving the vaccine.
• Side effects: Rash, itching, fever, and joint pains are common. Anyone who has had a previous reaction to the vaccine should avoid it. Women anticipating pregnancy within four weeks of vaccination and people with weakened immune systems should also avoid it. Breastfeeding is not a contraindication. Allow four to six weeks between doses.

Varicella-zoster virus (VZV) is a member of the herpes virus family. It can cause either chickenpox (varicella) or herpes zoster (shingles). Chickenpox is a common childhood disease that tends to be mild. However, it can be serious when occurring during adulthood. The virus is spread from person to person through the air or by contact with fluid from chickenpox blisters. The virus causes a rash, itching, fever, and tiredness. A person who previously had chickenpox can develop shingles years later. This happens because the VZV infects part of certain nerves. The virus "sleeps" there and may become reactivated in the future.

• Who gets the vaccine: susceptible adults and adolescents; susceptible health-care workers; susceptible family contacts of people with weakened immune systems; those at high risk for exposure such as day-care employees, employees in institutional settings such as prisons, college students, and military personnel; and international travelers.
• Females of childbearing age (regardless of age and year of birth) without evidence of immunity should be immunized. Women should not receive varicella while pregnant or may if they may become pregnant within four weeks of receiving the vaccine.
• When given: For those younger than 13 years of age, one dose is needed. The first dose of varicella vaccine should be given when a child is 12 to 18 months old and a second dose between 4 to 6 years of age. If older than 13, two doses are given four to eight weeks apart.
• Side effects: pain, swelling, redness at site of injection; a small rash may develop that can spread chickenpox to others; and chickenpox may develop years later, although less severe than the naturally occurring type. Avoid this vaccine if you have had a previous reaction to gelatin or the antibiotic neomycin or had a severe reaction, if you are pregnant or anticipate being pregnant in one month, if you have untreated, active tuberculosis, or if you have a weakened immune system (including HIV). Breastfeeding women may take the vaccine. Aspirin-containing products should be avoided for six weeks after the vaccine to avoid the rare risk of Reye syndrome (rapid liver failure, brain function abnormalities; 30% death rate).

Meningococcal (Neisseria meningitidis) infections are most common in close living conditions (such as college dormitories, military barracks, or child-care centers). The infection may invade the bloodstream or the brain (meningitis). Symptoms come on rapidly and can sometimes be quite severe (leading to shock, coma, or death). Meningitis caused by meningococcal bacteria is difficult to distinguish from that of other bacteria that cause meningitis, making the disease more difficult to recognize and treat. Routine immunization in children is not recommended because the infection is rare, response to the vaccine is poor in young children, the immunity to meningococcal does not last in young children, and early vaccination may later impair response to the vaccine.

Types of meningococcal vaccine:

• Meningococcal polysaccharide vaccine (MPSV4): used for children 2-10 years of age
• Meningococcal conjugate vaccine (MCV4): used for adolescents and adults (although MPSV4 is an acceptable alternative)
• Serogroup B meningococcal (MenB) vaccine can help prevent meningococcal disease caused by Neisseria meningitidis serogroup B. Other meningococcal vaccines are recommended to help protect against Neisseria meningitidis serogroups A, C, W, and Y.

Who gets the vaccine:

• Children 2 years of age or older in high-risk groups (those who have had their spleen removed or those with suppressed immune system, such as terminal complement deficiencies)
• Adolescents 11-12 years of age and unvaccinated adolescents entering high school should be vaccinated with a single dose of a quadrivalent meningococcal conjugate vaccine (MenACWY). The CDC recommends a booster shot at age 16.
• College students, military recruits, laboratory workers exposed to meningococcal vaccine components, and those traveling to hyperendemic or epidemic areas
  • Side effects: Pain, swelling and redness at site of injection may occur one to two days following immunization.

Selected conditions exist in which Haemophilus influenzae type b (Hib) conjugate vaccine may be used for adults. Hib vaccines are licensed for children 6 weeks to 71 months of age. No efficacy data is available on which to base a recommendation concerning the use of Hib vaccine for older children and adults with the chronic conditions associated with an increased risk for Hib disease. However, studies suggest that Hib vaccine may be beneficial in patients who have sickle cell disease, leukemia, or HIV infection, or have had splenectomies.

• When given: The first dose of Hib is given at 2 months of age, the second dose at 4 months, the third dose at 6 months (if needed, depending on brand of vaccine), and a final/booster dose given at 12-15 months of age.

HPV infection is considered to be the most common sexually transmitted infection (sexually transmitted disease, STD) in the U.S.

Although HPV infection may not cause symptoms, it is known that certain types of HPVs cause precancerous changes in the uterine cervix as well as cervical cancer. HPVs also cause genital warts.

• The human papillomavirus vaccine is recommended in a three-dose schedule with the second and third doses administered two and six months after the first dose. It is recommended for all women up to 26 years of age, and all men up to 21 years of age, who have not completed the vaccine series.
• When given: The first dose of HPV vaccine is usually given from ages 11 to 12 years, but vaccination can start as early as age 9. Both girls and boys should receive three doses of the HPV vaccine.

Centers for Disease Control and Prevention
1600 Clifton Rd
Atlanta, GA 30333
(800) 311-3435

National Foundation for Infectious Diseases
4733 Bethesda Avenue, Suite 750
Bethesda, MD 20814
(301) 656-0003

Immunization Action Coalition, Immunization Information for Adults