Recommended Adult Immunization Schedule, United States, 2019*

Abstract

Clinical Guidelines5 February 2019Recommended Adult Immunization Schedule, United States, 2019*FREECorrection(s) for this article:CorrectionsApr 2019Correction: Recommended Adult Immunization Schedule, United States, 2019FREEDavid K. Kim, MD, MA and Paul Hunter, MD, on behalf of the Advisory Committee on Immunization Practices†David K. Kim, MD, MACenters for Disease Control and Prevention, Atlanta, Georgia (D.K.K.) and Paul Hunter, MDUniversity of Wisconsin, Madison, Wisconsin (P.H.), on behalf of the Advisory Committee on Immunization Practices†Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M18-3600 Eligible for CME Point-of-Care SectionsSupplemental MaterialAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail This article has been corrected. The original version (PDF) is appended to this article as a Supplement.In October 2018, the Advisory Committee on Immunization Practices (ACIP) voted to approve the Recommended Adult Immunization Schedule, United States, 2019, for adults aged 19 years or older. The 2019 adult immunization schedule, available at www.cdc.gov/vaccines/schedules, summarizes ACIP recommendations in 2 tables and accompanying notes (Figure). The full ACIP recommendations for each vaccine are available at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The 2019 schedule has also been approved by the Director of the Centers for Disease Control and Prevention (CDC) and by the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.Figure. Recommended Adult Immunization Schedule, United States, 2019. Download figure Download PowerPoint Download figure Download PowerPoint Download figure Download PowerPoint Download figure Download PowerPoint Download figure Download PowerPoint Download figure Download PowerPoint The ACIP's recommendations on use of each vaccine are developed after in-depth review of vaccine-related data, including disease epidemiology and burden of disease, vaccine efficacy and effectiveness, vaccine safety, the quality of evidence, feasibility of program implementation, and economic analyses of immunization policy (1). ACIP recommendations can be complex and challenging to implement. The purpose of the annually published schedule is to consolidate and summarize updates to ACIP recommendations on vaccination of adults and assist providers in implementing current ACIP recommendations. The use of trade names of vaccines in this article and in the schedule is for identification purposes only and does not imply endorsement by the ACIP or the CDC.Changes to the 2019 Adult Immunization ScheduleUpdated ACIP RecommendationsInfluenza vaccination (2). In June 2018, the ACIP updated recommendations on the use of live attenuated influenza vaccine (LAIV) (FluMist Quadrivalent, AstraZeneca) after 2 influenza seasons (2016–2017 and 2017–2018) during which use of LAIV was not recommended in the United States. For the 2018–2019 season, any licensed influenza vaccine that is appropriate for the age and health status of the patient may be used. LAIV is an option for adults through age 49 years, except for those who have immunocompromising conditions, including HIV infection; have anatomical or functional asplenia; are pregnant; have close contact with or are caregivers of severely immunocompromised persons in a protected environment; have received influenza antiviral medications in the previous 48 hours; or have cerebrospinal fluid leak or a cochlear implant. Those with a history of Guillain–Barré syndrome within 6 weeks of a previous dose of influenza vaccine generally should not be vaccinated.Hepatitis B vaccination (3). In February 2018, the ACIP recommended use of the new single-antigen recombinant hepatitis B vaccine with a novel cytosine-phosphate-guanine 1018 oligodeoxynucleotide adjuvant (Heplisav-B, Dynavax) for prevention of hepatitis B virus infection in adults aged 18 years or older. Approved by the U.S. Food and Drug Administration in November 2017, Heplisav-B is routinely administered in 2 doses at least 4 weeks apart. It can be used as a substitute in a 3-dose series with a different hepatitis B vaccine, but a valid 2-dose series requires 2 doses of Heplisav-B with at least 4 weeks between them. When feasible, a vaccine from the same manufacturer should be used to complete the vaccination series. However, vaccination should not be deferred if the previously administered hepatitis B vaccine is unknown or if a vaccine from the same manufacturer is not available. A pregnant woman with an indication for hepatitis B vaccination should not receive Heplisav-B because no safety data are available on its use during pregnancy.Hepatitis A vaccination (4). In October 2018, the ACIP recommended adding homelessness as an indication for routine hepatitis A vaccination with a 2-dose series of single-antigen hepatitis A vaccine (Havrix, GlaxoSmithKline; Vaqta, Merck) or a 3-dose series of combination hepatitis A and B vaccine (Twinrix, GlaxoSmithKline). Other populations that are at increased risk for hepatitis A virus infection or severe hepatitis A disease and are recommended to receive routine vaccination include persons with chronic liver disease or clotting factor disorders, travelers in countries with high or intermediate endemic hepatitis A, persons with close personal contact with an international adoptee in the first 60 days after arrival from a country with high or intermediate endemic hepatitis A, men who have sex with men, persons who use injection or noninjection drugs, and persons who work with hepatitis A virus in a laboratory or nonhuman primates infected with the virus (5–7). In addition, any person who is not at risk for hepatitis A virus infection but wants protection against it may be vaccinated.Revised Content, Format, and GraphicsCover. Recommended Adult Immunization Schedule. The cover page of the 2019 schedule has been simplified and features a shorter title, provides basic instructions on how to use the schedule to systematically identify vaccination needs of adults, and lists routinely recommended vaccines and their standardized abbreviations and trade names. Web links have been added where providers can download the CDC Vaccine Schedules app and access reference materials on surveillance of vaccine-preventable diseases, including case identification and disease outbreak response. The cover page also has instructions on reporting suspected cases of reportable vaccine-preventable diseases to local or state health departments and significant postvaccination adverse events to the Vaccine Adverse Event Reporting System; information on the Vaccine Injury Compensation Program; and Web links to other resources, such as Vaccine Information Statements and recommended vaccines for travelers.Table 1. Recommended Adult Immunization Schedule by Age Group.Table 1 (previously known as Figure 1) describes routine and catch-up vaccination recommendations for adults by age. Table 1 contains 1 notable change from 2018: LAIV has been listed separately from inactivated influenza vaccine (IIV) (many branded products) and recombinant influenza vaccine (RIV) (Flublok Quadrivalent, Sanofi Pasteur) for adults through age 49 years. The ACIP recommends routine annual influenza vaccination for all persons aged 6 months or older who do not have contraindications; 1 annual dose of IIV, RIV, or LAIV that is appropriate for the age and health status of the patient is recommended.Table 2. Recommended Adult Immunization Schedule by Medical Condition and Other Indications.Table 2 (previously known as Figure 2) also lists LAIV separately from IIV and RIV. Table 2 contains 2 new recommendation displays designated by new colors: "Precaution—vaccine might be indicated if benefit of protection outweighs risk of adverse reaction" (orange) and "Delay vaccination until after pregnancy if vaccine is indicated" (pink). LAIV is contraindicated in pregnant women and immunocompromised adults, including those with HIV infection, because it is a live vaccine. The risk of associated adverse effects from the use of LAIV in adults with functional or anatomical asplenia or complement deficiencies is not clear; however, for display purposes, the use of LAIV in this population has been designated as "contraindicated" (red). For adults with end-stage renal disease, heart or lung disease, chronic liver disease, or diabetes, LAIV has been given the "precaution" (orange) designation. This designation has also been applied to serogroup B meningococcal vaccine (MenB) (Bexsero, GlaxoSmithKline; Trumenba, Pfizer) for pregnant women; MenB should be deferred in pregnant women unless they are at increased risk for serogroup B meningococcal disease and the benefits of vaccination outweigh potential risks (8). In pregnant women, the recommended use of MenB differs from that of serogroups A, C, W, and Y meningococcal vaccine (MenACWY) (Menactra, Sanofi Pasteur; Menveo, GlaxoSmithKline). Pregnancy should not preclude use of MenACWY if it is otherwise indicated (9). Therefore, MenACWY in pregnancy remains displayed as "Recommended vaccination for adults with an additional risk factor or another indication" (purple). The designation "Delay until after pregnancy" (pink) was applied to the use of human papillomavirus (HPV) vaccine (Gardasil 9, Merck) and recombinant zoster vaccine (RZV) (Shingrix, GlaxoSmithKline). The use of HPV vaccine is not recommended for pregnant women (10, 11), and pregnant women should consider delaying receipt of RZV (if it is indicated) until after pregnancy (12). Zoster vaccine live (ZVL) (Zostavax, Merck) is contraindicated in pregnancy (13).Notes. Recommended Adult Immunization Schedule. Each recommended vaccine for adults in Tables 1 and 2 is accompanied by notes (previously known as footnotes), which are designed to provide additional information on routine vaccination and recommendations in special situations. The notes have been reordered alphabetically by vaccination, and superscript footnote numbers in the former figures (now tables) have been removed. Each section contains concise information on vaccine indications, dosing frequencies and intervals, and other published ACIP recommendations. New recommendations on influenza, hepatitis B, and hepatitis A vaccinations have been added to their respective sections in the notes. Recommendations on vaccination in outbreak settings in the measles, mumps, and rubella vaccination and meningococcal vaccination sections have been removed. All vaccines identified in Tables 1 and 2 (except zoster vaccines) also appear in the Recommended Immunization Schedule for Children and Adolescents, United States, 2019 (14). The notes for vaccines that appear in both the adult immunization schedule and the child and adolescent immunization schedule have been harmonized to the extent possible.Adult Vaccination Coverage RatesAdults are at risk for illness, hospitalization, disability, and death from vaccine-preventable diseases. The schedule is updated annually to assist providers in implementing up-to-date ACIP recommendations for adults. The overarching goal is to improve adult vaccination coverage rates in the United States.Although modest increases in vaccination coverage rates were observed in several sectors of the adult population in 2016, the overall rates for adults in the United States have remained low (15). Among adults aged 19 years or older, the influenza vaccination coverage rate for the 2015–2016 influenza season remained similar to that for the 2014–2015 season, at 43.5%. For adults aged 65 years or older, there was a decrease of 3.1 percentage points, to 70.4%. The rate among black (39.5%) and Hispanic (33.1%) adults continued to lag behind that among white adults (46.3%).Among pregnant women, the influenza vaccination coverage rate in the 2017–2018 influenza season was 49.1% (16) compared with 53.6% in the 2016–2017 season and 49.9% in the 2015–2016 season (17). The coverage for tetanus, diphtheria, and acellular pertussis vaccine (Tdap) among pregnant women was 54.4% (16). The ACIP has recommended Tdap for every pregnancy since 2012 (18).The 2016 pneumococcal vaccination coverage rate among adults aged 65 years or older was 66.9%, an increase of 3.3 percentage points from 2015 (15). These rates do not distinguish between 13-valent conjugate (Prevnar 13, Pfizer) or 23-valent polysaccharide (Pneumovax 23, Merck) pneumococcal vaccines. For adults aged 19 through 64 years who are at increased risk for pneumococcal disease, such as those with heart or lung disease or diabetes, pneumococcal vaccination coverage remained unchanged, at 24.0%. Among adults for whom Tdap vaccination could be assessed, 26.6% were estimated to be current, an increase of 3.4 percentage points from 2015. Among adults aged 60 years or older, zoster vaccination coverage was 33.4%, an increase of 2.8 percentage points from 2015. Rates of HPV vaccination coverage for females and males aged 19 through 21 years were 51.6% and 21.2%, respectively, representing increases of 9.6 and 5.5 percentage points from 2015.Standards of Adult Immunization PracticeIn response to the persistently low vaccination coverage rates among adults, the National Vaccine Advisory Committee updated the standards for adult immunization practice in 2014 to promote integration of vaccinations as part of routine clinical care for adults (19). The standards for adult immunization practice is a call to action for providers to assess the vaccination status of adult patients at every clinical encounter, strongly recommend needed vaccines, offer vaccines or refer patients to another provider if they do not stock vaccines, and document administered vaccines in state or local immunization information systems. The schedule is an important clinical resource that providers can use to stay current on ACIP-recommended immunizations for adults and to implement the standards for adult immunization practice.Adult Immunization Schedule Usability TestingThe adult immunization schedule was first published in 2002 with the goal of enabling providers to easily identify vaccination needs of their adult patients and administer appropriate vaccines (20). In addition, providers can use the schedule to help implement use of standing orders, patient reminder and recall systems, and other strategies to vaccinate their adult patients and minimize missed opportunities. The 2002 schedule contained information on 8 vaccines and 6 special-indication categories for which vaccines were routinely recommended, such as pregnancy and HIV infection. In contrast, the 2019 schedule contains information on routinely recommended uses for 17 types of vaccines in 11 antigen groups and 10 special-indication categories. As ACIP recommendations for adults became more complex, a need arose to translate the recommendations more effectively and improve messaging to busy providers.In 2016–2017, the ACIP and the CDC conducted an ad hoc review of the 2016 schedule in collaboration with the Georgia Institute of Technology chapter of the Human Factors and Ergonomics Society (21). The goal was to apply user-centered visual design principles to improve the messaging efficiency of the schedule while maintaining a form that did not deviate from established user expectations. This initial review yielded many recommendations that were based on cognitive ergonomics and design principles. Several of these recommendations, such as using blocks instead of bars in figures for simplicity and clarity, were adopted in the 2017 and 2018 schedules.In 2017, the ACIP and the CDC began formal usability testing of the schedule that included in-depth interviews with primary care physicians, nurse practitioners and physician assistants, pharmacists, nurses, and medical assistants who reported being familiar with the schedule (22). In 2018, several versions of adult immunization schedule redesigns based on these interviews were prepared, and an Internet survey of internal medicine and family medicine physicians was conducted to assess their impressions of and preferences for redesigned drafts.The qualitative evaluation of the 2017 schedule, which featured in-depth interviews with 48 providers, revealed that most were familiar with Figure 1 (recommended adult immunization schedule by age group) but fewer were familiar with Figure 2 (recommended adult immunization schedule by medical condition and other indications). Interviewees were generally aware of the footnotes, but few accessed the information routinely and few were aware that the schedule included a table of contraindications and precautions for vaccines routinely recommended for adults. When given scenarios that required careful clinical assessments for vaccination needs in adult patients with more complex medical histories, providers generally did not know how to systematically use the schedule to assist them with decision making.Based on the results of these interviews, several drafts of the schedule with different layouts and color combinations were developed for usability testing. A survey was then administered to an Internet panel of 251 internal medicine and family medicine physicians comparing the characteristics of the published 2017 schedule and a redesigned draft of it to assess their impressions and preferences. The results indicated that the respondents preferred the color scheme of the published schedule and the simplicity of the redesigned draft schedule. Many respondents requested that a larger font be used. The 2019 schedule thus features a simplified cover page that contains a 3-step instruction on how to use the schedule, new versions of Tables 1 and 2 that use the same colors as previous iterations but with changes for improved cognition, and notes pages with a larger font that became possible with removal of the table of contraindications and precautions for vaccines recommended for adults. The cover page refers readers to www.cdc.gov/vaccines/hcp/acip-recs/general-recs to access the information on vaccine contraindications and precautions.Besides incorporating new ACIP recommendations on influenza, hepatitis B, and hepatitis A vaccinations, the notes in the 2019 schedule were revised for clarity, brevity, and consistency. Where appropriate, recommendations differentiated between routine and special situations. Populations and special situations for which vaccines are routinely recommended or are associated with important considerations were highlighted in boldface text so that they can be identified more easily.Along with routine use of the adult immunization schedule, health care providers can implement such proven strategies as incorporating vaccination assessments as part of routine patient flow and using patient reminders and recalls to improve vaccination of their adult patients (23). These and other activities associated with implementation of the standards for adult immunization practice can be used to develop quality improvement projects that readily meet maintenance of certification requirements. In addition, providers who participate in the Medicare Quality Payment Program's Merit-based Incentive Payment System can use their patients' immunization data, such as pneumococcal vaccination records for adults aged 65 years or older, as a quality measure (24). By consistently using the Recommended Adult Immunization Schedule, United States, 2019, and implementing the standards for adult immunization practice, providers can reduce the burden of illnesses, hospitalizations, and mortality associated with vaccine-preventable diseases among their adult patients.AppendixRecommendations for routine use of vaccines in children, adolescents, and adults are developed by the Advisory Committee on Immunization Practices (ACIP). ACIP is ch

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