Annals of Internal Medicine CLINICAL GUIDELINE

Recommended Adult Immunization Schedule, United States, 2023*

Neil Murthy, MD, MPH, MSJ; A. Patricia Wodi, MD, MPH; Sybil Cineas, MD; and Kevin A. Ault, MD; for the Advisory
Committee on Immunization Practices†

I n October 2022, the Advisory Committee on Immunization

Practices (ACIP) voted to approve the Recommended
Adult Immunization Schedule for Ages 19 Years or Older,
recommendations for persons who are moderately or
severely immunocompromised. Hyperlinks referring health
care providers to booster dose recommendations and to
United States, 2023. The 2023 adult immunization sched- the recommendation for persons who previously received
ule, available at www.cdc.gov/vaccines/schedules/hcp/ Janssen COVID-19 vaccine are also provided. Additionally,
imz/adult.html, summarizes ACIP recommendations in hyperlinks to the current COVID-19 vaccination schedules,
the cover page, tables, notes, and appendix (Figure). The use of COVID-19 preexposure prophylaxis in persons who
full ACIP recommendations for each vaccine are available are moderately or severely immunocompromised, as well
at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The as Emergency Use Authorization indications for COVID-19
2023 schedule has also been approved by the director of vaccines, are provided.
the Centers for Disease Control and Prevention (CDC) Haemophilus influenzae type b (Hib) vaccination. Vaccine
and by the American College of Physicians (www.acponline. recommendations for Hib vaccination have not changed.
org), the American Academy of Family Physicians (www. Hepatitis A (HepA) vaccination. Vaccine recommen-
aafp.org), the American College of Obstetricians and dations for HepA vaccination have not changed.
Gynecologists (www.acog.org), the American College of Hepatitis B (HepB) vaccination (2). A newly licensed
Nurse-Midwives (www.midwife.org), the American Academy HepB vaccine, PreHevbrio, was added to the description
of Physician Associates (www.aapa.org), the American of the 3-dose series. HepB vaccination continues to be uni-
Pharmacists Association (www.pharmacist.com), and the versally recommended for all adults 19 through 59 years of
Society for Healthcare Epidemiology of America (www. age. Language was added stating that persons aged
shea-online.org). 60 years and older with known risk factors for hepatitis B virus
The ACIP develops recommendations on the use of infection should complete a HepB vaccine series, while per-
sons 60 years of age and older without known risk factors
each vaccine after in-depth review of vaccine-related data,
for hepatitis B virus infection may complete a HepB vaccine
such as the epidemiology and burden of the vaccine-
series. The “Special situations” section provides dosing reg-
preventable disease (VPD), vaccine efficacy and effective- imens for patients on dialysis.
ness, vaccine safety, quality of evidence, feasibility of pro- Human papillomavirus (HPV) vaccination (3). Routine
gram implementation, and economic analyses of immu- recommendations for HPV vaccination have not changed.
nization policy (1). ACIP recommendations can be complex Influenza vaccination (4). Updates to the seasonal
and challenging to implement. The purpose of the immuni- influenza vaccine recommendations reflect discussions
zation schedule, published annually, is to consolidate and during public meetings of ACIP held on 20 October
summarize updates to ACIP recommendations on vaccina- 2021, 12 January 2022, 23 February 2022, and 22 June
tion of adults and to assist providers in implementing cur- 2022. For the 2022–2023 influenza season, routine annual
rent ACIP recommendations. The use of vaccine trade influenza vaccination is recommended for all persons aged
names in this article and in the schedule is for identification 6 months and older who do not have contraindications.
purposes only and does not imply endorsement by the Among persons who are 65 years of age and older, any
ACIP or CDC. one of the quadrivalent high-dose inactivated influenza
vaccine, quadrivalent recombinant influenza vaccine, or
quadrivalent adjuvanted inactivated influenza vaccine is
CHANGES TO THE 2023 ADULT IMMUNIZATION preferred compared with other influenza vaccine products.
SCHEDULE However, if none of these 3 vaccines is available, then any
COVID-19 vaccination. A new section was added to other age-appropriate influenza vaccine should be used.
the Notes section describing recommendations for This information has been provided as a bullet in the influ-
COVID-19 vaccines approved or authorized by the U.S. enza notes section, along with a hyperlink to the 2022–
Food and Drug Administration. A description of the pri- 2023 influenza recommendations.
mary series recommendations for the general population The composition of 2022–2023 U.S. influenza vaccines
is provided, followed by a description of the primary series includes updates to the influenza A(H3N2) and influenza

This article was published at Annals.org on 10 February 2023.

* The 2023 adult immunization schedule appeared in Annals of Internal Medicine and on the Centers for Disease Control and Prevention website at www.cdc.
gov/vaccines/schedules. An announcement summarizing changes to the 2023 adult immunization schedule was published in the Morbidity and
Mortality Weekly Report on 10 February 2023. Readers can cite the 2023 adult immunization schedule as follows: Murthy N, Wodi AP, Cineas S, Ault
KA; Advisory Committee on Immunization Practices. Recommended adult immunization schedule, United States, 2023. Ann Intern Med. Epub 10 Feb
2023..doi:10.7326/M23-0041
† The 2023 adult immunization schedule was prepared by the Advisory Committee on Immunization Practices (ACIP); the ACIP Combined
Immunization Schedule Work Group; Neil Murthy (Centers for Disease Control and Prevention, Atlanta, Georgia); A. Patricia Wodi (Centers for
Disease Control and Prevention, Atlanta, Georgia); Sybil Cineas (The Warren Alpert Medical School of Brown University, Providence, Rhode Island); and
Kevin A. Ault (Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan). For a list of members of the ACIP and the ACIP
Combined Immunization Schedule Work Group, see Appendix A (available at Annals.org).

Annals.org Annals of Internal Medicine 1

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 Figure. Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2023.

UNITED STATES
Recommended Adult Immunization Schedule
for ages 19 years or older 2023
Recommended by the Advisory Committee on Immunization Practices
How to use the adult immunization schedule

2 Annals of Internal Medicine

(www.cdc.gov/vaccines/acip) and approved by the Centers for Disease
Determine Assess need Review vaccine Review Control and Prevention (www.cdc.gov), American College of Physicians
1 recommended 2 for additional 3 types, dosing 4 contraindications (www.acponline.org), American Academy of Family Physicians (www.aafp.org),
vaccinations by recommended frequencies and and precautions American College of Obstetricians and Gynecologists (www.acog.org),
CLINICAL GUIDELINE

age (Table 1) vaccinations by intervals, and for vaccine types American College of Nurse-Midwives (www.midwife.org), American Academy of
medical condition considerations for (Appendix) Physician Associates (www.aapa.org), American Pharmacists Association
or other indication special situations (www.pharmacist.com), and Society for Healthcare Epidemiology of America
(Table 2) (Notes) (www.shea-online.org).
Vaccines in the Adult Immunization Schedule* Report
• Suspected cases of reportable vaccine-preventable diseases or outbreaks to
Vaccine Abbreviation(s) Trade name(s)
the local or state health department
COVID-19 vaccine 1vCOV-mRNA Comirnaty®/Pfizer-BioNTech COVID-19 Vaccine
SPIKEVAX®/Moderna COVID-19 Vaccine • Clinically significant postvaccination reactions to the Vaccine Adverse Event
2vCOV-mRNA Pfizer-BioNTech COVID-19 Vaccine, Bivalent Reporting System at www.vaers.hhs.gov or 800-822-7967
Moderna COVID-19 Vaccine, Bivalent Injury claims
1vCOV-aPS Novavax COVID-19 Vaccine All vaccines included in the adult immunization schedule except PPSV23, RZV,
Haemophilus influenzae type b vaccine Hib ActHIB® and COVID-19 vaccines are covered by the National Vaccine Injury Compensation
Hiberix® Program (VICP). COVID-19 vaccines that are authorized or approved by the FDA are
PedvaxHIB® covered by the Countermeasures Injury Compensation Program (CICP). For more
Hepatitis A vaccine HepA Havrix® information, see www.hrsa.gov/vaccinecompensation or www.hrsa.gov/cicp.
Vaqta®
Hepatitis A and hepatitis B vaccine HepA-HepB Twinrix®
Questions or comments
Contact www.cdc.gov/cdc-info or 800-CDC-INFO (800-232-4636), in English or
Hepatitis B vaccine HepB Engerix-B® Spanish, 8 a.m.–8 p.m. ET, Monday through Friday, excluding holidays.
Heplisav-B®
PreHevbrio® Download the CDC Vaccine Schedules app for providers at
Recombivax HB® www.cdc.gov/vaccines/schedules/hcp/schedule-app.html.
Human papillomavirus vaccine HPV Gardasil 9®
Influenza vaccine (inactivated) IIV4 Many brands Helpful information
Influenza vaccine (live, attenuated) LAIV4 FluMist® Quadrivalent • Complete Advisory Committee on Immunization Practices (ACIP) recommendations:
Influenza vaccine (recombinant) RIV4 Flublok® Quadrivalent www.cdc.gov/vaccines/hcp/acip-recs/index.html
Measles, mumps, and rubella vaccine MMR M-M-R II®
• General Best Practice Guidelines for Immunization
Priorix®
Meningococcal serogroups A, C, W, Y vaccine MenACWY-D Menactra®
(including contraindications and precautions):
MenACWY-CRM Menveo® www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html

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MenACWY-TT MenQuadfi® • Vaccine information statements: www.cdc.gov/vaccines/hcp/vis/index.html
Meningococcal serogroup B vaccine MenB-4C Bexsero® • Manual for the Surveillance of Vaccine-Preventable Diseases
MenB-FHbp Trumenba® (including case identification and outbreak response):
Pneumococcal conjugate vaccine PCV15 Vaxneuvance™ www.cdc.gov/vaccines/pubs/surv-manual
PCV20 Prevnar 20™ • Travel vaccine recommendations: www.cdc.gov/travel
Pneumococcal polysaccharide vaccine PPSV23 Pneumovax 23® • Recommended Child and Adolescent Immunization Schedule, United States, 2023:
Poliovirus vaccine IPV IPOL® www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
Tetanus and diphtheria toxoids Td Tenivac® • ACIP Shared Clinical Decision-Making Recommendations: Scan QR code
Tdvax™ www.cdc.gov/vaccines/acip/acip-scdm-faqs.html for access to
Tetanus and diphtheria toxoids and acellular Tdap Adacel® online schedule
pertussis vaccine Boostrix®
Varicella vaccine VAR Varivax®
Zoster vaccine, recombinant RZV Shingrix
*Administer recommended vaccines if vaccination 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-A

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Recommended Adult Immunization Schedule, United States, 2023
 Figure–Continued.

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Table 1 Recommended Adult Immunization Schedule by Age Group, United States, 2023

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

COVID-19 2- or 3-dose primary series and booster (See Notes)

Influenza inactivated (IIV4) or

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

Tetanus, diphtheria, pertussis 1 dose Tdap each pregnancy; 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 For healthcare personnel,

(MMR) (if born in 1957 or later) see notes

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

Zoster recombinant
2 doses for immunocompromising conditions (see notes) 2 doses
Recommended Adult Immunization Schedule, United States, 2023

(RZV)

2 or 3 doses depending on age at

Human papillomavirus (HPV) 27 through 45 years
initial vaccination or condition
1 dose PCV15 followed by PPSV23 See Notes
Pneumococcal OR
(PCV15, PCV20, PPSV23) 1 dose PCV20 (see notes) See Notes

Hepatitis A
2, 3, or 4 doses depending on vaccine
(HepA)

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Hepatitis B
2, 3, or 4 doses depending
2, 3,on
orvaccine depending
4 dosesor conditionon vaccine or condition
(HepB)

Annals of Internal Medicine

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 influenzae type 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 infection additional risk factor or another indication clinical decision-making Not applicable

3
CLINICAL GUIDELINE
 Figure–Continued.

Table 2 Recommended Adult Immunization Schedule by Medical Condition or Other Indication, United States, 2023

Immuno- HIV infection CD4 End-stage

percentage and count Asplenia, Heart or Men who
compromised renal Chronic liver Health care
Vaccine Pregnancy complement lung disease; Diabetes have sex
(excluding HIV <15% or ≥15% and disease, or on disease personnelb
deficiencies alcoholisma with men
infection) hemodialysis

4 Annals of Internal Medicine

<200 mm3 ≥200 mm3

COVID-19 See Notes

CLINICAL GUIDELINE

IIV4 or RIV4 1 dose annually

or or
LAIV4 Contraindicated Precaution 1 dose annually

1 dose Tdap each

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

MMR Contraindicated* Contraindicated 1 or 2 doses depending on indication

VAR Contraindicated* Contraindicated 2 doses

RZV 2 doses at age ≥19 years 2 doses at age ≥50 years

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

Pneumococcal
(PCV15, PCV20, 1 dose PCV15 followed by PPSV23 OR 1 dose PCV20 (see notes)
PPSV23)

HepA 2, 3, or 4 doses depending on vaccine

3 doses
HepB 2, 3, or 4 doses depending on vaccine or condition
(see notes)

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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 HSCTC
Hib recipients only
1 dose

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

a. Precaution for LAIV4 does not apply to alcoholism. b. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations. c. Hematopoietic stem cell transplant.

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Recommended Adult Immunization Schedule, United States, 2023
 Figure–Continued.

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Notes Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2023
For vaccine recommendations for persons 18 years Haemophilus influenzae type b vaccination - Travel in countries with high or intermediate
of age or younger, see the Recommended Child and endemic hepatitis A (HepA-HepB [Twinrix] may
Special situations be administered on an accelerated schedule of
Adolescent Immunization Schedule.
• Anatomical or functional asplenia (including sickle 3 doses at 0, 7, and 21–30 days, followed by a
COVID-19 vaccination cell disease): 1 dose if previously did not receive Hib; booster dose at 12 months)
if elective splenectomy, 1 dose preferably at least - Close, personal contact with international
Routine vaccination
14 days before splenectomy adoptee (e.g., household or regular babysitting) in
• Primary series: 2-dose series at 0, 4-8 weeks
• Hematopoietic stem cell transplant (HSCT): first 60 days after arrival from country with high or
(Moderna) or 2-dose series at 0, 3-8 weeks
3-dose series 4 weeks apart starting 6–12 months intermediate endemic hepatitis A (administer dose
(Novavax, Pfizer-BioNTech)
after successful transplant, regardless of 1 as soon as adoption is planned, at least 2 weeks
• Booster dose: see www.cdc.gov/vaccines/covid-19/ Hib vaccination history before adoptee’s arrival)
clinical-considerations/interim-considerations-us.html
Hepatitis A vaccination - Pregnancy if at risk for infection or severe outcome
Special situations from infection during pregnancy
Routine vaccination
Persons who are moderately or severely - Settings for exposure, including health care settings
immunocompromised • Not at risk but want protection from hepatitis A targeting services to injection or noninjection drug
(identification of risk factor not required): users or group homes and nonresidential day care
• Primary series
2-dose series HepA (Havrix 6–12 months apart or facilities for developmentally disabled persons
- 3-dose series at 0, 4, 8 weeks (Moderna) or Vaqta 6–18 months apart [minimum interval: (individual risk factor screening not required)
3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech) 6 months]) or 3-dose series HepA-HepB (Twinrix at 0,
- 2-dose series at 0, 3 weeks (Novavax) 1, 6 months [minimum intervals: dose 1 to Hepatitis B vaccination
Recommended Adult Immunization Schedule, United States, 2023

• Booster dose: see www.cdc.gov/vaccines/covid-19/ dose 2: 4 weeks / dose 2 to dose 3: 5 months]) Routine vaccination
clinical-considerations/interim-considerations-us.html Special situations • Age 19 through 59 years: complete a 2- or 3- or
• Pre-exposure prophylaxis (e.g., monoclonal • At risk for hepatitis A virus infection: 2-dose series 4-dose series
antibodies) may be considered to complement HepA or 3-dose series HepA-HepB as above - 2-dose series only applies when 2 doses of
COVID-19 vaccination. See www.cdc.gov/
- Chronic liver disease (e.g., persons with Heplisav-B* are used at least 4 weeks apart
vaccines/covid-19/clinical-considerations/interim-
hepatitis B, hepatitis C, cirrhosis, fatty liver disease, - 3-dose series Engerix-B, PreHevbrio*, or Recombivax
considerations-us.html#immunocompromised
alcoholic liver disease, autoimmune hepatitis, HB at 0, 1, 6 months [minimum intervals: dose 1 to
For Janssen COVID-19 Vaccine recipients see alanine aminotransferase [ALT] or aspartate dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose 1

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COVID-19 schedule at www.cdc.gov/vaccines/covid-19/ aminotransferase [AST] level greater than to dose 3: 16 weeks])
clinical-considerations/interim-considerations-us.html. twice the upper limit of normal)
- 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months
Note: Current COVID-19 schedule available at www. - HIV infection

Annals of Internal Medicine

[minimum intervals: dose 1 to dose 2:
cdc.gov/vaccines/covid-19/downloads/COVID-19- - Men who have sex with men 4 weeks / dose 2 to dose 3: 5 months])
immunization-schedule-ages-6months-older.pdf.
- Injection or noninjection drug use - 4-dose series HepA-HepB (Twinrix) accelerated
For more information on Emergency Use Authorization
- Persons experiencing homelessness schedule of 3 doses at 0, 7, and 21–30 days, followed
(EUA) indications for COVID-19 vaccines, please visit
by a booster dose at 12 months
www.fda.gov/emergency-preparedness-and-response/ - Work with hepatitis A virus in research
coronavirus-disease-2019-covid-19/covid-19-vaccines laboratory or with nonhuman primates *Note: Heplisav-B and PreHevbrio are not
with hepatitis A virus infection recommended in pregnancy due to lack of safety data
in pregnant persons.

5
CLINICAL GUIDELINE
 Figure–Continued.

Notes Recommended Adult Immunization Schedule, United States, 2023

• Age 60 years or older with known risk factors for Human papillomavirus vaccination Influenza vaccination
hepatitis B virus infection should complete a
HepB vaccine series. Routine vaccination Routine vaccination

6 Annals of Internal Medicine

• Age 60 years or older without known risk factors • HPV vaccination recommended for all persons • Age 19 years or older: 1 dose any influenza vaccine
for hepatitis B virus infection may complete a through age 26 years: 2- or 3-dose series depending appropriate for age and health status annually.
HepB vaccine series. on age at initial vaccination or condition: - Age 65 years or older: Any one of quadrivalent
CLINICAL GUIDELINE

- Risk factors for hepatitis B virus infection include: - Age 15 years or older at initial vaccination: high-dose inactivated influenza vaccine (HD-IIV4),
3-dose series at 0, 1–2 months, 6 months (minimum quadrivalent recombinant influenza vaccine (RIV4),
ƒ Chronic liver disease (e.g., persons with hepatitis intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: or quadrivalent adjuvanted inactivated influenza
C, cirrhosis, fatty liver disease, alcoholic liver disease, 12 weeks / dose 1 to dose 3: 5 months; repeat dose if vaccine (aIIV4) is preferred. If none of these three
autoimmune hepatitis, alanine aminotransferase administered too soon) vaccines is available, then any other age-appropriate
[ALT] or aspartate aminotransferase [AST] level influenza vaccine should be used.
greater than twice upper limit of normal) - Age 9–14 years at initial vaccination and received
ƒ HIV infection 1 dose or 2 doses less than 5 months apart: • For the 2022–2023 season, see www.cdc.gov/mmwr/
ƒ Sexual exposure risk (e.g., sex partners of hepatitis 1 additional dose volumes/71/rr/rr7101a1.htm
B surface antigen [HBsAg]-positive persons; sexually - Age 9–14 years at initial vaccination and received • For the 2023–2024 season, see the 2023–2024 ACIP
active persons not in mutually monogamous 2 doses at least 5 months apart: HPV vaccination influenza vaccine recommendations.
relationships; persons seeking evaluation or series complete, no additional dose needed Special situations
treatment for a sexually transmitted infection;
• Interrupted schedules: If vaccination schedule is • Egg allergy, hives only: any influenza vaccine
men who have sex with men)
interrupted, the series does not need to be restarted appropriate for age and health status annually
ƒ Current or recent injection drug use
ƒ Percutaneous or mucosal risk for exposure • No additional dose recommended when any HPV • Egg allergy–any symptom other than hives
to blood (e.g., household contacts of HBsAg- vaccine series has been completed using the (e.g., angioedema, respiratory distress or required
positive persons; residents and staff of facilities for recommended dosing intervals. epinephrine or another emergency medical
developmentally disabled persons; health care and Shared clinical decision-making intervention): Any influenza vaccine appropriate for
public safety personnel with reasonably anticipated age and health status may be administered. If using
• Some adults age 27–45 years: Based on shared
risk for exposure to blood or blood-contaminated egg-based IIV4 or LAIV4, administer in medical setting
clinical decision-making, 2- or 3-dose series as above
body fluids; persons on maintenance dialysis, under supervision of health care provider who can
including in-center or home hemodialysis and Special situations recognize and manage severe allergic reactions.
peritoneal dialysis, and persons who are predialysis;

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• Age ranges recommended above for routine and • Close contacts (e.g., caregivers, healthcare
patients with diabetes) catch-up vaccination or shared clinical decision- workers) of severely immunosuppressed persons
ƒ Incarceration making also apply in special situations who require a protected environment: these
ƒ Travel in countries with high or intermediate
- Immunocompromising conditions, including HIV persons should not receive LAIV4. If LAIV4
endemic hepatitis B
infection: 3-dose series, even for those who initiate is given, they should avoid contact with/caring
Special situations
vaccination at age 9 through 14 years. for such immunosuppressed persons for
• Patients on dialysis: complete a 3- or 4-dose series 7 days after vaccination.
- Pregnancy: Pregnancy testing is not needed before
- 3-dose series Recombivax HB at 0, 1, 6 months vaccination; HPV vaccination is not recommended • Severe allergic reaction (e.g., anaphylaxis) to a
(note: use Dialysis Formulation 1 mL = 40 mcg) until after pregnancy; no intervention needed if vaccine component or a previous dose of any
- 4-dose series Engerix-B at 0, 1, 2, and 6 months inadvertently vaccinated while pregnant influenza vaccine: see Appendix listing
(note: use 2 mL dose instead of the contraindications and precautions
normal adult dose of 1 mL)

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Recommended Adult Immunization Schedule, United States, 2023
 Figure–Continued.

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Notes Recommended Adult Immunization Schedule, United States, 2023
• History of Guillain-Barré syndrome within 6 weeks • In mumps outbreak settings, for information about Shared clinical decision-making for MenB
after previous dose of influenza vaccine: Generally, additional doses of MMR (including 3rd dose of MMR), • Adolescents and young adults age 16–23 years
should not be vaccinated unless vaccination benefits see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7. (age 16–18 years preferred) not at increased risk
outweigh risks for those at higher risk for severe htm for meningococcal disease: Based on shared clinical
complications from influenza • Health care personnel: decision-making, 2-dose series MenB-4C (Bexsero)
Measles, mumps, and rubella vaccination - Born before 1957 with no evidence of immunity at least 1 month apart or 2-dose series MenB-FHbp
to measles, mumps, or rubella: (Trumenba) at 0, 6 months (if dose 2 was administered
Routine vaccination less than 6 months after dose 1, administer dose 3
Consider 2-dose series at least 4 weeks apart for
• No evidence of immunity to measles, mumps, or protection against measles or mumps or 1 dose for at least 4 months after dose 2); MenB-4C and
rubella: 1 dose protection against rubella MenB-FHbp are not interchangeable (use same
product for all doses in series)
- Evidence of immunity: Born before 1957 (health - Born in 1957 or later with no evidence of
care personnel, see below), documentation of receipt immunity to measles, mumps, or rubella: Special situations for MenB
of MMR vaccine, laboratory evidence of immunity or 2-dose series at least 4 weeks apart for protection • Anatomical or functional asplenia (including sickle
disease (diagnosis of disease without laboratory against measles or mumps or at least 1 dose for cell disease), persistent complement component
confirmation is not evidence of immunity) protection against rubella deficiency, complement inhibitor (e.g., eculizumab,
Special situations Meningococcal vaccination ravulizumab) use, or microbiologists routinely
exposed to Neisseria meningitidis:
• Pregnancy with no evidence of immunity to
Special situations for MenACWY 2-dose primary series MenB-4C (Bexsero) at least
rubella: MMR contraindicated during pregnancy;
• Anatomical or functional asplenia (including sickle 1 month apart or 3-dose primary series
after pregnancy (before discharge from
Recommended Adult Immunization Schedule, United States, 2023

cell disease), HIV infection, persistent complement MenB-FHbp (Trumenba) at 0, 1–2, 6 months
health care facility), 1 dose
component deficiency, complement inhibitor (if dose 2 was administered at least 6 months after
• Nonpregnant persons of childbearing age with no (e.g., eculizumab, ravulizumab) use: 2-dose series dose 1, dose 3 not needed; if dose 3 is administered
evidence of immunity to rubella: 1 dose MenACWY-D (Menactra, Menveo, or MenQuadfi) earlier than 4 months after dose 2, a fourth dose
• HIV infection with CD4 percentages ≥15% and at least 8 weeks apart and revaccinate every 5 years should be administered at least 4 months after dose 3);
CD4 count ≥200 cells/mm3 for at least 6 months if risk remains MenB-4C and MenB-FHbp are not interchangeable
and no evidence of immunity to measles, mumps, (use same product for all doses in series); 1 dose MenB
• Travel in countries with hyperendemic or epidemic
or rubella: 2-dose series at least 4 weeks apart; MMR booster 1 year after primary series and revaccinate
meningococcal disease, or microbiologists
contraindicated for HIV infection with CD4 percentage every 2–3 years if risk remains
routinely exposed to Neisseria meningitidis: 1 dose

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<15% or CD4 count <200 cells/mm3 MenACWY (Menactra, Menveo, or MenQuadfi) and • Pregnancy: Delay MenB until after pregnancy unless
• Severe immunocompromising conditions: revaccinate every 5 years if risk remains at increased risk and vaccination benefits outweigh
MMR contraindicated potential risks
• First-year college students who live in residential

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• Students in postsecondary educational housing (if not previously vaccinated at age • For MenB booster dose recommendations for groups
institutions, international travelers, and 16 years or older) or military recruits: 1 dose listed under “Special situations” and in an outbreak
household or close, personal contacts of MenACWY (Menactra, Menveo, or MenQuadfi) setting (e.g., in community or organizational settings
immunocompromised persons with no evidence of and among men who have sex with men) and
• For MenACWY booster dose recommendations for additional meningococcal vaccination information,
immunity to measles, mumps, or rubella: groups listed under “Special situations” and in an
2-dose series at least 4 weeks apart if previously did see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm
outbreak setting (e.g., in community or organizational
not receive any doses of MMR or 1 dose if previously settings and among men who have sex with men) and Note: MenB vaccines may be administered
eceived 1 dose MMR additional meningococcal vaccination information, simultaneously with MenACWY vaccines if indicated,
see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm but at a different anatomic site, if feasible.
CLINICAL GUIDELINE

7
 Figure–Continued.

Notes Recommended Adult Immunization Schedule, United States, 2023

Pneumococcal vaccination • For guidance on determining which pneumococcal *Note: Immunocompromising conditions include
vaccines a patient needs and when, please refer to the chronic renal failure, nephrotic syndrome,
Routine vaccination
mobile app which can be downloaded here: www.cdc. immunodeficiency, iatrogenic immunosuppression,

8 Annals of Internal Medicine

• Age 65 years or older who have: gov/vaccines/vpd/pneumo/hcp/pneumoapp.html generalized malignancy, human immunodeficiency
- Not previously received a dose of PCV13, PCV15, virus, Hodgkin disease, leukemia, lymphoma, multiple
Special situations
or PCV20 or whose previous vaccination history myeloma, solid organ transplants, congenital or
• Age 19–64 years with certain underlying medical
CLINICAL GUIDELINE

is unknown: 1 dose PCV15 OR 1 dose PCV20. If acquired asplenia, sickle cell disease, or other
conditions or other risk factors** who have hemoglobinopathies.
PCV15 is used, this should be followed by a dose of
- Not previously received a PCV13, PCV15, or
PPSV23 given at least 1 year after the PCV15 dose. **Note: Underlying medical conditions or other risk
PCV20 or whose previous vaccination history is
A minimum interval of 8 weeks between PCV15 and factors include alcoholism, chronic heart/liver/lung
unknown: 1 dose PCV15 OR 1 dose PCV20. If
PPSV23 can be considered for adults with an disease, chronic renal failure, cigarette smoking,
PCV15 is used, this should be followed by a dose of
immunocompromising condition,* cochlear implant, cochlear implant, congenital or acquired asplenia,
PPSV23 given at least 1 year after the PCV15 dose.
or cerebrospinal fluid leak to minimize the risk of CSF leak, diabetes mellitus, generalized malignancy,
A minimum interval of 8 weeks between PCV15 and
invasive pneumococcal disease caused by serotypes HIV, Hodgkin disease, immunodeficiency, iatrogenic
PPSV23 can be considered for adults with an
unique to PPSV23 in these vulnerable groups. immunosuppression, leukemia, lymphoma, multiple
immunocompromising condition,* cochlear implant,
- Previously received only PCV7: follow the myeloma, nephrotic syndrome, solid organ
or cerebrospinal fluid leak
recommendation above. transplants, or sickle cell disease or other
- Previously received only PCV7: follow the hemoglobinopathies.
- Previously received only PCV13: 1 dose PCV20 at recommendation above.
least 1 year after the PCV13 dose OR complete the Polio vaccination
- Previously received only PCV13: 1 dose PCV20 at
recommended PPSV23 series as described here
least 1 year after the PCV13 dose OR complete the Routine vaccination
www.cdc.gov/vaccines/vpd/pneumo/downloads/
recommended PPSV23 series as described here Routine poliovirus vaccination of adults residing in the
pneumo-vaccine-timing.pdf.
www.cdc.gov/vaccines/vpd/pneumo/downloads/ United States is not necessary.
- Previously received only PPSV23: 1 dose PCV15 OR pneumo-vaccine-timing.pdf.
1 dose PCV20 at least 1 year after the PPSV23 dose. Special situations
- Previously received only PPSV23: 1 dose PCV15 OR
If PCV15 is used, it need not be followed by another • Adults at increased risk of exposure
1 dose PCV20 at least 1 year after the PPSV23 dose. If
dose of PPSV23. to poliovirus with:
PCV15 is used, it need not be followed by another
- Previously received both PCV13 and PPSV23 dose of PPSV23. - No evidence of a complete polio vaccination series
but NO PPSV23 was received at age 65 years or (i.e., at least 3 doses): administer remaining doses
- Previously received both PCV13 and PPSV23 but

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older: 1 dose PCV20 at least 5 years after their last (1, 2, or 3 doses) to complete a 3-dose series
have not completed the recommended series:
pneumococcal vaccine dose OR complete the
1 dose PCV20 at least 5 years after their last - Evidence of completed polio vaccination series
recommended PPSV23 series as described here
pneumococcal vaccine dose OR complete the (i.e., at least 3 doses): may administer one lifetime
www.cdc.gov/vaccines/vpd/pneumo/downloads/
recommended PPSV23 series as described here IPV booster
pneumo-vaccine-timing.pdf.
www.cdc.gov/vaccines/vpd/pneumo/downloads/
- Previously received both PCV13 and PPSV23, AND pneumo-vaccine-timing.pdf For detailed information, see www.cdc.gov/vaccines/
PPSV23 was received at age 65 years or older: Based vpd/polio/hcp/recommendations.html
• For guidance on determining which pneumococcal
on shared clinical decision-making, 1 dose of PCV20 at
vaccines a patient needs and when, please refer to the
least 5 years after the last pneumococcal vaccine dose.
mobile app which can be downloaded here: www.cdc.
gov/vaccines/vpd/pneumo/hcp/pneumoapp.html

Annals.org
Recommended Adult Immunization Schedule, United States, 2023
 Figure–Continued.

Annals.org
Notes Recommended Adult Immunization Schedule, United States, 2023
Tetanus, diphtheria, and pertussis vaccination Varicella vaccination Zoster vaccination
Routine vaccination Routine vaccination Routine vaccination
• Previously did not receive Tdap at or after age • No evidence of immunity to varicella: 2-dose series • Age 50 years or older*: 2-dose series recombinant
11 years: 1 dose Tdap, then Td or Tdap every 10 years 4–8 weeks apart if previously did not receive varicella- zoster vaccine (RZV, Shingrix) 2–6 months apart
containing vaccine (VAR or MMRV [measles-mumps- (minimum interval: 4 weeks; repeat dose if
Special situations
rubella-varicella vaccine] for children); if previously administered too soon), regardless of previous
• Previously did not receive primary vaccination received 1 dose varicella-containing vaccine, 1 dose at herpes zoster or history of zoster vaccine live
series for tetanus, diphtheria, or pertussis: 1 dose least 4 weeks after first dose (ZVL, Zostavax) vaccination.
Tdap followed by 1 dose Td or Tdap at least 4 weeks
- Evidence of immunity: U.S.-born before 1980 *Note: Serologic evidence of prior varicella is not
later, and a third dose of Td or Tdap 6–12 months later
(except for pregnant persons and health care necessary for zoster vaccination. However, if
(Tdap can be substituted for any Td dose, but preferred
personnel [see below]), documentation of 2 doses serologic evidence of varicella susceptibility becomes
as first dose), Td or Tdap every 10 years thereafter
varicella-containing vaccine at least 4 weeks apart, available, providers should follow ACIP guidelines for
• Pregnancy: 1 dose Tdap during each pregnancy, diagnosis or verification of history of varicella or varicella vaccination first. RZV is not indicated for the
preferably in early part of gestational weeks 27–36 herpes zoster by a health care provider, laboratory prevention of varicella, and there are limited data on
• Wound management: Persons with 3 or more doses evidence of immunity or disease the use of RZV in persons without a history of
of tetanus-toxoid-containing vaccine: For clean and Special situations varicella or varicella vaccination.
minor wounds, administer Tdap or Td if more than Special situations
• Pregnancy with no evidence of immunity to
10 years since last dose of tetanus-toxoid-containing
varicella: VAR contraindicated during pregnancy; • Pregnancy: There is currently no ACIP
vaccine; for all other wounds, administer Tdap or Td if
Recommended Adult Immunization Schedule, United States, 2023

after pregnancy (before discharge from health care recommendation for RZV use in pregnancy.
more than 5 years since last dose of tetanus-toxoid-
facility), 1 dose if previously received 1 dose varicella- Consider delaying RZV until after pregnancy.
containing vaccine. Tdap is preferred for persons who
containing vaccine or dose 1 of 2-dose series
have not previously received Tdap or whose Tdap • Immunocompromising conditions (including
(dose 2: 4–8 weeks later) if previously did not receive
history is unknown. If a tetanus-toxoid-containing persons with HIV regardless of CD4 count)**:
any varicella-containing vaccine, regardless of
vaccine is indicated for a pregnant woman, use Tdap. 2-dose series recombinant zoster vaccine
whether U.S.-born before 1980
For detailed information, see www.cdc.gov/mmwr/ (RZV, Shingrix) 2–6 months apart (minimum interval:
volumes/69/wr/mm6903a5.htm • Health care personnel with no evidence of 4 weeks; repeat dose if administered too soon).
immunity to varicella: 1 dose if previously received For detailed information, see www.cdc.gov/shingles/
1 dose varicella-containing vaccine; 2-dose series vaccination/immunocompromised-adults.html

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4–8 weeks apart if previously did not receive any
**Note: If there is no documented history of varicella,
varicella-containing vaccine, regardless of whether
varicella vaccination, or herpes zoster, providers should
U.S.-born before 1980
refer to the clinical considerations

Annals of Internal Medicine

• HIV infection with CD4 percentages ≥15% and for use of RZV in immunocompromised adults aged
CD4 count ≥200 cells/mm3 with no evidence of ≥19 years and the ACIP varicella vaccine
immunity: Vaccination may be considered recommendations for further guidance: www.cdc.gov/
(2 doses 3 months apart); VAR contraindicated for HIV mmwr/volumes/71/wr/mm7103a2.htm
infection with CD4 percentage <15% or
CD4 count <200 cells/mm3
• Severe immunocompromising conditions:
VAR contraindicated

2/17/2023 Centers for Disease Control and Prevention | Recommended Adult Immunization Schedule, United States, 2023

9
CLINICAL GUIDELINE
 Figure–Continued.

Appendix Recommended Adult Immunization Schedule, United States, 2023

Guide to Contraindications and Precautions to Commonly Used Vaccines
Adapted from Table 4-1 in Advisory Committee on Immunization Practices (ACIP) General Best Practice Guidelines for Immunization: Contraindication and Precautions available at www.cdc.
gov/vaccines/hcp/acip-recs/general-recs/contraindications.html and ACIP’s Recommendations for the Prevention and Control of 2022-23 Seasonal Influenza with Vaccines available at
www.cdc.gov/mmwr/volumes/71/rr/rr7101a1.htm

10 Annals of Internal Medicine

For COVID-19 vaccine contraindications and precautions see
www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#contraindications
CLINICAL GUIDELINE

Vaccine Contraindicated or Not Recommended1 Precautions2

Influenza, egg-based, • Severe allergic reaction (e.g., anaphylaxis) after previous dose of any influenza vaccine • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
inactivated injectable (IIV4) (i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency) influenza vaccine
• Severe allergic reaction (e.g., anaphylaxis) to any vaccine component3 (excluding egg) • Moderate or severe acute illness with or without fever

Influenza, cell culture-based • Severe allergic reaction (e.g., anaphylaxis) to any ccIIV of any valency, or to any • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
inactivated injectable component3 of ccIIV4 influenza vaccine
[(ccIIV4), Flucelvax® • Persons with a history of severe allergic reaction (e.g., anaphylaxis) after a previous
Quadrivalent] dose of any egg-based IIV, RIV, or LAIV of any valency. If using ccIV4, administer in
medical setting under supervision of health care provider who can recognize and
manage severe allergic reactions. May consult an allergist.
• Moderate or severe acute illness with or without fever

Influenza, recombinant • Severe allergic reaction (e.g., anaphylaxis) to any RIV of any valency, or to any component3 • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
injectable [(RIV4), Flublok® of RIV4 influenza vaccine
Quadrivalent] • Persons with a history of severe allergic reaction (e.g., anaphylaxis) after a previous
dose of any egg-based IIV, ccIIV, or LAIV of any valency. If using RIV4, administer in
medical setting under supervision of health care provider who can recognize and
manage severe allergic reactions. May consult an allergist.
• Moderate or severe acute illness with or without fever

Influenza, live attenuated • Severe allergic reaction (e.g., anaphylaxis) after previous dose of any influenza vaccine • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
[LAIV4, Flumist® (i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency) influenza vaccine
Quadrivalent] • Severe allergic reaction (e.g., anaphylaxis) to any vaccine component3 (excluding egg) • Asthma in persons aged 5 years old or older
• Anatomic or functional asplenia • Persons with underlying medical conditions (other than those listed under
• Immunocompromised due to any cause including, but not limited to, medications and contraindications) that might predispose to complications after wild-type influenza

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HIV infection virus infection [e.g., chronic pulmonary, cardiovascular (except isolated hypertension),
• Close contacts or caregivers of severely immunosuppressed persons who require a renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes
protected environment mellitus)]
• Pregnancy • Moderate or severe acute illness with or without fever
• Cochlear implant
• Active communication between the cerebrospinal fluid (CSF) and the oropharynx,
nasopharynx, nose, ear, or any other cranial CSF leak
• Received influenza antiviral medications oseltamivir or zanamivir within the previous
48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days.

1. When a contraindication is present, a vaccine should NOT be administered. Kroger A, Bahta L, Hunter P. ACIP General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/
contraindications.html
2. When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction. Kroger A, Bahta L, Hunter P. ACIP
General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html
3. Vaccination providers should check FDA-approved prescribing information for the most complete and updated information, including contraindications, warnings, and precautions. Package inserts for U.S.-licensed
vaccines are available at www.fda.gov/vaccines-blood-biologics/approved-products/vaccines-licensed-use-united-states.

Annals.org
Recommended Adult Immunization Schedule, United States, 2023
 Figure–Continued.

Annals.org
Appendix Recommended Adult Immunization Schedule, United States, 2023
Vaccine Contraindicated or Not Recommended1 Precautions2
Haemophilus influenzae type b • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
(Hib) • For Hiberix, ActHib, and PedvaxHIB only: History of severe allergic reaction to dry natural latex
Hepatitis A (HepA) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 including • Moderate or severe acute illness with or without fever
neomycin
Hepatitis B (HepB) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 including yeast • Moderate or severe acute illness with or without fever
• Pregnancy: Heplisav-B and PreHevbrio are not recommended due to lack of safety data in pregnant persons.
Use other hepatitis B vaccines if HepB is indicated4
Hepatitis A- Hepatitis B vaccine • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 including • Moderate or severe acute illness with or without fever
[HepA-HepB, (Twinrix®)] neomycin and yeast
3
Human papillomavirus (HPV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component • Moderate or severe acute illness with or without fever
• Pregnancy: HPV vaccination not recommended
Measles, mumps, rubella (MMR) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on
• Severe immunodeficiency (e.g., hematologic and solid tumors, receipt of chemotherapy, congenital product)
immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are • History of thrombocytopenia or thrombocytopenic purpura
severely immunocompromised) • Need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing
• Pregnancy • Moderate or severe acute illness with or without fever
• Family history of altered immunocompetence, unless verified clinically or by laboratory testing as
immunocompetent
Meningococcal ACWY (MenACWY) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
[MenACWY-CRM (Menveo®); • For MenACWY-D and MenACWY-CRM only: severe allergic reaction to any diphtheria toxoid–or
MenACWY-D (Menactra®); CRM197–containing vaccine
MenACWY-TT (MenQuadfi®)] • For MenACWY-TT only: severe allergic reaction to a tetanus toxoid-containing vaccine
Meningococcal B (MenB) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Pregnancy
[MenB-4C (Bexsero); MenB-FHbp • For MenB-4C only: Latex sensitivity
(Trumenba)] • Moderate or severe acute illness with or without fever
Recommended Adult Immunization Schedule, United States, 2023

Pneumococcal conjugate • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
(PCV15, PCV20) • Severe allergic reaction (e.g., anaphylaxis) to any diphtheria-toxoid–containing vaccine or to its vaccine
component3
Pneumococcal polysaccharide • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
(PPSV23)
3
Tetanus, diphtheria, and acellular • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus-toxoid–containing
pertussis (Tdap) • For Tdap only: Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures), not vaccine
Tetanus, diphtheria (Td) attributable to another identifiable cause, within 7 days of administration of previous dose of DTP, • History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid–
DTaP, or Tdap containing or tetanus-toxoid–containing vaccine; defer vaccination until at least 10 years have
elapsed since the last tetanus-toxoid–containing vaccine
• Moderate or severe acute illness with or without fever
• For Tdap only: Progressive or unstable neurological disorder, uncontrolled seizures, or progressive
encephalopathy until a treatment regimen has been established and the condition has stabilized

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Varicella (VAR) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on
• Severe immunodeficiency (e.g., hematologic and solid tumors, receipt of chemotherapy, congenital product)
immunodeficiency, long-term immunosuppressive therapy or patients with HIV infection who are • Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before
severely immunocompromised) vaccination (avoid use of these antiviral drugs for 14 days after vaccination)

Annals of Internal Medicine

• Pregnancy • Use of aspirin or aspirin-containing products
• Family history of altered immunocompetence, unless verified clinically or by laboratory testing as • Moderate or severe acute illness with or without fever
immunocompetent
Zoster recombinant vaccine (RZV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
• Current herpes zoster infection

1. When a contraindication is present, a vaccine should NOT be administered. Kroger A, Bahta L, Hunter P. ACIP General Best Practice Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html
2. When a precaution is present, vaccination should generally be deferred but might be indicated if the benefit of protection from the vaccine outweighs the risk for an adverse reaction. Kroger A, Bahta L, Hunter P. ACIP General Best Practice
Guidelines for Immunization. www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html
3. Vaccination providers should check FDA-approved prescribing information for the most complete and updated information, including contraindications, warnings, and precautions. Package inserts for U.S.-licensed vaccines are available at
www.fda.gov/vaccines-blood-biologics/approved-products/vaccines-licensed-use-united-states.
4. For information on the pregnancy exposure registries for persons who were inadvertently vaccinated with Heplisav-B or PreHevbrio while pregnant, please visit heplisavbpregnancyregistry.com/ or www.prehevbrio.com/#safety.
CLINICAL GUIDELINE

11
CLINICAL GUIDELINE Recommended Adult Immunization Schedule, United States, 2023

B/Victoria lineage components. All seasonal influenza prior varicella is not necessary for zoster vaccination and to
vaccines expected to be available for the 2022–2023 provide guidance if serologic evidence of varicella suscepti-
season are quadrivalent, containing hemagglutinin (HA) bility becomes available. The “Special situations” section was
derived from one influenza A(H1N1)pdm09 virus, one updated to provide guidance for persons with immunocom-
influenza A(H3N2) virus, one influenza B/Victoria lineage promising conditions who do not have a documented his-
virus, and one influenza B/Yamagata lineage virus. For tory of varicella, varicella vaccination, or herpes zoster.
the 2022–2023 season, U.S. egg-based influenza vac- Additionally, minor changes were made to the immunocom-
cines (i.e., vaccines other than cell culture–based inacti- promising conditions bullet to clarify that this includes per-
vated influenza vaccine [ccIIV4] and recombinant sons with HIV regardless of CD4 count.
influenza vaccine [RIV4]) will contain HA derived from an
influenza A/Victoria/2570/2019 (H1N1)pdm09–like vi-
rus, an influenza A/Darwin/9/2021 (H3N2)–like virus, an REVISED CONTENT, FORMAT, AND GRAPHICS
influenza B/Austria/1359417/2021 (Victoria lineage)-like Cover Page. The cover page of the 2023 schedule
virus, and an influenza B/Phuket/3073/2013 (Yamagata provides basic instructions on how to use the schedule
lineage)–like virus. U.S. ccIIV4 and RIV4 influenza vac- to systematically identify vaccination needs of adults and
cines will contain an influenza A/Wisconsin/588/2019 lists routinely recommended vaccines and their standar-
(H1N1)pdm09–like virus, an influenza A/Darwin/6/2021 dized abbreviations and trade names. Major edits to the
(H3N2)–like virus, an influenza B/Austria/1359417/2021 cover page include adding COVID-19 vaccines, PreHevbrio,
(Victoria lineage)–like virus, and an influenza B/Phuket/ and Priorix to the list of vaccines. Of note, ACIP has devel-
3073/2013 (Yamagata lineage)–like virus. oped new abbreviations for the COVID-19 vaccine prod-
Vaccination guidance for close contacts of severely
ucts; these abbreviations contain information on the
immunocompromised patients who require a protected
vaccine's valency (i.e., monovalent vs. bivalent, indicated
environment was added as a bullet in the notes section.
In addition, the text describing guidance for persons by “1v” and “2v,” respectively) and vaccine platform (mRNA
with egg allergy who have experienced any symptom vs. acellular protein subunit, or “aPS”). Additionally, the
other than hives was moved from the appendix to the American Pharmacists Association has been added to
“Special situations” section of the Influenza notes. the list of partner organizations approving the schedule.
Measles, mumps, and rubella (MMR) vaccination (5). The language in the injury claims section has been
Routine recommendations for MMR vaccination have not modified to indicate which vaccines are covered by the
changed. However, a hyperlink was provided that describes National Vaccine Injury Compensation Program and which
the recommendation for additional doses of MMR vaccine vaccines are covered by the Countermeasures Injury
(including the third dose of MMR) in the context of mumps Compensation Program. Like in past annual immuniza-
outbreak settings. tion schedules, hyperlinks are provided where providers
Meningococcal vaccination (6). Routine recommen- can download the CDC Vaccine Schedules app and
dations for meningococcal vaccination have not changed. access reference materials for the surveillance of VPDs,
However, in the “Special situations” section for MenB, guid- including case identification and disease outbreak response.
ance was added stating that if the third dose of Trumenba
Instructions on reporting suspected cases of reportable
is administered earlier than 4 months after the second dose, a
VPDs to local or state health departments and significant
fourth dose should be administered at least 4 months after
postvaccination adverse events to the Vaccine Adverse
the third dose.
Pneumococcal vaccination (7). ACIP has new recom- Event Reporting System are listed. Hyperlinks to other
mendations for the use of PCV15 and PCV20 in persons resources, such as vaccine information statements, rec-
who previously received pneumococcal vaccines. This ommended vaccines for travelers, and shared clinical de-
new guidance is presented in the revised pneumococcal cision-making guidance are also provided.
notes section. Additionally, a hyperlink to the CDC app Table 1. Recommended Adult Immunization Schedule
that can be used to determine a patient's pneumococcal by Age Group. Table 1 describes routine and catch-up vac-
vaccination needs has been included. cination recommendations for adults by age. For 2023, a
Polio vaccination (8). Routine poliovirus vaccination COVID-19 row has been added. The row is entirely yellow
of adults residing in the United States is not necessary. indicating that COVID-19 vaccination is now routinely rec-
However, a new polio vaccination section was added to ommended for all adults, with a text overlay that states “2-
the Notes to address polio vaccine recommendations for or 3- dose primary series and booster (See Notes).” For
adults who are at increased risk for exposure to poliovirus. MMR vaccination in Table 1, overlaying text has been
Tetanus toxoid, reduced diphtheria toxoid, and acellu- added for adults aged 65 years and older, referring pro-
lar pertussis (Tdap) vaccination. Routine recommendations viders to the Notes section for vaccination considerations
for Tdap or Td vaccination have not changed. However, for health care personnel who are 65 years of age or older.
minor grammatical edits were made to the “Special situa- For HepA vaccination in Table 1, the overlaying text now
tions” section to help improve clarity in the language. states “2, 3, or 4 doses depending on vaccine” to account
Varicella vaccination (9). Routine recommendations for the possibility of an accelerated Twinrix series requiring
for varicella vaccination have not changed. 4 doses.
Zoster vaccination (10). The “Routine vaccination” Table 2. Recommended Adult Immunization Schedule
section was revised to clarify that serologic evidence of by Medical Condition and Other Indications. Table 2
12 Annals of Internal Medicine Annals.org

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Recommended Adult Immunization Schedule, United States, 2023 CLINICAL GUIDELINE
describes vaccination recommendations for adults based was modified. The language now states “pregnancy: HPV
on medical conditions or other indications. For 2023, a vaccination not recommended.”
COVID-19 row has been added to this table. The HIV and
From Centers for Disease Control and Prevention, Atlanta,
immunocompromised conditions columns have the over-
Georgia (N.M., A.P.W.); The Warren Alpert Medical School of
laying text “See Notes,” since such patients may have
Brown University, Providence, Rhode Island (S.C.); and University
different primary series requirements and may have
of Kansas Medical Center, Kansas City, Kansas (K.A.A.).
additional considerations for preexposure prophylaxis
to complement COVID-19 vaccination. Additionally, for
Disclosures: To maintain the integrity of the Advisory Committee
the HepA row, the overlaying text now states “2, 3, or 4
on Immunization Practices (ACIP), the U.S. Department of Health
doses depending on vaccine” to include the 4-dose
and Human Services has taken steps to ensure there is technical
accelerated Twinrix schedule that can be used for HepA
adherence to ethics statutes and regulations regarding financial
vaccination.
conflicts of interest. Concerns regarding the potential for the
Notes. Recommended Adult Immunization Schedule.
appearance of a conflict are addressed or avoided altogether
Each recommended vaccine for adults in Tables 1 and 2
through preappointment and postappointment considerations.
is accompanied by a note, which is designed to provide
Individuals with particular vaccine-related interests will not be con-
additional information on routine vaccination and recom-
sidered for appointment to the committee. Potential nominees are
mendations in special situations. The COVID-19 note is a screened for conflicts of interest and, if any are found, are asked to
new addition to the 2023 adult immunization schedule. divest or forgo certain vaccine-related activities. In addition, at the
Guidance on COVID-19 primary series recommenda- beginning of each ACIP meeting, each member is asked to
tions is provided in addition to other information that declare their conflicts. Members with conflicts are not permitted to
providers may find helpful regarding COVID-19 vaccina- vote if the conflict involves the vaccine or biologic being voted on.
tion. Additionally, a new polio vaccination note was Details can be found at www.cdc.gov/vaccines/acip/committee/
added describing vaccine recommendations for adults index.html. Dr. Murthy has nothing to disclose. Dr. Wodi has
who are at increased risk for exposure to poliovirus. New nothing to disclose. Dr. Cineas has nothing to disclose. Dr. Ault
or revised language for influenza and pneumococcal vac- reports having received consulting fees from PathoVax, serving as
cines has been added to their respective notes. Changes a volunteer on the medical advisory board of Family Fighting Flu,
were also made to the hepatitis B vaccine, MMR vaccine, and serving as a committee member of the American College of
meningococcal vaccine, Tdap vaccine, and zoster vaccine Obstetricians and Gynecologists. Disclosures can also be viewed
notes to improve clarity in the language. All vaccines at. www.acponline.org/authors/icmje/ConflictOfInterestForms.
identified in Tables 1 and 2 (except PCV20 and RZV vac- do?msNum=M23-0041.
cines) also appear in the Recommended Child and
Adolescent Immunization Schedule for Ages 18 Years Corresponding Author: Neil Murthy, MD, MPH, MSJ, Immunization
or Younger, United States, 2023 (www.cdc.gov/ Services Division, National Center for Immunization and Respiratory
vaccines/schedules/hcp/imz/child-adolescent.html). Diseases, Centers for Disease Control and Prevention, 1600 Clifton
The notes for vaccines that appear in both the adult immu- Road NE, Atlanta, GA 30329-4027; e-mail, nmurthy@cdc.gov.
nization schedule and the child and adolescent immuniza-
tion schedule have been harmonized to the greatest extent Author contributions are available at Annals.org.
possible.
Appendix. Recommended Adult Immunization Schedule. Ann Intern Med. doi:10.7326/M23-0041
The appendix lists all of the contraindications and precautions
to each of the vaccines listed in the 2023 adult immuni- References
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dix is adapted from the 2022–2023 influenza vaccine Advisory Committee on Immunization Practices. 28 March 2022.
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Practice Guidelines for Immunization (11). The header of on 11 January 2023.
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14 Annals of Internal Medicine Annals.org

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Author Contributions: Conception and design: K.A. Ault, N.C. Perinatal Medicine and Pediatric Infectious Diseases,
Murthy, A.P. Wodi. Center for Perinatal Research, The Research Institute at
Analysis and interpretation of the data: K.A. Ault, A.P. Wodi. Nationwide Children's Hospital, Columbus, Ohio
Drafting of the article: N.C. Murthy. Nirav D. Shah, MD, JD, Maine Center for Disease
Critical revision for important intellectual content: K.A. Ault, Control and Prevention, Augusta, Maine
S. Cineas, N.C. Murthy, A.P. Wodi. Helen Keipp Talbot, MD, Vanderbilt University,
Final approval of the article: K.A. Ault, S. Cineas, N.C. Murthy, Nashville, Tennessee
A.P. Wodi.
Collection and assembly of data: K.A. Ault, A.P. Wodi. ACIP Combined Immunization Work Group
ACIP Members
Sybil Cineas (ACIP Work Group Chair)*
APPENDIX A: MEMBERS OF THE ACIP AND THE Kevin Ault*
ACIP COMBINED IMMUNIZATION WORK GROUP Veronica McNally
Unless otherwise indicated, the members listed
were nonauthor contributors to this article. Liaison Representatives
John Epling
Members of the ACIP Sarah Coles
Grace M. Lee, MD, MPH (Chair), Lucile Packard Children's Katherine Debiec
Hospital, Stanford University School of Medicine, Stanford, Rhoda Sperling
California Holly Fontenot
Melinda Wharton, MD, MPH (Executive Secretary), Amy Middleman
National Center for Immunization and Respiratory Diseases, Sandra Fryhofer
Centers for Disease Control and Prevention, Atlanta, Georgia Sarah McQueen
Lynn Bahta, RN, MPH, CPH, Infectious Disease, Epi- Marie-Michele Leger
demiology, Prevention & Control Division, Minnesota Mary-Margaret Fill
Department of Health, Saint Paul, Minnesota Chad Rittle
Beth P. Bell, MD, MPH, Department of Global Health, William Schafner
School of Public Health, University of Washington, Seattle, Ken Schmader
Washington Patsy Stinchfield
Oliver Brooks, MD, Watts HealthCare Corporation, Marci Drees
Los Angeles, California Pia Pannaraj
Wilbur H. Chen, MD, MS, Center for Vaccine Deve-
lopment and Global Health, University of Maryland Ex Officio Members
School of Medicine, Baltimore, Maryland David Kim
Sybil Cineas, MD, The Warren Alpert Medical School of Jane Kim
Brown University, Brown Combined Residency in Internal Susan Farrall
Medicine and Pediatrics, Providence, Rhode Island* Uzo Chukwuma
Matthew F. Daley, MD, Institute for Health Research,
Consultants
Kaiser Permanente Colorado, Aurora, Colorado
Hank Bernstein
Camille Nelson Kotton, MD, Infectious Diseases
Paul Hunter
Division, Massachusetts General Hospital, Harvard
Peter Szilagyi
Medical School, Boston, Massachusetts
Diane Peterson
Jamie Loehr, MD, Cayuga Family Medicine, Ithaca,
Carolyn Bridges
New York
Karen Ketner
Sarah S. Long, MD, Drexel University College of
Kathleen Harriman
Medicine, Section of Infectious Diseases, St. Christopher's
Litjen Tan
Hospital for Children, Philadelphia, Pennsylvania
Robert Hopkins
Veronica V. McNally, JD, Franny Strong Foundation,
Susan Lett
West Bloomfield, Michigan
Katherine A. Poehling, MD, MPH, Department of
CDC Co-Leads
Pediatrics, Wake Forest School of Medicine, Winston-
A. Patricia Wodi*
Salem, North Carolina
Neil Murthy*
Pablo J. Sánchez, MD, The Ohio State University,
Nationwide Children's Hospital, Divisions of Neonatal- * Authored the article.

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