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,
United States, 2023. The 2023 adult immunization sched-
ule, available at www.cdc.gov/vaccines/schedules/hcp/
imz/adult.html, summarizes ACIP recommendations in
the cover page, tables, notes, and appendix (Figure). The
full ACIP recommendations for each vaccine are available
at www.cdc.gov/vaccines/hcp/acip-recs/index.html. The
2023 schedule has also been approved by the director of
the Centers for Disease Control and Prevention (CDC)
and by the American College of Physicians (www.acponline.
org), the American Academy of Family Physicians (www.
aafp.org), the American College of Obstetricians and
Gynecologists (www.acog.org), the American College of
Nurse-Midwives (www.midwife.org), the American Academy
of Physician Associates (www.aapa.org), the American
Pharmacists Association (www.pharmacist.com), and the
Society for Healthcare Epidemiology of America (www.
shea-online.org).
The ACIP develops recommendations on the use of
each vaccine after in-depth review of vaccine-related data,
such as the epidemiology and burden of the vaccine-
preventable disease (VPD), vaccine efficacy and effective-
ness, vaccine safety, quality of evidence, feasibility of pro-
gram implementation, and economic analyses of immu-
nization policy (1). ACIP recommendations can be complex
and challenging to implement. The purpose of the immuni-
zation schedule, published annually, is to consolidate and
summarize updates to ACIP recommendations on vaccina-
tion of adults and to assist providers in implementing cur-
rent ACIP recommendations. The use of vaccine trade
names in this article and in the schedule is for identification
purposes only and does not imply endorsement by the
ACIP or CDC.
CHANGES TO THE 2023 ADULT IMMUNIZATION
SCHEDULE
COVID-19 vaccination. A new section was added to
the Notes section describing recommendations for
COVID-19 vaccines approved or authorized by the U.S.
Food and Drug Administration. A description of the pri-
mary series recommendations for the general population
is provided, followed by a description of the primary series
recommendations for persons who are moderately or
severely immunocompromised. Hyperlinks referring health
care providers to booster dose recommendations and to
the recommendation for persons who previously received
Janssen COVID-19 vaccine are also provided. Additionally,
hyperlinks to the current COVID-19 vaccination schedules,
use of COVID-19 preexposure prophylaxis in persons who
are moderately or severely immunocompromised, as well
as Emergency Use Authorization indications for COVID-19
vaccines, are provided.
Haemophilus influenzae type b (Hib) vaccination. Vaccine
recommendations for Hib vaccination have not changed.
Hepatitis A (HepA) vaccination. Vaccine recommen-
dations for HepA vaccination have not changed.
Hepatitis B (HepB) vaccination (2). A newly licensed
HepB vaccine, PreHevbrio, was added to the description
of the 3-dose series. HepB vaccination continues to be uni-
versally recommended for all adults 19 through 59 years of
age. Language was added stating that persons aged
60 years and older with known risk factors for hepatitis B virus
infection should complete a HepB vaccine series, while per-
sons 60 years of age and older without known risk factors
for hepatitis B virus infection may complete a HepB vaccine
series. The “Special situations” section provides dosing reg-
imens for patients on dialysis.
Human papillomavirus (HPV) vaccination (3). Routine
recommendations for HPV vaccination have not changed.
Influenza vaccination (4). Updates to the seasonal
influenza vaccine recommendations reflect discussions
during public meetings of ACIP held on 20 October
2021, 12 January 2022, 23 February 2022, and 22 June
2022. For the 2022–2023 influenza season, routine annual
influenza vaccination is recommended for all persons aged
6 months and older who do not have contraindications.
Among persons who are 65 years of age and older, any
one of the quadrivalent high-dose inactivated influenza
vaccine, quadrivalent recombinant influenza vaccine, or
quadrivalent adjuvanted inactivated influenza vaccine is
preferred compared with other influenza vaccine products.
However, if none of these 3 vaccines is available, then any
other age-appropriate influenza vaccine should be used.
This information has been provided as a bullet in the influ-
enza notes section, along with a hyperlink to the 2022–
2023 influenza recommendations.
The composition of 2022–2023 U.S. influenza vaccines
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
for adults who meet age
requirement, lack
documentation of
vaccination, or lack
evidence of past infection
Recommended vaccination
for adults with an additional
risk factor or another
indication
Recommended vaccination
based on shared clinical
decision-making
Precaution–vaccination
might be indicated if
benefit of protection
outweighs risk of adverse
reaction
Contraindicated or not No recommendation/
recommended–vaccine Not applicable
should not be administered.
*Vaccinate after pregnancy.

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
of age or younger, see the Recommended Child and
Adolescent Immunization Schedule.
COVID-19 vaccination
Routine vaccination
• Primary series: 2-dose series at 0, 4-8 weeks
(Moderna) or 2-dose series at 0, 3-8 weeks
(Novavax, Pfizer-BioNTech)
• Booster dose: see www.cdc.gov/vaccines/covid-19/
clinical-considerations/interim-considerations-us.html
Special situations
Persons who are moderately or severely
immunocompromised
• Primary series
- 3-dose series at 0, 4, 8 weeks (Moderna) or
3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech)
- 2-dose series at 0, 3 weeks (Novavax)
• Booster dose: see www.cdc.gov/vaccines/covid-19/
clinical-considerations/interim-considerations-us.html
• Pre-exposure prophylaxis (e.g., monoclonal
antibodies) may be considered to complement
COVID-19 vaccination. See www.cdc.gov/
vaccines/covid-19/clinical-considerations/interim-
considerations-us.html#immunocompromised
For Janssen COVID-19 Vaccine recipients see
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COVID-19 schedule at www.cdc.gov/vaccines/covid-19/
clinical-considerations/interim-considerations-us.html.
Note: Current COVID-19 schedule available at www.
Annals of Internal Medicine
cdc.gov/vaccines/covid-19/downloads/COVID-19-
immunization-schedule-ages-6months-older.pdf.
For more information on Emergency Use Authorization
(EUA) indications for COVID-19 vaccines, please visit
www.fda.gov/emergency-preparedness-and-response/
coronavirus-disease-2019-covid-19/covid-19-vaccines
5
Haemophilus influenzae type b vaccination
Special situations
• Anatomical or functional asplenia (including sickle
cell disease): 1 dose if previously did not receive Hib;
if elective splenectomy, 1 dose preferably at least
14 days before splenectomy
• Hematopoietic stem cell transplant (HSCT):
3-dose series 4 weeks apart starting 6–12 months
after successful transplant, regardless of
Hib vaccination history
Hepatitis A vaccination
Routine vaccination
• Not at risk but want protection from hepatitis A
(identification of risk factor not required):
2-dose series HepA (Havrix 6–12 months apart or
Vaqta 6–18 months apart [minimum interval:
6 months]) or 3-dose series HepA-HepB (Twinrix at 0,
1, 6 months [minimum intervals: dose 1 to
dose 2: 4 weeks / dose 2 to dose 3: 5 months])
Special situations
• At risk for hepatitis A virus infection: 2-dose series
HepA or 3-dose series HepA-HepB as above
- Chronic liver disease (e.g., persons with
hepatitis B, hepatitis C, cirrhosis, fatty liver disease,
alcoholic liver disease, autoimmune hepatitis,
alanine aminotransferase [ALT] or aspartate
aminotransferase [AST] level greater than
twice the upper limit of normal)
- HIV infection
- Men who have sex with men
- Injection or noninjection drug use
- Persons experiencing homelessness
- Work with hepatitis A virus in research
laboratory or with nonhuman primates
with hepatitis A virus infection
- Travel in countries with high or intermediate
endemic hepatitis A (HepA-HepB [Twinrix] may
be administered on an accelerated schedule of
3 doses at 0, 7, and 21–30 days, followed by a
booster dose at 12 months)
- Close, personal contact with international
adoptee (e.g., household or regular babysitting) in
first 60 days after arrival from country with high or
intermediate endemic hepatitis A (administer dose
1 as soon as adoption is planned, at least 2 weeks
before adoptee’s arrival)
- Pregnancy if at risk for infection or severe outcome
from infection during pregnancy
- Settings for exposure, including health care settings
targeting services to injection or noninjection drug
users or group homes and nonresidential day care
facilities for developmentally disabled persons
(individual risk factor screening not required)
Hepatitis B vaccination
Recommended Adult Immunization Schedule, United States, 2023
Routine vaccination
• Age 19 through 59 years: complete a 2- or 3- or
4-dose series
- 2-dose series only applies when 2 doses of
Heplisav-B* are used at least 4 weeks apart
- 3-dose series Engerix-B, PreHevbrio*, or Recombivax
HB at 0, 1, 6 months [minimum intervals: dose 1 to
dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose 1
to dose 3: 16 weeks])
- 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months
[minimum intervals: dose 1 to dose 2:
4 weeks / dose 2 to dose 3: 5 months])
- 4-dose series HepA-HepB (Twinrix) accelerated
schedule of 3 doses at 0, 7, and 21–30 days, followed
by a booster dose at 12 months
*Note: Heplisav-B and PreHevbrio are not
recommended in pregnancy due to lack of safety data
in pregnant persons.
CLINICAL GUIDELINE
 Figure–Continued.
Notes Recommended Adult Immunization Schedule, United States, 2023
• Age 60 years or older with known risk factors for
hepatitis B virus infection should complete a
HepB vaccine series.
6 Annals of Internal Medicine
• Age 60 years or older without known risk factors
for hepatitis B virus infection may complete a
HepB vaccine series.
- Risk factors for hepatitis B virus infection include:
ƒ Chronic liver disease (e.g., persons with hepatitis
C, cirrhosis, fatty liver disease, alcoholic liver disease,
autoimmune hepatitis, alanine aminotransferase
[ALT] or aspartate aminotransferase [AST] level
greater than twice upper limit of normal)
ƒ HIV infection
ƒ Sexual exposure risk (e.g., sex partners of hepatitis
B surface antigen [HBsAg]-positive persons; sexually
active persons not in mutually monogamous
relationships; persons seeking evaluation or
treatment for a sexually transmitted infection;
men who have sex with men)
ƒ Current or recent injection drug use
ƒ Percutaneous or mucosal risk for exposure
to blood (e.g., household contacts of HBsAg-
positive persons; residents and staff of facilities for
developmentally disabled persons; health care and
public safety personnel with reasonably anticipated
risk for exposure to blood or blood-contaminated
body fluids; persons on maintenance dialysis,
including in-center or home hemodialysis and
peritoneal dialysis, and persons who are predialysis;
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patients with diabetes)
ƒ Incarceration
ƒ Travel in countries with high or intermediate
endemic hepatitis B
Special situations
• Patients on dialysis: complete a 3- or 4-dose series
- 3-dose series Recombivax HB at 0, 1, 6 months
(note: use Dialysis Formulation 1 mL = 40 mcg)
- 4-dose series Engerix-B at 0, 1, 2, and 6 months
(note: use 2 mL dose instead of the
normal adult dose of 1 mL)
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Human papillomavirus vaccination
Routine vaccination
• HPV vaccination recommended for all persons
through age 26 years: 2- or 3-dose series depending
on age at initial vaccination or condition:
- Age 15 years or older at initial vaccination:
3-dose series at 0, 1–2 months, 6 months (minimum
intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3:
12 weeks / dose 1 to dose 3: 5 months; repeat dose if
administered too soon)
- Age 9–14 years at initial vaccination and received
1 dose or 2 doses less than 5 months apart:
1 additional dose
- Age 9–14 years at initial vaccination and received
2 doses at least 5 months apart: HPV vaccination
series complete, no additional dose needed
• Interrupted schedules: If vaccination schedule is
interrupted, the series does not need to be restarted
• No additional dose recommended when any HPV
vaccine series has been completed using the
recommended dosing intervals.
Shared clinical decision-making
• Some adults age 27–45 years: Based on shared
clinical decision-making, 2- or 3-dose series as above
Special situations
• Age ranges recommended above for routine and
catch-up vaccination or shared clinical decision-
making also apply in special situations
- Immunocompromising conditions, including HIV
infection: 3-dose series, even for those who initiate
vaccination at age 9 through 14 years.
- Pregnancy: Pregnancy testing is not needed before
vaccination; HPV vaccination is not recommended
until after pregnancy; no intervention needed if
inadvertently vaccinated while pregnant
Influenza vaccination
Routine vaccination
• Age 19 years or older: 1 dose any influenza vaccine
appropriate for age and health status annually.
- Age 65 years or older: Any one of quadrivalent
CLINICAL GUIDELINE
high-dose inactivated influenza vaccine (HD-IIV4),
quadrivalent recombinant influenza vaccine (RIV4),
or quadrivalent adjuvanted inactivated influenza
vaccine (aIIV4) is preferred. If none of these three
vaccines is available, then any other age-appropriate
influenza vaccine should be used.
• For the 2022–2023 season, see www.cdc.gov/mmwr/
volumes/71/rr/rr7101a1.htm
• For the 2023–2024 season, see the 2023–2024 ACIP
influenza vaccine recommendations.
Special situations
• Egg allergy, hives only: any influenza vaccine
appropriate for age and health status annually
• Egg allergy–any symptom other than hives
(e.g., angioedema, respiratory distress or required
epinephrine or another emergency medical
intervention): Any influenza vaccine appropriate for
age and health status may be administered. If using
egg-based IIV4 or LAIV4, administer in medical setting
under supervision of health care provider who can
recognize and manage severe allergic reactions.
• Close contacts (e.g., caregivers, healthcare
workers) of severely immunosuppressed persons
who require a protected environment: these
persons should not receive LAIV4. If LAIV4
is given, they should avoid contact with/caring
for such immunosuppressed persons for
7 days after vaccination.
• Severe allergic reaction (e.g., anaphylaxis) to a
vaccine component or a previous dose of any
influenza vaccine: see Appendix listing
contraindications and precautions
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
after previous dose of influenza vaccine: Generally,
should not be vaccinated unless vaccination benefits
outweigh risks for those at higher risk for severe
complications from influenza
Measles, mumps, and rubella vaccination
Routine vaccination
• No evidence of immunity to measles, mumps, or
rubella: 1 dose
- Evidence of immunity: Born before 1957 (health
care personnel, see below), documentation of receipt
of MMR vaccine, laboratory evidence of immunity or
disease (diagnosis of disease without laboratory
confirmation is not evidence of immunity)
Special situations
• Pregnancy with no evidence of immunity to
rubella: MMR contraindicated during pregnancy;
after pregnancy (before discharge from
health care facility), 1 dose
• Nonpregnant persons of childbearing age with no
evidence of immunity to rubella: 1 dose
• HIV infection with CD4 percentages ≥15% and
CD4 count ≥200 cells/mm3 for at least 6 months
and no evidence of immunity to measles, mumps,
or rubella: 2-dose series at least 4 weeks apart; MMR
contraindicated for HIV infection with CD4 percentage
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<15% or CD4 count <200 cells/mm3
• Severe immunocompromising conditions:
MMR contraindicated
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• Students in postsecondary educational
institutions, international travelers, and
household or close, personal contacts of
immunocompromised persons with no evidence of
immunity to measles, mumps, or rubella:
2-dose series at least 4 weeks apart if previously did
not receive any doses of MMR or 1 dose if previously
eceived 1 dose MMR
7
• In mumps outbreak settings, for information about
additional doses of MMR (including 3rd dose of MMR),
see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7.
htm
• Health care personnel:
- Born before 1957 with no evidence of immunity
to measles, mumps, or rubella:
Consider 2-dose series at least 4 weeks apart for
protection against measles or mumps or 1 dose for
protection against rubella
- Born in 1957 or later with no evidence of
immunity to measles, mumps, or rubella:
2-dose series at least 4 weeks apart for protection
against measles or mumps or at least 1 dose for
protection against rubella
Meningococcal vaccination
Special situations for MenACWY
• Anatomical or functional asplenia (including sickle
cell disease), HIV infection, persistent complement
component deficiency, complement inhibitor
(e.g., eculizumab, ravulizumab) use: 2-dose series
MenACWY-D (Menactra, Menveo, or MenQuadfi)
at least 8 weeks apart and revaccinate every 5 years
if risk remains
• Travel in countries with hyperendemic or epidemic
meningococcal disease, or microbiologists
routinely exposed to Neisseria meningitidis: 1 dose
MenACWY (Menactra, Menveo, or MenQuadfi) and
revaccinate every 5 years if risk remains
• First-year college students who live in residential
housing (if not previously vaccinated at age
16 years or older) or military recruits: 1 dose
MenACWY (Menactra, Menveo, or MenQuadfi)
• For MenACWY booster dose recommendations for
groups listed under “Special situations” and in an
outbreak setting (e.g., in community or organizational
settings and among men who have sex with men) and
additional meningococcal vaccination information,
see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm
Shared clinical decision-making for MenB
• Adolescents and young adults age 16–23 years
(age 16–18 years preferred) not at increased risk
for meningococcal disease: Based on shared clinical
decision-making, 2-dose series MenB-4C (Bexsero)
at least 1 month apart or 2-dose series MenB-FHbp
(Trumenba) at 0, 6 months (if dose 2 was administered
less than 6 months after dose 1, administer dose 3
at least 4 months after dose 2); MenB-4C and
MenB-FHbp are not interchangeable (use same
product for all doses in series)
Special situations for MenB
• Anatomical or functional asplenia (including sickle
cell disease), persistent complement component
deficiency, complement inhibitor (e.g., eculizumab,
ravulizumab) use, or microbiologists routinely
exposed to Neisseria meningitidis:
2-dose primary series MenB-4C (Bexsero) at least
1 month apart or 3-dose primary series
Recommended Adult Immunization Schedule, United States, 2023
MenB-FHbp (Trumenba) at 0, 1–2, 6 months
(if dose 2 was administered at least 6 months after
dose 1, dose 3 not needed; if dose 3 is administered
earlier than 4 months after dose 2, a fourth dose
should be administered at least 4 months after dose 3);
MenB-4C and MenB-FHbp are not interchangeable
(use same product for all doses in series); 1 dose MenB
booster 1 year after primary series and revaccinate
every 2–3 years if risk remains
• Pregnancy: Delay MenB until after pregnancy unless
at increased risk and vaccination benefits outweigh
potential risks
• For MenB booster dose recommendations for groups
listed under “Special situations” and in an outbreak
setting (e.g., in community or organizational settings
and among men who have sex with men) and
additional meningococcal vaccination information,
see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm
Note: MenB vaccines may be administered
simultaneously with MenACWY vaccines if indicated,
but at a different anatomic site, if feasible.
CLINICAL GUIDELINE
 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
Routine vaccination
• Previously did not receive Tdap at or after age
11 years: 1 dose Tdap, then Td or Tdap every 10 years
Special situations
• Previously did not receive primary vaccination
series for tetanus, diphtheria, or pertussis: 1 dose
Tdap followed by 1 dose Td or Tdap at least 4 weeks
later, and a third dose of Td or Tdap 6–12 months later
(Tdap can be substituted for any Td dose, but preferred
as first dose), Td or Tdap every 10 years thereafter
• Pregnancy: 1 dose Tdap during each pregnancy,
preferably in early part of gestational weeks 27–36
• Wound management: Persons with 3 or more doses
of tetanus-toxoid-containing vaccine: For clean and
minor wounds, administer Tdap or Td if more than
10 years since last dose of tetanus-toxoid-containing
vaccine; for all other wounds, administer Tdap or Td if
more than 5 years since last dose of tetanus-toxoid-
containing vaccine. Tdap is preferred for persons who
have not previously received Tdap or whose Tdap
history is unknown. If a tetanus-toxoid-containing
vaccine is indicated for a pregnant woman, use Tdap.
For detailed information, see www.cdc.gov/mmwr/
volumes/69/wr/mm6903a5.htm
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Annals of Internal Medicine
2/17/2023
9
Varicella vaccination
Routine vaccination
• No evidence of immunity to varicella: 2-dose series
4–8 weeks apart if previously did not receive varicella-
containing vaccine (VAR or MMRV [measles-mumps-
rubella-varicella vaccine] for children); if previously
received 1 dose varicella-containing vaccine, 1 dose at
least 4 weeks after first dose
- Evidence of immunity: U.S.-born before 1980
(except for pregnant persons and health care
personnel [see below]), documentation of 2 doses
varicella-containing vaccine at least 4 weeks apart,
diagnosis or verification of history of varicella or
herpes zoster by a health care provider, laboratory
evidence of immunity or disease
Special situations
• Pregnancy with no evidence of immunity to
varicella: VAR contraindicated during pregnancy;
after pregnancy (before discharge from health care
facility), 1 dose if previously received 1 dose varicella-
containing vaccine or dose 1 of 2-dose series
(dose 2: 4–8 weeks later) if previously did not receive
any varicella-containing vaccine, regardless of
whether U.S.-born before 1980
• Health care personnel with no evidence of
immunity to varicella: 1 dose if previously received
1 dose varicella-containing vaccine; 2-dose series
4–8 weeks apart if previously did not receive any
varicella-containing vaccine, regardless of whether
U.S.-born before 1980
• HIV infection with CD4 percentages ≥15% and
CD4 count ≥200 cells/mm3 with no evidence of
immunity: Vaccination may be considered
(2 doses 3 months apart); VAR contraindicated for HIV
infection with CD4 percentage <15% or
CD4 count <200 cells/mm3
• Severe immunocompromising conditions:
VAR contraindicated
Centers for Disease Control and Prevention | Recommended Adult Immunization Schedule, United States, 2023
Zoster vaccination
Routine vaccination
• Age 50 years or older*: 2-dose series recombinant
zoster vaccine (RZV, Shingrix) 2–6 months apart
(minimum interval: 4 weeks; repeat dose if
administered too soon), regardless of previous
herpes zoster or history of zoster vaccine live
(ZVL, Zostavax) vaccination.
*Note: Serologic evidence of prior varicella is not
necessary for zoster vaccination. However, if
serologic evidence of varicella susceptibility becomes
available, providers should follow ACIP guidelines for
varicella vaccination first. RZV is not indicated for the
prevention of varicella, and there are limited data on
the use of RZV in persons without a history of
varicella or varicella vaccination.
Special situations
• Pregnancy: There is currently no ACIP
Recommended Adult Immunization Schedule, United States, 2023
recommendation for RZV use in pregnancy.
Consider delaying RZV until after pregnancy.
• Immunocompromising conditions (including
persons with HIV regardless of CD4 count)**:
2-dose series recombinant zoster vaccine
(RZV, Shingrix) 2–6 months apart (minimum interval:
4 weeks; repeat dose if administered too soon).
For detailed information, see www.cdc.gov/shingles/
vaccination/immunocompromised-adults.html
**Note: If there is no documented history of varicella,
varicella vaccination, or herpes zoster, providers should
refer to the clinical considerations
for use of RZV in immunocompromised adults aged
≥19 years and the ACIP varicella vaccine
recommendations for further guidance: www.cdc.gov/
mmwr/volumes/71/wr/mm7103a2.htm
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
inactivated injectable
[(ccIIV4), Flucelvax®
Quadrivalent]
• Severe allergic reaction (e.g., anaphylaxis) to any ccIIV of any valency, or to any
component3 of ccIIV4
• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
influenza vaccine
• Persons with a history of severe allergic reaction (e.g., anaphylaxis) after a previous
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
injectable [(RIV4), Flublok®
Quadrivalent]
• Severe allergic reaction (e.g., anaphylaxis) to any RIV of any valency, or to any component3
of RIV4
• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
influenza vaccine
• 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
[LAIV4, Flumist®
Quadrivalent]
• Severe allergic reaction (e.g., anaphylaxis) after previous dose of any influenza vaccine
(i.e., any egg-based IIV, ccIIV, RIV, or LAIV of any valency)
• Severe allergic reaction (e.g., anaphylaxis) to any vaccine component3 (excluding egg)
• Anatomic or functional asplenia
• Immunocompromised due to any cause including, but not limited to, medications and
• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
influenza vaccine
• Asthma in persons aged 5 years old or older
• Persons with underlying medical conditions (other than those listed under
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
(PCV15, PCV20)
Pneumococcal polysaccharide
(PPSV23)
Tetanus, diphtheria, and acellular
pertussis (Tdap)
Tetanus, diphtheria (Td)
• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3
• Severe allergic reaction (e.g., anaphylaxis) to any diphtheria-toxoid–containing vaccine or to its vaccine
component3
• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3
3
• Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
• For Tdap only: Encephalopathy (e.g., coma, decreased level of consciousness, prolonged seizures), not
attributable to another identifiable cause, within 7 days of administration of previous dose of DTP,
DTaP, or Tdap
• Moderate or severe acute illness with or without fever
• Moderate or severe acute illness with or without fever
• Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of tetanus-toxoid–containing
vaccine
• History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid–
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

Zoster recombinant vaccine (RZV)
• 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
• 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
B/Victoria lineage components. All seasonal influenza
vaccines expected to be available for the 2022–2023
season are quadrivalent, containing hemagglutinin (HA)
derived from one influenza A(H1N1)pdm09 virus, one
influenza A(H3N2) virus, one influenza B/Victoria lineage
virus, and one influenza B/Yamagata lineage virus. For
the 2022–2023 season, U.S. egg-based influenza vac-
cines (i.e., vaccines other than cell culture–based inacti-
vated influenza vaccine [ccIIV4] and recombinant
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
influenza B/Austria/1359417/2021 (Victoria lineage)-like
virus, and an influenza B/Phuket/3073/2013 (Yamagata
lineage)–like virus. U.S. ccIIV4 and RIV4 influenza vac-
cines will contain an influenza A/Wisconsin/588/2019
(H1N1)pdm09–like virus, an influenza A/Darwin/6/2021
(H3N2)–like virus, an influenza B/Austria/1359417/2021
(Victoria lineage)–like virus, and an influenza B/Phuket/
3073/2013 (Yamagata lineage)–like virus.
Vaccination guidance for close contacts of severely
immunocompromised patients who require a protected
environment was added as a bullet in the notes section.
In addition, the text describing guidance for persons
with egg allergy who have experienced any symptom
other than hives was moved from the appendix to the
“Special situations” section of the Influenza notes.
Measles, mumps, and rubella (MMR) vaccination (5).
Routine recommendations for MMR vaccination have not
changed. However, a hyperlink was provided that describes
the recommendation for additional doses of MMR vaccine
(including the third dose of MMR) in the context of mumps
outbreak settings.
Meningococcal vaccination (6). Routine recommen-
dations for meningococcal vaccination have not changed.
However, in the “Special situations” section for MenB, guid-
ance was added stating that if the third dose of Trumenba
is administered earlier than 4 months after the second dose, a
fourth dose should be administered at least 4 months after
the third dose.
Pneumococcal vaccination (7). ACIP has new recom-
mendations for the use of PCV15 and PCV20 in persons
who previously received pneumococcal vaccines. This
new guidance is presented in the revised pneumococcal
notes section. Additionally, a hyperlink to the CDC app
that can be used to determine a patient's pneumococcal
vaccination needs has been included.
Polio vaccination (8). Routine poliovirus vaccination
of adults residing in the United States is not necessary.
However, a new polio vaccination section was added to
the Notes to address polio vaccine recommendations for
adults who are at increased risk for exposure to poliovirus.
Tetanus toxoid, reduced diphtheria toxoid, and acellu-
lar pertussis (Tdap) vaccination. Routine recommendations
for Tdap or Td vaccination have not changed. However,
minor grammatical edits were made to the “Special situa-
tions” section to help improve clarity in the language.
Varicella vaccination (9). Routine recommendations
for varicella vaccination have not changed.
Zoster vaccination (10). The “Routine vaccination”
section was revised to clarify that serologic evidence of
12 Annals of Internal Medicine
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Recommended Adult Immunization Schedule, United States, 2023
prior varicella is not necessary for zoster vaccination and to
provide guidance if serologic evidence of varicella suscepti-
bility becomes available. The “Special situations” section was
updated to provide guidance for persons with immunocom-
promising conditions who do not have a documented his-
tory of varicella, varicella vaccination, or herpes zoster.
Additionally, minor changes were made to the immunocom-
promising conditions bullet to clarify that this includes per-
sons with HIV regardless of CD4 count.
REVISED CONTENT, FORMAT, AND GRAPHICS
Cover Page. The cover page of the 2023 schedule
provides basic instructions on how to use the schedule
to systematically identify vaccination needs of adults and
lists routinely recommended vaccines and their standar-
dized abbreviations and trade names. Major edits to the
cover page include adding COVID-19 vaccines, PreHevbrio,
and Priorix to the list of vaccines. Of note, ACIP has devel-
oped new abbreviations for the COVID-19 vaccine prod-
ucts; these abbreviations contain information on the
vaccine's valency (i.e., monovalent vs. bivalent, indicated
by “1v” and “2v,” respectively) and vaccine platform (mRNA
vs. acellular protein subunit, or “aPS”). Additionally, the
American Pharmacists Association has been added to
the list of partner organizations approving the schedule.
The language in the injury claims section has been
modified to indicate which vaccines are covered by the
National Vaccine Injury Compensation Program and which
vaccines are covered by the Countermeasures Injury
Compensation Program. Like in past annual immuniza-
tion schedules, hyperlinks are provided where providers
can download the CDC Vaccine Schedules app and
access reference materials for the surveillance of VPDs,
including case identification and disease outbreak response.
Instructions on reporting suspected cases of reportable
VPDs to local or state health departments and significant
postvaccination adverse events to the Vaccine Adverse
Event Reporting System are listed. Hyperlinks to other
resources, such as vaccine information statements, rec-
ommended vaccines for travelers, and shared clinical de-
cision-making guidance are also provided.
Table 1. Recommended Adult Immunization Schedule
by Age Group. Table 1 describes routine and catch-up vac-
cination recommendations for adults by age. For 2023, a
COVID-19 row has been added. The row is entirely yellow
indicating that COVID-19 vaccination is now routinely rec-
ommended for all adults, with a text overlay that states “2-
or 3- dose primary series and booster (See Notes).” For
MMR vaccination in Table 1, overlaying text has been
added for adults aged 65 years and older, referring pro-
viders to the Notes section for vaccination considerations
for health care personnel who are 65 years of age or older.
For HepA vaccination in Table 1, the overlaying text now
states “2, 3, or 4 doses depending on vaccine” to account
for the possibility of an accelerated Twinrix series requiring
4 doses.
Table 2. Recommended Adult Immunization Schedule
by Medical Condition and Other Indications. Table 2
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Recommended Adult Immunization Schedule, United States, 2023
describes vaccination recommendations for adults based
on medical conditions or other indications. For 2023, a
COVID-19 row has been added to this table. The HIV and
immunocompromised conditions columns have the over-
laying text “See Notes,” since such patients may have
different primary series requirements and may have
additional considerations for preexposure prophylaxis
to complement COVID-19 vaccination. Additionally, for
the HepA row, the overlaying text now states “2, 3, or 4
doses depending on vaccine” to include the 4-dose
accelerated Twinrix schedule that can be used for HepA
vaccination.
Notes. Recommended Adult Immunization Schedule.
Each recommended vaccine for adults in Tables 1 and 2
is accompanied by a note, which is designed to provide
additional information on routine vaccination and recom-
mendations in special situations. The COVID-19 note is a
new addition to the 2023 adult immunization schedule.
Guidance on COVID-19 primary series recommenda-
tions is provided in addition to other information that
providers may find helpful regarding COVID-19 vaccina-
tion. Additionally, a new polio vaccination note was
added describing vaccine recommendations for adults
who are at increased risk for exposure to poliovirus. New
or revised language for influenza and pneumococcal vac-
cines has been added to their respective notes. Changes
were also made to the hepatitis B vaccine, MMR vaccine,
meningococcal vaccine, Tdap vaccine, and zoster vaccine
notes to improve clarity in the language. All vaccines
identified in Tables 1 and 2 (except PCV20 and RZV vac-
cines) also appear in the Recommended Child and
Adolescent Immunization Schedule for Ages 18 Years
or Younger, United States, 2023 (www.cdc.gov/
vaccines/schedules/hcp/imz/child-adolescent.html).
The notes for vaccines that appear in both the adult immu-
nization schedule and the child and adolescent immuniza-
tion schedule have been harmonized to the greatest extent
possible.
Appendix. Recommended Adult Immunization Schedule.
The appendix lists all of the contraindications and precautions
to each of the vaccines listed in the 2023 adult immuni-
zation schedule. The information presented in this appen-
dix is adapted from the 2022–2023 influenza vaccine
recommendations (4) and from ACIP General Best
Practice Guidelines for Immunization (11). The header of
the “Contraindications” column was changed to “Contra-
indicated or not recommended.” In the influenza row, in-
formation for persons with history of egg allergy was
moved from the precautions column to the influenza vacci-
nation notes section. In the HepB row, language regarding
the use of Heplisav-B and PreHevbrio among pregnant
persons was modified. The language now states that
“Heplisav-B and PreHevbrio are not recommended due to
lack of safety data in pregnant persons. Use other hepatitis
B vaccines if HepB is indicated.” A footnote providing infor-
mation on the pregnancy exposure registries for persons
who were inadvertently vaccinated with Heplisav-B and
PreHevbrio while pregnant was added. In the HPV row, lan-
guage regarding the use of HPV among pregnant persons
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CLINICAL GUIDELINE
was modified. The language now states “pregnancy: HPV
vaccination not recommended.”
From Centers for Disease Control and Prevention, Atlanta,
Georgia (N.M., A.P.W.); The Warren Alpert Medical School of
Brown University, Providence, Rhode Island (S.C.); and University
of Kansas Medical Center, Kansas City, Kansas (K.A.A.).
Disclosures: To maintain the integrity of the Advisory Committee
on Immunization Practices (ACIP), the U.S. Department of Health
and Human Services has taken steps to ensure there is technical
adherence to ethics statutes and regulations regarding financial
conflicts of interest. Concerns regarding the potential for the
appearance of a conflict are addressed or avoided altogether
through preappointment and postappointment considerations.
Individuals with particular vaccine-related interests will not be con-
sidered for appointment to the committee. Potential nominees are
screened for conflicts of interest and, if any are found, are asked to
divest or forgo certain vaccine-related activities. In addition, at the
beginning of each ACIP meeting, each member is asked to
declare their conflicts. Members with conflicts are not permitted to
vote if the conflict involves the vaccine or biologic being voted on.
Details can be found at www.cdc.gov/vaccines/acip/committee/
index.html. Dr. Murthy has nothing to disclose. Dr. Wodi has
nothing to disclose. Dr. Cineas has nothing to disclose. Dr. Ault
reports having received consulting fees from PathoVax, serving as
a volunteer on the medical advisory board of Family Fighting Flu,
and serving as a committee member of the American College of
Obstetricians and Gynecologists. Disclosures can also be viewed
at. www.acponline.org/authors/icmje/ConflictOfInterestForms.
do?msNum=M23-0041.
Corresponding Author: Neil Murthy, MD, MPH, MSJ, Immunization
Services Division, National Center for Immunization and Respiratory
Diseases, Centers for Disease Control and Prevention, 1600 Clifton
Road NE, Atlanta, GA 30329-4027; e-mail, nmurthy@cdc.gov.
Author contributions are available at Annals.org.
Ann Intern Med. doi:10.7326/M23-0041
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Annals of Internal Medicine 13
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Annals.org
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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