Annals of Internal Medicine CLINICAL GUIDELINE

Recommended Adult Immunization Schedule, United States, 2022*

Neil Murthy, MD, MPH, MSJ; A. Patricia Wodi, MD, MPH; Henry Bernstein, DO, MHCM; and Kevin A. Ault, MD; for the
Advisory Committee on Immunization Practices†

I n November 2021, the Advisory Committee on Immunization

Practices (ACIP) voted to approve the Recommended Adult
Immunization Schedule for Ages 19 Years or Older, United
and vaccination of adults aged 60 years and older at risk
for hepatitis B virus (HBV) infection. Additionally, ACIP
recommends vaccination of adults aged 60 years and
States, 2022. The 2022 adult immunization schedule, available older requesting protection from HBV without the need
at www.cdc.gov/vaccines/schedules/hcp/imz/adult.html, sum- to acknowledge a specific risk factor. In the notes for
marizes ACIP recommendations in the cover page, tables, notes, hepatitis B vaccine, the 2-, 3-, and 4-dose series are
and appendix (Figure). The appendix lists the contraindications described in detail under the “Routine vaccination” sec-
and precautions for all routinely recommended vaccines on the tion, which now states that all adults aged 19 through
adult immunization schedule (Figure). The full ACIP recommen- 59 years are recommended to receive vaccination. The
dations for each vaccine are available at www.cdc.gov/vaccines/ “Special situations” section outlines the risk-based rec-
hcp/acip-recs/index.html. The 2022 schedule has also been ommendations for adults aged 60 years and older.
approved by the director of the Centers for Disease Control and Human papillomavirus (HPV) vaccination (3). Routine
Prevention (CDC) and by the American College of Physicians recommendations for HPV vaccination have not changed.
(www.acponline.org), the American Academy of Family A minor edit was made to increase clarity to now say, “No
Physicians (www.aafp.org), the American College of Obste- additional dose recommended when any HPV vaccine se-
tricians and Gynecologists (www.acog.org), the American ries has been completed using the recommended dosing
College of Nurse-Midwives (www.midwife.org), the intervals.” Additionally, minor wording changes were made in
American Academy of Physician Associates (www.aapa. the “Special situations” section, under the immunocomprom-
org), and the Society for Healthcare Epidemiology of
ising conditions subbullet, to now read “3-dose series, even
America (www.shea-online.org).
for those who initiate vaccination at age 9 through 14 years.”
The ACIP develops recommendations on the use of
each vaccine after in-depth review of vaccine-related data, The wording for the pregnancy subbullet was rearranged
such as the epidemiology and burden of the vaccine- to improve clarity.
preventable disease (VPD), vaccine efficacy and effec- Influenza vaccination (4). Updates to the seasonal
tiveness, vaccine safety, quality of evidence, feasibility of influenza vaccine recommendations reflect discussions
program implementation, and economic analyses of im- during public meetings of ACIP held on 28 October 2020,
munization policy (1). The ACIP recommendations can 25 February 2021, and 24 June 2021. For the 2021–2022
be complex and challenging to implement. The purpose influenza season, routine annual influenza vaccination is
of the immunization schedule, published annually, is to recommended for all persons aged 6 months and older
consolidate and summarize updates to ACIP recommen- who do not have contraindications. No preferential rec-
dations on vaccination of adults and to assist providers in ommendation is made for one influenza vaccine product
implementing current ACIP recommendations. The use over another in persons for whom more than one licensed
of vaccine trade names in this article and in the schedule and recommended product based on patient age and
is for identification purposes only and does not imply health status is available. The composition of the 2021–
endorsement by the ACIP or CDC. 2022 U.S. influenza vaccines includes updates to the influ-
enza A(H1N1)pdm09 and influenza A(H3N2) compo-
nents. All seasonal influenza vaccines expected to be
CHANGES TO THE 2022 ADULT IMMUNIZATION available for the 2021–2022 season are quadrivalent, con-
SCHEDULE taining hemagglutinin (HA) derived from one influenza
Haemophilus influenzae type b (Hib) vaccination. Routine A(H1N1)pdm09 virus, one influenza A(H3N2) virus, one
recommendations for Hib vaccination have not changed. influenza B/Victoria lineage virus, and one influenza
Hepatitis A (HepA) vaccination. Routine recommen- B/Yamagata lineage virus. For the 2021–2022 season, U.S.
dations for HepA vaccination have not changed. egg-based influenza vaccines (i.e., vaccines other than
Hepatitis B vaccination (2). ACIP recommends univer- cell-culture–based inactivated influenza vaccine [ccIIV4]
sal vaccination of all adults aged 19 through 59 years, and recombinant influenza vaccine [RIV4]) will contain

Ann Intern Med. doi:10.7326/M22-0036

This article was published at Annals.org on 18 February 2022.
* The 2022 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 2022 adult immunization schedule was published in the Morbidity and Mortality
Weekly Report on 18 February 2022. Readers can cite the 2022 adult immunization schedule as follows: Murthy N, Wodi AP, Bernstein H, Ault KA; Advisory
Committee on Immunization Practices. Recommended adult immunization schedule, United States, 2022. Ann Intern Med. Epub 18 Feb 2022. doi:10.7326/
M22-0036
† The 2022 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); A. Patricia Wodi (Centers for Disease Control and Prevention); Henry
Bernstein (Cohen Children's Medical Center, New Hyde Park, and Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York); and Kevin A. Ault
(University of Kansas Medical Center, Kansas City, Kansas). 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

 Figure. Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2022.

UNITED STATES
Recommended Adult Immunization Schedule
for ages 19 years or older 2022
Recommended by the Advisory Committee on Immunization Practices
How to use the adult immunization schedule (www.cdc.gov/vaccines/acip) and approved by the Centers for Disease

2 Annals of Internal Medicine

Determine Assess need Review vaccine Review Control and Prevention (www.cdc.gov), American College of Physicians
1 recommended 2 for additional 3 types, frequencies, 4 contraindications (www.acponline.org), American Academy of Family Physicians (www.aafp.
vaccinations by recommended intervals, and and precautions org), American College of Obstetricians and Gynecologists (www.acog.org),
vaccinations by considerations for for vaccine types American College of Nurse-Midwives (www.midwife.org), and American
CLINICAL GUIDELINE

age (Table 1)
medical condition special situations (Appendix) Academy of Physician Associates (www.aapa.org), and Society for Healthcare
or other indication (Notes) Epidemiology of America (www.shea-online.org).
(Table 2) Report
• Suspected cases of reportable vaccine-preventable diseases or outbreaks to
Vaccines in the Adult Immunization Schedule*
the local or state health department
Vaccine Abbreviation(s) Trade name(s) • Clinically significant postvaccination reactions to the Vaccine Adverse Event
Haemophilus influenzae type b vaccine Hib ActHIB® Reporting System at www.vaers.hhs.gov or 800-822-7967
Hiberix®
PedvaxHIB® Injury claims
All vaccines included in the adult immunization schedule except pneumococcal
Hepatitis A vaccine HepA Havrix®
23-valent polysaccharide (PPSV23) and zoster (RZV) vaccines are covered by the
Vaqta®
Vaccine Injury Compensation Program. Information on how to file a vaccine injury
Hepatitis A and hepatitis B vaccine HepA-HepB Twinrix® claim is available at www.hrsa.gov/vaccinecompensation.
Hepatitis B vaccine HepB Engerix-B®
Recombivax HB®
Questions or comments
Heplisav-B® Contact www.cdc.gov/cdc-info or 800-CDC-INFO (800-232-4636), in English or
Spanish, 8 a.m.–8 p.m. ET, Monday through Friday, excluding holidays.
Human papillomavirus vaccine HPV Gardasil 9®
Influenza vaccine (inactivated) IIV4 Many brands Download the CDC Vaccine Schedules app for providers at
Influenza vaccine (live, attenuated) LAIV4 FluMist® Quadrivalent www.cdc.gov/vaccines/schedules/hcp/schedule-app.html.
Influenza vaccine (recombinant) RIV4 Flublok® Quadrivalent Helpful information
Measles, mumps, and rubella vaccine MMR M-M-R II® • Complete Advisory Committee on Immunization Practices (ACIP) recommendations:
Meningococcal serogroups A, C, W, Y vaccine MenACWY-D Menactra® www.cdc.gov/vaccines/hcp/acip-recs/index.html
MenACWY-CRM Menveo® • General Best Practice Guidelines for Immunization
MenACWY-TT MenQuadfi® (including contraindications and precautions):
Meningococcal serogroup B vaccine MenB-4C Bexsero® www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html
MenB-FHbp Trumenba® • Vaccine information statements: www.cdc.gov/vaccines/hcp/vis/index.html
Pneumococcal 15-valent conjugate vaccine PCV15 Vaxneuvance™ • Manual for the Surveillance of Vaccine-Preventable Diseases
(including case identification and outbreak response):
Pneumococcal 20-valent conjugate vaccine PCV20 Prevnar 20™ www.cdc.gov/vaccines/pubs/surv-manual
Pneumococcal 23-valent polysaccharide vaccine PPSV23 Pneumovax 23® • Travel vaccine recommendations: www.cdc.gov/travel
Tetanus and diphtheria toxoids Td Tenivac® • Recommended Child and Adolescent Immunization Schedule, United States, 2022:
Tdvax™ www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
Tetanus and diphtheria toxoids and acellular pertussis vaccine Tdap Adacel® • ACIP Shared Clinical Decision-Making Recommendations: Scan QR code
www.cdc.gov/vaccines/acip/acip-scdm-faqs.html for access to
Boostrix® online schedule
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, 2022
 Figure–Continued.

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Table 1 Recommended Adult Immunization Schedule by Age Group, United States, 2022

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

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

(MMR) (if born in 1957 or later)

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

Zoster recombinant
2 doses for immunocompromising conditions (see notes) 2 doses
(RZV)

2 or 3 doses depending on age at

Human papillomavirus (HPV) 27 through 45 years
Recommended Adult Immunization Schedule, United States, 2022

initial vaccination or condition

Pneumococcal 1 dose PCV15 followed by PPSV23 1 dose PCV15 followed by PPSV23

OR OR
(PCV15, PCV20, PPSV23) 1 dose PCV20 (see notes) 1 dose PCV20

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

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

Meningococcal A, C, W, Y
1 or 2 doses depending on indication, see notes for booster recommendations
(MenACWY)

Annals of Internal Medicine

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, 2022

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 personnel²
deficiencies alcoholism1 with men
infection) <200 mm3 ≥200 mm3 hemodialysis

4 Annals of Internal Medicine

IIV4 or RIV4 1 dose annually
or or
CLINICAL GUIDELINE

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 or 3 doses depending on vaccine

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

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 HSCT3
Hib recipients only 1 dose

Recommended vaccination Recommended vaccination Recommended vaccination Precaution—vaccination Contraindicated or not No recommendation/
 for adults who meet  for adults with an additional  based on shared clinical  might be indicated if  recommended—vaccine  Not applicable
age 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

1. Precaution for LAIV4 does not apply to alcoholism. 2. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations. 3. Hematopoietic stem cell transplant.

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Recommended Adult Immunization Schedule, United States, 2022
 Figure– Continued.

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Notes Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2022
For vaccine recommendations for persons 18 years - HIV infection Special situations
of age or younger, see the Recommended Child - Men who have sex with men • Age 60 years or older* and at risk for hepatitis B virus
- Injection or noninjection drug use infection: 2-dose (Heplisav-B) or 3-dose (Engerix-B,
and Adolescent Immunization Schedule.
- Persons experiencing homelessness Recombivax HB) series or 3-dose series HepA-HepB
- Work with hepatitis A virus in research laboratory or (Twinrix) as above
COVID-19 Vaccination
with nonhuman primates with hepatitis A virus infection - Chronic liver disease (e.g., persons with hepatitis
COVID-19 vaccines are recommended within the - Travel in countries with high or intermediate endemic C, cirrhosis, fatty liver disease, alcoholic liver disease,
scope of the Emergency Use Authorization or hepatitis A (HepA-HepB [Twinrix] may be administered autoimmune hepatitis, alanine aminotransferase [ALT] or
Biologics License Application for the particular on an accelerated schedule of 3 doses at 0, 7, and 21–30 aspartate aminotransferase [AST] level greater than twice
vaccine. ACIP recommendations for the use of days, followed by a booster dose at 12 months) upper limit of normal)
COVID-19 vaccines can be found at - Close, personal contact with international adoptee - HIV infection
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/ (e.g., household or regular babysitting) in first 60 days - Sexual exposure risk (e.g., sex partners of hepatitis B
covid-19.html. after arrival from country with high or intermediate surface antigen [HBsAg]-positive persons; sexually active
endemic hepatitis A (administer dose 1 as soon as persons not in mutually monogamous relationships;
CDC’s interim clinical considerations for use of adoption is planned, at least 2 weeks before adoptee’s persons seeking evaluation or treatment for a sexually
COVID-19 vaccines can be found at arrival) transmitted infection; men who have sex with men)
www.cdc.gov/vaccines/covid-19/clinical- - Pregnancy if at risk for infection or severe outcome from - Current or recent injection drug use
considerations/covid-19-vaccines-us.html. infection during pregnancy - Percutaneous or mucosal risk for exposure to blood
- Settings for exposure, including health care settings (e.g., household contacts of HBsAg-positive persons;
targeting services to injection or noninjection drug users residents and staff of facilities for developmentally
or group homes and nonresidential day care facilities for disabled persons; health care and public safety personnel
Haemophilus influenzae type b vaccination
developmentally disabled persons (individual risk factor with reasonably anticipated risk for exposure to blood or
Special situations screening not required) blood-contaminated body fluids; hemodialysis, peritoneal
Recommended Adult Immunization Schedule, United States, 2022

• Anatomical or functional asplenia (including sickle cell dialysis, home dialysis, and predialysis patients; patients
disease): 1 dose if previously did not receive Hib; if elective Hepatitis B vaccination with diabetes)
splenectomy, 1 dose, preferably at least 14 days before - Incarcerated persons
splenectomy Routine vaccination - Travel in countries with high or intermediate endemic
• Hematopoietic stem cell transplant (HSCT): 3-dose • Age 19 through 59 years: complete a 2- or 3-, or 4-dose
hepatitis B
series 4 weeks apart starting 6–12 months after successful series
- 2-dose series only applies when 2 doses of Heplisav-B* are *Note: Anyone age 60 years or older who does not meet
transplant, regardless of Hib vaccination history
used at least 4 weeks apart risk-based recommendations may still receive Hepatitis B
- 3-dose series Engerix-B or Recombivax HB at 0, 1, 6 months vaccination.
Hepatitis A vaccination
[minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to
Routine vaccination dose 3: 8 weeks / dose 1 to dose 3: 16 weeks]) Human papillomavirus vaccination
• Not at risk but want protection from hepatitis A - 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months
Routine vaccination
(identification of risk factor not required): 2-dose series [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to
• HPV vaccination recommended for all persons through
HepA (Havrix 6–12 months apart or Vaqta 6–18 months dose 3: 5 months])
age 26 years: 2- or 3-dose series depending on age at initial

Annals of Internal Medicine

apart [minimum interval: 6 months]) or 3-dose series HepA- - 4-dose series HepA-HepB (Twinrix) accelerated schedule
vaccination or condition:
HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 of 3 doses at 0, 7, and 21–30 days, followed by a booster
- Age 15 years or older at initial vaccination: 3-dose series
to dose 2: 4 weeks / dose 2 to dose 3: 5 months]) dose at 12 months
at 0, 1–2 months, 6 months (minimum intervals: dose 1 to
- 4-dose series Engerix-B at 0, 1, 2, and 6 months for persons
Special situations dose 2: 4 weeks / dose 2 to dose 3: 12 weeks / dose 1 to
on adult hemodialysis (note: each dosage is double that of
• At risk for hepatitis A virus infection: 2-dose series HepA dose 3: 5 months; repeat dose if administered too soon)
normal adult dose, i.e., 2 mL instead of 1 mL)
or 3-dose series HepA-HepB as above - Age 9–14 years at initial vaccination and received 1
- Chronic liver disease (e.g., persons with hepatitis B, *Note: Heplisav-B not recommended in pregnancy due to dose or 2 doses less than 5 months apart: 1 additional
hepatitis C, cirrhosis, fatty liver disease, alcoholic liver lack of safety data in pregnant women dose
disease, autoimmune hepatitis, alanine aminotransferase - Age 9–14 years at initial vaccination and received 2
[ALT] or aspartate aminotransferase [AST] level greater doses at least 5 months apart: HPV vaccination series
than twice the upper limit of normal) complete, no additional dose needed

5
CLINICAL GUIDELINE
 Figure– Continued.

Notes Recommended Adult Immunization Schedule, United States, 2022

• Interrupted schedules: If vaccination schedule is Measles, mumps, and rubella vaccination Meningococcal vaccination
interrupted, the series does not need to be restarted
• No additional dose recommended when any HPV Routine vaccination Special situations for MenACWY
• No evidence of immunity to measles, mumps, or • Anatomical or functional asplenia (including sickle
vaccine series has been completed using the

6 Annals of Internal Medicine

rubella: 1 dose cell disease), HIV infection, persistent complement
recommended dosing intervals.
- Evidence of immunity: Born before 1957 (health care component deficiency, complement inhibitor (e.g.,
Shared clinical decision-making personnel, see below), documentation of receipt of MMR eculizumab, ravulizumab) use: 2-dose series MenACWY-D
(Menactra, Menveo, or MenQuadfi) at least 8 weeks apart
CLINICAL GUIDELINE

• Some adults age 27–45 years: Based on shared clinical vaccine, laboratory evidence of immunity or disease
decision-making, 2- or 3-dose series as above (diagnosis of disease without laboratory confirmation is and revaccinate every 5 years if risk remains
not evidence of immunity) • Travel in countries with hyperendemic or epidemic
Special situations meningococcal disease, or microbiologists routinely
• Age ranges recommended above for routine and catch- Special situations exposed to Neisseria meningitidis: 1 dose MenACWY
up vaccination or shared clinical decision-making also • Pregnancy with no evidence of immunity to rubella: (Menactra, Menveo, or MenQuadfi) and revaccinate every 5
apply in special situations MMR contraindicated during pregnancy; after pregnancy years if risk remains
- Immunocompromising conditions, including HIV (before discharge from health care facility), 1 dose • First-year college students who live in residential
infection: 3-dose series, even for those who initiate • Nonpregnant women of childbearing age with no housing (if not previously vaccinated at age 16 years or
vaccination at age 9 through 14 years. evidence of immunity to rubella: 1 dose older) or military recruits: 1 dose MenACWY (Menactra,
- Pregnancy: Pregnancy testing is not needed before • HIV infection with CD4 percentages ≥15% and CD4 Menveo, or MenQuadfi)
vaccination; HPV vaccination is not recommended until count ≥200 cells/mm3 for at least 6 months and no • For MenACWY booster dose recommendations for
after pregnancy; no intervention needed if inadvertently evidence of immunity to measles, mumps, or rubella: groups listed under “Special situations” and in an outbreak
vaccinated while pregnant 2-dose series at least 4 weeks apart; MMR contraindicated setting (e.g., in community or organizational settings
for HIV infection with CD4 percentage <15% or CD4 count and among men who have sex with men) and additional
Influenza vaccination <200 cells/mm3 meningococcal vaccination information, see
• Severe immunocompromising conditions: MMR www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm
Routine vaccination
contraindicated Shared clinical decision-making for MenB
• Age 19 years or older: 1 dose any influenza vaccine
• Students in postsecondary educational institutions, • Adolescents and young adults age 16–23 years (age
appropriate for age and health status annually
international travelers, and household or close, 16–18 years preferred) not at increased risk for
• For the 2021–2022 season, see www.cdc.gov/mmwr/
personal contacts of immunocompromised persons meningococcal disease: Based on shared clinical decision-
volumes/70/rr/rr7005a1.htm
with no evidence of immunity to measles, mumps, or making, 2-dose series MenB-4C (Bexsero) at least 1 month
• For the 2022–23 season, see the 2022–23 ACIP influenza
rubella: 2-dose series at least 4 weeks apart if previously apart or 2-dose series MenB-FHbp (Trumenba) at 0, 6
vaccine recommendations. months (if dose 2 was administered less than 6 months
did not receive any doses of MMR or 1 dose if previously
Special situations received 1 dose MMR after dose 1, administer dose 3 at least 4 months after dose
• Egg allergy, hives only: any influenza vaccine appropriate • Health care personnel: 2); MenB-4C and MenB-FHbp are not interchangeable (use
for age and health status annually - Born before 1957 with no evidence of immunity to same product for all doses in series)
• Egg allergy—any symptom other than hives (e.g., measles, mumps, or rubella: Consider 2-dose series at Special situations for MenB
angioedema, respiratory distress) or required epinephrine least 4 weeks apart for measles or mumps or 1 dose for • Anatomical or functional asplenia (including sickle cell
or another emergency medical intervention: see Appendix rubella disease), persistent complement component deficiency,
listing contraindications and precautions - Born in 1957 or later with no evidence of immunity complement inhibitor (e.g., eculizumab, ravulizumab)
• Severe allergic reaction (e.g., anaphylaxis) to a vaccine to measles, mumps, or rubella: 2-dose series at least 4 use, or microbiologists routinely exposed to Neisseria
component or a previous dose of any influenza vaccine: weeks apart for measles or mumps or at least 1 dose for meningitidis:
see Appendix listing contraindications and precautions rubella • 2-dose primary series MenB-4C (Bexsero) at least 1 month
• History of Guillain-Barré syndrome within 6 weeks after apart or 3-dose primary series MenB-FHbp (Trumenba) at 0,
previous dose of influenza vaccine: Generally, should 1–2, 6 months (if dose 2 was administered at least 6 months
not be vaccinated unless vaccination benefits outweigh after dose 1, dose 3 not needed); MenB-4C and MenB-FHbp
risks for those at higher risk for severe complications from are not interchangeable (use same product for all doses in
influenza series); 1 dose MenB booster 1 year after primary series and
revaccinate every 2–3 years if risk remains

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Recommended Adult Immunization Schedule, United States, 2022
 Figure–Continued.

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Notes Recommended Adult Immunization Schedule, United States, 2022
• Pregnancy: Delay MenB until after pregnancy unless at *Note: Immunocompromising conditions include chronic - Evidence of immunity: U.S.-born before 1980 (except for
increased risk and vaccination benefits outweigh potential renal failure, nephrotic syndrome, immunodeficiency, pregnant women and health care personnel [see below]),
risks iatrogenic immunosuppression, generalized malignancy, documentation of 2 doses varicella-containing vaccine
• For MenB booster dose recommendations for groups human immunodeficiency virus, Hodgkin disease, leukemia, at least 4 weeks apart, diagnosis or verification of history
listed under “Special situations” and in an outbreak lymphoma, multiple myeloma, solid organ transplants, of varicella or herpes zoster by a health care provider,
setting (e.g., in community or organizational settings congenital or acquired asplenia, sickle cell disease, or other laboratory evidence of immunity or disease
and among men who have sex with men) and additional hemoglobinopathies.
meningococcal vaccination information, see
Special situations
**Note: Underlying medical conditions or other risk • Pregnancy with no evidence of immunity to varicella:
www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm factors include alcoholism, chronic heart/liver/lung VAR contraindicated during pregnancy; after pregnancy
Note: MenB vaccines may be administered simultaneously disease, chronic renal failure, cigarette smoking, cochlear (before discharge from health care facility), 1 dose if
with MenACWY vaccines if indicated, but at a different implant, congenital or acquired asplenia, CSF leak, diabetes previously received 1 dose varicella-containing vaccine
anatomic site, if feasible. mellitus, generalized malignancy, HIV, Hodgkin disease, or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if
immunodeficiency, iatrogenic immunosuppression, previously did not receive any varicella-containing vaccine,
Pneumococcal vaccination leukemia, lymphoma, multiple myeloma, nephrotic regardless of whether U.S.-born before 1980
syndrome, solid organ transplants, or sickle cell disease or • Health care personnel with no evidence of immunity
Routine vaccination other hemoglobinopathies. to varicella: 1 dose if previously received 1 dose varicella-
• Age 65 years or older who have not previously received
containing vaccine; 2-dose series 4–8 weeks apart if
a pneumococcal conjugate vaccine or whose previous Tetanus, diphtheria, and pertussis vaccination previously did not receive any varicella-containing vaccine,
vaccination history is unknown: 1 dose PCV15 or 1 dose
regardless of whether U.S.-born before 1980
PCV20. If PCV15 is used, this should be followed by a Routine vaccination • HIV infection with CD4 percentages ≥15% and CD4
dose of PPSV23 given at least 1 year after the PCV15 • Previously did not receive Tdap at or after age 11 years:
dose. A minimum interval of 8 weeks between PCV15 1 dose Tdap, then Td or Tdap every 10 years count ≥200 cells/mm3 with no evidence of immunity:
and PPSV23 can be considered for adults with an Vaccination may be considered (2 doses 3 months apart);
Special situations VAR contraindicated for HIV infection with CD4 percentage
immunocompromising condition,* cochlear implant, or • Previously did not receive primary vaccination series <15% or CD4 count <200 cells/mm3
Recommended Adult Immunization Schedule, United States, 2022

cerebrospinal fluid leak to minimize the risk of invasive for tetanus, diphtheria, or pertussis: 1 dose Tdap
pneumococcal disease caused by serotypes unique to • Severe immunocompromising conditions: VAR
followed by 1 dose Td or Tdap at least 4 weeks after Tdap contraindicated
PPSV23 in these vulnerable groups. and another dose Td or Tdap 6–12 months after last Td
• For guidance for patients who have already received a
or Tdap (Tdap can be substituted for any Td dose, but Zoster vaccination
previous dose of PCV13 and/or PPSV23, see preferred as first dose), Td or Tdap every 10 years thereafter
www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm. Routine vaccination
• Pregnancy: 1 dose Tdap during each pregnancy, preferably
Special situations in early part of gestational weeks 27–36 • Age 50 years or older: 2-dose series RZV (Shingrix) 2–6
• Age 19–64 years with certain underlying medical • Wound management: Persons with 3 or more doses of months apart (minimum interval: 4 weeks; repeat dose
conditions or other risk factors** who have not previously tetanus-toxoid–containing vaccine: For clean and minor if administered too soon), regardless of previous herpes
received a pneumococcal conjugate vaccine or whose wounds, administer Tdap or Td if more than 10 years since zoster or history of zoster vaccine live (ZVL, Zostavax)
previous vaccination history is unknown: 1 dose PCV15 last dose of tetanus-toxoid–containing vaccine; for all other vaccination (administer RZV at least 2 months after ZVL)
or 1 dose PCV20. If PCV15 is used, this should be followed wounds, administer Tdap or Td if more than 5 years since Special situations
by a dose of PPSV23 given at least 1 year after the last dose of tetanus-toxoid–containing vaccine. Tdap is • Pregnancy: There is currently no ACIP recommendation
PCV15 dose. A minimum interval of 8 weeks between preferred for persons who have not previously received for RZV use in pregnancy. Consider delaying RZV until after
PCV15 and PPSV23 can be considered for adults with an Tdap or whose Tdap history is unknown. If a tetanus-toxoid-

Annals of Internal Medicine

pregnancy.
immunocompromising condition,* cochlear implant, or containing vaccine is indicated for a pregnant woman, use • Immunocompromising conditions (including HIV): RZV
cerebrospinal fluid leak to minimize the risk of invasive Tdap. For detailed information, see www.cdc.gov/mmwr/ recommended for use in persons age 19 years or older
pneumococcal disease caused by serotypes unique to volumes/69/wr/mm6903a5.htm who are or will be immunodeficient or immunosuppressed
PPSV23 in these vulnerable groups.
because of disease or therapy. For detailed information, see
• For guidance for patients who have already received a Varicella vaccination www.cdc.gov/mmwr/volumes/71/wr/mm7103a2.htm.
previous dose of PCV13 and/or PPSV23, see
www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm. 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
CLINICAL GUIDELINE

7
 Figure– Continued.

Appendix Recommended Adult Immunization Schedule, United States, 2022

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 2021-22 Seasonal Influenza with Vaccines
available at www.cdc.gov/mmwr/volumes/70/rr/rr7005a1.htm

8 Annals of Internal Medicine

Interim clinical considerations for use of COVID-19 vaccines including contraindications and precautions can be found at
www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
CLINICAL GUIDELINE

Vaccine Contraindications1 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) • Persons with egg allergy with symptoms 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, 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, 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 • Guillain-Barré syndrome (GBS) within 6 weeks after a previous dose of any type of
injectable [(RIV4), Flublok® component3 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
• Adults age 50 years or older • Persons with egg allergy with symptoms other than hives (e.g., angioedema,
• Anatomic or functional asplenia respiratory distress) or required epinephrine or another emergency medical
• Immunocompromised due to any cause including, but not limited to, medications and intervention: Any influenza vaccine appropriate for age and health status may be
HIV infection administered. If using LAIV4 (which is egg based), administer in medical setting under
• Close contacts or caregivers of severely immunosuppressed persons who require a supervision of health care provider who can recognize and manage severe allergic
protected environment reactions. May consult an allergist.
• Pregnancy • Persons with underlying medical conditions (other than those listed under
• Cochlear implant contraindications) that might predispose to complications after wild-type influenza
virus infection [e.g., chronic pulmonary, cardiovascular (except isolated hypertension),
• Active communication between the cerebrospinal fluid (CSF) and the oropharynx,
renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes
nasopharynx, nose, ear, or any other cranial CSF leak
mellitus)]
• Received influenza antiviral medications oseltamivir or zanamivir within the previous 48
• Moderate or severe acute illness with or without fever
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, 2022
 Figure– Continued.

Annals.org
Appendix Recommended Adult Immunization Schedule, United States, 2022
Vaccine Contraindications1 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
3
Hepatitis B (HepB) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component including • Moderate or severe acute illness with or without fever
yeast
• For Heplisav-B only: Pregnancy
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
Human papillomavirus (HPV) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
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 • 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) • For MenACWY-D and Men ACWY-CRM only: severe allergic reaction to any diphtheria toxoid– or
[MenACWY-CRM (Menveo®); CRM197–containing vaccine
MenACWY-D (Menactra®); • For MenACWY-TT only: severe allergic reaction to a tetanus toxoid-containing vaccine
MenACWY-TT (MenQuadfi®)]
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, 2022

Pneumococcal conjugate (PCV15) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
• Severe allergic reaction (e.g., anaphylaxis) to any diphtheria-toxoid–containing vaccine or to its vaccine
component3
Pneumococcal conjugate (PCV20) • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • Moderate or severe acute illness with or without fever
• 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)
Tetanus, diphtheria, and acellular • Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component3 • 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, DTaP, • History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid—
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

Annals of Internal Medicine

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 vaccination
severely immunocompromised) (avoid use of these antiviral drugs for 14 days after vaccination)
• 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.

9
CLINICAL GUIDELINE
CLINICAL GUIDELINE Recommended Adult Immunization Schedule, United States, 2022

influenza A/Victoria/2570/2019 (H1N1)pdm09–like virus, added to harmonize language with the child and adoles-
an influenza A/Cambodia/e0826360/2020 (H3N2)–like cent schedule.
virus, an influenza B/Washington/02/2019 (Victoria line- Zoster vaccination (9). In the “Special situations” sec-
age)–like virus, and an influenza B/Phuket/3073/2013 tion under the pregnancy bullet, the language was re-
(Yamagata lineage)–like virus. U.S. ccIIV4 and RIV4 vised to increase clarity. This bullet now states, “There is
influenza vaccines will contain HA derived from an currently no ACIP recommendation for RZV use in preg-
influenza A/Wisconsin/588/2019 (H1N1)pdm09–like nancy. Consider delaying RZV until after pregnancy.”
virus, an influenza A/Cambodia/e0826360/2020 (H3N2)–like Additionally, the immunocompromising conditions bul-
virus, an influenza B/Washington/02/2019 (Victoria lineage)– let was revised to reflect the new ACIP recommendations
like virus, and an influenza B/Phuket/3073/2013 (Yamagata for zoster vaccination. This bullet now states “RZV is rec-
lineage)–like virus. ommended for use in persons aged 19 years and older
A previous severe allergic reaction to influenza who are or will be immunodeficient or immunosup-
vaccine is no longer a contraindication to future receipt pressed because of disease or therapy.”
of any influenza vaccine. Rather, individuals with a his-
tory of severe allergic reaction to an influenza vaccine
may have a precaution to receive a different type of influ- REVISED CONTENT, FORMAT, AND GRAPHICS
enza vaccine. Details about contraindications and precau- Cover Page. The cover page of the 2022 schedule
tions to influenza vaccination can now be found in the provides basic instructions on how to use the schedule
newly added appendix section of the adult immunization to systematically identify vaccination needs of adults and
schedule. lists routinely recommended vaccines and their standar-
Measles, mumps, and rubella (MMR) vaccination (5). dized abbreviations and trade names. Major edits to the
Routine recommendations for MMR vaccination have not cover page include adding a fourth step in the “How to
changed. However, in the “Special situations” section, use the adult immunization schedule” box that directs
CD4 percentages in addition to CD4 counts in the HIV providers to reference the appendix for all contraindica-
infection bullet were added to harmonize language with tions and precautions to the vaccines listed in the adult
the child and adolescent schedule. immunization schedule. Additionally, PCV15 and PCV20
Meningococcal vaccination (6). Routine recommenda- have been included in the table of vaccine abbreviations
tions for meningococcal vaccination have not changed. and trade names and PCV13 has now been removed to
However, a note was added at end of section that states, reflect the new ACIP pneumococcal vaccination recom-
“MenB vaccines may be administered simultaneously with mendations. Like in past annual schedules, web links are
MenACWY vaccines if indicated, but at a different anatomi- provided, where providers can download the CDC
cal site, if feasible.” Vaccine Schedules app and access reference materials
Pneumococcal vaccination (7). ACIP recommends rou- for the surveillance of VPDs, including case identification
tine vaccination against pneumococcal infection for all and disease outbreak response. Instructions on report-
adults aged 65 years or older. For persons aged 65 years ing suspected cases of reportable VPDs to local or state
and older who have not previously received a pneumococ- health departments and significant postvaccination
cal conjugate vaccine or whose previous vaccination history adverse events to the Vaccine Adverse Event Reporting
is unknown, they should receive 1 dose of PCV15 or 1 System are listed. Information on the Vaccine Injury
dose of PCV20. If PCV15 is used, this should be followed Compensation Program is provided, as well as web links
by a dose of PPSV23. This guidance has now been to other resources, such as vaccine information state-
included in the “Routine vaccination” section. Persons aged ments, recommended vaccines for travelers, and shared
19 through 64 years with certain underlying medical condi- clinical decision-making guidance.
tions or other risk factors who have not previously received Table 1. Recommended Adult Immunization Schedule
a pneumococcal conjugate vaccine or whose previous by Age Group. Table 1 describes routine and catch-up vac-
vaccination history is unknown should receive 1 dose of cination recommendations for adults by age. For 2022, the
PCV15 or 1 dose of PCV20. If PCV15 is used, this should be zoster row of Table 1 on the adult immunization schedule
followed by a dose of PPSV23. This guidance is now was changed to purple for adults aged 19 through 49 years,
included in the “Special situations” section. Guidance for indicating that recombinant zoster vaccine (RZV) is now rec-
dosing intervals between PCV15 and PPSV23 and for ommended for adults in this age group who have immuno-
patients who have previously received PCV13 or PPSV23 in compromising conditions. The text overlay now states, “2
the past is also included. A note is added to the end listing doses for immunocompromising conditions (see notes).”
all the underlying medical conditions or risk factors that For pneumococcal vaccination in Table 1, all recommended
would make those aged 19 through 64 years eligible to pneumococcal vaccines (i.e., PCV15, PCV20, and PPSV23)
receive pneumococcal vaccination. have been collapsed to one row. Guidance for which vac-
Tetanus toxoid, reduced diphtheria toxoid, and acel- cines are indicated for certain age groups is displayed by
lular pertussis (Tdap) vaccination. Routine recommenda- the corresponding colors and overlying text. The row is pur-
tions for Tdap or Td vaccination have not changed. ple from 19 through 64 years and yellow for adults aged
Varicella vaccination (8). Routine recommendations 65 years and older. The text overlay now states, “1 dose
for varicella vaccination have not changed. However, in PCV15 followed by PPSV23 OR 1 dose PCV20 (see notes).”
the “Special situations” section, CD4 percentages in The Hepatitis B row is now yellow from 19 through 59 years
addition to CD4 counts in the HIV infection bullet were of age, and purple for adults aged 60 years and older. The
10 Annals of Internal Medicine Annals.org
Recommended Adult Immunization Schedule, United States, 2022 CLINICAL GUIDELINE
text overlay now states, “2, 3, or 4 doses depending on vac- vaccine recommendations (2) and from ACIP General
cine or condition.” Best Practice Guidelines for Immunization (10).
Table 2. Recommended Adult Immunization Schedule
by Medical Condition and Other Indications. Table 2
describes vaccination recommendations for adults
VACCINATION DURING THE CORONAVIRUS
based on medical conditions or other indications. For DISEASE 2019 (COVID-19) PANDEMIC
2022, the header now includes CD4 percentages in Vaccination is an essential medical service for all children,
addition to CD4 counts in the HIV infection columns, adolescents, and adults; vaccines are ideally administered in
to harmonize the way this information is presented in the medical home. Providers should administer all due and
the child and adolescent schedule. Additionally, the overdue vaccines according to the routine immunization
description of the color red in the legend has been schedule during the same visit. In addition, providers should
reworded to “Contraindicated or not recommended.” implement strategies to catch up all patients on any overdue
The red boxes in the LAIV4, MMR, and VAR rows now vaccines. The CDC's interim guidance for the safe delivery of
have a text overlay of “Contraindicated” (as opposed to vaccines during the COVID-19 pandemic (11) includes the
“Not Recommended” in the 2021 schedule) to increase use of personal protective equipment and physical distanc-
ing. Routine immunization services remain critical during the
clarity and to align more closely with ACIP recommenda-
COVID-19 pandemic as they prevent disease in individuals,
tions. In the RZV row, under the Immunocompromised
families, and communities (11). For more information, see
and HIV infection columns, the row is yellow indicating that
www.cdc.gov/vaccines/pandemic-guidance/index.html.
RZV is recommended for these subgroups. Additionally,
The CDC has partnered with the National Adult and
the text overlay under these columns now states, “2 doses
Influenza Immunization Summit, which has developed a
at age ≥19 years.” The HepB row is now entirely yellow,
checklist of best practices for vaccination clinics held at
indicating that hepatitis B vaccination is recommended for satellite, temporary, or off-site locations, and can be
all risk-based groups in Table 2. The text overlay states, “3 downloaded at www.izsummitpartners.org/content/
doses (see notes),” in the pregnancy column, and “2, 3, or uploads/2019/02/off-site-vaccination-clinic-checklist.pdf.
4 doses depending on vaccine or condition,” for the This checklist is a step-by-step guide to help clinic coordi-
remaining columns. nators/supervisors overseeing vaccination clinics held at
Notes. Recommended Adult Immunization Schedule. satellite, temporary, or off-site locations follow the CDC
Additional language has been added to the box contain- guidelines and best practices for vaccine shipment, trans-
ing COVID-19 vaccination recommendations. In addition port, storage, handling, preparation, administration, and
to including the hyperlink to the Interim ACIP recommen- documentation. This checklist can be used in any nontradi-
dations for the use of COVID-19 vaccines, the hyperlink tional vaccination clinic settings, such as workplaces, com-
to CDC's Interim Clinical Considerations for the use of munity centers, schools, makeshift clinics in remote areas,
COVID-19 vaccines is also included in this box. Each and medical facilities when vaccination occurs in the public
recommended vaccine for adults in Tables 1 and 2 is areas or classrooms.
accompanied by a note (previously known as a foot-
note), which is designed to provide additional infor- From Centers for Disease Control and Prevention, Atlanta,
mation on routine vaccination and recommendations Georgia (N.M., A.P.W.); Cohen Children's Medical Center, New
in special situations. Each section contains concise in- Hyde Park, and Zucker School of Medicine at Hofstra/Northwell,
formation on vaccine indications, dosing frequencies Hempstead, New York (H.B.); and University of Kansas Medical
and intervals, and other published ACIP recommen- Center, Kansas City, Kansas (K.A.A.).
dations. New or revised language for influenza, hepa-
titis B, pneumococcal, and zoster vaccination has Disclosures: To maintain the integrity of the ACIP, the U.S.
been added to their respective sections in the notes. Department of Health and Human Services has taken steps to
Changes were also made to the MMR vaccine, HPV ensure there is technical adherence to ethics statutes and regula-
vaccine, meningococcal vaccine, and varicella vac- tions regarding financial conflicts of interest. Concerns regarding
cine sections to improve clarity in the language. All the potential for the appearance of a conflict are addressed or
vaccines identified in Tables 1 and 2 (except PCV15, avoided altogether through preappointment and postappoint-
PCV20, and RZV) also appear in the Recommended ment considerations. Individuals with particular vaccine-related
Child and Adolescent Immunization Schedule for interests will not be considered for appointment to the committee.
Ages 18 Years or Younger, United States, 2022 (www. Potential nominees are screened for conflicts of interest and, if any
cdc.gov/vaccines/schedules/hcp/imz/child-adolescent. are found, are asked to divest or forgo certain vaccine-related
html). The notes for vaccines that appear in both the activities. In addition, at the beginning of each ACIP meeting,
adult immunization schedule and the child and adolescent each member is asked to declare his or her conflicts. Members
immunization schedule have been harmonized to the with conflicts are not permitted to vote if the conflict involves the
greatest extent possible. vaccine or biologic being voted on. Details can be found at www.
Appendix. Recommended Adult Immunization Schedule. cdc.gov/vaccines/acip/committee/structure-role.html. Dr. Murthy
The appendix lists all the contraindications and precau- has nothing to disclose. Dr. Wodi has nothing to disclose.
tions to each of the vaccines listed in the 2022 adult im- Dr. Bernstein reports that he is the editor of Current Opinion in
munization schedule. The information presented in this Pediatrics Office Pediatrics Series and received a presentation
appendix is adapted from the 2021–2022 influenza honorarium from the Florida chapter of American Academy of

Annals.org Annals of Internal Medicine 11

CLINICAL GUIDELINE Recommended Adult Immunization Schedule, United States, 2022

Pediatrics. Dr. Ault reports having received a grant from the the Advisory Committee on Immunization Practices, United States,
National Cancer Institute, consulting fees from PathoVax, and 2021-22 influenza season. MMWR Recomm Rep. 2021;70:1-28.
payments supporting attending meetings and/or travel from [PMID: 34448800] doi:10.15585/mmwr.rr7005a1
the American College of Obstetricians and Gynecologists. 5. McLean HQ, Fiebelkorn AP, Temte JL, et al; Centers for Disease
Additionally, Dr. Ault reports that he serves as a volunteer on the Control and Prevention. Prevention of measles, rubella, congenital
rubella syndrome, and mumps, 2013: summary recommendations
medical advisory board of Family Fighting Flu and as a member of
of the Advisory Committee on Immunization Practices (ACIP).
the infectious disease working group for the American College of
MMWR Recomm Rep. 2013;62:1-34. [PMID: 23760231]
Obstetricians and Gynecologists. Disclosures can also be viewed at
6. Reefhuis J, FitzHarris LF, Gray KM, et al. Neural tube defects in
www.acponline.org/authors/icmje/ConflictOfInterestForms.do? pregnancies among women with diagnosed HIV infection—15 juris-
msNum=M22-0036. dictions, 2013-2017. MMWR Morb Mortal Wkly Rep. 2020;69:1-5.
[PMID: 31917782] doi:10.15585/mmwr.mm6901a1
Corresponding Author: Neil Murthy, MD, MPH, MSJ, Immunization 7. Kobayashi M, Farrar JL, Gierke R, et al. Use of 15-valent pneumococcal
Services Division, National Center for Immunization and Respiratory conjugate vaccine and 20-valent pneumococcal conjugate vaccine
Diseases, Centers for Disease Control and Prevention, 1600 Clifton among U.S. adults: updated recommendations of the Advisory Committee
Road NE, Atlanta, GA 30329-4027; e-mail, [email protected]. on Immunization Practices—United States, 2022. MMWR Morb Mortal
Wkly Rep. 2022;71: 109-117. doi:10.15585/mmwr.mm7104a1
8. Marin M, Güris D, Chaves SS, et al; Advisory Committee on
Author contributions are available at Annals.org.
Immunization Practices, Centers for Disease Control and Prevention
(CDC). Prevention of varicella: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep.
References 2007;56:1-40. [PMID: 17585291]
1. Centers for Disease Control and Prevention. Charter of the 9. Anderson TC, Masters NB, Guo A, et al. Use of recombinant
Advisory Committee on Immunization Practices. 22 March 2020. zoster vaccine in immunocompromised adults aged ≥19 years:
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pdf on 15 January 2022. Practices—United States, 2022. MMWR Morb Mortal Wkly Rep.
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meeting recommendations. Accessed at www.cdc.gov/vaccines/ 10. Kroger A, Bahta L, Hunter P. General Best Practice Guidelines for
acip/recommendations.html on 25 January 2022. Immunization. Best Practices Guidance of the Advisory Committee on
3. Meites E, Szilagyi PG, Chesson HW, et al. Human papilloma- Immunization Practices (ACIP). Updated 4 May 2021. Accessed at
virus vaccination for adults: updated recommendations of the www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/
Advisory Committee on Immunization Practices. MMWR Morb Mortal general-recs.pdf on 15 January 2022.
Wkly Rep. 2019;68:698-702. [PMID: 31415491] doi:10.15585/mmwr. 11. Centers for Disease Control and Prevention. Interim guidance for
mm6832a3 routine and influenza immunization services during the COVID-19
4. Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and pandemic. Accessed at www.cdc.gov/vaccines/pandemic-guidance/
control of seasonal influenza with vaccines: recommendations of on 2 December 2020.

12 Annals of Internal Medicine Annals.org

Author Contributions: Conception and design: K.A. Ault, H. Bernstein. Hospital, Stanford University School of Medicine, Stanford,
Analysis and interpretation of the data: K.A. Ault, H. Bernstein. California; Veronica V. McNally, JD, Franny Strong
Drafting of the article: K.A. Ault, H. Bernstein, N.C. Murthy, A.P. Foundation, West Bloomfield, Michigan; Katherine A.
Wodi. Poehling, MD, MPH, Wake Forest School of Medicine,
Critical revision for important intellectual content: K.A. Ault, H. Winston-Salem, North Carolina; Pablo J. Sánchez, MD, The
Bernstein, N.C. Murthy, A.P. Wodi. Research Institute at Nationwide Children's Hospital,
Final approval of the article: K.A. Ault, H. Bernstein, N.C. Columbus, Ohio; Peter Szilagyi, MD, MPH, University of
Murthy, A.P. Wodi. California, Los Angeles, Los Angeles, California; Helen
Administrative, technical, or logistic support: K.A. Ault, A.P. Keipp Talbot, MD, MPH, Vanderbilt University, Nashville,
Wodi. Tennessee. A list of current ACIP members is available at
Collection and assembly of data: N.C. Murthy, A.P. Wodi. www.cdc.gov/vaccines/acip/committee/members.html.

APPENDIX A ACIP Combined Immunization Work Group

Recommendations for routine use of vaccines in chil- Work Group Co-Chair: Kevin A. Ault, MD*, Kansas
City, Kansas.
dren, adolescents, and adults are developed by the
Work Group Members: Sybil Cineas, MD, Providence,
Advisory Committee on Immunization Practices (ACIP).
Rhode Island; Sarah Coles, MD, Phoenix, Arizona; Katherine
ACIP is chartered as a federal advisory committee to pro-
Debiec, MD, Seattle, Washington; Marci Drees, MD,
vide expert external advice and guidance to the Director of Philadelphia, Pennsylvania; John Epling, MD, Roanoke,
the Centers for Disease Control and Prevention (CDC) on Virginia; Holly Fontenot, PhD, Boston, Massachusetts;
the use of vaccines and related agents to control vaccine- Sandra Fryhofer, MD, Atlanta, Georgia; Molly Howell, MPH,
preventable diseases in the civilian population of the Bismarck, North Dakota; Marie-Michelle Leger, MPH, PA-C,
United States. Recommendations for routine use of vac- Alexandria, Virginia; Susan Lett, MD, MPH, Boston,
cines in children and adolescents are harmonized to the Massachusetts; Veronica V. McNally, JD, West Bloomfield,
extent possible with recommendations made by the Michigan; Sarah McQueen, DMS, PA-C, Charlotte, North
American Academy of Pediatrics (AAP), the American Carolina; Amy Middleman, MD, MSEd, MPH, Oklahoma
Academy of Family Physicians (AAFP), and the American City, Oklahoma; Sean O’Leary, MD, MPH, Denver,
College of Obstetricians and Gynecologists (ACOG). Colorado; Chad Rittle, DNP, MPH, RN, Pittsburgh,
Recommendations for routine use of vaccines in adults are Pennsylvania; William Schaffner, MD, Nashville, Tennessee;
harmonized with recommendations of AAFP, ACOG, the Ken Schmader, MD, Durham, North Carolina; Rhoda
American College of Physicians (ACP), the American Sperling, MD, New York, New York; Patricia Stinchfield, RN,
College of Nurse-Midwives (ACNM), and the American MS, Saint Paul, Minnesota; Thomas Weiser, MD, MPH,
Academy of Physician Assistants (AAPA). ACIP recommen- Portland, Oregon.
Work Group Contributors: Anna M. Acosta, MD,
dations adopted by the CDC Director become agency
Atlanta, Georgia; Tara C. Anderson, DVM, PhD, Atlanta,
guidelines on the date they are published in the Morbidity
Georgia; Kathy Byrd, MD, MPH, Atlanta, Georgia; Margaret
and Mortality Weekly Report (MMWR). Additional informa- M. Cortese, MD, Atlanta, Georgia; Kathleen Dooling, MD,
tion on ACIP is available at www.cdc.gov/vaccines/acip. MPH, Atlanta, Georgia; Amy Parker Fiebelkorn, MSN, MPH,
Atlanta, Georgia; Mark Freedman, DVM, MPH, New York,
Members of the ACIP
New York; Paul A. Gastañaduy, MD, Atlanta, Georgia; Lisa
Unless otherwise indicated, the members listed were
Grohskopf, MD, MPH, Atlanta, Georgia; Susan Hariri, PhD,
nonauthor collaborators to this article.
Atlanta, Georgia; Aaron M. Harris, MD, Atlanta, Georgia;
Jose R. Romero, MD, University of Arkansas for
Fiona Havers, MD, PhD, Atlanta, Georgia; Holly Hill, PhD,
Medical Sciences, Arkansas Children's Hospital, Little Rock,
MD, Atlanta, Georgia; Tara Jatlaoui, MD, MPH, Atlanta,
Arkansas (Chair); Amanda Cohn, MD, Centers for Disease
Georgia; Suzanne Johnson-DeLeon, MPH, Atlanta,
Control and Prevention, Atlanta, Georgia (Executive
Georgia; Miwako Kobayashi, MD, MPH, Atlanta, Georgia;
Secretary); Robert L. Atmar, MD, Baylor College of
Medicine, Houston, Texas; Kevin A. Ault, MD*, University of Ram Kopakka, MD, MPH, Atlanta, Georgia; Andrew Kroger,
Kansas Medical Center, Kansas City, Kansas; Lynn Bahta, MD, MPH, Atlanta, Georgia; Tatiana M. Lanzieri, MD,
RN, MPH, CPH, Minnesota Department of Health, Saint Atlanta, Georgia; Lucy McNamara, PhD, MS, Atlanta,
Paul, Minnesota; Beth P. Bell, MD, MPH, University of Georgia; Mona Marin, MD, Atlanta, Georgia; Lauri
Washington, Seattle, Washington; Henry Bernstein, DO, Markowitz, MD, Atlanta, Georgia; Sarah A. Mbaeyi, MD,
MHCM*, Cohen Children's Medical Center, New Hyde Atlanta, Georgia; Elissa Meites, MD, MPH, Atlanta, Georgia;
Park, and Zucker School of Medicine at Hofstra/Northwell, Noele P. Nelson, MD, PhD, Atlanta, Georgia; Sara Oliver,
Hempstead, New York; Sybil Cineas, MD, The Warren MD, MSPH, Atlanta, Georgia; Priti Patel, MD, MPH, Atlanta,
Alpert Medical School of Brown University, Providence, Georgia; Tamara Pilishvili, MPH, BS, Atlanta, Georgia; Hilda
Rhode Island; Sharon E. Frey, MD, Saint Louis University Razzaghi, PhD, Atlanta, Georgia; Janell Routh, MD, Atlanta,
Medical School, Saint Louis, Missouri; Paul Hunter, MD, City Georgia; Sarah Schillie, MD, Atlanta, Georgia; Mark K.
of Milwaukee Health Department, Milwaukee, Wisconsin; Weng, MD, Atlanta, Georgia; Akiko Wilson, BFA, Atlanta,
Grace M. Lee, MD, MPH, Lucile Packard Children's Georgia; JoEllen Wolicki, BSN, Atlanta, Georgia.
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 Work Group Consultants: Henry Bernstein, DO, Kim, MD, MPH, Durham, North Carolina; Diane
MHCM*, New Hyde Park, New York; Caroline Bridges, Peterson, Saint Paul, Minnesota; Litjen Tan, PhD,
MD, Moscow, Idaho; Kathleen Harriman, PhD, MPH, RN, Chicago, Illinois.
Richmond, California; Robert H. Hopkins Jr., MD, Little Work Group Co-Leads: Neil Murthy, MD, MPH,
Rock, Arkansas; Karen Ketner, DNP, Redwood City, MSJ*, Atlanta, Georgia; A. Patricia Wodi, MD, MPH*.
California; David Kim, MD, MPH, Washington, DC; Jane * Authored the article.

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