Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2023

Abstract

At its October 2022 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2023. The 2023 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, notes, and appendix from the 2022 immunization schedule.† This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together to determine recommended vaccinations for patient populations. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), the American Pharmacists Association (https://www.pharmacist.com), and the Society for Healthcare Epidemiology of America (https://shea-online.org).

Full text

Morbidity and Mortality Weekly Report
MMWR / February 10, 2023 / Vol. 72 / No. 6 141
US Department of Health and Human Services/Centers for Disease Control and Prevention
Advisory Committee on Immunization Practices Recommended Immunization
Schedule for Adults Aged 19 Years or Older — United States, 2023
Neil Murthy, MD1; A. Patricia Wodi, MD1; Veronica McNally, JD2; Sybil Cineas, MD3; Kevin Ault, MD4
At its October 2022 meeting, the Advisory Committee on
Immunization Practices* (ACIP) approved the Recommended
Adult Immunization Schedule for Ages 19 Years or Older,
United States, 2023. The 2023 adult immunization schedule
summarizes ACIP recommendations, including several changes
to the cover page, tables, notes, and appendix from the 2022
immunization schedule.† This schedule can be found on the
CDC immunization schedule website (https://www.cdc.gov/
vaccines/schedules). Health care providers are advised to use
the cover page, tables, notes, and appendix together to deter-
mine recommended vaccinations for patient populations.
This adult immunization schedule is recommended by ACIP
(https://www.cdc.gov/vaccines/acip) and approved by CDC
(https://www.cdc.gov), the American College of Physicians
(https://www.acponline.org), the American Academy of Family
Physicians (https://www.aafp.org), the American College
of Obstetricians and Gynecologists (https://www.acog.org),
the American College of Nurse-Midwives (https://www.
midwife.org), the American Academy of Physician Associates
(https://www.aapa.org), the American Pharmacists Association
(https://www.pharmacist.com), and the Society for Healthcare
Epidemiology of America (https://shea-online.org).
ACIP’s recommendations for the use of each vaccine are
developed after in-depth reviews of vaccine-related data,
including disease epidemiology and societal impacts, vaccine
efficacy and effectiveness, vaccine safety, quality of evidence,
feasibility of program implementation, and economic analyses
of immunization policy (1). The adult immunization schedule
is published annually to consolidate and summarize updates to
ACIP recommendations on vaccination of adults and to assist
health care providers in implementing current ACIP recom-
mendations. The use of vaccine trade names in this report and
* Recommendations for routine use of vaccines in adults are developed by ACIP,
a federal advisory committee chartered to provide expert external advice and
guidance to the CDC director on use of vaccines and related agents for the
control of vaccine-preventable diseases in the civilian population of the United
States. Recommendations for routine use of vaccines in adults are harmonized
to the greatest extent possible with recommendations made by the American
Academy of Pediatrics, the American Academy of Family Physicians, and the
American College of Obstetricians and Gynecologists. ACIP recommendations
approved by the CDC director become agency guidelines on the date published
in the Morbidity and Mortality Weekly Report. Additional information about
ACIP is available at https://www.cdc.gov/vaccines/acip/.
† Past immunization schedules are available at https://www.cdc.gov/vaccines/
schedules/hcp/schedule-related-resources.html#accordion-2-collapse-3.
in the adult immunization schedule is for identification pur-
poses only and does not imply endorsement by ACIP or CDC.
For further guidance on the use of each vaccine, including
any changes that might occur after annual publication of
the adult immunization schedule, health care providers are
referred to the respective ACIP vaccine recommendations
at https://www.cdc.gov/vaccines/hcp/acip-recs. If errors or
omissions are discovered within the schedule, CDC will post
revised versions on the CDC immunization schedule website.§
Printable versions of the 2023 adult immunization schedule
and instructions for ordering hard copies of the schedule are
available on the immunization schedule website (https://www.
cdc.gov/vaccines/schedules).
Changes in the 2023 Adult Immunization
Schedule
Vaccine-specific changes in the 2023 immunization schedule
for adults aged ≥19 years include new or updated ACIP
recommendations for influenza vaccines (2) and pneumococcal
vaccines (3). Additional information was added for the
measles, mumps, and rubella vaccine (MMR), meningococcal
vaccine, and recombinant zoster vaccine (RZV) sections.
The hepatitis B vaccine (HepB) section was rearranged and
revised to improve clarity in the language, and minor edits
were made to the tetanus, diphtheria, and acellular pertussis
vaccination (Tdap) notes to improve readability. In addition,
COVID-19 vaccines have been added to the Tables and to the
Notes sections summarizing ACIP recommendations. A new
poliovirus vaccination section was also added to the Notes
section to describe the use of inactivated poliovirus vaccine
(IPV) in adults who are at increased risk for exposure to
polioviruses. Changes were also made to the appendix section
to improve clarity in the language.
§ CDC encourages organizations to use syndication as a more reliable method
for displaying the most current and accurate immunization schedules on an
organization’s website rather than copying these schedules to their websites.
Use of content syndication requires a one-time step that ensures an organization’s
website displays current schedules as soon as they are published or revised;
instructions for the syndication code are available on CDC’s website (https://
www.cdc.gov/vaccines/schedules/resource-library/syndicate.html). CDC also
offers technical assistance for implementing this form of content syndication
(requests can be e-mailed to ncirdwebteam@cdc.gov).

Morbidity and Mortality Weekly Report
142 MMWR / February 10, 2023 / Vol. 72 / No. 6 US Department of Health and Human Services/Centers for Disease Control and Prevention
Cover page
• The American Pharmacists Association has been added as
a partner organization approving the adult immunization
schedule.
• A newly recommended HepB vaccine (PreHevbrio) and a
newly recommended MMR vaccine (Priorix) have been
added to the table of vaccine abbreviations and trade names.
• COVID-19 vaccines have been added to the table of vaccine
abbreviations and trade names. ACIP has developed new
abbreviations for the COVID-19 vaccine products. These
abbreviations contain information on the vaccine’s valency
(i.e., monovalent versus bivalent, indicated by “1v” and
“2v,” respectively) and vaccine platform (mRNA versus
acellular protein subunit, or “aPS”).
• The pneumococcal conjugate vaccines PCV15 and PCV20
have been combined into one row in the table of vaccine
abbreviations and trade names.
• 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.
Table 1 (Routine Immunization Schedule)
• COVID-19 row: The COVID-19 vaccine row is a new
addition to the tables this year. The color of this row is
yellow, indicating that COVID-19 vaccination is now
routinely recommended for all adults. The text overlay
states, “2- or 3-dose primary series and booster (See Notes).”
• MMR row: Overlaying text has been added to the column
for persons aged ≥65 years referring providers to the notes
for vaccination considerations for health care personnel
in this age group.
• Hepatitis A row: The overlaying text has been updated
to “2, 3, or 4 doses depending on vaccine,” to account for
the possibility of an accelerated Twinrix series requiring
4 doses.
Table 2 (Immunization by Medical Indication Schedule)
• COVID-19 row: The COVID-19 vaccine row is a new
addition to the tables this year. The color of this row is
yellow, indicating that COVID-19 vaccination is now
routinely recommended for adults with any of the medical
conditions or other indications listed. The text overlay for
the immunocompromised and HIV infection columns
states, “See Notes,” referring providers to the notes for
specific recommendations for this population.
• Hepatitis A row: The overlaying text has been updated
to “2, 3, or 4 doses depending on vaccine,” to account for
the possibility of an accelerated Twinrix series requiring
4 doses.
Vaccine Notes
The notes for each vaccine are presented in alphabetical
order. Edits have been made throughout the Notes section to
harmonize language between the child and adolescent and the
adult immunization schedules to the greatest extent possible.
• COVID-19: A new section was added to provide
additional details for use of COVID-19 vaccines. The
“Routine vaccination” section describes the primary series
recommendations for the general population. The “Special
situations” section describes the primary series
recommendations for persons who are moderately or
severely immunocompromised. Hyperlinks have been
provided referring health care providers to the latest
guidance for booster dose recommendations in both
populations, and to the recommendation for persons who
received the Janssen (Johnson & Johnson) COVID-19
vaccine. 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, have
been added.
• HepB: In the “Routine vaccination” section, PreHevbrio
was added to the description of the 3-dose series, and
information on the 4-dose series for persons on hemodialysis
was moved to the “Special situations” section. HepB
vaccination continues to be universally recommended for
all adults aged 19–59 years. Language has been added
stating that persons aged ≥60 years with known risk factors
for hepatitis B virus infection should complete a HepB
vaccination series, whereas persons aged ≥60 years without
known risk factors for hepatitis B virus infection may
complete a HepB vaccination series.
• Influenza: Information was added to the routine
vaccination section for persons aged ≥65 years stating that
any one of quadrivalent high-dose inactivated influenza
vaccine, quadrivalent recombinant influenza vaccine, or
quadrivalent adjuvanted inactivated influenza vaccine is
preferred for this age group. A hyperlink to the 2022–23
influenza recommendations and a bullet for the 2023–24
influenza recommendations were added. In the “Special
situations” section, guidance for close contacts of severely
immunocompromised patients who require a protected

Morbidity and Mortality Weekly Report
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US Department of Health and Human Services/Centers for Disease Control and Prevention
environment was added. 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.
• MMR: In the “Special situations” section, a hyperlink was
provided that describes the recommendation for additional
doses of MMR vaccine (including the third dose of
MMR vaccine) in the context of a mumps outbreak setting.
• Meningococcal: In the “Special situations” section for
meningococcal serogroup B vaccine, guidance 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 ≥4 months after the third dose.
• Pneumococcal: The section has been substantially
updated to reflect ACIP’s new recommendations for the
use of PCV15 and PCV20 in persons who previously
received pneumococcal vaccines. In addition, a hyperlink
to the CDC app that can be used to determine a patient’s
pneumococcal vaccination needs has been included.
• Poliovirus: A new section was added summarizing
poliovirus vaccination recommendations for adults.
Although routine vaccination of adults residing in the
United States is not necessary, the “Special situations”
section describes the use of IPV in adults who are at
increased risk for exposure to poliovirus.
• Tdap: Minor changes were made to the “Special situations”
section to improve clarity in the language.
• Zoster: The “Routine vaccination” section was revised to
clarify that serologic evidence of prior varicella is not
necessary for zoster vaccination and to provide guidance
for situations in which serologic evidence of varicella
susceptibility becomes available. The “Special situations”
section was updated to provide guidance for persons with
immunocompromising conditions who do not have a
documented history of varicella, varicella vaccination, or
herpes zoster. In addition, minor changes were made to
the immunocompromising conditions bullet to clarify that
this includes persons with HIV regardless of CD4 count.
Appendix (Contraindications and Precautions)
• The header of the “Contraindications” column was
changed to “Contraindicated or not recommended.”
• Influenza (egg-based) row: The information for persons
with history of egg allergy was moved from the precautions
column to the influenza vaccination notes section.
• HepB row: The language regarding the use of Heplisav-B
and PreHevbrio in pregnant persons was modified. The
language now states that “Heplisav-B and PreHevbrio are
not recommended because of lack of safety data in
pregnant persons. Use other hepatitis B vaccines if HepB
is indicated.” A footnote providing information on the
pregnancy exposure registries for persons who were
inadvertently vaccinated with Heplisav-B and PreHevbrio
while pregnant was added.
• Human papillomavirus row: The language regarding the
use of human papillomavirus (HPV) vaccination among
pregnant persons was modified. The language now states,
“pregnancy: HPV vaccination not recommended.”
Additional Information
The Recommended Adult Immunization Schedule, United
States, 2023, is available at https://www.cdc.gov/vaccines/
schedules/hcp/adult.html and in the Annals of Internal Medicine
(https://www.acpjournals.org/doi/10.7326/M23-0041). The
full ACIP recommendations for each vaccine are also available
at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. All
vaccines identified in Tables 1 and 2 (except PCV20 and RZV)
also appear in the Recommended Immunization Schedule for
Children and Adolescents, United States, 2023 (https://www.
cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html).
The notes and appendices for vaccines that appear in both
the adult immunization schedule and the child and adolescent
immunization schedule have been harmonized to the greatest
extent possible.
Acknowledgments
Rosters of current and past members of the Advisory Committee
on Immunization Practices are available at https://www.cdc.gov/
vaccines/acip/members/index.html.
ACIP Combined Immunization Schedule Work Group
Kevin Ault (Chair). Members: Henry Bernstein, Carolyn Bridges,
Uzo Chukwuma, Sybil Cineas, Sarah Coles, Katherine Debiec,
Marci Drees, John Epling, Susan Farrall, Mary-Margaret Fill, Holly
Fontenot, Sandra Fryhofer, Kathleen Harriman, Robert Hopkins,
Molly Howell, Paul Hunter, Karen Ketner, David Kim, Jane
Kim, Marie-Michelle Leger, Susan Lett, Veronica McNally, Sarah
McQueen, Amy B. Middleman, Pia Pannaraj, Diane Peterson,
Chad Rittle, William Schaffner, Ken Schmader, Rhoda Sperling,
Patricia Stinchfield, Peter Szilagyi, and L.J. Tan. Contributors:
A. Patricia Wodi (CDC co-Lead), Neil Murthy (CDC co-Lead);
CDC contributors: Tara Anderson, Jennifer Collins, Erin Conners,
Laura Cooley, Samuel Crowe, Lisa Grohskopf, Elisha Hall, Susan
Hariri, Holly Hill, Suzanne Johnson-DeLeon, Sarah Kidd, Miwako
Kobayashi, Andrew Kroger, Elisabeth Krow-Lucal, Tatiana Lanzieri,
Mona Marin, Lauri Markowitz, Lucy McNamara, Noele Nelson,
Sara Oliver, Lakshmi Panagiotakopoulos, Gabriela Paz-Bailey, Hilda
Razzaghi, Janell Routh, Sarah Schillie, Tami Skoff, Jacqueline Tate,
Mark Weng, Donna Williams, Akiko Wilson, and JoEllen Wolicki.

Morbidity and Mortality Weekly Report
144 MMWR / February 10, 2023 / Vol. 72 / No. 6 US Department of Health and Human Services/Centers for Disease Control and Prevention
Corresponding author: Neil Murthy, nmurthy@cdc.gov.
1Immunization Services Division, National Center for Immunization and
Respiratory Diseases, CDC; 2Fanny Strong Foundation, West Bloomfield,
Michigan; 3The Warren Alpert Medical School of Brown University, Providence,
Rhode Island; 4University of Kansas Medical Center, Kansas City, Kansas.
All authors have completed and submitted the International
Committee of Medical Journal Editors form for disclosure of
potential conflicts of interest. Veronica McNally reports that she is
the president of the Franny Strong Foundation. Kevin Ault reports
having received consulting fees from PathoVax, serving as a volunteer
on the medical advisory board of Family Fighting Flu, and as a
committee member of the American College of Obstetricians and
Gynecologists. No other potential conflicts of interest were disclosed.
References
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