Vaccine recommendations in the U.S. are issued primarily by two national bodies—the CDC Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics (AAP) Committee on Infectious Diseases. To access the most current ACIP recommendations, visit ACIP Vaccine Recommendations and Guidelines (CDC) for statements in alphabetical order or ACIP Vaccine Recommendations (Immunize.org) for statements in chronological order (can also be sorted by vaccine). AAP vaccine recommendations are published in the AAP Red Book, and are generally available on the AAP website.
Ask the Experts: Vaccine Recommendations
The ACIP-recommended child and adolescent schedules are and approved by the CDC (www.cdc.gov), American Academy of Pediatrics (www.aap.org), American Academy of Family Physicians (AAFP, www.aafp.org), American College of Obstetricians and Gynecologists (ACOG, www.acog.org), American College of Nurse-Midwives (www.midwife.org), American Academy of Physician Associates (AAPA, www.aapa.org), and National Association of Pediatric Nurse Practitioners (www.napnap.org).
The ACIP-recommended adult schedules are approved by CDC and American College of Physicians (www.acponline.org), AAFP, ACOG, American College of Nurse-Midwives, AAPA, American Pharmacists Association (www.pharmacist.com), and Society for Healthcare Epidemiology of America (www.shea-online.org).
You can download electronic versions of the schedules from CDC’s website at www.cdc.gov/vaccines/schedules/hcp/index.html. Immunize.org has also created laminated versions of the child and adolescent schedule, as well as the adult schedule, which make an excellent resource for placement in each exam room. Each is based on the immunization schedules recommended by ACIP and approved by CDC, AAP, AAFP, ACP, ACOG, and the American College of Nurse-Midwives. You can find them by going to shop.immunize.org.
There are several very easy to read pieces that can be downloaded from the Immunize.org website. This includes “Vaccinations for Infants and Children, Age 0–10 Years”, “When do children and teens need vaccinations?”, “Vaccinations for Preteens and Teens, Age 11–19 Years”. These handouts can be found at www.immunize.org/handouts/discussing-vaccines-parents.asp
Immunize.org has developed several screening questionnaires for patient use. These include:
- Do I Need Any Vaccinations Today? (adult vaccination assessment checklist)
- Vaccinations for Adults—You’re never too old to get immunized!
- Vaccinations Needed During Pregnancy
- Vaccinations for Adults with Chronic Liver Disease or Infection
- Vaccinations for Adults with Diabetes
- Vaccinations for Adults with Heart Disease
- Vaccinations for Adults with HIV Infection
- Vaccinations for Adults with Lung Disease
- Vaccinations for Adults without a Spleen
- Vaccinations for Men Who Have Sex with Men
- Should You Be Vaccinated Against Hepatitis B? A screening questionnaire for adults, and
- Should You Be Vaccinated for Hepatitis A? A screening questionnaire for adults.
These handouts can be found at www.immunize.org/handouts/view-all.asp
In addition to these printed pieces, there are several interactive tools on CDC’s website. For children, go to www2a.cdc.gov/vaccines/childquiz/, and for adults, go to www2.cdc.gov/nip/adultImmSched/.
There is usually very close agreement between vaccine package inserts and ACIP statements. The Food and Drug Administration (FDA) must approve the package insert, and requires documentation for all data and recommendations made in the insert. Occasionally, ACIP may use different data to formulate its recommendations, or try to add flexibility to its recommendations, which results in wording different than in the package insert. ACIP sometimes makes recommendations based on expert opinion and public health considerations. Published recommendations of ACIP should be considered equally as authoritative as those on the package insert.
Vaccines must always be dispensed with a prescription or order from a physician or other healthcare provider authorized by the state to prescribe medications. However, there are situations where vaccines can be administered using a standing order or vaccine protocol that is not patient-specific. In these situations, a physician or other healthcare provider does not need to be physically present for the vaccine to be administered. Several studies have shown that the use of standing orders can improve vaccination rates, and ACIP recommends the use of standing orders programs in both outpatient and inpatient settings. A comprehensive set of standing orders for the routine vaccines given to children and adults can be found at www.immunize.org/standing-orders.
No. According to ACIP, vaccines administered outside the U.S. generally can be accepted as valid if the schedule (i.e., minimum ages and intervals) is similar to that recommended in the U.S. However, with the exception of the influenza and pneumococcal polysaccharide vaccines, only written documentation should be accepted as evidence of previous vaccination. In general, if records cannot be located or will definitely not be available anywhere because of the patient’s circumstances, children without adequate documentation should be considered susceptible and should be started on the age-appropriate vaccination schedule. Serologic testing for immunity is an alternative to vaccination for certain antigens. More information is available in the ACIP “General Best Practice Guidelines for on Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html.
Effective December 14, 2009, the CDC revised the vaccination criteria for U.S. immigration. CDC will use these criteria for vaccines recommended by the ACIP to decide which vaccines will be required for U.S. immigration. The criteria will be used at regular periods, as needed, by CDC. The new criteria are:
- The vaccine must be age-appropriate* for the immigrant applicant, AND at least one of the following:
- The vaccine must protect against a disease that has the potential to cause an outbreak, OR
- The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States.
*ACIP recommends vaccines for a certain age range in the general U.S. public. These ACIP recommendations will be used to decide which vaccines are age-appropriate for the general immigrant population.
Current immigration law requires that immigrants have proof of vaccination against mumps, measles, rubella, tetanus, diphtheria, pertussis, meningococcal disease, pneumococcal disease, Haemophilus influenzae type B, rotavirus, varicella, influenza, hepatitis A, hepatitis B, and polio. Human papillomavirus (HPV) and zoster vaccines are not required for immigrants. Additional information is available on the CDC website at www.cdc.gov/immigrantrefugeehealth/laws-regs/vaccination-immigration/revised-vaccination-criteria-immigration.html.
Children adopted from outside the U.S. and political refugees are recommended to receive age-appropriate vaccination, with catch-up vaccination as appropriate, per the guidance in ACIP’s “General Best Practice Guidelines for Immunization” (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html). People entering the U.S. as visitors are not required to provide proof of vaccination regardless of the length of stay.
ACIP recommends that people working in healthcare settings be vaccinated against influenza, hepatitis B, measles, mumps, rubella, varicella, and pertussis. For measles, mumps, rubella, and varicella, serologic evidence of immunity is an acceptable substitute for documentation of vaccination. In addition, microbiologists working in a laboratory should receive meningococcal conjugate and meningococcal serogroup B vaccines. In rare cases, some laboratory personnel should also receive polio and typhoid vaccines. For more information, see www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.
You can get this information from CDC’s Travel Health website at wwwnc.cdc.gov/travel/. CDC also publishes Health Information for International Travel (a.k.a. the “Yellow Book”) as a reference for those who advise international travelers of health risks. The Yellow Book is written primarily for healthcare providers, although others might find it useful. The contents of the book are available on the CDC Travel Health website. The book can also be ordered in print form. Information on how to order it is on the Yellow Book website at wwwnc.cdc.gov/travel/page/yellowbook-home.
Infants who will travel outside the United States should be up to date for all routinely recommended vaccines. One dose of MMR is recommended for infants age 6 through 11 months before international travel. This dose does not count toward the two doses needed to complete the childhood schedule. Infants 6 through 11 months of age traveling to an area at risk for hepatitis A exposure also should receive a dose of hepatitis A vaccine. This dose does not count toward the two doses needed to complete the childhood schedule. Infants younger than age 12 months traveling to a hepatitis A endemic area are not recommended to receive immune globulin for prevention of hepatitis A because immune globulin could interfere with the response to MMR. Varicella vaccine is not recommended before age 12 months, even for travelers. For other vaccine recommendations for travelers, consult the CDC travel website at wwwnc.cdc.gov/travel/.
Due to the variety of causes and consequences of altered immunocompetence, and limited studies of vaccination with these conditions, vaccination recommendations for primary and secondary immunodeficiencies are generally based upon expert opinion.
CDC’s “General Best Practice Guidelines for Immunization” outline vaccine recommendations for people with various types of altered immunocompetence here: www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. For a summary of specific vaccine recommendations for people with different types of primary and secondary immunodeficiencies, refer to Table 8-1 at that site. Additional information is available in the 2013 Infectious Diseases Society of America (IDSA) expert guideline on vaccination of the immunocompromised host, which informed CDC’s recommendations: www.idsociety.org/practice-guideline/vaccination-of-the-immunocompromised-host/.
People who do not have a functioning spleen or who have had a splenectomy are at increased risk for infection with encapsulated bacteria, especially Pneumococcus, Neisseria meningitidis, and Haemophilus influenzae type b (Hib).
In addition to receiving routine vaccinations, children and adults without a functioning spleen who are age 2 years and older should receive 1 dose of pneumococcal polysaccharide vaccine (PPSV) at least 8 weeks after the last dose of pneumococcal conjugate vaccine (PCV). Adults should receive 1 dose of PCV either 8 weeks before PPSV, or 1 year after PPSV. If younger than 65, a second dose of PPSV should be administered 5 years after the first dose, with a third and final dose at age 65 (or 5 years after the previous dose, whichever comes later). Only one PPSV dose should be given to someone age 65 or older.
All asplenic persons should receive a primary series of at least 2 doses of meningococcal ACWY vaccine (MenACWY) with a booster dose every 5 years. See the MenACWY recommendation table at www.immunize.org/catg.d/p2018.pdf for details. Asplenic people age 10 years and older should also receive a series (either 2 or 3 doses depending on the vaccine brand) of meningococcal serogroup B vaccine (MenB) with an initial booster dose one year after completion of the primary series and subsequent booster doses every 2–3 years thereafter.
Two doses of Hib vaccine should be given to unimmunized children 12–59 months of age (defined as a child who received zero or 1 dose before 12 months of age). A single dose of Hib vaccine should be administered to unimmunized people age 5 years or older (defined as those who have not received at least 1 dose of Hib vaccine after 14 months of age).
Ideally, vaccination with both types of pneumococcal (conjugate [PCV] and polysaccharide [PPSV]), both types of meningococcal (MenACWY and MenB), and Hib vaccine should all be completed at least 2 weeks before a scheduled splenectomy, if time permits. When preparing a patient for splenectomy, follow the dosing recommendations for a patient who is already asplenic.
Vaccine doses administered within the two-week period before surgery or after surgery are valid; however, administration at least two weeks before surgery ensures the patient is protected from the moment the spleen is removed. Completing all doses preoperatively requires advanced planning based on the age and vaccination history of the patient. If vaccinations cannot be completed, administer as many as feasible at least 2 weeks prior to surgery. Postponing splenectomy to complete vaccination is not recommended.
Because the most likely vaccine-preventable threat to the patient is from pneumococcal sepsis, CDC subject matter experts consider PCV the highest priority vaccine to administer before splenectomy. PPSV must be administered at least 8 weeks after PCV. Splenectomy patients require a two-dose primary series of MenACWY, given at least 8 weeks apart. Because the Menactra brand of MenACWY may interfere with the immune response to PCV, the first dose of Menactra in asplenic patients should be delayed 4 weeks after PCV. PCV may be administered at the same visit with (or any time before or after) Menveo or MenQuadfi brands of MenACWY. The MenB primary vaccination series requires 2–3 doses, depending upon the brand.
If vaccines are not administered before surgery, they should be administered as soon as the person’s condition stabilizes post-operatively.
Since the patient is asplenic, the second dose of the primary series of MenACWY should be given at least 8 weeks after the first dose. He will need a dose of MenACWY every 5 years for the rest of his life. The series of MenB (whether Trumenba or Bexsero) should be completed. The first booster dose of MenB will be due one year after completion of the primary series and subsequent booster doses are recommended every 2–3 years for the rest of his life. The same MenB vaccine should be used for all doses in the series, including booster doses. The patient has already received the one dose of PCV13 recommended for adults, so no further doses are needed. He also has properly received his first dose of PPSV at least 8 weeks after the dose of PCV13. A second PPSV dose will be due at least 5 years after the first dose of PPSV. A third (and final) dose of PPSV should be given after the patient turns age 65. Based on the patient’s age, only one dose of Hib vaccine is recommended, so no further doses are needed. The patient should receive influenza vaccine annually.
Any of these vaccines can be given at the same appointment, except for PCV13 and PPSV23, and PCV13 and the Menactra brand of MenACWY. If Menactra is used for an asplenic person it should be separated from the PCV13 by at least 4 weeks. Menveo and MenQuadfi brands may be given at any time relative to PCV13.
Preterm infants should be vaccinated at the same chronological age and according to the same schedule as full-term infants, regardless of birth weight, with the exception of the birth dose of hepatitis B vaccine. Infants weighing less than 2 kg (4.4 lb) whose mothers’ HBsAg status is either positive or unknown should receive HBIG (hepatitis B immune globulin) and hepatitis B vaccine within 12 hours of birth. This dose of hepatitis B vaccine should not be counted as a valid first dose in the series, and it should be repeated at age 1 month. If the preterm infant’s mother’s HBsAg status is negative, the infant’s first dose of hepatitis B vaccine should be withheld until the infant is chronologically 1 month of age or is ready to be discharged from the hospital, whichever occurs first. For more information, see the Vaccination of Preterm Infants section of the ACIP “General Best Practice Guidelines for Immunization”, available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html.