For the schedule of vaccinations for infants and children, see Table 12: Approach to the Care of Normal Infants and Children: Recommended Immunization Schedule for Ages 0–6 yr(see also the Centers for Disease Control and Prevention's [CDC's] Childhood Immunization Schedule).

For vaccinations to be considered for all adults, see Table 2: Immunization: Common Vaccinations for Adults. (See also the CDC's Adult Immunization Schedule) Uses of nonroutine active vaccines (eg, for rabies, typhoid, yellow fever, and mycobacterial infections) and some routine vaccinations are discussed under specific disorders elsewhere in The Manual.

Table 2
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Common Vaccinations for Adults Vaccine Dose Indications Contraindications Haemophilus influenzae type b (Hib) conjugate vaccine 0.5 mL IM once Adults at high risk because of an immunocompromised state (eg, due to HIV infection), although the vaccine is not approved for use in adults History of anaphylaxis after vaccine or components Hepatitis A 1 mL IM initially and at 6–12 mo after the initial dose Anyone requesting vaccination or at increased risk, eg, because of the following: Travel to endemic areas Occupational exposure (eg, military employment) A chronic liver disorder Sex between men Use of illicit injected drugs Treatment with blood clotting factors Known hypersensitivity Hepatitis B 1.0 mL IM initially, then at 1–2 mo and at 4–6 mo after the initial dose Adults at high risk, eg, because of the following: Travel to endemic areas Likely to have repeated or occupational exposure (eg, health care workers, sex partner or household contact of a known carrier) A chronic liver disorder Hemodialysis Sex between men Multiple sex partners Use of illicit injected drugs History of anaphylactic reaction to common baker's yeast Herpes zoster 0.7 mL sc Anyone > 60 Same as varicella Human papillomavirus (HPV) 0.5 mL IM initially, then at 2 mo and 6 mo after the initial dose Females aged 9–26, but ideally at age 11–12 Pregnancy or history of anaphylaxis after an earlier dose Influenza, inactivated trivalent vaccine (TIV) 0.5 mL IM yearly Adults > 50, any one who requests vaccination, and anyone at high risk of complications, eg, because of the following: A chronic cardiovascular or pulmonary disorder Metabolic disorders (especially diabetes) Renal or hepatic dysfunction Hemoglobinopathies Immunosuppression HIV infection Residence in a long-term care facility Employment in health care facilities High fever, history of anaphylactic reactions to egg protein Influenza, live-attenuated vaccine (LAIV) 0.1 mL in each nostril once/yr Healthy people aged 5–49 Aspirin therapy, history of Guillain-Barré syndrome, pregnancy, asthma, chronic cardiorespiratory disorders, hemoglobinopathies, immunocompromised state Measles-mumps-rubella 0.5 mL sc initially and sometimes a 2nd dose Anyone who was born after 1956 and never had the vaccine or been infected 2nd dose for people with any of the following: Exposure to one of the infections Prior measles vaccine Likely to be exposed (eg, college students, health care workers, international travelers) Pregnancy, immunocompromised state, history of anaphylactic reactions to gelatin or neomycin, active TB (untreated), recent treatment with immune globulin Meningococcal polysaccharide or conjugate 0.5 mL sc for polysaccharide and IM for conjugate Adults at increased risk, eg, because of the following: Asplenia Travel to endemic areas First year of residence in a college dormitory or recruitment into the military if they have not already been vaccinated Sensitivity to thimerosal for polysaccharide, sensitivity to latex for conjugate, history of Guillain-Barré syndrome Pneumococcal pneumonia 0.5 mL IM or sc Anyone at high risk, eg, because of the following: HIV A chronic cardiac, pulmonary, or liver disorder Chronic alcoholism Asplenia CSF leaks Age ≥ 65 Pregnancy (relative contraindication) Tetanus and diphtheria toxoids adsorbed (Td) or tetanus-diphtheria-acellular pertussis (Tdap) 0.5 mL IM initially, then at 1 mo and 6 mo after the initial dose (primary series); booster vaccinations given q 10 yr Primary series for anyone who has never been vaccinated Booster vaccinations q 10 yr for all people History of severe allergic reaction to the vaccine Varicella 0.5 mL sc initially and at 1–2 mo after the initial dose Anyone never infected nor vaccinated, especially health care and child care workers Pregnancy, immunocompromised state, treatment with immune globulin or a blood transfusion within 5 mo, history of anaphylactic reactions to neomycin or gelatin, active TB (untreated), febrile infection Common Vaccinations for Adults Vaccine Dose Indications Contraindications Haemophilus influenzae type b (Hib) conjugate vaccine 0.5 mL IM once Adults at high risk because of an immunocompromised state (eg, due to HIV infection), although the vaccine is not approved for use in adults History of anaphylaxis after vaccine or components Hepatitis A 1 mL IM initially and at 6–12 mo after the initial dose Anyone requesting vaccination or at increased risk, eg, because of the following: Travel to endemic areas Occupational exposure (eg, military employment) A chronic liver disorder Sex between men Use of illicit injected drugs Treatment with blood clotting factors Known hypersensitivity Hepatitis B 1.0 mL IM initially, then at 1–2 mo and at 4–6 mo after the initial dose Adults at high risk, eg, because of the following: Travel to endemic areas Likely to have repeated or occupational exposure (eg, health care workers, sex partner or household contact of a known carrier) A chronic liver disorder Hemodialysis Sex between men Multiple sex partners Use of illicit injected drugs History of anaphylactic reaction to common baker's yeast Herpes zoster 0.7 mL sc Anyone > 60 Same as varicella Human papillomavirus (HPV) 0.5 mL IM initially, then at 2 mo and 6 mo after the initial dose Females aged 9–26, but ideally at age 11–12 Pregnancy or history of anaphylaxis after an earlier dose Influenza, inactivated trivalent vaccine (TIV) 0.5 mL IM yearly Adults > 50, any one who requests vaccination, and anyone at high risk of complications, eg, because of the following: A chronic cardiovascular or pulmonary disorder Metabolic disorders (especially diabetes) Renal or hepatic dysfunction Hemoglobinopathies Immunosuppression HIV infection Residence in a long-term care facility Employment in health care facilities High fever, history of anaphylactic reactions to egg protein Influenza, live-attenuated vaccine (LAIV) 0.1 mL in each nostril once/yr Healthy people aged 5–49 Aspirin therapy, history of Guillain-Barré syndrome, pregnancy, asthma, chronic cardiorespiratory disorders, hemoglobinopathies, immunocompromised state Measles-mumps-rubella 0.5 mL sc initially and sometimes a 2nd dose Anyone who was born after 1956 and never had the vaccine or been infected 2nd dose for people with any of the following: Exposure to one of the infections Prior measles vaccine Likely to be exposed (eg, college students, health care workers, international travelers) Pregnancy, immunocompromised state, history of anaphylactic reactions to gelatin or neomycin, active TB (untreated), recent treatment with immune globulin Meningococcal polysaccharide or conjugate 0.5 mL sc for polysaccharide and IM for conjugate Adults at increased risk, eg, because of the following: Asplenia Travel to endemic areas First year of residence in a college dormitory or recruitment into the military if they have not already been vaccinated Sensitivity to thimerosal for polysaccharide, sensitivity to latex for conjugate, history of Guillain-Barré syndrome Pneumococcal pneumonia 0.5 mL IM or sc Anyone at high risk, eg, because of the following: HIV A chronic cardiac, pulmonary, or liver disorder Chronic alcoholism Asplenia CSF leaks Age ≥ 65 Pregnancy (relative contraindication) Tetanus and diphtheria toxoids adsorbed (Td) or tetanus-diphtheria-acellular pertussis (Tdap) 0.5 mL IM initially, then at 1 mo and 6 mo after the initial dose (primary series); booster vaccinations given q 10 yr Primary series for anyone who has never been vaccinated Booster vaccinations q 10 yr for all people History of severe allergic reaction to the vaccine Varicella 0.5 mL sc initially and at 1–2 mo after the initial dose Anyone never infected nor vaccinated, especially health care and child care workers Pregnancy, immunocompromised state, treatment with immune globulin or a blood transfusion within 5 mo, history of anaphylactic reactions to neomycin or gelatin, active TB (untreated), febrile infection

Diphtheria-Tetanus-Pertussis

Preparations

Diphtheria (D) vaccines contain toxoids prepared from Corynebacterium diphtheriae. Tetanus (T) vaccines contain toxoids prepared from Clostridium tetani. Acellular (a) pertussis (P) vaccines contain semipurified or purified components of Bordetella pertussis. Whole-cell pertussis vaccine is no longer available in the US because of concerns about adverse effects, but it is still available in other parts of the world. There are 2 preparations of the acellular vaccine:

• DTaP for children < 7 yr
• Tdap for adolescents and adults

Tdap contains lower doses of diphtheria and pertussis components (indicated by the lower case d and p).

Administration

The vaccine is given as 5 primary and 1 booster IM injections during childhood as follows: the first 3 doses at 2-mo intervals, starting at age 2 mo; the 4th at age 12 to 15 mo; and the last before school entry at age 4 to 6 yr. A single booster of Tdap is given at age 11 or 12 yr.

Adverse effects

Adverse effects are rare and are mostly attributable to the pertussis component. They include encephalopathy within 7 days; a seizure, with or without fever, within 3 days; persistent, severe, inconsolable screaming or crying for ≥ 3 h; collapse or shock within 48 h; temperature of ≥ 40.5° C, unexplained by another cause, within 48 h; and immediate severe or anaphylactic reaction to the vaccine. These reactions contraindicate further use of pertussis vaccine; combined diphtheria and tetanus vaccine is available without the pertussis component.

Mild adverse effects include redness, swelling, and soreness at the injection site.

Tetanus-Diphtheria

Although tetanus is rare in the US, it has a high mortality rate. Because ¹/₃ of cases occur unpredictably (after minor or inapparent injuries), universal tetanus vaccination remains necessary.

Preparations

The most widely used preparations combine tetanus toxoid with diphtheria toxoid (Td for adults, DT for children); a preparation with only tetanus toxoid (TT) is also available. Td contains a lower dose of diphtheria toxoid than DTaP and DT, which are used in children.

Administration

Td boosters, 0.5 mL IM, are given every 10 yr after the Tdap booster that is given at age 11 to 12 yr. Boosters are needed to maintain immunity. Because the incidence of pertussis is increasing, at least one booster before age 65 should be Tdap. Adults who missed the primary series of vaccinations in childhood should receive it as adults.

Adverse effects

Adverse effects are very rare. They include anaphylactic reactions, Guillain-Barré syndrome, and brachial neuritis. Mild effects include redness, swelling, and soreness at the injection site.

Haemophilus influenzae Type b

Preparations

These vaccines are prepared from the purified capsule of Haemophilus influenzae type b (Hib). All Hib vaccines use polyribosylribitol phosphate (PRP) as the polysaccharide, but 4 different protein carriers produce 4 different Hib conjugate vaccines: diphtheria toxoid (PRP-D), Neisseria meningitidis outer membrane protein (PRP-OMP), tetanus toxoid (PRP-T), and diphtheria mutant carrier protein CRM₁₉₇ (HbOC).

Administration

A primary series is given in 3 IM doses at age 2, 4, and 6 mo or in 2 IM doses at age 2 and 4 mo, depending on the formulation. In either case, a booster is recommended at age 12 to 15 mo. Some adults at increased risk (eg, because of AIDS or asplenia) may benefit from this vaccine.

Adverse effects

Adverse effects are rare. They can include pain, redness, and swelling at the injection site.

Hepatitis A

Preparations

Hepatitis A vaccines are prepared from formalin-inactivated, cell culture–derived hepatitis A virus. There are 2 formulations; either can be used in children or adults.

Administration

The vaccine is given in 2 IM doses 6 mo apart. It is recommended for children aged 12 to 18 mo and for older children and adults who are at increased of the disease (see Table 2: Immunization: Common Vaccinations for Adults).

Adverse effects

No serious adverse effects have been reported. Mild effects include pain and occasionally induration at the injection site.

Hepatitis B

Preparations

Hepatitis B vaccine uses recombinant DNA technology. Single-antigen and combination formulations are available.

Administration

The vaccine is given in 2 or 3 IM doses, depending on the formulation. Universal vaccination is recommended beginning at birth.

Adverse effects

Serious adverse effects are very rare and include anaphylaxis. Mild effects include pain at the injection site and occasionally an increase in temperature to > 38°C.

Human Papillomavirus

Preparations

Recombinant technology is used to prepare the vaccine. The vaccine is made from HPV-like particles (VLP) from serotypes 6, 11, 16, and 18, which cause 70% of cervical cancers and 90% of genital warts.

Administration

The vaccine is given in 3 IM doses: initially, then at 1 to 2 and 4 to 6 mo after the initial dose. It is recommended for females aged 11 to 13 but can be given as early as age 9 or up to age 26 for catch-up. Vaccination is not recommended after age 26.

Adverse effects

No serious adverse effects have been reported. Mild effects include redness, swelling, and tenderness at the injection site.

Influenza

Preparations

Influenza vaccines may be inactivated trivalent vaccines (TIV) or live-attenuated vaccines (LAIV). Each type targets 3 virus strains (2 from influenza A and 1 from influenza B). Because antigenic drift is continual, 1 or 2 strains are changed each year in anticipation of the expected predominant influenza strains. An inactivated vaccine against avian influenza has been developed but is not commercially available. It is being nationally stockpiled in case person-to-person transmission of avian influenza becomes possible.

Administration

The vaccine is required annually for at-risk patients because of antigenic drift. Because outbreaks usually begin in early winter or midwinter, the vaccine is given in the fall, usually October and November in the Northern Hemisphere.

TIV, given as a single IM injection, is recommended for people at high risk of serious sequelae, including children aged 6 mo to 8 yr and anyone > 50 yr (see Table 2: Immunization: Common Vaccinations for Adults), as well as anyone who requests vaccination.

LAIV, given as an intranasal spray, is indicated for healthy people aged 2 to 49 yr; it is contraindicated during pregnancy.

Adverse effects

Rarely, TIV has adverse effects, such as Guillain-Barré syndrome, anaphylactic reactions, soreness at the injection site, and fever. Adverse effects of LAIV are unusual; they include possible triggering of asthma and transmission of the virus to unimmunized contacts.

Egg protein is used in both vaccine types; thus, the vaccine is contraindicated for people who have severe anaphylactic reactions to egg protein.

Measles, Mumps, and Rubella

Preparations

The vaccine contains live-attenuated virus prepared in chicken embryo cell cultures. Measles vaccine is available as a single-antigen (measles-only) vaccine or combined with rubella (MR), mumps and rubella (MMR), or mumps, rubella, and varicella (MMRV). There are also single-antigen vaccines for mumps, rubella, and varicella.

Administration

Most commonly, the combination vaccine MMR or MMRV is given sc. The vaccine should be given to all children in their 2nd yr of life, typically at age 12 to 15 mo, with a 2nd dose at age 4 to 6 yr. Adults at risk include those who have never received the vaccine and have never become naturally infected. Generally, people born before 1956 are considered immune because infection during their childhood was ubiquitous. Unless the vaccine is contraindicated, people who were born after 1956 and have not had 2 doses of the vaccine or the infections should receive at least one dose of the combined vaccine; people who have been or are likely to be exposed (eg, college students, health care workers, international travelers) should receive a 2nd dose.

Although the components of the vaccine can be given separately, the combined form is preferred because people who need one vaccine probably need all 3, and revaccination poses no particular risk.

Adverse effects

A mild, noncommunicable infection occurs in 15% of vaccine recipients. Symptoms appear 7 to 11 days after immunization and include fever, malaise, and a measles-like exanthem. Mumps vaccine has adverse effects only rarely; they include encephalitis (only from a Japanese mumps vaccine strain), seizures, nerve deafness, parotitis, purpura, rash, and pruritus.

Rubella vaccine can cause joint pain, usually in the small peripheral joints 2 to 8 wk after immunization, in < 1% of infants but in ≤ 26% of women. Rash or lymphadenopathy occasionally occurs. The vaccine is not recommended for pregnant women because of the theoretic risk to the fetus. However, inadvertent administration during pregnancy does not necessarily mean a therapeutic abortion is recommended because the actual fetal risk may be nil.

With all of the vaccine formulations, local adverse effects are unusual and include soreness at the injection site.

Pneumococcal Disease

Preparations

Pneumococcal conjugate vaccine (PCV7) contains 7 purified capsular polysaccharides of Streptococcus pneumoniae; each is coupled to a variant of diphtheria toxin. Pneumococcal polysaccharide vaccine (PPV23) contains antigens from the 23 most virulent of the 83 subtypes of S. pneumococcus. Unlike the older 23-valent vaccine, PCV7 can stimulate antibody responses in infants. It also seems to confer greater protection against invasive pneumococcal disorders than PPV23. PPV23 reduces bacteremia by 56 to 81% in adults overall but is less effective in debilitated elderly people. It reduces pneumonia incidence only minimally.

Administration

PCV7 is recommended as a 4-dose IM series for infants at age 2, 4, 6, and 12 to 15 mo. Children at high risk of pneumococcal disease (eg, children with sickle cell disease, asplenia, or a chronic disorder) should receive a dose of PPV23 at age 24 mo and an additional dose 3 to 5 yr after the first. PPV23 should be given to any older child or adult at high risk of pneumococcal disease (see Table 2: Immunization: Common Vaccinations for Adults). One immunization is recommended for lifetime protection; however, revaccination after 5 yr should be considered for patients at particularly high risk.

Adverse effects

Adverse effects are usually mild and include fever, irritability, drowsiness, anorexia, vomiting, and local erythema.

Poliomyelitis

Preparations

Inactivated poliovirus vaccine (IPV) contains a mixture of formalin-inactivated poliovirus types 1, 2, and 3. IPV may contain trace amounts of streptomycin, neomycin, and polymyxin B. A combination vaccine with IPV, DTaP, and hepatitis B is also available. The live-attenuated oral formulation is no longer available in the US because it causes polio in about 1 of every 2.4 million people who receive the vaccine.

Administration

A 4-dose IM series is given at age 2 mo, 4 mo, 6 to 18 mo, and 4 to 6 yr. Typically, a combination vaccine is used for the first 3 vaccinations and a single-antigen vaccine for the last dose.

Adverse effects

No adverse effects have been associated with IPV. Because it may contain trace amounts of neomycin, streptomycin, and polymyxin B, people who are sensitive to any of these drugs may have an allergic reaction to the vaccine.

Varicella

Preparations

The vaccine contains an attenuated wild strain of varicella and trace amounts of gelatin and neomycin. It is available as a single-antigen vaccine or as a combination vaccine with MMR.

Administration

The vaccine is given sc in 2 doses: at age 12 to 15 mo and at age 4 to 6 yr. The 2nd dose is a new recommendation; thus, a catch-up dose is suggested for children, adolescents, and adults who have received only one dose. The vaccine should be given to all children and to young adults not previously infected, especially health care practitioners and close contacts of immunocompromised patients. If adults have not had varicella, levels of protective antibodies should be measured to determine the need for vaccination. No immune globulins, particularly varicella-zoster immune globulin, should be given within 5 mo before or 2 mo after vaccination because immune globulins may prevent development of protective antibodies.

Adverse effects

Adverse effects are minimal and include transient pain, tenderness, and redness at the injection site. Occasionally, within 1 mo of vaccination, a mild maculopapular or varicella-like rash develops. Patients who develop this rash should avoid contact with immunocompromised people until it resolves. Spread of the virus from vaccine recipients to susceptible people has been documented in < 1% of recipients but only from those who developed a rash.

Because Reye's syndrome can develop, recipients < 16 yr should avoid salicylates for 6 wk.

Herpes Zoster

Preparations

The vaccine contains an attenuated wild strain of varicella, similar to the varicella vaccine but with a higher amount of the attenuated virus.

Administration

The vaccine is recommended for adults ≥ 60 yr regardless of prior infection. It is given sc.

Adverse effects

No serious adverse effects have been reported. Soreness at the site of the injection may occur.

Simultaneous Administration of Different Vaccines

Simultaneous administration is safe, effective, and convenient; it is particularly recommended when children may be unavailable for future vaccination or when adults require multiple simultaneous vaccines (eg, before international travel). Simultaneous administration may involve combination vaccines (see Table 1: Immunization: Vaccines Available in the US) or use of ≥ 1 single-antigen vaccines. More than one vaccine may be given at the same time using different injection sites and syringes. If live-virus vaccines (varicella and MMR) are not given at the same time, they should be given at least 4 wk apart.

Immunizations for Travelers

Immunizations may be required for travel to areas where infectious diseases are endemic. The Centers for Disease Control and Prevention can provide information; a telephone service (1-877-394-8747) and web site (wwwnc.cdc.gov/travel/) are available 24 h/day.

Last full review/revision July 2008 by Fred H. Rubin, MD