Online Medical Reference

Adult Immunization

Patricia Dandache, MD

Published: January 18, 2019


Introduction

Vaccination is safe, effective, and underused—many thousands of lives are still lost to vaccine-preventable infectious diseases. The need for vaccination persists in adulthood, due to waning of childhood vaccination as well as due to added risk for vaccine-preventable illnesses in certain adults with special predisposing risk factors such as immunodeficiency, certain jobs, travel, pregnancy, lifestyle, or certain health conditions. Every year, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) reviews and updates the adult immunization schedule. Below is a summary of recommended vaccinations in persons 19 years and older (Table 1), based on the ACIP/CDC recommended vaccination schedule that became effective in February 2018. This schedule has been endorsed by numerous professional medical organizations including the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American College of Nurse-Midwives.1,2


Table 1: Immunizations for Adults 19 Years and Older, 2018
Refer to text for contraindications and use in special populations
Influenza
1 dose of inactivated influenza vaccine or recombinant influenza vaccine annually
Tetanus, diphtheria, pertussis
1 dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap), then tetanus and diphtheria toxoids (Td) booster every 10 years
Measles, mumps, rubella
1 or 2 doses depending on indication (if born in 1957 or later)
Varicella
2 doses of varicella vaccine
Zoster
2 doses of recombinant zoster vaccine (age > 50, preferred) or 1 dose of zoster vaccine live (age > 60)
Human papillomavirus
2 or 3 doses of human papillomavirus vaccine depending on age at series initiation (through age 26, select population, see text for details)
Pneumococcal
1 dose of 13-valent pneumococcal conjugate vaccine or 1 or 2 doses of 23-valent pneumococcal polysaccharide vaccine, depending on indication
Hepatitis A
2 or 3 doses of hepatitis A vaccine, depending on vaccine
Hepatitis B
3 doses of hepatitis B vaccine
Meningococcal
1 or 2 doses of serogroups A, C, W, and Y meningococcal vaccine (MenACWY) depending on indication, then booster every 5 years if risk remains
2 or 3 doses of serogroup B meningococcal vaccine (MenB), depending on vaccine
Haemophilus influenzae
1 or 3 doses of Haemophilus influenzae type b vaccine, depending on indication

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Influenza Vaccination

In the absence contraindications, routine annual immunization with age-appropriate influenza vaccination is recommended. This includes pregnant women and adults with hives-only egg allergy. In adults with egg allergy other than hives (eg, angioedema or respiratory distress), administer inactivated influenza vaccine or recombinant influenza vaccine in a medical setting under supervision of a health care provider who can recognize and manage severe allergic conditions. Live attenuated influenza virus was not recommended for the 2017-2018 season due to low effectiveness against influenza A H1N1 pdm09 of the 2013-2014 season,3 but is again a recommended option for 2018-2019, for people in whom it is an option (healthy nonpregnant ages 2 to 49).

Contraindications and Precautions for Influenza Vaccines in Adults

  • History of Guillain-Barré syndrome within 6 weeks after previous influenza vaccination
  • History of severe allergic reaction to any component of the vaccine, or after previous dose of any influenza vaccine
  • Live attenuated influenza virus is contraindicated in people older than 50, in pregnancy, in any immunocompromised patient, and in those in close contact with or caregivers of immunocompromised persons, or if influenza antiviral medicine was given in preceding 48 hours.

A variety of influenza vaccines are available; see www.cdc.gov/flu/protect/vaccine/vaccines.htm

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Tetanus, Diphtheria and Acellular Pertussis Vaccination

Adults who have not already received a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) as an adult or child (routinely recommended at age 11–12 years) should get 1 dose of Tdap, followed by a dose of tetanus and diphtheria toxoids (Td) booster every 10 years.

In pregnant women, give 1 dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27 through 36.
For information on the use of Tdap or Td as tetanus prophylaxis in wound management, see: www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.

Tdap and other pertussis-containing vaccines are contraindicated in those with a history of encephalopathy, eg, coma, decreased level of consciousness, or prolonged seizures, not attributable to another identifiable cause, that occurred within 7 days of administration of a previous dose of a vaccine containing tetanus or diphtheria toxoid or acellular pertussis. Also, Tdap is contraindicated if severe allergic reaction has occurred after a previous dose or to a vaccine component.

Use tetanus, diphtheria, and acellular pertussis vaccination with caution in those with:

  • Guillain-Barré syndrome within 6 weeks after a previous dose of tetanus toxoid-containing vaccine
  • History of Arthus-type hypersensitivity reactions after a previous dose of tetanus or diphtheria toxoid-containing vaccine. Defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine
  • Progressive or unstable neurologic disease. Vaccination should be deferred until neurologic status clarified or stabilized.
  • Moderate or severe acute illness, febrile or not.

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Measels, Mumps, and Rubella Vaccination (MMR)

Adults born in 1957 or later should receive at least 1 dose of MMR vaccine unless they have evidence of immunity.

Evidence of immunity is:

  • Born before 1957 (except for health care personnel, see below)
  • Documented receipt of MMR
  • Laboratory evidence of immunity or disease (documentation of a health care provider-diagnosed disease without laboratory confirmation is not considered evidence of immunity).

In an update from October 25, 2017, the ACIP stated that adults who previously received ≤ 2 doses of mumps-containing vaccine and who are identified by a public health authority to be at increased risk of mumps during an outbreak should receive a dose of MMR.4


Special Populations

Pregnant women with no evidence of immunity to rubella: give 1 dose of MMR before discharge from the health care facility postpartum.
Give 2 doses of MMR at least 28 days apart (or 1 dose if they previously received 1 dose of MMR) in the following groups:

  • Human immunodeficiency virus (HIV) infection and CD4 cell count ≥ 200 cells/μL for at least 6 months and no evidence of immunity to measles, mumps, or rubella.
  • Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons (or 1 dose if MMR previously received)
  • Health care personnel born in 1957 or later with no evidence of immunity for measles or mumps, or 1 dose of MMR for rubella (if born before 1957, consider MMR vaccination).

MMR is contraindicated in those with:

  • Severe immunodeficiency, eg, hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy, HIV infection with severe immunocompromised state. Immunosuppressive steroid dose is considered to be daily receipt of 20 mg or more prednisone or equivalent for 2 or more weeks. Vaccination should be deferred for at least 1 month after discontinuation of immunosuppressive steroid therapy. Providers should consult ACIP recommendations for complete information on the use of specific live vaccines among persons on immune-suppressing medications or with immune suppression because of other reasons.
  • Anaphylaxis to neomycin
  • MMR should not be given to women who are pregnant or are attempting to be pregnant; pregnancy should be avoided until after 28 days of receipt of vaccine

Use MMR with caution in those with:

  • Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product). Vaccine should be deferred for the appropriate interval if replacement immune globulin products are being administered. See: Best practices guidance of the ACIP.
  • History of thrombocytopenia or thrombocytopenic purpura
  • Need for tuberculin skin testing. Measles vaccination may temporarily suppress tuberculin reactivity. Measles-containing vaccine may be administered on the same day as tuberculin skin testing, or should be postponed for at least 4 weeks after vaccination.

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Varicella Vaccination

Adults without evidence of immunity to varicella who have previously received no varicella-containing vaccine should receive 2 doses of varicella vaccine (VAR) 4 to 8 weeks apart. If they previously received 1 dose of varicella-containing vaccine, give 1 dose of VAR at least 4 weeks after the first dose. Evidence of immunity to varicella is:

  • US-born before 1980 (except for pregnant women and health care personnel, see below)
  • Documented receipt of 2 doses of varicella or varicella-containing vaccine at least 4 weeks apart
  • Diagnosis or verified history of varicella or herpes zoster by a health care provider
  • Laboratory evidence of immunity or disease.


Special Populations

The following groups should receive 2 doses of VAR 4 to 8 weeks apart if they previously received no varicella-containing vaccine (if they previously received 1 dose of varicella-containing vaccine, give 1 dose of VAR at least 4 weeks after the first dose):

  • Pregnant women without evidence of immunity: give the first of the 2 doses or the second dose after delivery and before discharge from health care facility.
  • Health care personnel without evidence of immunity
  • Adults with HIV infection and CD4 cell count ≤ 200 cells/μL: may receive, based on individual clinical decision, 2 doses of VAR 3 months apart.

VAR is contraindicated for pregnant women and adults with severe immunodeficiency, eg, hematologic and solid tumors, chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, or HIV infection with severe immunocompromised.

Use VAR with caution in adults with recent (within 11 months) receipt of antibody-containing blood product (blood, plasma or immunoglobulin, specific interval depends on product), or receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination), as well as in patients with thrombocytopenia.

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Zoster Vaccination

Recombinant zoster vaccine (RZV; Shingrix, GlaxoSmithKline) was approved by the US Food and Drug Administration on October 20, 2017 and is now the preferred zoster vaccine for immunocompetent persons age ≥ 50. On October 25, 2017, the ACIP recommended the following:

  • Give 2 doses of RZV 2 to 6 months apart to immunocompetent adults age 50 years or older regardless of past episodes of herpes zoster or receipt of zoster vaccine live (ZVL; Zostavax, Merck & Co.).
  • If the patient previously received ZVL, give the first of the 2 doses of RZV at least 2 months after the ZVL.
  • For adults age 60 or older, give either RZV or ZVL (RZV is preferred).5


Special populations

Adults with history of herpes zoster, adults with chronic medical illness (such as diabetes mellitus, renal failure, or rheumatoid arthritis) should receive RZV. No ACIP recommendation is made regarding use of RZV in severely immunocompromised adults; however, it does recommend RZV for mild immunosuppressed patients.

ZVL is contraindicated in pregnancy and in patients with severe immunodeficiency, eg, hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy, HIV infection with severe immunocompromise.

Use ZVL with caution with receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination).

MMR can be given together with VAR or ZVL on the same day. If not given on the same day, separate live vaccines by at least 28 days.

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Human Papillomavirus Vaccination

The ACIP recommends routine human papillomavirus (HPV) vaccination at age 11 or 12. Give HPV vaccine to females through age 26 and males through age 21, except for gay, bisexual, and other men who have sex with men, transgender people, and for immunocompromised persons (including those with HIV infection) not adequately vaccinated previously, in whom vaccination is recommended through age 26.

The number of doses of HPV vaccine to be given depends on age at initial HPV vaccination. For age over 15, if the patient has never received HPV vaccine, give a 3-dose series at 0, 1–2, and 6 months, with at least 4 weeks between first and 2nd dose, 12 weeks between second and third dose and 5 months between first and third dose. If initiating vaccination before age 15, 2 doses of HPV vaccine are recommended, given at intervals 0 and 6 to 12 months.


Special Populations

Adults with immunocompromising conditions (including HIV infection) should be vaccinated through age 26 years with 3-dose series at 0, 1–2, and 6 months.

Men who have sex with men are advised to get vaccinated through age 26 years: give 2- or 3-dose series depending on age at initial vaccination (see above); if no history of HPV vaccine, administer 3-dose series at 0, 1–2, and 6 months.

Pregnant women through age 26 years: HPV vaccination is not recommended during pregnancy, but there is no evidence that the vaccine is harmful and no intervention is needed for women who inadvertently receive HPV vaccine while pregnant; delay remaining doses until after pregnancy; pregnancy testing is not needed before vaccination. Lactating women can receive the vaccine.

HPV vaccine is contraindicated in persons with a history of immediate hypersensitivity to any vaccine component; this includes yeast (as vaccine is produced in Saccharomyces cervicae) and latex, which can be part of the tip cap of prefilled syringes of the HPV2 vaccine)

Vaccination should be deferred in people with moderate or severe acute illness; however, HPV vaccine can be given with minor acute illness.

Syncope has been the most common adverse reaction reported, and although uncommon, providers should consider observing the patient for 15 minutes after administration of vaccine.

HPV vaccine is not recommended for use in pregnancy. If pregnancy interrupts an already initiated series, this should be resumed after completion of pregnancy.

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Pneumococcal Vaccination

The ACIP recommends vaccination of all immunocompetent persons age 65 and older with both 13-valent pneumococcal conjugate vaccine (PCV 13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23) in a series; give 1 dose of PCV13 if not previously administered, followed by 1 dose of PPSV23 at least 1 year later. If PPSV23 was previously administered but not PCV13, give PCV13 at least 1 year after PPSV23.

When both PCV13 and PPSV23 are indicated, give PCV13 first (PCV13 and PPSV23 should not be administered during the same visit). Additional information on vaccine timing is available at www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.

Chronic medical conditions. Adults ages 19 through 64 with the below-listed chronic medical conditions should receive 1 dose of PPSV23 (at age 65 years or older, give 1 dose of PCV13 if not previously received, and another dose of PPSV23 at least 1 year after PCV13 and at least 5 years after PPSV23).

  • Chronic heart disease (excluding hypertension)
  • Chronic lung disease
  • Chronic liver disease
  • Alcoholism
  • Diabetes mellitus
  • Cigarette smoking.

Immunocompromising conditions. Adults age 19 years or older with the below-listed immunocompromising conditions should receive 1 dose of PCV13 followed by 1 dose of PPSV23 at least 8 weeks after PCV13, and a second dose of PPSV23 at least 5 years after the first dose of PPSV23.

  • Immunodeficiency disorders (including B- and T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders)
  • HIV infection
  • Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies)
  • Chronic renal failure and nephrotic syndrome.

Adults ages 19 years or older who have cerebrospinal fluid leak or a cochlear implant should receive with 1 dose of PCV13 followed by 1 dose of PPSV23 at least 8 weeks after PCV13 (if the dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least 5 years after the last dose of PPSV23).

PCV13 is contraindicated in patients who have had severe allergic reaction to any vaccine containing diphtheria toxoid.

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Hepatitis A Vaccination

Vaccinate adults who have a specific risk factor (see below), or lack a risk factor but want protection, with a 2-dose series of single-antigen hepatitis A vaccine (HepA; Havrix at 0 and 6–12 months or Vaqta at 0 and 6–18 months; minimum interval 6 months) or a 3-dose series of combined hepatitis A and hepatitis B vaccine (TWINRIX) at 0, 1, and 6 months; minimum intervals: 4 weeks between the first and second doses, 5 months between the second and third doses. In the October 2018 ACIP meeting, HepA was recommended for use in persons experiencing homelessness.

Risk Factors for Hepatitis A

  • Travel to or work in countries with high or intermediate hepatitis A endemicity
  • Men who have sex with men
  • Injection or noninjection drug use
  • Work with hepatitis A virus in a research laboratory or with nonhuman primates infected with hepatitis A virus
  • Clotting factor disorders
  • Chronic liver disease
  • Close, personal contact with an international adoptee (eg, household or regular babysitting) during the first 60 days after arrival in the United States from a country with high or intermediate endemicity (administer the first dose as soon as the adoption is planned)
  • Healthy adults through age 40 years who have recently been exposed to hepatitis A virus; adults older than age 40 years may receive HepA if hepatitis A immunoglobulin cannot be obtained.

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Hepatitis B Vaccination

Vaccinate adults who have a specific risk factor (see below), or lack a risk factor but are requesting protection. Schedule: 3-dose series of single-antigen hepatitis B vaccine (HepB) or combined hepatitis A and hepatitis B vaccine (HepA-HepB) at 0, 1, and 6 months (minimum intervals: 4 weeks between doses 1 and 2 for HepB and HepA-HepB; between doses 2 and 3, 8 weeks for HepB and 5 months for HepA-HepB).

Risk Factors for Hepatitis B

  • Chronic liver disease (eg, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase or aspartate aminotransferase level greater than twice the upper limit of normal)
  • HIV infection
  • Percutaneous or mucosal risk of exposure to blood (eg, household contacts of hepatitis B surface antigen [HBsAg]-positive persons; adults younger than age 60 years with diabetes mellitus or aged 60 years or older with diabetes mellitus based on individual clinical decision; adults in predialysis care or receiving hemodialysis or peritoneal dialysis; recent or current injection drug users; health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids)
  • Sexual exposure risk (eg, sex partners of HBsAg-positive persons; sexually active persons not in a mutually monogamous relationship; persons seeking evaluation or treatment for a sexually transmitted infection; and men who have sex with men)
  • Receiving care in settings where a high proportion of adults have risks for hepatitis B infection (eg, facilities providing sexually transmitted disease treatment, drug-abuse treatment and prevention services, hemodialysis and end-stage renal disease programs, institutions for developmentally disabled persons, health care settings targeting services to injection drug users or men who have sex with men, HIV testing and treatment facilities, and correctional facilities)
  • Travel to countries with high or intermediate hepatitis B endemicity.


Special Populations

Pregnant women with risk for hepatitis B virus infection (such as multiple sexual partners in last 6 months, evaluated or treated for an sexually transmitted infection, recent or current injection-drug use, or having had an HBsAg-positive sex partner) should receive hepatitis B virus vaccine, as well as counseling on other measures to prevent hepatitis B virus infection.

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Meningococcal Vaccination

Routine vaccination of healthy persons who are not at increased risk for exposure to Neisseria meningitidis is not recommended after age 21 years.
Give 2 doses of serogroups A, C, W, and Y meningococcal vaccine (MenACWY) at least 8 weeks apart and revaccinate with 1 dose of MenACWY every 5 years, if the risk remains, to adults with the following indications:

  • Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies)
  • HIV infection
  • Persistent complement component deficiency
  • Eculizumab use.

Administer 1 dose of MenACWY and revaccinate with 1 dose of MenACWY every 5 years, if the risk remains, to adults with the following indications:

  • Travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj
  • At risk from a meningococcal disease outbreak attributed to serogroup A, C, W, or Y
  • Microbiologists routinely exposed to N meningitidis
  • Military recruits
  • First-year college students who live in residential housing and have not receive MenACWY at age 16 years or older.

For protection against N meningitidis serogroup B, serogroup B meningococcal vaccine (MenB) can be given, based on individual clinical decision, to young adults and adolescents age 16 through 23 years who are not in the risk categories listed below, as a 2-dose series of MenB-4C (Bexsero) at least 1 month apart or 2-dose series of MenB-FHbp (Trumenba) at least 6 months apart.

MenB-4C and MenB-FHbp are not interchangeable.

Persons who fall in the below-listed risk categories should receive 2-dose series of MenB-4C at least 1 month apart or 3-dose series of MenB-FHbp at 0, 1–2, and 6 months:

  • Anatomical or functional asplenia (including sickle cell disease)
  • Persistent complement component deficiency
  • Eculizumab use
  • At risk from a meningococcal disease outbreak attributed to serogroup B
  • Microbiologists routinely exposed to N meningitidis.

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Haemophilus Influenzae Type B Vaccination

Administer Haemophilus influenzae type b vaccine to adults with the following indications:

Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: give 1 dose if not previously vaccinated (for elective splenectomy, time vaccine at least 14 days before splenectomy).

Hematopoietic stem cell transplant: administer 3-dose series with doses 4 weeks apart starting 6 to 12 months after successful transplant regardless of Haemophilus influenzae type b vaccination history.

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Special Populations That Need Additional Considerations

Pregnant women should receive Tdap during pregnancy and the influenza vaccine during or before pregnancy. Live vaccines (eg, MMR) are contraindicated.

Adults with asplenia have specific vaccination recommendations because of their increased risk for infection by encapsulated bacteria. Anatomical or functional asplenia includes congenital or acquired asplenia, splenic dysfunction, sickle cell disease and other hemoglobinopathies, and splenectomy.

Adults with immunosuppression should generally avoid live vaccines. Inactivated vaccines (eg, pneumococcal vaccines) are generally acceptable. High-level immunosuppression includes HIV infection with a CD4 cell count < 200 cells/μL, receipt of daily corticosteroid therapy with ≥ 20 mg of prednisone or equivalent for ≥ 14 days, primary immunodeficiency disorder (eg, severe combined immunodeficiency or complement component deficiency), and receipt of cancer chemotherapy. Other immunocompromising conditions and immunosuppressive medications to consider when vaccinating adults can be found in IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host and in General Best Practice Guidelines for Immunization.6 ,7

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Summary

  • The vaccination status of adult patients should be checked on a regular basis so that they can be kept up to date in their immunization.
  • Influenza should be offered yearly to all adults, while periodic boosters are recommended for other vaccines (eg, every 10 years for Td) and some special situations may require booster or new vaccinations series (eg, MMR outbreak, meningitis outbreak).
  • Although vaccination is safe and effective, it is underutilized. Physicians should recommend vaccination to their patients and try to dispel myths and misinformation.
  • Updated vaccination schedule information is available from the US Centers for Disease Control and Prevention; see www.cdc.gov/vaccines.

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References

    1. US Centers for Disease Control and Prevention. Recommended immunization schedule for adults aged 19 years or older, United States, 2018. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. Accessed June 6, 2018.
    2. Kim DK, Riley LE, Huner P. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older—United States, 2018. MMWR Morb Mortal Wkly Rep 2018; 67(5):158–160.
    3. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines. Recommendations of the Advisory Committee on Immunization Practices—United States, 2016–17 influenza season. MMWR Recomm Rep 2016; 65(RR-5):1–54.
    4. Marin M, Marlow M, Moore KL, Patel M. Recommendation of the Advisory Committee on Immunization Practices for use of a third dose of mumps virus–containing vaccine in persons at increased risk for mumps during an outbreak. MMWR Morb Mortal Wkly Rep 2018; 67(1):33–38.
    5. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep 2018; 67(3):103–108.
    6. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis 2014; 58(3):e44–e100.
    7. Kroger AT, Duchin J, Vázquez M. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accessed June 11, 2018.

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