Gerontology, Palliative Care & Prevention · Topic 10 of 13

Adult Immunizations

Prevention · adult vaccine schedule

Adult Immunizations

Annual flu shot; at 50, pneumococcal conjugate and two recombinant zoster doses; one RSV dose at 75 (50–74 at risk); Tdap then a booster every 10 years.

Key numbers

Influenza vaccine every year; high-dose at 65+≥ 65: HD-IIV3, RIV3, aIIV3

Pneumococcal at 50: PCV20 or PCV21 aloneage ≥ 50

Recombinant zoster: 2 doses from age 50≥ 50 · 2 doses

RSV once: 75+, or 50–74 at risk≥ 75, or 50–74 at risk

Tdap once, then Td/Tdap every 10 yearsevery 10 y

01 · The rulePneumococcal at 50: PCV20 or PCV21 alone

Every adult 50 or older (or 19–49 with a risk condition) without a prior conjugate vaccine gets one dose of PCV20 or PCV21 alone, or PCV15 followed by PPSV23 at least 1 year later.

02 · The ruleRecombinant zoster: 2 doses from age 50

Give recombinant zoster vaccine (RZV, Shingrix) as 2 doses 2–6 months apart to all adults 50 or older, regardless of prior shingles or prior live zoster vaccine; no varicella serology is needed.

03 · The ruleRSV once: 75+, or 50–74 at risk

Give a single lifetime dose of RSV vaccine to every adult 75 or older and to adults 50–74 at increased risk of severe RSV; repeat doses are not recommended. Best given August–October.

The rules

Know these

Influenza vaccine every year; high-dose at 65+ must knowGive every adult one age-appropriate influenza vaccine each year; at 65 or older, high-dose inactivated (HD-IIV3), recombinant (RIV3) or adjuvanted (aIIV3) vaccine is preferred, otherwise any available vaccine.

Tdap once, then Td/Tdap every 10 years must knowAn adult who never had Tdap at 10 or older gets one Tdap dose, then a Td or Tdap booster every 10 years; give Tdap in every pregnancy, ideally early in weeks 27–36.

Egg allergy does not limit flu vaccineA patient with egg allergy can receive any influenza vaccine, egg-based or not, that is appropriate for age and health status.

Prior PCV13 only: give PCV20 or PCV21An adult who received only PCV13 gets PCV20 or PCV21 at least 1 year later; after a dose of PCV20 or PCV21, no further pneumococcal vaccine is recommended.

Shingrix is non-live: give when immunocompromisedRecombinant zoster vaccine is not live, so give the 2-dose series to immunocompromised adults from age 19, including HIV at any CD4 count; defer during a current zoster episode.

Tetanus booster for wounds: 5 or 10 yearsAfter 3 or more tetanus doses, give Td or Tdap for a clean minor wound if the last dose was over 10 years ago, and for any other wound if over 5 years ago; prefer Tdap if never given.

Hepatitis B vaccine for all adults 19–59Vaccinate all adults 19–59 against hepatitis B; at 60 or older, vaccinate those with risk factors or who request it, and others may receive it.

Causes & risk factors

Why it happens

RSV risk: heart, lung, kidney, nursing homeRSV high-risk conditions include chronic heart or lung disease, end-stage kidney disease or dialysis, complicated or insulin/SGLT2-treated diabetes, BMI ≥ 40, moderate-severe immune compromise, chronic liver disease and nursing-home residence.

Management

Orders

Heplisav-B 2 doses; Engerix-B 3 dosesHepatitis B series: Heplisav-B 2 doses 4 weeks apart, or Engerix-B or Recombivax HB at 0, 1 and 6 months; dialysis needs higher doses (Recombivax 40 mcg, or Engerix-B 2 mL × 4).

Red flags & don'ts

Avoid harm

Flu vaccine: anaphylaxis contraindicates; GBS is a precaution avoidAnaphylaxis after a previous influenza vaccine contraindicates further doses (RIV or cell-culture vaccine may be given under supervision); Guillain-Barré within 6 weeks of a flu vaccine and moderate-severe acute illness are precautions.

No live nasal flu vaccine if immunocompromised avoidLive nasal influenza vaccine (LAIV) is contraindicated in pregnancy, immunocompromise, asplenia, cochlear implant, CSF leak, close contacts of protected-environment patients and within 48 hours of oseltamivir — use an injectable vaccine.

No live vaccines in pregnancy or severe immunosuppression avoidMMR and varicella vaccines are live: contraindicated in pregnancy (give after delivery) and severe immunocompromise, including HIV with CD4 < 200/mm³.

Anaphylaxis to a prior dose contraindicates any vaccine avoidA severe allergic reaction (anaphylaxis) to a previous dose or a vaccine component contraindicates that vaccine; moderate or severe acute illness, with or without fever, is a precaution to defer.

Inactivated influenza or live nasal (LAIV)?

Commonly confused

Pregnancy	Not a contraindication
Immunocompromise or asplenia	Not a contraindication
Close contact of a severely immunosuppressed patient	May vaccinate
Recent influenza antiviral	No interaction

More detail

Reference

Show 7 reference facts

Tdap is contraindicated after encephalopathy within 7 days of a previous pertussis-containing vaccine; Guillain-Barré within 6 weeks of a tetanus-containing vaccine is a precaution.

Pneumococcal immunocompromising conditions include chronic renal failure, nephrotic syndrome, asplenia or sickle cell disease, HIV, malignancy, solid organ transplant and iatrogenic immunosuppression.

Hepatitis B risk factors for adults 60 and older include chronic liver disease, HIV, sexual exposure risk, injection drug use, dialysis, incarceration and health care exposure to blood; diabetes at 60+ is shared decision-making.

Pregnancy: give Tdap and, at 32–36 weeks from September to January, RSV vaccine (Abrysvo) unless the infant will get nirsevimab; delay HPV, live vaccines and recombinant zoster until after delivery.

Asplenia, complement deficiency or complement-inhibitor therapy (eculizumab, ravulizumab) requires a 2-dose MenACWY series with boosters every 5 years plus a MenB series.

Health care personnel born in 1957 or later without evidence of immunity need 2 MMR doses at least 4 weeks apart, and 2 varicella doses if never vaccinated or immune.

A March 16, 2026 court order (AAP v. Kennedy, on appeal) stayed ACIP votes after June 11, 2025; CDC's 2025 adult schedule with its April 2025 additions remains in effect — check CDC for updates.

Pearl

Fifty is the vaccine birthday: pneumococcal conjugate plus two doses of Shingrix — and RSV once by 75.

Sources · CDC — Adult Immunization Schedule by Age, United States, 2025 (addendum updated July 2, 2025) · CDC — Adult Immunization Schedule Notes, 2025 · CDC — Adult Immunization Schedule Appendix: Contraindications and Precautions, 2025 · Congressional Research Service IN12684 — Changes to CDC Vaccine Recommendations in 2025 and 2026 (updated July 29, 2026) · CDC — Adult Immunization Schedule Addendum, 2025 (RSV 50–59 at increased risk) · Pharmacy Times — Overhaul of childhood vaccine guidance blocked by federal judge in Massachusetts (March 16, 2026) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).