• Any adult with the following underlying medical conditions: chronic heart or lung disease, diabetes mellitus, cerebrospinal fluid leaks, cochlear implants, chronic liver disease, cirrhosis, chronic alcoholism, functional or anatomic asplenia, and immunocompromising conditions (HIV infection, diseases that require immunosuppressive therapy, chemotherapy, or radiation therapy; congenital immunodeficiency).24
A one-time revaccination is recommended after five years for persons ages 19 to 64 who have chronic renal failure, nephrotic syndrome, or functional or anatomic asplenia, and for those who are immunocompromised.24
Note: According to the manufacturer of Zostavax18 and Pneumovax,23,19 these vaccines should not be given at the same time, as research has shown that Zostavax immunogenicity is reduced as a result.18-20
Zoster
For adults ages 60 and older, Zostavax18 is administered in a single 0.65-mL dose, subcutaneously in the upper arm. Providers are not required to ask about varicella vaccination history or history of varicella disease before administering the vaccine. Adults ages 60 and older who have previously had shingles can still be vaccinated during a routine health care visit.10,21,22
Immunization is contraindicated in adults with a previous anaphylactic reaction to neomycin or gelatin, although a nonanaphylactic reaction to neomycin (most commonly, contact dermatitis) is not considered a contraindication.8
Any adult patient who has close household or occupational contact with persons at risk for severe varicella (eg, infants) need not take precautions after receiving the zoster vaccine, except in the rare case in which a varicella-like rash develops.10,21,22
Note: Review the note appearing in “Pneumococcal Polysaccharide (PPSV),” above, regarding coadministration of Zostavax and Pneumovax 23.18-20
Varicella
Adults who were born in the US before 1980 are considered immune to varicella and don’t need to be vaccinated, with the exception of health care workers, pregnant women, and immunocompromised persons. Nonimmune healthy adults who have not previously undergone vaccination should receive two 0.5-mL doses of Varivax, administered subcutaneously, four to eight weeks apart.25
Immunization is contraindicated in adults with a previous anaphylactic reaction to neomycin or gelatin, although a nonanaphylactic reaction to neomycin (eg, contact dermatitis) is not considered a contraindication.8
Measles, Mumps, Rubella (MMR)
The MMR vaccine is administered at 0.5 mL, given subcutaneously in the posterolateral fat of the upper arm.8
MMR-susceptible adults who were born during or since 1957 and are not at increased risk (see below) need only one dose of the MMR vaccine; those considered at increased risk need two doses, and a second dose can also be considered during an outbreak. Adults who require two doses should wait at least four weeks between the first and second doses.12
The following factors place adults at increased risk for MMR:
• Anticipated international travel
• Being a student in a post–secondary educational setting
• Working in a health care facility
• Recent exposure to measles, or an outbreak of measles or mumps
• Previous vaccination with killed measles vaccine
• Previous vaccination with an unknown measles vaccine between 1963 and 1967.
Also at risk are health care workers born before 1957 who have no evidence of immunity, and women who plan to become pregnant and have no evidence of immunity.8,12
Tetanus, Diphtheria, Pertussis
Options for adults include a vaccine against tetanus and diphtheria (Td; Decavac); or a vaccine that protects against tetanus, diphtheria, and acellular pertussis (Tdap; Adacel, Boostrix). Adults who have not been previously vaccinated should receive one dose of Tdap and two doses of Td (the first, one month after Tdap; the second at six to 12 months after the Tdap). Each is administered as a 0.5-mL dose IM in the deltoid. A booster dose is recommended every 10 years but can be given earlier in patients who sustain wounds or who anticipate international travel.8,12
Adults ages 19 through 64 should receive a single dose of Tdap in place of a booster dose if the last Td dose was administered at least 10 years earlier and the patient has not previously received Tdap. Additionally, a dose of Tdap (if not previously given) is recommended for postpartum women, close contacts of infants younger than 12 months, and all health care workers with direct patient contact. An interval as short as two years from the last Td is suggested; shorter intervals may be appropriate.8,12
According to the new 2011 recommendations, persons ages 65 and older who have close contact with an infant younger than 12 months should be vaccinated with Tdap, and any person age 65 or older may be vaccinated with Tdap. Also added is a recommendation to administer Tdap, regardless of the interval since the patient received his or her most recent Td-containing vaccine.8,12