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Pulmonary Disorders and Adult Immunizations Table 14. Maintenance Therapy Modifications for the Predominant Treatable Trait of Exacerbations Current Treatment LABA or LAMA LABA + LAMA LABA + LAMA + ICS Recommended Treatment Change(s) LABA + LAMAa (if blood eosinophils < 300 cells/mcL OR LABA + L...

Pulmonary Disorders and Adult Immunizations Table 14. Maintenance Therapy Modifications for the Predominant Treatable Trait of Exacerbations Current Treatment LABA or LAMA LABA + LAMA LABA + LAMA + ICS Recommended Treatment Change(s) LABA + LAMAa (if blood eosinophils < 300 cells/mcL OR LABA + LAMA + ICSa (if blood eosinophils ≥ 300 cells/mcL) LABA + LAMA + ICSa (if blood eosinophils ≥ 100 cells/mcL) OR If blood eosinophils < 100 cells/mcL, consider adding roflumilast if FEV1 < 50% and chronic bronchitis AND/OR azithromycin daily if former smoker Consider de-escalation of ICS and change to LABA + LAMAb OR Consider adding roflumilast if FEV1 < 50% and chronic bronchitis AND/OR azithromycin daily if former smoker Single inhaler may be more convenient and effective than multiple inhalers. Consider if pneumonia, or other considerable adverse effects. De-escalation is more likely to be associated with future exacerbations if blood eosinophil count is ≥ 300 cells/mcL. FEV1 = forced expiratory volume in 1 second; ICS = inhaled corticosteroid; LABA = long-acting β2-agonist; LAMA = long-acting anticholinergic/ muscarinic antagonist. Information from: Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease, 2023. a b 6. Other pharmacologic treatments a. Phosphodiesterase type 4 (PDE-4) inhibitor: roflumilast (Daliresp) i. Indication: PDE-4 inhibitors may be used as a daily treatment to reduce the risk of COPD exacerbations in patients with severe COPD (FEV1 less than 50% of predicted) associated with chronic bronchitis and a history of frequent exacerbations despite treatment with LABA + LAMA + ICS, particularly if eosinophils are less than 100 cells/mcL. Studies show a reduction in exacerbations and a reduction in the composite end point of moderate exacerbations treated with oral or systemic corticosteroids or severe exacerbations necessitating hospitalization or causing death (level of evidence B). These effects also occur when roflumilast is added to LA bronchodilators (level of evidence B). No trials have assessed the effects of roflumilast on COPD exacerbations when added to an ICS/LA bronchodilator combination. No comparison of adding roflumilast versus ICS to LA bronchodilators is available (now being studied). ii. Reduces inflammation through inhibition of the breakdown of intracellular cyclic adenosine monophosphate; has no direct bronchodilator activity iii. Starting dose: 250 mcg orally once daily for four weeks and then increased to the maintenance dose of 500 mcg orally once daily, which may allow for better GI tolerance iv. Contraindicated in cases of moderate to severe liver impairment and in nursing mothers v. Can cause weight loss (monitor) and psychiatric events, including suicidality (monitor; weigh risk-benefit ratio in patients with preexisting psychiatric illness). Twenty percent of patients studied had weight loss of 5%–10% of body weight, compared with 7% with placebo; average weight loss was 2 kg. vi. Adverse reactions include diarrhea, weight loss or decreased appetite, nausea, headache, back pain, influenza, insomnia, and dizziness. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-384 Pulmonary Disorders and Adult Immunizations b. c. d. e. vii. Use with strong cytochrome P450 (CYP) enzyme inducers (e.g., rifampin, phenobarbital, carbamazepine, phenytoin) is not recommended; use with CYP3A4 inhibitors or dual inhibitors of CYP3A4 and CYP1A2 (e.g., erythromycin, ketoconazole, fluvoxamine) increases roflumilast exposure and adverse effects (weigh risk-benefit ratio). viii. According to the ACCP/CTS guidelines to prevent exacerbations, roflumilast is suggested for patients with moderate-severe COPD with chronic bronchitis and a history of at least 1 exacerbation in the past year. Antibiotics – azithromycin i. Actions are anti-inflammatory and antibacterial ii. Daily azithromycin at 250 mg orally daily for 1 year found to lengthen time to first exacerbation, decrease overall exacerbation rate, and improve quality of life (N Engl J Med 2011;365:689-98) iii. Azithromycin 500 mg orally 3 times per week and erythromycin 500 mg orally twice daily have reduced exacerbations (Lancet Respir Med 2014;2:361-8; N Engl J Med 2011;365:689-98) iv. Potential adverse effects include hearing loss (contradictory evidence), pneumonia, GI disturbances, and QTc prolongation v. Recommended as add-on to treatment intensification with LABA + LAMA +/- ICS if eosinophils < 100 cells/mcL and former smoker Smoking cessation therapy (essential for all patients) Vaccinations i. Influenza vaccine annually (essential for all patients) ii. Adults aged 19-64 years with COPD should receive one dose of PCV20 alone or one dose of PCV15 followed by one dose of PPSV23 at least 1 year later. iii. Tdap vaccination should be provided to patients with COPD to protect against tetanus, diphtheria, and pertussis if not vaccinated during adolescence. iv. COVID-19 vaccination according to CDC guidelines v. Shingles vaccination according to CDC guidelines α1-Antitrypsin augmentation therapy (level of evidence B) i. Once weekly intravenous therapy of an α1-proteinase inhibitor (Aralast NP, Glassia, Prolastin-C, Zemaira) ii. For young patients with a severe hereditary α1-antitrypsin deficiency and established emphysema. iii. Patients with an α1-antitrypsin deficiency are usually white, have COPD at a young age (younger than 45), and have a strong family history. It may be worthwhile to screen patients with these characteristics for α1-antitrypsin deficiency. iv. α1-Antitrypsin deficiency should be considered in patients with frequent COPD exacerbations (Cleve Clin J Med 2016;83:507-14). ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-385 Pulmonary Disorders and Adult Immunizations Patient Cases 5. A 62-year-old man was recently given a diagnosis of COPD. Spirometry reveals an FEV1/FVC 60% of predicted, pre-bronchodilator FEV1 70% of predicted, and post-bronchodilator FEV1 72% of predicted. His symptoms are quite bothersome. He has an mMRC score of 2. He had 1 exacerbation in the past year that did not require hospitalization. In addition to albuterol 2 puffs every 4–6 hours as needed, which pharmacotherapy option is most appropriate to initiate? A. Tiotropium 2.5 mg 2 puffs once daily. B. Salmeterol 50 mcg 1 puff twice daily. C. Tiotropium/olodaterol 2.5/2.5 2 puffs once daily. D. Fluticasone furoate/umeclidinium/vilanterol 100 mcg/62.5 mcg/25 mcg 1 inhalation once daily. 6. A 52-year-old woman with COPD reports a gradual worsening of shortness of breath during the past few years. Spirometry reveals FEV1/FVC 55% and FEV1 63% of predicted. Her CAT score is 10 and eosinophil count is 68 cells/mcL. She has not had a COPD exacerbation or received systemic corticosteroids in the past 2 years. Her current COPD medications are tiotropium inhaler once daily and albuterol HFA as needed. According to the GOLD guidelines, which is the most appropriate course of action? A. Adding salmeterol 50 mcg 1 puff twice daily. B. Adding long-term azithromycin 250 mg once daily. C. Adding fluticasone 110 mcg 2 puffs twice daily. D. Discontinuing tiotropium and initiating salmeterol/fluticasone 50 mcg/250 mcg 1 puff twice daily. 7. Nonpharmacologic therapy a. Home oxygen therapy i. Recommended in patients who have a Pao2 of 55 mm Hg or less (or 55–60 mm Hg if pulmonary hypertension, peripheral edema, or polycythemia [level of evidence D]) or Sao2 of 88% or less, with or without hypercapnia, confirmed twice during a 3-week period (level of evidence B) ii. Improved survival with long-term (more than 15 hours/day) use in patients with chronic respiratory failure b. Pulmonary rehabilitation (essential for patient groups B–D; level of evidence A) i. Includes exercise training, nutrition counseling, and education ii. Recommended when patients have moderate COPD instead of waiting until it is more severe iii. Improves many outcomes in COPD, including quality of life and survival c. Lung cancer screening i. USPSTF recommends annual lung cancer screening for aged 55-80 years old who have a 30 pack-year smoking history and currently smoke or quit < 15 years ago. ii. Concern related to appropriateness of recommendations as lung cancer is leading cause of death in patients with COPD iii. It has been suggested to change to a > 1 pack-year threshold for patients with COPD to lead to a higher life expectancy than currently seen (Cancer 2015;121:1556-62). 8. Other medications a. β-Blockers i. Observational data suggest that long-term treatment with β-blockers reduces risk of exacerbations and improves survival, even in patients without overt cardiovascular disease (Arch Intern Med 2010;170:880-7). (a) More than half of the patients studied had cardiovascular risk factors or coronary artery disease. (b) Mostly cardioselective β-blockers were used. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-386 Pulmonary Disorders and Adult Immunizations b. ii. β-Blockers should not currently be recommended for the treatment of COPD, but β-blockers should not be withheld in patients with COPD who also have heart disease, chronic heart failure, or other cardiovascular conditions in which β-blockers are beneficial (Cochrane Database Syst Rev 2005;4:CD003566). iii. The mechanism of benefit in COPD is unknown, but β-blockers can upregulate β2-receptors in the lungs, which may improve the effectiveness of inhaled β-agonists. Statins i. Several retrospective studies have found benefits for statin use in COPD for reducing exacerbations and COPD-related mortality (Thorax 2015;70:33-40; Am J Respir Crit Care Med 2013;187:A6017; Am J Med 2013;126:598-606). ii. The STATCOPE trial found no significant effect of simvastatin on the number of severe COPD exacerbations per person-year compared with placebo (Chest 2015;147:894-942). iii. The Rotterdam trial found a 78% lower risk of mortality in patients with COPD and highsensitivity C-reactive protein concentrations greater than 3 mg/dL, indicating a higher level of systemic inflammation (Pulm Pharmacol Ther 2013;26:212-7). iv. Authors of a meta-analysis involving 53 studies concluded that statins significantly reduced the risk of all-cause mortality by 28%, risk of COPD-associated mortality by 28%, and risk of acute COPD exacerbations by 16%. Authors hypothesized that statins decrease many inflammatory markers thought to play a role in COPD (CRP, IL-6, IL-8 and TNFα) (Respir Res 2019;20:Article 17). v. No strong prospective evidence exists to suggest statins provide a clinical benefit in patients with COPD without other cardiovascular disease risk factors. F. Management of Acute Exacerbations of Chronic COPD 1. A COPD exacerbation is an acute worsening of a patient’s baseline respiratory symptoms (e.g., dyspnea, cough, and/or an increase in quantity or purulence of sputum) that is worse than normal day-to-day variation and results in a change in medication. Diagnosis is based purely on clinical presentation. 2. Classification: a. Mild: SA bronchodilators only b. Moderate: SA bronchodilators plus antibiotics and/or oral corticosteroids c. Severe: hospitalization or ED visits i. No respiratory failure: respiratory rate of 20 to 30 breaths/minute; no accessory muscles; no mental status changes; hypoxemia improved with supplemental oxygen; no increase in PaCO2 ii. Acute respiratory failure, non–life-threatening: more than 30 breaths/minute; accessory respiratory muscles in use; no change in mental status; hypoxemia improved with supplemental oxygen; PaCO2 increased compared to baseline iii. Acute respiratory failure, life-threatening: more than 30 breaths/minute; accessory respiratory muscles in use; acute changes in mental status; hypoxemia not improved with supplemental oxygen; PaCO2 increased compared to baseline or pH of 7.25 or greater 3. Common precipitating factors include infection of the tracheobronchial tree and viral upper respiratory tract infections (most common) and air pollution. However, the cause of one-third of exacerbations cannot be determined. 4. Spirometry is inaccurate during an exacerbation and is not recommended. 5. Pulse oximetry can be used to determine the need for supplemental oxygen, which should be given in severe exacerbations. In exacerbations necessitating hospitalization, arterial blood gas measurement should be performed. Supplemental oxygen should be titrated to a target saturation of 88%–92% (BMJ 2010;341:c5462). ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-387 Pulmonary Disorders and Adult Immunizations 6. Inhaled bronchodilators (inhaled SABAs with or without SA anticholinergics) are the preferred treatment of COPD exacerbations (level of evidence C). a. The usual dose of albuterol is 2.5 mg by nebulizer every 1 to 4 hours as needed or 4 to 8 puffs by MDI with holding chamber every 1 to 4 hours as needed. b. SA anticholinergics (ipratropium) are generally added for acute exacerbations. 7. Systemic corticosteroids are effective, and they shorten recovery time, improve FEV1, and improve hypoxemia (level of evidence A). They also lower the risk of treatment failure and early relapse rate and shorten hospital stays. Systemic corticosteroids should be used in most exacerbations. OCS dose for outpatient treatment: 40 mg of oral prednisone once daily for 5 days is recommended in the GOLD guidelines (level of evidence B), but insufficient data are available to provide strong conclusions about the optimal duration. a. Higher daily doses or oral prednisone/prednisolone may be used (e.g., 50–60 mg daily). b. Studies have demonstrated that in patients with a COPD exacerbation, a shorter course of systemic corticosteroids (5 days) was non-inferior to a longer (14 days) course with respect to re-exacerbation (JAMA 2013;309:2223-31; Cochrane Database Syst Rev 2018;3:1-65.). 8. Antibiotic treatment should be initiated for exacerbations if the criteria below are met. The most common pathogens in COPD exacerbations are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. In patients with GOLD 3 and 4 severity, Pseudomonas aeruginosa should be considered a potential pathogen. a. The three cardinal symptoms in COPD exacerbations are: increased dyspnea, increased sputum volume, and increased sputum purulence. i. Antibiotics should be given if all three cardinal symptoms are present (level of evidence B). ii. Antibiotics should be given if two of the three cardinal symptoms are present and if increased sputum purulence is one of the symptoms (level of evidence C). iii. Antibiotics should be given to patients with severe exacerbations requiring mechanical ventilation (level of evidence B). b. The recommended duration of antibiotic treatment is usually 5 to 7 days (level of evidence B). c. Recommended antibiotics i. Empiric treatment consists of amoxicillin with clavulanic acid, a macrolide (e.g., azithromycin), or a tetracycline (e.g., doxycycline). Antibiotic selection should be decided on using local susceptibility data and trends. ii. If antibiotics have been used recently (in the last 3 months), use an alternative class. iii. In complicated COPD with risk factors, amoxicillin/clavulanate, levofloxacin, and moxifloxacin are antibiotics of choice. Risk factors include comorbid diseases, severe COPD (FEV1 less than 50% of predicted), more than three exacerbations/year, antibiotic use in past 3 months iv. If the patient is at risk of Pseudomonas infection: Obtain sputum culture(s) and administer high-dose levofloxacin (750 mg) or ciprofloxacin. Risk factors include: Four or more antibiotic courses within the past year, recent hospitalization (in the past 90 days), isolation of Pseudomonas during past hospitalization(s), severe COPD (FEV1 less than 50% of predicted) v. If exacerbation does not respond to the initial antibiotic, sputum culture and sensitivity should be performed. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-388 2-390 1 dose annually or 1 dose annually 1 or 2 doses depending on indication (if born in 1957 or later) 1 dose Tdap, then Td or Tdap booster every 10 years 2 or 3 doses depending on age at initial vaccination or condition Recommended vaccination for adults who meet age requirement, lack documentation of vaccination, or lack evidence of past infection  Recommended vaccination for adults with an additional risk factor or another indication ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course Recommended vaccination based on shared clinical decision-making  No recommendation/ Not applicable See Notes See Notes a The above recommendations must be read together with the footnotes on the following pages of this schedule. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule by Age Group, United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult.  1 or 3 doses depending on indication ≥65 years For healthcare personnel, see notes 2 or 3 doses depending on vaccine and indication, see notes for booster recommendations Figure 2. Recommended adult immunization scheduleby age group,a United States, 2023.  Haemophilus influenzae type b (Hib) Meningococcal B (MenB) 2 doses 2 doses 1 or 2 doses depending on indication, see notes for booster recommendations 2, 3, or 4 doses depending on vaccine or condition Hepatitis B (HepB) Meningococcal A, C, W, Y (MenACWY) 2, 3, or 4 doses depending on vaccine 1 dose PCV15 followed by PPSV23 OR 1 dose PCV20 (see notes) 27 through 45 years 2 doses for immunocompromising conditions (see notes) 19 through 23 years 50–64 years 2- or 3- dose primary series and booster (See Notes) 27–49 years 1 dose Tdap each pregnancy; 1 dose Td/Tdap for wound management (see notes) 2 doses (if born in 1980 or later) 19–26 years Hepatitis A (HepA) Pneumococcal (PCV15, PCV20, PPSV23) Human papillomavirus (HPV) Zoster recombinant (RZV) Varicella (VAR) Measles, mumps, rubella (MMR) Tetanus, diphtheria, pertussis (Tdap or Td) Influenza inactivated (IIV4) or Influenza recombinant (RIV4) or Influenza live, attenuated (LAIV4) COVID-19 Vaccine Pulmonary Disorders and Adult Immunizations III. ADULT IMMUNIZATIONS See Notes <15% or <200 mm3 2-391 Recommended vaccination for adults who meet age requirement, lack documentation of vaccination, or lack evidence of past infection  Precaution 3 doses (see notes) Not Recommended* Recommended vaccination for adults with an additional risk factor or another indication 3 doses HSCTc recipients only Diabetes 2, 3, or 4 doses depending on vaccine or condition 2, 3, or 4 doses depending on vaccine Recommended vaccination based on shared clinical decision-making  1 dose Precaution–vaccination might be indicated if benefit of protection outweighs risk of adverse reaction  *Vaccinate after pregnancy. Contraindicated or not recommended–vaccine should not be administered. ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course a The above recommendations must be read together with the footnotes on the following pages of this schedule. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule by Medical Condition and Other Indications, United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. Figure 3. Recommended Adult Immunization Schedule by Medical Condition and Other Indications, United States, 2023.  No recommendation/ Not applicable 1 dose PCV15 followed by PPSV23 OR 1 dose PCV20 (see notes) 2 or 3 doses depending on vaccine and indication, see notes for booster recommendations  Men who have sex with men or 1 dose annually Health care personnelb 2 or 3 doses through age 26 years depending on age at initial vaccination or condition 2 doses at age ≥50 years 2 doses 1 or 2 doses depending on indication 1 or 2 doses depending on indication, see notes for booster recommendations 3 doses through age 26 years Precaution Chronic liver disease 1 dose Tdap, then Td or Tdap booster every 10 years 1 dose annually End-stage Asplenia, Heart or renal complement lung disease; disease, or on deficiencies alcoholisma hemodialysis a. Precaution for LAIV4 does not apply to alcoholism. b. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations. c. Hematopoietic stem cell transplant.  Hib MenB MenACWY HepB HepA Pneumococcal (PCV15, PCV20, PPSV23) HPV 2 doses at age ≥19 years Contraindicated Contraindicated* VAR RZV Contraindicated Contraindicated* MMR ≥15% and ≥200 mm3 HIV infection CD4 percentage and count Contraindicated Immunocompromised (excluding HIV infection) 1 dose Tdap each pregnancy Pregnancy Tdap or Td IIV4 or RIV4 or LAIV4 COVID-19 Vaccine Pulmonary Disorders and Adult Immunizations 2-392 ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course laboratory or with nonhuman primates with hepatitis A virus infection - Work with hepatitis A virus in research Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule for Ages 19 Years and Older: United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. *Note: Heplisav-B and PreHevbrio are not recommended in pregnancy due to lack of safety data in pregnant persons. schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster dose at 12 months - 4-dose series HepA-HepB (Twinrix) accelerated - Injection or noninjection drug use - Persons experiencing homelessness [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 5 months]) - 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months HB at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 8 weeks / dose 1 to dose 3: 16 weeks]) - 3-dose series Engerix-B, PreHevbrio*, or Recombivax Heplisav-B* are used at least 4 weeks apart - 2-dose series only applies when 2 doses of 4-dose series y Age 19 through 59 years: complete a 2- or 3- or Routine vaccination Hepatitis B vaccination targeting services to injection or noninjection drug users or group homes and nonresidential day care facilities for developmentally disabled persons (individual risk factor screening not required) - Settings for exposure, including health care settings from infection during pregnancy - Pregnancy if at risk for infection or severe outcome adoptee (e.g., household or regular babysitting) in first 60 days after arrival from country with high or intermediate endemic hepatitis A (administer dose 1 as soon as adoption is planned, at least 2 weeks before adoptee’s arrival) - Close, personal contact with international endemic hepatitis A (HepA-HepB [Twinrix] may be administered on an accelerated schedule of 3 doses at 0, 7, and 21–30 days, followed by a booster dose at 12 months) - Travel in countries with high or intermediate - Men who have sex with men - HIV infection hepatitis B, hepatitis C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit of normal) - Chronic liver disease (e.g., persons with HepA or 3-dose series HepA-HepB as above y At risk for hepatitis A virus infection: 2-dose series Special situations (identification of risk factor not required): 2-dose series HepA (Havrix 6–12 months apart or Vaqta 6–18 months apart [minimum interval: 6 months]) or 3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 5 months]) y Not at risk but want protection from hepatitis A Routine vaccination Hepatitis A vaccination 3-dose series 4 weeks apart starting 6–12 months after successful transplant, regardless of Hib vaccination history y Hematopoietic stem cell transplant (HSCT): cell disease): 1 dose if previously did not receive Hib; if elective splenectomy, 1 dose preferably at least 14 days before splenectomy y Anatomical or functional asplenia (including sickle Figure 4. Footnotes from adult immunization schedule, United States, 2023. Note: Current COVID-19 schedule available at www. cdc.gov/vaccines/covid-19/downloads/COVID-19immunization-schedule-ages-6months-older.pdf. For more information on Emergency Use Authorization (EUA) indications for COVID-19 vaccines, please visit www.fda.gov/emergency-preparedness-and-response/ coronavirus-disease-2019-covid-19/covid-19-vaccines For Janssen COVID-19 Vaccine recipients see COVID-19 schedule at www.cdc.gov/vaccines/covid-19/ clinical-considerations/interim-considerations-us.html. antibodies) may be considered to complement COVID-19 vaccination. See www.cdc.gov/ vaccines/covid-19/clinical-considerations/interimconsiderations-us.html#immunocompromised y Pre-exposure prophylaxis (e.g., monoclonal clinical-considerations/interim-considerations-us.html y Booster dose: see www.cdc.gov/vaccines/covid-19/ - 2-dose series at 0, 3 weeks (Novavax) 3-dose series at 0, 3, 7 weeks (Pfizer-BioNTech) - 3-dose series at 0, 4, 8 weeks (Moderna) or y Primary series Persons who are moderately or severely immunocompromised Special situations clinical-considerations/interim-considerations-us.html y Booster dose: see www.cdc.gov/vaccines/covid-19/ (Moderna) or 2-dose series at 0, 3-8 weeks (Novavax, Pfizer-BioNTech) y Primary series: 2-dose series at 0, 4-8 weeks Routine vaccination COVID-19 vaccination Special situations Haemophilus influenzae type b vaccination Recommended Adult Immunization Schedule for ages 19 years or older, United States, 2023 For vaccine recommendations for persons 18 years of age or younger, see the Recommended Child and Adolescent Immunization Schedule. Notes Pulmonary Disorders and Adult Immunizations 2-393 ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course vaccination; HPV vaccination is not recommended until after pregnancy; no intervention needed if inadvertently vaccinated while pregnant - Pregnancy: Pregnancy testing is not needed before infection: 3-dose series, even for those who initiate vaccination at age 9 through 14 years. - Immunocompromising conditions, including HIV catch-up vaccination or shared clinical decisionmaking also apply in special situations y Age ranges recommended above for routine and Special situations clinical decision-making, 2- or 3-dose series as above y Some adults age 27–45 years: Based on shared Shared clinical decision-making vaccine series has been completed using the recommended dosing intervals. y No additional dose recommended when any HPV interrupted, the series does not need to be restarted y Interrupted schedules: If vaccination schedule is 2 doses at least 5 months apart: HPV vaccination series complete, no additional dose needed - Age 9–14 years at initial vaccination and received 1 dose or 2 doses less than 5 months apart: 1 additional dose - Age 9–14 years at initial vaccination and received 3-dose series at 0, 1–2 months, 6 months (minimum intervals: dose 1 to dose 2: 4 weeks / dose 2 to dose 3: 12 weeks / dose 1 to dose 3: 5 months; repeat dose if administered too soon) - Age 15 years or older at initial vaccination: through age 26 years: 2- or 3-dose series depending on age at initial vaccination or condition: Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule for Ages 19 Years and Older: United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. to a vaccine component or a previous dose of any influenza vaccine: see Appendix listing contraindications and precautions y Severe allergic reaction (e.g., anaphylaxis) workers) of severely immunosuppressed persons who require a protected environment: these persons should not receive LAIV4. If LAIV4 is given, they should avoid contact with/caring for such immunosuppressed persons for 7 days after vaccination. y Close contacts (e.g., caregivers, healthcare (e.g., angioedema, respiratory distress or required epinephrine or another emergency medical intervention): Any influenza vaccine appropriate for age and health status may be administered. If using egg-based IIV4 or LAIV4, administer in medical setting under supervision of health care provider who can recognize and manage severe allergic reactions. y Egg allergy–any symptom other than hives appropriate for age and health status annually y Egg allergy, hives only: any influenza vaccine Special situations influenza vaccine recommendations. y For the 2023–2024 season, see the 2023–2024 ACIP volumes/71/rr/rr7101a1.htm y For the 2022–2023 season, see www.cdc.gov/mmwr/ high-dose inactivated influenza vaccine (HD-IIV4), quadrivalent recombinant influenza vaccine (RIV4), or quadrivalent adjuvanted inactivated influenza vaccine (aIIV4) is preferred. If none of these three vaccines is available, then any other age-appropriate influenza vaccine should be used. - Age 65 years or older: Any one of quadrivalent appropriate for age and health status annually. Routine vaccination y Age 19 years or older: 1 dose any influenza vaccine Routine vaccination Influenza vaccination y HPV vaccination recommended for all persons Figure 4. Footnotes from adult immunization schedule, United States, 2023. (continued) (note: use 2 mL dose instead of the normal adult dose of 1 mL) - 4-dose series Engerix-B at 0, 1, 2, and 6 months (note: use Dialysis Formulation 1 mL = 40 mcg) - 3-dose series Recombivax HB at 0, 1, 6 months y Patients on dialysis: complete a 3- or 4-dose series C, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice upper limit of normal)  HIV infection  Sexual exposure risk (e.g., sex partners of hepatitis B surface antigen [HBsAg]-positive persons; sexually active persons not in mutually monogamous relationships; persons seeking evaluation or treatment for a sexually transmitted infection; men who have sex with men)  Current or recent injection drug use  Percutaneous or mucosal risk for exposure to blood (e.g., household contacts of HBsAgpositive persons; residents and staff of facilities for developmentally disabled persons; health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids; persons on maintenance dialysis, including in-center or home hemodialysis and peritoneal dialysis, and persons who are predialysis; patients with diabetes)  Incarceration  Travel in countries with high or intermediate endemic hepatitis B Special situations  Chronic liver disease (e.g., persons with hepatitis - Risk factors for hepatitis B virus infection include: for hepatitis B virus infection may complete a HepB vaccine series. y Age 60 years or older without known risk factors hepatitis B virus infection should complete a HepB vaccine series. Human papillomavirus vaccination Recommended Adult Immunization Schedule, United States, 2023 y Age 60 years or older with known risk factors for Notes Pulmonary Disorders and Adult Immunizations 2-394 ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course for groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm y For MenACWY booster dose recommendations housing (if not previously vaccinated at age 16 years or older) or military recruits: 1 dose MenACWY (Menactra, Menveo, or MenQuadfi) y First-year college students who live in residential meningococcal disease, or microbiologists routinely exposed to Neisseria meningitidis: 1 dose MenACWY (Menactra, Menveo, or MenQuadfi) and revaccinate every 5 years if risk remains y Travel in countries with hyperendemic or epidemic cell disease), HIV infection, persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use: 2-dose series MenACWY-D (Menactra, Menveo, or MenQuadfi) at least 8 weeks apart and revaccinate every 5 years if risk remains y Anatomical or functional asplenia (including sickle Special situations for MenACWY Meningococcal vaccination immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart for protection against measles or mumps or at least 1 dose for protection against rubella - Born in 1957 or later with no evidence of to measles, mumps, or rubella: Consider 2-dose series at least 4 weeks apart for protection against measles or mumps or 1 dose for protection against rubella - Born before 1957 with no evidence of immunity y Health care personnel: additional doses of MMR (including 3rd dose of MMR), see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7. htm Shared clinical decision-making for MenB Note: MenB vaccines may be administered simultaneously with MenACWY vaccines if indicated, but at a different anatomic site, if feasible. groups listed under “Special situations” and in an outbreak setting (e.g., in community or organizational settings and among men who have sex with men) and additional meningococcal vaccination information, see www.cdc.gov/mmwr/volumes/69/rr/rr6909a1.htm y For MenB booster dose recommendations for at increased risk and vaccination benefits outweigh potential risks y Pregnancy: Delay MenB until after pregnancy unless cell disease), persistent complement component deficiency, complement inhibitor (e.g., eculizumab, ravulizumab) use, or microbiologists routinely exposed to Neisseria meningitidis: 2-dose primary series MenB-4C (Bexsero) at least 1 month apart or 3-dose primary series MenB-FHbp (Trumenba) at 0, 1–2, 6 months (if dose 2 was administered at least 6 months after dose 1, dose 3 not needed; if dose 3 is administered earlier than 4 months after dose 2, a fourth dose should be administered at least 4 months after dose 3); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2–3 years if risk remains y Anatomical or functional asplenia (including sickle Special situations for MenB (age 16–18 years preferred) not at increased risk for meningococcal disease: Based on shared clinical decision-making, 2-dose series MenB-4C (Bexsero) at least 1 month apart or 2-dose series MenB-FHbp (Trumenba) at 0, 6 months (if dose 2 was administered less than 6 months after dose 1, administer dose 3 at least 4 months after dose 2); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series) y Adolescents and young adults age 16–23 years Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule for Ages 19 Years and Older: United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. Figure 4. Footnotes from adult immunization schedule, United States, 2023. (continued) institutions, international travelers, and household or close, personal contacts of immunocompromised persons with no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart if previously did not receive any doses of MMR or 1 dose if previously received 1 dose MMR y Students in postsecondary educational MMR contraindicated y Severe immunocompromising conditions: CD4 count ≥200 cells/mm3 for at least 6 months and no evidence of immunity to measles, mumps, or rubella: 2-dose series at least 4 weeks apart; MMR contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm3 y HIV infection with CD4 percentages ≥15% and evidence of immunity to rubella: 1 dose y Nonpregnant persons of childbearing age with no rubella: MMR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose y Pregnancy with no evidence of immunity to Special situations care personnel, see below), documentation of receipt of MMR vaccine, laboratory evidence of immunity or disease (diagnosis of disease without laboratory confirmation is not evidence of immunity) - Evidence of immunity: Born before 1957 (health rubella: 1 dose y No evidence of immunity to measles, mumps, or Routine vaccination Measles, mumps, and rubella vaccination after previous dose of influenza vaccine: Generally, should not be vaccinated unless vaccination benefits outweigh risks for those at higher risk for severe complications from influenza y In mumps outbreak settings, for information about Recommended Adult Immunization Schedule, United States, 2023 y History of Guillain-Barré syndrome within 6 weeks Notes Pulmonary Disorders and Adult Immunizations 2-395 ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course vaccines a patient needs and when, please refer to the mobile app which can be downloaded here: www.cdc. gov/vaccines/vpd/pneumo/hcp/pneumoapp.html y For guidance on determining which pneumococcal but have not completed the recommended series: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here www.cdc.gov/vaccines/vpd/pneumo/downloads/ pneumo-vaccine-timing.pdf. - Previously received both PCV13 and PPSV23 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23. - Previously received only PPSV23: 1 dose PCV15 OR least 1 year after the PCV13 dose OR complete the recommended PPSV23 series as described here www.cdc.gov/vaccines/vpd/pneumo/downloads/ pneumo-vaccine-timing.pdf. - Previously received only PCV13: 1 dose PCV20 at recommendation above. - Previously received only PCV7: follow the PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak - Not previously received a PCV13, PCV15, or conditions or other risk factors** who have y Age 19–64 years with certain underlying medical Special situations For detailed information, see: www.cdc.gov/vaccines/ vpd/polio/hcp/recommendations.html (i.e., at least 3 doses): may administer one lifetime IPV booster - Evidence of completed polio vaccination series (i.e., at least 3 doses): administer remaining doses (1, 2, or 3 doses) to complete a 3-dose series - No evidence of a complete polio vaccination series to poliovirus with: y Adults at increased risk of exposure Special situations Routine poliovirus vaccination of adults residing in the United States is not necessary. Routine vaccination Polio vaccination **Note: Underlying medical conditions or other risk factors include alcoholism, chronic heart/liver/ lung disease, chronic renal failure, cigarette smoking, cochlear implant, congenital or acquired asplenia, CSF leak, diabetes mellitus, generalized malignancy, HIV, Hodgkin disease, immunodeficiency, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplants, or sickle cell disease or other hemoglobinopathies. *Note: Immunocompromising conditions include chronic renal failure, nephrotic syndrome, immunodeficiency, iatrogenic immunosuppression, generalized malignancy, human immunodeficiency virus, Hodgkin disease, leukemia, lymphoma, multiple myeloma, solid organ transplants, congenital or acquired asplenia, sickle cell disease, or other hemoglobinopathies. Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule for Ages 19 Years and Older: United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. Figure 4. Footnotes from adult immunization schedule, United States, 2023. (continued) PPSV23 was received at age 65 years or older: Based on shared clinical decision-making, 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine dose. - Previously received both PCV13 and PPSV23, AND but NO PPSV23 was received at age 65 years or older: 1 dose PCV20 at least 5 years after their last pneumococcal vaccine dose OR complete the recommended PPSV23 series as described here www.cdc.gov/vaccines/vpd/pneumo/downloads/ pneumo-vaccine-timing.pdf. - Previously received both PCV13 and PPSV23 1 dose PCV20 at least 1 year after the PPSV23 dose. If PCV15 is used, it need not be followed by another dose of PPSV23. - Previously received only PPSV23: 1 dose PCV15 OR least 1 year after the PCV13 dose OR complete the recommended PPSV23 series as described here www.cdc.gov/vaccines/vpd/pneumo/downloads/ pneumo-vaccine-timing.pdf. - Previously received only PCV13: 1 dose PCV20 at recommendation above. - Previously received only PCV7: follow the or PCV20 or whose previous vaccination history is unknown: 1 dose PCV15 OR 1 dose PCV20. If PCV15 is used, this should be followed by a dose of PPSV23 given at least 1 year after the PCV15 dose. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition,* cochlear implant, or cerebrospinal fluid leak to minimize the risk of invasive pneumococcal disease caused by serotypes unique to PPSV23 in these vulnerable groups. - Not previously received a dose of PCV13, PCV15, y Age 65 years or older who have: Routine vaccination vaccines a patient needs and when, please refer to the mobile app which can be downloaded here: www.cdc. gov/vaccines/vpd/pneumo/hcp/pneumoapp.html y For guidance on determining which pneumococcal Recommended Adult Immunization Schedule, United States, 2023 Pneumococcal vaccination Notes Pulmonary Disorders and Adult Immunizations 2-396 ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course VAR contraindicated **Note: If there is no documented history of varicella, varicella vaccination, or herpes zoster, providers should refer to the clinical considerations for use of RZV in immunocompromised adults aged ≥19 years and the ACIP varicella vaccine recommendations for further guidance: www.cdc.gov/ mmwr/volumes/71/wr/mm7103a2.htm persons with HIV regardless of CD4 count)**: 2-dose series recombinant zoster vaccine (RZV, Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon). For detailed information, see www.cdc.gov/shingles/ vaccination/immunocompromised-adults.html y Immunocompromising conditions (including recommendation for RZV use in pregnancy. Consider delaying RZV until after pregnancy. y Pregnancy: There is currently no ACIP Special situations *Note: Serologic evidence of prior varicella is not necessary for zoster vaccination. However, if serologic evidence of varicella susceptibility becomes available, providers should follow ACIP guidelines for varicella vaccination first. RZV is not indicated for the prevention of varicella, and there are limited data on the use of RZV in persons without a history of varicella or varicella vaccination. zoster vaccine (RZV, Shingrix) 2–6 months apart (minimum interval: 4 weeks; repeat dose if administered too soon), regardless of previous herpes zoster or history of zoster vaccine live (ZVL, Zostavax) vaccination. Centers for Disease Control and Prevention | Recommended Adult Immunization Schedule, United States, 2023 y Severe immunocompromising conditions: CD4 count ≥200 cells/mm3 with no evidence of immunity: Vaccination may be considered (2 doses 3 months apart); VAR contraindicated for HIV infection with CD4 percentage <15% or CD4 count <200 cells/mm3 y HIV infection with CD4 percentages ≥15% and immunity to varicella: 1 dose if previously received 1 dose varicella-containing vaccine; 2-dose series 4–8 weeks apart if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980 y Health care personnel with no evidence of varicella: VAR contraindicated during pregnancy; after pregnancy (before discharge from health care facility), 1 dose if previously received 1 dose varicellacontaining vaccine or dose 1 of 2-dose series (dose 2: 4–8 weeks later) if previously did not receive any varicella-containing vaccine, regardless of whether U.S.-born before 1980 y Pregnancy with no evidence of immunity to Special situations (except for pregnant persons and health care personnel [see below]), documentation of 2 doses varicella-containing vaccine at least 4 weeks apart, diagnosis or verification of history of varicella or herpes zoster by a health care provider, laboratory evidence of immunity or disease - Evidence of immunity: U.S.-born before 1980 4–8 weeks apart if previously did not receive varicellacontaining vaccine (VAR or MMRV [measles-mumpsrubella-varicella vaccine] for children); if previously received 1 dose varicella-containing vaccine, 1 dose at least 4 weeks after first dose Centers for Disease Control and Prevention (CDC). Advisory Committee on Immunization Practices (ACIP). Recommended Adult Immunization Schedule for Ages 19 Years and Older: United States, 2023. Available at www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html. Figure 4. Footnotes from adult immunization schedule, United States, 2023. (continued) 2/17/2023 of tetanus-toxoid-containing vaccine: For clean and minor wounds, administer Tdap or Td if more than 10 years since last dose of tetanus-toxoid-containing vaccine; for all other wounds, administer Tdap or Td if more than 5 years since last dose of tetanus-toxoidcontaining vaccine. Tdap is preferred for persons who have not previously received Tdap or whose Tdap history is unknown. If a tetanus-toxoid-containing vaccine is indicated for a pregnant woman, use Tdap. For detailed information, see www.cdc.gov/mmwr/ volumes/69/wr/mm6903a5.htm y Wound management: Persons with 3 or more doses preferably in early part of gestational weeks 27–36 y Pregnancy: 1 dose Tdap during each pregnancy, series for tetanus, diphtheria, or pertussis: 1 dose Tdap followed by 1 dose Td or Tdap at least 4 weeks later, and a third dose of Td or Tdap 6–12 months later (Tdap can be substituted for any Td dose, but preferred as first dose), Td or Tdap every 10 years thereafter y Previously did not receive primary vaccination Special situations 11 years: 1 dose Tdap, then Td or Tdap every 10 years Routine vaccination y Age 50 years or older*: 2-dose series recombinant Routine vaccination y No evidence of immunity to varicella: 2-dose series y Previously did not receive Tdap at or after age Zoster vaccination Routine vaccination Varicella vaccination Recommended Adult Immunization Schedule, United States, 2023 Tetanus, diphtheria, and pertussis vaccination Notes Pulmonary Disorders and Adult Immunizations Pulmonary Disorders and Adult Immunizations A. General Immunization Guidelines 1. Basic recommendations for adult immunization are based on age and specific vaccines (see Figures 2 and 4). 2. Certain medical conditions require special consideration when determining whether additional immunizations are recommended (see Figure 3 and footnotes). 3. On the basis of patient-specific factors, specific vaccines or formulations should be avoided or used with caution. B. Contraindications and Precautions 1. Do not administer a vaccine when a contraindication is present due to an increased risk for a serious adverse reaction. a. Live vaccines should generally be avoided in patients who are severely immunocompromised. b. Pregnant women should not receive live, attenuated vaccines due to theoretical risk to the fetus. 2. In general, vaccines should be deferred if a precaution is present based on the risk of experiencing a more severe reaction to the vaccine (this risk is less severe than with a contraindication). a. A vaccine can be administered when a precaution is present if the benefit outweighs the risks. b. All vaccines have a precaution for administration in a patient with a moderate or severe acute illness (with or without fever). 3. Full lists of contraindications and precautions are available in package inserts or within the Advisory Committee on Immunization Practices (ACIP) Best Practice Guidelines for Immunizations (www.cdc. gov/vaccines/hcp/acip-recs/general-recs/contraindications.html). C. Major Changes in the 2023 Adult Immunization Schedule 1. COVID-19 vaccines were added to the schedule. 2. New abbreviations added for COVID-19 vaccines: 1vCOV-mRNA, 2vCOV-mRNA, and 1vCOV-aPS a. Valency: 1v and 2v = monovalent and bivalent, respectively b. Platform: mRNA or acellular protein subunit “aPS” 3. Updated shared clinical decision-making option for pneumococcal vaccines D. Pneumococcal Vaccination 1. PCV20 and PCV15 were FDA approved for adults 18 and older in 2021 on the basis of improved antibody responses compared with the 13-valent PCV (PCV13). 2. ACIP pneumococcal vaccine recommendations for patients who have not previously received PCV: a. Adults 65 and older should receive one dose of PCV20 alone or one dose of PCV15 followed by one dose of PPSV23 at least 1 year later. Doses do not need to be repeated if given before age 65. b. Adults 19–64 years of age with the following underlying conditions should receive one dose of PCV20 alone or one dose of PCV15 followed by one dose of PPSV23 at least 1 year later. i. Alcoholism ii. Chronic heart disease iii. Chronic liver disease iv. Chronic lung disease v. Cigarette smoking vi. Diabetes vii. Cochlear implant viii. CSF leak ix. Congenital or acquired asplenia x. Sickle cell disease or other hemoglobinopathies ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-397 Pulmonary Disorders and Adult Immunizations xi. Patients who are immunocompromised (chronic renal failure, congenital or acquired immunodeficiencies, generalized malignancy, HIV infection, Hodgkin disease, iatrogenic immunosuppression, leukemia, lymphoma, multiple myeloma, nephrotic syndrome, solid organ transplantation) c. At least 8 weeks between PCV15 and PPSV23 may be considered in adults who are immunocompromised. 3. Adults with previous PPSV23 only may receive PCV20 or PCV15 at least 1 year after their last PPSV23 dose. If PCV15 is used, an additional PPSV23 dose is not needed afterward. 4. Adults with previous PCV13 who have not completed the PPSV23 series should receive 1 dose of PCV20 at least 1 year after their last PCV13 or should complete the PPSV23 series. 5. Figure 4 provides more details for the pneumococcal vaccination recommendations. E. Influenza Vaccination 1.  Egg allergy a. Recombinant influenza vaccine (RIV) and cell culture-based inactivated vaccine (ccIIV4) do not contain egg protein. b. Patients with a history of severe allergic reaction to egg: If vaccine other than ccIIV4 or RIV is used, vaccinate in a medical setting supervised by a health care provider who is able to recognize and manage severe allergic reactions. c. If an adult has experienced only hives after eating eggs or egg-containing foods, the individual can safely receive any available influenza vaccine appropriate for age and health status. d. Some people who report egg allergies may not actually be allergic to eggs. Those who can eat a lightly cooked egg (e.g., scrambled egg) without a reaction are likely not allergic and can safely receive any influenza vaccine. 2. Live-attenuated influenza vaccine in adults a.  Nasal mist b. Indicated for those 49 years and younger, except for those: i. Who are immunocompromised as the result of any cause (including medications and HIV infection) ii. With anatomic or functional asplenia iii.  With a cochlear implant iv. With a cerebrospinal fluid-oropharyngeal communication condition v. Close contacts or caregivers of severely immunosuppressed individuals who require a protected environment vi.  Pregnancy vii. Received influenza antiviral medications oseltamivir or zanamivir in the past 48 hours, peramivir in the past 5 days, or baloxavir in the past 17 days 3. If patients have a history of Guillain-Barré syndrome within 6 weeks of a previous dose of influenza vaccine, they should generally not be vaccinated. F. Herpes Zoster Vaccine 1. Zoster vaccine, recombinant (RZV) a. Adults 50 years of age and older and adults 19 years of age and older who are or will be immunocompromised: two-dose regimen at 0 and 2–6 months, minimum 4-week interval b. Administer regardless of previous herpes zoster infection or history of zoster vaccine live (ZVL) vaccination c. Efficacy close to 90% compared with placebo d. Storage i. Stored in refrigerator ii. Used within 6 hours of reconstitution ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-398 Pulmonary Disorders and Adult Immunizations G. HPV Vaccine 1. Nine-valent HPV vaccine (9vHPV) is available and may be used for routine HPV vaccination of both females and males. 2. HPV vaccine recently had expanded ages approved for use. It is now approved to be used in males and females 9-45 years of age. HPV vaccination is now recommended as a catch-up vaccine for all people through age 26. For adults 27–45 years of age, shared decision-making is recommended because of lack of widespread public health benefit but recognition that some people may benefit. 3. The series is two doses when started before age 15, with at least 5 months between the two doses. If the series is started at 15 years of age or older or the doses are separated by less than 5 months, the threedose series (at 0, 1–2, and 6 months) is still recommended. 4. Revaccination with 9vHPV is not recommended if the complete regimen of 2vHPV or 4vHPV has previously been received. The 9vHPV regimen may be completed if started with the 2vHPV or 4vHPV product. H. COVID-19 Vaccines 1. Four COVID-19 vaccines are available for use: Pfizer-BioNTech, Moderna, Novavax, and Johnson & Johnson/Janssen. 2. An mRNA COVID-19 vaccine series (Pfizer-BioNTech, Moderna) is preferred over Johnson & Johnson/ Janssen for both primary series and booster doses due to the rare but serious adverse effect of thrombosis with thrombocytopenia syndrome (TTS). 3. Updated bivalent COVID-19 boosters (Pfizer-BioNTech and Moderna) containing subvariants BA.4 and BA.5 are recommended for individuals age 12 years and older after the primary series. 4. Monovalent vaccine should be used for primary series doses. 5. COVID-19 vaccines may be administered the same day as other vaccines, including influenza. 6. General recommendations for COVID-19 vaccine administration are included in Table 15. Table 15. Coronavirus Disease 2019 Vaccine Recommendations for Adults Age 18 Years and Older Patient Population Nonimmunocompromised Pfizer-BioNTech mRNA Doses Intervalb 1–2 Immunocompromised Vaccine Typea Moderna Novavax ≥ 3-8 wk mRNA Protein subunit Doses Interval Doses Interval Primary series: Monovalent 1–2 2–3 ≥ 8 wk 2–3 1–2 2–3 ≥ 3 wk ≥ 4 wk 1–2 2–3 3–4 ≥ 8 wk 3–4 ≥ 4-8 wk 1–2 ≥ 3-8 wk Booster dose: Bivalent Moderna or Pfizer≥ 8 wk 2–3 BioNTech ≥ 8 wk Primary series: Monovalent ≥ 4 wk 1–2 ≥ 3 wk ≥ 4 wk Booster dose: Bivalent Moderna or Pfizer≥ 8 wk 2–3 BioNTech ≥ 8 wk Johnson & Johnson/Janssen Adenovirus vector Considerations Safety concerns limit use Moderna or Pfizer-BioNTech ≥ 8 wk after previous dose Safety concerns limit use Moderna or Pfizer-BioNTech ≥ 8 wk after previous dose Complete the primary series with the same product if possible. Consider delaying a primary series or booster dose by 3 months after recent severe acute respiratory syndrome coronavirus 2 infection. Adapted from: Centers for Disease Control and Prevention (CDC). Interim COVID-19 Immunization Schedule for Ages 6 months and older. Available at www.cdc.gov/vaccines/covid-19/downloads/COVID-19-immunization-schedule-ages-6months-older.pdf. a b ACCP Updates in Therapeutics® 2023: Pharmacotherapy Preparatory Review and Recertification Course 2-399