The Advisory Committee on Immunization Practices (ACIP) recommends use of certain vaccines in adults residing in the US. Routine childhood immunization has reduced the overall incidence of some of these vaccine-preventable diseases, but many adults remain susceptible. Recommendations for vaccination against COVID-19, seasonal influenza, and monkeypox and vaccination of travelers have been reviewed separately.

The FDA has licensed PreHevbrio (VBI Vaccines), a recombinant, 3-antigen, 3-dose hepatitis B vaccine, for the prevention of infection caused by all known subtypes of hepatitis B virus (HBV) in adults. It has been available in Israel since 2000.

Persons planning to travel outside the US should be up to date on routine vaccines and, depending on their destination, duration of travel, and planned activities, may also receive certain travel-specific vaccines. Tickborne encephalitis and dengue vaccines, which are not available in the US, are reviewed in a separate article available online. Detailed advice for travel to specific destinations is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel/destinations/list. Recommendations for administration of vaccines as part of routine adult immunization are discussed in a separate issue.

No vaccines against tickborne encephalitis (TBE) or dengue are available in the US, but vaccines have been licensed in some other countries.

The US Advisory Committee on Immunization Practices (ACIP) recommends routine use of the following vaccines in adults residing in the US: influenza, tetanus/diphtheria alone (Td) and in combination with acellular pertussis (Tdap), measles/mumps/rubella (MMR), varicella (VAR), herpes zoster (RZV; ZVL), human papillomavirus (HPV), and pneumococcal conjugate (PCV13) and polysaccharide (PPSV23) vaccines. For adults with certain medical conditions or occupational, behavioral, or other risk factors, hepatitis A (HepA), hepatitis B (HepB), meningococcal (MenACWY; MenB), and Haemophilus influenzae type b (Hib) vaccines are also recommended. Recommendations for vaccination against seasonal influenza and vaccination of travelers are reviewed separately.

View the Expanded Table: Some Vaccines Recommended for Use in Adults

The FDA has approved a two-dose hepatitis B virus (HBV) vaccine (Heplisav-B – Dynavax) for use in adults ≥18 years old. The three other HBV vaccines marketed in the US are usually administered in 3 doses. Engerix-B and Recombivax HB are licensed for use in persons of all ages. A combination hepatitis A/B vaccine (Twinrix) contains the same hepatitis B component as Engerix-B and is licensed for use only in adults.

The 2017 adult immunization schedule approved by the CDC's Advisory Committee on Immunization Practices (ACIP) includes some new or revised recommendations.1 The complete schedule is available on the CDC's website (www.cdc.gov/vaccines/schedule). New recommendations for use of influenza vaccine during the 2016-2017 season were included in a previous issue of The Medical Letter.2 Updated recommendations for other vaccines are summarized below. Recommendations for routine use of vaccines in adults were reviewed in an earlier issue.3

1. DK Kim et al. Advisory Committee on Immunization Practices recommended immunization schedule for adults aged 19 years or older – United States, 2017. MMWR Morb Mortal Wkly Rep 2017; 66:136.
2. Influenza vaccine for 2016-2017. Med Lett Drugs Ther 2016; 58:127.
3. Adult immunization. Treat Guidel Med Lett 2014; 12:39.
4. Gardasil 9 – a broader HPV vaccine. Med Lett Drugs Ther 2015; 57:47.
5. Trumenba: a serogroup B meningococcal vaccine. Med Lett Drugs Ther 2015; 57:5.
6. Bexsero – a second serogroup B meningococcal vaccine. Med Lett Drugs Ther 2015; 57:158.

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The FDA has approved tenofovir alafenamide (Vemlidy – Gilead) for treatment of chronic hepatitis B virus (HBV) infection in adults with compensated liver disease. It is the first single-drug product containing tenofovir alafenamide (TAF), a prodrug of the nucleotide reverse transcriptase inhibitor tenofovir, to become available; several combination products containing TAF are approved for treatment of HIV-1 infection. Tenofovir disoproxil fumarate (TDF; Viread – Gilead), another tenofovir prodrug, has been used for many years for treatment of chronic HBV infection; a generic formulation of TDF is expected to become available in December 2017.

The FDA recently announced that it will require the labeling of all direct-acting antiviral drugs used for treatment of hepatitis C virus (HCV) infection to include a boxed warning about a risk of hepatitis B virus (HBV) reactivation associated with their use.1

Twenty-four cases of HBV reactivation occurring during treatment with direct-acting antiviral drugs for HCV were identified from the FDA Adverse Event Reporting System and the medical literature.2-5 Before starting direct-acting antiviral treatment for HCV, some of these patients were hepatitis B surface antigen (HbsAG) positive and others showed evidence of resolved HBV infection. HBV reactivation generally occurred within 4-8 weeks of starting treatment. Reactivation of HBV can cause increases in bilirubin and aminotransferase levels, fulminant hepatitis, hepatic failure, and death. Of the 24 patients, two died and one required a liver transplant.

HBV reactivation was not identified before FDA approval of these drugs because the clinical trials used to support their approval excluded patients with HBV co-infection. The mechanism by which HBV reactivation occurs during treatment with direct-acting antiviral drugs for HCV is unknown. Patients should be screened for current or past HBV infection before starting treatment with a direct-acting antiviral and monitored for HBV reactivation during and following treatment with these drugs.

1. FDA Drug Safety Communication: FDA warns about the risk of hepatitis B reactivating in some patients treated with direct-acting antivirals for hepatitis C. Available at: www.fda.gov. Accessed October 13, 2016.
2. JM Collins et al. Hepatitis B virus reactivation during successful treatment of hepatitis C virus with sofosbuvir and simeprevir. Clin Infect Dis 2015; 61:1304.
3. A De Monte et al. Direct-acting antiviral treatment in adults infected with hepatitis C virus: reactivation of hepatitis B virus coinfection as a further challenge. J Clin Virol 2016; 78:27.
4. AR Ende et al. Fulminant hepatitis B reactivation leading to liver transplantation in a patient with chronic hepatitis C treated with simeprevir and sofosbuvir: a case report. J Med Case Rep 2015; 9:164.
5. C Wang et al. Hepatitis due to reactivation of hepatitis B virus in endemic areas among patients with hepatitis C treated with direct-acting antiviral agents. Clin Gastroenterol Hepatol 2016 July 5 (epub).

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The FDA has approved Odefsey (Gilead), a once-daily, fixed-dose combination of the non-nucleoside reverse transcriptase inhibitor (NNRTI) rilpivirine and the nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs) emtricitabine and tenofovir alafenamide, for initial treatment of HIV-1 infection in patients with HIV-1 RNA (viral load) ≤100,000 copies/mL or to replace a stable antiretroviral regimen in patients who have been virologically suppressed (viral load <50 copies/mL) for at least six months with no history of treatment failure.

Patients planning to travel to other countries should be up to date on routine immunizations and, depending on their destination, duration of travel, and planned activities, may also need to receive certain travel-specific vaccines. Common travel vaccines are listed in Table 2. More detailed advice for travelers is available from the Centers for Disease Control and Prevention (CDC) at www.cdc.gov/travel. Guidelines for routine adult immunization are discussed in a separate issue.

Vaccines recommended for adults residing in the US are reviewed here. Vaccines for travel have been reviewed separately.

Eight vaccines are currently recommended by the US Advisory Committee on Immunization Practices (ACIP) for routine use in adults at various ages...

The drugs of choice for treatment of viral infections (other than HIV) and their dosages are listed in Tables 1-6 on the pages that follow. Some of the indications and dosages recommended here have not been approved by the FDA. Vaccines used for the prevention of viral infections are discussed elsewhere.

Vaccines recommended for routine use in US adults are reviewed here. Vaccines for travel have been reviewed separately.

Live-attenuated vaccines are generally contraindicated during pregnancy; inactivated vaccines can be given if indicated. A more detailed review of routine immunizations for adults will be available in the December issue of Treatment Guidelines from The Medical Letter.

The drugs of choice for treatment of non-HIV viral infections and their dosages are listed in Tables 1-6 on the pages that follow. Some of the indications and dosages recommended here have not been approved by the FDA. Vaccines used for the prevention of viral infections are discussed in another issue of Treatment Guidelines.

Patients planning to travel to other countries often ask physicians for information about appropriate vaccines and prevention of diarrhea and malaria. Guidelines are also available from the Infectious Diseases Society of America (IDSA).

Although immunization programs have produced high vaccination rates in US infants and children, similar successes have not been achieved in adults. Vaccines recommended for routine use in adults are reviewed here. Vaccines for travel are reviewed separately.

Many infections can be transmitted during sexual contact. The text and tables that follow are limited to management of sexually transmitted infections (STIs) other than HIV, viral hepatitis and enteric infections. Guidelines are available from the US Centers for Disease Control and Prevention (CDC) with detailed recommendations for treatment of these diseases.

The drugs of choice for treatment of non-HIV viral infections with their dosages and cost are listed in Tables 1-6. Some of the indications and dosages recommended here have not been approved by the FDA. Vaccines used in the prevention of viral infections are discussed in the "Adult Immunization" issue of Treatment Guidelines.

The FDA has approved the nucleoside analog telbivudine (Tyzeka - Novartis/Idenix) for treatment of patients ≥16 years old with active chronic hepatitis B virus (HBV) infection. It is the fourth oral drug marketed for this indication in the US.

Although immunization programs have produced high vaccination rates in US infants and children, similar successes have not been achieved in adults. Vaccines recommended for routine use in adults are reviewed here. Immunizations for travel were reviewed in a recent issue.

Patients planning to travel to other countries often ask physicians for information about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control and Prevention at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

Entecavir (Baraclude - Bristol-Myers Squibb), a nucleoside analog, has been approved by the FDA for treatment of adults with active chronic hepatitis B virus (HBV) infection.

The drugs of choice for non-HIV viral infections with their dosages and cost are listed in the tables that begin on page 24. Some of the indications and dosages recommended here have not been approved by the FDA.

Many infections can be transmitted during sexual contact. The text and tables that follow are limited to management of sexually transmitted infections (STIs) other than HIV, viral hepatitis and enteric infections. Guidelines are available from the US Centers for Disease Control and Prevention (CDC) with detailed recommendations for treatment of these diseases (MMWR Recomm Rep 2002; 51, RR-6:1). New guidelines are expected soon.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the Centers for Disease Control (CDC) at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel. Recommendations for the treatment of parasitic diseases are available in the public reading room of The Medical Letter's web site.

Adefovir dipivoxil (Hepsera - Gilead), a nucleotide analog, has been approved by the FDA for oral treatment of chronic active infection with hepatitis B virus (HBV). In 1999, because of concerns about renal toxicity, the FDA rejected a higher-dosage formulation of adefovir for treatment of HIV infection.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

The drugs of choice for non-HIV viral infections with their dosages and cost are listed in the table that begins on the next page. Since the last Medical Letter issue on this subject, some new drugs and some new recommendations for old drugs have been added.

The drugs of choice for non-HIV viral infections with their dosages and cost are listed in the [article's] table.

The drugs of choice for non-HIV viral infections with their dosages and cost are listed in the table on the next page. The treatment of HIV infection will be discussed in a future issue.

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. More detailed advice for travelers is available from the CDC at 877-FYI-TRIP (877-394-8747) or www.cdc.gov/travel.

The Immunization Practices Advisory Committee of the US Public Health Service now recommends immunizing all infants and some adolescents against hepatitis B and using a new diphtheria-tetanus-acellular pertussis vaccine (DTaP; ACEL-IMUNE - Lederle) for the fourth and fifth doses of DTP, usually given at 15 to 18 months of age and before school entry (Morbid Mortal Weekly Rep, 40 RR-13:1, November 22, 1991; Morbid Mortal Weekly Rep, 41 RR-1:1, Feb 7, 1992). The Committee on Infectious Diseases of the American Academy of Pediatrics has made similar recommendations but would extend hepatitis B immunization to all adolescents, if possible (Committee on Infectious Diseases, Pediatrics, 89:795, April 1992).

Patients planning to travel to other countries often ask physicians for advice about immunizations and prevention of diarrhea and malaria. Legal requirements for entry and epidemiological conditions in different countries vary from time to time, often unpredictably, but some reasonable recommendations can be made. More detailed information is available in Health Information for International Travel, published annually by the Centers for Disease Control (CDC), which can be obtained from the Superintendent of Documents, US Government Printing Office, Washington, DC 20402. Up-to-date automated information is available by telephone from the CDC (404-332-4559).

Since the last review of this topic (Medical Letter, 32:73, August 10, 1990) some new antiviral agents have been approved and the indications for several others expanded. The drugs of choice for viral infections are listed in the table on page 36.