2023 ACIP Updates for Immunizations in Adults and Children: What Pharmacists Need to Know

Pharmacists are a critical part of the vaccination workforce in the United States, helping to reduce the spread of disease and improve public health. Pharmacy teams provided more than 270 million COVID-19 vaccinations from the beginning of the pandemic through September 2022.¹ However, these teams were not just successful in vaccinating against COVID-19. In 2020 and 2021, nationwide results demonstrated that pharmacists provided more recommended routine vaccinations than any other provider type.² The results of a 2022 study confirmed that pharmacy teams provided more than 50 million vaccinations in addition to COVID-19 vaccinations each year during the pandemic.¹ Further, the results of a 2022 systematic review demonstrated that interventions involving pharmacists as immunizers were associated with significantly increased immunization rates compared with interventions where pharmacists were not involved.³ According to the results of a study by Hess et al, during the COVID-19 pandemic, community pharmacists proved to be “knowledgeable, capable, and accessible vaccination providers who were wellregarded by the public.”⁴ Pharmacists also play an important role in preventing adverse events following immunizations in pediatric populations by educating parents and guardians.⁵

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To continue providing safe and accessible immunization services, pharmacists who immunize must ensure that their knowledge about routine vaccinations for adults and children is up-to-date. Each year, the CDC’s Advisory Committee on Immunization Practices (ACIP) publishes the Recommended Adult Immunization Schedule and the Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger.^6,7 Changes are made each year based on the results of recent studies and data pertaining to safety and effectiveness of vaccines.

How Are The Immunization Schedules Updated Each Year?

Each year, the ACIP is charged with creating and updating adult and childhood immunization schedules. The ACIP holds 3 regular meetings per year and adds emergency sessions when needed. Meetings are typically held in Atlanta, Georgia, but members of the public can submit written comments, request to make an oral comment, and watch online.⁸

The ACIP is comprised of 15 voting members who are selected by the Secretary of the US Department of Health and Human Services. Fourteen of these members are experts in fields related to vaccines and public health, and 1 member is a consumer representative who provides social and community perspectives about vaccination.⁹ Eight nonvoting ex officio members representing federal agencies involved in US immunization programs are also included.⁹ Additionally, the ACIP also includes 30 nonvoting representatives of national health organizations who provide immunization expertise, including a representative of the American Pharmacists Association (APhA).⁹

In 2023, the APhA also was added as a partner organization to participate in approving the adult immunization schedule.¹⁰ APhA joins other national health-related organizations such as the CDC, the American College of Physicians, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American College of Nurse-Midwives, the American Academy of Physician Associates, and the Society for Healthcare Epidemiology of America.¹⁰ Each year, the updated immunization schedule is developed by the ACIP and presented to these partner organizations for approval.¹⁰

Updates for the Current Recommended Adult Immunization Schedule

The following are highlights of the updates from the 2023 Recommended Adult Immunization Schedule^6,7,10,11:

COVID-19

• The COVID-19 vaccine is a new addition to the routine immunization schedule because the COVID-19 vaccination is now routinely recommended for all adults. Details for use of COVID-19 vaccines are now included, with a description of the primary series recommendations for the general population. “The Special Situations section describes the primary series recommendations for persons who are moderately or severely immunocompromised.” Because COVID-19 vaccination information may change, hyperlinks have been provided that refer health care providers to the latest guidance for booster dose recommendations, to the recommendation for persons who received the Janssen (Johnson & Johnson) COVID-19 vaccine, the current COVID-19 vaccination schedules, use of COVID-19 preexposure prophylaxis in persons who are moderately or severely immunocompromised, as well as Emergency Use Authorization indications for COVID-19 vaccines.

Hepatitis A

• The Routine Immunization Schedule has been updated to “2, 3, or 4 doses depending on vaccine,” to account for the possibility of an accelerated hepatitis A and hepatitis B (recombinant) vaccine (Twinrix; GSK) series, which requires 4 doses.

Hepatitis B

• Recommendations for hepatitis B vaccination continue to include all adults aged 19 to 59 years. Persons who are aged 60 years and older with known risk factors for hepatitis B virus infection should complete a hepatitis B vaccination series, whereas persons aged 60 years and older without known risk factors for hepatitis B virus infection may complete a hepatitis B vaccination series. Please see the Special Situations section for dosing in certain populations.
• The hepatitis B vaccine (recombinant) (PreHevbrio; VBI Vaccines) was added as a 3-dose series.
• Information regarding the use of hepatitis B vaccine (recombinant) and adjuvanted (Heplisav-B; Dynavax Technologies Corporation) in pregnant persons was modified to state, “Heplisav-B and PreHevbrio are not recommended because of lack of safety data in pregnant persons. Use other hepatitis B vaccines if indicated.” A footnote providing information on the pregnancy exposure registries for persons who were inadvertently vaccinated with Heplisav-B and PreHevbrio while pregnant was also added.

Human Papillomavirus (HPV)

• Language regarding the use of HPV vaccination among pregnant persons was modified to state, “pregnancy: HPV vaccination not recommended.”

Influenza

• Information was added regarding persons aged 65 years and older stating that any 1 of the following is preferred for this age group: quadrivalent highdose inactivated influenza vaccine, quadrivalent recombinant influenza vaccine, or quadrivalent adjuvanted inactivated influenza vaccine.
• Guidance for close contacts of severely immunocompromised patients who require a protected environment was added. In addition, the text describing guidance for persons with an egg allergy who have experienced any symptom other than hives was moved from the appendix to the Special Situations section.
• In the Vaccine Notes section, “information for persons with history of [an] egg allergy was moved from the precautions column to the influenza vaccination notes section.”

Measles, Mumps, Rubella (MMR)

• Text has been added to the Routine Immunization Schedule column for persons aged 65 years and older referring providers to the notes for vaccination considerations for health care personnel in this age group.
• In the Vaccine Notes, Special Situations section, a hyperlink was provided that describes the recommendation for additional doses of MMR vaccine (including the third dose of MMR vaccine) in the event of a mumps outbreak.

Meningococcal

• Guidance was added stating that if the third dose of the meningococcal group B vaccine (Trumenba; Pfizer) is administered earlier than 4 months after the second dose, a fourth dose should be administered at least 4 months after the third dose.

Pneumococcal

• The Vaccine Notes section has been updated to reflect the ACIP’s new recommendations for the use of PCV15 and PCV20 in persons who previously received pneumococcal vaccines. In addition, a hyperlink to the CDC app that can be used to determine a patient’s pneumococcal vaccination needs has been included.

Poliovirus

• A new section was added summarizing poliovirus vaccination recommendations for adults. Although routine poliovirus vaccination of adults residing in the United States is not necessary, the Special Situations section describes the use of inactivated poliovirus (IPV) in adults who are at increased risk for exposure to poliovirus.

Zoster

• Clarification was provided that serologic evidence of prior varicella is not necessary for zoster vaccination and to provide guidance for situations in which serologic evidence of varicella susceptibility becomes available.
• Guidance was provided for persons with immunocompromising conditions who do not have a documented history of varicella, varicella vaccination, or herpes zoster. In addition, minor changes were made to the immunocompromising conditions bullet to clarify that this includes persons with HIV, regardless of CD4 count.

Updates for the 2023 Recommended Child and Adolescent Immunization Schedule

The following are highlights from the Updates for the 2023 Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger^11,12:

COVID-19

• As with the adult schedule, a new section was added to provide details on the use of COVID-19 vaccines. The routine vaccination section describes the recommendations for primary series in the general population, and the Special Situations section describes the recommendations for primary series in persons who are moderately or severely immunocompromised. Hyperlinks are included referring health care providers to the latest guidance for booster dose vaccination in all populations, and specific guidance for Janssen (Johnson & Johnson) COVID-19 vaccine recipients. In addition, hyperlinks to the current COVID-19 vaccination schedules, use of COVID-19 preexposure prophylaxis in persons who are moderately or severely immunocompromised, as well as Emergency Use Authorization indications for COVID-19 vaccines have been added.

Dengue

• Clarification was provided that “dengue vaccine should not be administered to children traveling to or visiting endemic dengue areas.”
• In the Contraindications and Precautions section, language was added stating that “lack of laboratory confirmation of previous dengue virus infection is a contraindication.”

Hepatitis B

• Recommendations were provided for infants born to mothers who have received positive test results for hepatitis B surface antigen (HBsAg), or whose HBsAg status is unknown. In addition, the Vaccine Notes catch-up vaccination section was updated to include Heplisav-B and PreHevbrio vaccines for persons aged 18 years and older.
• In the Contraindications and Precautions section, language was added to the contraindicated or not recommended column stating that “Heplisav-B and PreHevbrio are not recommended during pregnancy; other hepatitis B products should be used if vaccination is indicated.” A footnote providing information on the pregnancy exposure registries for persons who were inadvertently vaccinated with Heplisav-B or PreHevbrio while pregnant was added.

Influenza

• Available vaccines were provided for the 2022-2023 influenza season, and clarification was provided that live attenuated influenza vaccine should not be administered to close contacts of immunosuppressed persons who require a protected environment.
• In the Contraindications and Precautions section, the precautions for egg-based inactivated and live attenuated vaccines language for persons with an egg allergy with symptoms other than hives has been moved to the Notes section.

Human Papillomavirus (HPV)

• Clarification for HPV vaccination was provided and stated that “HPV is not recommended during pregnancy.”

Inactivated Poliovirus (IVP)

• In the Vaccine Notes, a new Special Situations section was created to describe the use of IPV in adolescents aged 18 years who are at increased risk for exposure to poliovirus⁶:
  • No evidence of a complete polio vaccination series (ie, ≥ 3 doses): administer remaining doses (1, 2, or 3 doses) to complete a 3-dose series
  • Evidence of completed polio vaccination series (ie, ≥ 3 doses): may administer 1 lifetime IPV booster

Measles, Mumps, Rubella (MMR)

• The Vaccine Notes section for Special Situations was updated to include recommendations for additional MMR doses in the event of a mumps:
  • In mumps outbreak settings, for information about additional doses of MMR (including 3rd dose of MMR), see www.cdc.gov/mmwr/volumes/67/wr/mm6701a7.htm

Measles, Mumps, Rubella, and Varicella Virus Vaccine (MMRV)

• Language was added to the precautions stating that “a personal or family history of seizure of any etiology is a precaution for using MMRV.”

Meningococcal

• The Vaccine Notes section language for MenACWY was changed to reflect that the newly licensed Menveo 1-vial (all liquid) formulation should not be administered before age 10 years.
• The Vaccine Notes section for MenB Special Situations was updated to include the recommendations for situations in which the second or third dose of Trumenba is administered earlier or later than the recommended minimum interval. If the second dose is administered at least 6 months after the first dose, then the third dose is not needed. If the third dose is administered earlier than 4 months after the second dose, a fourth dose should be administered at least 4 months after the third dose.

Pneumococcal

• PCV15 has been added to the Routine Immunization Schedule.
• In the Catch-up Immunization Schedule, language for the minimum interval between doses 3 and 4 was revised to clarify when a fourth dose is indicated. The text now reads, “This dose is only necessary for children aged 12–59 months regardless of risk, or aged 60–71 months with any risk, who received 3 doses before age 12 months.”
• In the Vaccine Notes section, the routine vaccination, catch-up vaccination, and Special Situations sections have been updated with the recommendations for use of PCV15.
• Language was added stating that 13-valent pneumococcal conjugate vaccine (PCV13) and PCV15 can be used interchangeably in both healthy children and those with any risk for invasive pneumococcal disease.

In addition, a hyperlink to the CDC app, which can be used to determine a patient’s pneumococcal vaccination needs, has been included.

Conclusions

Pharmacists who immunize must ensure their knowledge about routine vaccinations for adults and children is up-to-date by reviewing the changes to the immunization schedule each year. Utilizing the recommended immunizations schedules to confirm that each patient receives needed and appropriate vaccines is critical to providing quality patient care.

About The Author

Kimberly C. McKeirnan, PharmD, BCACP, is an associate professor in the Department of Pharmacotherapy and the director for the Center of Pharmacy Practice Research at Washington State University College of Pharmacy and Pharmaceutical Sciences in Spokane.

References

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8. ACIP meeting information. CDC. Updated April 24, 2023. Accessed May 1, 2023. https://www.cdc.gov/vaccines/acip/meetings/index.html

9. ACIP committee members. CDC. Updated March 15, 2023. Accessed May 1, 2023. https://www.cdc.gov/vaccines/acip/members/index.html

10. Murthy N, Wodi AP, McNally V, Cineas S, Ault K. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older — United States, 2023. MMWR. 2023;72(6):141-144. doi:10.15585/mmwr.mm7206a2

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