Immunization of adults: Canadian Immunization Guide

For health professionals

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Last complete chapter revision: July 2015

On this page

• Introduction
• Health care provider responsibilities
• Strategies to improve vaccine uptake in adults
• Recommended immunization for adults
  • Table 1: Adult immunization - recommendations for routine immunization in healthy adults at low risk
  • Table 2: Adult immunization - recommendations for specific risk situations
• Selected references

Introduction

Prevention of infection by immunization is not just for children; adults require immunization to restore waning immunity against some vaccine preventable diseases and to establish immunity against other diseases that are more common in adults. In addition, immunization of adults prevents infection and, therefore, subsequent exposure of young children and others at increased risk of vaccine preventable diseases. For example, adults who are in contact with infants should be prioritized to receive pertussis and influenza vaccination to reduce the risk of transmission of these infections to infants who are too young to be fully protected. Some vaccines are needed by all adults and other vaccines may be required due to individual risk resulting from occupation, travel, underlying illness, lifestyle or age.

In recent years, new vaccines such as herpes zoster and human papillomavirus have become available for adults. Despite these advances, the vaccination rates of adults in Canada are low, with the result that many adults remain vulnerable to vaccine preventable diseases.

Common reasons for incomplete immunization in adulthood include:

• lack of recognition of the importance of adult immunization
• lack of recommendations from health care providers
• lack of health care provider's knowledge about adult immunization and recommended vaccines
• misrepresentation and misunderstanding of the risks of vaccine and benefits of disease prevention in adults
• lack of understanding of vaccine safety and efficacy
• missed opportunities for vaccination in health care providers' offices, hospitals and nursing homes
• lack of publicly funded vaccine and reimbursement to vaccine providers
• lack of coordinated immunization programs for adults
• lack of regulatory or legal requirements
• fear of injections
• lack of availability of up-to-date records and recording systems

Adult immunization is an emerging issue that has seen an increasing emphasis in clinical care and health professional training programs.

Health care provider responsibilities

Health care providers have a responsibility to ensure that adults under their care have continuing and updated protection against vaccine preventable diseases through appropriate immunization. When considering immunization, the person's medical history will help to determine whether other immunizations are needed in addition to routinely recommended vaccines. Refer to Immunization of persons with chronic diseases and Immunization of immunocompromised persons in Part 3 for further information on how health conditions may modify vaccine recommendations.

Health care providers should provide adults under their care with factual information about immunization, including:

• information about vaccines
• expert recommendations regarding the use of vaccines
• benefits and risks of vaccination
• cost of the vaccine if it is not publicly funded
• possible consequences of declining a vaccine
• where vaccine can be obtained if the health care provider is unable to provide the vaccine

When more than one dose of a vaccine is required for optimal protection, the health care provider should arrange follow-up to encourage completion of the vaccine series.

Strategies to improve vaccine uptake in adults

All adults should be counselled concerning their immunization status. Opportunities for general immunization counselling of adults include:

• new patient encounters
• periodic health examinations
• pregnancy and the immediate post-partum period
• visits for chronic disease management
• assessment of new immigrants
• parents attending their child's vaccination visits
• hospitalization, especially when diagnosed with a chronic disease
• management protocols on admission to nursing homes, long-term care institutions, and acute care institutions
• management protocols on admission to health professional training programs
• new employee assessments in day care, health care and health care-related facilities
• persons requesting specific vaccination(s)
• persons with evidence of risk taking behaviour, such as disordered use of substances or a sexually transmitted infection
• individuals requesting advice concerning travel

Health care providers should regularly review individuals under their care to ensure that the person's immunization status is up to date and that they have been made aware of new vaccines that are or may be indicated for them. Practitioners should routinely audit immunization records during clinical encounters; scheduling record audits on a set birthday, for example, to coincide with a mid-decade birthday (i.e., 25, 35 years of age, etc.), is one effective reminder strategy. Health care institutions should have policies addressing immunization issues for patients and personnel.

Additional effective strategies for increasing the uptake of immunization by adults include patient and health care provider education about indicated prevention practices, and increasing accessibility to immunization through immunization clinics and greater engagement of non-physician staff in the execution of immunization programs. A sample adult immunization record and information resources for adult immunization are available on the Immunize Canada website.

Recommended immunization for adults

All adults in Canada without contraindications should be routinely immunized against vaccine preventable diseases. Routinely recommended adult immunizations are summarized in Table 1. Recommended immunization schedules for adults who have no record or an uncertain immunization history are available in Recommended immunization schedules in Part 1.

In addition to routinely recommended immunization, certain vaccines are recommended for adults in specific risk situations. These recommendations are summarized in Table 2. International travellers and workers in specific risk situations require assessment of immunization status, completion of routinely recommended vaccine series, and booster doses as necessary. Refer to Immunization of travellers, Immunization of workers, Immunization of immunocompromised persons and Immunization of persons with chronic diseases in Part 3; and vaccine-specific chapters in Part 4 for additional information.

Diphtheria toxoid-, tetanus toxoid-, containing vaccine

All adults in Canada should be immunized against diphtheria and tetanus. Booster doses of diphtheria and tetanus toxoid-containing vaccine are recommended every 10 years. Refer to Diphtheria toxoid and Tetanus toxoid in Part 4 for additional information.

Herpes zoster (shingles) vaccine

A two dose series of Recombinant Zoster Vaccine, (RZV) is recommended for adults 50 years of age or older without contraindications, including those who have previously been immunized with Live Zoster Vaccine (LZV), or who have had a previous episode of herpes zoster (HZ). Re-immunization with RZV may be considered at least one year after LZV or at least one year after an episode of HZ. In immunocompetent adults in whom RZV is contraindicated or when the vaccine is unavailable or inaccessible, LZV may be considered. Adults aged 50 years and older who are known to be varicella zoster virus seronegative should receive univalent varicella (chickenpox) vaccine, rather than herpes zoster (shingles) vaccine. Routine testing of adults aged 50 years and older for varicella zoster virus antibody prior to immunization is not recommended. Refer to Herpes Zoster (Shingles) Vaccine in Part 4 for additional information.

Human papillomavirus vaccine

Bivalent or nonavalent human papillomavirus (HPV) vaccine is recommended for women up to and including 26 years of age and may be administered to those 27 years of age and older who are at ongoing risk of exposure. Nonavalent HPV vaccine is recommended for men up to and including 26 years of age and may be administered to men 27 years of age and older who are at ongoing risk of exposure. Refer to Human Papillomavirus vaccine in Part 4 for additional information.

Influenza vaccine

Seasonal influenza vaccine is recommended annually for all adults without contraindications, with particular focus on individuals who are at high risk of influenza-related complications or hospitalization, who are capable of transmitting influenza to those at high risk, who provide essential community services and who are in direct contact during culling operations with poultry infected with avian influenza. Refer to Influenza vaccine in Part 4 for additional information.

Measles-mumps- rubella vaccine

Combined measles-mumps-rubella (MMR) vaccine is recommended for vaccination of adults born in or after 1970 susceptible to one or more of these viruses. Although adults born before 1970 are assumed to have acquired natural immunity, those at the greatest risk of measles or mumps exposure, such as travellers, health care workers, students in post-secondary educational settings, and military personnel, may require immunization. If MMR vaccine is indicated for a pregnant woman, it should be provided after delivery, preferably prior to discharge from hospital. Refer to Measles vaccine, Mumps vaccine and Rubella vaccine in Part 4 for additional information including criteria for determining susceptibility/immunity to measles, mumps and rubella.

Meningococcal vaccine

Healthy adults up to and including 24 years of age should receive meningococcal vaccine if it was not received in adolescence. Either a meningococcal conjugate monovalent or a meningococcal conjugate quadrivalent vaccine, depending on local epidemiology and programmatic considerations, is recommended for young adults, even if they have previously been vaccinated as an infant or toddler. In addition, multicomponent meningococcal vaccine may be considered on an individual basis to protect against invasive meningococcal disease caused by relevant serogroup B strains. Adults with specific risk conditions (refer to Table 2 ) are recommended to receive meningococcal conjugate quadrivalent vaccine, multicomponent meningococcal vaccine or both vaccines, depending on the risk situation. Refer to Meningococcal Vaccine in Part 4 for additional information.

Pertussis-containing vaccine

All adults (18 years of age and older) should receive one dose of acellular pertussis-containing vaccine (tetanus, diphtheria [reduced], acellular pertussis [reduced] [Tdap]) if it was not previously received during adulthood. This vaccine can be administered regardless of the interval since the last dose of tetanus and diphtheria toxoid-containing vaccine. In particular, adults who have not previously received Tdap vaccine in adulthood, and who anticipate having regular contact with an infant, should receive Tdap vaccine, ideally administered at least 2 weeks before contact with the infant. All pregnant women should receive one dose of Tdap vaccine in every pregnancy, ideally between 27 and 32 weeks of gestation. Refer to Pertussis vaccine in Part 4 for additional information.

Pneumococcal vaccine

Pneumococcal polysaccharide 23-valent (Pneu-P-23) vaccine is recommended for all adults 65 years of age and older. For additional information about the immunization of adults at highest risk of invasive pneumococcal disease refer to Table 2, Pneumococcal vaccine in Part 4, and Immunization of immunocompromised persons and Immunization of persons with chronic diseases in Part 3.

Poliomyelitis vaccine

All adults in Canada should be immune to polio. For previously unimmunized adults, a primary series of inactivated poliomyelitis vaccine (IPV) should be provided at the time of immunization with a tetanus and diphtheria toxoid-containing vaccine. For adults that have previously received a primary series of tetanus and diphtheria toxoid-containing vaccine, IPV-containing vaccine can be provided at the time of routine tetanus and diphtheria toxoid-containing vaccine booster immunization. Unimmunized or incompletely immunized adults at increased risk of exposure should complete a primary series of IPV-containing vaccine; previously immunized adults at increased risk of exposure should receive a single lifetime booster dose of IPV-containing vaccine. Refer to Table 2 and Poliomyelitis vaccine in Part 4 for additional information.

Varicella (chickenpox) vaccine

Univalent varicella vaccine is recommended for susceptible adults 18 to 49 years of age. Refer to Varicella (chickenpox) vaccine in Part 4 for additional information. For adults 50 years of age and older refer to Herpes Zoster (Shingles) Vaccine in Part 4.

Selected references

• Canadian Coalition for Immunization Awareness and Promotion. Adult Immunization. Are you up to date pamphlet from Immunize Canada. May 2012. Accessed February 2015.
• Canadian Medical Protective Association. New Vaccines - What are your obligations? An article for physicians by physicians. Originally published September 2008, revised January 2009. Accessed February 2015.
• Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on new oral cholera and travellers' diarrhea vaccination. Can Comm Dis Rep 2005;31(ACS7):1-12.
• Committee to Advise on Tropical Medicine and Travel (CATMAT). Poliomyelitis vaccination for international travellers. Can Comm Dis Rep 2003;29(ACS-10):1-7.
• Coulibaly N, De Serres G. Coverage of anti-tetanus vaccinations in adults in Canada-year 2002. Can J Public Health 2004;95(6):456-9.
• Health Canada. Smallpox vaccination of laboratory workers. Can Commun Dis Rep 2004;30(19):167-9.
• Johansen H, Nguyen K, Mao L et al. Influenza vaccination. Health Rep 2004;15(2):33-43.
• Johnston BL, Conly JM. Routine adult immunization in Canada: recommendations and performance. Can J Infect Dis 2002;13(4):226-231.
• Lau DT, Hewlett AT. Screening for hepatitis A and B antibodies in patients with chronic liver disease. Am J Med 2005;118 Suppl 10A:28S-33S.
• Shefer A, Briss P, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999;21(1):96-142.
• Spira AM. Preparing the traveller. Lancet 2003;361(9366):1368-81.
• Stone EG, Morton SC, Hulscher ME et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002;136(9):641-51.

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