Residency · Residency · Family Medicine

Adult Immunization Updates and Vaccine Hesitancy

Overview

Adult immunization remains one of the most effective preventive interventions available in primary care, yet uptake rates consistently fall short of national targets. Family physicians must maintain fluency with the evolving ACIP immunization schedule while also developing the communication skills needed to address vaccine hesitancy, which the WHO has identified as a top ten global health threat.

ACIP Adult Immunization Schedule

Routine Vaccines for All Adults

Several vaccines are recommended for all adults regardless of risk profile. Influenza vaccination is recommended annually for everyone six months and older, with high-dose or adjuvanted formulations preferred for adults 65 and older due to their age-related decline in immune response. Tdap should be given once to any adult who has not previously received it, followed by a Td or Tdap booster every 10 years. COVID-19 vaccination follows current ACIP recommendations, with shared decision-making guiding whether additional doses are appropriate based on individual risk. RSV vaccine is now available as a single dose for adults 60 and older, offered through shared decision-making, and is also recommended for pregnant individuals at 32 to 36 weeks gestation during RSV season.

Age-Based Vaccines

Certain vaccines become relevant at specific age thresholds. The recombinant zoster vaccine Shingrix is given as a two-dose series for adults 50 and older, and also for immunocompromised adults 19 and older. Pneumococcal vaccination has been simplified: PCV20 can be given alone, or PCV15 can be given followed by PPSV23, for adults 65 and older or those aged 19 to 64 with qualifying risk conditions. HPV vaccination is routinely recommended through age 26, with shared decision-making for catch-up vaccination in adults aged 27 to 45.

Risk-Based Vaccines

Additional vaccines are indicated based on specific risk factors. Hepatitis A vaccination is recommended for individuals with chronic liver disease, homelessness, substance use disorders, travel to endemic areas, or HIV infection. Hepatitis B vaccination is now universal for adults aged 19 to 59, with risk-based recommendations for those 60 and older, though it can be administered at any age if risk factors are present. Meningococcal ACWY vaccine is indicated for patients with asplenia, complement deficiency, HIV, travel to endemic areas, or college students living in dormitories. Meningococcal B vaccine may be given to individuals aged 16 to 23 through shared decision-making and is specifically indicated for those with asplenia, complement deficiency, or during outbreaks. Hib vaccine is recommended for patients post-splenectomy or after hematopoietic stem cell transplant.

Catch-Up Vaccination Strategies

Every new patient visit and every annual wellness exam should include a review of vaccination history. State immunization information systems (IIS) are valuable for verifying records, and when documentation is unavailable, serologic testing for measles, mumps, rubella, varicella, and hepatitis B can guide catch-up decisions. For patients with unknown Tdap history, a single dose of Tdap should be administered. Multiple vaccines can safely be given at the same visit at different injection sites. However, live vaccines such as MMR and varicella must either be administered on the same day or separated by at least 28 days to avoid interference.

Special Populations

Immunocompromised Patients

Live vaccines, including MMR, varicella, live attenuated influenza vaccine (LAIV), and the older live zoster vaccine, should be avoided in severely immunocompromised patients. Importantly, Shingrix is a recombinant (not live) vaccine and is both safe and recommended for immunocompromised adults aged 19 and older. Timing relative to immunosuppressive therapy matters: ideally, vaccination occurs two to four weeks before starting immunosuppression. After rituximab, a minimum six-month wait is recommended for optimal immune response. After hematopoietic stem cell transplant, patients should be revaccinated beginning three to six months post-transplant according to established protocols.

Pregnancy

Tdap should be given during each pregnancy, ideally between 27 and 36 weeks gestation, to maximize passive antibody transfer to the newborn. Inactivated influenza vaccine is safe in any trimester. RSV vaccine is recommended at 32 to 36 weeks gestation during the seasonal window of September through January. COVID-19 vaccination is recommended during pregnancy. Live vaccines, including MMR, varicella, live zoster, HPV, and LAIV, are contraindicated.

Healthcare Workers

Healthcare workers should receive annual influenza vaccination, hepatitis B vaccination with post-vaccination serologic testing to confirm immunity, documentation of MMR and varicella immunity, and Tdap if not previously received.

Vaccine Hesitancy

Understanding the Spectrum

Vaccine hesitancy exists on a continuum from full acceptance to complete refusal, and most hesitant patients fall somewhere in the middle, open to discussion and persuadable with the right approach. It is important to distinguish between hesitancy (where the patient is ambivalent and willing to engage) and firm refusal (where the patient has made a definitive decision). Root causes of hesitancy include safety concerns, mistrust of pharmaceutical companies or government institutions, religious or philosophical beliefs, and exposure to misinformation.

Evidence-Based Communication Strategies

Research supports several specific communication approaches. The presumptive approach, in which the clinician states "Today we'll be doing your flu shot" rather than asking "Would you like a flu shot?", increases vaccine acceptance by 15 to 20% compared to participatory framing. Motivational interviewing techniques, including open-ended questions, affirmation of autonomy, and reflective listening, help explore ambivalence without triggering defensiveness. The CASE method (Corroborate, About me, Science, Explain/advise) provides a structured framework for addressing concerns. When encountering specific objections, the most effective strategy is to acknowledge and redirect: validate the patient's concern without reinforcing misinformation, then pivot to accurate information from trusted sources like the CDC, AAP, and AAFP.

Common concerns have evidence-based responses. Vaccine ingredient worries can be addressed by explaining the role and safety profile of adjuvants and preservatives. The autism myth should be met with clear reference to the retraction of the Wakefield study and the large-scale studies that have definitively disproven any link. Concerns about natural immunity can be reframed by explaining that vaccine-induced immunity is substantially safer than disease-acquired immunity for most vaccine-preventable diseases. The "too many vaccines" objection can be addressed by noting that the immune system's capacity far exceeds the antigen load of the entire vaccination schedule.

Documentation and Follow-Up

The discussion and the patient's decision should be documented in the medical record. If a patient declines vaccination, the door should remain open for future conversations. Vaccine Information Statements (VIS) must be provided as required by federal law. Practice dismissal for vaccine refusal is controversial and generally discouraged by the AAFP, as maintaining the clinical relationship preserves the opportunity for future vaccination.

<image>A visual timeline showing the adult immunization schedule across the lifespan, from age 19 through 65+. Use a horizontal timeline with color-coded vaccine bars showing when each vaccine is recommended. Include separate tracks for routine, catch-up, and risk-based vaccines. Add icons for special populations (pregnancy, immunocompromised, healthcare workers) with modified recommendations.</image>

<image>An infographic illustrating the spectrum of vaccine hesitancy from full acceptance to complete refusal, with evidence-based communication strategies matched to each stage. Show the presumptive approach, motivational interviewing techniques, and the CASE method as intervention tools. Use a gradient color scheme from green (acceptance) to red (refusal) with conversation scripts at each stage.</image>

<image>A comparison diagram showing the contraindicated versus safe vaccines for three special populations: immunocompromised patients, pregnant women, and post-transplant patients. Use a clear table format with green checkmarks for recommended, yellow caution signs for use with special considerations, and red X marks for contraindicated vaccines.</image>

Clinical Pearls

Every clinical encounter is a vaccination opportunity, including urgent care visits, chronic disease follow-up appointments, and hospital discharges. Standing orders that allow nursing staff to administer vaccines without a physician order at the time of the visit significantly improve immunization rates. Shingrix requires two doses separated by two to six months, and completion of the second dose is frequently missed, making a reminder system essential. PCV20 has simplified pneumococcal vaccination by eliminating the need for sequential PCV15 followed by PPSV23. Egg allergy, including severe egg allergy, is no longer a contraindication to influenza vaccination. Clinicians should routinely check for updated ACIP recommendations, as schedules change frequently. Finally, coadministration of Shingrix with other vaccines, including influenza and COVID-19, is safe and should be offered to reduce the number of visits required.

References

• ACIP Recommended Adult Immunization Schedule (updated annually)
• CDC Epidemiology and Prevention of Vaccine-Preventable Diseases (Pink Book)
• AAFP Immunization Resources and Position Statements
• Opel DJ et al. The architecture of provider-parent vaccine discussions. Pediatrics. 2013
• WHO SAGE Working Group on Vaccine Hesitancy Report (2014)
• Brewer NT et al. Increasing vaccination: putting psychological science into action. Psychol Sci Public Interest. 2017

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