This document discusses adult vaccination guidelines. It covers immunization types including active, live attenuated, inactivated, subunit/recombinant vaccines. It provides guidance on vaccination for hepatitis A, hepatitis B, HPV, Hib, and influenza. High-risk groups are identified for each vaccine. It emphasizes that immunocompromised individuals and pregnant women should receive inactivated/recombinant vaccines only. Screening tools are referenced to help assess vaccination needs for adults.

1. AdultVaccination -1-
by Leena Rasmi

3. Immunization referred to
the artificial induction of immunity,
it can by:
Active immunization:
the use of live attenuated infectious agents
or inactivated toxins
or Antigens obtained by genetic
recombination .
long term protection sometimes life long
Passive immunization:
Temporary immunity obtained by
the administration of immunoglobulin or
antitoxins.
Temporary immunity that decreases with
time (turnover of the administrated
immunoglobulin)

4. Vaccines in the Adult Immunization Schedule Types of vaccines :
1. Live -Attenuated
2. Inactivated (killed)
3. Subunit, recombinant,
polysaccharide, and conjugate
vaccines
4.Toxoids
Important Points :
Immunocompromised patient
+ Pregnancy :
No live vaccines
Past history and anaphylactic
reaction to egg
influenza vaccine !!!!
Most vaccines carry a small
risk of B-symptoms following
administration, including
fever, fatigue, and myalgias
Swelling and redness may
occur at the injection site, and
localized muscle soreness may
also occur.

5. Hepatitis A
vaccination

6. Routine vaccination
• Not at risk but want protection from hepatitis
A (identification of risk factor not required):
2-dose series HepA
(Havrix 6–12 months apart orVaqta 6–18 months
apart [minimum interval: 6 months]) or
3-dose series HepA-HepB
(Twinrix at 0, 1, 6 months [minimum intervals: 4
weeks between doses 1 and 2, 5 months between
doses 2 and 3])
Hepatitis A vaccine is an
inactivated (killed) virus
vaccine.

7. Special situations​
•At risk for hepatitis A virus infection: 2-dose series HepA or 3-dose series HepA-HepB as
above
•Chronic liver disease (e.g., persons with 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)
•HIV infection
•Persons experiencing homelessnessThe key to the definition is the instability of
the person’s living arrangement.
•Work with hepatitis A virus in research laboratory or with nonhuman primates with
hepatitisA virus infection
•Travel in countries with high or intermediate endemic hepatitis A
•Close, personal contact with international adoptee (e.g., household or regular
babysitting) in first 60 days after arrival from country with high or intermediate endemic
hepatitisA (administer dose 1 as soon as adoption is planned, at least 2 weeks before
adoptee’s arrival)
•Pregnancy if at risk for infection or severe outcome from infection during pregnancy
•Settings for exposure, including health care settings 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)

8. Hepatitis B
vaccination
Hepatitis B vaccine is a Subunit virus vaccine.

9. Routine vaccination
• Not at risk but want protection from hepatitis B (identification of risk factor
not required):
2- or 3-dose series
(2-dose series Heplisav-B at least 4 weeks apart [2-dose series HepB only
applies when 2 doses of Heplisav-B are used at least 4 weeks apart] or
3-dose series Engerix-B or Recombivax HB at 0, 1, 6 months [minimum
intervals: 4 weeks between doses 1 and 2, 8 weeks between doses 2 and 3, 16
weeks between doses 1 and 3]) or
3-dose series HepA-HepB (Twinrix at 0, 1, 6 months [minimum intervals: 4
weeks between doses 1 and 2, 5 months between doses 2 and 3])

10. Special situations
• At risk for hepatitis B virus infection:
2-dose (Heplisav-B) or 3-dose (Engerix-B, Recombivax HB) series or 3-dose series HepA-HepB (Twinrix)
as above
• Chronic liver disease (e.g., persons with hepatitis 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 HBsAg-
positive 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; hemodialysis, peritoneal dialysis, home dialysis,
and predialysis patients; persons with diabetes mellitus age younger than 60 years and, at
discretion of treating clinician, those age 60 years or older)
• Incarcerated persons
• Travel in countries with high or intermediate endemic hepatitis B
• Pregnancy if at risk for infection or severe outcome from infection during pregnancy.
Heplisav-B not currently recommended due to lack of safety data in pregnant women

11. Human
papillomavirus
vaccination
HPV vaccine is a recombinant - inactivated (not live) virus vaccine.

12. Routine vaccination
• HPV vaccination recommended for all adults through age 26 years:
• 2- or 3-dose series depending on age at initial vaccination or condition:
• Age 15 years or older at initial vaccination: 3-dose series at 0, 1–2, 6 months
(minimum intervals: 4 weeks between doses 1 and 2/12 weeks between doses 2 and 3/5
months between doses 1 and 3; repeat dose if administered too soon)
• Age 9 through 14 years at initial vaccination and received 1 dose or 2 doses less than
5 months apart: 1 dose
• Age 9 through 14 years at initial vaccination and received 2 doses at least 5 months
apart: HPV vaccination complete, no additional dose needed.
• If completed valid vaccination series with any HPV vaccine, no additional doses needed
Shared clinical decision-making
• Age 27 through 45 years based on shared clinical decision-making:
• 2- or 3-dose series as above
Special situations
• Pregnancy through age 26 years: HPV vaccination not recommended until after pregnancy;
no intervention needed if vaccinated while pregnant; pregnancy testing not needed before
vaccination

13. Do women still need to get a Pap test if they’ve been vaccinated against HPV?
Yes.Women should continue to receive regular cervical cancer screening for three reasons.
First, the vaccine does not provide protection against all types of HPV that cause cervical cancer.
Second, women may not receive the full benefits of the vaccine if they do not complete the vaccine
series.
Third, women may not receive the full benefits of the vaccine if they were infected with HPV before
receiving the vaccine.
In addition, vaccinated people should continue to practice protective sexual behaviors since the
vaccine will not prevent all cases of genital warts or other sexually transmitted infections.

14. Haemophilus
influenzae type b
vaccination

15. Special situations
•Anatomical or functional asplenia (including sickle cell disease):
1 dose if previously did not receive Hib; if elective splenectomy, 1 dose,
preferably at least 14 days before splenectomy
•Hematopoietic stem cell transplant (HSCT): 3-dose series 4 weeks
apart starting 6–12 months after successful transplant, regardless of Hib
vaccination history

16. Influenza
vaccination
Routine vaccination
•Persons age 6 months or older:
1 dose any influenza vaccine appropriate for age and health status annually​
Two types of influenza vaccine are widely available:
inactivated influenza vaccines (IIV) and
live attenuated influenza vaccines
(LAIV) + recombinant .

17. Special situations
•Egg allergy, hives only: 1 dose any influenza vaccine appropriate for age and health status
annually
•Egg allergy more severe than hives (e.g., angioedema, respiratory distress): 1 dose any
influenza vaccine appropriate for age and health status annually in medical setting under
supervision of health care provider who can recognize and manage severe allergic reactions
•LAIV should not be used in persons with the following conditions or situations:
•History of severe allergic reaction to any vaccine component (excluding egg) or to a
previous dose of any influenza vaccine
•Immunocompromised due to any cause (including medications and HIV infection)
•Anatomic or functional asplenia
•Cerebrospinal fluid-oropharyngeal communication
•Close contacts or caregivers of severely immunosuppressed persons who require a
protected environment
•Pregnancy
•Received influenza antiviral medications within the previous 48 hours
•History of Guillain-Barré syndrome within 6 weeks of 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

18. The AdultVaccine AssessmentTool
https://www2a.cdc.gov/nip/adultimmsched/

20. An elderly patient that you follow has recently started hemodialysis for
chronic renal failure.You know that hepatitis B vaccination is
recommended for people on hemodialysis, and find that he is hepatitis B
surface antibody negative. Which of the following would be the best
guideline to follow in this case?
a. No vaccination is necessary based on his laboratory evaluation
b. Administer one dose of hepatitis B vaccine
c. Administer two doses of hepatitis B vaccine, at least 1 month apart
d. Administer two doses of hepatitis B vaccine, at least 6 months apart
e. Administer three does of hepatitis B vaccine at the appropriate time
interval

21. The answer is e.
Hepatitis B vaccination is recommended for nonimmune people who are
high risk.Those include men who have sex with men, people with multiple
sexual partners, sex industry workers, intravenous drug users, prison
inmates, people on hemodialysis, people living in households with
hepatitis B virus carriers, health care workers and people from endemic
areas.
In this question, having surface antibody negativity means that the
patient has never been exposed and is nonimmune.
The immunization schedule is one injection at time 0, one between 1–2
months after that, and a third injection between 4–6 months after the
second.

22. You are discussing vaccinations for a patient who is traveling internationally.
Due to a significant fear of needles, he is unwilling to obtain any vaccination
unless he feels there is significant risk of acquiring the condition.Which of
the following vaccine preventable illness is the most common one acquired
by travelers?
a.Yellow fever
b. Polio
c. Hepatitis A
d. Cholera
e.Typhus

23. The answer is c.
Hepatitis A is the most common vaccine preventable illness acquired
by travelers.Yellow fever is the only legally required immunization (and
then, only for some countries). A single inactivated polio vaccine (IPV)
booster is recommended for adult travelers who have had primary polio
immunization, but who will be traveling to an area where polio is
endemic. Cholera and typhus are generally not required immunizations
for travelers

24. A 68-year-old patient is seen for a
general examination Current recommendations for immunizations include
A)Tetanus booster every 5 years
B) Influenza vaccination yearly
C) Pneumococcal vaccination yearly
D) Hepatitis booster every 5 years
E) Meningococcal vaccination
Which of the following patients should not be vaccinated against influenza at
today’s office visit?
a. 32 year-old mother of 3 with UTI and fever 100 degrees
b. 18 year-old college student with egg allergy
c. 66 year old retired college professor with decompensated heart failure
d. 52 year-old Pediatrician
e. Pregnant 30 year-old woman
f. all of the patients listed should receive influenza vaccine today

25. The answer is B.
Adult immunizations should include tetanus immunization every 10 years
and influenza vaccination yearly beginning at age 50. Pneumococcal
immunization should be given at age 65.Those at high risk receiving
pneumococcal vaccination before age 65 and after 5 years may require
boosters.Vaccination can be started earlier in patients at high risk for
disease (e.g., patients who are immunocompromised, those with chronic
lung disease or diabetes). Patients who do not have functional spleens
should receive pneumococcal, meningococcal, and influenza immunization
The answer is F .
INFLUENZA VACCINATION IS RECOMMENDED IN ALL PATIENTS 6 MONTHS OF AGE AND
OLDERWHO WISHTO BE PROTECTED FROM INFLUENZA. THEREARE MULTIPLEVACCINE
PRODUCTSAVAILABLE INCLUDING 1 WHICH IS RECOMIBINANTAND IS COMPLETELY EGG-FREE
[FLUBLOCK] AND A SECOND [FLUCELVAX]WHICH IS ESSENTIALLY EGG-FREE [FEMTOGRAMS
OF EGG PROTEIN]. INACTIVATEDVACCINES MAY BE GIVENTO ANY PATIENT 6 MONTHS OF AGE
AND OLDERANDTHE LIVEATTENUATED NASALVACCINETO HEALTHY PATIENTS 1-50YEARS
OF AGE [NOTTHOSEWITH IMMUNE SUPPORESSION,ASTHMA ORWORKINGWITH SEVERELY
IMMUNE SUPPRESSED PERSONS

26. Which of the following statements is most correct about Haemophilus
influenza type B [HiB] vaccination in adults?
a. HiB vaccine is not indicated in adults [or children over 60 months of
age].
b. Hib vaccine is recommended in severely immune compromised HIV
patients [CD4 < 200 cells/mm3
c. A single dose of HiB vaccine is recommended in adults prior to
splenectomy
d. A primary HiB vaccine series [3 doses over 6 months] should be
completed prior to stem cell transplantation

27. The answer is C :
HAEMOPHILUS INFLUENZAETYPE BVACCINATION HAS BEENA COMPONENTOF
ROUTINE CHILDHOODVACCINATION PROGRAMS SINCETHE 1990’SAND HAS MADEA
TREMENDOUS IMPACT INTHE INCIDENCEOF INVASIVE HiB DISEASE IN
CHILDHOOD. HiBVACCINATION IS RECOMMENDED FORA SMALL NUMBER OF
ADULTSWHO ARE AT HIGHLY INCREASED RISK FOR INVASIVE HiB DISEASE. A SINGLE
DOSEOF HiBVACCINE IS INDICATED IN PREVIOUSLY UNIMMUNIZEDADULTSWHO
ARETO UNDERGO SPLENECTOMY, IDEALLY 2WEEKS PRIORTOTHE
PROCEDURE. UNIMMUNIZED PERSONSWITHANATOMIC OR FUNCTIONALASPLENIA
SHOULD RECEIVE 1 DOSEOF HiBVACCINE. PERSONSOF ANYAGEWHO UNDERGO
HEMATOPOIETIC STEMCELLTRANSPLANTS SHOULD RECEIVE A COMPLETE 3 DOSE
SERIES SEPARATED BY AT LEAST 4WEEKS, STARTING 6-12 MONTHSAFTERTHE
TRANSPLANT. 1 DOSEOF HiBVACCINEWAS PREVIOUSLY RECOMMENDED FOR
PREVIOUSLY IMMUNIZEDADULTSWITH HIV DISEASE; HOWEVER,THE ACIP NO
LONGER RECOMMENDS HiBVACCINATION INADULTSWITH HIV DISEASE.

28. A 66-year-old woman on 40 mg prednisolone/day for temporal arteritis was exposed to a
confirmed case of influenza A (H1N1)pdm09. She also had hypertension, asthma and
osteoarthritis, for which she took amlodipine, Lisinopril, paracetamol and inhaled salmeterol.
She had not yet received her seasonal influenza vaccination. She presented to her doctor 24
hours after the exposure and a choice of prophylaxis with either oral oseltamivir or inhaled
zanamivir was considered.
What side effect of zanamivir is she at risk of developing?
•Agitation
•Bronchospasm
•Cardiac arrhythmia
•Guillain–Barré syndrome
•Reye's syndrome