4.7 Immunization Schedules
Key Takeaways
Hepatitis B vaccine is given at birth, with a 3-dose series completed by 6-18 months; this is often the first vaccine a newborn receives
DTaP (Diphtheria, Tetanus, Pertussis) requires a 5-dose series at 2, 4, 6, 15-18 months, and 4-6 years; adults receive Tdap booster then Td every 10 years
MMR (Measles, Mumps, Rubella) and Varicella vaccines are live vaccines given at 12-15 months and 4-6 years; contraindicated in pregnancy and severe immunocompromise
Annual influenza vaccination is recommended for everyone 6 months and older; high-dose or adjuvanted formulations available for adults 65+
Shingles vaccine (Shingrix) is recommended for adults 50+ as a 2-dose series; pneumococcal vaccines (PCV15/PCV20 and PPSV23) recommended at 65+
Immunization Fundamentals
Vaccines prevent serious diseases by stimulating the immune system to develop protection without causing the disease itself. Nurses play a crucial role in administering vaccines, educating patients, and addressing vaccine hesitancy.
Types of Vaccines
| Type | Description | Examples |
|---|---|---|
| Live attenuated | Weakened live organism | MMR, Varicella, Rotavirus, Nasal flu |
| Inactivated | Killed organism | Injectable flu, Hepatitis A |
| Subunit/conjugate | Parts of organism | Hep B, HPV, Pertussis component |
| Toxoid | Inactivated toxin | Diphtheria, Tetanus |
| mRNA | Genetic instructions | COVID-19 (Pfizer, Moderna) |
Live Vaccine Considerations
Live vaccines are contraindicated in:
- Pregnancy
- Severe immunocompromise
- Recent blood product transfusion (varies by vaccine)
Key Point: Live vaccines can be given on the same day; if not given simultaneously, wait 4 weeks between live vaccines.
Childhood Immunization Schedule (Birth to 6 Years)
Birth
- Hepatitis B (first dose) - Given before hospital discharge
2 Months
| Vaccine | Disease Protected |
|---|---|
| DTaP | Diphtheria, Tetanus, Pertussis |
| IPV | Polio |
| Hib | Haemophilus influenzae type b |
| PCV15/PCV20 | Pneumococcal disease |
| Rotavirus | Rotavirus gastroenteritis |
| Hepatitis B | Hepatitis B (if not given earlier) |
4 Months
- DTaP, IPV, Hib, PCV, Rotavirus
6 Months
- DTaP, Hib, PCV, Rotavirus (final dose)
- Hepatitis B (if 3rd dose due)
- Influenza (begin annual vaccination; 2 doses first season if <9 years)
12-15 Months
| Vaccine | Notes |
|---|---|
| MMR | Live vaccine |
| Varicella | Live vaccine |
| Hepatitis A | 2-dose series starts |
| Hib | Final dose |
| PCV | Final dose |
| DTaP | 4th dose (15-18 months) |
4-6 Years
- DTaP (5th dose)
- IPV (4th dose)
- MMR (2nd dose)
- Varicella (2nd dose)
Childhood Schedule Summary Table
| Vaccine | Birth | 2 mo | 4 mo | 6 mo | 12-15 mo | 4-6 yr |
|---|---|---|---|---|---|---|
| Hep B | 1st | 2nd-3rd | ||||
| DTaP | 1st | 2nd | 3rd | 4th | 5th | |
| IPV | 1st | 2nd | 3rd | 4th | ||
| Hib | 1st | 2nd | 3rd | 4th | ||
| PCV | 1st | 2nd | 3rd | 4th | ||
| Rotavirus | 1st | 2nd | 3rd | |||
| MMR | 1st | 2nd | ||||
| Varicella | 1st | 2nd | ||||
| Hep A | 1st-2nd | |||||
| Influenza | Annual (begins at 6 mo) |
Adolescent Immunizations (11-18 Years)
11-12 Years
| Vaccine | Schedule |
|---|---|
| Tdap | Single dose (replaces Td booster) |
| HPV | 2-dose series (if starting before age 15) |
| Meningococcal ACWY | First dose |
| Annual Influenza | Every year |
16 Years
- Meningococcal ACWY (booster)
- Meningococcal B (based on risk/shared decision)
HPV Vaccine Details
- Protects against cervical, anal, oropharyngeal, and other HPV-related cancers
- Ages 9-14: 2-dose series (0 and 6-12 months)
- Ages 15-26: 3-dose series (0, 1-2, and 6 months)
- Catch-up available through age 45 (shared decision)
Adult Immunization Schedule
All Adults
| Vaccine | Recommendation |
|---|---|
| Influenza | Annual |
| Td/Tdap | Tdap once if not given in adolescence; Td every 10 years |
| COVID-19 | Per current recommendations |
Based on Age
| Age | Vaccine |
|---|---|
| 50+ | Shingrix (2-dose series) |
| 65+ | Pneumococcal (PCV15/PCV20, may add PPSV23) |
| 65+ | RSV vaccine (single dose) |
Based on Risk Factors
| Condition | Vaccines |
|---|---|
| Asplenia | Pneumococcal, Meningococcal, Hib |
| Immunocompromise | Inactivated vaccines (avoid live) |
| Chronic liver disease | Hepatitis A, Hepatitis B |
| Healthcare workers | Hepatitis B, annual flu |
Special Populations
Pregnancy
Recommended during pregnancy:
- Tdap (each pregnancy, preferably 27-36 weeks)
- Influenza (inactivated)
- COVID-19
- RSV (32-36 weeks, during RSV season)
Contraindicated during pregnancy:
- Live vaccines (MMR, Varicella, Live attenuated influenza)
Immunocompromised
- Avoid live vaccines
- May need higher doses or additional doses
- Household contacts should receive indicated vaccines
- Consider timing relative to immunosuppressive therapy
Common Vaccine Reactions
Expected Reactions
- Injection site pain, redness, swelling
- Low-grade fever
- Fussiness (infants)
- Fatigue, headache
Management: Acetaminophen or ibuprofen as appropriate; cold compress to site.
Concerning Reactions
| Reaction | Action |
|---|---|
| High fever (>104°F/40°C) | Notify provider |
| Severe local reaction | Document; may affect future doses |
| Anaphylaxis | Emergency treatment; document contraindication |
| Encephalopathy within 7 days (DTaP) | Contraindication to pertussis component |
Contraindications and Precautions
True Contraindications
- Severe allergic reaction (anaphylaxis) to previous dose or vaccine component
- Encephalopathy within 7 days of pertussis vaccine (for DTaP/Tdap)
- Severe immunodeficiency (for live vaccines)
- Pregnancy (for live vaccines)
NOT Contraindications
These are NOT reasons to delay vaccination:
- Mild illness without fever
- Current antibiotic therapy
- Premature birth (vaccinate per chronological age)
- Breastfeeding
- Family history of vaccine reactions
- Allergies to products not in the vaccine
Addressing Vaccine Hesitancy
Communication Strategies
- Listen to concerns without judgment
- Acknowledge emotions and provide empathy
- Provide information in clear, simple terms
- Use trusted sources (CDC, AAP, WHO)
- Give strong recommendation - provider recommendation is most influential
Common Concerns and Responses
| Concern | Response |
|---|---|
| "Too many vaccines" | Immune system handles thousands of antigens daily; vaccines add minimal burden |
| "Vaccines cause autism" | Thoroughly disproven; original study was fraudulent |
| "Natural immunity is better" | Disease risks far outweigh vaccine risks |
| "Ingredients are harmful" | Components are in safe amounts; strictly tested |
Exam Tips
- Know the childhood schedule - especially timing of first doses
- Hep B is given at birth (before hospital discharge)
- Live vaccines: MMR, Varicella, Rotavirus - avoid in pregnancy/immunocompromise
- Tdap in every pregnancy (27-36 weeks)
- Annual influenza for everyone 6 months and older
- Shingrix at age 50+ (not the old Zostavax)
- True contraindications are RARE - mild illness is not a reason to delay
A mother asks the nurse if her 6-month-old infant with a mild upper respiratory infection can receive vaccines today. The nurse should respond:
"We should wait until the infection completely resolves."
"We can give the vaccines today since mild illness is not a contraindication."
"Only inactivated vaccines can be given during illness."
"We need to check with the pediatrician before giving any vaccines."
A pregnant woman at 30 weeks gestation asks about recommended vaccines. Which vaccines should the nurse recommend?
MMR and Varicella
Tdap and inactivated influenza
Live attenuated influenza and Tdap
No vaccines are recommended during pregnancy
Which statement about the HPV vaccine is correct?
It is only recommended for females
The series should begin at age 18
It is a live vaccine contraindicated in immunocompromise
If started before age 15, only 2 doses are needed
Sections you finish are checked off in the contents.