12-phase flow (12)

1. 1FRAME
   Confirm adult preventive immunization context: age ≥19, not acutely ill with a contraindication — scope excludes pediatric schedule and travel-only vaccines (ACIP adult schedule 2025-26)
   inputs: age, sex
   advance: Patient confirmed as adult eligible for routine immunization assessment
2. 2ENTRY
   Trigger: routine wellness, catch-up request, pregnancy, immunocompromised reassessment, asplenia, or post-exposure prophylaxis (ACIP 2025-26)
   advance: Entry trigger captured
3. 3CONTEXT
   Collect immunization history, chronic conditions, occupation/travel, pregnancy — cross-reference with the current ACIP adult schedule to map age/risk → due/overdue vaccines AS DATA (PCV threshold now ≥50; RSV ≥75 or 50-74 high-risk)
   inputs: immunization_history, chronic_conditions, pregnancy_status
   advance: Vaccination history and risk factors documented
4. 4RED_FLAGS
   Contraindication-vs-precaution screen: anaphylaxis to a vaccine component = TRUE CI; severe immunocompromise/pregnancy = CI to LIVE vaccines (MMR/varicella/LAIV); encephalopathy ≤7 d of pertussis vaccine = CI to pertussis component; moderate/severe acute illness = DEFER (precaution); GBS ≤6 wk of prior tetanus/influenza = precaution; egg allergy is NOT a CI for any IIV (ACIP 2023)
   inputs: allergy_history, prior_adverse_reactions, immunocompromised_status, pregnancy_status
   actions: flag:live_vaccine_contraindication_if_immunocompromised_or_pregnant, flag:anaphylaxis_history_to_specific_component_is_true_CI
   advance: Each potential barrier classified true-CI vs precaution vs none
5. 5INITIAL_WORKUP
   Pre-vaccination serology where indicated: HBsAg/anti-HBs/anti-HBc (ACIP 2022 35358162), varicella IgG (uncertain history), rubella IgG (reproductive-age/pregnancy), measles/mumps IgG (HCW)
   inputs: hep_b_serology, varicella_titer, mmr_titers
   actions: panel.hep_b_serology, panel.varicella_igg, panel.mmr_titers, workup.pre_vaccination_serology
   advance: Pre-vaccination serology obtained or deemed unnecessary
6. 6BRANCHING_WORKUP
   Special-population branching as data: immunocompromised (additional PCV/COVID doses, Shingrix ≥19, NO live vaccines), asplenia/complement deficiency (MenACWY + MenB + PCV), HIV (CD4-gated MMR/varicella), pregnancy (Tdap 27-36 wk, maternal RSVpreF 32-36 wk seasonal, IIV any trimester), renal/dialysis & chronic liver (HepB high-dose/double), HCW (anti-HBs titer + annual flu + 2-dose MMR/varicella)
   inputs: cd4_count
   actions: workup.pneumococcal_pcv20, workup.covid19_updated, workup.shingrix
   advance: Special-population vaccine set and live-vaccine eligibility resolved
7. 7DIFFERENTIAL
   Disposition the CI-vs-precaution decision: TRUE contraindication (anaphylaxis to component; severe immunocompromise/pregnancy for LIVE vaccines; pertussis-component encephalopathy) → withhold that vaccine; PRECAUTION (moderate/severe acute illness; GBS ≤6 wk; mRNA myocarditis ≤3 wk) → defer/individualized; NONE (mild illness, egg allergy, breastfeeding, prior local reaction) → vaccinate now
   advance: Each candidate vaccine classified administer-now / defer / withhold
8. 8RISK_STRATIFICATION
   Age + risk group → vaccine set: 19-26 (HPV routine — FUTURE II 17494925), 27-45 (HPV shared decision), ≥50 (Shingrix — Lal 25916341; PCV per Jan-2025 ACIP 39773952), 50-59 high-risk + ≥75 + 50-74 high-risk (RSV — Papi 36791160), ≥65 (high-dose/adjuvanted/recombinant influenza — DiazGranados 25119609; PCV; COVID shared-decision), immunocompromised (enhanced schedule), HCW (annual flu + HepB titer)
   inputs: chronic_conditions, occupation_travel
   advance: Risk tier and age-appropriate vaccine set identified
9. 9TREATMENT
   Administer indicated vaccines: influenza annual (age-appropriate formulation), COVID-19 (current formulation, shared-decision ≥65 and 6mo-64yr per 2025-26 directive), PCV single dose ≥50 or 19-49 high-risk (PCV20/PCV21 or PCV15→PPSV23 — Bonten 25785969), Shingrix 2-dose ≥50 or immunocompromised ≥19 (Lal 25916341 / Cunningham 27626517), Tdap once then Td q10yr + each pregnancy (Amirthalingam 25037990), HepB 2-dose Heplisav-B or 3-dose Engerix-B universal 19-59 (Weng 35358162), HPV 2-3 dose ≤26 + shared 27-45, RSV single dose ≥75 or 50-74 high-risk or maternal 32-36 wk (Papi 36791160 / Kampmann 37018474), MMR/varicella catch-up if non-immune and not CI
   actions: workup.influenza_annual, workup.covid19_updated, workup.pneumococcal_pcv20, workup.shingrix, workup.tdap_td, workup.hepb, workup.hpv, workup.rsv, workup.mmr_catchup, workup.varicella_catchup
   advance: All indicated, non-contraindicated vaccines administered or scheduled
10. 10DISPOSITION
    Outpatient — all routine immunizations ambulatory; observe ≥15 min post-vaccination (30 min if syncope history) for anaphylaxis; document in immunization information system (ACIP 2025-26)
    advance: Post-vaccination observation complete, registry updated
11. 11MONITORING
    Track multi-dose series completion: Shingrix dose 2 at 2-6 mo (or 1-2 mo if immunocompromised), HepB Heplisav-B dose 2 at 1 mo / Engerix-B at 1 & 6 mo, HPV dose 2-3, PCV15→PPSV23 at ≥1 yr (≥8 wk if immunocompromised); annual influenza and current COVID-19 reminders; post-vaccination anti-HBs in HCW/immunocompromised (ACIP 2022 35358162)
    advance: Series completion dates scheduled and recall system active
12. 12FOLLOWUP
    Patient education: expected local/systemic reactions (Shingrix grade-3 reactogenicity expected — Lal 25916341), VAERS reporting for adverse events, return precautions (anaphylaxis, fever, neurologic symptoms), next vaccine due dates in patient portal and IIS (ACIP 2025-26)
    advance: Education delivered and follow-up scheduled