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Adult immunization (preventive)

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12/12 authored

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Frame

Detailed

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)

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Patient confirmed as adult eligible for routine immunization assessment

Patient inputs (13)

Age determines eligibility for every vaccine (PCV/RSV thresholds revised: PCV ≥50, RSV ≥75 or 50-74 high-risk per April-2025 ACIP)

Pregnancy status relevant for Tdap timing, maternal RSV, live-vaccine contraindications (ACIP 2025-26)

Prior vaccine records map age/risk → vaccine-due as data (ACIP 2025-26)

Tdap each pregnancy 27-36 wk (Amirthalingam 25037990 91% VE); influenza any trimester; maternal RSVpreF 32-36 wk seasonal (Kampmann 37018474); avoid LIVE vaccines (MMR/varicella/LAIV)

Immunocompromised → additional PCV/COVID doses, Shingrix ≥19 (not a live vaccine — Lal 25916341), AVOID live MMR/varicella/LAIV (ACIP 2025-26)

Anaphylaxis to a vaccine component = true CI; egg allergy NO LONGER a CI for any IIV (ACIP 2023); yeast (HepB/HPV), PEG/polysorbate (mRNA COVID-19), gelatin/neomycin (MMR/varicella)

Anaphylaxis to a prior dose/component = CI; GBS ≤6 wk of prior tetanus/influenza vaccine = precaution; encephalopathy ≤7 d of pertussis vaccine = CI to pertussis component

Diabetes, CKD/dialysis (HepB double-dose), chronic liver disease, heart/lung disease, asplenia, HIV alter vaccine recommendations and risk tier (ACIP 2025-26)

HIV: CD4 ≥200 cells/µL (≥15%, ≥6 mo) permits MMR/varicella; CD4 <200 = CI to MMR/varicella (live-vaccine gate) (ACIP 2025-26)

HBsAg/anti-HBs/anti-HBc before vaccination; post-vaccination anti-HBs <10 mIU/mL in HCW/immunocompromised → revaccinate (ACIP 2022 35358162)

Varicella IgG confirms immunity; negative = 2-dose catch-up if NOT pregnant/immunocompromised (live vaccine)

Rubella IgG for pregnancy/reproductive-age screening; measles/mumps IgG for HCW (ACIP 2025-26)

Healthcare workers (HepB + anti-HBs titer, annual influenza, 2-dose MMR/varicella), travel, lab workers (meningococcal) (ACIP 2025-26)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (3)

3 need judgement
  • informationallife_threateninganaphylaxis_post_vaccination — ACIP 2025-26
    Anaphylaxis within minutes to hours of vaccine administration — urticaria, angioedema, bronchospasm, hypotension (ACIP 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverelive_vaccine_in_immunocompromised_or_pregnancy — ACIP 2025-26
    Inadvertent LIVE vaccine (MMR, varicella, LAIV) given to a severely immunocompromised patient or during pregnancy (ACIP 2025-26)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecontraindication_vs_precaution_decision — ACIP 2025-26 (decision-as-data)
    Encoded barrier-classification logic. TRUE CI: anaphylaxis to a vaccine component; severe immunocompromise or pregnancy for any LIVE vaccine; encephalopathy ≤7 d of a pertussis-containing vaccine (→ use Td not Tdap). PRECAUTION (defer/individualize): moderate-or-severe acute illness; GBS ≤6 wk of prior tetanus/influenza vaccine; myocarditis ≤3 wk of a prior mRNA dose. NOT a barrier (vaccinate now): mild illness, breastfeeding, prior local reaction, EGG ALLERGY of any severity (any IIV acceptable — ACIP 2023), family history of adverse events.
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

Influenza vaccine — annual, age-appropriate formulation (ACIP 2025-26; DiazGranados NEJM 2014 25119609)
axis: vaccine_influenza
Selected axis "Influenza vaccine — annual, age-appropriate formulation (ACIP 2025-26; DiazGranados NEJM 2014 25119609)" by default fallback (first axis)
  • influenza vaccine (standard-dose, quadrivalent inactivated, IIV4)
    first line
    inactivated_vaccine
    0.5 mL • IM • annually
    triggers: all_adults_annually, pregnancy_any_trimester
    Standard IIV4 for adults 18-64 without a preferred-formulation indication; pregnancy any trimester — IIV only, never LAIV (ACIP 2025-26)
  • influenza vaccine (high-dose, quadrivalent, HD-IIV4)
    first line
    inactivated_vaccine
    0.7 mL • IM • annually
    triggers: age_ge_65
    Preferred age ≥65: high-dose IIV (Fluzone HD) had 24.2% relative efficacy vs standard-dose for lab-confirmed influenza (DiazGranados NEJM 2014 25119609)
  • influenza vaccine (adjuvanted, aIIV4)
    first line
    adjuvanted_vaccine
    0.5 mL • IM • annually
    triggers: age_ge_65
    Preferred age ≥65 (MF59-adjuvanted Fluad) as an alternative to high-dose (ACIP 2025-26)
  • influenza vaccine (recombinant, RIV4)
    first line
    recombinant_vaccine
    0.5 mL • IM • annually
    triggers: age_ge_65, egg_allergy_any_severity
    Preferred age ≥65 (recombinant Flublok, egg-free); egg allergy is NO LONGER a contraindication for ANY IIV — egg-allergic patients may receive any age-appropriate vaccine (ACIP 2023)

outpatient playbook — drug actions (8)

  1. 1. Influenza vaccine (age-appropriate; HD/adjuvanted/recombinant if ≥65)
    0.5-0.7 mL • IM • annually
    trigger: All adults during influenza season; egg allergy not a CI (ACIP 2023)
    Annual universal recommendation; ≥65 high-dose 24.2% relative efficacy vs SD (DiazGranados NEJM 2014 25119609)
  2. 2. COVID-19 current formulation (or Novavax if PEG/polysorbate allergy)
    0.3-0.5 mL • IM • per current ACIP
    trigger: Shared/individual decision ≥65 and 6mo-64yr; additional doses if immunocompromised (2025-26 directive)
    Current-formulation mRNA or protein-subunit per shared decision (ACIP/HHS 2025-26)
  3. 3. PCV20 or PCV21 (single dose) — or PCV15→PPSV23
    0.5 mL • IM • single dose
    trigger: PCV-naive ≥50 or 19-49 with risk (Kobayashi MMWR 2025 39773952)
    Single-dose PCV20/PCV21 preferred; PCV13 CAPiTA 45.6% VE vaccine-type CAP (Bonten NEJM 2015 25785969)
  4. 4. Shingrix (RZV) dose 1 then dose 2 at 2-6 mo (1-2 mo if immunocompromised)
    0.5 mL • IM • 2-dose series
    trigger: Age ≥50 or immunocompromised ≥19 (Lal NEJM 2015 25916341)
    ZOE-50 97.2% / ZOE-70 89.8% efficacy; recombinant, safe in immunocompromised (25916341 / 27626517)
  5. 5. Tdap (then Td/Tdap q10yr)
    0.5 mL • IM • once then q10yr; each pregnancy 27-36 wk
    trigger: No prior adult Tdap or pregnancy 27-36 wk (Amirthalingam Lancet 2014 25037990)
    Pertussis protection; maternal Tdap 91% effective for infant pertussis <3 mo (25037990)
  6. 6. Heplisav-B (2-dose) or Engerix-B/Recombivax (3-dose); double-dose if dialysis
    0.5-1 mL (40 mcg dialysis) • IM • 2 or 3 dose series
    trigger: Universal 19-59; risk-based ≥60 (Weng MMWR 2022 35358162)
    Universal HepB 19-59; Heplisav-B faster/higher seroprotection; pregnancy prefers Engerix/Recombivax (35358162)
  7. 7. RSV vaccine (Arexvy or Abrysvo); maternal Abrysvo if pregnant 32-36 wk
    0.5 mL • IM • single dose (one-time)
    trigger: All ≥75 or 50-74 high-risk; maternal 32-36 wk seasonal (Papi 36791160; Kampmann 37018474)
    AReSVi-006 82.6% VE RSV-LRTD; maternal RSVpreF protects infants (MATISSE) — do not duplicate with nirsevimab
  8. 8. HPV (Gardasil 9) 2-3 dose series
    0.5 mL • IM • 2 or 3 dose series
    trigger: Routine ≤26; shared decision 27-45 (FUTURE II 17494925)
    98% efficacy vs HPV-16/18 high-grade cervical lesions in naive women (17494925; PATRICIA 19586656)

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Routine wellness or preventive visit — review immunization status per current ACIP adult schedule (CDC 2025-26 addendum); Catch-up immunization for incompletely vaccinated adult — MMR, varicella, HepB, HPV (ACIP adult schedule 2025-26); Immunocompromised patient requiring modified vaccine schedule — live vaccine avoidance, additional PCV/COVID doses (ACIP 2025-26).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Adult immunization (preventive)** (prev.adult-immunization.core.v1).
Phenotype framing: 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
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Influenza vaccine — annual, age-appropriate formulation (ACIP 2025-26; DiazGranados NEJM 2014 25119609)**.
1. influenza vaccine (standard-dose, quadrivalent inactivated, IIV4) 0.5 mL IM annually (inactivated_vaccine, first line) — Standard IIV4 for adults 18-64 without a preferred-formulation indication; pregnancy any trimester — IIV only, never LAIV (ACIP 2025-26)
2. influenza vaccine (high-dose, quadrivalent, HD-IIV4) 0.7 mL IM annually (inactivated_vaccine, first line) — Preferred age ≥65: high-dose IIV (Fluzone HD) had 24.2% relative efficacy vs standard-dose for lab-confirmed influenza (DiazGranados NEJM 2014 25119609)
3. influenza vaccine (adjuvanted, aIIV4) 0.5 mL IM annually (adjuvanted_vaccine, first line) — Preferred age ≥65 (MF59-adjuvanted Fluad) as an alternative to high-dose (ACIP 2025-26)
4. influenza vaccine (recombinant, RIV4) 0.5 mL IM annually (recombinant_vaccine, first line) — Preferred age ≥65 (recombinant Flublok, egg-free); egg allergy is NO LONGER a contraindication for ANY IIV — egg-allergic patients may receive any age-appropriate vaccine (ACIP 2023)

Setting playbook (outpatient) — Complete age/risk-stratified adult immunization assessment, resolve contraindication-vs-precaution for each candidate vaccine, administer indicated non-contraindicated vaccines, document in IIS, and schedule multi-dose series follow-up (ACIP 2025-26)
5. Influenza vaccine (age-appropriate; HD/adjuvanted/recombinant if ≥65) 0.5-0.7 mL IM annually — All adults during influenza season; egg allergy not a CI (ACIP 2023) (Annual universal recommendation; ≥65 high-dose 24.2% relative efficacy vs SD (DiazGranados NEJM 2014 25119609))
6. COVID-19 current formulation (or Novavax if PEG/polysorbate allergy) 0.3-0.5 mL IM per current ACIP — Shared/individual decision ≥65 and 6mo-64yr; additional doses if immunocompromised (2025-26 directive) (Current-formulation mRNA or protein-subunit per shared decision (ACIP/HHS 2025-26))
7. PCV20 or PCV21 (single dose) — or PCV15→PPSV23 0.5 mL IM single dose — PCV-naive ≥50 or 19-49 with risk (Kobayashi MMWR 2025 39773952) (Single-dose PCV20/PCV21 preferred; PCV13 CAPiTA 45.6% VE vaccine-type CAP (Bonten NEJM 2015 25785969))
8. Shingrix (RZV) dose 1 then dose 2 at 2-6 mo (1-2 mo if immunocompromised) 0.5 mL IM 2-dose series — Age ≥50 or immunocompromised ≥19 (Lal NEJM 2015 25916341) (ZOE-50 97.2% / ZOE-70 89.8% efficacy; recombinant, safe in immunocompromised (25916341 / 27626517))
9. Tdap (then Td/Tdap q10yr) 0.5 mL IM once then q10yr; each pregnancy 27-36 wk — No prior adult Tdap or pregnancy 27-36 wk (Amirthalingam Lancet 2014 25037990) (Pertussis protection; maternal Tdap 91% effective for infant pertussis <3 mo (25037990))
10. Heplisav-B (2-dose) or Engerix-B/Recombivax (3-dose); double-dose if dialysis 0.5-1 mL (40 mcg dialysis) IM 2 or 3 dose series — Universal 19-59; risk-based ≥60 (Weng MMWR 2022 35358162) (Universal HepB 19-59; Heplisav-B faster/higher seroprotection; pregnancy prefers Engerix/Recombivax (35358162))
11. RSV vaccine (Arexvy or Abrysvo); maternal Abrysvo if pregnant 32-36 wk 0.5 mL IM single dose (one-time) — All ≥75 or 50-74 high-risk; maternal 32-36 wk seasonal (Papi 36791160; Kampmann 37018474) (AReSVi-006 82.6% VE RSV-LRTD; maternal RSVpreF protects infants (MATISSE) — do not duplicate with nirsevimab)
12. HPV (Gardasil 9) 2-3 dose series 0.5 mL IM 2 or 3 dose series — Routine ≤26; shared decision 27-45 (FUTURE II 17494925) (98% efficacy vs HPV-16/18 high-grade cervical lesions in naive women (17494925; PATRICIA 19586656))

Non-pharmacologic actions:
- Review the immunization information system (IIS) for prior records (ACIP 2025-26)
- Classify each candidate vaccine: true CI vs precaution vs none — administer all non-contraindicated at the same visit, no max number (ACIP 2025-26)
- Provide Vaccine Information Statements (VIS) before each vaccine (federal requirement)
- HPV shared decision-making 27-45 (ACIP 2025-26)
- COVID-19 shared/individual decision-making ≥65 and 6mo-64yr (2025-26 directive)
- RSV one-time-dose counseling — ≥75 or 50-74 high-risk; do not duplicate maternal RSV with infant nirsevimab (ACIP 2025-26)
- Post-vaccination observation ≥15 min (30 min if syncope/prior allergic reaction history) (ACIP 2025-26)
- Schedule multi-dose series follow-up: Shingrix dose 2, HepB doses 2-3, HPV doses 2-3, PCV15→PPSV23 interval (ACIP 2025-26)
- Order post-series anti-HBs for HCW/dialysis/immunocompromised (Weng MMWR 2022 35358162)

AVOID / contraindication checks:
- True_CI:anaphylaxis_to_a_prior_influenza_vaccine_or_component (ACIP 2025 26)
- Precaution:gbs_within_6wk_of_prior_influenza_vaccine_individualize (ACIP 2025 26)
- Precaution:moderate_or_severe_acute_illness_defer_until_resolved (ACIP general best practice)
- Not_a_CI:egg_allergy_of_any_severity_any_IIV_acceptable (ACIP 2023)
- Not_a_CI:mild_illness_breastfeeding_prior_local_reaction (ACIP general best practice)

Monitoring

Regimen monitoring:
- annual vaccination each influenza season (ACIP 2025-26)
- age ge 65 prefer HD adjuvanted or recombinant (DiazGranados 25119609)
- pregnancy any trimester IIV only never LAIV (ACIP 2025-26)
- observe ge 15min post vaccination 30min if syncope history

Setting (outpatient) monitoring:
- Annual influenza and current-formulation COVID-19 reminders (ACIP 2025-26)
- Td/Tdap booster every 10 years (ACIP 2025-26)
- Multi-dose series completion tracking — Shingrix, HepB, HPV, PCV15→PPSV23 (ACIP 2025-26)
- Post-vaccination anti-HBs for HCW/dialysis/immunocompromised; revaccinate if <10 mIU/mL (Weng 35358162)

Follow-up plan: 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)
- Close-out criterion: Education delivered and follow-up scheduled

Monitoring phase: 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)

Disposition

Current setting: outpatient — Complete age/risk-stratified adult immunization assessment, resolve contraindication-vs-precaution for each candidate vaccine, administer indicated non-contraindicated vaccines, document in IIS, and schedule multi-dose series follow-up (ACIP 2025-26)

Disposition criteria:
- Continue routine schedule — annual influenza, Td/Tdap q10yr (ACIP 2025-26)
- Schedule return for multi-dose series completion (ACIP 2025-26)
- Refer to specialist if complex immunodeficiency or severe allergy (ACIP 2025-26)

Escalation triggers (move to higher acuity):
- Anaphylaxis post-vaccination → IM epinephrine, call 911, observe, VAERS (route allergy.anaphylaxis.v1)
- GBS within 6 wk of vaccination → VAERS, treat the implicated vaccine as a precaution for future doses (ACIP 2025-26)
- Myocarditis/pericarditis after mRNA COVID-19 → cardiology referral; precaution for future mRNA doses, consider protein-subunit (ACIP 2025-26)
- Complex immunodeficiency or severe allergy → ID or allergy/immunology referral for individualized vaccine plan (ACIP 2025-26)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Anaphylaxis within minutes to hours of vaccine administration — urticaria, angioedema, bronchospasm, hypotension (ACIP 2025-26)
- [SEVERE] Inadvertent LIVE vaccine (MMR, varicella, LAIV) given to a severely immunocompromised patient or during pregnancy (ACIP 2025-26)
- [MODERATE] Encoded barrier-classification logic. TRUE CI: anaphylaxis to a vaccine component; severe immunocompromise or pregnancy for any LIVE vaccine; encephalopathy ≤7 d of a pertussis-containing vaccine (→ use Td not Tdap). PRECAUTION (defer/individualize): moderate-or-severe acute illness; GBS ≤6 wk of prior tetanus/influenza vaccine; myocarditis ≤3 wk of a prior mRNA dose. NOT a barrier (vaccinate now): mild illness, breastfeeding, prior local reaction, EGG ALLERGY of any severity (any IIV acceptable — ACIP 2023), family history of adverse events.

Citations

- ACIP Recommended Adult Immunization Schedule (CDC; addendum 2025-07-02, amended 2026-04-27 for the April-2025 RSV expansion) + vaccine-specific ACIP MMWR statements [PMID:25785969](https://pubmed.ncbi.nlm.nih.gov/25785969/)
- Cited evidence (PMID 25916341) [PMID:25916341](https://pubmed.ncbi.nlm.nih.gov/25916341/)
- Cited evidence (PMID 27626517) [PMID:27626517](https://pubmed.ncbi.nlm.nih.gov/27626517/)
- Cited evidence (PMID 25119609) [PMID:25119609](https://pubmed.ncbi.nlm.nih.gov/25119609/)
- Cited evidence (PMID 36791160) [PMID:36791160](https://pubmed.ncbi.nlm.nih.gov/36791160/)

Last reconciled with current guidelines: 2026-05-16.
References
  • ACIP Recommended Adult Immunization Schedule (CDC; addendum 2025-07-02, amended 2026-04-27 for the April-2025 RSV expansion) + vaccine-specific ACIP MMWR statements — PMID:25785969
  • Cited evidence (PMID 25916341) — PMID:25916341
  • Cited evidence (PMID 27626517) — PMID:27626517
  • Cited evidence (PMID 25119609) — PMID:25119609
  • Cited evidence (PMID 36791160) — PMID:36791160