What are the vaccination guidelines for pregnant and adult patients?

Vaccination Guidelines for Pregnant and Adult Patients

All pregnant women should receive Tdap vaccine during each pregnancy (preferably between 27-36 weeks gestation) and annual inactivated influenza vaccine regardless of trimester, as these are the only two vaccines universally recommended for all pregnant women. 1, 2

Vaccines Recommended for All Pregnant Women

Tdap (Tetanus, Diphtheria, Pertussis)

• Administer during each pregnancy between 27-36 weeks gestation, as early in this window as possible 1, 2
• Provides passive immunity to the newborn against pertussis, which has high infant mortality 2, 3
• Should be given during every pregnancy regardless of prior vaccination history 2

Influenza (Inactivated)

• Annual inactivated influenza vaccine (IIV or RIV) at any gestational age 1, 2
• Pregnant women with influenza face significantly increased risk of maternal morbidity, mortality, and fetal complications including congenital anomalies, spontaneous abortion, preterm birth, and low birth weight 2
• Can be administered postpartum if not given during pregnancy 3
• Live attenuated influenza vaccine (LAIV) is absolutely contraindicated in pregnancy 1

Vaccines to Delay Until After Pregnancy

The following vaccines should be deferred until after delivery unless specific high-risk circumstances exist: 1

• HPV vaccine (Gardasil 9): Delay until postpartum; if inadvertently given during pregnancy, no intervention needed and not a reason for pregnancy termination 1, 4
• Recombinant zoster vaccine (RZV/Shingrix): Consider delaying if indicated until after pregnancy 1
• Live attenuated zoster vaccine (ZVL/Zostavax): Absolutely contraindicated 1
• MMR vaccine: Contraindicated during pregnancy; should be offered during preconception counseling with advice to avoid pregnancy for one month after vaccination 1, 3
• Varicella vaccine: Contraindicated in pregnancy; if no evidence of immunity, administer postpartum before hospital discharge 1, 3

Vaccines Requiring Risk-Benefit Assessment in Pregnancy

MenB (Meningococcal Serogroup B)

• Defer unless pregnant woman is at increased risk for serogroup B meningococcal disease (e.g., complement deficiency, asplenia, microbiologist exposure, outbreak setting) 1
• When risk is present, benefits may outweigh potential risks 1

MenACWY (Meningococcal Conjugate)

• Pregnancy should NOT preclude use if otherwise indicated (e.g., asplenia, complement deficiency, travel to endemic areas, HIV infection) 1
• This differs from MenB—MenACWY can be given when indicated without deferral 1

Hepatitis A and B

• Administer if at high risk of exposure: chronic liver disease, travel to endemic areas, injection drug use, men who have sex with men, healthcare exposure 1, 3
• No evidence of adverse fetal effects from inactivated vaccines 2

Pneumococcal (PCV13, PPSV23)

• Give if high-risk conditions present: immunocompromising conditions, asplenia, chronic heart/lung disease, diabetes, chronic liver disease, cerebrospinal fluid leak, cochlear implant 1, 3

General Adult Vaccination Schedule (Non-Pregnant)

Routine Vaccinations by Age

• Influenza: Annual vaccination for all adults ≥19 years with IIV, RIV, or LAIV (if age ≤49 years and no contraindications) 1
• Tdap: One dose if not previously received, then Td booster every 10 years 1
• Zoster (RZV/Shingrix): 2-dose series 2-6 months apart for all adults ≥50 years 1
• Pneumococcal: Age ≥65 years: PCV13 followed by PPSV23 at least 1 year later 1
• HPV: Through age 26 years (2- or 3-dose series depending on age at initiation); ages 27-45 based on shared clinical decision-making 1

High-Risk Adult Populations

• Immunocompromising conditions (HIV, chemotherapy, solid organ transplant, immunosuppressive therapy): PCV13 followed by PPSV23 at 8 weeks, then repeat PPSV23 in 5 years; 2-dose MenACWY series; consider 2-dose varicella series if CD4 ≥200 cells/μL 1
• Asplenia/complement deficiency: PCV13, PPSV23, 2-dose MenACWY series (revaccinate every 5 years), MenB series 1
• Chronic medical conditions (heart disease, lung disease, liver disease, diabetes): PPSV23 for ages 19-64 years; annual influenza 1

Critical Safety Principles

Contraindications in Pregnancy

All live vaccines are contraindicated during pregnancy due to theoretical risk of fetal viremia/bacteremia: 3

• LAIV (live attenuated influenza vaccine) 1
• MMR 1, 3
• Varicella 1, 3
• Live zoster vaccine (ZVL) 1

Inactivated Vaccines Are Generally Safe

• No evidence of adverse fetal effects from inactivated virus vaccines, bacterial vaccines, or toxoids in pregnancy 2
• Growing body of data demonstrates safety of inactivated vaccines during pregnancy 2, 5
• Antibodies transfer to fetus in second and third trimesters, providing passive immunity in first months of life 6

Common Pitfalls to Avoid

• Never delay Tdap and influenza vaccines in pregnant women—these are universally recommended and safe at appropriate gestational ages 1, 2
• Do not restart vaccine series due to pregnancy interruption—continue from where patient left off per catch-up schedule 7
• Do not withhold MenACWY in pregnancy if indicated—unlike MenB, this should be given when risk factors are present 1
• Avoid accepting self-reported vaccination history without written documentation (except pneumococcal polysaccharide vaccine) 7
• Administer all indicated vaccines simultaneously when possible to maximize completion rates 7