When should vaccines be administered or withheld from individuals based on their medical history, risk factors, and demographics?

When to Give and When to Withhold Vaccines

Vaccines should be administered to all eligible individuals based on age, medical conditions, occupational exposure, and risk factors, with the only absolute contraindications being severe allergic reactions to vaccine components and specific circumstances of severe immunocompromise for live vaccines.

Absolute Contraindications (When NOT to Give Vaccines)

Severe Allergic Reactions

• Never administer any vaccine to individuals with a history of anaphylaxis to that vaccine or its components 1
• This applies universally across all vaccine types 1

Live Vaccines Specifically Contraindicated In:

• Severe immunodeficiency from hematologic/solid tumors, chemotherapy, long-term immunosuppressive therapy, or severely immunocompromised HIV patients 1, 2
• Pregnancy (for MMR, varicella, zoster, and live attenuated influenza vaccine) 1
• Recent receipt of antibody-containing blood products (within 11 months for MMR and varicella; specific interval depends on product) 1

Precautions (Defer Vaccination Temporarily)

• Moderate or severe acute illness with or without fever - applies to all vaccines; defer until recovery 1
• Recent antiviral therapy (acyclovir, famciclovir, valacyclovir) for varicella and zoster vaccines - avoid these antivirals 24 hours before and 14 days after vaccination 1

When TO Give Vaccines: Priority Groups

Universal Recommendations (Give to Everyone)

• Annual influenza vaccination for all adults regardless of age or health status 3
• Tetanus-diphtheria (Td) booster every 10 years, with one Tdap dose substituting for one Td booster 3

Age-Based Indications (Strongly Recommend)

Adults ≥65 years:

• Influenza vaccine annually 1
• Pneumococcal vaccination: PCV13 (based on shared decision-making) followed by PPSV23 at least 1 year later 3
• Zoster vaccine (one dose for adults ≥60 years, regardless of previous herpes zoster history) 3

Adults 50-64 years:

• Influenza vaccine (this age group has 24-32% prevalence of high-risk conditions) 1

Young adults:

• HPV vaccination through age 26 for women, age 21 for men (3-dose series) 3

Medical Condition-Based Indications (Strongly Recommend)

Pneumococcal vaccine indicated for:

• Chronic pulmonary disease (including asthma) 1, 3
• Chronic cardiovascular disease 1, 3
• Diabetes mellitus 1, 3
• Chronic liver disease 1, 3
• Chronic renal failure or nephrotic syndrome 1
• Functional or anatomic asplenia 1
• Immunocompromising conditions (strongest indication) 1, 3
• Cochlear implants and CSF leaks 1

Hepatitis B vaccine indicated for:

• End-stage renal disease/hemodialysis patients 1, 3
• HIV infection 1, 3
• Chronic liver disease 1, 3

Hepatitis A vaccine indicated for:

• Chronic liver disease 1
• Persons receiving clotting factor concentrates 1

Occupational Indications (Strongly Recommend)

Healthcare workers must receive:

• Annual influenza vaccination (protects both workers and patients; associated with decreased nursing home patient deaths) 1, 3
• Hepatitis B vaccination (for those exposed to blood/body fluids) 1, 3
• Hepatitis A vaccination (for laboratory workers with HAV exposure) 1, 3
• Meningococcal vaccination (for microbiologists exposed to N. meningitidis) 3

Pregnancy-Specific Recommendations (Give During Pregnancy)

• Tdap during each pregnancy, preferably between 27-36 weeks gestation 3
• Influenza vaccine during influenza season (women in second or third trimester during flu season are at increased risk) 1, 3

Behavioral/Lifestyle Risk Factors (Strongly Recommend)

Hepatitis A and B vaccines for:

• Men who have sex with men 1, 3
• Persons who use injection drugs 1, 3
• Sexually active persons not in long-term monogamous relationships 1
• Travelers to countries with high/intermediate hepatitis A endemicity 1, 3

Household Contact Indications

• Vaccinate household contacts and caregivers of high-risk individuals to prevent transmission 1
• Particularly important for contacts of children aged 0-23 months (at increased risk for influenza hospitalization) 1

Special Considerations for Immunocompromised Patients

Inactivated vaccines (safe and recommended):

• Pneumococcal and injectable influenza vaccines are essential for all immunocompromised patients 2
• Other inactivated vaccines indicated only in high-risk situations 2

Live vaccines (usually contraindicated):

• Contraindicated in patients on immunosuppressive therapy 2
• Contraindicated in HIV patients with CD4 count <200/mm³ 2

Common Pitfalls to Avoid

• Do not withhold vaccines for minor illnesses - only moderate/severe acute illness warrants deferral 1
• Do not assume immunocompromised patients cannot receive any vaccines - inactivated vaccines are safe and strongly indicated 2
• Do not give live attenuated influenza vaccine (FluMist) to immunocompromised patients, pregnant women, or adults ≥50 years - use inactivated vaccine instead 1
• Do not forget to vaccinate healthcare workers - their vaccination protects vulnerable patients and reduces nosocomial transmission 1, 4