Immunizations (Adult) & Travel Medicine
Who gets what shot — and the live-vaccine lines you never cross
The routine adult schedule
| Vaccine | Who | Schedule and notes |
|---|---|---|
| Influenza | Everyone 6 months and older | Every year; inactivated (IIV) or recombinant for most adults |
| Tdap / Td | All adults | One Tdap, then Td or Tdap every 10 years; Tdap in EVERY pregnancy |
| Pneumococcal | All adults 50 and older; younger adults with risk conditions | PCV20 or PCV21 alone, or PCV15 followed by PPSV23 |
| Zoster (Shingrix) | All adults 50 and older; immunocompromised adults 19 and older | 2 doses, 2–6 months apart; recombinant, not live |
| HPV (Gardasil-9) | Routine at 11–12 (may start at 9); catch-up through 26; shared decision at 27–45 | 2 doses if started before the 15th birthday; 3 if started at 15 or later or if immunocompromised |
| Hepatitis B | All adults 19–59; 60 and older with risk factors or on request | Universal; no risk assessment needed under 60 |
| Hepatitis A | Travelers, chronic liver disease, men who have sex with men, drug use | 2-dose series |
Influenza. The live attenuated nasal spray (LAIV) is contraindicated in pregnancy and immunocompromise. Egg allergy is no longer a contraindication to any age-appropriate influenza vaccine.
Tdap. One adult Tdap covers pertussis; the 10-year boosters can be Td or Tdap. Tdap in every pregnancy at 27–36 weeks passes maternal antibody that protects the newborn against pertussis.
Pneumococcal. The universal age threshold was recently lowered from 65 to 50. Adults 19–64 with risk conditions have long qualified, so risk-based vaccination now matters mainly below 50: chronic heart, lung, liver, or kidney disease, diabetes, smoking, alcoholism, immunocompromise, asplenia, CSF leak, or cochlear implant. After PCV15, PPSV23 follows in about 1 year (as soon as 8 weeks with immunocompromise, CSF leak, or cochlear implant).
Zoster. Because Shingrix is not live, it is safe in immunocompromised patients, unlike the old live Zostavax, which is off the market. Give it even after a prior episode of shingles.
HPV prevents cervical, anal, and oropharyngeal cancers and genital warts; it is deferred during pregnancy.
Live vaccines: the lines you never cross
The live list. MMR, varicella, LAIV (nasal influenza), yellow fever, oral typhoid, and BCG are live attenuated vaccines. They are contraindicated in pregnancy and in significant immunocompromise: HIV with a low CD4 count, chemotherapy, or high-dose steroids. Non-live vaccines (inactivated, recombinant, toxoid, mRNA) are safe in immunocompromise, although responses may be weaker.
- HIV: MMR and varicella may be given when the CD4 count is at least 200 cells/μL.
- Steroids: prednisone ≥20 mg/day for 14 days or more counts as high-dose immunosuppression.
- Timing: give a needed live vaccine BEFORE pregnancy or immunosuppression, and wait 4 weeks after it before conceiving.
- Spacing: two injected or intranasal live vaccines are given on the same day or at least 4 weeks apart.
Special populations
Pregnancy. Give inactivated vaccines: Tdap (every pregnancy), inactivated influenza (any trimester), and COVID-19. RSV vaccine at 32–36 weeks during RSV season is an option to protect the newborn. Withhold all live vaccines (MMR, varicella, LAIV) until postpartum; nonimmune mothers receive MMR and varicella after delivery, and breastfeeding is not a contraindication. RhoGAM for Rh-negative mothers is standard care, not a vaccine.
Federal COVID-19 vaccine recommendations have changed repeatedly since 2025; confirm current guidance for pregnancy and for each age group.
Asplenia (surgical, or functional as in sickle cell disease) impairs clearance of encapsulated organisms, SHiN: Streptococcus pneumoniae, Haemophilus influenzae type b, and Neisseria meningitidis. Give pneumococcal, Hib, and BOTH meningococcal vaccines (MenACWY and MenB), ideally at least 2 weeks before an elective splenectomy (or 2 weeks after an emergency one). MenACWY boosters recur every 5 years while risk persists, and fever in an asplenic patient demands urgent evaluation.
Encapsulated organisms: Some Killers Have Pretty Nice Capsules (Strep pneumoniae, Klebsiella, Hib, Pseudomonas, Neisseria, Cryptococcus).
Meningococcal vaccines. MenACWY is routine at 11–12 with a booster at 16; MenB is a shared decision at 16–23. Both are indicated for asplenia, complement deficiency or complement-inhibitor therapy (eculizumab), and microbiologists who handle N. meningitidis. MenACWY alone covers military recruits, first-year college students living in dorms, and travelers to the Hajj or the African meningitis belt; MenB is added during serogroup B outbreaks. When MenACWY and MenB are both due at the same visit, a pentavalent MenABCWY vaccine can replace the two separate shots.
Travel medicine
Travel vaccines. Hepatitis A and typhoid protect against fecal-oral exposure; typhoid comes as a live oral vaccine or an inactivated injectable vaccine, the latter used when live vaccines are contraindicated. Yellow fever vaccine is for endemic sub-Saharan Africa and South America; it is LIVE, must be given at least 10 days before travel, and is contraindicated in pregnancy and immunocompromise.
| Drug | Dosing | Key points |
|---|---|---|
| Atovaquone-proguanil (Malarone) | Daily; from 1–2 days before until 7 days after travel | Well tolerated; avoid in pregnancy and severe renal impairment |
| Doxycycline | Daily; from 1–2 days before until 4 weeks after | Photosensitivity and esophagitis; avoid in pregnancy and young children |
| Mefloquine | Weekly; from at least 2 weeks before until 4 weeks after | Neuropsychiatric effects; avoid with psychiatric or seizure history; acceptable in pregnancy |
| Chloroquine | Weekly | Only in chloroquine-sensitive regions |
| Primaquine or tafenoquine | Added for radical cure; tafenoquine (weekly) is also a primary prophylaxis option | Eradicates P. vivax and P. ovale hypnozoites; check G6PD first (hemolysis); avoid in pregnancy |
Always check G6PD activity before primaquine or tafenoquine to avoid hemolytic anemia.
Tetanus and wound management
| Wound | 3 or more prior doses | Unknown or fewer than 3 doses |
|---|---|---|
| Clean, minor | Td or Tdap if 10 or more years since the last dose | Td or Tdap; no TIG |
| Dirty or severe | Td or Tdap if 5 or more years since the last dose | Td or Tdap PLUS tetanus immune globulin (TIG) |