Common vaccine administration, including consent and delivery
Vaccine types - the distinction that drives every decision
| Type | Examples | Key rule |
|---|---|---|
| Live attenuated | MMR, varicella, zoster (Zostavax), yellow fever, oral typhoid, BCG, rotavirus, live attenuated influenza | *Contraindicated in significant immunosuppression and in pregnancy* |
| Inactivated / subunit / toxoid | dTpa, polio (IPV), hepatitis A and B, HPV, influenza, pneumococcal conjugate and polysaccharide, meningococcal, Shingrix (recombinant zoster), Hib, rabies, Q fever, JE (inactivated) | Safe in immunosuppression and pregnancy - response may be reduced |
| mRNA / viral vector | COVID-19 | Not live; safe in immunosuppression |
- *"Zoster vaccine" is ambiguous - Zostavax is LIVE, Shingrix is recombinant and non-live.* Shingrix is now the preferred and funded product and is the one safe in immunocompromised adults
Timing rules
- Two different live parenteral vaccines: give on the same day, or separate by >=4 weeks
- Inactivated vaccines may be co-administered with anything, at separate sites
- Interrupted schedules are resumed, never restarted - "the course does not need to start again"
- Live vaccines after immunoglobulin or blood products: delay 3-11 months (antibody interference)
The National Immunisation Program
- Australia's National Immunisation Program (NIP) funds the routine schedule; the Australian Immunisation Handbook is the authority
- Childhood coverage ~93-95%; adult coverage is far lower and is the main gap physicians can close
- Adult vaccination is markedly under-delivered in chronic disease, immunosuppression, asplenia and pregnancy - every admission is an opportunity
- Australian Immunisation Register (AIR) now records vaccinations at all ages - check it rather than relying on recall
How vaccines work
- Active immunisation -> antigen presentation -> B and T memory -> durable protection after a latent period of ~2 weeks
- Conjugate vaccines (protein-conjugated polysaccharide) generate T-dependent responses -> memory, boosting, herd protection and mucosal carriage reduction
- Plain polysaccharide vaccines (23vPPV) are T-independent -> no memory, poor response under 2 years, hyporesponsiveness on repeat dosing
- *This is why the conjugate vaccine is given first and the polysaccharide second*
- Passive immunisation (immunoglobulin) -> immediate but temporary protection; used for post-exposure prophylaxis (tetanus, hepatitis B, varicella, rabies, measles)
- Herd immunity threshold rises with transmissibility - measles needs ~95% coverage
Who needs extra vaccines - identify the risk group
| Group | Additional vaccines |
|---|---|
| Asplenia/hyposplenism (incl. sickle cell, coeliac with functional hyposplenism) | *Pneumococcal, meningococcal ACWY AND B, Hib, annual influenza* - "the encapsulated organisms" |
| Complement deficiency / eculizumab or ravulizumab | Meningococcal ACWY and B (plus antibiotic prophylaxis - vaccination is not sufficient) |
| Planned immunosuppression, transplant, biologic therapy | Give live vaccines >=4 weeks before, inactivated >=2 weeks before; hepatitis B, pneumococcal, influenza, COVID, Shingrix, varicella if non-immune |
| Chronic lung disease incl. COPD | Annual influenza + pneumococcal (inc risk of invasive pneumococcal disease and pneumonia), COVID, RSV where eligible |
| CKD/dialysis | Hepatitis B (double dose, 4-dose schedule, check anti-HBs), pneumococcal, influenza |
| Chronic liver disease | Hepatitis A and B, pneumococcal, influenza |
| Pregnancy | **dTpa every pregnancy (ideally 20-32 weeks), influenza (any trimester), COVID, RSV* - live vaccines contraindicated* |
| Aboriginal and Torres Strait Islander adults | Pneumococcal from 50 (conjugate from 25 with risk conditions), shingles from 50, influenza, hepatitis B |
| Healthcare workers | Hepatitis B with serology, MMR, varicella, dTpa, annual influenza, COVID |
| HIV | Full schedule; *avoid live vaccines if CD4 <200* |
Contraindications - genuine vs assumed
- True contraindications: anaphylaxis to a previous dose or a vaccine component; live vaccine in significant immunosuppression or pregnancy
- *NOT contraindications: minor illness with or without low-grade fever, antibiotic use, family history of adverse events, prematurity, breastfeeding, egg allergy for influenza vaccine (standard vaccines are safe*), stable neurological disease, previous local reaction
- Defer during moderate-severe acute febrile illness
Definitions of significant immunosuppression
Definitions of significant immunosuppression (live vaccines contraindicated)
- Prednisolone >=20 mg/day (or >=2 mg/kg/day in children) for >=14 days - wait 1 month after stopping
- Biologics, most DMARDs at immunosuppressive doses, chemotherapy, transplant immunosuppression
- Methotrexate <=0.4 mg/kg/week, azathioprine <=3 mg/kg/day and prednisolone <20 mg/day are generally NOT significant immunosuppression for this purpose
Tetanus prophylaxis in wound management
A. Tetanus prophylaxis in wound management - the classic exam table
| History of tetanus vaccine | Clean minor wound | All other (tetanus-prone) wounds |
|---|---|---|
| >=3 doses, last dose <5 yr | Nothing | Nothing |
| >=3 doses, last dose 5-10 yr | Nothing | Vaccine |
| >=3 doses, last dose >10 yr | Vaccine | Vaccine |
| <3 doses or uncertain | Vaccine (and complete the course) | Vaccine + TETANUS IMMUNOGLOBULIN |
- Tetanus-prone: deep, penetrating, contaminated with soil/faeces/saliva, devitalised tissue, compound fracture, burns, crush, delayed >6 h, retained foreign body, animal bite
- *TIG is indicated for a tetanus-prone wound whenever the vaccine history is fewer than 3 doses or uncertain - and, regardless of vaccination history, in humoral immunodeficiency including HIV*
- TIG 250 IU IM, or 500 IU if >24 h has elapsed; give at a separate site from the vaccine
- Use dTpa rather than dT where pertussis boosting is also useful
- Thorough wound cleaning and debridement is as important as either product
Pneumococcal vaccination in adults - the schedule changed in 2026
B. Pneumococcal vaccination in adults - the schedule changed in 2026
- 21vPCV (conjugate) replaced 13vPCV as the NIP-funded adult vaccine from 1 July 2026, and the routine age for adults without a risk condition was lowered from 70 to 65
- Single dose of 21vPCV for:
- Non-Indigenous adults >=65
- Aboriginal and Torres Strait Islander adults >=25 (earlier with risk conditions)
- Any adult >=18 with a risk condition
- Risk conditions with additional 23vPPV doses: asplenia, immunocompromise, CSF leak, cochlear implant, chronic lung/heart/liver/kidney disease, diabetes, smoking, Down syndrome, alcohol misuse
- *Give the conjugate vaccine before the polysaccharide* - the reverse order blunts the response
- COPD is a specific indication - invasive pneumococcal disease and pneumonia risk
Influenza, COVID and RSV
C. Influenza, COVID and RSV
- Annual influenza vaccine from 6 months of age; funded for >=65, pregnancy, Aboriginal and Torres Strait Islander people >=6 months, children 6 months-5 years, and anyone with a medical risk condition
- Enhanced (adjuvanted or high-dose) formulations are preferred for >=65
- COVID-19 boosters per current ATAGI advice, stratified by age and immunocompromise
- RSV: maternal vaccination in pregnancy and nirsevimab for infants; adult RSV vaccines are recommended for older adults - check current NIP funding, which is changing
Zoster
D. Zoster
- Shingrix (recombinant, 2 doses 2-6 months apart) is the preferred product and is NIP-funded for adults >=65, Aboriginal and Torres Strait Islander adults >=50, and immunocompromised adults >=18 in defined categories
- *Zostavax (live) is contraindicated in immunocompromise and has caused fatal disseminated disease when given in error*
Administration practicalities
E. Administration practicalities
- IM into the deltoid for most adult vaccines (anterolateral thigh in infants); do not aspirate
- Separate sites and record which vaccine went where
- Observe for 15 minutes after every vaccination; adrenaline must be immediately available
- Anaphylaxis: adrenaline 0.5 mg IM (1:1000) into the anterolateral thigh - antihistamines and steroids are not the treatment
- Cold chain: 2-8 degrees C; record and report breaches - a broken cold chain means revaccination
- Record every dose on the AIR; report adverse events to the state adverse events service
Special situations
F. Special situations
- Bleeding disorder or anticoagulation: use a 23-25 gauge needle, firm pressure for 5-10 min, IM route is still preferred
- Pregnancy: dTpa every pregnancy, even if recently given; influenza and COVID at any gestation; no live vaccines
- Needlestick/post-exposure: hepatitis B vaccine +/- HBIG, tetanus per the table above, rabies/lyssavirus vaccine + immunoglobulin after animal or bat exposure
- Overseas travel: yellow fever (live, certificate required), typhoid, hepatitis A, rabies, JE, cholera - refer to a travel clinic 6-8 weeks before departure
High-risk groups
- Asplenia and hyposplenism - lifelong vaccination and antibiotic prophylaxis; medical alert identification
- Terminal complement deficiency and complement inhibitor therapy (eculizumab, ravulizumab) - meningococcal disease risk
- Biologic and immunosuppressive therapy - plan vaccination before starting
- Solid organ and haematopoietic stem cell transplantation - HSCT requires a full revaccination programme from ~6-12 months post-transplant
- Chronic lung, liver, kidney and heart disease; diabetes; smoking
- Pregnancy - maternal antibody transfer protects the neonate (pertussis, RSV, influenza, tetanus)
- Vaccine hesitancy - address specifically; document the discussion
- Guillain-Barre syndrome after a previous influenza vaccine - a precaution, not an absolute contraindication
Onset and waning of protection
- Protection develops ~2 weeks after vaccination - relevant to pre-travel and pre-splenectomy timing (vaccinate >=2 weeks before elective splenectomy, or >=1 week after if emergency)
- Waning: pertussis immunity wanes within ~5-10 years; tetanus protection is long but not lifelong; pneumococcal polysaccharide responses wane over ~5 years; influenza requires annual revaccination for antigenic drift
- Immunosuppressed patients have lower and shorter-lived responses - check serology where an assay exists (hepatitis B anti-HBs, measles IgG, varicella IgG)
- Live vaccine given in error to an immunosuppressed patient -> seek immediate specialist advice; consider immunoglobulin and antiviral therapy
- Most adverse events are local and self-limiting; anaphylaxis occurs in ~1 per million doses
🔒
14 more sections, plus exam facts
Premium unlocks every note across every specialty, and the full exam fact library behind it.
Get premium access