6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B

Key Takeaways Explain This Topic AI

All adults require at least one lifetime dose of Tdap, followed by a decennial (every 10 years) booster of either Td or Tdap; pregnant women must receive Tdap during each pregnancy between 27 and 36 weeks of gestation regardless of prior vaccination history.

For contaminated or dirty wounds, patients with fewer than 3 lifetime doses of tetanus toxoid (or unknown status) require both tetanus vaccine and Tetanus Immune Globulin (TIG 250 units IM); fully immunized individuals (>=3 doses) require a vaccine booster only if more than 5 years have elapsed, and do NOT require TIG.

Recombinant Zoster Vaccine (RZV, Shingrix) is a 2-dose intramuscular series (0 and 2–6 months) indicated for all immunocompetent adults aged 50 and older and immunocompromised adults aged 19 and older, administered regardless of prior episodes of herpes zoster or prior Zostavax vaccination.

Human papillomavirus 9-valent vaccine (9vHPV) is routinely recommended for all individuals through age 26; for adults aged 27–45, vaccination involves shared clinical decision-making, using a 3-dose schedule (0, 1–2, 6 months) for any series initiated at or after age 15.

Universal hepatitis B vaccination is recommended for all adults aged 19–59, and adults aged 60 and older with risk factors; the 2-dose adjuvanted series (Heplisav-B at 0 and 1 month) offers superior seroprotection rates compared to the traditional 3-dose recombinant series (Engerix-B / Recombivax HB at 0, 1, 6 months).

Last updated: September 2026

• Tetanus, Diphtheria, and Pertussis (Tdap / Td)
• Microbiology and Clinical Manifestations

Clostridium tetani : An obligate anaerobic, spore-forming, gram-positive bacillus found ubiquitously in soil, animal feces, and road dust. Spores enter broken skin and germinate under anaerobic conditions. Vegetative cells release tetanospasmin , an extremely potent neurotoxin that undergoes retrograde intraneuronal transport to the spinal cord and brainstem. Tetanospasmin cleaves synaptobrevin, blocking the release of inhibitory neurotransmitters ( gamma-aminobutyric acid [GABA] and glycine ) from Renshaw interneurons. This leads to unregulated, continuous alpha-motor neuron firing manifesting as painful trismus ("lockjaw"), risus sardonicus , generalized muscle spasms, painful opisthotonos , autonomic lability, and respiratory arrest.

Corynebacterium diphtheriae : An aerobic gram-positive bacillus that produces diphtheria toxin (an ADP-ribosylating toxin inactivating elongation factor EF-2). Clinical manifestations include a dense, gray, adherent fibrinous pseudomembrane over the tonsils and pharynx, myocarditis with conduction block, and cranial/peripheral neuropathies.

Bordetella pertussis : A fastidious gram-negative coccobacillus producing pertussis toxin, filamentous hemagglutinin, and tracheal cytotoxin. Causes whooping cough, characterized by a catarrhal phase progressing to a paroxysmal phase of intense coughing spasms with post-tussive emesis, subconjunctival hemorrhages, rib fractures, and syncope.

Routine Adult Schedule

Primary Adult Booster : All adults aged 19 and older who have not previously received a dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) should receive 1 lifetime dose of Tdap .

Decennial Maintenance : Following the initial Tdap dose, adults should receive a booster dose of either Td or Tdap every 10 years . (ACIP guidelines explicitly state that Tdap may be used interchangeably with Td for decennial boosters, wound management, and catch-up regimens).

Maternal Pertussis Immunization

Mandate : Pregnant individuals must receive a dose of Tdap during EACH and EVERY pregnancy , regardless of the patient's prior vaccination history or the interval since their previous Td or Tdap booster.

Optimal Timing : Administered between 27 and 36 weeks of gestation (optimally early in this window, between 27 and 32 weeks).

Mechanism : Tdap stimulates peak maternal anti-pertussis IgG antibodies, which actively cross the placenta via the neonatal Fc receptor (FcRn). This confers high levels of protective transplacental antibodies to the newborn, shielding the infant against severe pertussis, apnea, encephalopathy, and death during the critical first 2 months of life before the infant can receive their first DTaP dose at 2 months.

Postpartum Catch-Up : If Tdap was not administered during pregnancy, it should be administered immediately postpartum prior to discharge ("cocooning" strategy), although passive placental transfer during pregnancy provides significantly superior infant protection.

Tetanus Wound Management Algorithm

Evaluating acute traumatic lacerations requires assessing both the wound characteristics (clean/minor vs contaminated/dirty) and the patient's tetanus vaccination history :

Contaminated / Dirty Wounds : Wounds contaminated with soil, feces, dirt, or saliva; puncture wounds (e.g., rusted nails, animal bites); avulsions; wounds resulting from crushing, burns, or frostbite; and wounds with devitalized tissue.

Clean and Minor Wounds : Superficial, non-penetrating abrasions or clean incisions without particulate contamination or tissue devitalization.

Vaccination History Clean, Minor Wounds Dirty, Contaminated Wounds

Uncertain or <3 Lifetime Doses Give Td or Tdap vaccine.; Do NOT give TIG. Give Td or Tdap vaccine; PLUS Tetanus Immune Globulin (TIG) .

≥ 3 Documented Lifetime Doses Give vaccine ONLY if >10 years since last dose.; Do NOT give TIG. Give vaccine ONLY if >5 years since last dose.; Do NOT give TIG.

Important

Administration Rule for TIG : When both tetanus vaccine (Td or Tdap) and Tetanus Immune Globulin (TIG, 250 units IM) are indicated, they must be administered at separate anatomical sites (e.g., opposite deltoids or deltoid and gluteus) using separate syringes to avoid direct antigen-antibody neutralization.

• Recombinant Zoster Vaccine (RZV, Shingrix)
• Pathophysiology of Herpes Zoster & Complications

Primary infection with Varicella Zoster Virus (VZV) causes chickenpox, after which the virus establishes lifelong latency within sensory cranial nerve and dorsal root ganglia. With advancing age or immunosuppression, VZV-specific cell-mediated CD4+ T-cell immunity declines , allowing viral replication, ganglionitis, and anterograde migration down sensory axons to the skin. This manifests as a painful, unilateral, dermatomal maculopapular eruption that rapidly evolves into grouped vesicles.

Postherpetic Neuralgia (PHN) : The most frequent chronic complication, defined as persistent dermatomal neuropathic pain lasting >90 days after the onset of the rash . PHN occurs in up to 20–30% of zoster patients over age 60 and can persist for months to years, causing severe debilitation.

Herpes Zoster Ophthalmicus (HZO) : Reactivation involving the ophthalmic division (V1) of the trigeminal nerve. The presence of vesicles on the tip or side of the nose ( Hutchinson's sign ) indicates involvement of the nasociliary branch and strongly correlates with ocular complications (keratitis, anterior uveitis, secondary glaucoma, permanent visual loss), requiring immediate ophthalmology consultation.

Vaccine Biology & Efficacy

Formulation : Recombinant Zoster Vaccine (RZV, Shingrix) is an adjuvanted, non-live sub-unit vaccine containing 50 μg of recombinant VZV glycoprotein E (gE) lyophilized antigen reconstituted with the AS01B adjuvant system .

Adjuvant AS01B : Formulated with QS-21 (a triterpene glucoside saponin) and 3-O-desacyl-4'-monophosphoryl lipid A (MPL, a TLR4 agonist) in a liposomal suspension. This adjuvant strongly activates dendritic cells and induces exceptionally high, durable frequencies of gE-specific CD4+ T cells.

Clinical Efficacy : Shingrix demonstrates >90–97% efficacy in preventing herpes zoster and PHN across all adult age brackets (including patients ≥ 80 years), maintaining >85% efficacy at 10 years post-vaccination.

Retirement of Zostavax : The live attenuated zoster vaccine (Zostavax, ZVL) was permanently discontinued in the United States in November 2020 due to low initial efficacy (<51% overall, <38% in age ≥ 70), rapid waning, and strict contraindications in immunocompromised hosts.

Target Populations and Dosing Regimens

Immunocompetent Adults Aged ≥ 50 Years : 2 doses of Shingrix administered intramuscularly (0.5 mL each) separated by 2 to 6 months .

Immunocompromised Adults Aged ≥ 19 Years : 2 doses of Shingrix administered intramuscularly separated by 1 to 2 months (the accelerated interval ensures completion prior to planned immunosuppression or chemotherapy).

Prior Herpes Zoster Episode : Patients with a documented history of shingles should still be vaccinated. Recurrence rates after natural zoster are significant. Vaccination should be administered once the acute zoster rash has fully resolved and crusted.

Prior Zostavax Recipients : Adults who previously received Zostavax should be revaccinated with the complete 2-dose Shingrix series, waiting at least 2 months after the Zostavax dose.

Varicella Serologic Screening : Pre-vaccination serologic testing for varicella immunity is not recommended for adults aged ≥ 50; >99% of individuals born in the US before 1980 have had wild-type varicella.

Reactogenicity and Patient Counseling

Shingrix induces substantial local and systemic reactogenicity due to the potent AS01B adjuvant:

Local Reactions : Injection site pain occurs in up to 78% of recipients, with redness and swelling in 30–40%.

Systemic Reactions : Fatigue, myalgias, headache, and low-grade fever occur in 10–15% of patients, typically lasting 1 to 3 days.

Clinical Pearl : Proactive pre-vaccination counseling is vital. Explain to patients that acute local soreness and flu-like symptoms are expected physiological indicators of strong immune activation, are self-limiting, and do not represent active herpes zoster or a contraindication to receiving the mandatory second dose.

• Human Papillomavirus (9vHPV, Gardasil 9)
• Virology, Oncogenesis, and Serotype Stratification

Human papillomavirus is a small, non-enveloped, double-stranded circular DNA virus infecting mucosal and cutaneous basal keratinocytes. Persistent infection with high-risk oncogenic types drives malignant transformation through viral oncoproteins E6 (which targets the p53 tumor suppressor protein for proteasomal degradation) and E7 (which binds and inactivates the retinoblastoma tumor suppressor protein Rb, releasing E2F transcription factors to drive unregulated cell division).

High-Risk Oncogenic Types : Types 16 and 18 cause approximately 70% of invasive cervical cancers and a high proportion of anal, oropharyngeal, vulvar, vaginal, and penile cancers. Types 31, 33, 45, 52, and 58 account for an additional 20% of cervical cancers.

Low-Risk Non-Oncogenic Types : Types 6 and 11 cause >90% of anogenital warts ( condylomata acuminata ) and recurrent respiratory papillomatosis.

9-Valent HPV Vaccine (Gardasil 9)

Formulated with recombinant virus-like particles (VLPs) of the L1 major capsid protein of types 6, 11, 16, 18, 31, 33, 45, 52, and 58, adsorbed onto an aluminum adjuvant. It provides comprehensive prophylaxis against approximately 90% of cervical cancers and 90% of genital warts.

Age-Based Recommendations and Shared Clinical Decision-Making

Routine Vaccination (Through Age 26 Years) : Universally recommended for all individuals (males and females) through age 26. Routine vaccination is routinely initiated at age 11–12 years (can start as early as age 9).

Adults Aged 27 Through 45 Years (Shared Clinical Decision-Making [SCDM]) :

Clinical Rationale : Most sexually active adults have already been exposed to some HPV types; thus, population-wide cost-effectiveness is lower. However, many individuals in this age cohort have not been exposed to all 9 vaccine serotypes.

Ideal Candidates : Adults with new sexual partners, multiple partners, or recent relationship dissolution (e.g., divorce), who remain at risk for acquiring new HPV strains.

Prophylactic Nature : The vaccine is strictly prophylactic, not therapeutic . It does not treat or accelerate clearance of pre-existing HPV infections, existing anogenital warts, or established cervical dysplasia (CIN).

Cervical Cancer Screening Mandate : Emphasize that HPV vaccination does NOT alter cervical cancer screening schedules. Vaccinated women must continue routine cervical cytology and hrHPV cotesting according to USPSTF guidelines.

Dosing Schedules

Series Initiated Before Age 15 Years (<15th birthday) : 2-dose series at 0 and 6–12 months (minimum interval between doses is 5 months; if dose 2 is given <5 months after dose 1, an additional third dose must be given ≥ 12 weeks after dose 2 and ≥ 5 months after dose 1).

Series Initiated at Age ≥ 15 Years OR Immunocompromised Hosts : 3-dose series at 0, 1–2, and 6 months (minimum intervals: 4 weeks between dose 1 and 2; 12 weeks between dose 2 and 3; 5 months between dose 1 and 3).

Pregnancy & Lactation : HPV vaccination is deferred during pregnancy . If a woman is discovered to be pregnant after initiating the series, pause the series; remaining doses are administered postpartum (no need to restart). HPV vaccine can be safely administered to breastfeeding individuals.

• Hepatitis B Immunization: Universal Adult Recommendation & Adjuvanted Formulations
• The Landmark 2022 ACIP Universal Recommendation

Prior to 2022, adult hepatitis B immunization relied on risk-based screening. Because risk-based strategies failed to increase adult vaccine coverage and required disclosure of stigmatized behaviors (substance use, sexual practices), the ACIP fundamentally restructured the adult schedule:

Universal Adult Recommendation (Ages 19–59 Years) : All adults aged 19 through 59 years should receive hepatitis B vaccination without requiring any disclosure or assessment of risk factors .

Adults Aged ≥ 60 Years : Recommended for any adult aged ≥ 60 with risk factors, OR any adult aged ≥ 60 without identified risk factors who requests protection against hepatitis B.

Risk Factors in Older Adults (≥ 60) : Chronic liver disease (cirrhosis, NAFLD/MASH, hepatitis C, autoimmune hepatitis), end-stage renal disease (hemodialysis), diabetes mellitus, HIV infection, injection drug use, sexual exposure risk (multiple partners, MSM, history of STIs), healthcare personnel, public safety workers exposed to blood, incarcerated individuals, and travel to regions with high/intermediate HBV endemicity (HBsAg ≥ 2%).

Adult Vaccine Formulations & Regimens

Vaccine Formulation Antigen / Adjuvant Schedule Clinical Pearls & Efficacy

Heplisav-B Recombinant HBsAg with CpG 1018 adjuvant (TLR9 agonist) 2-dose series at 0 and 1 month Achieves >95% seroprotection within 1 month. Dramatically superior seroprotection in hyporesponsive populations (older adults, diabetics, smokers, CKD).

Engerix-B / Recombivax HB Recombinant HBsAg with aluminum hydroxide adjuvant 3-dose series at 0, 1, and 6 months Standard traditional vaccine. Lower seroprotection rates in diabetics (~60%) and older adults (~70%).

PreHevbrio 3-antigen recombinant (S, pre-S1, pre-S2) in mammalian cells 3-dose series at 0, 1, and 6 months Expresses all three surface antigens; indicated for adults ≥ 18 years.

Post-Vaccination Serologic Testing

Target Population for Serology : Post-vaccination testing is NOT recommended for routine healthy adults. It is strictly indicated for high-risk cohorts:

• Healthcare personnel and public safety workers with risk of blood exposure
• Hemodialysis patients
• Immunocompromised individuals (HIV, chemotherapy, organ transplant)
• Sexual partners of HBsAg-positive individuals

Timing : Serum quantitative anti-HBs (hepatitis B surface antibody) drawn 1 to 2 months after the final dose of the vaccine series.

Seroprotection Threshold : An anti-HBs titer ≥ 10 mIU/mL defines seroprotection and indicates durable, lifelong immunity against acute and chronic hepatitis B, even if circulating titers subsequently wane below 10 mIU/mL due to immunologic memory.

Management of Non-Responders (anti-HBs < 10 mIU/mL)

Step 1 (Repeat Full Series) : Administer a second complete vaccine series. (Using the 2-dose Heplisav-B series is highly effective, inducing seroconversion in >80% of prior non-responders to alum-adjuvanted vaccines).

Step 2 (Retest) : Retest anti-HBs 1 to 2 months after the final dose of the second series.

Step 3 (Evaluate for Occult/Chronic Infection) : If anti-HBs remains < 10 mIU/mL after two full series (6 total doses of standard vaccine or 2 complete series), test for active or chronic HBV infection by ordering HBsAg and total anti-HBc .

Step 4 (Counseling Persistent Non-Responders) : If seronegative for HBsAg and anti-HBc, the patient is declared a persistent "non-responder" . The patient must be counseled that they remain fully susceptible to HBV. In the event of a documented percutaneous or mucosal exposure to HBsAg-positive blood, they must receive Hepatitis B Immune Globulin (HBIG) immediately (within 24 hours), followed by a second dose of HBIG 1 month later.

Loading diagram... Adult Tetanus Wound Management & Hepatitis B Non-Responder Decision Algorithm