16.3 Adult Immunization & Vaccines in Special Populations

ABIM Internal Medicine Exam

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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy

0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan

2 Chapter 1: Cardiovascular Disease (14% of Exam)

1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection

3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)

2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia

4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)

3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV

5 Chapter 4: Infectious Disease (9% of Exam)

4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections

6 Chapter 5: Pulmonary Disease (9% of Exam)

5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)

6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease

8 Chapter 7: Hematology (6% of Exam)

7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation

9 Chapter 8: Medical Oncology (6% of Exam)

8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care

10 Chapter 9: Nephrology & Urology (6% of Exam)

9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria

11 Chapter 10: Neurology (4% of Exam)

10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders

12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)

11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health

13 Chapter 12: Dermatology (3% of Exam)

12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease

14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)

13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications

15 Chapter 14: Geriatric Syndromes (3% of Exam)

14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings

16 Chapter 15: Allergy & Immunology (2% of Exam)

15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders

17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology

16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design

18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)

17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity

19 Chapter 18: Perioperative Medicine & Medical Consultation

18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications

20 Chapter 19: Ophthalmology (1% of Exam)

19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease

21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)

20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders

16.3 Adult Immunization & Vaccines in Special Populations

Key Takeaways Explain This Topic AI

Immunization is explicitly enumerated under prevention of infectious disease in the blueprint.

Live vaccines including measles-mumps-rubella, varicella, live attenuated influenza and yellow fever are contraindicated in significant immunosuppression and pregnancy.

Recombinant zoster vaccine is not a live vaccine and is recommended for immunocompromised adults.

Asplenic patients require pneumococcal, meningococcal including serogroup B, and Haemophilus influenzae type b vaccination.

Elective splenectomy vaccination should occur at least two weeks before surgery, and after emergency splenectomy about two weeks afterward.

Last updated: August 2026

Mastery of adult immunization schedules, vaccine indications in vulnerable patient populations, biostatistical calculations, diagnostic test performance, and epidemiological study design is essential for clinical practice and consistently tested on the ABIM Internal Medicine Board Examination.

• 1. CDC / ACIP Adult Immunization Schedule (2024–2026 Standards)
• A. Pneumococcal Vaccination

Target Populations:

All adults aged >= 65 years (universal recommendation).

Adults aged 19 to 64 years with Chronic Medical Conditions: Diabetes mellitus, chronic heart failure/cardiomyopathy, chronic lung disease (COPD, asthma, interstitial lung disease), chronic liver disease (cirrhosis, hepatitis), alcohol use disorder, current cigarette smoking, cerebrospinal fluid (CSF) leaks, or cochlear implants.

Adults aged 19 to 64 years with Immunocompromising Conditions: Functional or anatomic asplenia (sickle cell disease, splenectomy), HIV infection (any CD4 count), chronic renal failure / end-stage renal disease (ESRD) on hemodialysis, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, solid organ transplant, multiple myeloma, or iatrogenic immunosuppression (radiation, systemic chemotherapy, prolonged high-dose corticosteroids >=20 mg prednisone daily for >=14 days, or biologic immunosuppressants).

Recommended Pneumococcal Regimens (Pneumococcal Conjugate Vaccine [PCV] vs. Polysaccharide Vaccine [PPSV]):

Option 1 (Single-Dose Conjugate Alone - Preferred Modern Regimen):

Administer 1 single dose of PCV20 (Prevnar 20) OR PCV21 (Capvaxive) alone. No subsequent PPSV23 booster is needed.

Option 2 (Sequential Conjugate + Polysaccharide Regimen):

Administer 1 dose of PCV15 (Vaxneuvance) followed by 1 dose of PPSV23 (Pneumovax 23) .

Interval between PCV15 and PPSV23: >= 1 year for immunocompetent individuals; shortened to >= 8 weeks for immunocompromised individuals, patients with CSF leaks, or cochlear implants.

B. Herpes Zoster (Shingles) Vaccination

Recombinant Zoster Vaccine (RZV / Shingrix):

Dosing Schedule: 2-dose series administered intramuscularly at 0 and 2 to 6 months .

Target Population:

All immunocompetent adults aged >= 50 years , regardless of whether they have a prior history of shingles, herpes zoster ophthalmicus, or previous receipt of the older live zoster vaccine (Zostavax [ZVL]).

Immunocompromised adults aged >= 19 years (give 2nd dose at 1 to 2 months ).

Key Note: Live zoster vaccine (Zostavax) has been discontinued. Shingrix is a non-live recombinant subunit vaccine and is safe in immunocompromised hosts.

C. Respiratory Syncytial Virus (RSV) Vaccination

ACIP Recommendations (Arexvy [GSK] or Abrysvo [Pfizer]):

All adults aged >= 75 years: Administer a single dose of RSV vaccine.

Adults aged 60 to 74 years: Administer a single dose of RSV vaccine if at increased risk of severe RSV disease :

• Chronic cardiovascular disease (heart failure, coronary artery disease),
• Chronic pulmonary disease (COPD, asthma, pulmonary fibrosis),
• Chronic kidney disease (stage 3–5 or ESRD),
• Chronic liver disease,
• Diabetes mellitus with end-organ damage,
• Severe obesity (BMI >=40 kg/m2),

Residents of nursing homes and long-term care facilities.

D. COVID-19 & Influenza Vaccination

COVID-19 Vaccine: Administer an annual updated COVID-19 vaccine formulation to all individuals aged >= 6 months .

Influenza Vaccine: Administer an annual influenza vaccine to all individuals aged >= 6 months .

Adults aged >= 65 years: Preferential administration of higher-dose or adjuvanted influenza vaccines to overcome immunosenescence:

• High-Dose Inactivated Influenza Vaccine (Fluzone High-Dose Quadrivalent) ,
• Recombinant Influenza Vaccine (Flublok Quadrivalent) , OR

Adjuvanted Inactivated Influenza Vaccine (Fluad Quadrivalent) .

Egg Allergy: Current guidelines state that any age-appropriate influenza vaccine (inactivated or recombinant) can be administered to patients with egg allergy of any severity without special precautions.

E. Tetanus, Diphtheria, Pertussis (Td / Tdap) & Wound Management

Routine Dosing: Administer 1 dose of Tdap to all adults who have not received it previously, followed by a Td or Tdap booster every 10 years .

Pregnancy: Administer 1 dose of Tdap during EACH pregnancy , ideally between 27 and 36 weeks gestation , to maximize transplacental transfer of maternal pertussis antibodies to the neonate, regardless of the interval since prior Tdap doses.

Tetanus Prophylaxis in Wound Management:

Wound Classification Vaccination History: >=3 Prior Doses (Complete) Vaccination History: <3 Doses or Unknown

Clean, Minor Wounds • Give Td/Tdap ONLY if last dose was >10 years ago .; • NO Tetanus Immune Globulin (TIG). • Give Td/Tdap .; • NO Tetanus Immune Globulin (TIG).

All Other Wounds ; (Contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; burns; crush injuries) • Give Td/Tdap ONLY if last dose was >5 years ago .; • NO Tetanus Immune Globulin (TIG). • Give Td/Tdap PLUS ; • Give Tetanus Immune Globulin (TIG 250 units IM) at a separate anatomical site with a separate syringe.

F. Hepatitis B & Human Papillomavirus (HPV) Vaccination

Hepatitis B: Universal vaccination for all adults aged 19 to 59 years (2-dose series with Heplisav-B at 0 and 1 month, or 3-dose series with Engerix-B/Recombivax HB at 0, 1, and 6 months). For adults aged >=60 years , vaccinate if risk factors are present (diabetes, hemodialysis, chronic liver disease, HIV, HCV, injection drug use, MSM, incarcerated) or if the patient requests protection.

Human Papillomavirus (HPV): 9-valent HPV vaccine (Gardasil-9) recommended routinely through age 26 years . In adults aged 27 to 45 years , use clinical shared decision-making (greatest benefit in individuals with new sexual partners who were not previously infected/vaccinated).

• 2. Vaccines in Special Populations
• A. Immunocompromised Host Contraindications

Absolute Rule: LIVE ATTENUATED VACCINES ARE STRICTLY CONTRAINDICATED in severely immunocompromised patients, solid organ transplant recipients, active hematologic malignancy, severe primary immunodeficiencies, HIV with CD4 <200 cells/mcL, or patients taking high-dose systemic immunosuppression (>=20 mg/day prednisone equivalent for >=14 days, anti-TNF-alpha biologics, antimetabolites, calcineurin inhibitors).

Contraindicated Live Vaccines:

• Measles, Mumps, Rubella ( MMR ),
• Varicella vaccine ( Varivax ),
• Live Attenuated Influenza Vaccine ( LAIV - Flumist nasal spray ),
• Yellow Fever vaccine,

Oral Typhoid vaccine (Ty21a).

B. Asplenia & Functional Asplenia Immunization Protocol

Patients with anatomic asplenia (post-splenectomy) or functional asplenia (sickle cell disease) are at catastrophic risk for Overwhelming Post-Splenectomy Infection (OPSI) caused by encapsulated bacteria. They require a dedicated vaccination bundle:

Pneumococcal Series: Single-dose PCV20 (or PCV15 followed by PPSV23 >=8 weeks later).

Meningococcal Conjugate (MenACWY - Menveo / MenQuadfi): 2-dose primary series administered 8 weeks apart , followed by a booster dose every 5 years .

Serogroup B Meningococcal (MenB - Bexsero / Trumenba): 2-dose (Bexsero at 0, 1 month) or 3-dose (Trumenba at 0, 1–2, 6 months) series, with booster 1 year later and q2–3y.

Haemophilus influenzae type b (Hib): 1 dose .

Annual Inactivated Influenza Vaccine .

Timing of Administration: In elective splenectomy, administer all vaccines >=14 days prior to surgery . In emergency splenectomy, administer vaccines >=14 days postoperatively (or upon hospital discharge) to achieve optimal antibody titers.