A 29-year-old man comes to the physician for a routine health maintenance examination. He feels well. He works as a nurse at a local hospital in the city. Three days ago, he had a needlestick injury from a patient whose serology is positive for hepatitis B. He completed the 3-dose regimen of the hepatitis B vaccine 2 years ago. His other immunizations are up-to-date. He appears healthy. Physical examination shows no abnormalities. He is concerned about his risk of being infected with hepatitis B following his needlestick injury. Serum studies show negative results for hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis C antibody. Which of the following is the most appropriate next step in management?

Administer hepatitis B immunoglobulin and 3-dose regimen of hepatitis B vaccine

Revaccinate with 3-dose regimen of hepatitis B vaccine

Revaccinate with two doses of hepatitis B vaccine

Administer hepatitis B immunoglobulin

Administer hepatitis B immunoglobulin and single dose hepatitis B vaccine

A 40-year-old pregnant woman, G4 P3, visits your office at week 30 of gestation. She is very excited about her pregnancy and wants to be the healthiest she can be in preparation for labor and for her baby. What vaccination should she receive at this visit?

Tetanus, diphtheria, and acellular pertussis (Tdap)

Measles, mumps, and rubella (MMR)

Live attenuated influenza vaccine

A 7-year-old African-American boy presents to his physician with fatigue, bone and abdominal pain, and mild jaundice. The pain is dull and remitting, and the patient complains it sometimes migrates from one extremity to another. His mother reports that his jaundice and pain have occurred periodically for the past 5 years. At the time of presentation, his vital signs are as follows: the blood pressure is 80/50 mm Hg, the heart rate is 87/min, the respiratory rate is 17/min, and the temperature is 36.5°C (97.7°F). On physical examination, the patient appears to be pale with mildly icteric sclera and mucous membranes. On auscultation, there is a soft systolic ejection murmur, and palpation reveals hepatosplenomegaly. His musculoskeletal examination shows no abnormalities. Laboratory investigations show the following results: Complete blood count Erythrocytes 3.7 x 106/mm3 Hgb 11 g/dL Total leukocyte count Neutrophils Lymphocytes Eosinophils Monocytes Basophils 7,300/mm3 51% 40% 2% 7% 0 Platelet count 151,000/mm3 Chemistry Total bilirubin 3.1 mg/dL (53 µmol/L) Direct bilirubin 0.5 mg/dL (8.55 µmol/L) A peripheral blood smear shows numerous sickle-shaped red blood cells. Among other questions, the patient’s mother asks you how his condition would influence his vaccination schedule. Which of the following statements is true regarding vaccination in this patient?

The patient should receive serogroup B meningococcal vaccination at the age of 10 years.

The patient’s condition does not affect his chances to get any infection; thus, additional vaccinations are not advised.

The patient should not receive meningococcal, pneumococcal, or Haemophilus influenzae vaccines, because they are likely to cause complications or elicit disease in his case.

The patient should receive the pneumococcal polysaccharide vaccine as soon as possible, because he is at higher risk of getting pneumococcal infection than other children.

The patient should receive serogroup B meningococcal vaccination as soon as possible, because he is at higher risk of getting meningococcal infection than other children.

A 29-year-old man presents to the primary care clinic in June for post-discharge follow-up. The patient was recently admitted to the hospital after a motor vehicle collision. At that time he arrived at the emergency department unconscious, hypotensive, and tachycardic. Abdominal CT revealed a hemoperitoneum due to a large splenic laceration; he was taken to the operating room for emergency splenectomy. Since that time he has recovered well without complications. Prior to the accident, he was up-to-date on all of his vaccinations. Which of the following vaccinations should be administered at this time?

13-valent pneumococcal conjugate vaccine

Inactivated (intramuscular) influenza vaccine

Live attenuated (intranasal) influenza vaccine

A 27-year-old G0P0 female presents to her OB/GYN for a preconception visit to seek advice before becoming pregnant. A detailed history reveals no prior medical or surgical history, and she appears to be in good health currently. Her vaccination history is up-to-date. She denies tobacco or recreational drug use and admits to drinking 2 glasses of wine per week. She states that she is looking to start trying to become pregnant within the next month, hopefully by the end of January. Which of the following is NOT recommended as a next step for this patient's preconception care?

Administer measles, mumps, rubella (MMR) vaccination

Begin 400 mcg folic acid supplementation

Recommend inactivated influenza vaccination

A 27-year-old man presents to the family medicine clinic for a routine check-up. The patient recently accepted a new job at a childcare center and the employer is requesting his vaccination history. After checking the records from the patient’s childhood, the physician realizes that the patient never had the varicella vaccine. The patient is unsure if he had chickenpox as a child, and there is no record of him having had the disease in the medical record. There is no significant medical history, and the patient takes no current medications. The patient’s heart rate is 82/min, respiratory rate is 14/min, temperature is 37.5°C (99.5°F), and blood pressure is 120/72 mm Hg. The patient appears alert and oriented. Auscultation of the heart reveals no murmurs, rubs, or gallops. The lungs are clear to auscultation bilaterally. With regard to the varicella vaccine, which of the following is recommended for the patient at this time?

Serology then administer the vaccine (2 doses)

Serology then administer the vaccine (1 dose)

A 19-year-old male arrives to student health for an annual check up. He is up to date on his infant and childhood vaccinations up to age 10. At age 12, he received a single dose of the tetanus, diphtheria, and acellular pertussis vaccine, and a quadrivalent meningococcal conjugate vaccine. A month ago, he received the influenza vaccine. The patient has no significant medical history. He takes over the counter ibuprofen for occasional headaches. He has a father with hypertension and hyperlipidemia, and his brother has asthma. He is sexually active with his current girlfriend. He denies tobacco use, illicit drug use, and recent or future travel. The patient’s temperature is 98°F (36.7°C), blood pressure is 118/78 mmHg, pulse is 70/min, and respirations are 14/min with an oxygen saturation of 99% O2 on room air. A physical examination is normal. What of the following is the best recommendation for vaccination?

Tetanus and reduced diphtheria toxoid booster

Adult immunization recommendations for USMLE Step 3: High-Yield Microbiology Lessons

Routine Vaccines - The Standard Shield

Influenza (IIV/RIV/LAIV): Annually for all adults. Crucial for healthcare workers.
Tdap/Td:
- One lifetime dose of Tdap.
- Td or Tdap booster every 10 years.
- Tdap during each pregnancy (27-36 weeks).
MMR (Measles, Mumps, Rubella):
- 1-2 doses for those born after 1956 lacking immunity evidence.
- Contraindicated in pregnancy & severe immunocompromise.
VAR (Varicella):
- 2 doses for those without immunity evidence.
- Contraindicated in pregnancy & severe immunocompromise.
HPV (Human Papillomavirus):
- Recommended for all through age 26.
- Shared decision-making for ages 27-45.

⭐ In adults with an unknown or incomplete history of the primary tetanus series, a three-dose series should be initiated, including one Tdap dose.

2024 CDC Adult Immunization Schedule by Age Group

Medical Conditions - Shields for the Sick

Asplenia (Anatomic/Functional): Crucial due to risk of encapsulated bacteria.
- Pneumococcus: PCV20 alone, or PCV15 then PPSV23 ≥8 weeks later.
- Meningococcus: MenACWY (2 doses) & MenB (2-3 doses).
- Haemophilus influenzae type b (Hib): 1 dose.
HIV: Recommendations vary by CD4 count.
- CD4 <200/μL: Contraindicated to give live vaccines (MMR, Varicella).
- Pneumococcus: PCV20 or PCV15 -> PPSV23 sequence.
- Meningococcus: MenACWY series.
Chronic Liver Disease / Alcoholism:
- Hepatitis A & B series if not immune.
- Pneumococcus: PCV20 or PCV15 -> PPSV23 sequence.
Diabetes Mellitus:
- Hepatitis B: Recommended for ages 19-59; consider if ≥60.
- Pneumococcus: As above.

⭐ High-Yield Fact: For elective splenectomy, all indicated vaccines should be given 14 days before the procedure. If emergent, give 14 days after or at discharge.

Special Populations - Targeted Protection

Pregnancy: Inactivated influenza (any trimester), Tdap for every pregnancy (27-36 wks).
- ⚠️ Contraindicated: All live vaccines (MMR, Varicella, live attenuated influenza).
Asplenia (Surgical/Functional) & Complement Deficiency:
- Pneumococcal (PCV20 or PCV15+PPSV23), Meningococcal (MenACWY & MenB), Hib.
Healthcare Personnel:
- Annual flu, Hepatitis B, MMR, Varicella, Tdap.
HIV:
- Pneumococcal, Meningococcal, Hep A & B.
- ⚠️ Live vaccines contraindicated if CD4 < 200/μL.
Chronic Liver Disease:
- Hepatitis A & B, Pneumococcal.

⭐ Patients with asplenia are at profound risk from encapsulated bacteria (S. pneumoniae, H. influenzae, N. meningitidis).

All adults need an annual influenza vaccine and a Td booster every 10 years after a one-time Tdap dose.

Pregnant women require Tdap during each pregnancy (ideally 27-36 weeks) to protect the newborn from pertussis.

Pneumococcal vaccines are for all adults ≥65 years and younger patients with chronic conditions or immunocompromise.

The recombinant zoster vaccine (RZV) is for all adults ≥50 years, regardless of prior shingles history.

Live vaccines (e.g., MMR, varicella) are contraindicated in pregnancy and severe immunodeficiency.

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