💉 Immunizations
Live vs inactivated is the distinction that decides who can be vaccinated, and it drives almost every question on the topic.
⚖️ Live vs inactivated
This one distinction answers most immunization questions.
Live vaccines contain a weakened organism, so they are withheld from anyone who cannot fight even a weakened infection.
| LIVE attenuated | Inactivated / subunit | |
|---|---|---|
| Examples | MMR, Varicella, Rotavirus, intranasal flu, BCG | DTaP, Hib, IPV, Hep A & B, PCV, HPV, injectable flu, Tdap |
| Give to immunocompromised? | NO | Yes |
| Give in pregnancy? | NO | Yes — Tdap is recommended |
| Spacing | Give together or 4 weeks apart | No spacing rule |
🚨 Withhold live vaccines when
- Immunocompromised — chemotherapy, high-dose steroids, HIV with low CD4, transplant
- Pregnant
- Recently had IVIG or a blood product — wait about 11 months; the antibodies block the response
- Severe febrile illness — postpone until recovered
A mild cold with a low fever is NOT a reason to postpone. Withholding vaccines for minor illness is the single commonest missed opportunity.
📅 The schedule, in outline
| Age | Given |
|---|---|
| Birth | Hepatitis B |
| 2 months | DTaP, IPV, Hib, PCV, RV, HepB |
| 4 months | DTaP, IPV, Hib, PCV, RV |
| 6 months | DTaP, PCV, RV, HepB, influenza annually from 6 months |
| 12–15 months | MMR, Varicella, Hib, PCV, HepA |
| 4–6 years | DTaP, IPV, MMR, Varicella boosters |
| 11–12 years | Tdap, HPV, meningococcal |
The two anchors worth memorizing: MMR and varicella are not given before 12 months, because maternal antibodies interfere before then. And Tdap, HPV and meningococcal are the adolescent set at 11–12.
🧠 True contraindications
- Anaphylaxis to a previous dose or a vaccine component
- Severe egg allergy — care with some influenza formulations
- Encephalopathy within 7 days of a pertussis-containing vaccine → use DT instead of DTaP
- Live vaccines in the situations above
Not contraindications: mild illness, low fever, current antibiotics, family history of reactions, prematurity (vaccinate by chronological age), or breastfeeding.
🩺 Giving them well
✅ Technique
- Vastus lateralis for infants — the largest muscle they have
- Deltoid once walking well and the muscle is developed (usually 3+ years)
- Give the most painful injection last
- Different sites for different vaccines; document site, lot number and expiry
- Comfort: swaddle, breastfeed or give sucrose to infants; hold upright afterwards
🏠 Aftercare teaching
- Expected: soreness, redness, mild swelling, low-grade fever, fussiness for a day or two
- Acetaminophen or ibuprofen for comfort — not routinely before, as it may blunt the response
- Cool compress to the site; move the limb normally
- MMR and varicella reactions come late — a rash or fever 7–14 days afterwards is normal
Report a fever over 40C, a seizure, persistent inconsolable crying over 3 hours, or any breathing difficulty.
💬 Talking with a hesitant parent
Listen first, do not lecture. Ask what specifically worries them and answer that.
- Acknowledge the concern as reasonable rather than dismissing it
- Give concrete local information — what these diseases actually do
- Hib vaccine all but eliminated epiglottitis; that is a vivid, true example
- Document the discussion and any refusal; keep the door open for next visit
🎯 NCLEX traps
- Live = MMR, varicella, rotavirus, nasal flu — not for immunocompromised or pregnant
- Mild illness is not a reason to postpone
- MMR/varicella not before 12 months
- Vastus lateralis in infants
- MMR reaction appears 7–14 days later
- After IVIG, delay live vaccines about 11 months