🛡️ Module 3 · Immunomodulators & Antineoplastics

🧵 Exam traps ⭐ HIGH YIELD

• Nadir is when blood counts are LOWEST, usually 7 to 14 days after a dose. Teaching about infection precautions is timed to the nadir, not to the infusion day.
• Mesna and leucovorin are rescue agents, not cancer drugs. They are given because of a specific chemo drug, not instead of it.
• Doxorubicin's red urine is expected and harmless. Cyclophosphamide's red urine is bleeding and is not.
• DTaP is for children under 7; Tdap is the adolescent and adult version; Td is the 10-year booster. Capital letters mean full-strength antigen.
• 'Monitor for infection' in an immunosuppressed client also means do not rely on fever — they may not be able to produce one. Look at the wound, the lungs, and the mental status.
• Etanercept and infliximab both block TNF but etanercept is a fusion protein, not a true -mab. The nursing care (TB screening, infection watch) is identical.

Monoclonal Antibodies (What are some examples of monoclonal antibody drugs?)⭐ HIGH YIELD

Monoclonal antibodies are lab-made antibodies engineered to bind one specific target (a receptor, a cytokine, or a tumor antigen). Every generic name ends in -MAB. Examples: rituximab, trastuzumab, bevacizumab, infliximab, adalimumab, omalizumab, palivizumab, pembrolizumab.

• INFUSION REACTIONS are the universal nursing concern: fever, chills, rigors, urticaria, bronchospasm, hypotension, usually during the first infusion. Premedicate (acetaminophen, diphenhydramine, sometimes a corticosteroid), start slowly, stay with the patient, and keep emergency equipment ready.
• Anything that suppresses immune function raises infection risk: screen for latent TB and hepatitis B BEFORE starting TNF inhibitors or rituximab, and give NO LIVE VACCINES during therapy.
• Drug-specific toxicities you must know: TRASTUZUMAB is CARDIOTOXIC (get a baseline ejection fraction and monitor it). RITUXIMAB can reactivate hepatitis B and cause PML. BEVACIZUMAB causes hypertension, bleeding, impaired wound healing, and GI perforation. Checkpoint inhibitors (pembrolizumab, nivolumab) cause autoimmune 'itis' of any organ: colitis, pneumonitis, hepatitis, thyroiditis.
• Naming clue: -ximab is chimeric (mouse-human, higher reaction risk), -zumab is humanized, -umab is fully human. The syllable before -mab often names the target: -tu- tumor, -ci- circulatory, -li- immune.
• Most are given IV or subcutaneously; they are proteins and would be digested if swallowed. Handle per hazardous drug policy where applicable, do not shake vials, and check for the correct diluent and filter.
• Common uses: cancer (rituximab, trastuzumab, bevacizumab, cetuximab, pembrolizumab), autoimmune disease (infliximab, adalimumab, etanercept is a fusion protein not a mab), asthma (omalizumab), RSV prophylaxis in high-risk infants (palivizumab, nirsevimab), migraine prevention (erenumab), and cholesterol (evolocumab).

If it ends in -MAB, it's a Monoclonal AntiBody: watch the infusion, watch for infection.

DTaP⭐ HIGH YIELD

DTaP protects against Diphtheria, Tetanus, and acellular Pertussis, and is the CHILDHOOD formulation given under age 7. It is INACTIVATED (toxoid plus acellular components), so it is NOT a live vaccine and is safe in immunocompromised children and pregnant household contacts.

• Schedule: FIVE doses at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years. It is IM.
• Capital letters mean full-strength antigen. DTaP (big D, big P) is for children under 7. Tdap (little d, little p) is the reduced-antigen adolescent and adult version.
• DT (no pertussis) is substituted for a child under 7 who has a contraindication to the pertussis component.
• Expected reactions: injection-site redness, swelling and pain, low-grade fever, and fussiness. Teach acetaminophen and a cool compress. Do NOT give prophylactic antipyretics before the dose.
• Contraindications: anaphylaxis to a prior dose, and ENCEPHALOPATHY within 7 days of a previous pertussis-containing dose (then use DT). Precautions include a progressive neurologic disorder, and Guillain-Barre within 6 weeks of a prior tetanus toxoid.
• Pertussis (whooping cough) immunity wanes, which is why the Tdap booster at age 11 to 12 and in every pregnancy exists: to protect infants too young to be fully vaccinated.

BIG letters for LITTLE kids: DTaP under 7, five doses, and it is not live.

Tdap⭐ HIGH YIELD

Tdap is the reduced-antigen Tetanus, diphtheria, and acellular Pertussis booster for age 7 and older. INACTIVATED, not live. One dose at age 11 to 12, then a Td or Tdap booster every 10 years, and a dose during EVERY PREGNANCY at 27 to 36 weeks.

• THE PREGNANCY POINT IS THE MOST TESTED: give Tdap in EVERY pregnancy, in the third trimester (27 to 36 weeks, preferably early in that window), regardless of when she last had one. Maternal antibodies cross the placenta and protect the newborn before the infant's own DTaP series can.
• COCOONING: everyone who will be around a new baby (partner, grandparents, siblings 11 and over, childcare providers) should be up to date on Tdap, ideally at least 2 weeks before contact.
• Any adult who has never had a Tdap should get one dose in place of a Td booster, at any age.
• It is also given for wound management when the last tetanus-containing dose was more than 5 years ago for a dirty or contaminated wound (more than 10 years for a clean minor wound).
• It is inactivated, so it is safe in pregnancy and in immunocompromised patients. Give IM in the deltoid.
• Expected: sore arm, low-grade fever, headache, fatigue.

Tdap: little letters, big kids and adults. EVERY pregnancy, 27 to 36 weeks, every time.

Td booster⭐ HIGH YIELD

Td is the Tetanus and diphtheria toxoid booster, given EVERY 10 YEARS to adults. It is INACTIVATED. Tdap may be substituted for any Td dose, and one lifetime Tdap should be given if the person has never had one.

• Ten years is the routine interval. In WOUND MANAGEMENT the interval shortens: for a dirty or contaminated wound, boost if it has been more than 5 years since the last tetanus-containing dose; for a clean minor wound, more than 10 years.
• If the patient has fewer than 3 lifetime tetanus doses or an unknown history, give the vaccine AND, for a dirty wound, tetanus immune globulin (TIG) at a different site with a different syringe.
• TIG is passive immunity: it gives borrowed antibodies that work now but wear off. The vaccine is active immunity: it takes weeks but lasts years. Give both when the wound is high risk and the history is inadequate.
• Safe in pregnancy and in immunocompromised patients because it is inactivated, but in pregnancy Tdap is preferred so the fetus also gets pertussis protection.
• Give IM in the deltoid. Expect a sore arm; report severe swelling of the whole limb or a hypersensitivity reaction.

Every 10 years routine, every 5 years for a dirty wound.

Haemophilus influenzae (Hib)⭐ HIGH YIELD

Hib is the Haemophilus influenzae type b CONJUGATE vaccine. It is INACTIVATED (a polysaccharide linked to a protein carrier), not live. It prevents Hib meningitis, epiglottitis, and sepsis in infants, and it essentially eliminated those diseases in the US.

• Schedule: primary doses at 2 and 4 months (plus 6 months depending on the brand), then a booster at 12 to 15 months. PedvaxHIB is a 2-dose primary series; ActHIB and Hiberix are 3-dose.
• It is NOT the flu vaccine. Haemophilus influenzae is a BACTERIUM that was misnamed during a flu epidemic. This confusion is a classic exam distractor.
• Not routinely needed after age 5 in healthy children, because natural immunity develops. It IS given to older children and adults with asplenia or sickle cell disease, HIV, complement deficiency, or after a stem cell transplant.
• Conjugation to a protein carrier is what makes it work in infants under 2, whose immune systems respond poorly to plain polysaccharide vaccines. Same principle as the pneumococcal and meningococcal conjugate vaccines.
• Given IM. Expected reactions are mild: injection-site soreness and low-grade fever.
• Because it is inactivated, it is safe for immunocompromised children.

Hib is a BACTERIUM, not influenza. Conjugated so babies can respond, and not live.

Influenza⭐ HIGH YIELD

Influenza vaccine is given ANNUALLY to everyone 6 months and older, ideally by the end of October. The INJECTED forms (IIV, RIV) are INACTIVATED; the intranasal spray (LAIV, FluMist) is LIVE ATTENUATED.

• THE LIVE-VS-INACTIVATED QUESTION: the nasal spray is LIVE and is therefore avoided in pregnancy, in immunocompromised patients, in children under 2, in adults 50 and over, in asthma or wheezing, and in close contacts of severely immunocompromised people. When in doubt, give the SHOT.
• The shot is safe and RECOMMENDED in pregnancy at any trimester, and safe in immunocompromised patients. Maternal antibodies also protect the infant, who cannot be vaccinated until 6 months.
• Children 6 months through 8 years getting flu vaccine for the FIRST time need 2 doses at least 4 weeks apart. After that, one dose a year.
• It is reformulated every year because influenza mutates (antigenic drift), which is why annual dosing is required. Protection takes about 2 weeks to develop.
• Egg allergy is no longer a barrier: any licensed flu vaccine may be given regardless of egg allergy severity. Cell-based and recombinant options exist.
• The vaccine CANNOT give you the flu. Post-vaccine soreness, low-grade fever, and achiness are the immune response, not infection. This is the teaching point patients need most. The 2025-2026 federal schedule moved routine influenza vaccination toward shared clinical decision-making; the AAP and most nursing curricula still teach universal annual vaccination from 6 months. Answer the universal recommendation on your exam.

Shot = dead and safe for everyone. Nasal spray = LIVE, so not for pregnancy or immunosuppression.

Poliovirus⭐ HIGH YIELD

In the United States the polio vaccine is IPV (inactivated poliovirus vaccine), given by injection. It is NOT LIVE. The oral polio vaccine (OPV) IS live and is no longer used in the US because it could rarely cause vaccine-associated paralytic polio.

• Schedule: 4 doses at 2 months, 4 months, 6 to 18 months, and 4 to 6 years. Given IM or subcutaneously.
• Because IPV is inactivated, it is safe in pregnancy when indicated and safe in immunocompromised patients and their household contacts. That is the entire reason the US switched from OPV to IPV in 2000.
• OPV is still used in some countries because it is cheap, needs no needle, and produces gut immunity that interrupts transmission. Its downside is vaccine-derived poliovirus.
• Adults in the US are not routinely revaccinated. A one-time booster is offered to adults at increased risk: travelers to endemic areas, lab workers handling the virus, and health care workers with possible exposure.
• Expected reactions are minimal: injection-site soreness and redness.
• IPV contains trace neomycin, streptomycin, and polymyxin B; a history of anaphylaxis to those is a contraindication.

IPV = Injected, Protected, not alive. OPV = Oral, live, and retired in the US.

Pneumococcal⭐ HIGH YIELD

Pneumococcal vaccines protect against Streptococcus pneumoniae (pneumonia, meningitis, bacteremia, otitis media). Both types are INACTIVATED, not live. PCV (conjugate: PCV15, PCV20, PCV21) is the infant series and the adult starting point; PPSV23 (polysaccharide) is used to complete the series after PCV15 and for certain high-risk groups.

• CHILDREN: a 4-dose PCV series at 2, 4, 6, and 12 to 15 months.
• ADULTS: everyone 50 and older who has never had a conjugate vaccine gets one dose of PCV15, PCV20, or PCV21. (The age was lowered from 65 to 50 in late 2024.) Adults 19 to 49 with risk conditions are also vaccinated.
• THE SEQUENCE RULE: if PCV15 is used, give PPSV23 one year later (minimum 8 weeks if immunocompromised, asplenic, or with a CSF leak or cochlear implant). If PCV20 or PCV21 is used, NO PPSV23 is needed.
• High-risk conditions that trigger earlier vaccination: chronic heart, lung, liver, or kidney disease, diabetes, smoking, alcoholism, asplenia or sickle cell disease, HIV, malignancy, transplant, cochlear implant, and CSF leak.
• Conjugate vaccines work in infants because the polysaccharide is linked to a protein carrier; plain polysaccharide (PPSV23) does not work well under age 2.
• Both are inactivated, so both are safe in immunocompromised patients, who are exactly the people who need them most. May be given at the same visit as influenza vaccine, in different arms.

PCV first, always. PPSV23 only chases PCV15, never PCV20 or PCV21.

Meningococcal⭐ HIGH YIELD

Meningococcal vaccines prevent Neisseria meningitidis meningitis and sepsis. Both types are INACTIVATED. MenACWY: one dose at 11 to 12 years with a BOOSTER at 16. MenB: ages 16 to 23, usually 16 to 18, by shared clinical decision-making.

• The age-16 booster is the point: protection needs to be at its peak during the high-risk years of late adolescence, college dorms, and military barracks.
• First-year college students living in residence halls who have not had a dose after their 16th birthday should be vaccinated. Same for military recruits and travelers to the African meningitis belt or Hajj pilgrims.
• High-risk conditions that require the vaccine at any age, plus boosters: ASPLENIA or sickle cell disease, complement deficiency, HIV, and use of eculizumab or ravulizumab (complement inhibitors, which carry a boxed warning for meningococcal disease).
• MenACWY and MenB are NOT interchangeable and do not substitute for each other. Serogroup B is not covered by ACWY. Pentavalent MenABCWY products now exist.
• Both are inactivated, so they are safe in pregnancy and immunosuppression.
• CLOSE CONTACTS of a meningococcal case need chemoprophylaxis, not just vaccine: rifampin, ciprofloxacin, or ceftriaxone, given as soon as possible. The 2025-2026 federal schedule shifted routine adolescent meningococcal vaccination toward shared clinical decision-making or high-risk groups; the AAP continues to recommend 11-12 with a booster at 16. Answer the classic schedule.

MenACWY at 11-12, BOOST at 16 for the dorm years. MenB is separate and does not cover for it.

Human papillomavirus⭐ HIGH YIELD

HPV vaccine (Gardasil 9) is a RECOMBINANT, INACTIVATED vaccine (virus-like particles, no viral DNA at all, so it cannot cause infection). Routine at age 11 to 12, may start at 9. It prevents cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancers and genital warts.

• DOSE RULE: if the series is STARTED BEFORE the 15th birthday, 2 doses 6 to 12 months apart. If started at 15 or older, or if the person is immunocompromised, 3 doses at 0, 1 to 2, and 6 months.
• Routine catch-up through age 26 for everyone. Ages 27 to 45 is shared clinical decision-making, with less benefit because most people have already been exposed.
• It is PREVENTIVE only. It does not treat an existing HPV infection, existing warts, or existing cervical dysplasia, and it does NOT replace Pap screening.
• Give it BEFORE any sexual activity, which is the whole reason for vaccinating at 11 to 12. Frame it to parents as CANCER PREVENTION, not as a sex conversation.
• SYNCOPE is the notable adverse event, because adolescents faint. Have the patient seated or lying down and OBSERVE FOR 15 MINUTES after the injection.
• It is not live, so it is safe in immunocompromised patients. It is not recommended in pregnancy simply for lack of data; if a dose is given and pregnancy is discovered, no intervention is needed, just delay remaining doses. Note: the 2025-2026 federal schedule moved to a single-dose HPV recommendation. The 2-dose/3-dose rule above is what nursing curricula and NCLEX still test; use it unless your handout says otherwise.

Under 15 = 2 doses. 15 and up = 3 doses. Sit them down for 15 minutes so they don't hit the floor.

Herpes zoster⭐ HIGH YIELD

Shingrix (recombinant zoster vaccine, RZV) is the current herpes zoster vaccine and it is NOT LIVE. Two doses IM, 2 to 6 months apart, for adults 50 and older AND for immunocompromised adults 19 and older. The old live vaccine (Zostavax) was discontinued in the US in 2020.

• THIS IS THE MOST-TESTED VACCINE SWITCH: Shingrix is recombinant, so it CAN be given to immunocompromised patients. Zostavax was live and could not. If a question says the zoster vaccine is live, it is testing the old vaccine.
• Give it even if the patient has already had shingles, already had chickenpox, or previously received Zostavax. Prior disease does not exempt them.
• It is 90%+ effective and also prevents POSTHERPETIC NEURALGIA, the burning nerve pain that can last months to years after the rash.
• Warn patients about reactogenicity: Shingrix hurts. Expect a very sore arm, fatigue, myalgia, headache, fever, and chills for 1 to 3 days, especially after dose 2. Tell them in advance or they will not come back for the second dose.
• Shingles happens because latent varicella-zoster virus in the dorsal root ganglia reactivates when immunity wanes with age, illness, or immunosuppression.
• Do not confuse the vaccine with treatment. Active shingles is treated with acyclovir or valacyclovir started within 72 hours of rash onset, plus pain control.

Shingrix is NOT live, 2 doses, 50 and up (19+ if immunocompromised), and it will make their arm miserable.