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  • Vaccines are substances administered to generate a protective immune response. They can be live attenuated or killed.

  • Toxoids are inactivated bacterial toxins. They retain the ability to stimulate the formation of antitoxins, which are antibodies directed against the bacterial toxin.

  • Adjuvants are inert substances, such as aluminum salts (ie, alum), which enhance vaccine antigenicity by prolonging antigen absorption.

  • Immune sera are sterile solutions containing antibody derived from human (immunoglobulin [Ig]) or equine (antitoxin) sources.


  • The childhood, adolescent, and adult immunization schedules are updated frequently and published annually. Recommendations for the use of influenza vaccine are issued annually. Healthcare providers involved in primary care and immunization delivery must keep themselves abreast of these changes in a systematic way. Electronic newsletters and browsing reliable websites are efficient methods for obtaining information (Table 52-1).

  • In general, killed vaccines can be administered simultaneously at separate sites. Killed and live-attenuated vaccines may be administered simultaneously at separate sites. If they cannot be administered simultaneously, they can be administered at any interval between doses with the exception of cholera (killed) and yellow fever (live) vaccines, which should be given at least 3 weeks apart. If live vaccines are not administered simultaneously, their administration should be separated by at least 4 weeks.

  • Administration of live vaccines, such as rubella or varicella, are deferred until postpartum and are routinely recommended for new mothers who do not have evidence of immunity prior to hospital discharge. These live vaccines can be administered without regard to administration of Rho(D) Ig (RDIg) in the postpartum period. Pregnant women should receive Tdap during the late second trimester or third trimester of pregnancy. Additionally, Tdap is recommended for all new mothers who have not received a Tdap before because household contacts are frequently implicated as the source of pertussis infection in a young infant.

  • In general, severely immunocompromised individuals should not receive live vaccines.

  • Patients with chronic conditions that cause limited immunodeficiency (eg, renal disease, diabetes, liver disease, and asplenia) and who are not receiving immunosuppressants may receive live-attenuated and killed vaccines, as well as toxoids.

  • Patients with active malignant disease may receive killed vaccines or toxoids but should not be given live vaccines. Live virus vaccines may be administered to persons with leukemia who have not received chemotherapy for at least 3 months.

  • If a person has been receiving high-dose corticosteroids or has had a course lasting longer than 2 weeks, then at least 1 month should pass before immunization with live virus vaccines.

  • Responses to live and killed vaccines generally are suboptimal for human immune deficiency virus (HIV)–infected patients and decrease as the disease progresses.

  • Whenever possible, transplant patients should be immunized before transplantation. Live vaccines generally are not given after transplantation.

TABLE 52-1Web Resources for Vaccine Information

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