129.1 🎓 醫學生版

129.1.0.1 📌 一頁重點

• Adult 必備疫苗:
  • Annual flu (全民)
  • Tdap booster every 10 yr
  • Zoster (Shingrix) ≥ 50
  • PCV15/20 + PPSV23 ≥ 65 (or 19-64 with high-risk condition)
  • HPV: 9-26 yr (個別至 45)
  • HBV: 高風險 (HCW, IVDU, MSM, ESRD)
  • COVID-19 annual update
• 重要 special situations:
  • Pregnancy: Tdap (27-36 wk), flu (any), RSV (32-36 wk)
  • Asplenic: PCV + Hib + Men ACWY + Men B
  • Immunocompromised (HIV/transplant/biologic): avoid LA; consider higher-dose flu, additional doses

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129.1.0.2 1️⃣ 各疫苗深度

129.1.0.2.1 A. Influenza

• Annual for everyone ≥ 6 months
• 種類:
  • Quadrivalent inactivated (IIV4) (most common)
  • High-dose (Fluzone HD, ≥ 65 elderly preferred)
  • Adjuvanted (Fluad), ≥ 65 alternative
  • Recombinant (Flublok, RIV4), egg-allergic alternative
  • Live attenuated (FluMist, LAIV): 2-49 yr nonpregnant, healthy
• Best timing: October-November in N. Hemisphere

129.1.0.2.2 B. Pneumococcal

• PCV13 (2010) — 13 serotypes
• PCV15 (2021) — adds 22F, 33F
• PCV20 (2021, FDA) — adds more serotypes
• PPSV23 (1983) — 23 polysaccharide
• 2026 Schedule (ACIP):
  • ≥ 65: PCV20 alone, OR PCV15 then PPSV23 ≥ 1 yr later
  • 19-64 high-risk (CSF leak, cochlear, asplenia, immunocompromised, CKD): same
  • Smokers, COPD, DM, CHF, CLD, alcoholic: PCV20 (single)

129.1.0.2.3 C. Tetanus / Diphtheria / Pertussis

• DTaP (children): 5 doses (2, 4, 6, 18 mo, 4-6 yr)
• Tdap (adolescent/adult): 1 dose at 11-12 yr; adult booster: Td or Tdap every 10 yr
• Td alternative (no acellular pertussis)
• Pregnant: Tdap each pregnancy (27-36 wk) — protects infant via passive Ab

129.1.0.2.4 D. Zoster (Shingles)

• Shingrix (recombinant zoster, 2017): 2 doses 2-6 mo apart; > 90% efficacy
• ≥ 50 yr universal; ≥ 19 yr immunocompromised (off-label expanded)
• Zostavax (live, 2006) — discontinued in US 2020 (Shingrix superior)

129.1.0.2.5 E. HPV

• 9-valent (Gardasil 9) — 9 HPV types (HPV 16, 18, 31, 33, 45, 52, 58 + 6, 11)
• 9-14 yr: 2 doses
• 15+ yr: 3 doses (0, 2, 6 mo)
• ACIP: routinely 11-12 yr; can start 9; catch-up to 26; shared decision 27-45

129.1.0.2.6 F. Hepatitis B

• 0, 1, 6 month schedule
• Heplisav-B (2017): 2-dose (0, 1) — adjuvanted, faster protection
• PreHevbrio (3-antigen, 2021)
• High-risk: HCW, IVDU, MSM, multiple sex partners, ESRD/dialysis, chronic liver disease, HIV
• Universal infant vaccination since 1991

129.1.0.2.7 G. COVID-19

• mRNA (Pfizer/Moderna) + protein (Novavax) + adenovirus (J&J/AZ — withdrawn)
• Annual updated formula (now JN.1/KP.3 lineages 2026)
• ≥ 6 months: at least 1 dose annual update
• High-risk + immunocompromised: additional doses

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129.1.0.3 2️⃣ Special Populations

📖 中文概念說明：特殊族群的疫苗決策最容易踩雷，臨床上要記三條鐵則：(1) 孕婦只能 inactivated/subunit/recombinant — 任何 LA 都禁 (例外：Shingrix 是 recombinant 但孕婦仍非 routine 建議)；(2) 免疫低下避開所有 LA，但 Shingrix 因為是 recombinant 反而強烈建議；(3) Asplenic 必打 4 大 encapsulated 疫苗 (PCV20 + Hib + Men ACWY + Men B)。Travel vaccine 需要在出國前 4-6 週 travel clinic 評估，yellow fever 是唯一 WHO 法定強制 (進入某些國家須出示黃皮書)。

129.1.0.3.1 Pregnant

• Recommended: Tdap (27-36 wk), flu (any trimester), RSV (32-36 wk)
• Contraindicated: LA (MMR, VZV, LAIV)

129.1.0.3.2 Immunocompromised (HIV, transplant, biologic, chemo)

• Avoid all LA vaccines: MMR, VZV, zoster (Shingrix is recombinant — OK), yellow fever, OPV, rotavirus, BCG
• Higher dose / additional doses: flu HD, PCV20, Shingrix expanded, COVID booster
• Live vaccines wait: 3 months after chemo; 1 month before steroid taper; 4 weeks 後 transplant

129.1.0.3.3 Asplenic / Splenectomy

• Encapsulated bacteria 風險: PCV20, Hib, Men ACWY (Menveo, Menactra), Men B (Bexsero, Trumenba)
• Annual flu

129.1.0.3.4 Travel

• Yellow fever (Africa, S. America)
• Typhoid (Vi or Ty21a)
• Hepatitis A (any developing country)
• Polio (booster every 10 yr if travel to endemic)
• Meningococcal ACWY (Hajj, sub-Saharan Africa, college dorms US)
• Cholera (specific endemic)
• Rabies (pre-exposure for high-risk travel)
• JEV (Japanese Encephalitis) (rural Asia)

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