CCFP priority topic 51 of 105
Immunization on the CCFP exam
6 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 6 key features for Immunization. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 6
Don't wait to vaccinate
Give vaccines on time, and don't let a minor illness push them back.
CFPC skill Clinical reasoningPhase TreatmentSources Public Health Agency of Canada / NACI
On the exam
A 15-year-old missed his school booster for tetanus, diphtheria and whooping cough (Tdap). He has a cold. Expect one best answer.
Pick what to do today.
Common mistakes
Waiting for the cold to clear, checking his antibodies first, or sending him back to the school program. Each delay leaves him without the booster.
Approach
- Vaccinate through a mild illness, with or without fever. It does not raise the risk of a reaction.
- A very blocked nose matters only for the nasal flu spray. Offer a flu shot instead.
- Moderate or severe illness: weigh the risks and benefits. Expert advice helps.
- Antibiotics do not block non-live vaccines or most live ones. Only oral typhoid vaccine and BCG, the tuberculosis vaccine, are affected.
- Don't check antibodies before a Tdap booster. Pertussis serology is not recommended before or after the vaccine.
- A febrile seizure, long crying or fainting after a past dose does not stop the next one.
- Egg allergy does not rule out the measles, mumps and rubella (MMR) vaccine or flu vaccine.
| Reason given | Wait? | Know this |
|---|---|---|
| Cold or mild fever | No | Does not raise the risk of a reaction |
| On antibiotics | No, for most vaccines | Only oral typhoid and BCG are affected |
| Moderate or severe illness | Weigh it | Balance risk and benefit; get expert advice |
| Febrile seizure, long crying or fainting after a past dose | No | Not a reason to skip the next dose |
| Egg allergy | No | Not a bar to MMR or flu vaccine |
Key feature 2 of 6
Hesitant parents
When parents doubt vaccines, learn what worries them and explain what saying no could cost.
CFPC skill Patient-centred approach, communicationPhase Treatment, historySources Public Health Agency of Canada / NACI
On the exam
A parent wants to put off a baby's first vaccines. Expect a short menu (pick several from a list).
Pick what to ask and what to say.
Common mistakes
A lecture full of facts, or ending the visit when the parent says no. A one-way talk rarely changes a mind. Accepting "later" without naming the risk is wrong too.
Approach
- Ask where the worry comes from, and listen. Keep your tone calm and free of judgement.
- Find out why the parent holds the belief, above all if it rests on false information.
- Make it a two-way talk, not a lecture. Motivational interviewing, a guiding style that helps people change, can help.
- Say plainly that you are worried about the diseases if the child stays unvaccinated.
- Explain that some complications cannot be fixed, even with the best care.
- Weigh vaccine risks against the risk to the child, and to others, of staying unvaccinated.
- If the answer is still no, stay patient and respectful. Trust keeps the door open.
Key feature 3 of 6
Who needs more
Spot the people whose health, habits or travel call for extra vaccines, and offer them.
CFPC skill Clinical reasoningPhase Treatment, hypothesis generationSources Public Health Agency of Canada / NACI
On the exam
A young adult with sickle cell disease, or a teen leaving for Pakistan. Expect a short menu (pick several from a list).
Pick the vaccines this person needs.
Common mistakes
Thinking of extra vaccines only for babies and seniors. Or testing hepatitis A antibodies in a Canadian-born traveller, or giving immune globulin instead of the vaccine.
Approach
- Check risk at every visit, not just age. Health, habits and travel all add vaccines (table below).
- Before travel, hepatitis A vaccine is first choice. Immune globulin is for people who cannot have the vaccine or may not respond to it.
- Give hepatitis A vaccine at this visit. It can be given up to the day of departure. One dose gives protective antibodies in 95 to 100%. A second dose 6 to 12 months later, or up to 36 months for some products, completes the series.
- Consider testing hepatitis A antibodies first only if the person was born where it is common, born before 1945, or had hepatitis or jaundice.
- Offer typhoid vaccine to most travellers to South Asia. Risk is highest in India, Pakistan and Bangladesh.
- Planned spleen removal: give the vaccines at least 2 weeks before surgery. Before a solid organ transplant: non-live vaccines at least 2 weeks before, live vaccines at least 4 weeks before.
- Severe immune suppression rules out live vaccines. Non-live vaccines are fine but may work less well.
| Who | Add | Know this |
|---|---|---|
| No spleen or a weak one, as in sickle cell disease | Pneumococcal conjugate, Haemophilus influenzae type b (Hib), both meningococcal vaccines, yearly flu | Hepatitis B too if repeat transfusions are needed |
| Chronic liver disease | Hepatitis A and B, pneumococcal conjugate | Vaccinate early in the disease |
| Chronic kidney disease or dialysis | Hepatitis B, pneumococcal conjugate | Use the higher hepatitis B dose |
| Diabetes, chronic heart or lung disease | Pneumococcal conjugate, yearly flu | Smoking adds pneumococcal too; asthma that needed care in the past 12 months counts |
| Age 65 and older | One dose of Pneu-C-20 or Pneu-C-21, the pneumococcal conjugate vaccines | At least 1 year after an older pneumococcal vaccine; never a second Pneu-C-20 or Pneu-C-21 |
Key feature 4 of 6
Record every dose
Keep a full, clear record of each vaccine you give.
CFPC skill Clinical reasoning, professionalismPhase TreatmentSources Public Health Agency of Canada / NACI
On the exam
You give a flu shot in a busy clinic. Expect a short menu (pick several from a list) of what to record.
Pick what goes in the record.
Common mistakes
Writing only the vaccine name and date. Without the lot number, a recall or a reaction cannot be traced. Forgetting the patient's own record is a miss too.
Approach
- Record the brand name, date and time, dose, site, route, lot number and expiry date.
- Add your name and your professional title.
- Write it in your chart, in the patient's own record, and in the provincial or territorial registry where one exists.
- Give each patient a lasting personal record. Ask them to bring it to every visit.
- At each visit, ask about reactions to past doses. Chart every reaction that matters clinically.
- Record useful test results too: rubella or hepatitis B antibodies, and tuberculosis skin tests.
Key feature 5 of 6
Vaccines in the history
When infection is on your list, ask which vaccines the patient has had, and when.
CFPC skill Clinical reasoningPhase History, hypothesis generationSources Public Health Agency of Canada / NACI
On the exam
A teen has 6 days of fever, headache, belly pain and constipation after 6 weeks in Pakistan. Expect a short menu (pick several from a list).
Pick the history that matters most.
Common mistakes
Chasing the headache, the constipation or a head injury as separate problems. Or asking about chickenpox immunity: it does not bear on this fever.
Approach
- Read the fever, headache, belly pain and constipation as one illness, picked up abroad.
- Ask about every vaccine, travel ones too, such as typhoid and hepatitis A, and when each was given.
- Ask where the patient went, for how long, and whether it was to visit family. Those visiting friends and relatives carry more risk.
- After South Asia, think of typhoid (enteric fever). Risk is highest after India, Pakistan or Bangladesh.
- A typhoid shot does not settle it. The vaccine prevents only about half of cases.
Key feature 6 of 6
Vaccinated is not immune
A vaccine on record does not rule out the illness, so keep it on your list.
CFPC skill Clinical reasoning, selectivityPhase Hypothesis generationSources Public Health Agency of Canada / NACI
On the exam
A vaccinated woman on ramipril has 18 days of coughing fits with vomiting, and minds a baby. Expect one best answer.
Pick the most likely diagnosis.
Common mistakes
Calling it a lingering cold, reflux or a cough from her blood pressure pill. That misses whooping cough near a baby. Giving tetanus-diphtheria (Td) alone adds no pertussis protection.
Approach
- Keep whooping cough (pertussis) on the list in a vaccinated adult with coughing fits that end in vomiting or a whoop.
- Pertussis protection fades after the boosters. Past infection does not give lasting immunity either.
- Every adult needs one Tdap dose if not given one as an adult. Td has no pertussis part.
- Adults who will be around a baby: Tdap ideally at least 2 weeks before contact.
- Pregnancy: Tdap every time, ideally at 27 to 32 weeks.
- Give the vaccine after whooping cough too. Don't order pertussis antibodies before or after it.
- A typhoid shot lowers risk but does not rule typhoid out. Food and water care still matters.
| Vaccine | Protection | So |
|---|---|---|
| Whooping cough | About 85% after the infant series, about 90% after boosters. Fades after the second booster. | Think of it in vaccinated teens and adults |
| Typhoid, oral or injected | About 50% | A vaccinated traveller can still have it |
| Rubella | 95% or more after one dose | A few do not respond; a second dose may help |
| Live shingles vaccine (stopped in Canada in 2023) | Older product, now replaced | Give 2 doses of recombinant vaccine, at least 1 year after the live dose |
Flashcards
Answer it first, then check.
KF 1A teen due for Tdap has a cold and a mild fever. Give it today?
Yes. A mild illness, with or without fever, does not raise the risk of a reaction. Source: Public Health Agency of Canada / NACI
KF 1He finished an antibiotic yesterday. Which vaccines does that affect?
Only oral typhoid vaccine and BCG. Non-live vaccines such as Tdap go ahead today. Source: Public Health Agency of Canada / NACI
KF 3A young adult has sickle cell disease. Which extra vaccines?
Pneumococcal conjugate, Hib, both meningococcal vaccines and yearly flu. Hepatitis B too with repeat transfusions. Source: Public Health Agency of Canada / NACI
KF 3A Canadian-born teen leaves for Pakistan. Test hepatitis A antibodies first?
No. Testing is for people born where it is common, born before 1945, or with past hepatitis or jaundice. Vaccinate now. Source: Public Health Agency of Canada / NACI
KF 4You just gave a vaccine. What goes in the record?
Brand, date and time, dose, site, route, lot number, expiry date, and your name and title. Source: Public Health Agency of Canada / NACI
KF 5Fever after 6 weeks in Pakistan. Which vaccine do you ask about?
Typhoid, and when it was given. Even so, the vaccine prevents only about half of cases. Source: Public Health Agency of Canada / NACI
KF 6She had Td three years ago and minds a new baby. Which vaccine now?
Tdap. Td has no pertussis part, and every adult needs one Tdap dose. Source: Public Health Agency of Canada / NACI
KF 6A 72-year-old had live shingles vaccine in 2017. What now?
Two doses of recombinant zoster vaccine, 2 to 6 months apart. No antibody test first. Source: Public Health Agency of Canada / NACI
FAQ
Does the exam follow my province's schedule or the national guide?
Learn the national Canadian Immunization Guide. Provinces set their own ages and products, and these vary. The exam tests the principles: who needs what, and when not to wait.
Is the 23-type pneumococcal vaccine still used?
No. The polysaccharide vaccine, Pneu-P-23, was stopped in Canada in August 2025. Adults 65 and older, and younger adults at higher risk, now get one dose of a conjugate vaccine, Pneu-C-20 or Pneu-C-21.
Should I check antibody levels before giving a vaccine?
Usually not. Antibody tests are not advised before or after pertussis or zoster vaccine. Hepatitis A testing is for people likely to be immune already.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- Canadian Immunization GuidePublic Health Agency of Canada / NACIcanada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…canada.ca/en/public-health/services/publication…