| Contraindications
and Precautions |
|
|
|
| Where can I
find a comprehensive listing of
contraindications and precautions to
vaccination? |
|
| An excellent
resource for vaccine contraindications and
precautions is the ACIP General Best Practice
Guidelines for Immunization, available at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html.
A table in the Contraindications and
Precautions chapter has a listing for all
routine vaccines available in the United
States. IAC also has summary tables of
contraindications and precautions for persons
of all ages (www.immunize.org/catg.d/p3072a.pdf)
and a summary for vaccines given to adults (www.immunize.org/catg.d/p3072.pdf). |
|
| What is the
difference between a contraindication and a
precaution? |
|
| A
contraindication is a condition in a recipient
that increases the risk for a serious adverse
reaction to vaccination and is a condition
under which
vaccines should not be administered. In
addition to contraindications found in prescribing information, ACIP may recommend
against the use of a vaccine
under certain conditions (e.g., a lack of
data). |
|
| A precaution is a
condition in a recipient that might increase
the risk for a serious adverse reaction, might
cause diagnostic confusion, or might
compromise the ability of the vaccine to
produce immunity. For example, not vaccinating
a person who is moderately or severely acutely
ill avoids
diagnostic confusion between the underlying
illness and side effects of vaccination.
Vaccination may be deferred if a precaution is
present, although a
vaccination might be indicated in the presence
of a precaution if the benefit of protection
from the vaccine outweighs the risk for an
adverse reaction. |
|
| Is
hospitalization or surgery a contraindication
to vaccination? |
|
| No.
Hospitalization should be used as an
opportunity to provide recommended
vaccinations. Hospitalized patients who are
not moderately or severely
acutely ill may be vaccinated during
hospitalization or at discharge. Current, recent or upcoming anesthesia, surgery or
hospitalization are not
contraindications to vaccination, although certain factors may lead a healthcare provider
to consider these situations a precaution to
vaccination for a
specific patient. |
|
| I am a
pharmacist who administers vaccines. I was
recently told by a colleague that pregnant
healthcare personnel were not to administer
live vaccines to
others. I had never heard that in school or
practice. Is that true? |
|
| This is not true.
Pregnant healthcare personnel may administer
any vaccine except smallpox vaccine. |
|
| Do we need to
check vital signs before giving vaccines? |
|
| No. ACIP does not
recommend routinely checking a patient's
temperature or other vital signs before
vaccination. Requiring these extra steps can
be a
barrier to immunization. |
|
| We frequently
see patients who are febrile or have an acute
illness and are due for vaccinations. We are uncertain if we should withhold the vaccines
or
not. What do you advise? |
|
| A "moderate or
severe acute illness" is a precaution for
administering any vaccine. A mild acute
illness (e.g., diarrhea or mild
upper-respiratory tract
infection) with or without fever is not a
precaution, and vaccines may be given. The
concern in vaccinating someone with moderate
or severe illness is that
a fever following the vaccine could complicate
management of the concurrent illness - it
could be difficult to determine if the fever
was from the vaccine or
due to the concurrent illness. In deciding
whether to vaccinate a patient with moderate
or severe illness, the clinician needs to
determine if deferring
vaccination will increase the patient's risk
of vaccine-preventable diseases, as is the
case if the patient is unlikely to return for
vaccination or to seek
vaccination elsewhere. |
|
| Should you
administer vaccine to a child who is taking
antibiotics? |
|
| Treatment with
antibiotics is not a valid reason to defer
vaccination. If the child or adult is
otherwise well, or has only a minor illness,
vaccines should be
administered. But if the person has a moderate
or severe acute illness (regardless of
antibiotic use) vaccination may be deferred
until the person's
condition has improved. |
|
| Should I
vaccinate a child who has recently been
exposed to an infectious disease? What about a
child who is convalescing from illness? What
about
COVID-19? |
|
| In general,
neither exposure to or recovery from an
infectious disease is a contraindication or
precaution to vaccination. In particular,
recovery from
varicella (chickenpox) is not a reason to
withhold a live vaccine, such as MMR. |
|
| COVID-19 is the
exception to this general rule. CDC recommends
that routine vaccination should be deferred
for persons with suspected or confirmed
COVID-19, regardless of symptoms, until
criteria have been met for them to discontinue
isolation. The reason for this exception is
that vaccination visits for
these individuals should be postponed to avoid
exposing healthcare personnel and other
patients to the virus that causes COVID-19. |
|
| Is it
necessary to routinely obtain a pregnancy test
before administering any vaccines to young
women? |
|
| No. Pregnancy
tests prior to vaccination are not routinely
recommended. However, females of childbearing
age should be asked about the possibility of
their being pregnant prior to being given any
vaccine for which pregnancy is a
contraindication or precaution. The patient's
answer should be documented
in the medical record. If the patient is
uncertain if she is pregnant, a test should be
performed before administering live virus
vaccines (e.g., measles-mumps-rubella, varicella, live attenuated
influenza, yellow fever). |
|
| Which vaccines
are recommended to be given postpartum to
mothers of newborns before hospital discharge? |
|
| The following
vaccines are recommended for new mothers
before they leave the hospital: (1) women
without documentation of previous Tdap
vaccination
need a dose to protect themselves; (2) women
who did not receive influenza vaccination
during pregnancy need to be vaccinated if it
is still influenza
vaccination season (October through March);
(3) women who tested susceptible to rubella on
prenatal testing need MMR vaccine even if they have 1 or 2
documented doses of MMR in their medical
record; (4) women who are not immune to
chickenpox need 2 doses of varicella vaccine –
the first dose
before hospital discharge and the second dose
4 to 8 weeks after the first dose. |
|
| Is it
acceptable practice to administer MMR, Tdap,
and influenza vaccines to a postpartum mom who received RhoGam after delivery? |
|
| Yes. Receipt of
RhoGam is not a reason to delay vaccination.
See the ACIP General Best Practices Guidelines
for Immunization at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html. |
|
| For how long
should a woman of child-bearing age avoid
pregnancy after receiving a live attenuated vaccine? |
|
| Due to
theoretical risk to the developing fetus, ACIP
recommends that women avoid pregnancy for four
weeks after receiving a live attenuated
vaccine
(MMR, varicella, live attenuated influenza,
yellow fever). This interval may be shorter
than that recommended by the manufacturer. |
|
| Which vaccines
are contraindicated if a child's mother or
other household member is pregnant? |
|
| Having a pregnant
woman in a household, including the child's
mother, is not a contraindication to
administration of any routinely recommended
vaccine. |
|
| Which vaccines
can be given to breastfeeding women? |
|
| All vaccines
except smallpox and yellow fever vaccine may
be given to breastfeeding women. |
|
| Smallpox vaccine
is contraindicated due to the theoretical risk
of contact transmission of the vaccine virus
from mother to child. |
|
| The only yellow
fever (YF) vaccine licensed in the United
States (YF-Vax, Sanofi Pasteur) is
contraindicated in women who are breastfeeding
infants
younger than 9 months of age. There have been
three case reports of YF vaccine-associated
encephalitis in infants under one month of age
who were
being exclusively breastfed at the time the
mother received YF vaccine. ACIP currently
recommends that women who are breastfeeding
should be advised
to postpone travel to YF endemic or epidemic
regions; however, if travel cannot be avoided
or postponed, the woman should receive YF
vaccine. Although
there are no data, some experts recommend that breastfeeding women who receive YF vaccine
should temporarily suspend breastfeeding,
pump, and
discard pumped milk for at least 2 weeks after
vaccination before resuming breastfeeding. |
|
| Is there a
risk for a pregnant staff person administering
live-virus vaccines? |
|
| A pregnant woman
may administer any vaccine except smallpox
vaccine. |
|
| What
percentage of vaccine recipients will
experience an anaphylactic reaction? |
|
| It is estimated
that for every million doses administered,
about one (~0.0001%) will result in an
anaphylactic reaction following vaccination.
With proper
screening, most providers who administer
thousands of vaccines in their lifetimes will
never see an anaphylactic reaction. |
|
| The Vaccine
Information Statement for inactivated
influenza vaccine states that you should not
get the vaccine if you are severely allergic
to antibiotics.
Which antibiotics are they referring to? |
|
| The antibiotics,
of which there are trace amounts in some
influenza vaccines, are neomycin, gentamicin,
and polymyxin B. You should check each
product's package insert information to see
which, if any, antibiotics are listed. Links
to all current vaccine package inserts for
vaccines is available on the
IAC website a
www.immunize.org/fda/. |
|
| For which
vaccines is an egg allergy a contraindication? |
|
| 1) Yellow fever
is contraindicated for people who have a
history of a severe (anaphylactic) allergy to
eggs. |
|
| 2) ACIP revised
its guidance on influenza vaccination of
persons with egg allergy in 2018. ACIP
recommends that people with a history of egg
allergy who have experienced only hives after
exposure to egg should receive any influenza
vaccine (inactivated, recombinant or live
attenuated) without
specific precautions (except a 15-minute observation period for syncope). People who
report having had an anaphylactic reaction to
egg (more severe
than hives) may also receive any age- and
condition-appropriate influenza vaccine
(inactivated, recombinant or live attenuated).
If the influenza vaccine
administered is not egg-free (not recombinant
or grown in cell culture), the vaccine for
those individuals should be administered in a
medical setting (such
as a health department or physician office)
and vaccine administration should be
supervised by a healthcare provider who is
able to recognize and
manage severe allergic conditions. For this
reason, although not specifically recommended
by ACIP, providers may prefer the egg-free
cell culture or
recombinant vaccine options for people age 18
years and older with severe egg allergy. |
|
| A previous severe
allergic reaction to influenza vaccine,
regardless of the component suspected to be
responsible for the reaction, is a
contraindication to
future receipt of the vaccine. For a complete
list of vaccine components (i.e., excipients
and culture media) used in the production of
the vaccine, check
the package insert (at
www.immunize.org/fda)
or go to
www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf. |
|
| For more details
about giving influenza vaccine to people with
a history of egg allergy, go to
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html for a link to the current
ACIP recommendations for influenza
vaccination. You also may find the IAC handout
"Influenza Vaccination of
People with a History of Egg Allergy" helpful
(see
www.immunize.org/catg.d/p3094.pdf). |
|
| Is egg allergy
a contraindication for MMR? |
|
| Allergy to egg is
not a contraindication for MMR vaccine.
Although measles and mumps vaccines are grown
in chick embryo tissue culture, several
studies
have documented the safety of these vaccines
in children with severe egg allergy. |
|
| What should we
ask a patient when screening to determine a
gelatin allergy? |
|
| Begin by asking a
general question about whether the person has
an allergy to any food, medication, or
vaccine. If they report an allergy to gelatin
or
foods that contain gelatin, you could follow
up by asking if they can eat Jell-O™ and
gelatin-type products. Gelatin allergies are
extremely rare. Only
severe, life-threatening (anaphylactic) allergy is a contraindication to vaccination. |
|
| Is peanut
allergy a contraindication to any vaccine? |
|
| No. Vaccines
available in the United States do not contain
peanut products. |
|
| If a patient
has had an anaphylactic reaction to a bee
sting, is it safe for her to receive injected
vaccines? |
|
| Yes. Allergy to
bee venom is not a contraindication for any
vaccine. |
|
| What is a
latex allergy and why should we be concerned? |
|
| Latex is a
product of the rubber tree. It is processed
and used in various products, including some
that come in contact with vaccines. Latex may
be
present in syringe plungers, vial stoppers, or
in the tip caps on prefilled syringes. Some
people develop sensitivity to latex,
particularly if they have had
significant cumulative latex exposure, such as
from repeated surgeries early in life or
employment in the healthcare industry. |
|
| The most common
type of latex sensitivity is contact-type
allergy; however, on rare occasions, severe (anaphylactic) allergy occurs. People with a
history
of anaphylactic reactions to latex should
generally not be given vaccines that have been
in contact with natural rubber or latex,
either in the vial or in the
syringe, unless the benefit of vaccination
outweighs the risk of a potential allergic
reaction. People with latex allergies that are
not anaphylactic in nature
may be vaccinated as usual. |
|
| Do any or all
vial stoppers still contain latex? |
|
| Not all stoppers
in vaccine vials contain latex. Some
manufacturers have switched to synthetic
rubber-like materials that do not contain
rubber latex or dry
natural rubber. The best approach is to check
the package insert, which will indicate if the
packaging contains latex. Also, remember that prefilled syringes
could contain natural rubber in the plunger,
in the needle cover, or in the tip cap. This
information is also supplied in the package insert. |
|
| Which vaccines
are supplied in vials or syringes containing
latex? |
|
| You can find
information on latex in vaccine packaging in
Appendix B of CDC's Epidemiology and
Prevention of Vaccine-Preventable Diseases
(the "Pink
Book") at
www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/latex-table.pdf. |
|
| If we have a
patient who has a severe latex allergy, why
shouldn't we just remove the stopper from the
vial before withdrawing the vaccine in order
to
prevent a latex reaction? |
|
| It is not
recommended to remove the stopper from a
vaccine vial before administering a vaccine to
a person who has a severe life-threatening
allergy to
latex. The vaccine has already been exposed to
the rubber stopper in the vial, which might be
enough of an exposure to cause a reaction.
These people
should not be given the vaccine. |
|
| We usually
instruct our patients that they should
separate vaccinations and allergy shots by at
least 24 hours because if there were a
reaction to one or
the other, it wouldn't be possible to
determine which was the cause. This becomes
problematic during influenza vaccination
season. What should we do? |
|
| The probability
of a serious allergic reaction following any
vaccine is extremely low if the person is
properly screened. ACIP has not issued a
recommendation that desensitization injections
and vaccines be separated by any specific time
period; consequently, we feel that you should
take the
opportunity to vaccinate. |
|
| Is there any
reason to delay or adjust the immunization
schedule for children with Down syndrome? |
|
| No. Children with
Down syndrome should receive all indicated
vaccines on the recommended schedule. These children are often at greater risk for
complications from vaccine-preventable
diseases than are children without Down
syndrome. |
|
| We have a
question concerning delaying vaccinations for
an infant born to a heroin-addicted mother. We had a foster parent come into our health
department requesting only certain vaccines
for a 3-month-old, stating that the private
physician recommends delaying the schedule due
to the possible
residual effects of the heroin. The baby
appeared to be healthy. |
|
| Heroin use or
addiction of the mother is not a reason to
delay vaccination of an otherwise healthy
infant. |
|
| Should
vaccines be withheld for patients on steroids? |
|
| Steroid
treatment, and possible immunosuppression, is
primarily a concern with live virus vaccines.
Steroid therapy that is short term (less than
2 weeks);
alternate-day; physiologic replacement;
topical (skin or eyes); aerosol; or given by
intra-articular, bursal, or tendon injection
are not considered
contraindications to the use of live virus
vaccines. The immunosuppressive effects of
corticosteroid treatment vary, but many
clinicians consider a dose
equivalent to either 2 mg/kg of body weight or
a total of 20 mg per day of prednisone (or
equivalent) for 2 or more weeks as
sufficiently
immunosuppressive to raise concern about the
safety of vaccination with live virus vaccines
(e.g., MMR, varicella, live attenuated
influenza, yellow fever).
Providers should wait at least 1 month after
discontinuation of therapy or reduction of
dose before administering a live virus vaccine
to patients who have
received high systemically absorbed doses of
corticosteroids for 2 weeks or more.
Inactivated vaccines and toxoids can be
administered to all
immunocompromised patients in usual doses and
schedules, although the response to these
vaccines may be suboptimal. |
|
| Do people who
received chemotherapy need their vaccines
repeated? |
|
| Vaccines received
before starting chemotherapy generally do not
need to be repeated after chemotherapy is completed. Chemotherapy does not negate
vaccine-induced immunity. However,
revaccination is recommended for people who
are recipients of a hematopoietic cell
transplant (HCT), such as a
bone marrow transplant, because immunity
present before the transplant is lost and may
not be replaced by donor cells. For more
information on this
issue please refer to the Altered
Immunocompetence section of the ACIP General
Best Practices Guidelines for Immunization at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. |
|
| I have a
healthy 5 year-old patient whose close
household contact (her mother) is
immunocompromised due to cancer chemotherapy.
Can I administer
live vaccines to the healthy child? |
|
| Yes. Household
contacts and other close contacts of people
who are immunocompromised (due to a disease,
or treatment for a disease) should receive all
routinely recommended vaccines, with the
exception of smallpox vaccine. The live MMR,
varicella, and rotavirus vaccines should be
administered to
susceptible household contacts and other close
contacts of immunocompromised patients when
indicated. MMR vaccine viruses are not transmitted to
contacts, and transmission of vaccine strain
varicella-zoster virus is rare. No specific
precautions are needed unless the varicella
vaccine recipient has a
rash after vaccination, in which case direct
contact with susceptible immunocompromised
household contacts should be avoided until the
rash resolves. All
members of the household should wash their
hands after changing the diaper of an infant
who received rotavirus vaccine. This minimizes
rotavirus
transmission, as shedding may occur up to one
month after the last dose. |
|
| Household and
other close contacts of immunocompromised
persons should receive annual influenza
vaccination. Introduction of low levels of
vaccine
viruses into the environment likely is
unavoidable when administering live attenuated
influenza vaccine (LAIV; Flumist, Medimmune).
LAIV vaccine viruses
are cold-adapted so they can replicate in the
nose and generate an immune response without
entering the lungs (that is, they are
temperature sensitive
and replicate poorly at core body
temperatures). No instances have been reported
of illness caused by attenuated vaccine virus
infections among
healthcare providers or immunocompromised
patients. LAIV may be administered to healthy
nonpregnant household and other close contacts
of
immunocompromised people unless the
immunocompromised person is hospitalized in a
protective environment, typically defined as a
specialized
patient-care area with a positive airflow
relative to the corridor, high-efficiency
particulate air filtration, and frequent air
changes. |
|
| Which
vaccinations should be given to a patient who
is a recipient of hematopoietic cell
transplantation (HCT)? |
|
| Antibody titers
to vaccine-preventable diseases decline during
the 1-4 years after HCT, if the recipient is
not revaccinated. HCT recipients are at
increased
risk for certain vaccine-preventable diseases,
including those caused by encapsulated
bacteria. In short, all HCT recipients should
begin revaccination
with inactivated vaccines 6 months after HCT.
Three doses of pneumococcal conjugate vaccine
(PCV) should be given 6 months following
transplant
followed by a dose of pneumococcal
polysaccharide vaccine (PPSV) at least 8 weeks
later. HCT recipients should receive 3 doses
of Hib vaccine starting
6 to 12 months after successful transplant, regardless of vaccination history; doses
should be administered at least 4 weeks apart.
Immunocompetent
people should receive MMR vaccine 24 months
after transplant. For a complete discussion of
the indications and schedule of vaccination,
refer to the
sub-section on recipients of HCT in the
Altered Immunocompetence section of ACIP's
General Best Practices Guidelines for
Immunization available at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. |
|
| What vaccines
can a child with severe combined
immunodeficiency disease (SCID) receive? |
|
| Children with
SCID may be given inactivated vaccines (e.g.,
DTaP, Hib, hepatitis B, pneumococcal
conjugate, hepatitis A, IPV, and injectable
influenza).
They should not be given live virus vaccines
(e.g., live attenuated influenza, MMR,
rotavirus, and varicella). |
|
| I know that
immunosuppressed patients can receive
inactivated vaccines, but not live vaccines.
Will these patients who receive inactivated
vaccines
develop a sufficient immune response to make
vaccinating them worthwhile? |
|
| Inactivated
vaccines can be administered to people who
take immunosuppressive drugs or who have a
condition that causes them to be
immunocompromised. The vaccines might not be
as effective as they would be when given to a
person with an intact immune system. If
possible, the
immunosuppresive drug should be discontinued
for a month prior to vaccination, then allow
the vaccine 2–3 weeks to generate an immune
response
before restarting the immunosuppressive
treatment, but obviously, this is not always
possible. |
|
| Determination of
altered immunocompetence is important because
incidence or severity of some
vaccine-preventable diseases is greater in
people with
altered immunocompetence. As a result, certain
vaccines (e.g., inactivated influenza vaccine
and pneumococcal vaccines) are recommended
specifically
for people with altered immunocompetence. |
|
| More information
can be found in ACIP's General Best Practices
Guidelines for Immunization available at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. |
|
| We have a 40
lb six-year-old patient who has been taking 15
mg of methotrexate weekly for arthritis for 12 months. Can we give the child MMR and
varicella vaccine based on this methotrexate
dosage? |
|
| Based on the
weight and dosage provided (40 lbs and 15
mg/week), the child is currently receiving
more than 0.4 mg/kg/week of methotrexate. This
meets the Infectious Disease Society of
America (IDSA) definition of high-level
immunosuppression. Administration of both
varicella and MMR vaccines are contraindicated
until such time as the methotrexate dosage can
be reduced. The 2013 IDSA definition of
low-level immunosuppression for methotrexate
is a dosage of less than 0.4 mg/kg/week. For
additional details, see the 2013 IDSA Clinical
Practice Guideline for Vaccination of the
Immunocompromised Host:
cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf. |
|
| I had an
18-year-old in the clinic today for varicella
vaccination. He reports having
antiphospholipid syndrome being treated with
rituximab (a drug that
affects the function of lymphocytes). The next
dose of rituximab will be in 2 weeks. He has
also had 12 immune globulin (IG) injections in
the last year.
Should he get the varicella vaccine at all
with this condition, and if so, what time
frame do we need to be concerned with in
relation to the rituximab
treatment and/or IG? |
|
| The IDSA
guidelines indicate that persons receiving
rituximab should be considered to have
high-level immunosuppression. Both inactivated
and live
vaccines should be withheld at least 6 months
following treatment with lymphocyte depleting
medications such as rituximab. As for the IG,
the interval to live
vaccination depends on the dose. For guidance,
please refer to the Timing and Spacing of Immunobiologics section of the ACIP’s General
Best Practices
Guidelines for Immunization, table 3-5:
"Recommended intervals between administration
of antibody-containing products and measles-
or varicella-containing vaccine, by product and indication
for vaccination" at
www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html.
This interval could be as
long as 11 months, depending on the dose he
receives. |
|
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ACIP Recommendations
Vaccine Information Statements 
