Recommendations
> Contraindications
Guide
to Contraindications
to Vaccinations |
|
|
At
a glance:
This guide is designed to help immunization
providers determine what common symptoms
and conditions should contraindicate
vaccination and which ones should not.
It supersedes the 2000 Guide to Contraindications
to Childhood Vaccination and, unlike
that and previous Guides, contains information
on all licensed U.S. vaccines, not just
pediatric vaccines:
| Anthrax |
Hepatitis
B (HB) |
Rabies |
| BCG |
Japanese
Encephalitis (JE) |
Td |
| DTaP |
MMR |
Typhoid |
| DT |
Pneumococcal
Conjugate (PCV) |
Vaccinia
(routine,
non-emergency use)* |
| Influenza
(Flu) |
Pneumococcal
Polysaccharide (PPV) |
Varicella
|
| Hepatitis
A (HA) |
Polio
(IPV) |
Yellow
Fever (YF) |
|
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Contents of this page: |
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| Links to
other pages: |
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Using
this Guide
The Guide is
arranged alphabetically according to symptoms
and conditions that may, correctly or not,
be perceived as contraindications to vaccination.
The first column states the symptom
or condition. The second column lists
individual vaccines, when recommendations differ
by vaccine. The third column states
whether or not a person with that symptom or
condition should be vaccinated. Notes
describe exceptions and special situations,
or provide additional information.
When assessing a patient with multiple symptoms, if any one of them is a contraindication,
do not vaccinate.
When using a combination vaccine, if there is a contraindication to any
of the components, do not vaccinate.
*Vaccinia Vaccination During a Smallpox Emergency: No absolute
contraindications exist regarding vaccination of a person with a high-risk exposure to smallpox.
Persons at greatest risk for experiencing serious vaccination complications are also at greatest risk for death from smallpox.
If a relative contraindication to vaccination exists, the risk for experiencing serious vaccination
complications must be weighed against the risk for experiencing a potentially fatal smallpox infection.
When the level of exposure risk is undetermined, the decision to vaccinate should be made after prudent
assessment by the clinician and the patient of the potential risks versus the benefits of smallpox
vaccination.
 |
|
The Guide to Contraindications to Vaccinations was developed
by the National Immunization Program, Centers for Disease Control
and Prevention, using information derived from the Standards
for Pediatric Immunization Practices, recommendations of
the Advisory
Committee on Immunization Practices (ACIP), and those of
the Committee on Infectious Diseases (Red Book Committee) of
the American Academy of Pediatrics
(AAP). Some of these recommendations may differ from those
stated in manufacturers' package inserts. For more details,
consult the published recommendations of the ACIP,
the AAP, and the American
Academy of Family Physicians (AAFP), and manufacturers'
package inserts.
September 2003
|
|
|
| Symptom
or Condition |
Vaccine(s) |
Vaccinate? |
| Allergies (anaphylactic)
|
Allergic reaction to any vaccine component
(See Appendix A)
|
All |
No |
|
Allergy to 2-phenoxyethanol |
HA (HAVRIX
only)
All others |
No
Yes |
|
Allergy to alum |
HA
All others |
No
Yes |
|
Allergy to baker's yeast |
HB
All others |
No
Yes |
|
Allergy to chlortetracycline hydrochloride |
Vaccinia
All Others |
No
Yes |
Allergy to duck meat or duck feathers |
All |
Yes |
Allergy to eggs
|
Note 1: |
Protocols have been published for safely administering influenza vaccine to persons
with egg allergies. See "Prevention and Control of influenza," MMWR 2003;52 (No. RR-8) p. 13
|
|
Flu
YF
All Others |
No (See Note 1)
No
Yes |
Allergy to gelatin
|
Note 2: |
If vaccinating persons with a history of an anaphylactic reaction to gelatin or gelatin-containing
products with MMR or its component vaccines, or with varicella vaccine, extreme caution should be
exercised. Before administering these vaccines to such persons, skin testing for sensitivity to gelatin
can be considered. However, no specific protocols for this purpose have been published.
|
|
Varicella
MMR
All others |
See
Note 2
See Note 2
Yes |
Allergy to latex
|
Note 3: |
If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes
that contain natural rubber should not be administered, unless the benefit of vaccination outweighs
the risk of an allergic reaction to the vaccine. For latex allergies other than anaphylactic allergies
(e.g., a history of contact allergy to latex gloves), vaccines supplied in vials or syringes that contain
dry natural rubber or rubber latex can be administered.
|
|
All |
See Note 3 |
|
Allergy to neomycin |
MMR
IPV
Vaccinia
Varicella
All others |
No
No
No
No
Yes |
|
Allergy to penicillin |
All |
Yes |
|
Allergy to polymyxin B |
IPV
Vaccinia
All others |
No
No
Yes |
| Allergy to proteins of rodent or neural origin |
JE
All Others |
No
Yes |
|
Allergy to streptomycin |
IPV
Vaccinia
All others |
No
No
Yes |
|
Allergy nonspecific or nonanaphylactic |
All |
Yes |
|
Allergy in relatives |
All |
Yes |
| Allergy to thimerosal |
JE
All Others |
No
Yes |
Anaphylactic
(life-threatening) reaction to previous dose of vaccine
|
Note 4: |
Contraindicates vaccination only with vaccine to which
reaction occurred. (Also, see "Allergies,") |
|
All |
No
(See Note 4) |
| Anthrax, prior infection |
Anthrax
All Others |
No
Yes |
Antimicrobial
therapy (current)
|
Note 5: |
It is not known whether administering influenza antiviral medications affects
the safety or efficacy of live, attenuated influenza vaccine (LAIV); LAIV should
not be administered until 48 hours following cessation of influenza antiviral
therapy, and influenza antiviral medications should not be administered for two
weeks following receipt of LAIV.
|
|
Note 6: |
Antiviral drugs active against herpesviruses (e.g., acyclovir or valacyclovir)
might reduce the efficacy of live attenuated varicella vaccine. These drugs should
be discontinued >24 hours before the administration of varicella vaccine, if
possible.
|
|
Note 7: |
The vaccine manufacturer advises that Ty21a should not be administered to persons
receiving sulfonamides or other antimicrobial agents. Ty21a should be administered
>24 hours after an antimicrobial does. Mefloquine can inhibit the growth of the
live Ty21a strain in vitro; if this antimicrobial is administered, vaccination with Ty21a
should be delayed for 24 hours.
|
|
Flu (LAIV only)
Varicella
Typhoid
All Others |
Yes
(See Note 5)
Yes (See Note 6)
Yes (See Note 7)
Yes |
| Aspirin or salicylate therapy (children or adolescents) |
Flu (LAIV only)
All Others |
No
Yes |
Blood Disorders (See also Thrombocytopenia)
|
Note 8: |
Persons with hemoglobinopathies should not get LAIV
|
|
Note 9: |
When [any] intramuscular vaccine is indicated for a patient with a bleeding
disorder or a person receiving anticoagulant therapy, the vaccine should be
administered intramuscularly if, in the opinion of a physician familiar with
the patient's bleeding risk, the vaccine can be administered with reasonable
safety by this route. If the patient receives antihemophilia or similar therapy, intramuscular
vaccinations can be scheduled shortly after such therapy is administered. A fine needle (<23 gauge)
should be used for the vaccination and firm pressure applied to the site, without rubbing for
>2 minutes. The patient or family should be instructed concerning the risk for hematoma from
the injection.
|
|
Flu (LAIV only)
All Others |
See Note 8
Yes (See Note 9) |
| Breastfeeding (vaccinate nursing infant) |
All |
Yes |
| Breastfeeding (vaccinate lactating mother) |
Vaccinia
All Others |
No
Yes |
| Convalescing
from illness |
All |
Yes |
Convulsions
(fits, seizures), family history (including epilepsy)
|
Note 10: |
Consider giving acetaminophen before DTaP and every 4
hours thereafter for 24 hours to children who have a personal
or a family history of convulsions. (If an underlying
neurologic disorder is involved, also see "Neurologic
Disorders" later in this chart.) |
|
All |
Yes (See Note 10)
|
Convulsions
(fits, seizures) within 3 days of previous dose of DTaP
|
Note 11: |
Not
a contraindication, but a precaution. Consider carefully
the benefits and risks of this vaccine in these circumstances.
If the risks are believed to outweigh the benefits, withhold
the vaccination; if the benefits are believed to outweigh
the risks (for example, during an outbreak or foreign
travel), give the vaccine. (If convulsions are accompanied
by encephalopathy, also see "encephalopathy
within 7 days after dose". If an underlying neurologic
disorder is involved, also see "Neurologic
Disorders" later in this chart.) |
|
DTaP
All others |
See
Note 11
Yes |
| Diarrhea |
|
mild (with or without low-grade fever) |
All |
Yes |
moderate to severe (with or without
fever)
|
Note 12: |
Persons
with moderate or severe illnesses, with or without fever,
can be vaccinated as soon as they are recovering and no
longer acutely ill. |
|
All |
See
Note 12 |
| Eczema
or Atopic Dermatitis (presence or history of, or household contact
with history of) |
Vaccinia
All Others |
No
Yes |
| Encephalopathy (See
"Reaction after a previous dose of DTaP," later in
this chart.) |
|
|
| Exposure
(recent) to infectious disease |
All |
Yes |
| Fever |
low-grade fever with or without mild
illness |
All |
Yes |
|
fever with moderate-to-severe illness |
All |
See
Note 12 (above) |
Guillain
Barré Syndrome (GBS), history of
|
Note 13: |
Whether influenza vaccination specifically might increase the risk for
recurrence of GBS is not known; therefore, avoiding vaccinating persons who
are not at high risk for severe influenza complications and who are known to have
developed GBS within 6 weeks after a previous influenza vaccination is prudent.
Although data are limited, for the majority of persons who have a history of GBS
and who are at high risk for severe complications from influenza, the established
benefits of influenza vaccination justify yearly vaccination.
|
|
Note 14: |
The decision to give additional doses of DTaP to children who develop
GBS within 6 weeks of a prior dose should be based on consideration of the
benefits of further vaccination vs. the risk of recurrence of GBS. For example,
completion of the primary series in children is justified.
|
|
Flu (LAIV)
Flu (Inactivated)
DTaP
All Others |
No
See Note 13
See Note 14
Yes |
Heart Conditions
|
Note 15: |
As a precaution, a patient who has been diagnosed by a doctor as having a heart
condition with or without symptoms should not get the smallpox vaccine at this time
while experts continue their investigations. These conditions include: known
coronary disease including previous myocardial infarction or angina, congestive heart failure,
cardiomyopathy, stroke or transient ischemic attack, chest pain or shortness of breath with
activity, or other heart conditions under the care of a doctor.
In addition, a patient should not get smallpox vaccine who has 3 or more of the following
factors:
-has been diagnosed with high blood pressure
-has been diagnosed with high blood cholesterol
-has been diagnosed with diabetes or high blood sugar
-has a first degree relative who had a heart condition before the age of 50
-smokes cigarettes
|
|
Note 16: |
Persons with chronic disorders of the cardiovascular system should not get live, attenuated
influenza vaccine.
|
|
Vaccinia
Flu (LAIV only)
All Others |
No (See Note 15)
See Note 16
Yes |
Hematopoietic
Stem Cell Transplant (HSCT)
|
Note 17: |
Other vaccines
are recommended, or many be given, at varying times after
transplant and under certain circumstances. For some vaccines,
no data exist. Use of live vaccines is indicated only among immunocompetent persons
and is contraindicated for recipients after HSCT who are not presumed immunocompetent. HSCT recipients are presumed immunocompetent at >24 months after
HSCT if they are not on immunosuppressive therapy and do not have graft-versus-host disease. For more information, see "Guidelines for Preventing
Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients" (MMWR Vol 49 No. RR-10,
October 20, 2000), especially Tables 4 and 6. |
|
Varicella
All Others |
No
See Note 17 |
| HIV
infection |
in recipient (asymptomatic)
|
Note 18: |
Varicella
vaccination should be considered for asymptomatic or mildly
symptomatic HIV-infected children, specifically children
in CDC class N1 or A1 [See "Prevention of Varicella"
(MMWR Vol 8 No RR-6, May 28, 1999), p. 3 footnote],
with age-specific T cell percentages of 25% or higher. |
|
Note 19: |
MMR
vaccination is recommended for all asymptomatic HIV-infected
persons who do not have evidence of severe immunosuppression and
for whom measles vaccination would otherwise be indicated.
[For definition of severe immunosuppression, see 2003
AAP Red Book, Table 3.25, p. 364.] |
|
Flu (LAIV only)
Typhoid (Ty21a only)
Vaccinia
Varicella
MMR
BCG
YF
All Others |
No
No
No
See Note 18
See Note 19
No
No
Yes |
in recipient (symptomatic)
|
Note 20: |
MMR
vaccination should be considered for all symptomatic HIV-infected
persons who do not have evidence of severe immunosuppression
or of measles immunity. [For definition of severe
immunosuppression, see 2003 AAP Red Book,
Table 3.25, p. 364.] |
|
Flu (LAIV only)
Typhoid (Ty21a only)
Vaccinia
Varicella
MMR
BCG
YF
All Others |
No
No
No
See Note 18
See Note 20
No
No
Yes |
|
in household contact |
Flu (LAIV only)
Vaccinia
All others |
No
No
Yes |
IG
administration, recent or simultaneous (intramuscular or intravenous)
|
Note 21: |
Do
not give immune globulin products and MMR simultaneously.
If unavoidable, give at different sites and revaccinate
or test for seroconversion in 3 months. If MMR is given
first, do not give IG for 2 weeks. If IG is given first,
the interval between IG and measles vaccination depends
on the product, the dose, and the indication. See "Appendix B: Suggested Intervals Between Administration of
Antibody-Containing Products for Different Indications and Measles-Containing Vaccine and Varricella Vaccine" chart that follows. Because of the importance of rubella immunity among childbearing-age
women, the postpartum vaccination of rubella-susceptible women with rubella or MMR vaccine should not be delayed because
of receipt of anti-Rho(D) globulin or any other blood product during the last trimester of pregnancy or
at delivery. These women should be vaccinated immediately after delivery and, if possible, tested >3
months later to ensure immunity to rubella and, if necessary, to measles. |
|
Note 22: |
Do
not give varicella vaccine for at least 5 months after
administration of blood (except washed red blood cells)
or after plasma transfusions, IG, or VZIG. Do not give
IG or VZIG for 3 weeks after vaccination unless the benefits
exceed those of the vaccination. In such instances, either
revaccinate 5 months later or test for immunity 6 months
later and revaccinate if seronegative. |
|
MMR
Varicella
All others |
See
Note 21
See Note 22
Yes |
| Illness |
|
mild acute (with or without low-grade fever) |
All |
Yes |
moderate-to-severe acute (with or without
fever)
|
Note
23: |
Persons
with moderate or severe illnesses, with or without fever,
can be vaccinated as soon as they are recovering and no
longer acutely ill. |
|
All |
See
Note 23 |
chronic
|
Note
24: |
Persons with asthma, reactive airways disease or other
chronic disorders of the pulmonary or cardiovascular systems;
persons with other underlying medical conditions, including
metabolic diseases such as diabetes, renal dysfunction,
and hemoglobinopathies should not receive LAIV. |
|
Note
25: |
The
great majority of persons with chronic illnesses should
be appropriately vaccinated. The decision whether or not
to vaccinate these persons, and what vaccines to give,
should be made on an individual basis. |
|
Flu (LAIV only)
All Others |
See
Note 24
See Note 25 |
Immunodeficiency*
*See
HIV infection; recommendations differ slightly
for that condition. |
family history
|
Note
26 : |
Varicella
vaccine should not be administered to a person with a
family history of congenital or hereditary immunodeficiency
in parents or siblings unless that person's immune competence
has been clinically substantiated or verified by a laboratory. |
|
Varicella
All others |
See Note 26
Yes |
in household contact
|
Note
27: |
There are no data assessing the risk of transmission of
LAIV from vaccine recipients to immunosupressed contacts.
In the absence of such data, use of inactivated flu vaccine
is preferred for vaccinating household members, healthcare
workers, and others who have close contact with immunosuppressed
individuals. |
|
Flu (LAIV only)
Vaccinia
All others |
No (See Note 27)
No
Yes |
in recipient (hematologic and solid tumors,
congenital immunodeficiency, long-term
immunosuppressive therapy, including
steroids)
|
Note
28 : |
When cancer chemotherapy or other immunosuppressive therapy is being considered (e.g., for
patients with Hodgkins disease or those who undergo organ or bone marrow transplantation),
the interval between vaccination and initiation of immunosuppressive therapy should be at least
2 weeks. Vaccination during chemotherapy or radiation therapy should be avoided.
|
|
Note
29 : |
Preexposure: Patients who are immunosuppressed by disease or medications should postpone
preexposure vaccinations and consider avoiding activities for which rabies preexposure prophylaxis
is indicated. When this course is not possible, immunosuppressed persons who are at risk for rabies should be vaccinated by the IM route and their antibody titers checked.
Failure to seroconvert after the third dose should be managed in consultation with apropriate public
health officials. Postexposure: Immunosuppressive agents should not be administered during
postexposure therapy unless essential for treatment of other conditions. When postexposure
prophylaxis is administered to an immunosuppressed person, it is especially important that a serum sample be tested for rabies antibody
to ensure that an acceptable antibody response has developed.
|
|
Note
30 : |
Varicella
vaccine should not be administered to persons who have
cellular immunodeficiences, but persons with impaired
humoral immunity may be vaccinated. A protocol
exists for use of varicella vaccine in patients with acute
lymphoblastic leukemia (ALL). See "Prevention of
Varicella: Recommendations of the Advisory Committee on
Immunization Practices." MMR 1996;45 (No. RR-11). |
|
Flu (LAIV only)
MMR
PPV
Rabies
Typhoid (Ty21a only)
Vaccinia
Varicella
BCG
YF
All Others |
No
No
See Note 28
See Note 29
No
No
See Note 30
No
No
Yes |
Neurologic
disorders, underlying (including seizure disorders, cerebral
palsy, and developmental delay)
|
Note 31: |
Whether and
when to administer DTaP to children with proven or suspected
underlying neurologic disorders should be decided individually.
Generally, infants and children with stable neurologic
conditions, including well-controlled seizures, may be
vaccinated. |
|
DTaP
All Others |
See
Note 31
Yes |
| Otitis
media |
|
mild (with or without low-grade fever) |
All |
Yes |
moderate to severe (with or without fever)
|
Note
32: |
Children with
moderate or severe illnesses, with or without fever, can
be vaccinated as soon as they are recovering and no longer
acutely ill. |
|
All |
See
Note 32 |
|
resolving |
All |
Yes |
| Pregnancy |
|
in mother or household contact of recipient |
Vaccinia
All Others |
No
Yes |
in recipient
|
Note
33: |
Women should avoid becoming pregnant for 4 weeks following vaccination.
|
|
Note
34: |
If a pregnant woman is at increased risk for infection and requires immediate protection
against polio, IPV can be administered in accordance with the recommended schedules for adults.
|
|
Note
35: |
The theoretical risk to the developing fetus is expected to be low. The risk associated with vaccination should
be weighed against the risk for hepatitis A in women who may be at high risk for exposure to hepatitis A virus.
|
|
Note
36: |
Pregnant women who must travel to an area where risk of JE is high should be vaccinated
when the theoretical risks of immunization are outweighed by the risk of infection to the
mother and developing fetus.
|
|
Note
37: |
Pregnant women should not be routinely vaccinated on theoretical grounds, and travel
to areas where yellow fever is present should be postponed until after delivery. If
international travel requirements constitute the only reason to vaccinate a pregnant
woman, rather than an increased risk of infection, efforts should be made to obtain a
waiver letter from the traveler's physician. Pregnant women who must travel to areas where
the risk of yellow fever is high should be vaccinated.
|
|
Note
38: |
Vaccine is not contraindicated, but no data exist on its use among pregnant women.
|
|
MMR
Varicella
Flu (LAIV only)
BCG
Vaccinia
IPV
HA
JE
YF
PPV
Typhoid
All Others
|
No (See Note 33)
No (See Note 33)
No
No
No
See Note 34
See Note 35
See Note 36
See Note 37
See Note 38
See Note 38
Yes |
Prematurity
| Note
39: |
If an infant
weights less than 2 kg at birth, and the mother is antigen-negative,
this infant can receive the first dose of hepatitis B
vaccine at chronological age 1 month. Premature infants
discharged from the hospital before chronological age
1 month can also be administered hepatitis B vaccine at
discharge, if they are medically stable and have gained
weight consistently. If the mother is antigen-positive
or if her antigen status is not known, use the vaccine
schedule in which the first dose, plus HBIG, is given
within 12 hours of birth, regardless of the infant's birth
weight. If these infants weigh less than 2 kg at birth,
this initial dose should not be counted toward completion
of the hepatitis B vaccine series, and three additional
doses should be administered beginning when the infant
is 1 month of age. |
| Note
40: |
The appropriate
age for initiating vaccinations in the prematurely born
infant is the usual chronologic age (same dosage and indications
as for normal, full-term infants). |
|
HB
All Others |
Yes (See Note 39)
Yes (See Note 40) |
| Reactions
to a previous dose of any vaccine |
anaphylactic (life-threatening)
|
Note
41: |
Contraindicates
vaccination only with vaccine to which reaction occurred.
If tetanus toxoid is contraindicated for someone who has
not completed a primary tetanus series
and that person has a wound that is neither clean nor minor,
give only passive vaccination, using tetanus immune globulin
(TIG). |
|
All |
No
(See Note 41) |
local (mild-to-moderate soreness, redness,
swelling) |
All |
Yes |
| Reactions
to a previous dose of DTP/DTaP |
collapse or shock-like state within 40 hours of
dose
|
Note
42: |
Not a contraindication,
but consider carefully the benefits and risks of this
vaccine under these circumstances. If the risks are believed
to outweigh the benefits, withhold the vaccination; if
the benefits are believed to outweigh the risks (for example,
during an outbreak or foreign travel), give the vaccine. |
|
DTaP |
See
Note 42 |
persistent, inconsolable crying lasting for 3 or
more hours, occurring within 48 hours
of dose
|
DTaP |
See
Note 42 |
encephalopathy* within 7 days after
dose
* An acute, severe central nervous
system
disorder, generally consisting of major
alternations in consciousness,
unresponsiveness, or generalized or
focal
seizures that persist more than a few
hours,
with failure to recover within 24 hours. |
DTaP |
No |
family history of any adverse event after a
dose
|
Note
43 : |
Consider giving
acetaminophen before DTaP and every 4 hours thereafter
for 24 hours. |
|
DTaP |
Yes
(See Note 43) |
fever of <40.5° C (105° F)
within 48 hours after a dose
|
DTaP |
Yes
(See Note 43) |
fever of >40.5° C
(105° F) within 48 hours
after
a dose
|
DTaP |
See
Notes 42 & 43 |
Guillain-Barrè Syndrome (GBS) within 6
weeks after a dose
|
Note
44: |
The decision
to give additional doses of DTaP should be based on consideration
of the benefits of further vaccination vs. the risk
of recurrence of GBS. For example, completion of the primary
series in children is justified. |
|
DTaP |
Yes
(See Note 44) |
seizures within 3 days after a dose
|
DTaP |
See
Notes 42 & 43 |
Simultaneous
administration of vaccines
| Note
45: |
There
is a theoretical risk that the administration of multiple
live virus vaccines within 4 weeks of one another, if
not given on the same day, will result in a suboptimal
immune response. Parenterally administered live vaccines,
and live attenuated influenza vaccine, when not administered
on the same day should be administered >4 weeks
apart whenever possible. If these live vaccines are separated
by <4 weeks, the vaccine administered second should
not be counted as a valid dose and should be repeated
>4 weeks after the last, invalid, dose. |
|
All |
Yes
(See Note 45) |
Skin Condition
(acute, chronic or exfoliative) in recipient or household contact
| Note
45: |
Vaccination may be administered after condition resolves.
(Recommendations differ for Eczema and
Atopic Dermatitis, earlier in this chart). |
|
Vaccinia
All Others |
No (See Note 46)
Yes |
| Sudden
infant death syndrome (SIDS), family history |
All |
Yes |
| Steroids (See "Immunodeficiency") |
|
|
| Steroid Eye Drops |
Vaccinia
All Others |
No
Yes |
Thrombocytopenia,
or history of thrombocytopenic purpura
| Note
47: |
Consider
the benefits of immunity to measles, mumps, and rubella
versus the risk of recurrence or exacerbation of thrombocytopenia
after vaccination, or risk from natural infections of
measles or rubella. In most instances, the benefits of
vaccination will be much greater than the potential risks
and will justify giving MMR, particularly in view of the
even greater risk of thrombocytopenia following measles
or rubella disease. However, if a prior episode of thrombocytopenia
occurred near the time of vaccination, it might be prudent
to avoid a subsequent dose. |
|
MMR
All Others |
See
Note 47
Yes |
Tuberculin
skin testing, performed simultaneously with vaccination
| Note
48: |
Measles vaccination
may temporarily suppress tuberculin reactivity. MMR vaccine
may be given after, or on the same day as, TB testing.
If MMR has been given recently, postpone the TB test until
4-6 weeks after administration of MMR. If giving MMR simultaneously
with tuberculin skin test, use the Mantoux text, not multiple
puncture tests, because the latter, if results are positive,
require confirmation (and confirmation would then have
to be postponed 4-6 weeks). |
| Note
49: |
No data exist for the potential degree of PDD suppression that might be associated with other
parenteral live attenuated virus vaccines. Nevertheless, in the absence of data, following
guidelines for measles-containing vaccine when scheduling PPD screening and administering other
parenteral live attenuated virus vaccines is prudent.
|
|
MMR
Varicella
Vaccinia
YF
All others |
Yes (See
Note 48)
Yes (See Note 49)
Yes (See Note 49)
Yes (See Note 49)
Yes |
Tuberculosis
(TB) or positive PPD
| Note
50: |
A theoretical
basis exists for concern that measles vaccine might exacerbate
tuberculosis. Consequently, before administering MMR to
persons with untreated active tuberculosis, initiating
antituberculosis therapy is advisable. |
| Note
51: |
Although no data exist regarding whether either varicella or live varicella virus vaccine
exacerbates tuberculosis, vaccination is not recommended for persons who have untreated,
active tuberculosis.
|
|
MMR
Varicella
All Others |
See Note 50
See Note 51
Yes
|
| Unvaccinated
household contact
|
All |
Yes |
| Vomiting |
|
mild (with or without low-grade fever) |
All |
Yes |
moderate to severe (with or without fever)
|
Note
32: |
Persons with
moderate or severe illnesses, with or without fever, can
be vaccinated as soon as they are recovering and no longer
acutely ill. |
|
All |
See
Note 52 |
Appendix A
Summary of Contents of
Vaccines Licensed in the U.S.
In addition to identifying specific
substances that contraindicate certain vaccines (shown under
the category "Allergies" on the Symptom or Condition chart), the ACIP also
makes the more general statement that a "serious allergic reaction
[e.g., anaphylaxis] to a vaccine component" is a contraindication.
The following table summarizes excipients (i.e., inert substances added as a vehicle)
contained in vaccines licensed in the United States. While these substances, except as noted
above, are not specified by the ACIP as contraindications to vaccination, providers should be
aware of substances contained in vaccines should they encounter a patient with a known
anaphylactic allergy.
|
| Vaccine |
Contains |
| Anthrax (BioThrax) |
Aluminum hydroxide, Benzethonium chloride, Formaldehyde or formalin, Sodium chloride |
| BCG (Tice) |
Lactose, Sodium chloride |
| DTaP (Daptacel) |
Aluminum phosphate, Formaldehyde or formalin, Sodium chloride, 2-phenoxyethanol |
| DTaP (Infanrix) |
Formaldehyde or formalin, 2-phenoxyethanol, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polysorbate 80, Sodium chloride |
| DTap (Tripedia) |
Aluminum potassium sulfate, Formaldehyde or formalin, Gelatin, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polysorbate 80, Sodium chloride, Thimerosal* |
| DTap (Most brands) |
Hydrochloric acid |
| DTaP/Hib (TriHIbit) |
Aluminum potassium sulfate, Formaldehyde or formalin, Gelatin, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polysorbate 80, Sodium chloride, Thimerosal*, Ammonium sulfate, Sucrose |
| DTaP/HepB/IPV (Pediarix) |
2-phenoxyethanol, Sodium chloride, Aluminum, Formaldehyde, Polysorbate 80, Thimerosal*, Neomycin, Polymyxin B, Yeast protein |
| DT (Aventis) |
Aluminum potassium sulfate, Formaldehyde or formalin, Sodium chloride, Thimerosal |
| DT (Massachusetts) |
Aluminum hydroxide, Formaldehyde or formalin, Sodium chloride, Thimerosal |
| DT (Some brands) |
Glycine, Hydrochloric acid, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Sodium acetate, Sodium hydroxide |
| Hib (ACTHib) |
Ammonium sulfate, Formaldehyde or formalin, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Sodium chloride, Sucrose |
| Hib (PedvaxHib) |
Aluminum hydroxide, Sodium chloride |
| Hib (HibTITER) |
Yeast protein, Thimerosal (multi-dose) |
| Hib (Some packages) |
Lactose |
| Hib/HepB (Comvax) |
Aluminum hydroxide, Sodium borate, Sodium chloride, Yeast protein |
| Hep A (Havrix) |
Aluminum hydroxide, Amino acids, Bovine albumin or serum, Formaldehyde or formalin, MRC-5 cellular protein, 2-phenoxyethanol, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polysorbate 20, Sodium chloride |
| Hep A (Vaqta) |
Aluminum hydroxide, Bovine albumin or serum, DNA, Formaldehyde or formalin, MRC-5 cellular protein, Sodium borate, Sodium chloride |
| Hep B (Engerix-B) |
Aluminum hydroxide, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Sodium chloride, Yeast protein, Thimerosal* |
| Hep B (Recombivax) |
Aluminum hydroxide, Sodium chloride, Yeast protein |
| HepA/HepB (Twinrix) |
Phosphate-buffer sodium chloride, Alunimum Phosphate, Aluminum hydroxide, 2-phenoxyethanol, Amino acids, Polysorbate 20, Formalin, Thimerosal*, Yeast protein, Neomycin sulfate |
| Influenza (Fluvirin) |
Beta-propiolactone, Egg protein, Neomycin, Polymyxin B, Polyoxyethylene 9-10 nonyl phenol (Triton N-101, octoxynol 9), Sodium chloride, Thimerosal |
| Influenza (Fluzone) |
Egg protein, Formaldehyde or formalin, Gelatin, Polyethylene glycol p-isooctylphenyl ether (Triton X-100), Sodium chloride, Thimerosal |
| Influenza (Flumist) |
Egg protein, Gentamicin, Monosodium glutamate, Sucrose, Potassium phosphate |
| Influenza (Varies) |
Bactopeptone |
| IPV (Ipol) |
Formaldehyde or formalin, Neomycin, 2-phenoxyethanol, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polymyxin B, Sodium chloride, Streptomycin |
| Japanese Encephalitis (JE-Vax) |
Formaldehyde or formalin, Gelatin, Mouse serum protein |
| Measles (Attenuvax) |
Gelatin, Neomycin, Sorbitol |
| Meningococcal (Menomune) |
Lactose, Thimerosal* |
| Mumps (Mumpsvax) |
Gelatin, Neomycin, Sorbitol |
| MMR (MMR-II) |
Gelatin, Neomycin, Sorbitol |
| Pneumococcal (Pneumovax) |
Phenol, Sodium chloride |
| Pneumococcal (Prevnar) |
Aluminum phosphate, Sodium chloride |
| Rabies (BioRab) |
Aluminum phosphate, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Thimerosal |
| Rabies (Imovax) |
Beta-propiolactone, Bovine albumin or serum, Human serum albumin, MRC-5 cellular protein, Neomycin, Phenol red (phenolsulfonphthalein), Sodium chloride, Vitamins (unspecified) |
| Rabies (RabAvert) |
Amphotericin B, Beta-propiolactone, Bovine albumin or serum, Chlortetracycline, Ethylenediamine-tetraacetic acid sodium (EDTA), Gelatin, MRC-5 cellular protein, Neomycin, Ovalbumin, Potassium glutamate, Sodium chloride |
| Rubella (Meruvax II) |
Gelatin, Neomycin, Sorbitol |
| Td (Aventis) |
Aluminum potassium sulfate, Formaldehyde or formalin, Sodium chloride, Thimerosal, (may contain Glycine, Sodium acetate, Sodium hydroxide) |
| Td (Massachusetts) |
Aluminum hydroxide, Aluminum Phosphate, Formaldehyde or formalin, Sodium chloride, Thimerosal, (may contain Glycine, Sodium acetate, Sodium hydroxide) |
| Typhoid (inactivated - Typhim Vi) |
Phenol, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Polydimethylsilozone, sodium chloride |
| Typhoid (oral - TY21a) |
Amino acids, Ascorbic acid, Gelatin, Lactose, Magnesium stearate, Sucrose |
| Vaccinia (DryVax) |
Bovine albumin or serum, Brilliant green, Chlortetracycline, Glycerin, Neomycin, Phenol, Polymyxin B, Streptomycin |
| Varicella (Varivax) |
Bovine albumin or serum, Ethylenediamine-tetraacetic acid sodium (EDTA), Gelatin, Monosodium glutamate, MRC-5 cellular protein, Neomycin, Phosphate buffers (e.g., disodium, monosodium, potassium, sodium dihydrogen phosphate), Sodium chloride, Sucrose |
| Yellow Fever (YF-Vax) |
Egg protein, Gelatin, Sodium chloride, Sorbitol |
*Whenever "thimerosal" is marked with an asterisk (*) it indicates that the product should be
considered equivalent to thimerosal-free products. This vaccine may contain trace amounts
(<3 mcg) of mercury left after post-production thimerosal removal, but these amounts have no
biological effect. JAMA 1999;282(18) and JAMA 2000;283(16).
All reasonable efforts have been made to assure the accuracy of this information, but manufacturers
may change product contents. If in doubt, check the appropriate package insert.
Information in this appendix was adapted primarily from:
Grabenstein JD. ImmunoFacts: Vaccines & Immunologic Drugs. St. Louis:
Facts and Comparisons, August 2002
|
Appendix B
Suggested Intervals Between Administration of
Antibody-Containing Products for Different Indications and
Measles-Containing Vaccine and Varricella Vaccine*
|
| Product/Identification |
Dose (Including mg immunoglobulin G (lgG)/kg body weight* |
Suggested Interval before Measles or Varicella Vaccination |
| Respiratory syncytial virus immune globulin (IG) monoclonal antibody (Synagis)** |
15 mg/kg intramuscularly (IM) |
None |
| Tetanus IG |
250 Units (10 mg lgG/kg) IM |
3 months |
| Hepatitis A IG |
|
|
| Contact prophylaxis |
0.02 mL/kg (3.3 mg lgG/kg) IM |
3 months |
| International travel |
0.06 mL/kg (10 mg lgG/kg) IM |
3 months |
| Hepatitis B IG |
0.06 mL/kg (10 mg lgG/kg) IM |
3 months |
| Rabies IG |
20 IU/kg (22 mg lgG/kg) IM |
4 months |
| Varicella IG |
125 units/10kg (20-40 mg lgG/kg) IM (maximum 625 units |
5 months |
| Measles prophylaxis IG |
|
|
| Standard (i.e., nonimmunocompromised contact) |
0.25 mL/kg (40 mg lgG/kg) IM |
5 months |
| Immunocompromised contact |
0.50 mL/kg (80 mg lgG/kg) IM |
6 months |
| Blood transfusion |
|
|
| Red blood cells (RBCs), washed |
10 mL/kg negligible lgG/kg intravenously (IV) |
None |
| RBCs, adenine-saline added |
10 mL/kg (10 mg lgG/kg) IV |
3 months |
| Packed RBCs (Hct 65%)*** |
10 mL/kg (60 mg lgG/kg) IV |
6 months |
| Whole blood (Hct 35-50%)*** |
10 mL/kg (80-100 mg lgG/kg) IV |
6 months |
| Plasma/platelet products |
10 mL/kg (160 mg lgG/kg) IV |
7 months |
| Cytomegalovirus (IGIV) |
150 mg/kg maximum |
6 months |
| RSV prophylaxis (IGIV) |
750 mg/kg |
9 months |
| IGIV |
|
|
| Replacement therapy for immune deficiencies**** |
300-400 mg/kg IV**** |
8 months |
| Immune thrombocytopenic purpura |
400 mg/kg IV |
8 months |
| Immune thrombocytopenic purpura |
1000 mg/kg IV |
10 months |
| Kawasaki disease |
2 grams/kg IV |
11 months |
*This table is not intended for determining the correct indications and dosage for using antibody-containing
products. Unvaccinated persons might not be fully protected against measles during the entire recommended interval, and additional doses of immune globulin or measles vaccine might be indicated after measles exposure.
Concentrations of measles antibody in an immune globulin preparation can vary by manufacturer's lot.
Rates of antibody clearance after receipt of an immune globulin preparation might vary also. Recommended
intervals are extrapolated from an estimated half-life of 30 days of passively acquired antibody and an
observed interference with the immune response to measles vaccine for 5 months after a dose of 80 mg lgG/kg. (Source: Mason W, Takahashi M, Schneider T. Persisting passively acquired measles
antibody following gamma globulin therapy for Kawasaki disease and response to live virus vaccination
[Abstract 311]. Presented at the 32nd meeting of the Interscience Conference on Antimicrobial Agents and
Chemotherapy, Los Angeles, California, October, 1992.)
**Contains antibody only to respiratory syncytial virus (RSV)
***Assumes a serum lgG concentration of 16 mg/mL
****Measles and varicella vaccination is recommended for children with asymptomatic or mildly
symptomatic human immunodeficiency virus (HIV) infection but is contraindicated for persons
with severe immunosuppression from HIV or any other immunosuppressive disorder.
Adapted from ACIP "General Recommendations on Immunization"
February 8, 2002
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