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> Guidelines
> Vaccinating Pregnant Women
Guidelines
for Vaccinating Pregnant Women
from Recommendations of the Advisory Committee on Immunization Practices
(ACIP)
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This
page in
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October
1998 (updated June 2004)
Centers
for Disease Control and Prevention (CDC)
Department of Health and Human Services (DHHS)
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(live, attenuated vaccine)
Vaccination of
Pregnant Women:
"Risk
to a developing fetus from vaccination of the mother during pregnancy
is primarily theoretical. No evidence exists of risk from vaccinating
pregnant women with inactivated virus or bacterial vaccines or toxoids.
Benefits of vaccinating pregnant women usually outweigh potential
risks when the likelihood of disease exposure is high, when infection
would pose a risk to the mother or fetus, and when the vaccine is
unlikely to cause harm." ACIP General Recommendations on
Immunization, p. 18.
Generally,
live-virus vaccines are contraindicated for pregnant women because
of the theoretical risk of transmission of the vaccine virus to
the fetus. If a live-virus vaccine is inadvertently given to a pregnant
woman, or if a woman becomes pregnant within 4 weeks after vaccination,
she should be counseled about the potential effects on the fetus.
But it is not ordinarily an indication to terminate the pregnancy.
Whether
live or inactivated vaccines are used, vaccination of pregnant women
should be considered on the basis of risks versus benefits - i.e.,
the risk of the vaccination versus the benefits of protection in
a particular circumstance. The following table may be used as a
general guide.
Vaccine |
Should
be considered if otherwise indicated |
Contraindicated
during pregnancy |
Special
or absent recommendation
(see text) |
Routine |
Hepatitis
A |
|
|
See
Hepatitis A text |
Hepatitis
B |
X |
|
|
Influenza
(Inact.) |
X |
|
|
Influenza
(LAIV) |
|
X |
|
Measles |
|
X |
|
Mumps |
|
X |
|
Pneumococcal |
|
|
See
Pneumococcal text |
Polio
(IPV) |
|
|
See
Polio text |
Rubella |
|
X |
|
Tetanus/
Diphtheria |
X |
|
|
Varicella |
|
X |
|
Travel
& Other |
Anthrax |
|
|
See
Anthrax text |
BCG |
|
X |
|
Japanese
Encephalitis |
|
|
See
Japanese Encephalitis text |
Meningococcal |
X |
|
|
Rabies |
X |
|
|
Typhoid
(Parenteral & Ty21a) |
|
|
See
Typhoid text |
Vaccinia |
|
|
See
Vaccinia text |
Yellow
Fever |
|
|
See
Yellow Fever text |
Passive
Immunization during Pregnancy
"No known risk exists for the fetus from passive immunization
of pregnant women with immune globulin preparations." ACIP
General Recommendations on Immunization, p. 19.
Information
from this point forward
Below
are relevant passages from ACIP recommendations are reprinted for
each vaccine. Material in quotation marks is taken verbatim from
ACIP (emphasis in bold type added); material not
in quotation marks is paraphrased.
Guidelines
for Vaccinating Pregnant Women
Abstracted from recommendations of the Advisory Committee
on Immunization Practices (ACIP).
Routine
Vaccines:
Hepatitis
A |
- "The
safety of hepatitis A vaccination during pregnancy has not
been determined; however, because hepatitis A vaccine is
produced from inactivated [hepatitis A virus], 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]." 1
|
Top
Hepatitis
B |
- "On
the basis of limited experience, there is no apparent risk
of adverse effects to developing fetuses when hepatitis
B vaccine is administered to pregnant women (CDC, unpublished
data). The vaccine contains noninfectious HBsAg particles
and should cause no risk to the fetus. [Hepatitis B virus]
infection affecting a pregnant woman may result in severe
disease for the mother and chronic infection for the newborn.
Therefore, neither pregnancy nor lactation should
be considered a contraindication to vaccination of women." 2
-
"Hepatitis B vaccine is recommended for pregnant women
at risk for hepatitis B virus infection . . ." 3
|
Top
Influenza
(Inactivated) |
- "Because
of the increased risk for influenza-related complications,
women who will be pregnant during the influenza
season should be vaccinated." 4
-
"Vaccination can occur in any trimester." 4
-
"One study of influenza immunization of >2,000 pregnant
women demonstrated no adverse fetal effects associated with
influenza vaccine."
4
|
Top
Influenza
(LAIV) |
- "The
following populations should not be vaccinated with LAIV
. . . pregnant women. (These persons should receive inactivated
influenza vaccine.)" 5
|
Top
Measles |
- "Measles-mumps
rubella (MMR) vaccine and its
component vaccines should not be administered to
women known to be pregnant. Because a risk to the
fetus from administration of these live virus vaccines
cannot be excluded for theoretical reasons, women
should be counseled to avoid becoming pregnant for 28
days after vaccination with measles or mumps vaccines
or MMR or other rubella-containing vaccines." 6
-
"If a pregnant woman is inadvertently vaccinated or
if
she becomes pregnant within four weeks after MMR . . .
vaccination, she should be counseled regarding the
theoretical basis of concern for the fetus; however,
MMR . . . vaccination during pregnancy should not
ordinarily be a reason to terminate pregnancy." 3
|
Top
Mumps |
- "Measles-mumps
rubella (MMR) vaccine and its component vaccines should
not be administered to women known to be pregnant.
Because a risk to the fetus from administration of these
live virus vaccines cannot be excluded for theoretical reasons,
women should be counseled to avoid becoming pregnant for
28 days after vaccination with measles or mumps vaccines
or MMR or other rubella-containing vaccines." 6
-
"If a pregnant woman is inadvertently vaccinated or
if she becomes pregnant within four weeks after MMR . .
. vaccination, she should be counseled regarding the theoretical
basis of concern for the fetus; however, MMR . . . vaccination
during pregnancy should not ordinarily be a reason to terminate
pregnancy." 3
|
Top
Pneumococcal
(PPV23) |
-
"The
safety of pneumococcal polysaccharide vaccine during the
first trimester of pregnancy has not been evaluated, although
no adverse consequences have been reported among newborns
whose mothers were inadvertently vaccinated during pregnancy."
7
|
Top
Polio
(IPV) |
- "Although
no adverse effects of IPV have been documented among pregnant
women or their fetuses, vaccination of pregnant
women should be avoided on theoretical grounds.
However, 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." 8
|
Top
Rubella |
- "Measles-mumps
rubella (MMR) vaccine and its component vaccines should
not be administered to women known to be pregnant.
Because a risk to the fetus from administration of these
live virus vaccines cannot be excluded for theoretical reasons,
women should be counseled to avoid becoming pregnant for
28 days after vaccination with measles or mumps vaccines
or MMR or other rubella-containing vaccines." 6
- "If
a pregnant woman is inadvertently vaccinated or if she becomes
pregnant within four weeks after MMR . . . vaccination,
she should be counseled regarding the theoretical basis
of concern for the fetus; however, MMR . . . vaccination
during pregnancy should not ordinarily be a reason to terminate
pregnancy." 3
- "Rubella-susceptible
women who are not vaccinated because they state they are
or may be pregnant should be counseled about the potential
risk for CRS and the importance of being vaccinated as soon
as they are no longer pregnant." 9
-
A registry of susceptible women vaccinated with rubella
vaccine between three months before and three months after
conception - the "Vaccine in Pregnancy (VIP) Registry"
- was kept between 1971 and 1989. No evidence of CRS occurred
in the offspring of the 226 women who received the current
RA 27/3 rubella vaccine and continued their pregnancy to
term. 9
|
Top
Tetanus
& Diphtheria (Td) |
- "Td
toxoid is indicated routinely for pregnant women. Previously
vaccinated pregnant women who have not received a Td vaccination
within the last 10 years should receive a booster dose."
3
-
"Pregnant women who are not immunized or only partially
immunized against tetanus should complete the primary series."
3
- "Although
no evidence exists that tetanus and diphtheria toxoids are
teratogenic, waiting until the second trimester of pregnancy
to administer Td is a reasonable precaution for minimizing
any concern about the theoretical possibility of such reactions."
10
|
Top
Varicella |
- "The
effects of the varicella virus vaccine on the fetus are
unknown; therefore, pregnant women should not be
vaccinated. Nonpregnant women who are vaccinated
should avoid becoming pregnant for one month following each
injection. For susceptible persons, having a pregnant household
member is not a contraindication to vaccination." 11
- "Because
the virulence of the attenuated virus used in the vaccine
is less than that of the wild-type virus, the risk to the
fetus, if any, should be even lower." 11
- "If
a pregnant woman is inadvertently vaccinated or if she becomes
pregnant within four weeks after . . . varicella vaccination,
she should be counseled regarding the theoretical basis
of concern for the fetus; however, . . . varicella vaccination
during pregnancy should not ordinarily be a reason to terminate
pregnancy." 3
- "VZIG
[Varicella Zoster Immune Globulin] should be strongly considered
for susceptible, pregnant women who have been exposed."
11
-
The manufacturer & CDC have established a VARIVAX®
Pregnancy Registry to monitor outcomes of women who got
the vaccine three months before or any time during pregnancy.
Call 1-800-986-8999.
|
Top
Travel
& Other Vaccines:
Anthrax |
- "No
studies have been published regarding use of anthrax vaccine
among pregnant women. Pregnant women should be vaccinated
against anthrax only if the potential benefits of vaccination
outweigh the potential risks to the fetus."
12
|
Top
BCG |
- "Although
no harmful effects to the fetus have been associated with
BCG vaccine, its use is not recommended during pregnancy."
13
|
Top
Japanese
Encephalitis (JE) |
- "No
specific information is available on the safety of JE vaccine
in pregnancy. Vaccination poses an unknown but theoretical
risk to the developing fetus, and the vaccine should
not be routinely administered during pregnancy."
14
- "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." 14
|
Top
Meningococcal |
- Studies
have shown the vaccine to be both safe and efficacious when
given to pregnant women. While high antibody levels were
found in umbilical cord blood following vaccination during
pregnancy, antibody levels in the infants decreased during
the first few months after birth. Subsequent response to
meningococcal vaccination was not affected.
- "Based
on data from studies involving use of meningococcal vaccines
administered during pregnancy, altering meningococcal
vaccination recommendations during pregnancy is unnecessary."
15
|
Top
Rabies |
- "Because
of the potential consequences of inadequately treated rabies
exposure, and because there is no indication that fetal
abnormalities have been associated with rabies vaccination,
pregnancy is not considered a contraindication to
postexposure prophylaxis." 16
- "If
the risk of exposure to rabies is substantial, preexposure
prophylaxis might also be indicated during pregnancy."
16
|
Top
Typhoid |
- "No
data have been reported on the use of any of the
three typhoid vaccines among pregnant women." 17
|
Top
Vaccinia
(Smallpox) |
- "Live-viral
vaccines are contraindicated during pregnancy; therefore,
vaccinia vaccine should not be administered to pregnant
women for routine nonemergency indications."
18
- "However,
vaccinia vaccine is not known to cause congenital malformations.
Although <50 cases of fetal vaccinia infection have been
reported, vaccinia virus has been reported to cause fetal
infection on rare occasions, almost always after primary
vaccination of the mother." 18
- "Pregnant
women who have had a definite exposure to smallpox virus
(i.e., face-to-face, household, or close-proximity contact
with a smallpox patient) and are, therefore, at high risk
for contracting the disease, should . . . be vaccinated.
Smallpox infection among pregnant women has been reported
to result in a more severe infection than among nonpregnant
women. Therefore the risks to the mother and fetus from
experiencing clinical smallpox substantially outweigh
any potential risks regarding vaccination. In addition,
vaccinia virus has not been documented to be teratogenic,
and the incidence of fetal vaccinia is low." 18
- "When
the level of exposure risk is undetermined, the decision
to vaccinate should be made after assessment by the clinician
and the patient of the potential risks versus the benefits
of smallpox vaccination." 18
|
Top
Yellow
Fever |
- "The
safety of yellow fever vaccination during
pregnancy has not been established, and the vaccine
should be administered only if travel to an endemic
area is unavoidable and if an increased risk for
exposure exists." 19
-
". . . infection of the fetus with YF17D apparently
occurs
at a low rate . . . and has not been associated with
congenital anomalies." 19
-
"If international travel requirements are 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." 19
-
"Pregnant women who must travel to areas where
the
risk of yellow fever is high should be vaccinated
and,
despite the apparent safety of this vaccine, infants born
to these women should be monitored closely for
evidence of congenital infection and other possible
adverse effects resulting from yellow fever
vaccination" 19
-
"If vaccination of a pregnant woman is deemed
necessary, serologic testing to document an immune
response to the vaccine can be considered, because the
seroconversion rate for pregnant women in a developing
nation has been reported to be substantially lower than
that observed for other healthy adults and children. To
discuss the need for serologic testing, the appropriate
state health department or the Division of Vector-Borne
Infectious Diseases (telephone: 970-221-6400) or the
Division of Global Migration and Quarantine (telephone:
404-639-1600) at CDC should be contacted." 19
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References
-
Centers for Disease Control & Prevention.
Prevention of Hepatitis A Through Active or Passive Immunization:
Recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 48 (No. RR-12): 24, 1999.
-
Centers for Disease Control & Prevention.
Hepatitis B Virus: A Comprehensive Strategy for Eliminating Transmission
in the United States Through Universal Childhood Vaccination:
Recommendations of the Immunization Practices Advisory ommittee
(ACIP). MMWR 40 (No. RR-13): 4, 1991.
-
Centers for Disease Control & Prevention.
General Recommendations on Immunization: Recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR
51 (No. RR-2): 18-19, 2002.
-
Centers for Disease Control & Prevention.
Prevention and Control of Influenza: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 53 (No.
RR-6): 10, 2004.
- Centers
for Disease Control & Prevention. Using Live, Attenuated Influenza
Vaccine for Prevention and Control of Influenza: Supplemental
Recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR 52 (No. RR-13): 5, 2003.
-
Centers for Disease Control & Prevention.
Notice to Readers: Revised ACIP Recommendation for Avoiding Pregnancy
After Receiving a Rubella-Containing Vaccine. MMWR 50
(No. 49); 1117, 2001.
-
Centers for Disease Control & Prevention.
Prevention of Pneumococcal Disease: Recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR 46 (No.
RR-8): 6, 1997.
-
Centers for Disease Control & Prevention.
Poliomyelitis Prevention in the United States: Recommendations
of the Advisory Committee on Immunization Practices (ACIP). MMWR
49 (No. RR-5): 14, 2000.
-
Centers for Disease Control & Prevention.
Measles, Mumps, and Rubella—Vaccine Use and Strategies for
Elimination of Measles, Rubella, and Congenital Rubella Syndrome
and Control of Mumps: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 47 (No. RR-8):
32-33, 1998.
-
Centers for Disease Control & Prevention.
Diphtheria, Tetanus, and Pertussis: Recommendations for Vaccine
Use and Other Preventive Measures: Recommendations of the Immunization
Practices Advisory Committee (ACIP). MMWR 40 (No. RR-10):
14, 1991.
-
Centers for Disease Control & Prevention.
Prevention of Varicella: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 45 (No. RR-11):
19, 1996.
-
Centers for Disease Control & Prevention.
Use of Anthrax Vaccine in the United States: Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR
49 (No. RR-15): 11, 2000.
-
Centers for Disease Control & Prevention.
The Role of BCG Vaccine in the Prevention and Control of Tuberculosis
in the United States: A Joint Statement by the Advisory Council
for the Elimination of Tuberculosis and the Advisory Committee
on Immunization Practices. MMWR 45 (No. RR-4): 13, 1996.
-
Centers for Disease Control & Prevention.
Inactivated Japanese Encephalitis Vaccine: Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR
42 (No. RR-1): 12-13, 1993.
- Centers
for Disease Control & Prevention. Control and Prevention of
Meningococcal Disease and
Control and Prevention of Serogroup C Meningococcal Disease: Evaluation
and Management of Suspected Outbreaks: Recommendations of the
Advisory Committee on Immunization Practices (ACIP). MMWR
46 (No. RR-5): 5, 1997.
-
Centers for Disease Control & Prevention.
Human Rabies Prevention-United States, 1999: Recommendations of
the Advisory Committee on Immunization Practices (ACIP). MMWR
48 (No. RR-1): 17, 1999.
-
Centers for Disease Control & Prevention.
Typhoid Immunization: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 43 (No. RR-14):
7, 1994.
-
Centers for Disease Control & Prevention.
Vaccinia (Smallpox) Vaccine: Recommendations of the Advisory Committee
on Immunization Practices (ACIP). MMWR 50 (No. RR-10):
12 & 19, 2001.
-
Centers for Disease Control & Prevention.
Yellow Fever Vaccine: Recommendations of the Advisory Committee
on Immunization Practices (ACIP), 2002. MMWR 51 (No.
RR-17): 7, 2002.
Prenatal
Screening for Vaccine-Preventable Diseases
The
ACIP currently recommends prenatal screening for rubella and hepatitis
B:
"Prenatal
serologic screening ... is indicated for all pregnant women who
lack acceptable evidence of rubella immunity. Upon completion or
termination of their pregnancies, women who do not have serologic
evidence of rubella immunity or documentation of rubella vaccination
should be vaccinated with MMR before discharge from the hospital,
birthing center, or abortion clinic." ACIP, Measles, Mumps,
and Rubella— Vaccine Use and Strategies/or Elimination of
Measles, Rubella, and Congenital Rubella Syndrome and Control of
Mumps, p. 18.
"All
pregnant women should be routinely tested for HBsAg during an early
prenatal visit in each pregnancy. . . . HBsAg-positive mothers
identified during screening may have HBV-related acute or chronic
liver disease and should be evaluated by their physicians."
ACIP,
Protection Against Viral Hepatitis, p. 14.
Vaccinating Women who are Breastfeeding
"Neither
inactivated nor live vaccines administered to a lactating woman
affect the safety of breast-feeding for mothers or infants. Breast-feeding
does not adversely affect immunization and is not a
contraindication for any vaccine."ACIP, General Recommendations
on Immunization, p. 18.
The
following applies to varicella vaccine, which was licensed after
the ACIP General Recommendations were published: "Whether
attenuated vaccine VZV is excreted in human milk and, if so, whether
the infant could be infected are not known. Most live vaccines have
not been demonstrated to be secreted in breast milk. Attenuated
rubella vaccine virus has been detected in breast milk but has produced
only asymptomatic infection in the nursing infant. Therefore, varicella
vaccine may be considered for a nursing mother." ACIP, Prevention
of Varicella, pp. 19-20.
For
More Information
More detailed information about vaccination
of pregnant women can be found in:
-
ACIP statements for specific diseases.
-
The ACIP's Update on Adult Immunization
(MMWR Vol. 40, No. RR-12, November 15, 1991). See especially
p.9 and Appendix 5, pp.82-88.
-
Current ACIP recommendations can be found on the National
Immunization Program's website at <http://www.cdc.gov/nip/publications/ACIP-list.htm>.
Or call the National Immunization Program's Information Center
at (404) 639-8226.
-
The American College of Obstetricians and Gynecologists (ACOG)
Technical Bulletin Number 160, October 1991. This publication
is available from the American College of Obstetricians and Gynecologists,
Attn: Resource Center, 409 12th Street S.W., Washington, D.C.
20024-2188.
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The American College of Physicians' Guide for Adult
Immunization, Third Edition, pp. 25-29. Customer
Service for the American College of Physicians can be contacted
at (215) 351-2600 or (800) 523-1546.
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