Cdc - Guide To Vaccine Contraindications

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Symptoms and Conditions

This guide is for childhood (pre-adolescent) vaccinations only.

Allergies Anaphylactic reaction to previous dose of vaccine . . . . . . . . . . . . . . . . Antimicrobial therapy (current) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . Cerebral palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Convalescing from illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Convulsions, family history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Convulsions within 3 days of previous dose of DTP or DTaP Developmental delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..

DTP/DTaP Hib IPV OPV MMR HB Var

2

2

2

3

14

4

4

4

14

5

19

Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Exposure (recent) to infectious disease. . . . . . . . . . . . . . . . . . . . . . . 6 Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 4 Fits (see "Convulsions") ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gastroenteritis (see "Diarrhea"). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Genetic disorders (see "Neurologic disorders") . . . . . . . . . . . . . . . . . 14 Guillain-Barre syndrome (GBS) ". . . . . . . . . . . . . . . . . . . 20 HIV infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 IG administration, recent or simultaneous. . . . . . . . . . . . . . . . . . . . . 9-10 Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Immunodeficiency 12-13 Neurologic disorders, underlying. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Otitis media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 16 Pr~gnancy, mother or household contact of recipient. . . . . . . . . . . .

DTP/DTaP Hib IPV OPV MMR HB Var

16 Prematurity . 17 Reactions to a previous dose of any vaccine . . 18-20 Reactions to a previous dose of DTP or DTaP . res (see lieonvu I' 4 slons ") . Selzu 21 Simultaneous administration of vaccines . Steroids (see "Immunodeficienct) . 12-13 21 Sudden infant death syndrome (SIDS), family history . 22 Thrombocytopenia . 23 Tuberculin skin testing, performed simultaneously with vaccination. 23 Tuberculosis (TB) or positive PPD . 24 Unvaccinated household contact . 25 Vomiting .

DTP/DTaP Hib IPV OPV MMR HB Var

This guide is designed to help providers of childhood vaccinations decide what common symptoms and conditions should be considered contraindications to vaccination and which ones should not. It covers all of the routine pre-adolescent childhood vaccinations (DTP/DTaP, MMR, hepatitis B, Hib, OPV, IPV, and varicella). Following is a checklist of events in a patient's medical history that are contraindications to or precautions for childhood vaccines. The rest of the guide, beginning on page 1, is arranged alphabetically according to symptoms and conditions that are often considered contraindications to vaccina­ tion. The first column states the symptom or condition. The second column lists individual vaccines when recommendations differ by vaccine; and the third column states whether or not vaccination of a child with that symptom or condition is recommended. Footnotes describe exceptions and special situations. When assessing a child with multiple symptoms, consider all of the symptoms, and if anyone of them is a contraindication, do not vaccinate.

DTP/DTaP Hib IPV OPV MMR HB Var

The Guide to Contraindications to Childhood 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.

DTP/DTaP Hib IPV OPV MMR HB Var

Use the following checklist when reviewing a child's history for contraindications to any of the childhood vaccines. Reason

Check for Anaphylactic allergy to baker's yeast gelatin neomycin streptomycin Anaphylactic reaction to previous dose of any vaccine Encephalopathy within 7 days of previous dose of DTP

Contraindicates Contraindicates Contraindicates Contraindicates

Page HB Varicella & MMR MMR, IPV & Varicella IPV

Contraindicates that vaccine Contraindicates DTP/DTaP

DTP/DTaP Hib IPV OPV MMR HB Var

1 1 1 2 2 19

Check for

Reason

Page

18-20 Any of these conditions after previous dose of Precaution for DTP/DTaP DTP or DTaP: • Fever of .?40.5° C (105° F) within 48 hours • Collapse or shocklike state within 48 hours • Convulsions (seizures) within 3 days • Persistent, inconsolable crying lasting

~3 hours within 48 hours

• Guillain-Barre syndrome (GBS) within 6 weeks HIV (in recipient) Contraindicates OPV & Varicella 8 HIV (in household contact) Contraindicates OPV 8 Immune globulin (I G) administration, recent Precaution for MMR & Varicella 9 Immunodeficiency (family history or household contact) Contraindicates OPV 12 Immunodeficiency (in recipient) Contraindicates MMR, OPV & Varicella 13 Neurologic disorder, underlying Precaution for DTP/DTaP 14 Thrombocytopenic purpura (history) Precaution for MMR 22

DTP/DTaP Hib IPV OPV MMR HB Var

Symptom or Condition

Vaccine(s)

Vaccinate?

HB All others

No Yes

to duck meat or duck feathers

All

Yes

to eggs

All

Yes

to gelatin (anaphylactic)

Varicella MMR All others

See Note 1 See Note 1 Yes

to neomycin (anaphylactic)

MMR IPV Varicella All others

No No No Yes

Allergies to baker's yeast (anaphylactic)

Note 1: In 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.

Symptom or Condition

Vaccine(s)

Vaccinate?

All

Yes

to streptomycin (anaphylactic)

IPV All others

No Yes

nonspecific or nonanaphylactic

All

Yes

in relatives

All

Yes

Anaphylactic (life-threatening) reaction to previous dose of vaccine

All

No See Note 2

Antimicrobial therapy (current)

All

Yes

Allergies (continued) to penicillin

Note 2: Contraindicates vaccination only with vaccine to which reaction occurred. (Also, see "Allergies," pages 1 and 2.)

Symptom or Condition

Vaccine('s)

Vaccinate?

Convalescing from illness

All

Yes

Convulsions (fits, seizures), family history (including epilepsy)

All

Yes See Note 3

DTP/DTaP All others

See Note 4 Yes

Convulsions (fits, seizures) within 3 days of previous dose of DTP or DTaP

Note 3: Consider giving acetaminophen before DTP or 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 page 14.) Note 4: Not a contraindication, but a precaution. 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. (If convulsions are accompanied by encephalopathy, also see page 19. If an underlying neuro­ logic disorder is involved, also see page 14.)

Symptom or Condition

Vaccine(s)

Vaccinate?

mild (with or without low-grade fever)

All

Yes

moderate to severe (with or without fever)

All

No

Diarrhea

Symptom or Condition

Vaccine(s)

Vaccinate?

low-grade fever with or without mild illness

All

Yes

fever with moderate-to-severe illness

All

See Note 5

Fever

Note 5: Children with moderate or severe febrile illnesses can be vaccinated as soon as they are recovering and no longer acutely ill.

Symptom or Condition

Vaccine(s)

Vaccinate?

in household contact

OPV All others

No Yes

in recipient (asymptomatic)

OPV Varicella

No No See Note 6 Yes

HIV infection

MMR All others in recipient (symptomatic)

OPV Varicella

MMR All others

No No See Note 7 Yes

Note 6: MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not have evidence of severe immunosuppression* for whom measles vaccination would otherwise be indicated. Note 7: 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 1997 AAP "Red Book," Table 3.22, p. 282.

Symptom or Condition IG administration (intramuscular or intravenous), recent or simultaneous (see suggested intervals on next page)

Vaccine(s)

Vaccinate?

MMR

See Note 8 See Note 9 Yes

Varicella All others

Note 8: 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 page 10.) Note 9: 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.

Months before measles vaccination

TIG for tetanus prophylaxis IG for hepatitis A contact prophylaxis or foreign travel HBIG for hepatitis B prophylaxis HRIG for rabies prophylaxis VZIG for varicella prophylaxis IG for measles prophylaxis (normal contact) IG for measles prophylaxis (immunocompromised contact) Blood transfusion (red blood cells [RBCs], washed) Blood transfusion (RBCs, adenine-saline added) Blood transfusion (packed RBCs [Hct 65%]) Blood transfusion (whole blood [Hct 35% - 50%]) Blood transfusion (plasma/platelet products) Cytomegalovirus prophylaxis (CMV IGIV) Replacement therapy for humoral immune deficiencies (given as IGIV) Respiratory syncytial virus prophylaxis (RSV IGIV) Treatment of immune thrombocytopenic purpura (400 mg/kg IV) Treatment of immune thrombocytopenic purpura (1000 mg/kg IV) Kawasaki disease

3 3 3 4 5 5 6 0 3 6 6 7 6 8 9 8 10 11

(For guidelines, see J Pediatr 1993; 122:204-11.) Also, see General Recommendations on Immunization: Advisory Committee on Immunization Practices, Jan. 18, 1994, for a more detailed version of this table.

Symptom or Condition

Vaccine(s)

Vaccinate?

mild acute (with or without low-grade fever)

All

Yes

moderate-to-severe acute (with or without fever)

All

No

chronic

All

See Note 10

Illness

Note 10: The great majority of children with chronic illnesses should be appropriately vaccinated. The decision whether or not to vaccinate these children, and what vaccines to give, should be made on an individual basis.

Symptom or Condition

Vaccine(s)

Vaccinate?

family history

OPV Varicella All others

See Note 11 See Note 11 Yes

in household contact

OPV All others

No Yes

Imm unodeficiency*

* See "HIV infection" (page 8); recommendations differ slightly for that condition.

Note 11: Do not give OPV or varicella vaccine to a member of a household with a family history of immuno­ deficiency until the immune status of the recipient and other children in the family is documented.

Symptom or Condition

Vaccine(s)

Vaccinate?

OPV

No No No See Note 12 Yes

Immunodeficiency (continued) in recipient (hematologic and solid tumors, congenital immunodeficiency, long-term immunosuppressive therapy, including steroids)

MMR Varicella All others

Note 12: A protocol exists for use of varicella vaccine in patients with acute lymphoblastic leukemia (ALL). See Varicella Prevention: Recommendations of the Advisory Committee on Immunization Practices.

u.

Symptom or Condition

Vaccine(s)

Vaccinate?

Neurologic disorders, underlying (including seizure disor­ ders, cerebral palsy, and developmental delay)

DTP/DTaP All others

See Note 13 Yes

Note 13: Whether and when to administer DTP or DTa P 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.

Symptom or Condition

Vaccine(s)

Vaccinate?

mild (with or without low-grade fever)

All

Yes

moderate to severe (with or without fever)

All

No

resolving

All

Yes

Otitis media

Symptom or Condition

Vaccine(s)

Vaccinate?

Pregnancy, mother or household contact of recipient

All

Yes

Prematurity

All

Yes See Notes 14 and 15

Note 14: The appropriate age for initiating vaccinations in the prematurely born infant is the usual chronologie age (same dosage and indications as for normal, full-term infants). Note 15: For hepatitis B vaccine, if the mother is antigen-positive, use the vaccine schedule in which the first dose is given at birth.

Symptom or Condition

Vaccine(s)

Vaccinate?

anaphylactic (life-threatening)

All

No See Note 16

local (mild-to-moderate soreness, redness,

swelling)

All

Yes

Reactions to a previous dose of any vaccine

Note 16: Contraindicates vaccination only with vaccine to which reaction occurred. If tetanus toxoid is contraindicated for a child who has not completed a primary series of tetanus toxoid immunization and that child has a wound that is neither clean nor minor, give only passive vaccination, using tetanus im­ mune globulin (TIG).

Symptom or Condition

Vaccine(s)

Vaccinate?

collapse or shocklike state within 48 hours of dose

DTP/DTaP

See Note 17

persistent, inconsolable crying lasting for 3 or more hours, occurring within 48 hours of dose

DTP/DTaP

See Note 17

Reactions to a previous dose of DTP/DTaP

Note 17: 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.

Symptom or Condition

Vaccine(s)

Vaccinate?

encephalopathy* within 7 days after dose

DTP/DTaP

No

family history of any adverse event after a dose

DTP/DTaP

Yes See Note 18

fever of <40.5 0 C (105 0 F) within 48 hours after a dose

DTP/DTaP

Yes See Note 18

Reactions to a previous dose of DTP/DTaP (continued)

* An acute, severe central nervous system disorder, generally consisting of major alterations in conscious­

ness, unresponsiveness, or generalized or focal seizures that persist more than a few hours, with failure to recover within 24 hours. Note 18: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours to children who have a personal or a family history of convulsions.

Symptom or Condition

Vaccine(s)

Vaccinate?

fever of >40.5° C (105° F) within 48 hours after a dose

DTP/DTaP

See Notes 19 and 20

Guillain-Barre syndrome (GBS) within 6 weeks after a dose

DTP/DTaP

See Note 21

seizures within 3 days after a dose

DTP/DTaP

See Notes 19 and 20

Reactions to a previous dose of DTP/DTaP (continued)

Note 19: 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. Note 20: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours. Note 21: The decision to give additional doses of DTP/DTaP should be based on consideration of the ben­ efit of further vaccination vs. the risk of recurrence of GBS. For example, completion of the primary series in children is justified.

Symptom or Condition

Vaccine(s)

Vaccinate?

Simultaneous administration of vaccines

All

Yes See Note 22

Sudden infant death syndrome (SIDS), family history

All

Yes

Note 22: There is a theoretical risk that the administration of multiple live virus vaccines (OPV, MMR, and varicella) within 30 days of one another if not given on the same day will result in a suboptimal immune response. There are no data to substantiate this with current vaccines.

-'­

Symptom or Condition

Vaccine(s)

Vaccinate?

Thrombocytopenia

MMR All others

See Note 23 Yes

Thrombocytopenic purpura (history)

MMR All others

See Note 23 Yes

Note 23: Consider the benefits of immunity to measles, mumps, and rubella vs. 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.

Symptom or Condition Tuberculin skin testing, performed simultaneously with vaccination Tuberculosis (T8) or positive PPD

Vaccine(s)

Vaccinate?

MMR Varicella All others

See Note 24 See Note 24 Yes

All

Yes

Note 24: 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 test, not multiple puncture tests, because the latter, if results are positive, require confirmation (and confir­ mation would then have to be postponed 4 - 6 weeks). While no data are available on the effect of varicella vaccination on tuberculin reactivity, it is prudent to apply the same precautions when using varicella vaccine.

Unvaccinated household contact*

OPV

All others

Yes See Note 25 Yes

* Parent or other household contact who has not been vaccinated with a vaccine the child is receiving.

Note 25: If the parent or other adult household contact of a child receiving OPV has never received polio vaccine, this person should consider being vaccinated with IPV before or at the same time as the child. Vaccination of the child should not be delayed.

Symptom or Condition

Vaccine(s)

Vaccinate?

mild (with or without low-grade fever)

All

Yes

moderate to severe (with or without fever)

All

No

Vomiting

NOTE: Vomiting and OPV Infants sometimes do not swallow OPV. If, in the judgment of the vaccinator, a substantial amount of the vaccine is spit out or vomited within 5 - 10 minutes after administration, another dose can be given at the same visit. If this repeat dose is not retained, neither dose should be counted, and the vaccine should be readministered at the next visit.