Vaccine Update: Vaccination Precautions and Contraindications
Column Author: Christine Symes, MSN, CPNP-PC
Column Editor: Angela L. Myers, MD, MPH | Division Director, Infectious Diseases; Medical Director, Center for Wellbeing
Providing vaccines is a daily occurrence in pediatric health care. Knowing when to withhold or delay vaccines is important and sometimes complicated. In the case of routine illness, since there is no evidence that acute illness reduces vaccine effectiveness or safety, they can be administered. As a precaution, however, it is recommended that vaccines should be delayed in the case of moderate or severe acute illness until the illness has abated. Mild illnesses with or without fever (such as otitis media, upper respiratory tract infection or gastroenteritis) and antibiotic use are not contraindications to routine vaccination.
Some cases of type I allergic reactions indicate potential risk with certain vaccines. Those with immediate-type allergic reactions to gelatin, yeast or latex may need evaluation by an allergist, and their vaccines may need to be given in graded doses and be under observation, with competent personnel and medications and equipment available to treat anaphylaxis. Anaphylaxis due to a previous vaccine dose or vaccine component is a contraindication for subsequent doses of that vaccine.1
In the case of pertussis-containing vaccines, a history of encephalopathy that is not attributable to another cause within seven days of receiving a pertussis-containing vaccine is a contraindication for further doses of any pertussis-containing vaccine.
There are some contraindications for vaccines during pregnancy. Live virus vaccines are not recommended during pregnancy due to the theoretical risk of virus transmission to the fetus. People who could become pregnant and who receive a live virus vaccine should be counseled to avoid pregnancy for at least one month following vaccination. However, there are no data from surveillance studies in which pregnant women have inadvertently received a dose of a live virus vaccine early in their pregnancy to substantiate this risk, and pregnancy testing before vaccination is not needed. Due to limited safety data, the following vaccines are generally deferred during pregnancy: pneumococcal vaccines, meningococcal B vaccine and human papilloma virus vaccine. Meningococcal B vaccine can be considered for those with an elevated risk of exposure during pregnancy.
Measles, mumps, and rubella and measles, mumps, and rubella/varicella, and varicella vaccines should not be given to a patient with a family history in a first-degree relative of congenital or hereditary immunodeficiency until the patient’s immune competence has been verified clinically or by a laboratory evaluation. This verification may require Immunology evaluation.
Patients not at high risk for severe influenza complications and with a history of developing Guillain-Barré syndrome within six weeks after receiving a previous influenza vaccination should be cautioned about receiving further influenza vaccines.
For infants with a history of intussusception, rotavirus vaccine is contraindicated.
Live attenuated influenza vaccine (LAIV) is not recommended for children with cerebrospinal fluid leak, with anatomic or functional asplenia, with cochlear implant(s), or who are aged 2-4 years with a history of asthma or wheezing, or who are receiving current aspirin or salicylate-containing medications. For these patients, inactivated influenza vaccine is recommended.
Children who have received antibody-containing product such as intravenous (IVIG) or subcutaneous immune globulin (SCIG) or blood products need to delay live virus vaccines to ensure that they have an adequate response. A chart that shows how long to wait to administer vaccines after receiving antibody-containing products is available at: https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html#t-05.2 In general, for children who have received packed red blood cell transfusion, live vaccines should be withheld for six months; following any plasma or platelet product, seven months; and IVIG/SCIG, eight to 11 months depending on the dose and indication.
Regarding the timing of multiple vaccine administration, patients given live virus vaccines should wait 28 days before receiving another live virus vaccine, if the vaccines are not given at the same time. In the case of yellow fever vaccine, the gap should be 30 days before any other live vaccines. A 23-valent pneumococcal polysaccharide vaccine should be given at least eight weeks after any pneumococcal conjugate vaccine (PCV) to optimize the immune response. If meningococcal ACWY-D (Menactra) is administered within 30 days after diphtheria and tetanus toxoid and acellular pertussis vaccines, it interferes with the immune response to the meningococcal vaccine. Meningococcal ACWY-D should be administered either before or concurrently with diphtheria and tetanus toxoid and acellular pertussis vaccines or >30 days after. Children with functional or anatomic asplenia or human immunodeficiency virus (HIV) infection should not be vaccinated with meningococcal ACWY-D before the age of 2 years, as it can interfere with the immune response to the PCV vaccine. Meningococcal ACWY-CRM (Menveo) should be used in this group.
Patients who are immunocompromised require some considerations around childhood vaccinations. The Infectious Diseases Society of America (IDSA) has created guidelines for vaccinating immunocompromised hosts. These can be found at https://academic.oup.com/cid/article/58/3/e44/336537.3 General principles around vaccinations in patients who will be starting immune suppressive therapies include vaccinating patients prior to the initiation of immunosuppressive therapy, if possible. Non-live vaccines should be given at least two weeks prior to immune suppression. Live vaccines to be given prior to immune suppression should be given at least four weeks prior to starting immunosuppression. If vaccines cannot be given before, they should be held until after recovery from profound immunosuppression. Household members of immunocompromised patients can receive all age-appropriate vaccines, except for smallpox vaccine and oral poliovirus vaccine. If a household contact develops skin lesions after varicella vaccination, the immunocompromised patient should avoid contact until the lesions resolve. Household members should wash hands thoroughly after diaper changes of an infant who received rotavirus vaccine for one month following the vaccine, as the virus is shed in the stool.
Many circumstances can impact the administration of vaccines to certain populations of patients. These include those on corticosteroid therapy, those receiving biologic response-modifying drugs, patients who are post solid organ or hematopoietic cell transplantation, and patients with HIV or primary immunodeficiencies. In these cases, the IDSA guidelines, the Red Book Report of the Committee on Infectious Diseases, the Centers for Disease Control, and the American Academy of Pediatrics are reliable sources of information regarding ways to provide vaccines safely to these special populations.
References:
- Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH; Committee on Infectious Diseases, American Academy of Pediatrics. Red Book: 2024–2027 Report of the Committee on Infectious Diseases. 33rd ed. American Academy of Pediatrics; doi:10.1542/9781610027359
- Table 3-5. Guidelines for administering antibody-containing products and vaccines. Centers for Disease Control and Prevention. Last reviewed August 1, 2023. Accessed November 6, 2024. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html#t-05
- Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host [published correction appears in Clin Infect Dis. 2014 Jul 1;59(1):144]. Clin Infect Dis. 2014;58(3):309-318. Accessed November 7, 2024. https://academic.oup.com/cid/article/58/3/e44/336537