CDC - Guide to Vaccine Contraindications

8/14/2019 CDC - Guide to Vaccine Contraindications

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Symptoms and ConditionsThis guide is for childhood (pre-adolescent) vaccinations only.Allergies 2Anaphylactic reaction to previous dose of vaccine . . . . . . . . . . . . . . . . 2Antimicrobial therapy (current) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . 3Cerebral palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Convalescing from illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Convulsions, family history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Convulsions within 3 days of previous dose of DTP or DTaP 4Developmental delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

DTP/DTaP Hib IPV OPV MMR HB Var


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Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Exposure (recent) to infectious disease. . . . . . . . . . . . . . . . . . . . . . . 6Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Gastroenteritis (see "Diarrhea"). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Genetic disorders (see "Neurologic disorders") . . . . . . . . . . . . . . . . . 14

". . . . . . . . . . . . . . . . . . . 20HIV infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8IG administration, recent or simultaneous. . . . . . . . . . . . . . . . . . . . . 9-10

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1112-13

Neurologic disorders, underlying. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Otitis media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15mother or household contact of recipient. . . . . . . . . . . . 16

MMR HB Var

Fits (see "Convulsions")

Guillain-Barre syndrome (GBS)

IllnessImmunodeficiency

P r ~ g n a n c y ,

DTP/DTaP Hib IPV OPV


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Prematurity .Reactions to a previous dose of any vaccine .Reactions to a previous dose of DTP or DTaP .S . ( lie I' ")lzures see onvu slons .Simultaneous administration of vaccines .Steroids (see "Immunodeficienct) .Sudden infant death syndrome (SIDS), family history .Thrombocytopenia .Tuberculin skin testing, performed simultaneously with vaccination.Tuberculosis (TB) or positive PPD .Unvaccinated household contact .Vomiting .


161718-20

421

12-13212223232425


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



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The Guide to Contraindications to Childhood Vaccinations was developed by theNational Immunization Program, Centers for Disease Control and Prevention, usinginformation 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 theAmerican Academy of Pediatrics (AAP). Some of these recommendations maydiffer from those stated in manufacturers' package inserts.For more details, consult the published recommendationsof theACIP, theAAP,and the American Academy of Family Physicians (AAFP), and manufacturers'package inserts.



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Use the following checklist when reviewing a child's history for contraindications toany of the childhood vaccines.Check for Reason PageAnaphylactic allergy tobaker's yeastgelatinneomycinstreptomycinAnaphylactic reaction to previous dose ofany vaccineEncephalopathy within 7 days of previousdose of DTP

Contraindicates HB 1Contraindicates Varicella & MMR 1Contraindicates MMR, IPV & Varicella 1Contraindicates IPV 2Contraindicates that vaccine 2Contraindicates DTP/DTaP 19



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Reason Pageheck forAny of these conditions after previous dose of Precaution for DTP/DTaP 18-20DTP 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~ hours within 48 hours Guillain-Barre syndrome (GBS) within 6 weeks

HIV (in recipient) Contraindicates OPV & Varicella 8HIV (in household contact) Contraindicates OPV 8Immune globulin (IG) administration, recent Precaution for MMR & Varicella 9Immunodeficiency (family history or household contact) Contraindicates OPV 12Immunodeficiency (in recipient) Contraindicates MMR, OPV & Varicella 13Neurologic disorder, underlying Precaution for DTP/DTaP 14Thrombocytopenic purpura (history) Precaution for MMR 22



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Symptom or ConditionAllergies

to baker's yeast (anaphylactic)to duck meat or duck feathersto eggs

Vaccine(s)

HBAll othersAllAll

Vaccinate?

NoYesYesYes

to gelatin (anaphylactic) Varicella See Note 1MMR See Note 1All others Yesto neomycin (anaphylactic) MMRIPV NoNoVaricella NoAll others Yes

Note 1: In vaccinating persons with a history of an anaphylactic reaction to gelatin or gelatin-containing products with MMR orits component vaccines, or with varicella vaccine, extreme caution should be exercised. Before administering these vaccines tosuch persons, skin testing for sensitivity to gelatin can be considered. However, no specific protocols for this purpose havebeen published.


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Symptom or Condition Vaccine(s) Vaccinate?Allergies (continued)

to penicillin All Yesto streptomycin (anaphylactic) IPV NoAll others Yesnonspecific or nonanaphylactic All Yesin relatives All Yes

Anaphylactic (life-threatening) reaction to All Noprevious dose of vaccine See Note 2Antimicrobial therapy (current) All Yes

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


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Vaccine('s) Vaccinate?ymptom or ConditionConvalescing from illness All YesConvulsions (fits, seizures), family history All Yes(including epilepsy) See Note 3Convulsions (fits, seizures) within 3 days of DTP/DTaP See Note 4previous dose of DTP or DTaP All others Yes

Note 3: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours tochildren who have a personal or a family history of convulsions. (If an underlying neurologic disorder isinvolved, also see page 14.)Note 4: Not a contraindication, but a precaution. Consider carefully the benefits and risks of this vaccineunder these circumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if thebenefits are believed to outweigh the risks (for example, during an outbreak or foreign travel), give thevaccine. (If convulsions are accompanied by encephalopathy, also see page 19. If an underlying neuro-logic disorder is involved, also see page 14.)


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Symptom or ConditionDiarrhea

Vaccine(s) Vaccinate?

NoYes

AllAll

moderate to severe (with or without fever)mild (with or without low-grade fever)


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Vaccine(s) Vaccinate?ymptom or ConditionFever

low-grade fever with or without mild illness All Yesfever with moderate-to-severe illness All See Note 5

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


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Vaccine(s) Vaccinate?ymptom or ConditionHIV infection

in household contact OPV NoAll others Yesin recipient (asymptomatic) OPV NoVaricella No

MMR See Note 6All others Yes

in recipient (symptomatic) OPV NoVaricella NoMMR See Note 7All others Yes

Note 6: MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not haveevidence 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 haveevidence of severe immunosuppression* or of measles immunity.

"For definition of severe immunosuppression, see 1997 AAP "Red Book," Table 3.22, p. 282.


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Vaccine(s) Vaccinate?See Note 8MR

Symptom or ConditionIG administration (intramuscular or intravenous), recentor simultaneous (see suggested intervals on next page) Varicella See Note 9All others Yes

Note 8: Do not give immune globulin products and MMR simultaneously. If unavoidable, give at differentsites and revaccinate or test for seroconversion in 3 months. If MMR is given first, do not give IG for 2weeks. If IG is given first, the interval between IG and measles vaccination depends on the product, thedose, and the indication. (See page 10.)Note 9: Do not give varicella vaccine for at least 5 months after administration of blood (except washed redblood cells) or after plasma transfusions, IG, or VZIG. Do not give IG or VZIG for 3 weeks after vaccinationunless the benefits exceed those of the vaccination. In such instances, either revaccinate 5 months later ortest for immunity 6 months later and revaccinate if seronegative.


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Monthsbeforemeasles vaccinationTIG for tetanus prophylaxis 3IG for hepatitis A contact prophylaxis or foreign travel 3HBIG for hepatitis B prophylaxis 3HRIG for rabies prophylaxis 4VZIG for varicella prophylaxis 5IG for measles prophylaxis (normal contact) 5IG for measles prophylaxis (immunocompromised contact) 6Blood transfusion (red blood cells [RBCs], washed) 0Blood transfusion (RBCs, adenine-saline added) 3Blood transfusion (packed RBCs [Hct 65%]) 6Blood transfusion (whole blood [Hct 35% - 50%]) 6Blood transfusion (plasma/platelet products) 7Cytomegalovirus prophylaxis (CMV IGIV) 6Replacement therapy for humoral immune deficiencies (given as IGIV) 8Respiratory syncytial virus prophylaxis (RSV IGIV) 9Treatment of immune thrombocytopenic purpura (400 mg/kg IV) 8Treatment of immune thrombocytopenic purpura (1000 mg/kg IV) 10Kawasaki disease 11

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


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Symptom or Condition Vaccine(s) Vaccinate?

NoYes

See Note 10

All

AllAll

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

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

Illnessmild acute (with or without low-grade fever)

individual basis.


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Symptom or Condition Vaccine(s) Vaccinate?Immunodeficiency*

family history OPV See Note 11Varicella See Note 11All others Yesin household contact OPV NoAll others Yes

* 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.


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NoNoNoSee Note 12Yes

OPVMMRVaricella

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.

in recipient (hematologic and solid tumors, congenitalimmunodeficiency, long-term immunosuppressive

Vaccine(s) Vaccinate?ymptom or ConditionImmunodeficiency (continued)

therapy, including steroids)


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Symptom or Condition Vaccine(s) Vaccinate?See Note 13YesDTP/DTaPAll othersNeurologic disorders, underlying (including seizure disorders, cerebral palsy, and developmental delay)

Note 13: Whether and when to administer DTP or DTa P to children with proven or suspected underlyingneurologic disorders should be decided individually. Generally, infants and children with stable neurologicconditions, including well-controlled seizures, may be vaccinated.

.


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NoYes

YesAllAll

All

Symptom or ConditionOtitis media

mild (with or without low-grade fever)moderate to severe (with or without fever)resolving


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Vaccine(s) Vaccinate?All Yes

Symptom or ConditionPregnancy, mother or household contactof recipientPrematurity All YesSee Notes 14and 15

Note 14: The appropriate age for initiating vaccinations in the prematurely born infant is the usualchronologie 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 thefirst dose is given at birth.


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YesNoSee Note 16

AllAll

Symptom or ConditionReactions to a previous dose of any vaccineanaphylactic (life-threatening)

local (mild-to-moderate soreness, redness,swelling)

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


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See Note 17TP/DTaP

Note 17: Not a contraindication, but consider carefully the benefits and risks of this vaccine under thesecircumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the benefits arebelieved to outweigh the risks (for example, during an outbreak or foreign travel), give the vaccine.

Reactions to a previous dose of DTP/DTaPcollapse or shocklike state within 48 hours of dosepersistent, inconsolable crying lasting for 3 or morehours, occurring within 48 hours of dose DTP/DTaP See Note 17


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children who have a personal or a family history of convulsions.

Symptom or ConditionReactions to a previous dose of DTP/DTaP (continued)

encephalopathy* within 7 days after dose DTP/DTaP Nofamily history of any adverse event after a dose DTP/DTaP YesSee Note 18fever of


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Vaccine(s) Vaccinate?ymptom or ConditionReactions to a previous dose of DTP/DTaP (continued)

fever of >40.5 C (105F) within 48 hours after a dose DTP/DTaP See Notes19 and 20Guillain-Barre syndrome (GBS) within 6 weeks after a DTP/DTaP See Note 21doseseizures within 3 days after a dose DTP/DTaP See Notes

19 and 20Note 19: Not a contraindication, but consider carefully the benefits and risks of this vaccine under thesecircumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the benefits arebelieved 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 benefit of further vaccination vs. the risk of recurrence of GBS. For example, completion of the primary series inchildren is justified.


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Symptom or Condition Vaccine(s) Vaccinate?Simultaneous administration of vaccines All YesSee Note 22

Yesll

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

Sudden infant death syndrome (SIDS), family history

-'


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See Note 23Yes

See Note 23YesMMRAll others

MMRAll othersThrombocytopenic purpura (history)

Note 23: Consider the benefits of immunity to measles, mumps, and rubella vs. the risk of recurrence orexacerbation of thrombocytopenia after vaccination, or risk from natural infections of measles or rubella. Inmost instances, the benefits of vaccination will be much greater than the potential risks and will justify givingMMR, 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 prudentto avoid a subsequent dose.

Thrombocytopenia


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apply the same precautions when using varicella vaccine.

Symptom or ConditionTuberculin skin testing, performed simultaneously with MMR See Note 24vaccination Varicella See Note 24All others YesTuberculosis (T8) or positive PPD All Yes

Note 24: Measles vaccination may temporarily suppress tuberculin reactivity. MMR vaccine may be givenafter, or on the same day as, TB testing. If MMR has been given recently, postpone the TB test until 4 - 6weeks after administration of MMR. If giving MMR simultaneously with tuberculin skin test, use the Mantouxtest, not multiple puncture tests, because the latter, if results are positive, require confirmation (and confirmation 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


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

YesSee Note 25YesOPV

All others

Note 25: If the parent or other adult household contact of a child receiving OPV has never received poliovaccine, 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.

Unvaccinated household contact*


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Symptom or ConditionVomiting

mild (with or without low-grade fever) All Yes


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

moderate to severe (with or without fever)

NOTE: Vomiting and OPV

All No

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