GUIDE TO CONTRAINDICATIONS TO VACCINATIONS Department of Health & Human Services Centers for Disease Control and Prevention National Immunization Program INTRODUCTION Guide to Contraindications to Vaccination 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) Using this Guide The Guide is arranged alphabetically according to symptoms and conditons 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 CHECKLIST (Selected Conditions) CHECK FOR REASON SEE PAGE(S) Anaphylactic allergies Contraindicates some vaccines 1-2 Anaphylactic reaction to previous Contraindicates that vaccine 2 dose of any vaccine Anthrax (prior infection) Contraindicates anthrax vaccine 2 Antimicrobial therapy (current) Precaution for several vaccines 2 Eczema or atopic dermatitis in Contraindicates vaccinia vaccine 3 patient or household contact Guillian-Barré Syndrome, history of Precaution for DTaP and influenza vaccines 4 Hematopoietic stem cell transplant Contraindicates varicella vaccine, 4 precaution for several other vaccines HIV (in recipient) Contraindication or precaution for several 5 vaccines Immune globulin (IG) Precaution for MMR and varicella vaccines 5 administration, recent Illness (moderate to severe acute Deferral of vaccination until recovery may 3, 6, 7, 11 illness, fever, otitis, diarrhea, be prudent vomiting) Immunodeficiency: -Family history -Precaution for varicella vaccine 6 -In household contact -Contraindicates vaccinia and live flu vaccines 6 -In recipient -Contraindication or precaution for several 6 vaccines Neurologic disorder Precaution for DTaP 7 Pregnancy: -In mother or household contact -Contraindicates vaccinia vaccine 7 of recipient -In recipient -Contraindication or precaution for several 8 vaccines Reaction to pevious vaccine dose May be contraindication or precaution for 9 that vaccine Skin condition (acute, chronic or Contraindication for vaccinia vaccine 10 exfoliative) Thrombocytopenic purpura Precaution for MMR vaccine 10 (history) Symptom or Condition Vaccine(s) Vaccinate? Allergies (anaphylactic) to any vaccine component (See Appendix A) All No to 2-phenoxyethanol HA (HAVRIX only) No All Others Yes to alum HA No All Others Yes to baker’s yeast HB No All Others Yes to chlortetracycline hydrochloride Vaccinia No All Others Yes to duck meat or duck feathers All Yes to eggs Flu No (See Note 1) YF No All others Yes 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. to gelatin Varicella See Note 2 MMR See Note 2 All Others Yes 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. to latex All See Note 3 Note 3: If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that con- tain 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. to neomycin MMR No IPV No Vaccinia No Varicella No All Others Yes to penicillin All Yes 1 Symptom or Condition Vaccine(s) Vaccinate? Allergies, continued to polymyxin B IPV No Vaccinia No All Others Yes to proteins of rodent or neural origin JE No All Others Yes to streptomycin IPV No Vaccinia No All Others Yes nonspecific or nonanaphylactic All Yes in relatives All Yes to thimerosal JE No All Others Yes Anaphylactic (life-threatening) reaction to All No (See Note 4) previous dose of vaccine Note 4: Contraindicates vaccination only with vaccine to which reaction occurred. (Also, see “Allergies,” pp 1 - 2). Anthrax, prior infection Anthrax No All Others Yes Antimicrobial therapy (current) Flu (LAIV only) Yes (See Note 5) Varicella Yes (See Note 6) Typhoid Yes (See Note 7) All Others Yes 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 sulfon- amides or other antimicrobial agents. Ty21a should be administered >24 hours after an antimicrobial dose. Mefloquine can inhibit the growth of the live Ty21a strain in vitro; if this antimalarial is administered, vaccination with Ty21a should be delayed for 24 hours. Aspirin or salicylate therapy (children or Flu (LAIV only) No adolescents) All Others Yes 2 Symptom or Condition Vaccine(s) Vaccinate? Blood Disorders Flu (LAIV only) See Note 8 (Also see Thrombocytopenia, p. 10) All Others Yes (See Note 9) 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. Breastfeeding (vaccinate nursing infant) All Yes Breastfeeding (vaccinate lactating mother) Vaccinia No All Others Yes Convalescing from illness All Yes Convulsions (fits, seizures), family history All Yes (See Note 10) (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 page 7.) Convulsions (fits, seizures) within 3 days of DTaP See Note 11 previous dose of DTaP All Others Yes 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,