General Recommendations on Immunization

Epidemiology and Prevention of Vaccine-Preventable Diseases

National Immunization ProgramCenters for Disease Control and Prevention

Revised March 2002

Issues Regarding Spacing and Timing of Vaccines

• Interval between receipt of antibody- containing blood products and measles vaccine

• Interval between doses of different vaccines not administered simultaneously

• Interval between subsequent doses of the same vaccine

Antibody and Live Vaccines

• Inactivated vaccines are generally not affected by circulating antibody to the antigen.

• Live attenuated vaccines may be affected by circulating antibody to the antigen.

General Rule

Product Given FirstVaccine

Antibody

ActionWait 2 weeks before

giving antibody

Wait >3 months before giving vaccine

(See Table, Appendix A)

Antibody and Live Vaccines

Spacing of Antibody-Containing Products and Measles and Varicella Vaccines

Product

Hepatitis A (IG)Washed red blood cells

Measles prophylaxis (IG) normal contactWhole blood

Intravenous immune globulin (IGIV)

0 months3 months

5 months

6 months

7-11 months

Interval

• RSV-IG–Human–Contains other antibodies

• Palivizumab (Synagis)–Monoclonal–Contains only RSV antibody

Antibody for Prevention of RSV

Simultaneous Administration

General RuleThere are no contraindications to simultaneous administration of any vaccines.

CombinationTwo live injected

All other

Minimum Interval4 weeks

None

Spacing of vaccine combinations not given simultaneously

Spacing of live vaccines not given simultaneously

• If two live parenteral vaccines are given <28 days apart the vaccine given second should be repeated.

• Exception is yellow fever vaccine given <28 days after measles vaccine.

Interference Between Live Virus Vaccines Separated by <28 days• Retrospective cohort study of 115,000

children vaccinated in 2 HMOs during January 1995 through December 1999

• Risk of breakthrough varicella 2.5 times higher if varicella vaccine given <30 days following MMR

• No increased risk if varicella vaccine given simultaneously or >30 days after MMR

MMWR 2001;50(47):1058-61

Intervals Between DosesGeneral RuleIncreasing the interval between doses of a multi-dose vaccine does not diminish the effectiveness of the vaccine.

Decreasing the interval between doses of a multi-dose vaccine may interfere with antibody response and protection.

Minimum Intervals and Ages

Vaccine doses should not be given at intervals less than the minimum intervals or earlier than the minimum age

Violation of Minimum Intervals or Minimum Age

• ACIP recommends that vaccine doses given up to four days before the minimum interval or age be counted as valid

• Immunization programs and/or school entry requirements may not accept all doses given earlier than the minimum age or interval

Use of the “Grace Period”• Basic principles–The recommended interval or

age is preferred

–The minimum interval can be used to catch up

–Grace period is last resort

Use of the “Grace Period”• To schedule a future

appointment

•When evaluating a vaccination record

• Client is in the office or clinic early

NO!

Yes

Maybe

Use of the “Grace Period”• Client is in the office or clinic

–Client/parent is known and dependable

–Client/parent is unknown or undependable

Reschedule

Vaccinate

Extended Interval Between Doses• Not all permutations of all schedules

for all vaccines have been studied

• Every study of extended intervals have shown no significant difference in final titer

• It is not necessary to add doses or restart the series because of an extended interval between doses

Vaccine Adverse Reaction• Adverse reaction–extraneous effect caused by

vaccine– "side effect"

• Adverse event– any event following a vaccine– may be true adverse reaction– may be only coincidental

Vaccine Adverse Reactions• Local– pain, swelling, redness at

site of injection– common with inactivated

vaccines– usually mild and self-limited

Vaccine Adverse Reactions• Systemic– fever, malaise, headache– nonspecific– may be unrelated to vaccine

Live Attenuated Vaccines•Must replicate to produce

immunity

• Symptoms usually mild

• Occur after an incubation period(usually 7-21 days)

Vaccine Adverse Reactions• Allergic– due to vaccine or vaccine

component– rare– risk minimized by screening

Contraindication

• A condition in a recipient which greatly increases the chance of a serious adverse event.

Precaution

• A condition in a recipient which may increase the chance or severity of an adverse event, or

•May compromise the ability of the vaccine to produce immunity.

Contraindications and Precautions

• severe allergy to a prior dose of vaccine or to a vaccine component

• encephalopathy following pertussis vaccine

Permanent contraindications to vaccination:

Contraindications and Precautions

ConditionAllergy to ComponentEncephalopathyPregnancyImmunosuppressionSevere illnessRecent blood product

LiveC---CCPP

InactivatedCCVVPV

C=contraindication P=precaution V=vaccinate if indicated

Immunosuppression

• Congenital immunodeficiency

• Leukemia or lymphoma

• Generalized malignancy

Disease

Immunosuppression

• Alkylating agents

• Antimetabolites

• Radiation

Chemotherapy

Immunosuppression

• >20 mg per day

• >2 mg/kg per day

• NOT aerosols, topical, alternate day, short courses

Corticosteroids

Recommendations for Routine Immunization of HIV-infected Children

VaccineVaricellaMMRAll others

AsymptomaticYesYesYes

SymptomaticNoNoYes

Yes=vaccinate No=do not vaccinateYes=vaccinate No=do not vaccinate

Vaccination of Hematopoietic Stem Cell Transplant Recipients

• Includes recipients of bone marrow, peripheral cell, and umbilical cord blood transplants

• Autologous or allogeneic

• HSCT recipients should be revaccinated

Vaccination of Hematopoietic Stem Cell Transplant Recipients

• Influenza vaccine at >6 months following transplant and annual thereafter

• Inactivated vaccines (DTaP, Td, Hib, IPV, hepatitis B, PPV) at 12 months

• MMR at 24 months if immunocompetent

• Varicella and PCV7 vaccines not recommended (insufficient data)

Invalid Contraindications to Vaccination Mild illness Antibiotic therapy Disease exposure or convalescence Pregnancy in the household Breastfeeding Premature birth Allergies to products not in vaccine Family history unrelated to

immunosuppression Need for TB skin testing Need for multiple vaccines

Invalid ContraindicationsMinor Illness

• Low grade fever• Upper respiratory infection• Otitis media• Mild diarrhea

• Only one small study has suggested decreased efficacy of measles vaccine in children with URI

• Findings not replicated by multiple prior and subsequent studies

• No evidence of increased adverse reactions

Screening Questions

• Allergies to food or medication?

• How is your child today?

• Any problem after last shots?

Screening Questions

• Problems with immune system

• Anyone in household with immune problems?

• Blood products in last year?

• Pregnant?

Screening Questions• Standardized screening questionnaires

are available from many state immunization programs, and from the Immunization Action Coalition website at <http://www.immunize.org>

National Immunization Program

•Hotline 800.232.2522

•Email nipinfo@cdc.gov

•Website www.cdc.gov/nip