Contraindications and Precautions

Key points

  • Contraindications to vaccination are conditions that increase the risk for a serious adverse reaction. Vaccines should not be administered when a contraindication is present.
  • Precautions are conditions that might increase the risk for a serious adverse reaction, cause diagnostic confusion, or compromise the ability of the vaccine to produce immunity.
  • In general, vaccinations should be deferred when a precaution is present. However, vaccination might still be indicated if the benefit outweighs the risk.

Updates

Major changes to the best practice guidance in this section include 1) enhancement of the definition of a “precaution” to include any condition that might confuse diagnostic accuracy and 2) recommendation to vaccinate during a hospitalization if a patient is not acutely moderately or severely ill.

General Principles

National standards for pediatric vaccination practices have been established and include descriptions of valid contraindications and precautions to vaccination1. Persons who administer vaccines should screen patients for contraindications and precautions to the vaccine before each dose of vaccine is administered (Table 4-1). Screening is facilitated by consistent use of screening questionnaires, which are available from certain state vaccination programs and other sources (e.g., the Immunization Action Coalition.

Contraindications

Contraindications (conditions in a recipient that increases the risk for a serious adverse reaction) to vaccination are conditions under which vaccines should not be administered. Because the majority of contraindications are temporary, vaccinations often can be administered later when the condition leading to a contraindication no longer exists. A vaccine should not be administered when a contraindication is present; for example, MMR vaccine should not be administered to severely immunocompromised persons2. However, certain conditions are commonly misperceived as contraindications (i.e., are not valid reasons to defer vaccination).

Severely immunocompromised persons generally should not receive live vaccines3. Because of the theoretical risk to the fetus, women known to be pregnant generally should not receive live, attenuated virus vaccines4. Persons who experienced encephalopathy within 7 days after administration of a previous dose of pertussis-containing vaccine not attributable to another identifiable cause should not receive additional doses of a vaccine that contains pertussis45. Severe Combined Immunodeficiency (SCID) disease and a history of intussusception are both contraindications to the receipt of rotavirus vaccines6.

Precautions

A precaution is a condition in a recipient that might increase the risk for a serious adverse reaction, might cause diagnostic confusion, or might compromise the ability of the vaccine to produce immunity (e.g., administering measles vaccine to a person with passive immunity to measles from a blood transfusion administered up to 7 months prior)7. A person might experience a more severe reaction to the vaccine than would have otherwise been expected; however, the risk for this happening is less than the risk expected with a contraindication. In general, vaccinations should be deferred when a precaution is present. However, a vaccination might be indicated in the presence of a precaution if the benefit of protection from the vaccine outweighs the risk for an adverse reaction.

The presence of a moderate or severe acute illness with or without a fever is a precaution to administration of all vaccines (Table 4-1). The decision to administer or delay vaccination because of a current or recent acute illness depends on the severity of symptoms and etiology of the condition. The safety and efficacy of vaccinating persons who have mild illnesses have been documented891011. Vaccination should be deferred for persons with a moderate or severe acute illness. This precaution avoids causing diagnostic confusion between manifestations of the underlying illness and possible adverse effects of vaccination or superimposing adverse effects of the vaccine on the underlying illness. After they are screened for contraindications, persons with moderate or severe acute illness should be vaccinated as soon as the acute illness has improved. Studies indicate that failure to vaccinate children with minor illnesses can impede vaccination efforts121314. Among persons whose compliance with medical care cannot be ensured, use of every opportunity to administer appropriate vaccines is critical.

Hospitalization should be used as an opportunity to provide recommended vaccinations. Health-care facilities are held to standards of offering influenza vaccine for hospitalized patients, so providers are incentivized to vaccinate these patients at some point during hospitalization15. Likewise, patients admitted for elective procedures will not be acutely ill during all times during their hospitalization. Most studies that have explored the effect of surgery or anesthesia on the immune system were observational, included only infants and children, and were small and indirect, in that they did not look at the immune effect on the response to vaccination specifically1617181920212223242526272829303132333435. They do not provide convincing evidence that recent anesthesia or surgery significantly affect response to vaccines. Current, recent, or upcoming anesthesia/surgery/hospitalization is not a contraindication to vaccination, but certain factors might lead a provider to consider current, recent, or upcoming anesthesia/surgery/hospitalization as a precaution1617181920212223242526272829303132333435. Efforts should be made to ensure vaccine administration during the hospitalization or at discharge. For patients who are deemed moderately or severely ill throughout the hospitalization, vaccination should occur at the earliest opportunity (i.e., during immediate post-hospitalization follow-up care, including home or office visits) when patients’ clinical symptoms have improved.

A personal or family history of seizures is a precaution for MMRV vaccination; this is because a recent study found an increased risk for febrile seizures in children 12-23 months who receive MMRV compared with MMR and varicella vaccine36.

Neither Contraindications nor Precautions

Clinicians or other health-care providers might misperceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they actually do not preclude vaccination1 (Table 4-2). These misperceptions result in missed opportunities to administer recommended vaccines37.

Routine physical examinations and procedures (e.g., measuring temperatures) are not prerequisites for vaccinating persons who appear to be healthy. The provider should ask the parent or guardian if the child is ill. If the child has a moderate or severe illness, the vaccination should be postponed.

TABLE 4-1. Contraindications and precautions(a) to commonly used vaccines

References in this table:24638394041424344454647484950515253

Vaccine Citation Contraindications Precautions
Dengue– ONLY use in persons who have laboratory confirmation of previous dengue infection AND reside in endemic dengue areas(b) (38) Lack of laboratory evidence of previous dengue infection
Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
Severe immunodeficiency (e.g., hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy(c) or patients with HIV infection who are severely immunocompromised)
 Pregnancy
HIV infection without evidence of severe immunosuppression
Moderate or severe acute illness with or without fever
DT, Td (4) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component GBS <6 weeks after previous dose of tetanus-toxoid–containing vaccine
History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid—containing or tetanus-toxoid–containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus-toxoid-containing vaccine
Moderate or severe acute illness with or without fever
DTaP (39) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Encephalopathy (e.g., coma, decreased level of consciousness,  prolonged seizures), not attributable to another identifiable cause, within 7 days of administration of previous dose of DTP or DTaP

Progressive neurologic disorder, including infantile spasms, uncontrolled epilepsy, progressive encephalopathy; defer DTaP until neurologic status clarified and stabilized
GBS <6 weeks after previous dose of tetanus-toxoid–containing vaccine
History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid–containing or tetanus-toxoid–containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus-toxoid–containing vaccine
Moderate or severe acute illness with or without fever
Hepatitis A (40) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Moderate or severe acute illness with or without fever
Hepatitis B (41) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Hypersensitivity to yeast

Moderate or severe acute illness with or without fever
Hib (42) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Age <6 weeks

Moderate or severe acute illness with or without fever
HPV(d) (43) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component, including yeast
Moderate or severe acute illness with or without fever
IIV(e) (44) Severe allergic reaction (e.g., anaphylaxis) after previous dose of influenza vaccine or to vaccine component
GBS <6 weeks after a previous dose of influenza vaccine
Moderate or severe acute illness with or without fever
IPV (45) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
Pregnancy
Moderate or severe acute illness with or without fever
LAIV(f) (44) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
Concomitant use of aspirin or salicylate- containing medication in children and adolescents
LAIV4 should not be administered to persons who have taken oseltamivir or zanamivir within the previous 48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days.(h)
Pregnancy
Children aged 2 through 4 years who have received a diagnosis of asthma or whose parents or caregivers report that a health care provider has told them during the preceding 12 months that their child had wheezing or asthma or whose medical record indicates a wheezing episode has occurred during the preceding 12 months.
Persons with active cerebrospinal fluid/oropharyngeal communications/leaks.
Close contacts and caregivers of severely immunosuppressed persons who require a protected environment.
Persons with cochlear implants (due to the potential for CSF leak, which might exist for some period of time after implantation. Providers might consider consultation with a specialist concerning risk of persistent CSF leak if an age-appropriate inactivated or recombinant vaccine cannot be used).
Altered Immunocompetence
Anatomic or functional asplenia (e.g. sickle cell disease)
GBS <6 weeks after a previous dose of influenza vaccine
Asthma in persons aged 5 years old or older
Medical conditions which might predispose to higher risk of complications attributable to influenza(g)
Moderate or severe acute illness with or without fever
MenACWY (46) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
Moderate or severe acute illness with or without fever

Preterm birth (MenACWY-CRM)(i)

MenB (46, 48) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component
Moderate or severe acute illness with or without fever
Pregnancy
Latex sensitivity (MenB-4c)
MMR(j),(k) (1) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Pregnancy

Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy(c) or patients with HIV infection who are severely immunocompromised)

Family history of altered immunocompetence(m)

Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product)

History of thrombocytopenia or thrombocytopenic purpura

Need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing(l)

Moderate or severe acute illness with or without fever

MPSV4 (49) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Moderate or severe acute illness with or without fever
PCV13, PCV15, PCV20 (50) Severe allergic reaction (e.g., anaphylaxis) after a previous dose of PCV or any diphtheria-toxoid– containing vaccine or to a component of a vaccine (PCV or any diphtheria-toxoid– containing vaccine) Moderate or severe acute illness with or without fever
PPSV23 (51) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component Moderate or severe acute illness with or without fever
RIV (44) Severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine
GBS <6 weeks after a previous dose of influenza vaccine
Moderate or severe acute illness with or without fever
Rotavirus (6) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

SCID

History of intussusception

Altered immunocompetence other than SCID
Chronic gastrointestinal disease
Spina bifida or bladder exstrophy(n)

Moderate or severe acute illness with or without fever

Tdap (52) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Encephalopathy (e.g., coma, decreased level of consciousness,  prolonged seizures), not attributable to another identifiable cause, within 7 days of administration of previous dose of DTP, DTaP, or Tdap

GBS <6 weeks after a previous dose of tetanus-toxoid–containing vaccine

Progressive or unstable neurological disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized

History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria-toxoid—containing or tetanus-toxoid–containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus-toxoid–containing vaccine

Moderate or severe acute illness with or without fever

Varicella(j),(k) (53) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

Known severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency,  long-term immunosuppressive therapy(c) or patients with HIV infection who are severely immunocompromised)(j)

Pregnancy

Family history of altered immunocompetence(m)

Recent (≤11 months) receipt of antibody-containing blood product (specific interval depends on product)
Moderate or severe acute illness with or without fever
Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
Use of aspirin or aspirin-containing products(o)
Zoster (54) Severe allergic reaction (e.g., anaphylaxis) after a previous dose or to a vaccine component

 

Moderate or severe acute illness with or without fever

Abbreviations: DT = diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus toxoids and acellular pertussis; DTP = diphtheria toxoid, tetanus toxoid, and pertussis; GBS = Guillain-Barré syndrome; Hib = Haemophilus influenzae type b; HIV = human immunodeficiency virus; HPV = human papillomavirus; IIV = inactivated influenza vaccine; IPV = inactivated poliovirus; LAIV = live, attenuated influenza vaccine; MenACWY = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV13 = pneumococcal conjugate vaccine; PPSV23= pneumococcal polysaccharide vaccine; SCID = severe combined immunodeficiency; RIV=recombinant influenza vaccine; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.

(a) Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the risk, the vaccine should be administered. Whether and when to administer DTaP to children with proven or suspected underlying neurologic disorders should be decided on a case-by-case basis.

(b) Only persons with laboratory confirmation of immunity according to strict guidance at Laboratory Testing Requirements for Vaccination with Dengvaxia Dengue Vaccine should receive dengue vaccination.

(c) Substantially immunosuppressive steroid dose is considered to be ≥2 weeks of daily receipt of 20 mg or 2 mg/kg body weight of prednisone or equivalent.

(d) HPV vaccine is not recommended during pregnancy

(e) When applying this contraindication to ccIIV, the history of severe allergic reaction (e.g., anaphylaxis) must be specific to the event occurring following a dose of ccIIV. Likewise, when applying this contraindication to RIV, the history of severe allergic reaction (e.g., anaphylaxis) must be specific to the event occurring following a dose of RIV. A history of severe allergic reaction (e.g., anaphylaxis) to a non-ccIIV vaccine or to a component specific to components not contained in ccIIV, is a precaution to ccIIV. A history of severe allergic reaction (e.g., anaphylaxis) to a non-RIV vaccine or to a component specific to components not contained in RIV is a precaution to RIV.

(f) In addition, ACIP recommends LAIV not be used for pregnant women, immunosuppressed persons, and children aged 2-4 years who have asthma or who have had a wheezing episode noted in the medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma within the last 12 months. LAIV should not be administered to persons who have taken influenza antiviral medications within the previous 48 hours. Persons who care for severely immunosuppressed persons who require a protective environment should not receive LAIV, or should avoid contact with such persons for 7 days after receipt.

(g) See reference: Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021-2022 Influenza Season. MMWR Recomm Rep 2021;70(No. RR-5):1-30.

(h) These values are based on the clearance of the particular antiviral. LAIV4 should not be administered to persons who have taken oseltamivir or zanamivir within the previous 48 hours, peramivir within the previous 5 days, or baloxavir within the previous 17 days. This “contraindication” is due to concern with reduced effectiveness of the vaccine. To obtain specific information, please refer to Grohskopf LA, Alyanak, E, Broder KR, et. al. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2020–21 Influenza Season. MMWR Recomm Rep 2020;69 (No. RR-8:1-26. Also at https://www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6908a1-H.pdf

(i) This precaution applies to infants younger than 9 months old

(j) HIV-infected children may receive varicella vaccine if CD4+ T-lymphocyte count is ≥15% and should receive MMR vaccine if they are aged ≥12 months and do not have evidence of current severe immunosuppression (i.e., individuals aged ≤5 years must have CD4+T lymphocyte [CD4] percentages ≥15% for ≥6 months; and individuals aged >5 years must have CD4+percentages ≥15% and CD4+≥200 lymphocytes/mm3 for ≥6 months) or other current evidence of measles, rubella, and mumps immunity. In cases when only CD4+cell counts or only CD4+percentages are available for those older than age 5 years, the assessment of severe immunosuppression can be based on the CD4+values (count or percentage) that are available. In cases when CD4+percentages are not available for those aged ≤5 years, the assessment of severe immunosuppression can be based on age-specific CD4+counts at the time CD4+counts were measured; i.e., absence of severe immunosuppression is defined as ≥6 months above age-specific CD4+count criteria: CD4+count >750 lymphocytes/mm3 while aged ≤12 months and CD4+count ≥500 lymphocytes/mm3 while aged 1 through 5 years. Sources: 249.

(k) MMR and varicella-containing vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days.

(l) If active tuberculosis is suspected, MMR should be delayed. Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin or IGRA testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for ≥4 weeks after the vaccination. If an urgent need exists to skin test or IGRA, do so with the understanding that reactivity might be reduced by the vaccine.

(m) family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents and siblings), unless the immune competence of the potential vaccine recipient has been substantiated clinically or verified by a laboratory

(n) For RV1 only, based on latex in product/packaging. Note that anaphylactic allergy to latex is covered in the contraindication and would also be isolated to RV 1 in the case of latex. For more details, see 54.

(o) No adverse events associated with the use of aspirin or aspirin-containing products after varicella vaccination have been reported; however, the vaccine manufacturer recommends that vaccine recipients avoid using aspirin or aspirin-containing products for 6 weeks after receiving varicella vaccines because of the association between aspirin use and Reye syndrome after varicella. Vaccination with subsequent close monitoring should be considered for children who have rheumatoid arthritis or other conditions requiring therapeutic aspirin. The risk for serious complications associated with aspirin is likely to be greater in children in whom natural varicella develops than it is in children who receive the vaccine containing attenuated VZV. No association has been documented between Reye syndrome and analgesics or antipyretics that do not contain aspirin.”

TABLE 4-2. Conditions incorrectly perceived as contraindications or precautions to vaccination (i.e., vaccines may be given under these conditions)

Vaccine Conditions commonly misperceived as contraindications or precautions
General for all vaccines, including DTaP, pediatric DT, adult Td, adolescent-adult Tdap, IPV, MMR, Hib, hepatitis A, hepatitis B, varicella, rotavirus, PCV13, IIV, LAIV, PPSV23, MenACWY, MPSV4, HPV, and herpes zoster Mild acute illness with or without fever
Lack of previous physical examination in well-appearing person
Current antimicrobial therapy(a)
Convalescent phase of illness
Preterm birth (hepatitis B vaccine is an exception in certain circumstances)(b)
Recent exposure to an infectious disease
History of penicillin allergy, other nonvaccine allergies, relatives with allergies, or receiving allergen extract immunotherapy
History of GBS(c)
DTaP Fever within 48 hours after vaccination with a previous dose of DTP or DTaP
Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP
Seizure ≤3 days after receiving a previous dose of DTP/DTaP
Persistent, inconsolable crying lasting ≥3 hours within 48 hours after receiving a previous dose of DTP/DTaP
Family history of seizures
Family history of sudden infant death syndrome
Family history of an adverse event after DTP or DTaP administration
Stable neurologic conditions (e.g., cerebral palsy, well-controlled seizures, or developmental delay)
Hepatitis B Pregnancy
Autoimmune disease (e.g., systemic lupus erythematosus or rheumatoid arthritis)
HPV Immunosuppression
Previous equivocal or abnormal Papanicolaou test
Known HPV infection
Breastfeeding
History of genital warts
IIV Nonsevere (e.g., contact) allergy to latex, thimerosal, or egg
Concurrent administration of Coumadin (generic: warfarin) or aminophylline
IPV Previous receipt of ≥1 dose of oral polio vaccine
LAIV Health-care providers that see patients with chronic diseases or altered immunocompetence (an exception is providers for severely immunocompromised patients requiring care in a protected environment)
Breastfeeding
Contacts of persons with chronic disease or altered immunocompetence (an exception is contacts of severely immunocompromised patients requiring care in a protected environment)
MMR(d),(e) Positive tuberculin skin test
Simultaneous tuberculin skin or interferon-gamma release assay (IGRA) testing(f)
Breastfeeding
Pregnancy of recipient’s mother or other close or household contact
Recipient is female of child-bearing age
Immunodeficient family member or household contact
Asymptomatic or mildly symptomatic HIV infection
Allergy to eggs
PPSV23 History of invasive pneumococcal disease or pneumonia
Rotavirus Prematurity
Immunosuppressed household contacts
Pregnant household contacts
Tdap History of fever of ≥40.5°C (≥105°F) for <48 hours after vaccination with a previous dose of DTP or DTaP
History of collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP
History of seizure <3 days after receiving a previous dose of DTP/DTaP
History of persistent, inconsolable crying lasting >3 hours within 48 hours after receiving a previous dose of DTP/DTaP
History of extensive limb swelling after DTP/DTaP/Td that is not an Arthus-type reaction
History of stable neurologic disorder
History of brachial neuritis
Latex allergy that is not anaphylactic
Breastfeeding
Immunosuppression
Varicella Pregnancy of recipient’s mother or other close or household contact
Immunodeficient family member or household contact(g)
Asymptomatic or mildly symptomatic HIV infection
Humoral immunodeficiency (e.g., agammaglobulinemia)
Zoster Therapy with low-dose methotrexate (≤0.4 mg/kg/week), azathioprine (≤3.0 mg/kg/day), or 6-mercaptopurine (≤1.5 mg/kg/day) for treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease, or other conditions
Health-care providers of patients with chronic diseases or altered immunocompetence
Contacts of patients with chronic diseases or altered immunocompetence
Unknown or uncertain history of varicella in a U.S.-born person

Abbreviations: DT = diphtheria and tetanus toxoids; DTP = diphtheria toxoid, tetanus toxoid, and pertussis; DTaP = diphtheria and tetanus toxoids and acellular pertussis; GBS = Guillain-Barré syndrome; HBsAg = hepatitis B surface antigen; Hib = Haemophilus influenzae type b; HIV = human immunodeficiency virus; HPV = human papillomavirus; IIV = inactivated influenza vaccine; IPV = inactivated poliovirus; LAIV = live, attenuated influenza vaccine; MenACWY = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV = pneumococcal conjugate vaccine; PPSV23= pneumococcal polysaccharide vaccine; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis.

(a) Antibacterial drugs might interfere with Ty21a oral typhoid vaccine, and certain antiviral drugs might interfere with varicella-containing vaccines and LAIV4.

(b) Hepatitis B vaccination should be deferred for infants weighing <2,000 g if the mother is documented to be HBsAg negative. Vaccination should commence at chronological age 1 month or at hospital discharge. For infants born to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 hours after birth, regardless of weight.

(c) An exception is Guillain-Barré syndrome within 6 weeks of a dose of influenza vaccine or tetanus-toxoid–containing vaccine, which are precautions for influenza vaccines and tetanus-toxoid containing vaccines, respectively.

(d) MMR and varicella vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days.

(e) HIV-infected children should receive immune globulin after exposure to measles. HIV-infected children can receive varicella and measles vaccine if CD4+ T-lymphocyte count is >15%54.

(f) Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin or IGRA testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test or IGRA, do so with the understanding that reactivity might be reduced by the vaccine.

(g) If a vaccinee experiences a presumed vaccine-related rash 7-25 days after vaccination, the person should avoid direct contact with immunocompromised persons for the duration of the rash.

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  1. National Vaccine Advisory Committee. Standards for child and adolescent immunization practices. Pediatrics. 2003;112(4):958-963.
  2. McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of measles, rubella, congenital rubella syndrome, and mumps, 2013: summary recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-4):1-34.
  3. Rubin L, Levin M, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-100. DOI: 10.1093/cid/cit684
  4. Kroger A, Atkinson W, Pickering L. General immunization practices. In: Plotkin S, Orenstein W, Offit P, eds. Vaccines. 6th ed. China: Elsevier Saunders; 2013:88-111.
  5. CDC. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep. 1991;40(RR-10):1-28.
  6. CDC. Addition of history of intussusception as a contraindication for rotavirus vaccination. MMWR Morb Mortal Wkly Rep. 2011;60(41):1427.
  7. Siber GR, Werner BG, Halsey NA, et al. Interference of immune globulin with measles and rubella immunization. J Pediatr. 1993;122(2):204-211. DOI: 10.1016/S0022-3476(06)80114-9
  8. Halsey NA, Boulos R, Mode F, et al. Response to measles vaccine in Haitian infants 6 to 12 months old. Influence of maternal antibodies, malnutrition, and concurrent illnesses. N Engl J Med. 1985;313(9):544-549. DOI: 10.1056/nejm198508293130904
  9. Ndikuyeze A, Munoz A, Stewart J, et al. Immunogenicity and safety of measles vaccine in ill African children. Int J Epidemiol. 1988;17(2):448-455. DOI: 10.1093/ije/17.2.448
  10. Lindegren ML, Atkinson WL, Farizo KM, Stehr-Green PA. Measles vaccination in pediatric emergency departments during a measles outbreak. JAMA. 1993;270(18):2185-2189. DOI: 10.1001/jama.1993.03510180055033
  11. Atkinson W, Markowitz L, Baughman A, et al. Serologic response to measles vaccination among ill children [Abstract 422]. 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy; 1992; Anaheim, CA.
  12. Orenstein W, Rodewald L, Hinman A, Schuchat A. Immunization in the United States. In: Plotkin S, Orenstein W, Offit P, eds. Vaccines. 5th ed. China: Saunders/Elsevier; 2008:1479-1510.
  13. Lewis T, Osborn LM, Lewis K, Brockert J, Jacobsen J, Cherry JD. Influence of parental knowledge and opinions on 12-month diphtheria, tetanus, and pertussis vaccination rates. Am J Dis Child. 1988;142(3):283-286. DOI: 10.1001/archpedi.1988.02150030053018
  14. Farizo KM, Stehr-Green PA, Markowitz LE, Patriarca PA. Vaccination levels and missed opportunities for measles vaccination: a record audit in a public pediatric clinic. Pediatrics. 1992;89(4 Pt 1):589-592.
  15. Centers for Medicare & Medicaid Services. Overview of specifications of measures displayed on hospital compare as of December 14, 2006 [11 pages]. 2006. Accessed 9 March, 2017.
  16. Donovan R, Soothill JF. Immunological studies in children undergoing tonsillectomy. Clin Exp Immunol. 1973;14(3):347-357.
  17. Puri P, Reen DJ, Browne O, Blake P, Guiney EJ. Lymphocyte response after surgery in the neonate. Arch Dis Child. 1979;54(8):599-603. DOI: 10.1136/adc.54.8.599
  18. Mollitt DL, Steele RW, Marmer DJ, Stevers Golladay E, Costas S. Surgically induced immunologic alterations in the child. J Pediatr Surg. 1984;19(6):818-822. DOI: 10.1016/S0022-3468(84)80376-0
  19. Mollitt DL, Marmer DJ, Steele RW. Age-dependent variation of lymphocyte function in the postoperative child. J Pediatr Surg. 1986;21(7):633-635. DOI: 10.1016/S0022-3468(86)80420-1
  20. Kurz R, Pfeiffer KP, Sauer H. Immunologic status in infants and children following surgery. Infection. 1983;11(2):104-113. DOI: 10.1007/BF01641075
  21. Merry C, Puri P, Reen DJ. Effect of major surgery on neutrophil chemotaxis and actin polymerization in neonates and children. J Pediatr Surg. 1997;32(6):813-817. DOI: 10.1016/S0022-3468(97)90626-6
  22. Platt MP, Lovat PE, Watson JG, Aynsley-Green A. The effects of anesthesia and surgery on lymphocyte populations and function in infants and children. J Pediatr Surg. 1989;24(9):884-887. DOI: 10.1016/S0022-3468(89)80588-3
  23. Mattila-Vuori A, Salo M, Iisalo E. Immune response in infants undergoing application of cast: comparison of halothane and balanced anesthesia. Can J Anaesth. 1999;46(11):1036-1042. DOI: 10.1007/bf03013198
  24. Espanol T, Todd GB, Soothill JF. The effect of an aesthesia on the lymphocyte response to phytohaemagglutinin. Clin Exp Immunol. 1974;18(1):73-79.
  25. Hauser GJ, Chan MM, Casey WF, Midgley FM, Holbrook PR. Immune dysfunction in children after corrective surgery for congenital heart disease. Crit Care Med. 1991;19(7):874-881.
  26. Puri P, Lee A, Reen DJ. Differential susceptibility of neonatal lymphocytes to the immunosuppressive effects of anesthesia and surgery. Pediatr Surg Int. 1992;7(1):47-50. DOI: 10.1007/bf00181002
  27. Hansen TG, Tonnesen E, Andersen JB, Toft P, Bendtzen K. The peri-operative cytokine response in infants and young children following major surgery. Eur J Anaesthesiol. 1998;15(1):56-60. DOI: 10.1046/j.1365-2346.1998.00230.x
  28. Mattila-Vuori A, Salo M, Iisalo E, Pajulo O, Viljanto J. Local and systemic immune response to surgery under balanced anaesthesia in children. Paediatr Anaesth. 2000;10(4):381-388. DOI: 10.1046/j.1460-9592.2000.00505.x
  29. Romeo C, Cruccetti A, Turiaco A, et al. Monocyte and neutrophil activity after minor surgical stress. J Pediatr Surg. 2002;37(5):741-744. DOI: 10.1053/jpsu.2002.32268
  30. Vuori A, Salo M, Viljanto J, Pajulo O, Pulkki K, Nevalainen T. Effects of post-operative pain treatment using non-steroidal anti-inflammatory analgesics, opioids or epidural blockade on systemic and local immune responses in children. Acta Anaesthesiol Scand. 2004;48(6):738-749. DOI: 10.1111/j.1399-6576.2004.00404.x
  31. Siebert JN, Posfay-Barbe KM, Habre W, Siegrist CA. Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence. Paediatr Anaesth. 2007;17(5):410-420. DOI: 10.1111/j.1460-9592.2006.02120.x
  32. Currie J. Vaccination: is it a real problem for anesthesia and surgery? Paediatr Anaesth. 2006;16(5):501-503. DOI: 10.1111/j.1460-9592.2006.01898.x
  33. Siebert J, Posfay-Barbe KM, Habre W, Siegrist C-A. Author’s reply. Paediatr Anaesth. 2007;17(12):1218-1220. DOI: 10.1111/j.1460-9592.2007.02369.x
  34. Nafiu OO, Lewis I. Vaccination and anesthesia: more questions than answers. Paediatr Anaesth. 2007;17(12):1215-1215. DOI: 10.1111/j.1460-9592.2007.02318.x
  35. Short JA, Van Der Walt JH, Zoanetti DC. Author’s reply. Paediatr Anaesth. 2007;17(12):1215-1216. DOI: 10.1111/j.1460-9592.2007.02321.x
  36. Marin M, Broder KR, Temte JL, Snider DE, Seward JF. Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-3):1-12.
  37. Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manag Pract. 1996;2(1):18-25. DOI: 10.1097/00124784-199600210-00005
  38. Paz-Bailey G, Adams L, Wong JM, et al. Dengue Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021. MMWR Recomm Rep 2021;70(No. RR-6):1-18.
  39. CDC. Use of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine as a five-dose series. Supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49(RR-13):1-8.
  40. Fiore AE, Wasley A, Bell BP. Prevention of hepatitis A through active or passive immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-7):1-23.
  41. Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: immunization of infants, children, and adolescents. MMWR Recomm Rep. 2005;54(RR-16):1-31.
  42. Briere EC, Rubin L, Moro PL, Cohn A, Clark T, Messonnier N. Prevention and control of Haemophilus influenzae type b disease: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep. 2014;63(RR-1):1-14.
  43. Markowitz L, Dunne E, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.
  44. Grohskopf LA, Sokolow LZ, Olsen SJ, et al. Prevention and Control of Seasonal Influenza with Vaccines Recommendations of the Advisory Committee on Immunization Practices — United States, 2016–17 Influenza Season. MMWR Recomm Rep 2016;65(No. RR-5):1-54.
  45. Prevots DR, Burr RK, Sutter RW, Murphy TV. Poliomyelitis prevention in the United States. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2000;49(RR-5):1-22; quiz CE21-27.
  46. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2013;62(RR-2):1-28.
  47. Trumenba Package Insert [15 pages] (accessed 05/04/17).
  48. Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54(RR-7):1-21.
  49. Advisory Committee on Immunization Practices. Preventing pneumococcal disease among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2000;49(RR-9):1-35.
  50. CDC. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 1997;46(RR-8):1-24.
  51. Broder KR, Cortese MM, Iskander JK, et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-3):1-34.
  52. Marin M, Guris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1-40.
  53. Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30; quiz CE32-34.
  54. Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2014-15 influenza season. MMWR Morb Mortal Wkly Rep. 2014;63(32):691-697.
  • Bexsero Package Insert (accessed 05/04/17).
  • Cortese MM, Parashar UD. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009;58(RR-2):1-25.
  • American Academy of Pediatrics. Passive immunization. In: Pickering L, Baker C, Kimberlin D, Long S, eds. Red Book: 2012 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.