TOPIC 23: Immunization Contraindications – Recognize situations in which various immunizations may be contraindicated and manage patients appropriately
OFFICIAL ABP TOPIC:
Recognize situations in which various immunizations may be contraindicated and manage patients appropriately
BACKGROUND
Vaccine contraindications are relatively uncommon but critical for pediatricians to recognize to prevent serious adverse reactions. In addition, it is important to be aware of evolving guidelines. Children without contraindications should be encouraged to receive vaccines, such as children with egg allergy who may now receive influenza vaccine without any special precautions.
VACCINE CONTRAINDICATIONS
There are two general contraindications to vaccines:
- Severe anaphylactic reaction to a prior dose of a vaccine or vaccine component
- For live viral vaccines, administration to individuals with a known severe immunodeficiency
HISTORY OF ANAPHYLAXIS TO A VACCINE
Severe anaphylactic reaction to a prior vaccine dose or component is an absolute contraindication to future receipt of that vaccine. Patients with a history of vaccine anaphylaxis should be referred to an allergist for evaluation since anaphylaxis may be triggered by different vaccine components, including:
- Vaccine antigens
- Gelatin, a stabilizer in vaccines against MMR, varicella, rabies, typhoid, zoster, and influenza, and the most common reason for anaphylaxis to MMR. Providers should be extremely cautious about administering another vaccine with gelatin.
- Egg proteins in vaccines against yellow fever, influenza, MMR, and rabies. Only yellow fever vaccines have enough egg protein to potentially cause an allergic reaction in most children with egg allergies. Children with egg allergies needing yellow fever vaccines should be referred to an allergist.
- Baker’s yeast in Hepatitis B and HPV vaccines. An allergy to baker’s yeast is a contraindication to receiving Hepatitis B and HPV vaccines.
- Latex in some vaccine vials or syringes (avoid in severe latex allergy unless benefits outweigh risks).
IMMUNOCOMPROMISED PATIENTS
Immunocompromised patients may safely receive inactivated vaccines. Live viral vaccines (e.g., MMR, varicella, rotavirus, zoster, and live influenza vaccines) are generally contraindicated in children with:
- T-cell deficiency
- Antibody deficiency
- Current chemotherapy treatment
All infants with HIV infection or perinatal exposure may receive rotavirus vaccine. However, children with HIV should not receive live influenza vaccine or MMRV. If their absolute CD4 count is above 200, they may receive the separated MMR and varicella vaccines.
Patients with complement deficiency or isolated IgA deficiency can receive live vaccines. Patients with phagocyte cell defects (e.g., chronic granulomatous disease, leukocyte adhesion deficiency) may receive live viral vaccines but not live bacterial vaccines (oral typhoid, BCG).
Any child with immunocompromise should receive the inactivated influenza vaccine rather than the live intranasal influenza vaccine.
VACCINATION OF HOUSEHOLD CONTACTS OF IMMUNOCOMPROMISED CHILDREN
Household contacts of immunocompromised children may receive MMR, varicella, rotavirus, and zoster vaccines.
Household contacts of immunocompromised children can usually receive the live influenza vaccine as well. However, the live influenza vaccine is contraindicated for contacts of children with severe combined immune deficiency and for stem cell transplant recipients with GVHD or within 2 months after stem cell transplant.
OTHER CONTRAINDICATIONS
- Pertussis-containing vaccines are contraindicated for children who developed encephalopathy with no alternative explanation within 7 days after a pertussis-containing vaccine.
- Hib vaccine is contraindicated for infants younger than 6 weeks.
- Rotavirus vaccine is contraindicated in children with severe combined immune deficiency or a history of intussusception.
- No live viral vaccines should be administered during pregnancy.
VACCINE PRECAUTIONS
Precautions are conditions that may increase the risk of a vaccine reaction or compromise vaccine efficacy. Vaccination is generally deferred when a precaution exists, but there may be circumstances where benefits outweigh risks (e.g., during disease outbreaks).
The presence of moderate or severe acute illness, with or without fever, is a precaution for all vaccines. This is because adverse effects of vaccination might be confused with progression of the illness.
Live viral vaccines such as live influenza, MMR, varicella, or zoster vaccines may be given on the same day. If they are not given on the same day, they should be given at least 28 days apart for optimal immunogenicity.
Recent history of antibody-containing products is a precaution for MMR and varicella vaccines. It is recommended to wait at least 3 months to give MMR or varicella vaccines after a child has received immunoglobulins, IGIV, or blood transfusions, with the particular recommended interval depending on the specific blood product.
The latest guidance states that patients with any severity of egg allergy (including anaphylaxis) can safely receive influenza vaccines (inactivated or live). No special precautions are needed beyond standard vaccination practices. No special observation periods are required beyond routine post-vaccination monitoring.
REFERENCES
https://www.uptodate.com/contents/influenza-vaccination-in-persons-with-egg-allergy