Contraindications to Vaccination

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• Contraindications to Vaccination

William L. Atkinson, MD, MPH National Center for
Immunization and Respiratory Diseases
North Carolina Immunization Conference Greensboro,
NC September 18, 2007
SD 08/16/07
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To Vaccinate or Not To Vaccinate?

• All vaccination decisions should be based on the
  benefit from vaccine (immunity) versus the risk
  from the vaccine (adverse reaction)
• Risk depends on characteristics of the vaccine
  and recipient

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Contraindications and Precautions

• Contraindication
• A condition in a recipient that greatly increases
  the chance of a serious adverse reaction
• Vaccine is usually not given
• Precaution
• A condition in a recipient that might increase
  the chance or severity of an adverse reaction, or
• Might compromise the ability of the vaccine to
  produce immunity
• Vaccine may be given

MMWR 2006 55(RR-15)9-14
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Contraindications and Precautions
Permanent contraindications to vaccination

• Severe allergic reaction to a vaccine component
  or following a prior dose (applicable to all
  vaccines)
• Encephalopathy not due to another identifiable
  cause occurring within 7 days of pertussis
  vaccination

MMWR 2006 55(RR-15)9-14
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Severe Allergy to a Vaccine Component

• May be caused by the vaccine antigen, residual
  animal protein, antimicrobial agents,
  preservatives, stabilizer or other vaccine
  component
• May be local or systemic
• generalized urticaria (hives)
• wheezing
• swelling of the mouth and/or throat
• difficulty breathing
• hypotension
• shock

MMWR 2006 55(RR-15)30-31
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Severe Allergy to a Vaccine Component

• Most common animal protein allergen is egg
• contained in influenza and yellow fever vaccines
• desensitization protocols available (see annual
  influenza ACIP statement)
• Most severe allergic reactions can be prevented
  by careful screening prior to vaccination

MMWR 2006 55(RR-15)30-31
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Latex Allergy

• Dry natural rubber and natural rubber latex is
  used to make medical gloves, catheters, syringe
  plungers, vial stoppers and injection ports
• The most common type of latex sensitivity is
  contact-type (type 4) allergy
• Anaphylactic latex allergy is very rare
• Contact-type allergy is NOT a contraindication to
  vaccination with products in contact with latex

MMWR 2006 55(RR-15)31
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Contraindications and Precautions
Condition Allergy to component Encephalopathy Pre
gnancy Immunosuppression Mod or severe
illness Recent blood product
Live C --- C C P P
Inactivated C C V V P V
Ccontraindication Pprecaution Vvaccinate if
indicated except HPV vaccine. MMR and
varicella-containing (except zoster vaccine), and
rotavirus vaccines only
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Classification of Vaccines

• Live
• MMR
• Varicella/zoster
• Rotavirus
• LAIV
• Yellow fever
• Oral typhoid
• Smallpox (vaccinia)
• BCG
• Inactivated
• All others

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Vaccination in Pregnancy

• Risk to a developing fetus from vaccination of
  the mother during pregnancy is mostly theoretical
• Only smallpox (vaccinia) vaccine has ever been
  shown to injure a fetus
• All vaccines administered to adolescents and/or
  adults are pregnancy category C
• The benefits of vaccinating usually outweigh
  potential risks

except anthrax vaccine, which is category D
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FDA Pregnancy Categories
Source FDA website
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Vaccination in Pregnancy

• Inactivated vaccines
• Routine (influenza)
• Vaccinate if indicated (hep B, Td, Tdap, MPSV,
  rabies)
• Vaccinate if benefit outweighs risk (all other)
• HPV vaccine not recommended during pregnancy
• Live vaccine do not administer
• Exception is yellow fever vaccine

MMWR 2006 55(RR-2)32-33
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Pregnancy and Inactivated Influenza Vaccine

• Risk of hospitalization more than 4 times higher
  than nonpregnant women
• Risk of complications comparable to nonpregnant
  women with high risk medical conditions
• ACIP recommends vaccination for ALL women who
  will be pregnant during influenza season
• May be vaccinated during ANY trimester of
  pregnancy

MMWR 200656(No. RR-6)1-56
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Yellow Fever Vaccination in Pregnancy

• No evidence of harm to fetus from vaccination of
  mother
• Pregnant women who must travel to areas where the
  risk for yellow fever is high should receive the
  vaccine

CDC Travel Health. www2.ncid.cdc.gov/travel/
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Rubella Immunity

• Documentation of one dose of rubella-containing
  vaccine on or after the first birthday
• Serologic evidence of immunity
• Born before 1957 (except women of childbearing
  age)
• Birth before 1957 is not acceptable evidence of
  rubella immunity for women who might become
  pregnant only serology or documented vaccination
  should be accepted
• Once immune always immune

MMWR 199847(RR-8)1-57
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Live Virus Vaccination of Women of Childbearing
Age

• Ask if pregnant or likely to become so in next 4
  weeks
• Exclude those who say "yes
• For others
• Explain theoretical risks
• Vaccinate
• Routine pregnancy testing prior to vaccination is
  not recommended

MMWR 199847(RR-8)1-57
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Vaccination in Pregnancy Study 1971-1989

• Registry developed to determine the risk of
  congenital rubella syndrome (CRS) following
  rubella vaccination during pregnancy
• 321 women vaccinated within 3 months of
  conception
• 324 live births
• No observed CRS (95 CI 0-1.2)

MMWR 199847(RR-8)1-57
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Use of Tdap Among Pregnant Women

• Infants complications and death from pertussis
• Passive maternal antibody could help protect
  young infants
• Most pregnant women have little or no antibody to
  pertussis (hence no transfer to infant)
• Tdap vaccination of childbearing-age women could
  boost maternal antibody
• Concern by some experts that passive antibody
  could blunt infants response to DTaP
• No safety data among pregnant women

MMWR 200655(RR-17)18
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Use of Tdap Among Pregnant Women

• Any woman who might become pregnant is encouraged
  to receive a single dose of Tdap (Adacel only)
• Women who have not received Tdap should receive a
  dose in the immediate post-partum period
• Td generally preferred during pregnancy
• Clinician may choose to administer Tdap to a
  pregnant woman in certain circumstances (such as
  during a community pertussis outbreak)
• Pregnancy is not a contraindication for Tdap

MMWR 200655(RR-17)18
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Summary of all ACIP recommendations for
vaccination of pregnant women is avaialable on
the CDC Vaccines and Immunization website
at www.cdc.gov/vaccines/pubs/downloads/f_preg_ch
art.pdf
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Immunosuppression

• Disease
• Congenital immunodeficiency
• Leukemia or lymphoma
• Generalized malignancy
• Chemotherapy
• Alkylating agents
• Antimetabolites
• Radiation
• Corticosteroids
• Immunomodulators?

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Immunosuppression

• The amount or duration of corticosteroid therapy
  needed to increase adverse event risk is not well
  defined
• Dose generally believed to be a concern
• 20 mg or more per day for 2 weeks or longer
• 2 mg/kg or more per day
• NOT aerosols, topical, alternate day, short
  courses (less than 2 weeks)
• Delay live vaccines for at least 1 month after
  discontinuation of high dose therapy

MMWR 2006 55(RR-15)24-29
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Vaccination of Immunocompromised Persons

• Immunocompromised persons may receive
  inactivated, recombinant, subunit, conjugate and
  toxoid vaccines when indicated
• Response to vaccine may be suboptimal
• Persons vaccinated during immuno-suppressive
  therapy or radiation should be revaccinated at
  least 3 months after therapy discontinued

MMWR 2006 55(RR-15)24-29
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Vaccination of Immunocompromised Persons

• It is preferable to vaccinate an
  immunocompromised person and obtain a
  less-than-optimal response than to withhold the
  vaccine and obtain NO response

inactivated vaccines only
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Vaccination of Immunocompromised Persons

• Susceptible immunocompromised persons are at
  increased risk of adverse events following live
  vaccines
• Live vaccines may be administered at least 3
  months following termination of therapy (at least
  1 month after high-dose steroids)
• MMR and varicella vaccines should be administered
  to susceptible household and other close contacts

MMWR 2006 55(RR-15)24-29
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New Categories of Immunosuppressive Agents

• Immune mediators
• Colony stimulating factors, interferons,
  interleukins
• Immune modulators
• BCG, levamisol
• Isoantibodies
• Tumor necrosis factor inhibitors
• Effect of these agents on the safety of live
  vaccine is not certain
• Prudent to manage like high-dose steroids

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Vaccination of Asplenic Persons

• Persons with functional or anatomic asplenia are
  at increased risk of infection with encapsulated
  bacteria
• Vaccines recommended (in addition to those
  routinely recommended for age)
• Pneumococcal polysaccharide (2 doses 5 years
  apart)
• Meningococcal polysaccharide or conjugate (11-55
  years of age)
• Hib
• Administer at least 2 weeks prior to splenectomy
  if possible otherwise ASAP after surgery

Children with anatomic or functional asplenia
24-59 months of age are also candidates for
pneumococcal conjugate vaccine. MMWR 200049(RR-6)
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Persons with HIV Infection

• Persons with HIV/AIDS are at increased risk for
  complications of measles and varicella
• Increased risk of complications of influenza and
  pneumococcal disease

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Recommendations for Routine Immunization of
Persons with HIV/AIDS

• Documented Td series with booster doses every 10
  years (Tdap once)
• Annual influenza vaccination (TIV)
• Pneumococcal polysaccharide (2 doses separated by
  5 years)
• Hepatitis A and B (and other inactivated
  vaccines) if indicated
• MMR and varicella if susceptible, depending on
  level of immuno-suppression

off-label ACIP recommendation. MMWR 2006
55(RR-15)1-48
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Recommendations for Routine Immunization of
Persons with HIV/AIDS
Vaccine Varicella Zoster MMR LAIV All others
Asymptomatic Yes No Yes No Yes
Symptomatic No No No No Yes
Yesvaccinate Nodo not vaccinate
Symptomatic or laboratory evidence of severe
immuno-suppression, as defined by a low
age-specific CD4 T lymphocyte count or a low CD4
T lymphocyte count as a percentage of total
lymphocytes. See specific ACIP recommendations
for details.
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Vaccination of Hematopoietic Stem Cell Transplant
Recipients

• Recipients of bone marrow, peripheral cell, and
  umbilical cord blood transplants following bone
  marrow ablation
• Antibody titers to vaccine-preventable diseases
  decline 1-4 years after HSCT if the recipient is
  not revaccinated
• HSCT recipients should be routinely revaccinated
• Household and other close contacts should be
  immune

MMWR 200049(RR-10)
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Vaccination of Hematopoietic Stem Cell Transplant
Recipients

• Inactivated influenza vaccine beginning 6 months
  following transplant and annual thereafter
• Inactivated vaccines (DTaP, Td, Hib, IPV,
  hepatitis B, PCV, PPV) at 12 months
• MMR and varicella (not zoster) at 24 months if
  immunocompetent

MMWR 200049(RR-10) MMWR 200655(15)
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Vaccination of Persons with an Acute Illness

• The decision to administer or delay vaccination
  because of a current or recent acute illness
  depends on severity of symptoms and etiology of
  the illness
• All vaccines may be administered to persons with
  minor acute illnesses
• Vaccination of persons with a moderate or severe
  acute illness should be deferred until the
  symptoms improve
• moderate or severe has never been defined
• clinical judgment required

MMWR 2006 55(RR-15)14
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Blood Products and Vaccination

• Inactivated vaccines are generally not affected
  by circulating antibody to the antigen
• Inactivated vaccine may be given any time before
  or after a blood product
• Live attenuated vaccines may be affected by
  circulating antibody to the antigen
• Exception the response to zoster vaccine does
  not appear to be affected by circulating
  varicella antibody

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Timing of Blood Products and Live Virus
Vaccination
Action Wait at least 2 weeks before giving blood
product Wait at least 3 months before giving
vaccine (see table in General Recommendations)
Product given first Vaccine Blood Product
MMWR 2006 55(RR-15)6-8
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National Center for Immunization and Respiratory
DiseasesContact Information

• Telephone 800.CDC.INFO
• Email nipinfo_at_cdc.gov
• Website www.cdc.gov/nip
• Vaccine Safety
• http//www.cdc.gov/od/science/iso/