What illnesses contraindicate immunization?

Journal of Family Practice, July, 2005 by Marcus Plescia, Laura Leach

* Evidence summary

Public misperceptions and provider uncertainty about contraindications create missed opportunities for immunization. (1-3) The Centers for Disease Control and Prevention (CDC) defines contraindications as conditions that increase the risk of a serious reaction to vaccination. Precautions are conditions that might increase the risk of a serious reaction, or that diminish vaccine efficiency. (4) Recommendations about contraindications and precautions for vaccine administration are partially based on studies of adverse effects (see the TABLE for common situations). Complete information on the contraindications and precautions for all common vaccinations can be accessed at www.cdc.gov/mmwr/preview/mmwrhtml/rr5102al.htm#tab5.(4)

Data on vaccination risks are limited by a relative lack of experimental studies. Initial recommendations of the Advisory Council on Immunization Practices have been based on the findings of a 14-member Institute of Medicine (IOM) expert committee and are updated regularly. (5-7) The IOM committee reported that because vaccine-related adverse events occur infrequently, available randomized controlled trials were too small to detect differences in incidence. (6) Much of the data come from adverse effect surveillance systems, such as the Vaccine Adverse Event Reporting System (VAERS), to which health care providers report possible adverse effects of vaccinations.

Updated contraindications by ACIP to the initial IOM recommendations have also been based on observational reports and studies. (4) A recent Cochrane review on acellular pertussis vaccines concluded that the acellular vaccine had fewer adverse effects than the whole-cell version, but did not support any changes in contraindications or precautions. (8)

Recommendations from others

The ACIP recommendations serve as national standards and have been adopted by American Academy of Pediatrics and the American Academy of Family Physicians and are included in most standard reference texts. (4, 9)

TABLE
Contraindications and precautions for vaccine administration

SITUATION                            COMMENTS

Mild acute illness (with or          No contraindication
fever) (otitis media, diarrhea,
etc)

Breastfeeding                        No contraindication

Serious allergic reaction to         Absolute contraindication
vaccine or component (anaphylaxis)

Pregnancy                            Tetanus and influenza should be
                                       kept current
                                     No contraindication to give
                                       indicated inactivated
                                       immunizations
                                     Live vaccines are contraindicated,
                                       although no reports of adverse
                                       reactions reported

Moderate to severe illness           Temporary precaution-hold until
                                     patient improved

Encephalopathy <1 week               Pertussis immunization
after DTP or DtaP                    contraindicated

Fever >40.5[degrees] C               Avoid pertussis, but vaccination
or Hypotonic, hyporesponsive         may be appropriate during an
episode or Persistent,               outbreak
inconsolable crying >3 hours <48
hours after DTP or DTaP or
seizure <3 days after DTP or DTaP

Recipients of blood, IVIG, and       Hold live vaccines for variable
other antibody-containing products     timing depending on dose (see
                                       CDC Recommendations)
                                     Oral typhoid and yellow fever OK

Chemotherapy or radiotherapy         Give influenza
                                     Avoid others (decreased immune
                                       response)

Antibacterials                       Should not be taken with oral
                                     (live) typhoid vaccine
                                     (decreased effectiveness)

Antivirals against herpes spp        Should not be taken with live
                                     varicella vaccine (decreased
                                     effectiveness)

Postpartum anti-Rho(D)               Simultaneous rubella vaccination
                                     effective

Hematopoietic Stem Cell              See separate CDC Recommendations *
transplant recipients

Altered immune status (HIV, solid    See separate CDC Recommendations
organ transplant recipients, etc)      ([dagger])
                                     Inactivated immunizations are
                                       safe, may be less effective

Table based on general recommendations on immunization, MMWR Recomm
Rep 2002. (4)

* Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr4910al.htm

([dagger]) For HIV, www.cdc.gov/mmwr/preview/mmwrhtml/rr5108al.htm;
for others,
www.cdc.gov/mmwr/preview/mmwrhtml/00023141.htm.

REFERENCES

(1.) Wald ER, Dashefsky B, Byers C, Guerra N, Taylor F. Frequency and severity of infections in day care. J Pediatr 1988; 112:540-546.

(2.) Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manag Pract 1996; 2:18-25.

(3.) 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; 89:589-592.