Invalid Contraindications to Vaccination : Mild Illness, Antimicrobial Therapy, Breastfeeding and Allergy That is Not Anaphylactic
Some healthcare providers inappropriately consider certain conditions or circumstances to be contraindications or precautions to vaccinations. Such conditions or circumstances are known as invalid contraindications; these misperceptions result in missed opportunities to administer needed vaccines. Some of the most common invalid contraindications are mild illnesses, conditions related to pregnancy and breastfeeding, allergies that are not anaphylactic in nature, and certain aspects of the patient’s family history.
Mild Illness
Children with mild acute illnesses, such as low-grade fever, upper respiratory infection (URI), colds, otitis media, and mild diarrhea, should be vaccinated on schedule. Several large studies have shown that young children with URI, otitis media, diarrhea, and/or fever respond to measles vaccine as well as those without these conditions. There is no evidence that mild diarrhea reduces the success of immunization of infants in the United States.
Low-grade fever is not a contraindication to immunization. Temperature measurement is not necessary before immunization if the infant or child does not appear ill and the parent does not say the child is currently ill. ACIP has not defined a body temperature above which vaccines should not be administered. The decision to vaccinate should be based on the overall evaluation of the person rather than an arbitrary body temperature.
Antimicrobial Therapy
Antibiotics do not have an effect on the immune response to most vaccines. The manufacturer advises that Ty21a oral typhoid vaccine should not be administered to persons receiving sulfonamides or other antibiotics; Ty21a should be administered at least 72 hours after a dose of an antibacterial drug.
No commonly used antimicrobial drug will inactivate a live-virus vaccine. However, antiviral drugs may affect vaccine replication in some circumstances. Live attenuated influenza vaccine should not be administered until 48 hours after cessation of therapy using antiviral drugs active against influenza (amantadine, rimantadine, zanamivir, oseltamivir). Antiviral drugs active against herpesviruses (acyclovir, famciclovir) should be discontinued 24 hours before administration of a varicella-containing vaccine, if possible. Disease Exposure or Convalescence
If a person is not moderately or severely ill, he or she should be vaccinated. There is no evidence that either disease exposure or convalescence will affect the response to a vaccine or increase the likelihood of an adverse event.
Pregnant or Immunosuppressed Person in the Household
It is critical that healthy household contacts of pregnant women and immunosuppressed persons be vaccinated. Vaccination of healthy contacts reduces the chance of exposure of pregnant women and immunosuppressed persons.
Most vaccines, including live vaccines (MMR, varicella, zoster, rotavirus, LAIV, and yellow fever) can be administered to infants or children who are household contacts of pregnant or immunosuppressed persons, as well as to breastfeeding infants (where applicable). Vaccinia (smallpox) vaccine should not be administered to household contacts of a pregnant or immunosuppressed person in a nonemergency situation. Live attenuated influenza vaccine should not be administered to persons who have contact with persons who are hospitalized and require care in a protected environment (i.e., who are in isolation because of immunosuppression). LAIV may be administered to contacts of persons with lesser degrees of immunosuppression.
Transmission of measles and mumps vaccine viruses to household or other contacts has never been documented. Rubella vaccine virus has been shown to be shed in human milk, but transmission to an infant has rarely been documented. Transmission of varicella vaccine virus has been reported very rarely, and most women and older immunosuppressed persons are immune from having had chickenpox as a child. Transmission of zoster vaccine virus to household or other close contacts has not been reported.
Breastfeeding
Breastfeeding does not decrease the response to routine childhood vaccines and is not a contraindication for any vaccine except smallpox. Yellow fever vaccine should be avoided in breastfeeding women. However, when nursing mothers cannot avoid or postpone travel to areas endemic for yellow fever in which risk for acquisition is high, these women should be vaccinated. Breastfeeding also does not extend or improve the passive immunity to vaccine-preventable disease that is provided by maternal antibody except possibly for Haemophilus influenzae type b. Breastfed infants should be vaccinated according to recommended schedules. Although rubella vaccine virus might be shed in human milk, infection of an infant is rare. LAIV may be administered to a woman who is breastfeeding if she is otherwise eligible; the risk of transmission of vaccine virus is unknown but is probably low.
Preterm Birth
Vaccines should be started on schedule on the basis of the child’s chronological age. Preterm infants have been shown to respond adequately to vaccines used in infancy.
Studies demonstrate that decreased seroconversion rates might occur among preterm infants with very low birth weight (less than 2,000 grams) after administration of hepatitis B vaccine at birth. However, by 1 month chronological age, all preterm infants, regardless of initial birth weight or gestational age are as likely to respond as adequately as older and larger infants. All preterm infants born to hepatitis B surface antigen (HBsAg)-positive mothers and mothers with unknown HBsAg status must receive immunoprophylaxis with hepatitis B vaccine within 12 hours after birth. Hepatitis B immunoglobulin (HBIG) also must be given to these infants. If the maternal HBsAg status is unknown, and the infant weighs 2,000 grams or more, HBIG must be given within 7 days of birth. If the maternal HBsAg status is positive or the infant weighs less than 2,000 grams, HBIG must be given within 12 hours of birth. Note that if the infant weighs less than 2,000 grams, the initial hepatitis B vaccine dose should not be counted toward completion of the hepatitis B vaccine series, and three additional doses of hepatitis B vaccine should be administered beginning when the infant is 1 month of age.
Preterm infants with a birth weight of less than 2,000 grams who are born to women documented to be HBsAg-negative at the time of birth should receive the first dose of the hepatitis B vaccine series at 1 month of chronological age or at the time of hospital discharge.
Allergy to Products Not Present in Vaccine
Infants and children with nonspecific allergies, duck or feather allergy, or allergy to penicillin, children who have relatives with allergies, and children taking allergy shots can and should be immunized. No vaccine available in the United States contains duck antigen or penicillin.
Allergy That is Not Anaphylactic
Anaphylactic allergy to a vaccine component (such as egg or neomycin) is a true contraindication to vaccination. If an allergy to a vaccine component is not anaphylactic or is not severe, it is not a contraindication to that vaccine
Family History of Adverse Events
A family history of seizures is a precaution for the use of MMRV vaccine. Immunosuppression may affect the decision for varicella vaccine. A family history of adverse reactions unrelated to immunosuppression or family history of seizures or sudden infant death syndrome (SIDS) is not a contraindication to vaccination. Varicella vaccine should not be administered to persons who have a family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents and siblings) unless the immunocompetence of the potential vaccine recipient has been clinically substantiated or verified by a laboratory.
Tuberculin Skin Test
Infants and children who need a tuberculin skin test (TST) can and should be immunized. All vaccines, including MMR, can be given on the same day as a TST, or any time after a TST is applied. For most vaccines, there are no TST timing restrictions.
MMR vaccine may decrease the response to a TST, potentially causing a false-negative response in someone who actually has an infection with tuberculosis. MMR can be given the same day as a TST, but if MMR has been given and 1 or more days have elapsed, in most situations a wait of at least 4 weeks is recommended before giving a routine TST. No information on the effect of varicella-containing vaccine or LAIV on a TST is available. Until such information is available, it is prudent to apply rules for spacing measles vaccine and TST to varicella-containing vaccine and LAIV.
There is a type of tuberculosis test known as an interferon-gamma release assay (IGRA). Even though this test improves upon the TST because it is less affected by previous doses of BCG vaccine and less affected by previous doses of tuberculosis diagnostic testing, it still may be affected by previous doses of other live vaccines so it is prudent to apply the same spacing rules as for TST.
Multiple Vaccines
As noted earlier in this chapter, administration at the same visit of all vaccines for which a person is eligible is critical to reaching and maintaining high vaccination coverage. Varicella vaccine should not be administered simultaneously with smallpox vaccine; and PCV13 and Menactra should not be administered simultaneously in children with functional or anatomic asplenia.
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