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9. Special Situations
Updates
Major revisions to this section of the best practices guidance include the timing of
intramuscular administration and the timing of clotting factor deficiency replacement.
Concurrent Administration of Antimicrobial Agents and
Vaccines
With a few exceptions, use of an antimicrobial agent does not interfere with the
effectiveness of vaccination. Antibacterial agents have no effect on non-live vaccines. They
also have no effect on response to live, attenuated vaccines, except live oral Ty21a typhoid
vaccine and BCG vaccines. Ty21a typhoid vaccine should not be administered to persons
receiving antimicrobial agents until 72 hours after the last dose of antimicrobial (1). If
feasible, to avoid a possible reduction in vaccine effectiveness, antibacterial drugs should
not be started or resumed until 1 week after the last dose of Ty21a. Antimicrobial or
immunosuppressive agents may interfere with the immune response to BCG and should
only be used under medical supervision (for additional information, see
www.merck.com/product/usa/pi_circulars/b/bcg/bcg_pi.pdf).
Antiviral drugs used for treatment or prophylaxis of influenza virus infections have no
effect on the response to inactivated influenza vaccine (2). However, live, attenuated
influenza vaccine should not be administered until 48 hours after cessation of therapy
with antiviral influenza drugs. If feasible, to avoid possible reduction in vaccine
effectiveness, antiviral medication should not be administered for 14 days after LAIV
administration (2). If influenza antiviral medications are administered within 2 weeks
after receipt of LAIV, the LAIV dose should be repeated 48 or more hours after the last
dose of zanamivir or oseltamivir. The LAIV dose should be repeated 5 days after peramivir
and 17 days after baloxavir. Alternatively, persons receiving antiviral drugs within the
period 2 days before to 14 days after vaccination with LAIV may be revaccinated with
another approved vaccine formulation (e.g., IIV or recombinant influenza vaccine).
Antiviral drugs active against herpesviruses (e.g., acyclovir or valacyclovir) might reduce
the efficacy of vaccines containing live, attenuated varicella zoster virus (i.e., Varivax and
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ProQuad) (3,4). These drugs should be discontinued at least 24 hours before
administration, if possible. If clinically appropriate, delay use or resumption of antiviral
therapy for 14 days after vaccination. No data exist to suggest that commonly used
antiviral drugs have an effect on rotavirus vaccine or MMR.
Administration of Live Vaccines and Tuberculin Skin
Tests (TSTs) and Interferon-gamma Release Assays
(IGRAs)
Measles illness, severe acute or chronic infections, HIV infection, and malnutrition can
create a relatively anergic state during which the TST might have a false-negative reaction
(5-7). Although live, attenuated measles vaccine theoretically can suppress TST reactivity,
the degree of suppression is likely less than that occurring from acute infection from wild-
type measles virus. Screening children for tuberculosis exposure is accomplished by
medical history rather than TST testing; universal TST screening of all children is no
longer recommended, though TST screening is sometimes indicated (e.g., for persons at
increased risk for tuberculosis exposure based on medical history, or for employees for
occupational health reasons).
In a general screening situation, a provider may find that: both TST and live vaccine are
recommended; live vaccine is recommended, and TST has already been administered
more than one day previous; or TST is indicated, and the live vaccine has already been
administered more than one day previous. TST may be administered simultaneously with
live vaccines, and this is the preferred scenario. If live vaccine is indicated, and TST has
been administered more than one day previous, the live vaccine can be administered at
any interval after the TST. If TST is recommended, and the live vaccine has already been
administered more than one day previous, providers should ensure a 28 day interval, in
other words defer the TST for 28 days after vaccination. A delay in performing the TST
removes the concern of any theoretical transient suppression of TST reactivity. Some
providers choose to perform TST screening and then delay the vaccine until the patient
returns to have the TST read. This option is less favored compared with simultaneous
TST/live vaccination, because it delays receipt of the measles-containing vaccine.
While the above rationale is based on measles suppression of TST response, because of
similar concerns about smallpox vaccine and TST suppression, a TST should not be
performed until 4 weeks after smallpox vaccination (8). No data exist regarding the
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potential degree of TST suppression that might be associated with other live, attenuated
virus vaccines (e.g., varicella or yellow fever). However, in the absence of data, following
guidelines for measles-containing vaccine when scheduling TST screening and
administering other live, attenuated virus vaccines is prudent.
If the opportunity to vaccinate might be missed, vaccination should not be delayed only
because of these theoretical considerations. TST can be repeated 4 weeks after vaccination
if it is negative and concern for TB infection persists.
Interferon gamma release assays (IGRAs), such as the QuantiFERON-TB Gold In-Tube
test and the T-Spot TB test, are blood-test alternatives to the TST for
detecting Mycobacterium tuberculosis infection. The IGRA requires only a single visit to
complete and may be less effected by previous BCG vaccination (9). The same timing
guidelines that apply to the interval between a live vaccine and TST apply to IGRA (i.e., 28
days between live vaccine and IGRA if they do not occur on the same day), because IGRA
(like TST) might be suppressed through immunologic mechanisms. The potential for a
previous TST to cause boosting of future TST results should be considered in adults who
have a negative initial TST (9). Two-step testing, in which TST is repeated in a short time
frame (e.g., 1 to 3 weeks) after an initial negative TST, can illicit boosting and identify
persons whose immune response may have waned with time since infection or BCG
vaccination. For people undergoing serial screening for infection, for instance health care
personnel who are tested yearly, differentiation of positive tests due boosting versus new
infection is important (9). The 2-step test, in which the test is given twice in a short time
frame, reduces the chance of these false negatives, which are important to identify among
adults who may have had or plan to have repeat testing anyway—for example, healthcare
personnel who are tested yearly (9). Because this test consists of 2 TSTs separated by an
interval of 1-3 weeks, there is a greater window of time during which live vaccine
replication could suppress reactivity. If a live vaccine is administered, the first dose of a 2-
step TST should be delayed for 4 weeks, and if additional doses of live vaccines are
indicated thereafter, they should be delayed until the second TST is measured.
TST or IGRA reactivity in the absence of active tuberculosis is not a contraindication to
administration of any vaccine, including live, attenuated virus vaccines.
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Note that TST screening of an asymptomatic individual is clinically different than testing a
person suspected to have active tuberculosis. If a person is suspected to have active
tuberculosis, MMR vaccine is typically not administered. Active tuberculosis should be
considered severe acute illness, and moderate or severe acute illness is a precaution for
vaccination.
Although no studies have reported on the effects of MMR vaccine on persons with active
untreated tuberculosis, a theoretical basis exists for concern that measles vaccine might
exacerbate active tuberculosis (10). As a result, before administering MMR to persons with
untreated active tuberculosis, initiating antituberculosis therapy is advisable (10).
Considering whether concurrent immunosuppression (e.g., immunosuppression caused by
HIV infection) is present before administering live, attenuated vaccines also is necessary,
because immunosuppression is a contraindication to MMR vaccine.
Vaccination of Preterm Infants
In the majority of cases, preterm infants (infants born before 37 weeks’ gestation),
regardless of birth weight, should be vaccinated at the same chronological age and
according to the same schedule and using the same precautions as for full-term infants
and children. Birth weight and size are not factors in deciding whether to vaccinate a
clinically stable preterm infant (11-15), except for hepatitis B vaccination. The full
recommended dose of each vaccine should be used. Divided or reduced doses are not
recommended.
Decreased seroconversion rates might occur among certain preterm infants (i.e., those
with low birth weights [<2,000 g]) after administration of hepatitis B vaccine at birth (16).
However, by the chronological age of 1 month, all preterm infants, regardless of initial
birth weight, are likely to respond as adequately as larger infants (17-19). Infants weighing
<2,000 g born to HBsAg-negative mothers should receive the first dose of the hepatitis B
vaccine series at chronological age 1 month or hospital discharge, if hospital discharge
occurs when the infant is younger than one month of age. Preterm low-birth-weight–
infants born to HBsAg-positive mothers should receive immunoprophylaxis with hepatitis
B vaccine within 12 hours after birth. The initial vaccine dose should not be counted
toward completion of the hepatitis B series, and 3 additional doses of hepatitis B vaccine
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should be administered, beginning when the infant is aged 1 month. For mothers with
unknown HBsAg status, hepatitis B vaccine is recommended within 12 hours of birth
regardless of low-birth-weight status.
In addition to hepatitis B vaccines, hepatitis B Immunoglobulin (HBIG) is recommended
for infants whose mothers are HBsAg positive or unknown.
If the mother is HBsAg positive, HBIG must be given within 12 hours of birth. If the
mother’s HBsAg status is unknown, providers should first attempt to determine the
mother’s status. Regardless, if the infant is preterm or low birth weight, HBIG must be
given within 12 hours of birth. If the infant is neither preterm nor low birth weight,
providers have up to 7 days from birth to determine if the mother is HBsAg negative;
because the protective efficacy of HBIG declines the longer that administration is delayed,
if results are unlikely to be known by day 7 of life, HBIG should be given no later than day
7 if not earlier. If the mother is determined to be HBsAg positive, HBIG should be
administered as soon as possible (20).
If a child aged at least 6 weeks has been in the hospital since birth, deferral of rotavirus
vaccine is recommended until the time of discharge. If an infant were to be vaccinated
with rotavirus vaccine while still needing care in the NICU or nursery, at least a theoretic
risk exists for vaccine virus being transmitted to infants in the same unit who are acutely
ill and to preterm infants who are not age-eligible for vaccine (21). The rotavirus vaccine
series should not be initiated for infants aged ≥15 weeks, 0 days.
Breastfeeding and Vaccination
With 2 exceptions, neither non-live nor live-virus vaccines administered to a lactating
woman affect the safety of breastfeeding for women or their infants. Although live viruses
in vaccines can replicate in the mother, the majority of live viruses in vaccines have been
demonstrated not to be excreted in human milk. Varicella vaccine virus has not been
found in human milk (22). Although rubella vaccine virus has been excreted in human
milk, the virus usually does not infect the infant. If infection does occur, it is well tolerated
because the virus is attenuated (23). Non-live vaccines pose no risk for mothers who are
breastfeeding or for their infants. Breastfeeding is a contraindication for smallpox
vaccination of the mother because of the theoretical risk for contact transmission from
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mother to infant. Yellow fever vaccine should be avoided in breastfeeding women, because
2 cases (one confirmed, one probable) of yellow-fever vaccine associated acute neurotropic
disease (YEL-AND) have been detected in infants whose mothers were vaccinated but
were not vaccinated themselves. In both infants, vaccine virus was recovered from the
cerebrospinal fluid of the infant, but the exact mode of transmission was not precisely
determined because vaccine virus was not recovered from breast milk (24).
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.
Limited data indicate that breastfeeding can enhance the response to certain vaccine
antigens (25). There are no data to suggest that passive transfer of antibodies in human
milk can affect the efficacy of live-virus vaccines. Breastfed infants should be vaccinated
according to the recommended schedule (26-28).
Vaccination During Pregnancy
No evidence exists of risk to the fetus from vaccinating pregnant women with non-live
virus or bacterial vaccines (29,30). In spite of the lack of evidence of risk, HPV vaccine, a
non-live vaccine, is not recommended during pregnancy. Live vaccines administered to a
pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and
live bacterial vaccines generally are contraindicated during pregnancy. Women should
avoid conception for 4 weeks after vaccination with live vaccines. However, benefits of
vaccinating pregnant women usually outweigh potential risks when the likelihood of
disease exposure is high, when infection would pose a risk to the mother or fetus, and
when the vaccine is unlikely to cause harm. Recommendations for vaccination during
pregnancy are developed using ACIP’s Guiding Principles for Development of ACIP
Recommendations for Vaccination During Pregnancy and Breastfeeding (31).
Women who are pregnant should receive a dose of Tdap for the prevention of infant
pertussis whether or not they have previously received Tdap. Vaccination of the mother
generates antibodies that pass transplacentally to the fetus (32). Vaccination in the third
trimester optimizes the duration of this antibody protection until after birth. Additionally,
preventing pertussis in the mother reduces the risk that the infant is exposed to pertussis
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after birth (33). Health care personnel should administer Tdap during pregnancy,
preferably during the third trimester. If Tdap is not administered during pregnancy to
women who have never received it, it should be administered immediately postpartum.
Pregnant women who are not vaccinated or are only partially vaccinated against tetanus
should complete the primary series (34). Women for whom Td is indicated but who did
not complete the recommended 3-dose series during pregnancy should receive follow-up
after delivery to ensure the series is completed.
One dose of the tetanus vaccine series should be Tdap, if Tdap has not already been
received.
Pregnant and postpartum women are at higher risk for severe illness and complications
from influenza than women who are not pregnant (2, 35). Pregnant women have
protective levels of anti-influenza antibodies after vaccination (36,37). Passive transfer of
anti-influenza antibodies that might provide protection from vaccinated women to
neonates has been reported (36, 38-41). Routine vaccination with inactivated influenza
vaccine is recommended for all women who are or will be pregnant (in any trimester)
during influenza season.
IPV can be administered to pregnant women who are at risk for exposure to wild-type
poliovirus. This includes travelers to areas or countries where polio is epidemic or
endemic; members of communities or specific population groups with disease caused by
wild polioviruses; laboratory workers who handle specimens that might contain
polioviruses; healthcare personnel who have close contact with patients who might be
excreting wild polioviruses; and unvaccinated persons whose children will be receiving
oral poliovirus vaccine (42). Hepatitis A, pneumococcal polysaccharide, meningococcal
conjugate, and meningococcal polysaccharide vaccines should be considered for women at
increased risk for those infections (43-45). Pregnant women who must travel to areas
where there is a risk for acquiring yellow fever should receive yellow fever vaccine, because
the limited theoretical risk from vaccination is outweighed substantially by the risk for
yellow fever infection (24, 46). Hepatitis B vaccine is not contraindicated in pregnancy and
should be given to a pregnant woman for whom it is indicated (20, 47).
Pregnancy is a contraindication for smallpox (vaccinia) vaccine and measles-, mumps-,
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rubella-, and varicella-containing vaccines. Smallpox vaccine is the only vaccine known to
harm a fetus when administered to a pregnant woman. In addition, smallpox vaccine
should not be administered to a household contact of a pregnant woman (8). Women who
are pregnant should not have close contact with anyone who has recently (within the last
28 days) received the smallpox vaccine. Data from studies of children born to mothers
inadvertently vaccinated with rubella vaccine during pregnancy demonstrate rubella
antibody in unvaccinated infants. This could represent passive transfer of maternal
antibody or a fetal antibody response to vaccine virus infection in the fetus.
No cases of congenital rubella or varicella syndrome or abnormalities attributable to fetal
infection have been observed among infants born to susceptible women who inadvertently
received rubella or varicella vaccines during pregnancy (48-50). Because of the importance
of protecting women of childbearing age against rubella and varicella, reasonable practices
in any vaccination program include asking women if they are pregnant or might become
pregnant in the next 4 weeks; not vaccinating women who state that they are or plan to
become pregnant within that interval; explaining the theoretical risk for the fetus if MMR,
varicella, or MMRV vaccine were administered to a woman who is pregnant; and
counseling women who are vaccinated not to become pregnant during the 4 weeks after
MMR, varicella, or MMRV vaccination (10, 48-51). MMRV is an unlikely option for a
pregnant woman because the vaccine is only licensed through 12 years of age. Routine
pregnancy testing of women of childbearing age before administering a live-virus vaccine
is not recommended (3, 10). If a pregnant woman is inadvertently vaccinated or becomes
pregnant within 4 weeks after MMR or varicella vaccination, she should be counseled
about the theoretical basis of concern for the fetus; however, MMR or varicella vaccination
during pregnancy should not be considered a reason to terminate pregnancy (3, 10, 50).
Persons who receive MMR vaccine do not transmit the vaccine viruses to contacts (10).
Transmission of varicella vaccine virus to contacts is exceedingly rare (3). MMR and
varicella vaccines should be administered when indicated to children and other household
contacts of pregnant women (10). Infants living in households with pregnant women
should be vaccinated with rotavirus vaccine according to the same schedule as infants in
households without pregnant women.
Pregnant women should be evaluated for evidence of immunity to rubella and varicella
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and be tested for the presence of HBsAg during every pregnancy (10, 20, 52). Women
without evidence of immunity to rubella and varicella should be vaccinated immediately
after delivery. A second dose of varicella vaccine should be administered 4-8 weeks later. A
woman found to be HBsAg positive should be followed-up carefully to ensure that the
infant receives HBIG and begins the hepatitis B vaccine series no later than 12 hours after
birth and that the infant completes the recommended hepatitis B vaccine series on
schedule (20). No known risk exists for the fetus from passive immunization of pregnant
women with immune globulin preparations.
Persons Vaccinated Outside the United States
Clinicians have a limited ability to determine whether persons are protected on the basis of
their country of origin and their vaccination records alone. Vaccines administered outside
the United States generally can be accepted as valid if the schedule (i.e., minimum ages
and intervals) is similar to that recommended in the United States. There are exceptions
(providers should not accept documentation of these vaccines): Aimmugen, a hepatitis A
vaccine; and Twinrix Jr., a combination vaccine containing hepatitis A and hepatitis B
components (providers can accept the hepatitis B component but NOT the hepatitis A
component).
Only written documentation should be accepted as evidence of previous vaccination. There
is one exception, influenza vaccine, for which self-report can be accepted. Written records
are more likely to predict protection if the vaccines, dates of administration, intervals
between doses, and age at the time of vaccination are comparable to U.S.
recommendations. Although vaccines with inadequate potency have been produced in
other countries (53,54), the majority of vaccines used worldwide are produced with
adequate quality control standards and are potent. Medscape has a guide to pediatric
vaccines used in other countries, available at
https://emedicine.medscape.com/article/2500038-overview. Persons vaccinated outside
of the United States can enter the country through a number of different mechanisms.
Those seeking to immigrate to the United States may be vaccinated under the authority of
a civil surgeon or a panel physician. Some enter the United States as refugees and are
vaccinated under the authority of the Office of Refugee Resettlement, part of the
Administration for Children and Families, in the Department of Health and Human
Services.
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Adopted children’s birth countries often have vaccination schedules that differ from the
recommended childhood vaccination schedule in the United States. Differences in the U.S.
schedule and those used in other countries include the vaccines administered, the
recommended ages of administration, and the number and timing of doses.
Data are inconclusive regarding the extent to which an internationally adopted child’s
vaccination record reflects the child’s protection.
A child’s record might indicate administration of MMR vaccine when only single-antigen
measles vaccine was administered. A study of children adopted from orphanages in the
People’s Republic of China, Russia, and countries in Eastern Europe determined that 67%
of children with documentation of >3 doses of DTP before adoption had nonprotective
titers to these antigens (54).
In contrast, children adopted from these countries who received vaccination in the
community (not only from orphanages) and had documentation of ≥1 doses of DTP
exhibited protective titers 67% of the time (54). However, antibody testing was performed
by using a hemagglutination assay, which tends to underestimate protection and cannot
directly be compared with antibody concentration (55). Data are likely to remain limited
for areas other than the People’s Republic of China, Russia, and Eastern Europe.
Healthcare providers should ensure that household contacts of international adoptees are
vaccinated adequately, particularly for measles, hepatitis A, and hepatitis B (56).
Healthcare providers may use one of multiple approaches if the immunogenicity of
vaccines or the completeness of series administered to persons outside the United States is
in question. Repeating the vaccinations is an acceptable option that usually is safe and
prevents the need to obtain and interpret serologic tests. If avoiding unnecessary
injections is desired, judicious use of serologic testing might help determine which
vaccinations are needed. For some vaccines, the most readily available serologic tests
cannot document protection against infection. This best practices document provides
guidance on possible approaches to evaluation and revaccination for each vaccine
recommended in the United States (Table 9-1).
DTaP Vaccine
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Vaccination providers can revaccinate children younger than 7 years of age with DTaP
vaccine without regard to recorded doses; however, data indicate increased rates of local
adverse reactions after the fourth and fifth doses of DTaP (57). If a revaccination approach
is adopted and a severe local reaction occurs, serologic testing for specific IgG antibody to
tetanus and diphtheria toxins can be measured before administering additional doses.
Protective concentration
(a)
indicates that additional doses are unnecessary and subsequent
vaccination should occur as age appropriate. No established serologic correlates exist for
protection against pertussis.
For a child whose record indicates receipt of ≥3 doses of DTP or DTaP, serologic testing
for specific IgG antibody to both diphtheria and tetanus toxin before additional doses is a
reasonable approach. If a protective concentration is present, recorded doses are
considered valid, and the vaccination series should be completed as age appropriate.
An indeterminate antibody concentration might indicate immunologic memory but
waning antibody; serologic testing can be repeated after a booster dose if vaccination
providers or parents want to avoid revaccination with a complete series.
Alternately, for a child whose records indicate receipt of ≥3 doses, a single booster dose
can be administered followed by serologic testing after 1 month for specific IgG antibody
to both diphtheria and tetanus toxins. If the child has a protective concentration, the
recorded doses are considered valid, and the vaccination series should be completed as age
appropriate. Children with an indeterminate concentration after a booster dose should be
revaccinated with a complete series.
Hepatitis A Vaccine
Children aged 12-23 months without documentation of hepatitis A vaccination or serologic
evidence of immunity should be vaccinated on arrival in the United States (45). Persons
who have received 1 dose should receive the second dose if 6-18 months have passed since
the first dose was administered.
Hepatitis B Vaccine
Persons not known to be vaccinated for hepatitis B should receive an age-appropriate
series of hepatitis B vaccine. A person whose records indicate receipt of a complete series
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of vaccine is considered protected
(b)
, and additional doses are not needed if ≥1 dose was
administered at age ≥24 weeks. Persons who received their last hepatitis B vaccine dose at
an age <24 weeks should receive an additional dose at age ≥24 weeks. People who have
received no doses or a partial series of vaccine should complete the series at the
recommended intervals and ages.
All foreign-born persons and immigrants, refugees, and internationally adopted children
born in Asia, the Pacific Islands, Africa, and other regions of high or intermediate hepatitis
B endemicity should be tested for HBsAg, regardless of vaccination status (58). Those
determined to be HBsAg positive should be monitored for development of liver disease.
Household members of HBsAg-positive children or adults should be vaccinated if they are
not already immune.
Hib Vaccine
Interpretation of a serologic test to verify whether children who were vaccinated >2
months previously are protected against Hib bacteria can be difficult. Because the number
of vaccinations needed for protection decreases with age and because adverse events are
rare (59), age-appropriate vaccination should be provided. Hib vaccination is not
recommended routinely for persons aged ≥5 years (59).
Meningococcal Vaccine
Quadrivalent meningococcal conjugate vaccines are not routinely used in other countries
in adolescents (the United Kingdom is the exception). Unless patients have documented
receipt they should be considered unvaccinated and receive the age-appropriate doses.
MMR Vaccine
The simplest approach to resolving concerns about MMR vaccination is to revaccinate
with 1 or 2 doses of MMR vaccine, depending on age. Serious adverse events after MMR
vaccinations are rare (10). No evidence indicates that administering MMR vaccine
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increases the risk for adverse reactions among persons who are already immune to
measles, mumps, or rubella as a result of previous vaccination or natural disease. Doses of
measles-containing vaccine administered before the first birthday should not be counted
as part of the series (10). Alternatively, serologic testing for IgG antibody to vaccine viruses
indicated on the vaccination record can be considered. Serologic testing is widely available
for measles and rubella IgG antibody.
A person whose record indicates receipt of monovalent measles or measles-rubella vaccine
on or after the first birthday and who has protective antibody against measles and rubella
should receive 1 or 2 doses of MMR or MMRV as age appropriate to ensure protection
against mumps and varicella (and rubella if measles vaccine alone had been
administered). If a person whose record indicates receipt of MMR at age ≥12 months has a
protective concentration of antibody to measles, no additional vaccination is needed
unless a second dose is required for school entry.
Pneumococcal Vaccines
Many industrialized countries now routinely use pneumococcal vaccines. Although
recommendations for pneumococcal polysaccharide vaccine also exist in many countries,
the pneumococcal conjugate vaccine might not be routinely administered. PCV13 and
PPSV23 should be administered according to age-appropriate vaccination schedules or as
indicated by the presence of underlying medical conditions (43, 60).
Poliovirus Vaccine
The simplest approach to vaccinating with poliovirus vaccine is to revaccinate persons
aged <18 years with IPV according to the U.S. schedule. Adverse events after IPV are rare
(42). Children appropriately vaccinated with 3 doses of OPV in economically developing
countries might have suboptimal seroconversion, including to type 3 poliovirus (42).
Rotavirus Vaccine
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Rotavirus vaccination should not be initiated for infants aged ≥15 weeks, 0 days. Infants
who began the rotavirus vaccine series outside the United States but who did not complete
the series and who are still aged ≤8 months, 0 days, should follow the routine schedule
and receive doses to complete the series. If the brand of a previously administered dose is
live, reassortment pentavalent rotavirus vaccine or is unknown, a complete series of
rotavirus vaccine should be documented for series completion
(b)
. All doses should be
administered by age 8 months, 0 days.
Td and Tdap Vaccines
Children aged ≥7 years who are not considered fully vaccinated for pertussis should
receive Tdap vaccine. “Fully vaccinated” means at least 5 doses of DTaP before the seventh
birthday or at least 4 doses of DTaP before the seventh birthday if the fourth dose is given
after the fourth birthday. One dose of Tdap is recommended after the seventh birthday. If
additional doses of vaccine are needed, Td should be administered as age appropriate.
Varicella Vaccine
Varicella vaccine is not available in most countries. A person who lacks evidence of
varicella immunity should be vaccinated as age appropriate (3, 59).
Zoster Vaccine
In the United States, zoster vaccination is recommended for all persons aged ≥50 years
who have no contraindications, including persons who report a previous episode of zoster
or who have chronic medical conditions. For persons who do not have documentation of
receipt of zoster vaccine, the vaccine should be offered at the patient’s first clinical
encounter with the healthcare provider. Two doses of vaccine are recommended 2-6
months apart, each dose a 0.5-mL intramuscular dose. Zoster vaccination is not indicated
to treat acute zoster, to prevent persons with acute zoster from developing postherpetic
neuralgia, or to treat ongoing postherpetic neuralgia. Patients do not need to be asked
about their history of varicella or to have serologic testing conducted to determine zoster
immunity prior to administration of zoster vaccine.
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Vaccinating Persons with Increased Bleeding Risk
Providers often avoid giving intramuscular injections or choose alternative routes for
persons with bleeding disorders because of the risk for hematoma formation after
injections. In one study, hepatitis B vaccine was administered intramuscularly to 153
persons with hemophilia. The vaccination was administered with a 23-gauge or smaller
caliber needle, followed by application of steady pressure to the site for 1-2 minutes. The
vaccinations resulted in a low (4%) bruising rate, and no patients required factor
supplementation (61). Whether antigens that produce more local reactions (e.g., pertussis)
would produce an equally low rate of bruising is unknown.
When hepatitis B or any other intramuscularly administered vaccine is indicated for a
patient with a bleeding disorder, the vaccine should be administered intramuscularly if a
physician familiar with the patient’s bleeding risk determines that the vaccine can be
administered by this route with reasonable safety. If the patient receives antihemophilia or
similar therapy, intramuscularly administered vaccinations can be scheduled shortly after
such therapy is administered.
A fine-gauge needle (23-gauge or smaller caliber) should be used for the vaccination,
followed by firm pressure on the site, without rubbing, for at least 2 minutes. The patient
or family should be given information on the risk for hematoma from the injection.
Patients receiving anticoagulation therapy presumably have the same bleeding risk as
patients with clotting factor disorders and should follow the same guidelines for
intramuscular administration. If possible, vaccination could be scheduled prior to the use
of these medications, so that the patients’ risk of bleeding is not increased by their
therapeutic action.
(a) Enzyme immunoassay tests are available. Physicians should contact the laboratory performing the test for interpretive
standards and limitations. Protective concentrations for antibody to diphtheria and tetanus toxins are defined as >0.1 IU/mL.
(b) A complete series may consist of two or three doses, depending on the brand of vaccine used in the country of origin.
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TABLE 9-1. Approaches to evaluation and vaccination of persons
vaccinated outside the United States who have no (or questionable)
vaccination records
Vaccine Recommended
approach
Alternative approach
(a)
DTaP Revaccination with DTaP,
with serologic testing for
specific IgG antibody to
tetanus and diphtheria
toxins in the event of a
severe local reaction
Persons whose records indicate
receipt of ≥3 doses: serologic testing
for specific IgG antibody to
diphtheria and tetanus toxins before
administering additional doses (see
text), or administer a single booster
dose of DTaP, followed by
serological testing after 1 month for
specific IgG antibody to diphtheria
and tetanus toxins with
revaccination as appropriate (see
text)
HepA Age-appropriate
revaccination
Serologic testing for IgG antibodies
to hepatitis A
HepB Age-appropriate
revaccination and serologic
testing for HBsAg
(b)
—
Hib Age-appropriate
revaccination
—
HPV Age-appropriate
revaccination
—
Meningococcal
conjugate
(MenACWY)
Age-appropriate
revaccination
—
MMR Revaccination with MMR
Serologic testing for IgG antibodies
to measles, mumps, and rubella
Pneumococcal
conjugate (or in
some cases, both
PCV13 and
PPSV23)
Age-appropriate
revaccination
—
General Best Practice Guidelines for Immunization: Special Situations
165
Poliovirus
Revaccination with
inactivated poliovirus
vaccine
—
Rotavirus Age-appropriate
revaccination
—
Tdap Age-appropriate
revaccination of persons
who are candidates for
Tdap vaccine
—
Varicella Age-appropriate
revaccination of persons
who lack evidence of
varicella immunity
—
Zoster
Age-appropriate
revaccination
—
Abbreviations: DTaP = diphtheria and tetanus toxoids and acellular pertussis; HBsAg = hepatitis B surface
antigen; HepA = hepatitis A; HepB = hepatitis B; Hib = Haemophilus influenzae type b; HPV = human
papillomavirus; IgG = immune globulin G; MMR = measles, mumps, and rubella; PCV13 = pneumococcal conjugate
vaccine; PPSV23= pneumococcal polysaccharide vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis.
(a)
There is a recommended approach for all vaccines and an alternative approach for some vaccines.
(b)
In rare instances, hepatitis B vaccine can give a false-positive HBsAg result up to 18 days after vaccination;
therefore, blood should be drawn to test for HBsAg before vaccinating (20).
General Best Practice Guidelines for Immunization: Special Situations
166
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