General Recommendations on Immunization

1. General Recommendations on Immunization Epidemiology and Prevention of Vaccine-Preventable Diseases National Immunization Program Centers for Disease Control and Prevention Revised March 2002

2. Issues Regarding Spacing and Timing of Vaccines • Interval between receipt of antibody- containing blood products and measles vaccine • Interval between doses of different vaccines not administered simultaneously • Interval between subsequent doses of the same vaccine

3. Antibody and Live Vaccines • Inactivated vaccines are generally not affected by circulating antibody to the antigen. • Live attenuated vaccines may be affected by circulating antibody to the antigen. General Rule

4. Antibody and Live Vaccines Product Given First Vaccine Antibody Action Wait 2 weeks before giving antibody Wait >3 months before giving vaccine (See Table, Appendix A)

5. 0 months Washed red blood cells Hepatitis A (IG) 3 months Measles prophylaxis (IG) normal contact 5 months 6 months Whole blood Intravenous immune globulin (IGIV) 7-11 months Spacing of Antibody-Containing Products and Measles and Varicella Vaccines Product Interval

6. Antibody for Prevention of RSV • RSV-IG • Human • Contains other antibodies • Palivizumab (Synagis) • Monoclonal • Contains only RSV antibody

7. Simultaneous Administration General Rule There are no contraindications to simultaneous administration of any vaccines.

8. Combination Minimum Interval Two live injected All other 4 weeks None Spacing of vaccine combinations not given simultaneously

9. Spacing of live vaccines not given simultaneously • If two live parenteral vaccines are given <28 days apart the vaccine given second should be repeated. • Exception is yellow fever vaccine given <28 days after measles vaccine.

10. Interference Between Live Virus Vaccines Separated by <28 days • Retrospective cohort study of 115,000 children vaccinated in 2 HMOs during January 1995 through December 1999 • Risk of breakthrough varicella 2.5 times higher if varicella vaccine given <30 days following MMR • No increased risk if varicella vaccine given simultaneously or >30 days after MMR MMWR 2001;50(47):1058-61

11. Intervals Between Doses General Rule Increasing the interval between doses of a multi-dose vaccine does not diminish the effectiveness of the vaccine. Decreasing the interval between doses of a multi-dose vaccine may interfere with antibody response and protection.

12. Minimum Intervals and Ages Vaccine doses should not be given at intervals less than the minimum intervals or earlier than the minimum age

13. Violation of Minimum Intervals or Minimum Age • ACIP recommends that vaccine doses given up to four days before the minimum interval or age be counted as valid • Immunization programs and/or school entry requirements may not accept all doses given earlier than the minimum age or interval

14. Use of the “Grace Period” • Basic principles • The recommended interval or age is preferred • The minimum interval can be used to catch up • Grace period is last resort

15. Use of the “Grace Period” • To schedule a future appointment • When evaluating a vaccination record • Client is in the office or clinic early NO! Yes Maybe

16. Use of the “Grace Period” • Client is in the office or clinic • Client/parent is • known and • dependable • Client/parent is • unknown or • undependable Reschedule Vaccinate

17. Extended Interval Between Doses • Not all permutations of all schedules for all vaccines have been studied • Every study of extended intervals have shown no significant difference in final titer • It is not necessary to add doses or restart the series because of an extended interval between doses

18. Vaccine Adverse Reaction • Adverse reaction • extraneous effect caused by vaccine • "side effect" • Adverse event • any event following a vaccine • may be true adverse reaction • may be only coincidental

19. Vaccine Adverse Reactions • Local • pain, swelling, redness at site of injection • common with inactivated vaccines • usually mild and self-limited

20. Vaccine Adverse Reactions • Systemic • fever, malaise, headache • nonspecific • may be unrelated to vaccine

21. Live Attenuated Vaccines • Must replicate to produce immunity • Symptoms usually mild • Occur after an incubation period(usually 7-21 days)

22. Vaccine Adverse Reactions • Allergic • due to vaccine or vaccine component • rare • risk minimized by screening

23. Contraindication • A condition in a recipient which greatly increases the chance of a serious adverse event.

24. Precaution • A condition in a recipient which may increase the chance or severity of an adverse event, or • May compromise the ability of the vaccine to produce immunity.

25. Contraindications and Precautions • severe allergy to a prior dose of vaccine or to a vaccine component • encephalopathy following pertussis vaccine Permanent contraindications to vaccination:

26. Contraindications and Precautions ConditionAllergy to Component Encephalopathy Pregnancy Immunosuppression Severe illness Recent blood product Live C --- C C P P Inactivated C C V V P V C=contraindication P=precaution V=vaccinate if indicated

27. Immunosuppression • Congenital immunodeficiency • Leukemia or lymphoma • Generalized malignancy Disease

28. Immunosuppression • Alkylating agents • Antimetabolites • Radiation Chemotherapy

29. Immunosuppression • >20 mg per day • >2 mg/kg per day • NOT aerosols, topical, alternate day, short courses Corticosteroids

30. Recommendations for Routine Immunization of HIV-infected Children Vaccine Varicella MMR All others Asymptomatic Yes Yes Yes Symptomatic No No Yes Yes=vaccinate No=do not vaccinate Yes=vaccinate No=do not vaccinate

31. Vaccination of Hematopoietic Stem Cell Transplant Recipients • Includes recipients of bone marrow, peripheral cell, and umbilical cord blood transplants • Autologous or allogeneic • HSCT recipients should be revaccinated

32. Vaccination of Hematopoietic Stem Cell Transplant Recipients • Influenza vaccine at >6 months following transplant and annual thereafter • Inactivated vaccines (DTaP, Td, Hib, IPV, hepatitis B, PPV) at 12 months • MMR at 24 months if immunocompetent • Varicella and PCV7 vaccines not recommended (insufficient data)

33. Invalid Contraindications to Vaccination • Mild illness • Antibiotic therapy • Disease exposure or convalescence • Pregnancy in the household • Breastfeeding • Premature birth • Allergies to products not in vaccine • Family history unrelated to immunosuppression • Need for TB skin testing • Need for multiple vaccines

34. Invalid ContraindicationsMinor Illness • Low grade fever • Upper respiratory infection • Otitis media • Mild diarrhea • Only one small study has suggested decreased efficacy of measles vaccine in children with URI • Findings not replicated by multiple prior and subsequent studies • No evidence of increased adverse reactions

35. Screening Questions • Allergies to food or medication? • How is your child today? • Any problem after last shots?

36. Screening Questions • Problems with immune system • Anyone in household with immune problems? • Blood products in last year? • Pregnant?

37. Screening Questions • Standardized screening questionnaires are available from many state immunization programs, and from the Immunization Action Coalition website at <http://www.immunize.org>

38. National Immunization Program • Hotline 800.232.2522 • Email nipinfo@cdc.gov • Website www.cdc.gov/nip