infectious diseases
Overview of Immunization
Restrictions, Precautions, and High Risk Groups
Restrictionsandprecautionsare conditions that increase the risk of an adverse reaction to a vaccine or that compromise the ability of a vaccine to produce immunity. These conditions are usually temporary, meaning the vaccine can be given later. Sometimes vaccination is indicated when a precaution exists because the protective effects of the vaccine outweigh the risk of an adverse reaction to the vaccine. Contraindicationsare conditions that increase the risk of a serious adverse reaction. A vaccine should not be given when a contraindication is present. For many vaccines, the only contraindication is a serious allergic reaction (eg, Anaphylaxis ) to the vaccine or to one of its components. is common in the United States. Some vaccines produced in cell culture systems, including most Influenza Vaccine , contain trace amounts of egg antigens; thus, there is concern about using such vaccines in patients who are allergic to eggs. CDC guidelines for the influenza vaccine (considered generalizable to other egg-derived vaccines) state that although mild reactions may occur, serious allergic reactions (ie, anaphylaxis) are unlikely, and vaccination with inactivated influenza vaccine is contraindicated only in patients who have had anaphylaxis after a previous dose of any influenza vaccine or to a vaccine component, including egg protein. Other recommendations for patients with a history of egg allergy include the following: Only hives after exposure to egg: Patients should be given an age-appropriate influenza vaccine. Other reactions to eggs (eg, angioedema, respiratory distress, light-headedness, recurrent emesis, and reactions that requiredepinephrineor other emergency treatment): Patients may be given an age-appropriate influenza vaccine. If using an egg-based vaccine such as inactivated influenza vaccine (IIV) or live-attenuated influenza vaccine (LAIV), the vaccine should be given in a medical setting and supervised by a health care professional who can recognize and manage severe allergic reactions. NOTE: A previous severe allergic reaction to influenza vaccine, regardless of the component suspected of being responsible for the reaction, is a contraindication to future receipt of the vaccine. Patients who developed Guillain-Barré Syndrome (GBS) (GBS) within 6 weeks after a previous influenza or diphtheria-tetanus-acellular pertussis (DTaP) vaccination may be given the vaccine if the benefits of vaccination are thought to outweigh the risks. For example, for patients who developed the syndrome after a dose of DTaP, clinicians may consider giving them a dose of the vaccine if a pertussis outbreak occurs; however, such decisions should be made in consultation with an infectious disease specialist. The Advisory Committee on Immunization Practices no longer considers a history of GBS to be a contraindication or precaution for use of the meningococcal conjugate vaccine, although it remains listed as a precaution in the package insert (seeCDC: Meningococcal Vaccines Safety Information). A significant fever (temperature of>39°C) or severe illness without fever requires delaying vaccination, but minor infections, such as the common cold (even with low-grade fever), do not. This precaution prevents confusion between manifestations of the underlying illness and possible adverse effects of the vaccine and prevents superimposition of adverse effects of the vaccine on the underlying illness. Vaccination is postponed until the illness resolves, if possible. Pregnancy is a contraindication to vaccination withmeasles/mumps/rubella vaccines,intranasal influenza vaccine(live),varicella-zoster virus vaccine, and other live-virus vaccines. The Advisory Committee on Immunization Practices recommends delaying vaccination withhuman papillomavirus 9-valent vaccineand recombinantzoster vaccineuntil after pregnancy (seeAdult Immunization Schedule by Medical Condition and Other Indication). Immunocompromised patients should, in general, not receive live-microbial vaccines, which could provoke severe or fatal infections. If immunocompromise is caused by immunosuppressive therapy (eg, high-dose corticosteroids [≥ 20 mgprednisoneor equivalent for ≥ 2 weeks], antimetabolites, immune modulators, alkylating compounds, radiation), live-virus vaccines should be withheld until the immune system recovers after treatment (the interval of time varies depending on the therapy used). Patients taking immune-suppressing drugs for any of a wide variety of disorders, including dermatologic, gastrointestinal, rheumatologic, and lung disorders, should not receive live-virus vaccines. For patients receiving long-term immunosuppressive therapy, clinicians should discuss risks and benefits of vaccination and/or revaccination with an infectious disease specialist. Live-virus vaccines should not be given to immunocompromised patients, including patients receiving immunosuppressive therapy. Patients with HIV infectionshould generally receive inactivated vaccines (eg, diphtheria-tetanus-acellular pertussis [Tdap], polio [IPV], Hib) according to routine recommendations. Despite the general caution against giving a live-virus vaccine, patients who have CD4 counts ≥ 200/mcL (ie, are not severely immunocompromised) can be given certain live-virus vaccines, including measles-mumps-rubella (MMR). Patients with HIV infection who have not received a conjugatepneumococcal vaccineor whose previous vaccination history is unknown should be given PCV15 or PCV20; if PCV15 is given, follow with PPSV23 ≥ 8 weeks after the PCV15 dose. Asplenia are predisposed to overwhelming bacteremic infection, primarily due to encapsulated organisms such as Haemophilus influenzae Type b (Hib) Vaccine : Patients are given a single dose and no booster. Meningococcal Vaccine (MenACWY): Patients are given 2 doses at least 8 weeks apart and a booster every 5 years. Dose and Administration (MenB): Patients are given a 2-dose series of MenB-4C ≥ 1 month apart or a 3-dose series of MenB-FHbp at 0, 1 to 2, and 6 months (if dose 2 was given at least 6 months after dose 1, dose 3 is not needed; if dose 3 was given < 4 months after dose 2, a fourth dose should be given at least 4 months after dose 3); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2 to 3 years if risk remains. Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweigh potential risks. Pneumococcal Vaccine : Patients are given one dose of PCV20 or one dose of PCV15 followed by a dose of PPSV23 if they have not previously received a pneumococcal conjugate vaccine or if their vaccination history is unknown. A minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition (including congenital or acquired asplenia), cochlear implant, or cerebrospinal fluid (CSF) leak. Additional doses may be given based on clinical judgment. Before solid organ transplantation, patients should receive all appropriate vaccines. Patients who have had allogeneic or autogeneic hematopoietic stem cell transplantation should be considered unimmunized and should receive repeat doses of all appropriate vaccines. Care of these patients is complex, and vaccination decisions for these patients should involve consultation with the patient's hematologist-oncologist and an infectious disease specialist. Live-microbial vaccinesshould not be given simultaneously with blood or plasma transfusions or immune globulin; these products can interfere with development of desired antibodies. Ideally, live-microbial vaccines should be given 2 weeks before or 6 to 12 weeks after the immune globulins. Live-microbial vaccines include the following: Bacille Calmette-Guérin (BCG) live (for Tuberculosis (TB) ) Cholera vaccine Ebola Vaccine None Influenza virus vaccine(LAIV) Measles/mumps/rubella vaccines(MMR) Measles virus/mumps virus/rubella virus/varicella virus vaccine(MMRV) Polio (oral preparation only; no longer licensed or available in the United States) Rotavirus vaccine Smallpox and monkeypox vaccine, live, nonreplicating Typhoid vaccine Varicella-zoster virus vaccine(no longer available in the United States) Yellow fever vaccine 