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Morbil dity aqd Morta,llty Weqkiy RJaport

Recommendations and,Reports’ February 8* 2002 / Vuf. 51/ No. RR-2

RecommendcHionq of the Advisory ~,~mrni~~ee

on Im,~unizcHion Pructicqsl Pi-
and the American Academy of Fclmil$ ,~~~~~~~~ns (AAFP)
-__. __ .-.. 1-1


C O N T E N ,l S
T h e M M W R s e r i e os f p u b ti c a ti o ni s p u b l i s h eb dy th e
T i m i n ga n d S p a c i n go f l m m u n a b i o l o g i c..............................
i E p i d e m i o l o g Py r o g ra mO ffi c e ,C e n te rs fo r D i s e a s e G e n e ra l P r i n c i p l e fo s r V a c c i n eS c h e d u l i n g......................... i:
C o n tro l a n d P r e v e n ti o n(C D C ), U .S . D e p a rtm e n ot f S p a & g o f M u l ti p l e R o s e s o f th e S a m e A n ti g e n ................ 2
H e a l tha n d H u .m a nS e rv i c e sA,tl a n ta ,G A 3 0 3 3 3 . S i m L i l fa n e a u~sd m ~ n i s fra tj a n............................................
N a n s i m u i fo n e o u As ~ ~ ~ ~ s f~ ~ o n ...................................... 5
S p a c i n go f A n fi b o d y - C o n i ri i n i n gP r o d u c ts a n d V a c c i n e s ... .. 6
S U G G E S T E D C Z T A T rO J U C n tc rc h a n g e o b i l oi tyf V a c c i ~ s fro m ‘D i ffe re n tM o n u fa c fu re rs 8
C e n te rsfo r D i s e a sCeo n tro la n d& e v e r & o n G. e n e ra l L a p s e dV a c c i n a fi a nS c h e d u l e............................................ 8
re c o m m e n d a ti o n so n i m m u n i z a ti o n : re c o m - U n k n o w n o r U n c e ri a i riV a c c i n a ti o n .S ta tu s......................... 8
m e n d a ti o n s o f th e A d v i s o ry C o m m i tte e 0 5 C o n tra i n d i c a ti o n as n d P r e c a u ti o n s....................................... 8
Im m u n i z a ti o Pnr a c ti c easn dth e A m e r i c a An c a d e m y V a c c i & A d m i n i s tra ti o n...................................................... 11
o f F a mi l y P h y s i c i a nMs .M W R 2 0 0 2 31 W O .m -2 ): In fe c ti o n Q n fra f~ a n d S te ri l e T e c h n i q u e...........................
[i n c l u s i vpea g en u m b e rs ]. RecammendeR d & fe s o f In j e c ti a n a n d N e e d l e L e n g th .... ::
& tti p l e V a c c i n a ti o n ......................................................
s 12
J e t i n j e c ti o n.................................................................... 13
M e fh b d s fo r A i k & a fi n ~ D i s c o m fo rt a n d P a i n A s s o c i a te d
C e n te rs fo r D i s e a s eC o n tro l a n d P r e v e n ti o n
w i th V o c c i n a fi o n........................................................... 13
J e ffh e I?
r K a p l a n M, .D ., M .P .H . N a n & a n d & d . V a c c i n a i i o nP r a c ti c e s .................................. 13
D i w ti P r e v e n fi n g ,A d v e rs R e e a c ti o n s.......................................... 14
M a n a g i n gA c u te V a c c i n eR w c fi o n t ................................. 14
ID a v i d W . F l e m i n gM, .D . Q c c u p a ti o n o Sl a fe fy R e g u l a ti o.....................................
ns 15
D&y D i m w rfo r S c i m c ar d P u t% H e a k b” : S to ra g e a n d H a n d l i n.d gf Im m u n a b i o l ;o g i c ........................
s 15
/, S p e c i a lS i tu a ti o n s.............................................................. 16
D i x i e E . S n i d e Jr, r,, M .D ., M & H . C o n c u rre n tl yA d m i n i s fe ri n gA n ti m i c ro b i a lA g e n ts
A s s o c i aDki r c c tw fi r S t& m e _ a n d V a c c i n e s............................................................... 16
fu b e rc o l a s i s .S c r e e n i na gn d S k i n T e s tR e a c fi v ................ i fy 16
Ep i d e &lo g y P r o g ra m O ffi c e S e v e rb A i l e rg y fo V a c c i n eC o m p o n e n ts ............................ 16
L a te x A l l e rg y ................................................................... 17
S te p h e nB ; T h a c k e Mr, .D ., M .S c . V o c c i n a fi o na f P r e m a tu re In fa n ts .. ................................... 18
. I.. . :.D i m c to r j’ B r e a s f-F e e d i n ag n d V a c c i n c i fi o n...................................... 18
V a c c i n a ti o n‘D u ri n g P r e g n a n c y......................................... 18
V o c c i n o fi o n,e f J n fe rn a fi o ~ a l tyA d o p te d C h i l d re n.............. ?9
A l te re d l m m u n ~ c o m ~ fe ~ c ~ .-. ........................................ 22
V a c c i n o fi o no f H e rn a fo p o i e fi cS te m C e l l T ra n s p l a n t
R e c i p i e n ts .................................................................... 23
V a c c i n o fi n gP e rs a n sw i th B b e d i n D g i s o rd e rs
a n d P e m n s R e c e i v i n gA n fi c o a g u .l a n Tt h e ra p y .............. 2 3
V a c c i n a ti o nR & o rd s ...........................................................
C o n s e nto t V a c & a fe ...................................................... ff
P r o v i d e rR e c o rd s............................................................. 24
P a fi e n fs ’P i trs o n ti l ~ K e c ~ s...............................................
R e g i s tri e s........................................................................ 4:
R e p o rfi n gA d v e rs e E v e & A fte r V a c c i n a ti o n........................ 24
V a c c i n eIn j u ry C o m p e n s a ti o nP r o g ra m ............................ 25
B e n e fi ta n d R & k C o m m u ri i c o ti o n..................................... 25
V a c B n o i i o riP r o g ra m s ........................................................
V a c c i n ei n fo rm a ti o n S o u rc e s.............................................. it
N a ti a ,n a l l m ti u n i z a fi o n ~. n fo rm o ti o nH o fi i n e .................... 28
C D C ’s N a ti o n a l l m m u n i z a i i a n& o g ra m ..........................
M o rb i d i fy a n d M a ~ a ~ ~ ~ ‘~ e e k R~ ey p & .............................. 2
A m & c o n - A c a d e m y o f P e d i a fri c s{ A A P ) ............................
Am & o n A c a d b m y d F a m i fy P h y s i c i a n (sA A F P } .............. ft
Im m u n i z ;a ti o n ’A c ti oCn o a l i ti o n ........................................
N a ti o n a l N & w o r k fa r i m m v i ri z a fi o nIn fo rm a ti o n ............. ;:
V a c c i n eE. d u c a fi o nC e n te r ............................................... 28
l n s ti i i te fa r V a c c i n eS a E e fyi .... . ........................................ 28
N o ti o n 4 P a rtn e rs h i pfo r tm m u n i z a ti o n............................ 28
S ta te a n d L o c a lX e a l fl h D e p o rtm e n ts ............................... 28
R e fe re n c e s......................................................................... 29
A b b re h o ti o n s U s e d i n T h i s P u b l i c a ti o n............................... 34
D e fi n i ti o n sU s e d -i nT h i sR e p o ti .......................................... 34
C o n ti n u i n g E d u c a ti o En x a m i ti o ti i m ................................. CE-1
Vol. 51 I RR.2 Wxommandations and 33qwts 1

Recommendafions of: the Advbry Commiftee an ~mm~~izufion Practices

(ACIP) and the American Academy of ~FggiEpr Fhy&ians (AAFP)
Prepared by
William L. Arkinson. M.D.’
larry K. Pickering, M.D.2
Benjamin Schwara, M.D.1
Bruce G. Wtniger, M.D.’
Jdhn K. &u&r, M.DP
John C. Watson, M.D.’
fImmmieationSmrierr Divirion
aOfice ofhe Director
‘&pi&mialb and Sn~*Uance Dittirian
Nutxa*J Immm~tion Pwgram
‘DiviJion ofRar&ic Dizcam

This report iz a ret&m of Gencrd Rccommm&d~~ ot2 lmmunizahbn and, up&es the .lP94 statement by the Advimry
Comkttee otf Immun;p;at;on Pructic~ (ACIPj &DC. General recommendations on immunization: recommendations of
the Advhory Committee on Immunization Pracrices [ACIP]. MMWR 1994;43mo. RR-S&1-38). Tbeprinc$~J &nges
in&h cxp~.~~&n of tbr disczusionaf vacchtitm spkng and timing rec~mmcn&titmr flir wuccizu~ths rrdmnistered by an
incorrect route, inform&m regarding need&he injectiion t&ho&~ u~ccir~tion of chitirex adaptedfrom count&s outside the
United States,timing of live-vina vaccination and tubercr+s screening q&ion sfthe d&cl&m a*rd t&s of
and precautions “garding va&tatzhs, and &titnz of a directory of immunikatiun WOWC%FTheserecommendationsare ?wt
comprebenshejh ea& vckne. The most rrrmt AC.@ rrcommenh&ms fur
adrh spe~$%vrlcrinc should be consultedfir ad&-
tional a&z&. This report, ACIP ~~mme&&cm.s fir each vaccine, czn4 other isfomtionngardipg itimutition CSPIbe
acessedat CZXX Ntionai Immunivrtiort Prognzm wtbsxte dt http://wwwcdkguuh~ (access#d&t&r 1 I, 2001).

Inf roducfion proved quality of life and~productivity, and prevention of death.

SocieJ benefa inch& cre+ion and maintenance of herd im-
This report provides technical guidance regarding common
munity against communicable diseases,prevention of disease
immunization concerns for health-care providers who admin-
outbreaks, and reduction in health-care-related costs. Vacci-
ister vaccines to children, adolescents, and adults. Vaccine rec-
nation risks range from common, minor, and local adverse
ommen.dations are based on characteristics of the e&us to rare, sew&e, and life-ehreacenitrg conditions. Thus,
immunobiologic product, scientific knowledge regarding the recommendations for iminunization practices balance scien-
principles of active and passive immunization, the epidemiol-
tific evidence.ofbenefits for eacfi person and to society against
ogy and burden of diseases(i.e., morbidity, mortality, costs of
the potential posts and risksof vaccination programs.
treatment, and loss of productivity), the safety of vaccines, Standards for child and adolescent immunization practices
and the cost analysis of preventive measures asjudged by pub-
and standards foradult immunization practices (1,2) have been
lic health officials and specialists in clinical and preventive published to assist with implementing vaccination programs
medicine. and maximizing their benefits. Any person or institution that
Benefits and risks are associated with using al!
provides vaccination servic@ should adopr these standards to
immunobiologics. ‘No vaccine is completely safe or 100% ef-
improve immunization delive,ry and protect children, adoks-
fective. Benefits of vaccination include partial or complete cents, and adults from vaccine-preventable diseases.
protection against the consequences of infection for the vacci- To maxim& the benefits of vaccination, this tepoct,pro-
nated person, as welI as overall benefits to society as a whole. vides general information regarding immunobiologics and
Beneftts include protection from symptomatic illness, im- provides.practic;rl guidelines concerning vaccine administra-
tion and technique. Ta minimize risk from vaccine adminis-
tration, this report dekeates situations that warrant
Immunization ServicesDiiision, Lance E. Rodewald,M.D., Dictctor. precautions or contraindication to using a vaccine. These rec-
ommerxlations are intended for use in the United States be-
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2 MMWR February 8.2002

cause vaccine availability and use, as well as epidemiologic cell-mediated immunity md neutralizing antibodies (e.g.,
circumstances, differ in other countries. Individual circurn- live attenuated virus vaccines) usually can induce prolonged,
stances might warrant deviations from these cecommenda- often lifelong immunity, even if antibody titers decline as
tions. The relative balance of benefits and risks can change time progresses (5). Subsequent exposure to infection usu-
as diseases are controlled or eradicated. For example, be- ally does not iead to viremia but to a rapid anamnestic
cause wild poliovirus transmission has been interrupted in antibody response.
the United States since 1979, the only indigenous CWLSof Approximately 90Yi93% of recipients of a single dose of a
paralytic poliomyelitis reported since that time have been parenterally administered live vaciine at the recommended age
caused by live oral poliovirus vaccine (ON). In 1997, to (i.e., measles, mump, rubella [MMRJ, varicelh, and yellow
reduce the risk for vaccine-associated paralytic Polio (VAPP), fever),:deve&opprotective antibody within 2 weeks of the dose.
increased use of inactivated potiovirus vaccine (IPV) was However, because a limited ProPortion of recipients (&o/b) of
recommended in the United States (3). In 1999, co elimi- MMR vaccine fail to respond to one dose, a second dose is
nate the risk for VAPR exclusive use of IPV was recomminded recommended to Provide another opportunity to develog im-
for routine vaccination in the United States (4, and OPV munity (1). The’ majority of persons who fail to respond to
subsequently became unavailable for routine use. However, the first dose of&?fMR respond to a second dose (3. Similarly,
because of superior ability to induce intestinal immunity approximately 20% of persons aged ~13 years to respond
and to prevent spread among close contacts, QPV remains to the first dose of varicella vaccine; 99% of recipients
the vaccine of choice for areas where wild poliovirus is still seroconvert after two doses (8).
present. Until worldwide eradication of poliovirus is accom- The recommended chiidhood vaccination s&&de is re-
plished, continued vaccination of the U.S. population against vised annually and is published each January. Recommen-
poliovirus will be necessary dations for vaccination of a&.4escents and adults are revised
less frequently, except for influenza vaccine recommenda-
tions, which are published annualiy. Physicians and other
Timing and Seating health-care providers .should always ensure that they are
of Bmmunebiel,ogrics following the most up-to-date schedules, which are avail-
abie from CDC’s National Immunization Program website
General Principles at http:l/ (accessed October 11, 2001).
for Vaccine Scheduling
Optimal response to a vaccine depends on multiple fac- Spacing of M
tors, including the nature of the vaccine and the age and
immune status of the recipient. Recommendations for the
of the Same A@igen
age at which vaccines are administered are influenced by V&ination providers are encouraged to adhere as closely
age-specific risks for disease, age-specific risks for compfica- as possible to the recommended childhood immunization
tions, ability of persons of a certain age to resPond to the schedule. Clinicai~studies h&e reported that recommended
vaccine, and potential interference with the immune re- ages and intervals between doses of multidose antigens pro-
sponse by passively transferred maternal antibody. Vaccines vide optimal protection or have the best evidence of efft-
are recommended for members of the youngest age group cacy. Recommended vaccines and recommended intervals
at risk for experiencing the disease for whom efficacy and between doses are Provided in this report (Tab& I).
safety have been demonstrated. In certain circumstances, administering doses of a
Certain products, in&ding inactivated vaccines, toxoids, multidose vaccine at shorter than the recommended inter-
recombinant subunit and polysaccbaride conjugate vaccines, vals might be necessary. This -can occur when a person is
require administeringtsg22doses for development ofan adequate behind schedule and needs to be brought up-to-date as
and persisting antibody response. Tetanus and diphtheria tox- quickty as possible or when international travel is impend-
oids require periodic reinforcement or booster doses to main- ing. In these situations, an accelerated schedule can be used
tain protective antibody concentrations. &conjugated that uses intervals-between doses shorter than those recom-
polysaccharide vaccines do nor induce T-ceil memoryr, and mended for routine vaccination. tithough the effectiveness
booster doses are not expected to produce substantially in- of ail accelerated schedub has not been evaluated in clini-
creasedprotection. Conjugation with a protein cartier improves cal trials, the Advisory Committee on Immunization Prac-
the effectivenessof polysacchatide vaccines by inducingT~elf- tices (ACIP), believes that the immune response when
dependent immunologic function. Vaccines that stimulate both accelerated intervals are used is acceptable and will lead to
adequate protection. The accelerated, or minimum, inter-
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Vol. 511 RR-2 Recommendations and Rwxwts 3

.~ --..- ~~~~ .-~

- ~

TABLE 1. Recommended and minimum ages end intervals between vaccine dgees”,
Vsccfne Recommend&l aas Mtt@mumags Rt?conwnand8d Minimum
and dase number far thb do&e for thls dose intetyil io next cfosa Interval to next dose
Hepatilis B1+ Birth-2 mos Birth 1-4 mos 4Wks
tiepatilis 8.2 l-4 mos 4 weeks Z-17 ma5 8WkS
Hepatitis 831 6-18 mos 6 moss -
Diphtheria and tetanus 2 mos 6WkS 2mos 4 wks
toxoids and acellular
pertussis (DTaP)l
DTaP2 4 mos 10 wks 2 mos 4 wks
DTaP3 6 mos 14 wks 6-12 mas 6 masp’
DTaP4 15-18 mos 12mos’ 3YW 6 mos*
DTaPS 4-6YB 4yrs
Haemophilus infhrenzae, 2ltlOS SWkS 2 mos 4wks
type b (Hib)W+
Hib2 4rnos 10 wks P-mos 4wk.s
Hib3H 6mos 14 wks 6-S mos Etwks
Hib4 12-l 5 mos t2rnos
Inactivated poliovirus 2 mos 6 wks 2 mos 4wks
vaccine (IPV)l
IPV2 4rnos IOwks 2-14 mw 4wka
IPV3 6-l 8 mos 14 wks 3*5 yrs 4wks
lPV4 4-6YS 18wlcs
Pneumococcal conjugate 2 mos 6 wks 2 mos 4wks
vaccine (PCV)l*
PCVZ 4 mos 1owks 2 mo8 4wks
PCV3 6 mos I4wke 8 mof3 8Wks
PCV4 12-l 5 mds 12 mos
Measles, mumps, and 12-l 5 mosm 12 mos 3-5 yrs 4wks
rub&a (MMR)l
MMR2 4-6YB 13mos
VariceHa’*’ 12-15 mos 12 mos 4 wks*” 4 WksF
Hepatitis Al 22 yrs 2yrs 6-10mosr 6 mast
Hepatitis A2 ,530 mos 30 mos
hlluenzam - 6 mosq
pneumacocaal 2 yrs
polyssccharkfe (PPV)i
PPV2 7 y&M
Combinationvsccinesere available.Using llcensfrdcomblnrtl b!-
nalton vecclnesfokchiXdhood itnmunizstion:reao(nmendatiab
the Am&an Academyaf Family Pbysiciene(AMP). M & W ii
oldest ego far eny of the indivldealcompanenhi;lbe minirn~.
A camMneUan hepatitis EHlb tina is a&able (Comv#, mehufadured tp Mar& Vwair16 Dhk?on). 31s iraocine ahoukl not be adtninistaredto infsnts agsd ~6 weeks
becauseof tlw wibcornponent
Hepatitis83 shauld be adminietemd28 weeks after Hepatitk 52 end 16 wwks after HepatitisBl , and it BhDuldnot be adminie&@dbeforeqe B months.
Cakndar mpnttu.
The minimuminlenwl between DTaP3end DTaP4is recommendedto b6‘;rcsmonUIaHowevijr,DTaP4does ?ot Wad
. $ be
~. rq%Med
_-i ifadminltieredrg
.. . . . monthe
. alter OTaP3.
. _
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A MMWR .pebruatv 8.2002

vals and ages chat can be used for scheduling catch-up vat- ules can decrease the incidence of such reactions without
cinations is provided in this report (Table 1). Vaccine doses adversely af&cting immunity
should not be administered ac intervals less than these mini-
mum intervals or earlier than the minimum age.* Sirn~l~u~e~~~ ~~rn~~~~r~~~o~
In clinical practice, vaccine doses occasionally are admin- Experimental evidence and extensive clinical experience
istered at intervals less than the minimum interval or at have strengthened tbr: scientific basis for administering vac-
ages younger than the minimum age. Doses administered cines simuhaneously (i.e., during rhe same office visit, not
too close together or at too young an age can lead to o sub- combined in ~the same syringe). Simultaneously adminis-
optimal immune :response. However, administering a’dose tering all vaccines for which a person is eIigible is critical,
a limited number of days earlier than the minimum inter- inc[uding for childhood vaccination programs, because si-
val or age is unlikely to have a sub&antially negative effect multaneous administration increases the probability that a
on the immune response to that dose. Therefore, ACIP rec- child will be fully immunized at the appropriate age. A
ommends that vaccine doses adminisrered ,54 days before study conducted dzlring a measles outbreak demonstrated
the minimum interval or age be counted as valid.’ How- that approximately one third of measles cases among un-
ever, because of its unique schedule, this recommendation vaccinated but vaccine-eligible preschool ,chiIdren could have
does not apply to rabies vaccine (9). Doses administered been prevented if MMR had been administered at the same
ti days earlier than the minimum interval or age should visit when another vaccine was administered (12). Simulta-
not be counted as valid doses and should be repeated as neous administratiun a&o is critical when preparing for for-
age-appropriate. The repeat dose should be spaced after the eign travel and if uncertainty exists that a person wiIl return
invalid dose by the recommended minimum interval as for fiirther doses of vaccine.
provided in this report (Table 1). For example, if H’ophiluJ Sirn~~neo~~ya~i~i~~~ most widely used live and
infliLcnzut type b (Hib) doses one and two were adminis- inactivated vaccines have produced seroconv&sion rates and
tered only 2 weeks apart, dose two is invalid and,shouid be rates of adverse &actions similar to those observed when the
repeated. The repeat dose should be administered 24 weeks v&cine.s are administered separately (1.51G). Routinely ad-
after the invalid (second) dose. The repeat dose would be ministering all vaccines simultaneously is recommended for
counted as the second valid dose. Doses administered 25 children who are rhe appropriate age to receive them and for
days before the minimum age should be repeated on or whom no specific contraindications exist at the time of the
after the child reaches the minimum age and 24 weeks after visit. Administering combined MMR vaccine yields results
the invalid dose. For example, if varicella vaccine were ad- similar to administering individual mea&t, mumps, and ru-
ministered at age 10 months, the repeat dose would be bella vaccines at different sites. Therefore, no medial basis
administered no earlier than the child’s first birthday. exists for administering these vaccines separately for routine
Certain vaccines produce increased rates of local or systemic vaccination instead ofthe preferred MMR combined vaccine
reactions in certain recipients when administered too frequently (6)i).Admin&z&gseparate antigens would result in a delay in
(e.g., adult tetanus-diphtheria roxoid [Td], pediatric protection,for the deferred components. Response to MMR
diphtheria-tetanus toxoid [DT], and tetanus toxoid) (10,fl). and varicella vaccines administered on the same day is identi-
Such reactions are thought to result from the formation of cal to vaccinu‘administered a month apart (17). No evidence
antigen-antibody complexes. Optimal record keeping, main- exists that OPV interferes with parenterally administered live
taining patient histories, and adhering to recommended sched- vaccines. QpV can be administeted simultaneously or at any
interval be&e or after parenteral live vaccines. No data exist
* During measlesourbreaks, if casesarc occurring among infanrs aged cl2 regarding the immunogenic&y of orai Ty2la typhoid vaccine
months, measlesvaccination of infants asyoung as6 months can beundertaken when administered concurrently err within 30 days of live vi-
as an outbreak control measure. However, doses admimktered SCa~ cl2
months should nor be counted as part of the series (So~ CDC. Me&s, rus vaccines. In the absence of such data, if typhoid vaccina-
mumps, and rubella - vaccine use and strategiesfor elimination of measles, tion is warranted, it should not be delayed because of
rubella, and congenital rubella syndrome and control of mumps: administration of virus vaccines (38).
recommendations of the Advisory Conunitre~ an lmmuniaarionPnrcticez
[ACIP]. MMWR 1998;4J[No. RR-8]:1-57). Simuftaneottslyadr~te~i~&,p~e~~ococ pc&mxhatide
t In centin situations, local or state rquiremmts might ma&ace that daw of vaccine and inactivated influenza vaccine elicits a satisfactory
seltaed vaccines be administered on or afrer specific ages.-For Cxunpe~ a antibody responsewithout increasing the incidence or severity
rhoolentryrequinzment might not accept rdoseofMMRatrviccll~~ne
administeredb&c the child’s first birthday. ACIP recomrn~nds&at Physti~ls ofadverse reactions (19). Simultaneously administering pneu-
and other health-care providers comply with local or stacc vaccinarion mococcal polysaccharide vaccine and inactivated influenza
requirements whm scheduling and administer@ vaccines.
Vol. 51 I RR-2 Retqommendatiqns and,Reports 5

vaccine is strongly recommended for all persans for whom marketed as TriHII3iP [manufactured by Aventis Pasteur])
both vaccines are indicated. is FDA-approved for mixing in the same syringe. This vac-
Hepatitis B vaccine administered tiith yellow fever vaccine cine should not be used for primary vaccination in infants
is as safe and immunogenic as when these -vaccines are admin- aged 2, 4, and 6 months, but it can be used as a booster
istered separately (20). Measles and yellow fever vaccines after any Hib vaccine.
have been administered safely at the,same visit and without
reduction of immunogenicity of each of the components N~n~jmwl~~M~,ws ~~rnj~j~~~~~~
(21.22). Inactivated vaccines do -not interfere with the immune
Depending on vaccines administered in the first year of life, response to other inactlvatcd vaccines or to live vaccines.
children aged 12-l 5 months can receive ~7 injections during An inactivared vaccine can be administered either simulta-
a single visit (MM% varicella, Wib, pneumococcal conjugate, neous&y or ar any time before or after a different inactivated
diphtheria and tetanus toxoids and aceltuktr pertussis [DTaIQ vaccine or live vaccine (Table 2).
WV, and hepatitis B vaccines). To help reduce the number of
injections at the 12-15-month visit, the XPV primary series
can be completed before the child’s first birthday. MMR and TABLE 2. OWetim+ for sp@$ng of live and inactivated
varicella vaccines should be administered at the,same visit that antigens
AIlt&M Roi;oinm~ndod~mtnlmum interval
occurs as soon as possible on or after the first birthday The com4hation between doses
majority of children aged 1 year who have received two 3 inactivated Ncnq can be administered simutteneously
(polyribosyhibitol phosphate-meningococcal outermembrane or at any interval behveen dosee
protein [PRP-OMPJ) or three (PRPtetanus [PRP-T], diph- Jnaotiveted and jive None; can be adminiete~ed simihneouety
or at any interval beWen doses
theria CRM,s, [CRM, cross-reactive material] protein conju- 22 iivo parenter&’ +wesk minimum fnterval. if not administered
gate MbOC]) prior doses of Hib vaccine, and three prior doses simuHan*Wry
l Live omivaccinas~(e:g., 7y2ra t~vaeeine, oral patiovaeeirte)can be
of DTal? and pneurnococcal conjugate vaccine have developed admir$itered ~rn~~e~~~y or &Itany Entarvalbefore or after inaetivatcU
protection (23,24). The third (PRP-OMP) or fourth @RR-T, or live p&ente@ vaccines.
HbOC) dose of the Hib series, and the fourth doses of DTaP
and pneumococcal conjugate vaccines are critica in boosting The immune response ta one Jive-virus vaccine might be
antibody titer and ensuring continued protection (24-26). impaired if administered within 30 days of another five-
However, the booster dose of the Hib or pneumococ&l con- virus vaccine (Z8,Zsa).Data are limited concerning inrer-
jugate series can be deferred until ages 15-18 months forchil- ference between live vaccines. In a study conducted in two
dren who are likely to return for future visits. The fourth dose U.S. healthmaintenance organizations, persons who received
of DTaP is recommended to be administered at ages 15-18 varicella vaccine c3cB days after MMR vaccination had an
months, but can be administered as early & age 12 months increased risk ‘far vari,celIa vaccine failure (i.e., varicella dis-
under certain circumstances (25)* For infants at low,risk for ease in a vaccinated person) of2Sfold compared with those
infection with hepatitis B virus (i.e., the mother tesred nega- who received varicefla vaccisle before or $0 days after MMR
tive for hepatitis B surface antigen [HBsAgJ at the time of (30). In contrast, a 1999 stndy determined that the re-
delivery and the child is not of Asian or Pacific Islander de- sponse to yellow her vaccine is not affected by monova-
scent), the hepatitis B vaccine series can be completed at any lent measles vaccine administered 1-27 days earlier (21).
time during ages6- 18 months. Recommended spacing ofdoses The effect of nonsimuhaneously administering rubella,
should be maintained (Table 1). mumps, variceha, and yellow fever vaccines is unknown.
Use of combination vaccines can reduce the number of To minimize the po~erttiab risk for interference, pzttenter-
injections required at an of&e visit. Licensed combination ally administered live vaccines not administered on the same
vaccines can be used whenever any components of the com- day shotrId be administered 24 weeks apart whenever pos-
bination are indicated and its other components are not sible (Table 2). If parent&ally administered live vaccines
contraindicated. Use of licensed combination vaccines is are separated by <4 weeks, she vaccine administered sec-
preferred over separate injection of their equivalent compo- ond should not be counted as a valid dose and should be
nent vaccines (27). Only combination vaccines approved repeated. The repeat dose should he administered 2;4 weeks
by the Food and Drug Administration (FDA) should be after the last, invahd’dose. Ye&w fever vaccine can be ad-
used. individual vaccines must never be mixed in the ?ame ministered at any rime after single-antigen measles vaccine.
syringe unfess they are specifically approved for mixing by Ty2la typhoid vaccine and parenteraI live vaccines (i.e.,
FDA. Only one vaccine (DTaP and PRP-T Hib vaccine,

6 MMWR February 8; 2002

MMR, varicella, yellow fever) can be adminisrered simul- should be delayed until the passive antibody has degraded
taneously or ac any interval before or afrer each orher, if (Table 3). Recommended intervals between receipt of vari-
indicated. ous blood prdducts and measles-containing vaccine and
varicella vaccine are listed in this report (Table 4). If a dose
Spacing of Antibody-Containing of parenteral live-virus vackine (except yellow fever vaccine)
is administered after art anribody-containing product but
Products and Vaccines at an interra shorter than, recommended in this report, the
Live Vaccines vaccine dose shorild be repeared unless serologic testing in-
Ty2la typhoid and yellow fever vaccines can be adminis- dicates a response to the vaccine. The repeat dose or sero-
tered at any time before, concurrent with, or after adminis- logic testing should be performed after ,the interval indicated
tering any immune globulin or hyperimmune globulin (e.g., for the antibody-containitig product (Table 4).
hepatitis B immune globulin and tabies immune globu- Although passively acquired antibodies can interfere with
lin). Blood (e.g., whole blood, packed red blood cells, and the response to rubetia vaccine, ttre low dose of anti-Rho(D)
plasma) and other antibody-containing biood products glob&n administered to .postpartum women has not been
(e.g., immune globulin, hyperimmune globulin, and in- demonstrated the tcsp&se to ‘the RA27f3 strain ru-
travenous immune globulin [IGIV’J) cm inhibit the im- bella vaccine @$)., Be”ause of the imporrance qf rubella im-
mune response to measles and rubclia, vaccines for 23 months munity among’childbearing-age women t&,35), the
(31,321. Th e eff ect of blood and immurie globulin prepa- postpartum vaq!ination of rubella-susceptible women with
rations on the response to mumps and variceila vaccines is rubella or MMR vaccine dould not be delayed because of
unknown, but commercial immune globulin preparations receipt of anti-Rho(D) globulin M any other biood prod-
contain antibodies to these viruses. Blood products avail- uct during the iasr trir&ster, of pregnancy or at delivery.
able in the United States are unlikely to contain a substan- These”women should be vaccinated immediately afcet de-
tial amount of antibody to yeltow fever vaccine vi+s. The livery and, if.possible, tested ti mont-hs later to ensure
length of time that interference with parenteral live va+- immunity to rubella and, if necessary, to measles (6j.
nation (except yellow fever vaccine) can persist after the an- Intcrference’can &cur if administering an antibody-
tibody-containing product is a function of the amount of containing product becomis necessary after administering
antigen-specific antibody contained in the product (31- MMR, its individnaJ components, or varicdla vaccine. Usu-
33). Therefore, after an antibody-containing product is re- all% vaccine virus ~epkation and stimulation of immunity will
ceived, parenteral lie vaccines (except yellow fever vaccine) occur l-2 weeks afier ~&nation. Thus, if the interval be-

TABLE 3. Guidelineq for administering antibody-contatMng products’ and vaccines

Simultaneous adMinl8tmtiOa
Cambiwition R~~~m~ Werval b&men doses
Antibody-ccntaining products and inactivate&antigen Nom; ran bs ~~i~~~ stm&eneo~~& at different sites or at any
lime bolwe%h i-&x&s
Antibody-containing products and live antigen Should not be administ+rad s~muftaneously.+ II simultaneous
admin’Wation of maaslaa-tieWr+lng vaccine or varkella v&Me is
unavoldabfe, adndnisllr at diffarimt &es and rev&Mate ar test for
seroumvemion after &a ra&nmended in&al (see Table 4)
Nonsimultaneous edministratIon
Product administered
First Second Ro~~rn~d~.mi~m~m interval between &tee
Antibody-conkaining products InactiWed eptigen None
Inactivatedantigen Antiiy-containing products None
Antibody-containing producls Live antigen Dase-relatedf‘
Live antigen Antibody-contaking products 2 week5
* Blood productscontaining substanlfff amoWs of inimoneglobulin, inch&g intramuscular arid intqenous *k&nl+nef$obu~in, specili hy&Wb%muneglobulin
(e.g, hepatitis B immune globulin, tetanus immune gfobuh, variceffa zo&er itimune gkhulin, ?r!d mbfacdmmune glob+&+), whole #ood, p-red eels,
plasma, and platetet prxxlucts.
+ Yellow fever and oral TjQl a typhoid vaccines are exceptions to these recommendations;.7he~e~!ii attenuated v$xiriea q3n be administered at any time
before, afler,or sirtiultaneousiy with an antfbody-contair$ng product without 5ubst~~i~~d~~~asf~ the antibody r++ponse,
f The duration of in&forence al antibody-containing products witti%e immune response to the mea.sfes comporisnt of meeties-containing vaccine, and
possibly varicella vaccine, is dose-related (see Table 4):
Vol. 51 I RR9 Recommendations and Reiwts 7

TABLE 4. Sulcroestsd intervals between admintstratian of antibody-containing -. woducts for different fndications and msasles-
containing v&&in6 and varicetla vaccine’
Dose, including mg Fkwommended Interval
lmmui%ogio&ultn G IlgGYkg be&F& m&&es or varfcalia
ProdueMndication body weight” wxinstion (months)
Respiratory syncytief virus immune gfobulin 15 m@lcgintmrnu&ularly (iM) None
(IG) monoclonai antibody (Synagis’“)’
Tetanus IO 250 units ($0 mg IgG/kg) IM
Hepatitis A IG
Contact prophylaxis 0.02 mL& (3.3 mg 19-g) IM
International travel 0,06 mblrg (10 mg IgG/kg] IM
Hepatitis B IG 0.06 ml& (10 mg IgGikg) IM
Rabies fG 20 IV/kg (22 mg IgO/@) IM
Varicella IG 125 unitsll0 kg (20-40 mg @Z&g) IM,
maximum 626 units
Measles prophylaxis IG
Standard (i.e., nonimmune-compromised) contact 0.23 ml&g (40 mg IgGIkgj IM 5
lmmunocompromised contact 0.50 mLIkg (80 mg IgG/kgJ 1M 6
Blood transfusion
Red blood cells (RBCs), washed 10 mUkg Regligible IgGJIcg None
intravenously (IV)
RBCs, adenine-saline added 10 mUkg (10 mg IgG&g) N
Packed RSCs {hematocrit 65%)’ 10 mvkg (60 mg IgGNg) IV
whole blood (hematocdt 35%50%)5 IO mtJlrg (60-100 rng ig@kgf IV
Ptasmalplatelel pmducts 10 ml&f (160 mg IgG/kg) IV
Cylomegalovirus intravenous immune 150 mgkg maximum
globulin (IGlV)
Respiratory syncytial virus prophylaxis IGlV 750 wW 9
Replacement therapy for immune deficiencies1 3-00 mgntg Iv1 8
Immune thrombocytopenic purpure roo~rngkg IV 8
Immune thrombocytopenic purpura l,OWmghg IV 10
Kawasaki disease 2 grams&g IV 11
l This table is not intended for determining the correct indications and dcg@ee for using antibody+onbMng j@&@cts,Unvaccinated persons mfght not be
fully protected against mea&s during the entire reccrnimended ipt@vaf, hndaklitionai &s&of irnrnuns”~lo~~~ 0) measles vaccine migfrtbe indii~
after measles exposure. Concentrations of nieaslee antibody in an immune gbbulii prepsration fan vaty ~~‘~~~u~~s tot. Rates of antibody cleamnce
after receipt of an immune globulin preparation might va!y also.~~Recommandedinte~~.~,~~bl~~ ~~QQIan ?Mimatad half-life of 30 days for
passively acquired antibody and an observed interference with fhe immune response to m-es, mqe for S mm after a dose of 60 mg IgGIkg
(Sourcez Mason W, Takahashi M, Scfmeidet’T. Persisting passively aaqtnred me%sieeantibody ~lowi~~~rna gfebubn fhempy for Kawasaki &ease
and responseto live virus vaccination [Abstraot 3111.Pr&6entedat ttie 32 meetfng of the kters&nce Cwnterenceon Antimicrobial Agents and Chemotherapy,
Los Angates, California, October 1992).
t Contains antibody only to respiratory syncytial virus.
’ Assumes a serum tgG concenlration of 16 mg/mL.
’ Measles and varicella vaccinafion is recommended #orchildren with asymptomatic or mildly symptoma@ human i~munodeficienoy virus (HIV) infection but
is contraindicated for persons with severe immunosuppxession from HIV or any Othei immonoeuppressiva diso@r.

tween administering any of these vaccines and subsequent lntactivuied V&c&ms

administration of an antibody-containing product is ~14 Antibody-rcoatainittg products interact less with inacti-
days, vaccination should be repeated after the recommended vated vaccines, ro~oids, recombinant subunit, and polysac-
interva1 (Tables 3,4), unless serologic testing indicates that charide vaccines than v&h Eive vaccines (3c;), Therefore,
antibodies were produced. administering inactivated vaccines and toxoids either simuf-
A humanized mouse monoclonal antibody product taneously with or at any interval before, or after receipt of an
(palivizumab) is available for prevention of respiratory syn- antibody-containing product should not substantially im-
cytial virus infection among infants and young chiidren. pair development of a protective antibody response (T&te
This product contains only antibody to’ respiratoty syncy- 3). The vaccine or toxoid and antibody preparation should
tial virus; hence, ia will not interfere,with immune response be administered,at different sites by using the standard rec-
to live or inactivated vaccines.
?,. MMWR February 8,2002

ommended dose. Increasing the vaccine dose volume or However, longer-&an-recommended intervals berween
number of vaccinations is not indicated or recommended. doses do not reduce final antibody concentrations, although
protection might not be attained until the recommended
Interchangeability of Vaccines number of doseshas bcsn zadministered. An interruption in
the vaccination schedule does not require restarting the entire
from Different Manufacturers
series of a vaccine or toxoid or the addition of extra doses.
Numerous vaccines are available from different manufac-
turers, and these vaccines usualIy are not identical in anti-
gen content or amount or method of formulation. Unknowrxor Ctncertain
Manufacturers use different production process* and their Vacdnation St4W S
products might contain different concentrations of antigen Vaccination providers frequently encounter persons who
per dose or different stabifizers or preservatives. do not have adequate documentation of vaccinations. Pro-
Available data indicate that infants who receive sequen- viders should only accept tieitten, dated records as evidence
tial doses of different Hib conjugate, hepatitis B, and hepa- ofvaccination, w;th the exception of pneumococcal polysac-
titis A vaccines produce a satisfictoryantibody response after charide vaccine (43), self-reported doses of vaccine without
a complete primary series (37-40). All brands. of Hib con- written documentation should not be accepted. Althuugh
jugate, hepatitis B,s and hepatitis A vaccines are interckange- vaccinations should nac be postponed if records cannot be
able within their respective series. If different brands qf Hib found, an attempt Ko, locate missing records should be made
conjugate vaccine are administered, a total of three doses is by contacting previous health-care providers and searching
considered adequate for the primary seriesamong infants. for a personally held record. If records cannot be located,
After completing the primary series, any Hib conjugate vac- these persons shodd be considered susceptible and should
cine can be used for the booster dose at ages 12-18 months. be started on the age-appropriate vaccination schedule. Se-
Data are limited regarding the safety, immunogenicity, rologic testing f& immunity is an’alternative to vaccination
and efficacy of using acellular pertussis (as DTaP) vaccines for certain” antigens (e.g., measles, mumps, rubena, vari-
from different manufacturers for successivedoses of the per- Celia, retat&, diphtheria, kepatitis A, hepatitis B, and po-
tussis series. Available data from one study indicate that, liovirus) (see Vaccination of Internationally Adopted
for the first three doses of the DTaP series, one or two doses Children).
of Tripedia* (manufactured by Aventis Pasteur) followed by
Infanrixe (manufactured by GlaxoSmithKIine) for the re-
maining doses(s) is comparable >to three doses of Tripedia
with regard to immunogenicity, as measured by antibodies Gomraindications and precautions to vaccination dictate
to diphtheria, tetanus, and pertussis toxoid, and filaenen- circumstances when vaccines will not be administered. The
tow hemagglutinin (41). However, in the absence of a clear majority ofcontmindicativns and precautions are temporary,
serologic correlate of protection for pertussis, die relevance and the vaccination can beadministered later, A contraindica-
of these immunogenicity data for protection against per- tion is a cvndition in a’recipient thar increases the risk For a
tussis is unknown. Whenever feasible, the same brand of serious adverse reaction. A vaccine will not be administered
DTaP vaccine should be used for all doses of the,vaccina- when a contraindication is present. For example, administer-
tion series; however, vaccination providers might not know ing infksenza vaccine to a person with an anaphylactic aMergy
or have available the type of DTaP vaccine previously ad- to egg protein could cause serious illness in or death of the
ministered to a child. In this situation, any DTaP vaccine recipient.
should be used to continue or complete tke series. Vaccina- National standards for pediatric immunization practices
tion should not be deferred because the brand used for pre- have been estaSii&ed and: include true contraindications
vious doses is not available or is unknown (2.542). and precautions to vaccination {Table 5) (I), The only true
contraindication applicable to all vaccines is a history of a
Lapsed Vaccination Schedule severe allergic reaction after a prior dose of vaccine or to a
Vaccination providers are encouraged to administer vac- vaccine constiruent (unless the recipient has been desensi-
cines as ctose to the recommended intervals as possible. tized). Severely immunocompromised persons should nor
receive live vaccines. Children who experience an encepkal-
1 The exceptionis rhe two-dose hep&ir B vaccinrrion series for ado&cents opathy 17 days &er administration of a previous dose of
aged 114.5 yews. Only R~~ombivaxHB* (Merck Vaccine Division) should diphtheria and teranus toxoids and whole-cell pertussis vac-
be used in drisschedule. Engerk-Be is not approved by FDA far t&schedule.
Vol. 51 I RFK2, Recommfx&lions and Rerxxts 9

TABLE 5. Guide to contraindications ,and precwtibrrs*. to commonly used VaCCine§

Vaccine Yrue canCrain&aCiowand prectiutldns’ Mntrue (vaocines can be admlnister~
General for all vaccines, induding ContraindicatJons MlJd soule Ulnks with or without fever
diphtheria and tetanus ioxoids Setiotp allergic reaction (e.g., anaphylaxis) after a MJJdta muderate,Joosf reaction (J-e.,sweling, redness,
and acellular pertus& vaccine previous vaccine dose soreneas);~luw-grade M madefate fever after previous
(DTaP); pediatric diphtheria- Serious allergic readhn (e.g,. anaphyfaxis) to a vaccine d&SC
tetanus toxo*kJ(DT); aduN tetanus- component
diphtheria toxoid CTd); inactivated kick of previous physical examination in well-appearing
poliovirus vaccine (IPV); measles- Precautions person
mumps-rubella vaccine (MMR); Moderate or severe acute JlJnesswith or without fever Current antJrnJcrobialtherapy
IiaemophUus influenzao type b Convalescent phase o? itlness
vaccine (Hib); hepatitis A vaccine;
hepatitis B vaccine; varicetla Premature birth (hepatitis 6 vaccine% an exception In
vaccine; pneumococcal conjugate certaJn.circumetances)+
vaccine (PCV); lnlluenza vaccine; Recent exposure to an infechous disease
and pneumacoecal polysaccha. History of pemcillin aJfergy, other nonvaccJne aJiargies,
ride vaccine (WV) r~~‘wi~ allergies, receiving allergen extract
DTaP ContralndlcatJons Temperature c? <4g.tJ”G, Jusslness or mild drowsbtess
Severti alletgk rciaclbn after a previous dose or to a after a previous dose of dJphtheda IoxoJUWanus
vacdne component toxoid+MussJs vacckte (DTP)/MaP
Enoephalopathy (e.g. coma, decreased Jevel of Fan@ h&tory ‘ol seizures+
consciousneris;‘profonged s&zuree) within 7 days of Family histery of st+en Infant death syndrome
adminlstratlon of prevkxis doeeof DTP or DTaP
Family hJJtory of an adverse event after DTP or DTaP
Progressive naurulogi~disorder, iniuding infantile adminis~ado~
spasms, uncontrolled epiJepq prcgresehre encephaJ-
apathy. deter DTaP until neumlogio status darkd and StabJe r$suroJogJoconditJons (e.g,, cerebral patsy, well-
stabBed, centrolled ccnvulsions. developmental delay)
Fever of >4d.S*C #J hours sfter vacdnatfon with a
pnwious dose of DTP or DTaP
Cobapse or shock-like state @,e.,hypotonJ0
hyporesponsJveepisode) 548 hours after receJvJnga
p~i~us dose of DTPrDTaP
S$e ~3 days of receiving o previous dose of DTPi

PersJstent,inconsolable crying lasting 13 hours 98

hours after receiving a prevJous dose of DTP/DTaP
Modmate or severe acute illness with or without fever
DT, Td ContralndlcatJans
Severe allergic raaotion after a prevloua dose or to a
vaodnri oornrjaneni
GuilJaiMarr6 &ndrome $6 weeks after previous dose
of tetanus toxoJ&ontaJJng VaGdne
Moderate or severe acute illnasc with or without fever
IPV ContraJndlcallens
Severeallergk tea&on to prevJous dose or vaccJne
Moderate or severe acute iJlnasswith or without fever
MMR’ Contthdfcatlans Positfva tubarqfin skJn test
Severe alrergio resetion after a previous dose or to a SJJull~ie~lpi TEI skin testJng*,
vaccine ccmponant
Pregnancy of recJpient’s,mother or other close or
Known sevens immunodeiieiency (e.g., hematoiosio ho&&old contact
atxJ soki tumors: oongenilaf bnmunodefidency: Jon@
term immunosuppmsshre therapy,” or severely Recipiam is chbd-beadng-age female
symptomatic human immunodatlciency virus [HIVI lmmunod&ient famiiy member or housahoid contact
infection) A~rnpt~~~ or mildly symptomatic HIV Jofaction
Precautions AWgy fo eggs
Ftecant &l t months) receipt of antibody-containing
blood product (spedfic Intervat depends on produ@
History of thrombocytopeni‘a ar thrombocytopenJc
Moderate or severe acute illness with or without fever
_,.. February 8.2002

TABLE 5. (Cunrinucsd) Guide to wntraindications and precrautions* to CWftIt’tanly. ~&~~.VWX&W~S

Vaccine True contraihclkaikms and pmcautlons’ Un#rua~@aceinas can ba admlntaterad)
f-fib Cont~atndlcatlons
Severe aiiafgic reaction alter a previous dose or to a
vaccine component
Age ~6 weeks
Moderate or severe acute illness with or without fever
Hepatitis B Contratndtcation Pregnancy
Savera, aliqic reaction after a previous dose or fo a Autoi~rrnme disease (e.g., systemic lupus
vacdns compomnf etythama~osi~ or fbeumatoid arthritis)
infant ‘weighing *2,OaO gramst
Moderate or eevere acute illness with or without fever
Hepatitis A ContraIndicatIona
Sever6 allergic reaolion after a previous dose or to a
vaccine component
Moderate or aever@acute Illness with or without fever
Variceiia~ Contraindlcationa Pregnancy of recipient’s mother or othr dose or
Severe aiiergfc reaction af{er a previous dose or to a humid contact
vaccine component frnrn~~~~~t iamily member or household contactn
Sub&&i supression of cetiufar immunity kymp~amatic br mildiy symptomaHc HIV infection
Pregnancy Hirmeral fmmunodeAciency (e.g., agammaglobuiinemia)
Rec8nt (all mmihn) recntpl of antibody-oontalning
blood product [specific intenkai depends on products
Moderate or severe acute illness with or without fever
PCV Contralndtcattcm
Severe allergic reaction after a previous dose or to a
vaccine cxrmponent
Moderate or severe acute iiine$s with or wilhoutfever
influenza Contraindka~ion Nanwvera (e+ contact) allergy to latex or thierosal
Severti aiiergic reaction to previous doee or vaccine Gencufreirt admfnisiration of caumadin or amlnophyi-
component, ind,uding egg pr@ein iifbe
Moderate or savers acute illness with or without fever
PPV Contraindto~tion
Severe allergic reaction afler a previws dose or toa
vaueina component
Moderale or aevere acute itlnssr with of without fever
* Eventsor conditienafirted aa
f Hep&s EtvacclnaUonshoufd be deferredfor
infanrsbirth.Vaccinationcan commelya at ch
admlntsteredat or soon after birth regard&s

l * Substantiallyimmunosc~ppresslve steroid dose Is con~kWed tobe J weekaof daffyrer~efptof 20 mg or2 m$kg bo$y weight of ptedrirparwror equivalent.
tf Mensleswednation can suppresstuberculin reactivitytempnratil . fvleish&oM$ning vacdne can beadminMared on the ~a:daytitubercuiin testing cannot
rmnd until after the da of MMFt vaccination,the test%XoulZlbe~kK,wl~aftcrrthtt\twrbria#an.ifanuigentneedBxlststoekb,leatdosowHhthe
un r&ndfng thel reactivity m Yght be reduced by the vaccine.
@ See tuxt for details.
99 If a vaccinoeexperiencesa presumedvaa%e-related rash 7-25 days after vaccination,avokf dire?3contact with imIWnoWmpromisedpersons for the dufntion of the rash.

tine (DTP) or DTaP not attributable to another identifi- A precaution, is- a condition in a recipient that might in-
able cause should not receive further doses of a vaccine that crease the risk far a serious adverse reaction or that might
contains pertussis, Because of the theoretical risk to the compromise the ability of the vaccine to produce immu-
fetus, women known to be pregnant should not receive live nity (e.g., adrninist+n~ tieasks vaccine to a person with
attenuated virus vaccines (see Vaccination During passive immunity to measles from a blood transflsion). In-
Pregnancy). jury could result, or a person might experience a more se-
Vol. 51/ RR-2 Recorypendatiops and Repori~ I1

vere reaction to the vaccine than would have otherwise been serocanversiun (739/o} to the measles component of MMR
expected; however, the risk for this happening is less than vaccine among children &ith minor, afebrile upper-respira-
expected with a contraindication. ‘Under normal circum- tory tract infections ($2). Therefore, vaccination should not
stances, vaccinations should be deferred when a precaution be deIayed because of the presence of mild respiratory tract
is present. However, a vaccination mighr be indicated in illness or other acute illness with or without fever.
the presence of a precaution because the benefit of protec- Persons with moderate :or severe acute illness should be
tion from the vaccine outweighs the risk for an adverse re- vaccinated as soon as they have recovered from the acute
action. For example, caution shouiif be exercised in -phase of the illness, This precaution avoids superimposing
vaccinating a child with DTaP who, within 48 hours of. adverse effects of the vaccine on the underlying ilfness or
receipt of a prior dose of DTP or DTaP, experienced fever mistakenly attributing a manifestation of the underlying
140.X (105F); had persistemS inconsolable crying for 23 illness to the vacci,ne.
hours; collapsed or experienced a shock-like state; or had a Routine physical examinations and measuring tempera-
seizure $9 days after receiving the previous dose of DTP or wea are not prerequisites ‘for vaccinating in&us and chil-
DTal? However, administering a pertussis-containing vac- dren who appear to be healthy. Asking the parent or guardian
cine should be considered if the risk for pertussis. is in- if the child ‘$ ilt’anc! then postponing vaccination for those
creased (e.g., during a portussis outbreak) (255. The presence with moderare to severe illness, or proceeding with vacci-
of a moderate or severe acute illness with or without a fever nation if no, contn&dieations exist, are appropriate proce-
is a precaution to administration of all vaccines. Other pre- dures in childhood immuniz&an programs.
cautions are listed. in this report (Tit& 5). A fiimily history of seiiums or other central nervous system
Physicians and other health-care providers might inap- disorders is not a conrraindication to administration of per-
propriately consider certain conditions or circumstances to tussis or other vaccines. However, delaying pertussis vaccina-
be true contraindications or precautions to vaccination. This tion for infants and children with a history of previous
misconception resuits in missed opportunities to ,adminis- seizure& unril the‘&ild”s neurologic sratus has been assessed
ter recommended vaccines (44). Likewise, physicians and is prudent. Dertussis vaccine should not be administered to
other health-care providers might fait to understand what infants with evolving nrarrologic conditions until a treat-
constitutes a true contraindication or precaution and might ment regimen has been e&b&shed and the condition has
administer a vaccine when it should be withheId. This prac- stabilized (2s).
tice can result in an increased risk for an adverse reaction to
the vaccine. Conditions often inappropriately regarded as
contraindications to vaccination are listed in this report (Xable
5). Among the most common are diarrhea and minor upper-
respiratory tract illnesses (including otitis media) withor,with-
out fever, mild to moderate Iocal reactions to a previous dose
of vaccine, current antimicrobial therapy, and the convales- Personsadministering vaccines should fotlow necessarypre-
cautions to minimize risk for spreading disease.Hands should
cent phase of an acute illness.
be washed with soap and water or cleansed with an alcohol-
The decision to administer or delay vaccination because of
a current or recent acute illness depends on the severity of based waterless antiseptic,hand rub between each patient con-
tact. Gloves are not required $&en administering vaccinations,
symptoms and the etiology of the disease.All vaccines can be
unless persons admitistecing vaccinations are likely to come
administered to persons with minor acute illness (e.g., diar-
rhea or mild upper-respiratory tract infection with or without
into cuntacr with Potentiallj infectious. body fhrids or have
open lesions on their hands. Syringes and needles used for
fever). Studies indicate that f%lure to vaccinate chikiren~~ith
injections must beste;riIe and disposable to minimize the risk
minor illnesses can seriously impede vaccination efforts (45-
of contamination. A separate needle and syringe should be
47). Among persons whose compliancewith medical care can-
used for each injection, Changing needles between drawing
not be ensured, use of every opportunity to provide
vaccine from a vial at&injecting it into a recipient is unneces-
appropriate vaccinations is crirical.
The majority of studies support the safety and efhcacy of sary. Dif%erent vaccines’shouid never be mixed in the same
syringe unless specifically licensed for such use.
vaccinating persons who have mild illness (4&5U). For ex-
Disposable needles and syringes shodd be discarded in
ample, in the United States, ~97% of children with mild
labeled, puncture-proof containers to prevent inadvertent
illnesses produced measles antibody after vaccination (51).
needle-stick injury or reuse. Salety needles or needle-free
Only one limited study has repoited a lower rate of
injection devices also can reduce the risk far injury and
12 MMWR February 8,2002

should be used whenever available [see Occupational Safety If aspiration results in blood in the needle hub, the needle
Regulations). should be withdrawn and-a new site should be selected.
~&MS @er~ons ugedi < 12 ~o&w). Among the ma-
Recommended Routes of injection jority of,infa&, the anterolateral aspect of the thigh
provides the largest muscle mass and is therefore the rec-
and Needle Length
ommended site for injection. For the majority of infants, a
Routes of administration are recommended by the manu-
7/g-l-inch; 22-2%gauge ueedle is sufficient to penetrate
facturer for each immunobidogic. Deviation from the rec-
muscle in the ~infsnt’s thigh.
ommended route of administration might reduce vaccine
roddfers and Sk@r t%&hm lpersons aged ~12
efficacy (5.334) OK increase local adverse reactions (55-57).
monfha-I8 yys}~ The deltoid muscle can be used if the
Injectable immunobiologics should be administered where
muscle mass is adequare. The needle size can range from 22
the likelihood of local, neural, vascular, or tissue injury is to 25 gauge and from 718 to I ti inches, on the basis of the
limited. Vaccines containing adjuvants shouid be injected
size of the muscle. For toddlers, the anteroiateral thigh can
into the muscle mass; when administered subcutaneously
be used; but the needle should be longer, usually 1 inch.
or intradermally, they can cause lo& irritation, induration,
Adults &msoswuged :> ?8 yew@. For adults, the del-
skin discoloration, inflammation, and granuloma formation.
toid muscle is rtlfommended &r routine intramuscular vac-
Subcutaneous Injections cinations. The anterolateral tvgh can be used. The suggested
Subcutaneous injections usually are administered at a 45- needle size is l-II/t inches and 22-25 gauge.
degree angle into the thigh of infants aged <l2 months and Jntradepaf Jsnjectioqs
in the upper-outer triceps area of persons aged 212 months.
Intradermal inj&lms are usualIy administered on the volar
Subcutaneous injections can be administered into the up- sucfacit of the forearm. With the bevel facing upwards, a s/8-
per-outer triceps area of an infant, if necessary A S/g-inch,
3/4-inch, 25-27-gaqgsneedle ian be inserted into the epider-
23-25-gauge needle should be inserted into the subcuta-
mis at an angIe parallel to the long axis of the forearm. The
neous tissue.
needle should be inserted so tkat rhe entire bevel penetrates
Jntramusculcw Injections the skin and the injected sol&on raises a small bleb. Because
intramuscular injections are administered at a go-degree of the small amounts of antigen used in intradermai vaccina-
angle into the anteroiateral aspect of the thigh or the det tions, care must be taken not to inject the vaccine subcutane-
toid muscle of the upper arm. The buttock shouid not be ously because it can result in a s&optimal immunologic
used for administration of vaccines or toxoids because of response.
the potential risk of injury to the sciatic nerve (58). In ad-
dition, injection into the buttock has been associated with
decreased immunogenicity of hepatitis B and rabies vat- If 12 vaccine preparations are administered or if vaccine and
tines in adults, presumably because of inadvertent subcu- an immune glob&n preparation am administered simulta-
taneous injection or injection into deep fat tissue (53,53). neousiy, each ‘preparation should be administered at a differ-
For all intramuscular injections, the needle should be long ent anatomic site” If 22 injectiuns must be administered in a
enough to reach the muscle mass and prevent vaccine from single limb, the thigh is usuaily the preferred site because of
seeping into subcutaneous tissue, but not so long as to in- the greater muscle mass; the injeltions should be sufficiently
volve underlying nerves and blood vessels or bone (%,GO- separated (i.e., 2) inch) so that any local reactions can be dif-
62). Vaccinators should be familiar with the anaromy of f&en&ted (55,63). For o&r children andadults, the deltoid
the area into which they are injecdng vaccine. An individual muscle can bc used for muitiple in&muscular injections, if
decision on needle size and site of injection must be made necessary.The location of e&h injection should documented
for each person on the basis of age, the volume of the mate- in the person’s medical record.
riaI to be administered, the size of the muscle, and the depth
below the muscle surface into which the material is to be
jet injectors (Jls) are qeedle-free devices that drive liquid
Although certain vaccination specialists advocate aspira-
medication through a nomie orifice, creating a narrow stream
tion (i.e., the syringe plunger pulled back’before injection),
under high pressure t&t penetrates skin to deliver a drug or
no data exist to document the necessity for this procedure.
vaccineinto intradermal,subcutaneous,or intramusculartis-

__ . _.-- __ ._-

Vol. a/ RR-2

sues (64,65). Increasing attention to JI technology as an cartridge for each patient and other correct use, these de-
alternative to conventional needle injection has resuited from vices avoid the s,afety concerns described previously for
recent efforts to reduce the frequency of needle-stick inju- multiple-use-noz@devices. They can be used in accor-
ries to health-care workers (66) and to overcome the im- dance with their labeling for intradermai, subcutaneous, or
proper reuse and other drawbacks of needles and syringes intramuscular administration-
in economically developing countries (67-69). JIs have been
reported safe and. effective in administering different live
and inactivated vaccines for viral and bacterial diseases (69).
The immune responses generated are usually rquivalmt ‘to,
Comfort measures and distraction techniques (e.g., play-
and occasionally greater than, those induced by needle in-
ing music or pretending to. blow away the pain) might help
jection. However, local reactions or injury (e.g., redness,
children cope with the discomfort associated with vaccina-
induration, pain, blood, and ecchymosis at the injection
tion. Pretreitment (30-60 minutes before injection) with
site) can be more frequent for vaccines delivered by JIs com-
5% topical lidocaine-prilocaine emulsion (EMLA* cream
pared with needle injection (65,69).
or disk [mam&ctured by. AstraZeneca LPJ) can decrease
Certain Jls were deveIoped for situations in which substan-
the pain of vaccination among infants by causing superfi-
tial numbers of persons must be vaccinated rapidly, but per-
cial anesthesia (74,75). Preliminary evidence indicates that
sonnel or supplies are insufficient to do so with conventional
this cream does not interfere with the immune response to
needle injection. Such high-workload devices vaccinate con-
MMR (76)..Topical lidocaine-prilocaine emulsion should
secutive patients from the same nozzle orifice, fluid pathway,
nor be used on infaats aged si2 months who are receiving
and dose chamber, which is refilled automatically from attached
treatment with‘methemoglobin-inducing agents because
vials containing&(l doses each. Since the I95Os, these devices
of the possible development of methemoglabinemia (77).
have been used extensively among military recruirs and for
Acetaminophen has heen used among children to reduce
mass vaccination campaigns for disease control and eradica-
the discomfort and fever associated with vaccination (78).
tion (64). An outbreak of hepatitis B among patients receiv-
However, acetaminophen can cause formation of methemo-
ing injections from a muhiple-use-nozzle JI was documented
globin and, thus, might interact with lidocaine-prilocaine
(70,71), and subsequent laboratory, field, and animal studies
cream, if used~concurre$y (77). Ibuprofen or other
demonstrated that such devices could become contaminated
nonaspirin analgesic can be used, if necessary.Use of a topi-
with blood (69,72,73).
cal refrigerant (vapocoolant)’ spray can reduce the short-
No U.S.-licensed, high-workload vaccination devices of
term pain associated with injections and can be as effective
unquestioned safety are available to vaccination programs.
as lidocaine:prilocaine cream (79). Administering sweet-
Efforts are under way for the research and development of
tasting fluid orally be&e injection can result
new high-workload JIs using disposable-cartridge technatogy
in a calming or an among certain infants.
that avoids reuse of any unsterilized components having con-
tact with the medication fluid pathway,or patient’s blood. Until
such devices become licensed and availabie, the use of existing Nonstandiwd citnation Practices
multiple-use-nozzle JIs should be limited. Use can beconsid- Recommendations regarding route, site, and dosage of
ered when the theoretical risk for bloodbornc disease trans- immuuobiologics are derived from data from clinical trials,
mission is outweighed by the benefits of rapid vaccination with from practical experience?and from theoretical considerations.
limited personnel in responding to serious diseaset@eat+ (e.g., ACIP strongly discourages variations from the recommended
pandemic influenza or bioterrorism event}, and by any corn- route, site, volume, or number of doses of any vaccine.
peting risks of iatrogenic or occupational infections resulting Variation from-the recommended route and site can re-
from conventional needles and syringes. Before such emer- sult in inadequate protection. The immunogenic& of hepa-
gency use of multiple-use-nozzle JIs, health-care workers titis B vaccine and rahii vaccine is substantially lower when
should consult with local, state, national, or international the gluteal ratbet than the deltoid site is used for adminis-
health agencies or organizations that have experience in tration (53.59). Hepatitis B vaccine administered intrad-
their use. ermally can result in a lower seroconversion rate and final
In the 199Os, a new generation of‘low-work&ad Jiswere titer of hepatitis B surface antibody than when adminis-
introduced with disposable cartridges serving as dose cham- tered by the deleoid intramuscular route (8i28l); Doses of
bers and nozzle (63). With the provision of a new sterile rabies vaccine administered in the giuteal site should not
- -_. -- -.- .- .-. --

14 MMWR Feibruary 8,2002

be counted as valid doses and should be repeated. Wepati- other sources (e.g., ehe Immunization Action Coalition at
tis B vaccine administered by any route or site other than http:~/ [accessed October 3 1, ZOOl]).
intramuscufarly in the anterolateral thigh or deltoid muscle Severe allergic reactions after vaccination are rare. Wow-
should not be counted as valid and should be repeated, ever, all phpkians ind achcr health-care providers who
unless serologic testing indicates that an adequate response administer vaccines should hake procedures in place for the
has been achieved. emergency- management of a person who experiences an
Live attenuated parenteral vaccines (e.g., MMR, vkzella, anaph&ctic reaction. All ‘vaccine providers should be fa-
or yellow fever) and certain inactivated vaccines (e.g.* IPV, miliar with the &ice emergency plan and be certified in
pneumococcal polysaccharide, and anthrax) are recom- cardiopulmonary .resuscitation.
mended by the manufacturers to be administered by sub- Syncope (vaskagal Or vasodepressor reaction) can occur af-
cutaneous injection. Pneumococcal polysaczharide and I’PV ter vaccination, most corninn& among adolescentsand young
are approved for either intramuscuiar or subcutaneous ad- adults. D&g 199~&gust 2001, a total of2,269 repam to
ministration. Response to these vaccines probably will not the Vacciqe Adverse Event &porting system were coded as
be affected if the vaccines are administered by the iotra- syncopel Forty percent of thesl: epikdes were reported among
muscular rarher then subcutaneous route. Repeating doses persons aged 10-I& years (CDC, unpublished data, 2DQl).
of vaccine administered by the intramuscular route tather Approximately 12% ofrepbrtikd syi~opal episodes resulted in
than by the subcutaneous route is unnecessary. hospitalization because of&jury or medical evaluation. Seri-
Administering volumes smaller than those recommended ous i&upincludi~g skull fractures andcerebral bleeding, have
(e.g., split doses) can result in inadequate protection. Us- been report$d to result from syncopal episodes a&r vacci-
ing larger than the recommended dose can be hazardous nation. A published r&i& of syncope after vaccination re-
because of excessive local or systemic concentrations of an- ported rhat 63% of syncopal episodes occurred ~5 minutes
tigens or other vaccine constituents. Using multiple reduced after vaccination, and 89% occurred within 15 minutes af-
doses that together equal a fi.dI .immuoizing dose or using ter vaccination (83)* Although sytacopal episodes are un-
smaller divided doses is not endorsed or recommended. Any common and &rious’all&gic reactions are rare, certain
vaccination using less than the standard dose should not be vaccination specialists recommend that persons be obsetved
counted, and the person should be revaccinated according for 15-20 minutes afkr being vaccinated, if possible (84).
to age, unless serologic testing indicates chat an adequate If syncope develops, patients should be observed untif the
response has been achieved. symptoms resolve.

Preventhg Adverse Reactions Mancaghg Acute Yarrrcine Reactions

Vaccines are intended to produce active immunity to spe- Although rare aftet traccination, the immediate onset and
cific antigens. An adverse reaction is an untow+td effect that life-threatening nature c&an ‘&phylactic reaction require that
occurs after a vaccination that is extraneous co the vaccine’s pirsonnel and facilitie& Providing vaccinations be capable of
primary purpose of producing immunity. +vcrse reactioas providing initial care fbr suspc?ztedanaphylaxis, Epinephrine
also are called vaccjne skie &ts. and equipment for maintaining an airviray should be available
All vaccines might cause adverse reactions (8.2). Vkcinc ad- for immediie use.
verse reactions are classified by three general cacegc+s: local, AnaI?hyiaxis usually begins within minutes of vaccine ad-
systemic, and allergic. Local reactions are usually the least se- ministration, ~pjdly.r~cog~i~~~g and initiating treatment are
vere and most frequent. Systemic reactions (e.g.* fever) occur required to,ptevept possible progtession to cardiovascular col-
less frequently than local reactions. Serious allergic reactions lapse. If flushing,: @&I edema, u&aria, itching, sweliing of
anaphylaxis) are the most severe and Ieast kequent. Se- the mouth or throat, wheezing, difficulty breathing, or ather
ZHdyverse reactions are rare, signs ol’&phyla& occur, “she patient should be @lacedin a
The key co preventing the majority of serious adverse reac- recumb&n<po&ion with the legs elevared. Aqueous epineph-
tions is screening. Every person who administers vaccines rine (1:lOOO) should be administered and carx be repeated
should screen patients for contraindications and preckions within 10~26 minute+ (sa). A dose of diphenhydtamine hy-
co the vaccine before it is administered (Table 5). Standard- drochloride might tharren the reaction, but it wilf have
ized screening questionnaires have been developed and are little immediare’effkct Maintenance of an airway and oxy-
available from certain state immunization programs and gen administrkion might:bi necessary.Asrangements should
Vol. 511 RR-2 Rsf3ammrmdations and @qmrts ’ 15

be made for immediate transfer to an emergency facility for the cold chain has been maintained. Vaccines shot&i con-
further evaluation and treatment. tinue to be stored at recommended temperatures immedi-
ately upon receipt. Certain vaccines (e.g., MMR, varicelia,
Occupa#ioncd Safety Regulations and yellow fever) are~smsitive to increased temperature. Ah
other vaccines are sensitive to freezing. Mishandled vaccine
Bloodborne diseases (e.g., hepatitis B and C and human
usually is not- ~s~~n~~isha~~e‘from potenc vaccine. When
immunodeficiency virus [I-WI) are occupational hazards for
in doubt. regarding the appropriate handling of a vaccine,
health-care workers. In November 2000, to reduce the in-
vac&ation pmvid& should contact the manufacturer. Vac-
cidence of needle-stick injuries among health-care workers
cines that have been mishandled (e.g.~,inactivated vaccines
and the consequent risk for bioodborne diseases acquired
and toxoids that have been exposed to freezing tempera-
from patients, the Needlestick Safety and Prevention Act
tures) or that are beyond their expiration date should not
was signed into law. The act directed the Occupacion~ Safety
be administered. If mishandled’ or expired vaccines are ad-
and Health Administration (OSHA} to strengthen irs ex-
ministered inadvertently, they should not be counted as
isting bloodborne pathogen standards, Those standardswere
valid doses and should be repeated, unless serologic testing
revised and became effective in April 2OOfr (66). These,,fed-
indicates a response to the vaccine,
era1 regulations require that safer injection devices (e.g.,
Live attenuated virus vaccines shouid be administered
needle-shielding syringes or needle-free injectors) be used
promptly after reconstitution, Varicella vaccine must be ad-
for parenteral vaccination in all clinical settings when such
ministered 90 minutes after reconstitution. Yellow fever vac-
devices are appropriate, commercially available, and capable
of achieving the intended clinical purpose. The rules aiso cine must be used nil hour tier reconstitution. MMRvaccine
must be administered $3 bouts &er reconstitution. If not
require that records be kept documenting the incidence of
administered within these prescribed time periods after recon-
injuries caused by medical sharps (except in workpk~es with
stitution, the vaccine,musi be discarded.
110 employees) and that nonmanagerial employees be in-
The majority of vaccines have a simihu appearance after
volved in the evaluation and selection of s&r devices to be
procured. being drawn into a syringe, Instances in which the wrong
vaccine inadvertently was administered are attributable to
Needle-shielding or needle-free devices that might satisfy the
the practice of pref2lin~ syringes or drawing doses of a vac-
occupational safety regulations for administering parenteral
cine into multiple sytinges.before their immediate need.
injections are available in the United States and are listed at
ACE’ discourages the rotnine practice of prefilfing syringes
multiple websites (&W-87).t Additional information regatd-
because of the potentia;t for such administration errors. To
ing implementation and enforcement of these regulations is
prevent errors, vatiine dams should not be drawn into a
avaiiable at the OSHA website at
syringe until immediately before administration. In certain
needlesticks (accessedOctober 31, ZOOI).
circumstsnces where a single vaccine type is being used (e.g.,
in advance of a community influenza vacciriation campaign),
Storage and .Handiinrg filling muhi~le syring&e&re their immediate use can be
‘considered. Care sh&ld be taken to ensure thar the cold
of ltitmunobiolagics chain is mainrainedunr~t the vaccine is administered. When
Failure to adhere to recommended specifications for stor- the syringes are f&xl, the type of vaccine, lot number, and
age and handling of immunobiologics can reduce potency date of filing must be camfuily labeled on each syringe,
resufting in an inadequate immune response in the n&pi- and the doses should bti administered as soon as possible
ent. Recommendations included in a product’s package after filling.
insert, including reconstitution of the vaccine, should be Certain”vaccines are distributed in multidosc vials. When
followed carefully. Vaccine quality is the shared respoasi- opened, the remaining doses fmm partiaky used multidose
bifity of all parties from the time the vaccine is manufac- vials can be adrnmistered untiil the expiration date printed on
tured until administration. All vaccines should be inspected the vial,or vaccine packagingt provided that the vial has been
upon delivery and monitored during storage to ensure that stored correcriy and that the vaccine is not visibly contami-

1 Incernct siteswith devicclitings ate identified for infixmation purposeaonly.

CDC, the U.S. P&ii Health Service,and the Deparrmen<of He&h and
Human Servicesdo not endorseany specific&vice or imply thnt the devices
listed would 211sati+ the needle-stickpreventionregulationtS

_-- -
16 MMWR February 8,2002

Special Situa$oqs move the concern of snny.theoretical but transient sup-

pression of PPD reactivity From the vaccine.
Concurrently Administering * PPD screening can be prformed and read before ad-
Antimicrobiul Agents and Vaccines ministering the measles-containing vaccine. This op-
Wirh limited exceptions, using an antibiotic is not a con- tioti is the least favored because it will deiay receipt of
traindication to vaccination. Antimicrobial agents have no ef- the measlcs;cank~ing vaccine.
fect on the response to live atrenuated vaccines, except live No .data exisrfor the potential degree of PPD suppression
oral Ty2Ia typhoid. vaccine, and have no effect on inactivated, that might be associated with other parenteral live attenuated
recombinant subunit, or polysaccharide vaccines or toxoids. virus yaccines.(e,gl, varicetia or yellow fever). Nevertheless, in
Ty2la typhoid vaccine should not be administered to per- the absence of data, following guidelines far measles-
sons receiving antimicrobial agents until 224 hours after containing vaccine vv)ren scheduting Pl?D screening and ad-
any antibiotic dose (28). ministering other p,arenteral live attenuated virus vaccines
Antiviral drugs used for treatment or prophylaxis of influ- is ‘prudent. If a risk exists that the opportunity to vaccinate
enza virus infections have no effect on the response to inacti- might be missed, vaccination should not be delayed only
vated influenza vaccine (88). Antiviral drugs active against becaae of these theoretica considerations.
herpesviruses (e.g., acyclovir or valacyclovir) might reduce the MucosaIIy administqed .Jjivc+rtenuated virus vaccines {e.g.,
efficacy of live attenuated varicellavaccine. Thesedrugs should OPV and intnnasatly admitjstered influenza vaccine) are un-
be discontinued 124 hours before ahinistration of varicelh IikeJy to affect the respo?? to PPD. No evidence has been
vaccine, if possible. reported that inactivared v&&es, polysaccharide vaccines,
The antimalarial drug mefloquine (L&am@ [manu&cmred recombinant, or sub&r vaccines, or toxoids interfere with
by Roche Laboratories, Inc.]) could affect rhe immune response response to PPD.’
to oralTy2la typhoid vaccine if both are takensimuitaneously PPD reactivity in the absence of tuberculosis diseaseis not a
(89,PU). To minimize this effect, administeringTy2la typhoid contraindication cu adminisnarion of any vaccine, including
vaccine 224 hours before or after a dose of mefloquine is parenteral live attenuated virus vaccines. Tuberculosis dis-
prudent. easeis not a contraindication~to vaccination, unless the per-
son is moderarely or severely ill. Although no studies have
Tubercu’losis Screening repolned the e&a of MMR vaccine on persons with un-
and Skin Test Reactivity treated tuberculosis, a theoretical basis exists for concern
that measles vaccine might exacerbate tuberculosis (6).
Measles illness, severe acute or chronic infecrions, HIV
Consequently, be&e administering MMR to persons wirh
infection, and malnutrition can create ti ancrgic state dur-
untreated active tubeiculasis, initiating antituberculosis
ing which the tuberculin skin test (usually known as puti-
therapy is advisable (G). Ruling out concurrent -immuno-
firdprutcin derivative [PlYI] skin test} mighr give a faise
suppression (e.g., immunosuppression caused by HIV in-
negative reaction (31-93). Although any live attenuated
fection) before administering five attenuated vaccines is also
measles vaccine can theoretically suppress PPD reactivity
the degree of suppression is probably less than rhat occur-
ring from acute infection from wild measles virus- Although
routine PPD screening of all children is no longer recum-
mended, PPD screening is sometimes needed at‘the &me
time as administering a measles-containing vaccine (e.g., Vaccine campnnents can cause allergic reactions among cer-
for well-child care, school entrance, or for.empfoyee heaIth tain recipients. These reactions can be local or systemic and
reasons), and the fouowing options should be considered: can inch& mild to severe anaphylvds or anaphylactic-like
* PPD and measles-containing vaccine can be adminis- responses(~g.; generalized urticaria or hives, wheezing, swell-
tered at the same visit (preferred option). Simultaneously ing of,the mouth,.and throar, @%ifieultybrearhing, hypoten-
administering PPD and measles-containing vaccine does sion, and shack), Al&$ reactions might be caused by the
not interfere with reading the PPD result at 46-72 hours vaccine antigen, residuil animaf protein, anrimicrobiai agents,
and ensures that the person has received mea&s vaccine. preservarives~stibiliz~rrs, or arher vaccine components (94).
l If the measles-containing vaccine has been administered plr; extensive listing of vaccine compon&s, their use, and rhe
recently, DPD screening should be delayed 24 weeks vaecinti thar contain ash component has been published (95)
after vaccination. A delay in performing PPD will re- and is .atso available f’ram CQCs National Immunizarion
Vul. 51 I RR-2 Recommenda?ions and @epqrts 17

Program websire at hctp:llwww.cdc.govlnip (accessed. Oc- preservative. A joint statement issued by the U.S. Public
tober 31, 2001). Heatth Service tind the American Academy of Pediatrics
The most common animal protein allergen is egg pro- (AAl?) in 1999’(103) and agreed to by the American Acad-
tein, which is found in vaccines prepared by using embryo- emy of Family Physicians (AAFP) later in 1999, established
nated chicken eggs (influenza and yellow fever vaccines}. the goal of removing thimerosal as soon as possible from
Ordinarily, persons who are able to eat eggs or egg prod- vaccines rourinely recommended .for infants. Although no
ucts safely can receive these vaccines; persons with hi$ories evidence exists of any harm caused by low levels of thimero-
of anaphylactic or anaphylacric-like: allergy to eggs or egg sal in vaccines and the risk was only tbeoreticat (I&& this
proteins should not be administered these vaccines. Asking goa was established, as a Breoautionary measure.
persons if they can eat eggs without adverse effects is a rea- The pubhc is concerned about the heaith effects of mer-
sonable way to determine who might be at risk for allergic cury exposure of any type, and the elimination of mercury
reactions from receiving yellow fever and influen% vaccines. from vaccines was judged a feasible means of reducing an
A regimen for administering influenza vaccine to children infant’s total exposure to rne,mury in a world where other
with ‘egg hypersensitivity and severe asthma has been de- environmental sources of exposure ore more difBcu1-t or im-
veloped (96). possible to eliminate (e*g,, certain foods). Since mid-2001,
Measles and mumps vaccine viruses are grown in chick vaccines rcutinely recuimended for children have been
embryo fibroblasr tissue culrute. Persons with a serious egg manufacrured YiFhout thimerosal as a preservative and con-
allergy can receive measles- or mumps-containing vaccines tam either no thimerosal or only trace amounts. Thimero-
without skin testing or desensitization to egg pt+ein (G). Ru- sal as a preservative is present in certain other vaccines (e.g.,
bella and varicella vaccines are grown in human diploid cell Td, DT, one of two ad& hepatitis B vaccines, and influ-
cultures and can safely be administered to persons with histo- enza vaccine). A trace thimerosal formulation of one brand
ries of severe allergy to eggs or egg proteins. The rare serious of influenza vaccine was hcensed by FDA in September
allergic reaction after measles or mumps vaccination or MMR 2001.
are not believed, to be caused by egg antigens, but. ra other Receivingthimerosa-canfairrin vaccines has been believed
components of the vaccine (e.g., gelatin) (%UOO). MMR, its to lead to in&&on of:$&rgy. Hovvevet, limited scientific ba-
component vaccines, and other vaccines contain hydmlyzed sis exists for this assertion f~..Hiypersensitivity to thimerosal
gelatin as a stabilizer. Extremecaution~should be exercised when usually consists of &al.deiayed type hypersensitivity reactions
administeringvaccine that contain gelatin ro persons who have (I6!5407). i”himero;sal~e&ts positive delayed type hypersen-
a history of an anaphylactic reaction to gelatin or gelatin- sitivity patch tests in l%-18% of persons tested, but these
containing products. Before administering gelatin- tests have limited or no clinica~refevance (1U8,2&9). The ma-
containing vaccines to such persons, skin testing for jority of’padents .do not experience reactions to thimerosal
sensitivity to gelatin can be considered. However, no spe- administered as a component of vaccines even when patch or
cific protocols for this approach have been published.’ inrradermal tests for thimerosaI&&ate hypersensirivity (109).
Certain vaccines contain trace amounts of iufubiotics or A localized or delayed type hypersensitivity reaction to thime-
other preservatives (e.g., neomycin or thimerosal) ro which rosal is not a contra$cat%n to receipt of a vaccine thatcon-
patients might be severely allergic. The information provided rains thimerosal.
in the vaccine package insert should be reviewed carefully be-
fore deciding,ifthe rare patient with such allergies should re-
ceive the vaccine. No licensed vaccine contains penicilhn or Latex is liquid sap. from the commercial rubber tree. La-
penicillin derivatives. tex contains naturalIy occu&g impurities (e.g., plant pro-
Certain vaccines contain trace amounts of neomycin; Per- teins and peBtid&), which are believed to be responsible
sons who have experienced anaphylactic reactions to neomy- for allergic reactions. I+tex is processed m form naturai rub-
cin should not receive these vaccines. Most often, neomycin ber latex and dry natural rubber. Dry natural rubber and
allergy is a contact dermatitis, a manifestation of a delayed natural rubber latex might contain the same plant imputi-
type (cell-mediated) immune response, rather than anaphy- ties as-latex but in iesset amounts. Natural rubber latex is
laxis (101,~02). A history of delayed type reactions to neomy- used to produce medicat gI5ve5, catheters, and other prod-
cin is not a contraindication for administration of these ucts, Dry natural rubber is used in syringe plungers, vial
vaccines. stoppers, and injection. pans an intravascular tubing. Syn-
Thimerosal is an organic mercurial compound in use since thetic rubber and synthetic latex also are used in medical
the 1930s and added to certain immunobiologic products as a
18 MMWR February 8.2002

gloves, syringe plungers, and vial stoppers. Synthetic rub- weight of <Z,OQO grams has not been determined. How-
ber and synthetic latex do not contain natural rubber or ever, these i&its can receive the first dose of the hepatitis
natural latex, and therefore, do not contain the impurities B vaccine series at chronological age 1 month. Premature
linked to allergic reactions. infants discharged from the hospital before chronological
The most common type of latex sensitivity is contact- age 1 month can also be administered hepatitis B vaccine at
type (type 4) allergy, usually as a result of prolonged contact discharge, if they are medically stable and have gained weight
with latex-containing gloves (110). However, injection- consistently.
procedure-associated latex ailergies among patients with
diabetes have been described (111-113). Allergic reactions
(including anaphylaxis) after vaccination Procedures are rare. nor live vaccines administered to a lac-
Only one report of an allergic reaction after adminisrering taring woman affect the safety of breast-feeding for mothers
hepatitis B vaccine in a patient with known severe allergy or infants. &e&t-feting docsnot adversely aifecr immuniza-
(anaphylaxis) to latex has been published (114). tion and is nor a contraindication for any vaccine. Limited
If a person reports a severe (anaphylactic) allergy to latex, data indicate that breast-feeding can enhance the response
vaccines supplied in vials or syringes that contain natural to certain vaccine antigens (12%. ‘Breast-fed infants should
rubber should not be administered, unless the benefit of be vaccinated according to routine recommended sched-
vaccination outweighs the risk of an atlergic reaction to the ules (X24-126).
vaccine. For latex allergies other than anaphylactic aJJergies Although iive~vaccines muhiply within the mother’s body,
(e.g., a history of contact allergy to latex gloves), vaccines the majority have nor been, demonstrated to be excreted in
supplied in vials or syringes that contain dry natumJ rub- human milk. Although rubella vaccine virus might be excreted
ber or natural rubber latex can be administered. in human milk, the virus u#alJy does not infect the infant. if
infection does occur, it is well-toierated because the viruses are
Vaccination of Premature Infants attenuated (X27). Inactivated, recombinant, subunit, polysac-
In the majority of cases, infants ,born prematurely, re- charide, conjugate vaccines and toxoids pose no risk for mothers
gardless of birth weight, should be vaccinated at the same who are breast-feeding or for thei,r infants.
chronological age and according co the same schedule and
precautions as J&11-term infints and children. Birth weight Vuccinatian ‘~~rln~ Pr+gnaney
and size are not facrors in deciding whether to postpone Risk to a develaping fetus from vaccination of the mother
routine vaccination of a clinically stable premature infant during pregnancy is prim&y theoretical. No evidence exists
(I&117), except for hepatitis B vaccine. The full recom- of risk.from ~c~~ar~~pre~ant women with inactivated vi-
mended dose of each vaccine should be used, Divided or rus or bat terial vaccines or toxoids ( 128,22Y). Benefits of vac-
reduced doses are not recommended (118). cinating pregnant ‘women usually outweigh Potential risks
Studies demonstrate that decreased seroconversion rates when the Jikelihood of d&se exposure is high, when in-
might occur among certain premature infantswith low birth fection.would pose a risk cotbe mother or fetus, and when
weights (i.e., ~2,000 grams) after administration of hepatitis the vaccine 4s unlikely to cause harm.
B vaccine at birth (119). However, by chronoiogical age 1 Td toxoid is indicated routinely for pregnant women. Pre-
month, all premature infants, regardless of initial birth weight viously vaccinated.ptegtiant women who have not received a
or gestational age are as likely to respond as adequately asolder Td vaccination within thy Iaet 10 years should receive a.boosrer
and larger infants (120-322). A premature infant born to dose. Pregnant women who are not immunized or only par-
HBsAg-positive mothers and mothers.with unkqown tialhy immunized against tetanus should complete the primary
HBsAg status must receive immunoprophylaxis with hepa- series (130). Dependingon when a woman seeksprenatal care
titis B vaccine and hepatitis B immunoglobulin (HBIG) and the requited intervaJ between doses, one or two doses of
512 hours after birth. If these infants weigh ~2,000 grams Td can be administered before delivery Women for whom
at birrh, the initial vaccine dose should not be counted to- the vaccine, is indicated, but who have not completed the rec-
wards completion of the hepatitis B vaccine series, and &ree ommended three-dose series during pregnancy, shauld receive
additional doses of hepatitis B vaccine should be adminis- follow-up after delivery to ensure the series is compleced,
tered, beginning when the infant is age 1 month. Tke opti- Women in the second and third trimesters of pregnancy have
mal timing of the first dose of hegatitis B vaccine for been demonstrated to be at increasedrisk for hospitalization
premature infants of HBsAg-negative mothers with a birth from influenza (131). Therefore, routine influenza vaccina-

I-__-- ---

cion is recommended for heaithywomen who will be be- ately after delivery. A woman known to be HBsAg-positive
yond the first trimester of pregnancy (i.e., 214 weeks of should be followed carefully to ensure chat the infant re-
gestation) during influenza season (usually December- ceives HBIG. and,begins the hepatitis B vaccine series 112
March in the United States) (88). Women who have medi- hours -afier.,birth and rhat the infant completes the recom-
cal conditions that increase their risk for complications of mended hepatitis 3 vaccine series (132). No known risk
influenza should be vaccinated before the influenza season, exists for the fetus from passive immunization of pregnant
regardless of the stage of pregnancy. women with immune globulin preparations.
IPV can be administered to pregnant women who are ac
risk for exposure to wild-type poliovirus infect+ {4). Hepa-
titis B vaccine is recommended for pregnant women at risk
for hepatitis B virus infection (132). Hepatitis A, pneumo-
The abiiity of a clinician to determine that a person is
coccaf polysaccharide, and meningococcal polysaccharide
protected on the basis of their country of origin and their
vaccines should be considered for women at increased risk
records alone is limited.. Internationally adopted children
for those infections (43,133,134).
should receive vac+& according to recommended sched-
Pregnant women who must travel to areas where the risk
ules far children in the United States. Onty written docu-
for yellow fever is high should receive yellow fever vaccine,
mentation should ‘be accepted as evidence of prior
because the limited theoretical risk Born vaccinarion is Sub-
vaccination. Written records ate more likely to predict pro-
stantially outweighed by the risk for yellow fever infection
tection if the vaccines, dates of administration, intervals
(22,133. Pregnancy is a contraindication for measles,
between doses, and the chil& age at the time of immuni-
mumps, rubella, and varicella vaccines. Although of xheo-
zation are comparable RO the- cumnt U.S. recommenda-
retical concern, no cases of congenital rubella or varicella
tions. Although vaccines w&inadequate potency have been
syndrome or abnormalities attributable to fetal infection
produced in other countries (J39,14U), the majority of vac-
have been observed among infants born to susceptible
cines used worlclwide are Produced with adequate quality
women who received rubella or varicella vaccines during
contro1 standards +d are Potent.
pregnancy (6,139. Because of the importance of pr&tect-
The number of &n&an families adopting children from
ing women of childbearing age against rubella, reasonable
outside the United States has increased.substantially in recent
practices in any immunization program include asking
years (~41). Adopted children’s birth countries ofien have im-
women if they are pregnant or intend to become pregnant
mu&ation schedules that&&r from the recommended child-
in the next 4 weeks, not vaccinating women who state that
hood immunitition schedule in the United States.Differences
they are pregnant, explaining the potential risk for the fe-
in the U.S. immuniz&m schedule and those used in other
tus to women who state that they are not pregnant, and
countries in&d&he vaccines administered, the recommended
counseling women who are vaccinated not to become preg-
ages of administration, andihe number and timing of doses.
nant during the 4 weeks after M M R vaccination (6,35,137).
Data are inconclusive regarding the extent to which an
Routine pregnancy testing of women of childbearing age
internationalfy adoPted child’s immunization record reflects
before administering a live-virus vaccine is not recommended
the child’s protection. A child’s record might indicate ad-
(6). If a pregnant woman is inadvertently vaccinated or if
ministration of M M R vaccine when only single-antigen
she becomes pregnant within 4 weeks &er M M R or vari-
measles vaccine was administered. A study of children
cella vaccination, she should be counseled regarding the
adopted from the PeoPle’s Republic of China, Russia, and
theoretical basis of concern for the fetus; however, M M R or
Eastern Europe determined that only 39% (range: 17%-
varicella vaccination during pregnancy should not ordinarily
88% by country) of children with documentation of >3
be a reason to terminate pregnancy (68).
doses of DTP before adoption had protective levels of diph-
Personswho receive M M R vaccine do not transmit the vat-
theria and tetanus antitoxin (14Z). However, antibody test-
tine viruses to contacts (6). Tnnsmission of varicella vaccine
ing was perfbrmed by using’s hemagglnrination assay,which
virus to contacts is rare (138) M M R and varicella vaccines
tends to underestimate protertion and cannot directly be
should be administered when indicated to the children and
compared wirli antibody concentration (243). Another
other household contacts of pregnant women (6”8).
study measu& antibody to diphtheria and tetanus toxins
All pregnant women should be evaluated for immunity to
among 51 &l&en who had records of having received 22
rubella and be tested for the presence .of HBsAg (635,132).
doses of XXI? The majority of the children were from Rus-
Women susceptible to rubella should be vaccinated immedi-
sia, Eastern Europe, and Asian countries, and 78% had re-
20 NMWR February 8,2002

ceived all their vaccine doses in an orphanage. Q~edl~ 34% munogenic, Repeating the vaccinations is an acceptable op-
had evidence of protection against diphtheria (ELA > b.1 tion. Doing so is usualfy safe and avoids the need to obtain
IU/mL), A total of 84% had protection against tetanus (en- and inrerpret serologictests. If avoiding unnecessary injec-
zyme-linked immunosorbent assay [ELBA] > ‘0.5 IWmL), tions is desired, judicious use of serologic testing might be
Among children without protective tetanus antitoxin con- helpful in determining which immunizations are needed.
centration, ali except one had records of 23 doses of vac- This report provides~ guidance on possible approaches to
cine, and the majority of nonprotective concentrations were evaluation and revaccination f&r each vaccine recommended
categorized as indeterminate (ELBA = 0.05-0.49 IU/mL) universally for children in the United States (see Table 6
(144). Reasons for the discrepant findings in these twostud- and the following sections).
ies probably relate to different laboratory methodologies;
MMR Vcwxine
the study using a hemagglutination assay might have un-
derestimated the number of children who were protected. The simplest approach to resoiving concerns regarding
Additional studies using standardized methodologies are MMR immunization among,‘internadonally adopted chif-
needed. Data are likely to remain limited for countries’other dren is to rwatxi~artz with one or two doses of MMR vac-
than the People’s Republic of China, Russia, and Eastern cine, depending on the child3 age. Serious adverse events
Europe because of the limited number of adoptees. from after MMR vaccination! ate rare (6). No evidence indicates
other countries. that adminisreringM&fR vaccine increases the risk for ad-
Physicians and other health-care providers can follow one verse reactions among persons who are already immune to
of multiple approaches if a question exists regarding whether measles, mumps, or rubeha as a result of previous vaccina-
vaccines ‘administered to an international adoptee wete im- tion or natural disease. Doses of measles-containing vaccine

TABLE 6. Approaches to the evaluation and vrrccination~ot ktemationally adoptad chijdfen

Vaccine Recommended apprasch Alt$BWWQ approach

Mea&s, mumps, and rubella [MMR) Ryaccimte with MMR Samlogjj khg for knm~noglobulii G (tgG)
ar@ib~dy to veccke ‘viruses indicated by
vaccination record

Haemophilus influenzee type b (Hib) Age-appropriate revaccination

Hepatitis B ’ Serological testing for hepatitis B

surface qntigen

POlioviNS Revaccinate with inactivated pofiivbus Sarolcgk~Wsthg far neutralking antibody to

vaccine (IPV) poliovirars ,typps 1,2, and 3 (limited avali;&ity),
or ad&i&r single doq of tmsI, followed by
sem$krgiq @&ingfor nautraiizinganllbody ta
poliovkw&f~es 1,2, and 3

Diphtheria and tetanus toxoids and aceklar Revaccinatiin with DTaP, With semlogio Children whose racords indicate receipt of $S
pertussis (DTaP) testing for &mific JpG ant&* to tetanw das~?pe_sr
se@agii testing for specific IgG a&body
and diphtheria toxins in the event of P to ckphfhsria and tetanustoxins before adminis-
sever81local reaction Ming addItional closes {See text), or administer
a ~~~~~~r day of OTaP, lolloyd by
serfagkel testing after 1 month for specili IgG
a&body @ diphtheria and tetanus toxins with
revaccinatian as appropriate (see text)

Varicella Age-appropriate vaccination of children who

lack a relfabls history of previous~varfoellil

Pneumococcal Age-appropriate vaccination


administered before the first birthday should not be counted dose of IPV can be administered initially with serologic
as part of the seties (s). Alternatively, serologic testing for testing performed I montb her.
immunoglobulin G (IgG) antibody co vaccine viruses indi-
DTaP vaccine
cated on the vaccination record can be considered., Sero-
logic testing is widely available for rxpsb and rub&a IgC Vaccination providers can revaccinate a child with DTaP
antibody. A child whose record indicates receipt of monova- vaccine without regard to recorded dose& however, one con-
lent measles ot measles-rubella vaccine at age 21 ye+r and cern regarding this approach is that data indicate increased
who has protective antibody against measles and rubella rates of local adverse reactiozts after the fourth .and fifth doses
should receive a singie dose of MMR as age-appropriate to of D’lP or D’W (42), irf a revaccination approach is adopted
ensure protection against mumps (and rubella if measles and a severe local reaction-occurs, serologic testing for spe-
vaccine alone had been used). If a child whose record indi- cific IgG antibody to tetanus and diphtheria toxins can be
cates receipt of MMR at age 212 months has a proeective measured before administering additional doses. Protective
concentration of antibody to measles, no additional vacci- concentrarion** indicates that firtther doses are unneces-
nation is needed unless required for school entry. sary and subsequent vaccination should occur as age-
appropriate. No established serologic correlates exist for
Hib Vaccine protection- against pertussix
Serologic correlates of protection for children vaccinated For a child whose record indicates receipt of ti doses of
>2 months previously might be difficult to interpret Be- DTP or DTaR serologic test+ fbt specific IgC antibody to
cause the number of vaccinations needed-for protection both diphtheria and tetanl;ls toxin before additional doses
decreases with age and adverse events are rare (24), age- is a reasonable approach. If a protective concentrarion is
appropriate vaccination should be provided. Hib vaccination present, recotded dosw can be considered v&d, and the
is not recommended routinely for children age+ 25 years. vaccination series should be completed as age-appropriate.
Indeterminate andbady concentration might indicate im-
Hepatitis B Vaccine munologic memory but antibody waning; serology can be
Serologic testing for HBsAg is recommended for interna- repeated after a booster dose if the vaccination provider
tional adoptees, and children determined to be HEhAg- wishes to avoid revaccination v&h a complete series.
positive should be monitored for the development .of liver AlternateIF for a child w&e records indicate receipt of
disease. Household members of HBsAg-positive chiidren 13 doses, a single booster dose can be administered, fol-
should be vaccinated. A child whose records. indicate re- lowed ,by serologic resting after 1 month for specific IgC
ceipt of 13 doses of vaccine can be considered protected, antibody to’both diphtheria and tetanus toxins. ff a pro-
and additional doses are not needed if 21 doses were ad- tective concena&ion is obtained, the recorded doses can
ministered at age $5 months. Children who received their be considered,vaiid and the vaccination series completed as
last hepatitis B vaccine dose at age <6 months should re- age-appropriate. Children with indeterminate concentra-
ceive an additional dose at age 26 months. Those who, have tion after a bYrosterdose should be revaccinated with a com-
received ~3 doses should complete the series at the tecom- plete series.
mended intervals and ages (Table I).
Vcaricelfa Vacdnie
Poliovirus Vaccine Varicella vaccine is not adminkered in the majority of
The simplest approach is to revadcinate internationally countries. A child. who lacks a reliable medical history re-
adopted children with IPV according to the U.S. schedule. garding prior varicella .&ease should be vaccinated as age-
Adverse events after IPV are rare (4). Children appropri- appropriate (8).
ately vaccinated with three doses of OPV in economkaliy
developing countries might have suboptimal seroconversion,
including to type 3 poliovirus (1.25). Serologic testing for Pneumocooeal conjugate and pneumococcal polysaccha-
neutralizing antibody to poliovirus types 1, 2, and 3 can be ride vaccines are.not admkstered in the majority of COUR-
obtained commercially and at certain state health depart-
ment laboratories. Children with protective titers against
all three types do not need revaccination and should cam-
piece the schedule as age-appropriate. Alternately, because
the booster response after a single dose of IPV is excellent
among children who previously received OPV {3), a single
22 MVIMWR ’ , Fcabtuary t&2002

tries and should be administered as age-;tppropriate or as lymphocyte percentages crf 225%) indicare that varicella
indicated by the presence of underlying medical conditions vaccine is immunogenic, effecnve! and safe (138,159). Va-
(2643). ricella’ vaccin,e should Abeconsidered for asympcomatic or
mild+ symptomatic HIV-infected children in CDC class
Altered lmmunocompetence N1 or Al with age+pec& CD4+ T lymphocyte percent-
ACIP’s statement regarding vaccinatitig immuno- ages of ~25%. Eligible children should receive two doses of
compromised persons summarizes recommendations regard- varicella vaccine with a f-months interval between doses
ing the efftcacy, safety, and use of specific vaccines and 1138).
immune globulin preparations for immunocomptomised HIV-infected persons who arc receiving reg&r doses of
persons (14.5). ACIP statements regarding individual vac- IGIV might not respond to vzuiceila vaccine or MMR or its
cines or immune globulins contain addidona! information individual component vaccines because of the continued
regarding those concerns. presence of pas&ety acquired antibody. However, because
Severe immunosuppression can be the resuir of congeni- of rhe potemU bene&, measles vaccination should be con-
sidered approximately 2 we&s before the next scheduled
cal immunodeficiency, HIV inEkction, leukemia, fymphoma,
generalized malignancy or therapy with alkylating agents, dose of IGIV (if not otherwise c&traindicated), although
an optimal immune response is unlikely ro occur. Unless
antimetabolices, radiation, or a high dose, prc$onged course
serologic testing indi~res that specific antibodies have been
of corticosteroids. The ‘degree to which a person is
immunocompromised should be determined by a physi- produced, wccination ,should be repeat?d (if not otherwise
cian. Severe complications have followed vaccination with contra&&at.&} after ‘the recommended interval (Table 4).
live-virus vaccines and live bacterial vaccines “among An additionai dp,M of IGIV should be considered for per-
saris on maintegance IGW therapy who are exposed to
immunocompromised patients (I4&153). These patients
measles,23 weeks after ‘a&+&&g a standard dose (1 OO-
should not receive live vaccines except in certain circum-
stances that are noted in the following paeagraphs. MMR 400 mg/kg body weight) of IGN.
Persons wish celiutar immunodeficiency should not re-
vaccine viruses are not transmitted to contact, and trans-
mission of varicella vaccine vims is rare (6138). MMR and ceive varicella vaccine. Haweyer, ACIP recommends chat
persons wiith .imPaired humoral immunity (e.g.,
varicella vaccines should be administered tu susceptible
household and other close cornacts of immune-compromised hypogammagbbulintimia or dysgammaglobufinemia)
should be v&&at&d (138,160).
patients when indicated.
Inactivated, recomb&am, subunit, pqlysaccharide, and
Persons with HIV infection are at increased risk for severe
complications if infected with measles. No severe or un- conjugate vacc$es and toxoids can be administered to all
usual adverse events have been reported afrer measlesv&i- immunocotipromised patients, although response to such
vaccines mi&t bC suboptimal. ff indicated, all inactivated
nation among HIV-infected pecsons who did not have
vaccines are -recommended for immunocompromised per-
evidence of severe immunosuppre6sion (156157). As a
sons in usual-doses and schedules. In addition, pneumo-
result, MMR vaccination is recommended for all HIV-
coccal, meningococcal, and Hib vaccines are recommended
infected persons who do not have evidence of severe immu-
specifidly for certain groups 5f immunocompromised pa-
nosuppressionti and for whom measles vaccination would
tients,.inclu&g those with, functional or anatomic asplenia
otherwise be indicated.
Children with HIV infection are at increased risk for com- (145 I&).
Except for influenza vaccine, which should be adminis-
plications of primary varicelh and f?r herpes zoster, cum-
rered annually t&8), vaccination during chemotherapy or
pared with immunocompecent children (138,358). L&&red
radiation therapy should be avoided because antibody re-
data among asymptomatic or mildly symptomatic HIV-
sponse is subopsimal. ‘P&enrs vaccinated while receiving
infected children (CDC class Nl or’A1, age-specific CD4’
immunosuppressiye rherapy 0~ in the 2 weeks before stiut-
ing therapy should be considered unimmunized and should
n As defined by a low age-qaiftc tutal CD4’ T lymphcqte cnunt 01 a low CD4’ be revaccinated &J months afrer rherapy is discontinued.
Tlymphoqxcwnt urpenxnngcoftodlymp~.ACIPiecc3mmurdationl
for using MMR vaccine contain additionsI dails regatdiag the criteria fur
Patients with fiukemia in remission whose chemotherapy
severe immunooupprcrsion in persuns with HIV infection (SOWW CDC. ha,s been terminated for 23 months can receive live-virus
Mw.des. mumps, and Nbda - vaccine use and strategiesfbr elimination of vaccines.
meada, rubella, and congenital rubella syndrome and control of mumps:
r~d~~onsof*c~~~~~~ouImmunivttionP l?miccs[ACIPI.
MMWR 1998;4f[No. RR-81:1-57).
Corticosteroids ventable diseases, including those caused by encapsulated
The exact amount of systemically absorbed corticoster- bacteria (i.e., pneum&o~cal and Hib infections). As a re-
oids and the duration of administration needed to $uppress sult, HSa recipients B&Id be rqutinely revaccinated af-
the immune system of an otherwise immunocompetent ter H$n, .rega&ess of the source.of the transplanted stem
person are not well-defined. The majority of experts agree cells. Revaccination with inactivated, recombinant, subunit,
that corticosteroid therapy usually is not a contraindica- polysaccharide* and- Hib ,vpccines should begin 12 months
tion to administering five-virus vaccine wbe,n it’is short- after HSdT (X2)). A’n exception 6 this recommendation
term (Le., <2 weeks); a low,to moderate dose; long-term, is for influenza vaccine, which should be admir&te&d at
alternate-day treatment with short-acting preparations; 26 months &er HSirr and annually for the life of the re-
maintenance physiologic doses (replacement therapy); or cipient thereaf’ter, MMR vaccine’shoufd be administered
administered topically (skin or eyes) or by intra-articular, 24~ months after transpfantation if the HSCT recipient is
bursal, or tendon injection (143. Although of theoretical presumed to be immunocompetent. Varicella, meningo-
concern, no evidence of increased severity of reactions to coccal, and pneum+zoccai.conjugate vaccines are not rec-
live vaccines has been reported among persons receiving ommended for~MS@T recipientj because of insuf&ient
corticosteroid therapy by aerosol, and such therapy is not a experience using these’vaccines among HSCT recipients
reason to delay vaccination. The immunosupprcrsive &ects (162). The household and clthr?r close co$acrs of HSCT
of steroid treatment vary, but the majority of clinicians con- recipierits and health-care -workers who care for HSCT re-
sider a dose equivalent to either 22 mglJcg of bady weight cipients, should be appropriately vaccinated, including
or a total of 20, mglday of prednisone or equivalent for chil- against influenza, r+sles, and variceflaa.Additional details
dren who weigh ~10 kg, when administered for 12 weeks of vaccinatjon of~H6CT recipients and their contacts can
as sufficiently immunosuppressive to raise concern regard- be found in a specifio.CDi= &port on this topic (162).
ing the safety of vaccination with live-virus vaccines
(34,145). Corticosteroids used in greater than physioIogic
doses also can reduce the immun&,response to vaccines.
Vaccination providers should wait 21 month a&r discon-
tinuation of therapy before administering a. live-virui vac-
Persons with bleeding &orders (e.g., hemophilia) and
cine to patients who have received high systenically
persons receiving anticoag&nt therapy have an increased
absorbed doses of corticosteroids fat 12 weeks.
risk for acquiring~ hkpatitis” B and at least the same risk as
the general ‘popuiarion of acquiring ocher vaccine-
Vaccination of Hematopc$liefic preventable~ diseases. However, because of the risk for he-
Stem Cell Trcmsplanf Recipients matoma formation a&r injections,~inuamuscular injections
Hematopoietic stem cell transplant (HSCXJ is the infu- are often avoided ambng persons with bleeding disorders
sion of hematopoietic stem cells from a donor i&o a-patient by using the s&cutaGeous or intradermal routes for vac-
who has received chemotherapy and often radiatiojn, both cines that are administeted normally by the intramuscular
of which are usually bone marrow ablative. HSCT is used route. Hepatitis B vaccine &dministered in&muscularly to
to treat a variety of neoplastic diseases, hematolqic disor- 153 persons with h ophilia by using a 23-gauge needle,
ders, immunodeficiency syndromds, congenital enzyme followed by sre’ady ssure u> the site for 1-2 minutes,
deficiencies, and autoimmune disorders. HSCT recipients resulted in a 4% &&sing rate with no patients requiring
can receive either their own cells (i.‘e., autologous HSCT) factor sup$ementation (168). Whether antigens that pro-
or cells from a donor other than the transplant recipient duce maze local reactions (e.g., pertussis} would produce
(i.e., allogeneic HSCT). The source of the t;ansplanted stem an equally low r& of brui&g is unknot.
cells can be from either a donot’s bone marrow or periph- When hepatitis B or any other intramuscular vaccine is
eral blood or harvested from the umbilical card of a new- indicated for a -patient with 3 bleeding disorder or a person
born infant (Z62). receiving anticoagulant -therapy, the vaccine shoufd be ad-
Antibody titers to vaccine-preventable diseases(e.g,, teta- ministered ~~~~~~u~r~y,if, ‘m the opinion of a physician
nus, poliovirus, mea&s, mumps, rubella, and encapsulated f&miliar with r&e.patiMst’s l+eding risk, the vaccine can be
bacteria) decline during the 1-4 years after allogeneic or au- administered with reas~n+Ie safety by this route. If the
tologous HSCT if the recipient is not revaccinated (16~167). patient receives “a~tih~moph~~a or similar therapy, intra-
HSCT recipients are at increased risk for certain vaccine-pre- muscuiar vaccinations can be scheduled shortly after such

---- ---- - .

MMWR ^ Februarv 8.2002

therapy is administered. A fine needle k.23 gauge) should tered, ACIP recommends that this same information be
be used for the vaccination and firm pressure applied to the kept for all vacchs, not just for those required by the Na-
site, without rubbing, for 22 minutes. The patient or fam- tional Childhood Vxcine- Injury Act.
ily should be instructed concerning the risk for hen+toma
from the injection. Patients’ IFkmmal Records
Official, immrinitation cards have been adopted by every
state, territory, and the District of Columbia to encourage
Vacc,ination Records
uniformity .of records .and xo lFdcilitate assessmentof immu-
Consent to Vaccinate nization status by s&o& and child care centers. The records
The National Childhood Vaccine Injury Act of 1986 (42 also are in immunization education programs aimed
U.S.C. 5 3OOaa-26) requires that ail heaich-we prov$ers at increasing parental &d patienr awareness of $e need for
in the United States who administer <anyvaccine covered by vaccines. A permanent immunization record card should
the act55 must provide a copy of the r&aant, current edi- be established for each n&born infanr and maintained by
tion of the vaccine information materials that have been the parent .or guardian. In certain states, these cards are
produced by CDC before administering each dose of the distributed to n&v m,others before discharge from the hos-
vaccine. The vaccine information material must be provided pit& ,Wsing imtiunizatian record cards for adolescents and
to the parent or legal representative of any child or to any adults also is encouraged.
adult to whom the physician or other health-care provider
intends to administer the vaccine. The Act does not require Registries
that a signature be obtained, but documentation of con- Immunization registries, are confidential, population-
sent is recommended or required by certain stare or local based, compure+zed~infor&a~on systems that collect vac-
authorities. cination data fer as many children as possible within a
geographic area. 1RegistGes are a critical tool that can in-
Provider Records crease and sustaicl increased vaccination coverage by con-
I Documentation of patient vaccinations helps ensu~c that solidating vaccination records of children from multiple
persons in need of a vaccine receive it and that adequately providers, generating reminder and recall vaccination no-
vaccinated patients are not overimmunized, possibly in&as- tices for each child, and providing offxial vaccination forms
ing the risk for local adverse events (e.g.; tetanus toxoid). and vaccina&n coyerage assessments (10). A fully opera-
Serologic test results for vaccine-preventable dies (e.g., tianal immunization registry also can prevent duplicate vac-
those for rubella screening) as well as documented episodes cinations, limit missed appointments, reduce vaccine waste,
of adverse events also should be recorded in the permanent and reduce sta# time requites to produce or locate immu-
medical record of the vaccine recipient. nization rem& or c&if&z&es. The National Vaccine Advi-
Health-care providers who administer vaccines covered sory Committee strongly encourages development of
by the National Childhood Vaccine Injury Acx are required comm&ity- or state-based immunization registry systems
to ensure that the permanent medical record of the recipi- and recommends char vaccinatibn providers participate in
ent (or a permanent office log or file) indicates the date the these registries whenever possible {l70,Z72). A 95% par-
vaccine was administered, the vaccine manufacturer, the ticipario~ of-c&$&en aged ~6 years in fully operational
vaccine lot number, and the name, address, and rirlc of the population-based .irmm&zition registries is a national
person adt&nistering the vaccine. Additionally, the provider health objective far 2010 (172).
is required to record the edition date. of the vaccine kfob~-
mation materials distributed and the date those mareriais
were provided. Regarding this Act, the term be&&-carepro-
vi&r is defined as any licensed health-care professional, or-
ganization, ot institution, whether private of pu.blic Modern vaccines am safe atid ef&ctive; however, adverse
(including federal, state, and local deparrinenu and agen- events have been reported &er administration of all vaccines
cies), under whose authority a specified vsccine is adminis- (82). These events range fro& ftequent, minor, local reactions
S’As of January 2002, vaccine covcrcd by the act include diphtheria, rcw”nw,
to ext&mety rare, seveie, systemic illness {e.g., encephalupa-
pcrcussis.marks, mumps, rub&, poliovirus, hepadris 8, Hib, varicdla, and thy). Etablishing evidence for cause-and-effect relationships
&mwwaal conjugate. on the basis bf case reports and case series alone is impos-
._- .--_

Vol. 51 I RR;2 R~qommqfldatiorts and Reports “25 I’

sible because temporal association alone does not necessar- the table is proven, thus avoiding the need to prove actual
ily indicate causation. Unless the syndrome chat occurs af- causation in an individual case. Claimants also can prevail for
ter vaccination is clinically or pathologically distinctive, more conditions not listed in the table if they prove causation. Inju-
detailed epidemiologic studies to compare the incidence of ries after’administration of vaccines not listed in the legisla-
the event among vaccinees with the incidence among un- tion authorizing the program are not eligible for
vaccinated persons are often necessary Reporting adverse compensatitm ,thmug~ the program. Additional informa-
events to publid health authorities, including serious events, tion is ava&ble from the foiloiruing.
is a key stimulus to developing studies to confirm or refute National, Vaccine Injury Compensation Prugram
a causal association with vaccination.. More complete i&or- HeaIch Resources and Services Administration
mation regarding adverse reactions to a specific vaccine can Pa&lawn B$lding, Room 8-46
be found in the ACIP recommendations for that vaccine 5600 .Fishers Lane
and in a specific statement on vaccine adverse reactions (S.2). Rockville, MD 30857
The National Childhood Vaccine Injury Act requires Telephone: 800-338-2382 (24-hour reco$ing)
health-care providers to report selected events occurring af- Internet: http:/4 wwwhrsa.govlbhpr/vicp (accessed
ter vaccination to the Vaccine Adverse Event Reporting Sys- November 7, ZQOl)
tem (VEERS). Events for which reporting is required appear Persons wishing ‘to fild ‘a claini for vaccine injury should
in the Vaccine Injury Table. si Persons other than health- call or- write the folhrwingz
care workers also can report adverse events to VAERS. Ad- US, Court of Federal Claims
verse events other than those that must be reported or that 717 Madison, PIace, N.W
occur after administration of vaccines not covered by the Washington, D.C. 20005
act, including events that are serious or unusuat also should Telephon‘e: 202-2 19-9657
be reported to VAERS, even if the physician or other health-
care provider is uncertain they are related causally. VXERS Benefit and Risk Communication
forms and instructions are available in the FDA I%ug Rul- Parents, guardians, legal representatives, and adolescent
Ietin, by calling the 24-hour VAERS Hotline ‘at 800.822- and ad& patients should be ‘informed regarding the ben-
7967, or from the VEERS website at http:J/ efits and risks of vaccines in understandable language. Op-
(accessed November 7, 2QOI). portunity for questions. sh;ouId be provided before each
vaccination. Discus&m of the benefits and risks of vaccina-
Vaccine In jury Compensafion PIrqgram tion is sound .med$+ practkc and is .required by law.
The NationaI Vaccine Injury Compensation Program,,es- The National C&ld@od Vaccine Injury Act requires that
tablished by the National Childhood Vaccine fnjury Act, is a vaccine information materials be developed for each vaccine
no-fault system in which persons thought to have suffered an covered by the Act. These mater&, known as Vacn’ne In-
injury or death as a result of administration of aeovered vac- firqtition StatRmcnts, must be provided by all public and
cine can seekcompensation. The progaam, which became op- private vaccination. providers each time a vaccine is admin-
erational on October I, 1988, is intended as an alternative to istered. Copies of Vaccine Inf&ation Statements are avaif-
civil litigation under the traditional tort system in that aegli- able from state health authorities responsible for
gence need not be proven. Claims arising from covered vac- immunization, or thejr can be obtained from CDC’s Na-
cines must first be adjudicated through the program before tional Immunizarion program website at http://
civil litigation can be pursued. www.cdc,gov/nip (accessed Ntivember 7, 2001). Tmnsla-
The program relies on avaccine InjuryTable listing thcvac- tions of%@ne Qxfotm~tion Statements into languagesother
tines covered by the program as well as the injuries, disabili- than English are avai able‘Eom certain state immunization
ties, illnesses, and conditions {including death) for which programs and from the Immunization Action Coalition
compensation might be awarded. The, tabie defines the time website at ht~~/J~~m~ni~.o~ (accessedNovember 7,
during which the first symptom or substantial aggravation of 2001).
an injury must appear &et vaccination. Su~ces&l claimants Health-care providers should anticipate that certain par-
receive a fegal presumption of causation if a condition listed in ents or patients will question the need for or safety of vacci-
nation, refuse certain vaccines, or even reject all vaccinations.
~TbeVaccinelnjuryTablecrn beobtained from tbeVwincInjury~~~&n
A limited number of persons might have religious or per-
program Internet site at <hcrp://www.hrsa.dhhs.go~/bh~r/vicplrable~hrm> sonal objections to.vac&a~ions. Others wish to enter into
(accessedNovember 7, 2001).
26 _ i1 I” MMWR February 8.2002

a dialogue regarding the risks and benefits of certain vac- a critical part of quality health care and should- be accom-
cines. Having a basic understanding of how patients view plished thrcugh r&wine and intensive vaccination programs
vaccine risk and developing effective approaches in dealing implemented in physicians’ offices and in public health clin-
with vaccine safety concerns when they arise is imperative ics. Programs should be estabh~hed and maintained in all
for vaccination providers. communities to ensure vaccination of all children at the
Each person understands and reacts to vaccine infirma- recommended age. In addition, appropriate vaccinations
tion on the basis of different factors, including prior experi- should be available for all adolescents and adults.
ence, education, personal values, method of data Physicians and other pediatric vaccination providers
presentation, perceptions of the risk for. disease, perceived shot&l- adhere to the standards for child and adolescent im-
ability to control those risks, and their risk preference. Xn- munization practices (1). These standards define appropri-
creasingly, through the media and nonauthoritative inremet ate vaccination practices for” both the public and private
sites, decisions regarding risk are based on ir+curate infor- sectors. The standards provide guidance on practices that
mation. Only through direct dialogue with parents and by will result in eliminating barriers to vaccination. These in-
using available resources, health-care professionals can pre- clude practices aim&l ‘at eliminating unnecessary prerequi-
vent acceptance of media reports and information:from sites for receiving vaccinations, eliminating missed
nonauthoritative Internet sites as scientific fact. opportunities to vaccinate, improving procedures to assess
When a parent or patient initiates .discussion regarding a vaccination needs, enhancing knowledge regarding vacci-
vaccine controversy, rhe heahh-care professional should dis- nations among parents and providers, and improving the
cuss the specific concerns and provide factual information, management and reporting, of,adverse events. Additionally,
using language that is appropriate. Effective, empathetic the standards address the’importance of recall and reminder
vaccine risk communication is essential in responding to systems and using assessments to monitot clinic or office
misinformation and concerns, although recognizing that for vaccinatian caverage tevels among pacients.
certain persons, risk assessment and decision-making is dif- Standards ,oEpm&c also have.been published to increase
ficult and confusing. Certain vaccines might be acceptable vaccination coverage among adults (2). Persons aged $5
to the resistant parent. Their concerns should then be ad- years and all adults with medical conditions that place them
dressed in the context of this information, using the Vac- at risk for pnet&coccaI disease should receive 21 doses of
cine Information Statements and offering orher resource pneumococcal polysaccharide vaccine. All persons aged 250
materials (e.g., information available on the National Im- years and those with medicalconditions that increase the
munization Program website). risk for complications from influenza should receive annual
Although a limited number of providers might choose to influenza vaccination. All adults should complete a primary
exclude from their practice those patients who question or series of teranus and ~~~h~~r~a toxqids and receive a booster
refuse vaccination, the more effective public health strategy dose every 10 years. Adult vaccination programs also should
is to identify common ground and cbscuss measures that provide MMd and varicella vaccines whenever possible to
need to be followed if the patient’s decision is co defer vac- anyone susceptible to measles, mumps, rubella, or varida.
cination. Health-care providers can reinforce key points. re- Persons born aFter 1956 who are attending college [or ocher
garding each vaccine, including safety, and emph&z.e risks posthigh s&c4 ~ucutianal,institutions), who are employed
encountered by unimmunized children. Parents shoufd be in environments that place them at increased risk for measles
advised of state laws pertaining to school OY child care en- transmission (c& he&h-care facilities), or who are travel-
try, which might require that unimmunized children stay ing to areas.with endemic measles, should have documen-
home from school during outbreaks. Qocumentation ofthese ration of having rcceivcd two d&es of MMR on or after
discussions in the patient’s record, including the tefmai to their first b&h&y- or other evidence of immunity (6173).
receive certain vaccines (i.e., informed refusal), might re- All other adultsborn r&r 1946 should have documenta-
duce any potential liability if a vaccine-preventable disease tion ofil doses of MMR vaccine on or after their first birth-
occurs in the unimmunized patient. day or have other evidence of immunity. No evidence
indicates that administering MMR vaccine increases the
risk for adverse reactions among persons who are already
Vaccination Praigrrtms immune to measles, mumps, or rubelia as a result of previ-
The best way to reduce vaccine-preventable diseasesis to ous vacciuation pr disease. Widespread use of hepatitis B
have a highly immune population. Universal vacdnqzivn is vaccine is encouraged for 2u persons who might be at in-

Vol. 51 I RR-2 Recommandatlons and RepMs 27

creased risk (e.g., adolescents and adults who are eirhe; in a terventions co promoze he&h and prevent disease, injury,
group at high risk or reside in areas with increased rates-of disability, and premature death. The recommendations are
injection-drug use, teenage pregnancy, or s~x&lly trans- based on systen@c reviews of the scientific ,lieeratute re-
mitted disease). garding ’e&cdvenesI; and cost-effecttveness of these inter-
Every visit to a physician or other health-care provider ventions. In addition, the Task Force identifies critical
can be an opportunity to update a patient’s immunization inform&m regarding the other effects of these incerven-
status with needed vaccinations. Official health agencies [ions, as weil as the ppplicability to, specific populations
should take necessary steps, including developing and en- and settings irnd the potential barriers to implementation.
forcing school immunization requirements, to ens&e that This information is a&Glable through the Internet at
students at all grade levels (including college) and those in http:/! (accessed November 7,
child care centers are protected ag$st vaccine-preventable 2001).
diseases.Agencies also should endourage institutions (e.g., Begiming,in, 1336, the Task Force sy~temarically reviewed
hospitals and long-term care facilities) to adopt policies re- published evi+nce on the &&ctiveness and cost-effectiveness
garding the appropriate vaccination of patients,~ residents, of population-basedinterv&ti,ons to increase coverage of vac-
and employees (1.73). cines recommet+d~ for roxst$e use among chiidren, ado-
Dates of vaccination (day, month, and year) should be lescents, arrd adults. A to4 of 197 articles were identified
recorded on institutional immunization retards (e-g., those that evaluated a relevairt ir,mzvenrion, met inclusion crite-
kept in schools alld child care centers). This record will ria, and were pUblished during 3980-1997. Reviews of 17
facilitate assessments that a primary vaccination series has specific interven$ons -were published in 1999 (~?‘4-,~76).
been completed according to an apprapridte schedule and Using the resul+ of their ra+w, the Task Force made rec-
that needed booster doses have been administered at the ommendations regarding ihe use df these interventions
appropriate time. (177). A number. of iaterventions were identified and rec-
The independent, nonfederal Task Force on Community ommended on the basis 06’published evidence.,The inter-
Preventive Services (the Task Force) gives public health ventions and, the rectimmenddons are summarized in this
decision-makers recommendations on population-based in- report {Table 7).

TABLE 7. Summary of r%comm%ndations regerdtng ~ntenrentione to imprtp4 ooyerage of vifqb&%e recommended for routine use
among children..adol‘%scents. and adults*
Dntervhntfon R~~m”e~d~~~n
interventfone that Increaee community demand for Inlm&Zettons
Client reminder or recall systems Strong& recamme~ded
Multicomponent interventions, including education StronSly rsoorqmencfed
School-, child care-, end college-entry requirements Recommended
Community education alone insuffiiient evi+ce
Clinic-based education hsutfieiimt ev’ntence
Patient or family incentives or sanctions lnsufffiient evktefjce
Cliant-held medical records f nsulf&ier+t stitieti
Intervbtkns that enhance acceee to vaccinatkn eervkae
Reducing out-of-pocket costs Strengfy rewmmebd L
Enhancing access through the U.S. Department of Recommanded
&dculture’s Women, Infants, and Chitdreti program
Home visits, outreach, and case managemeht Reoommended
Enhancing access at child care cenlars lnsuffidsflt evidence
Enhancing access at schools Insufiiti evkienae ,
Expanding access in health-care settings Rec9mtnemfsd ds Sart of ~~i~~nant interventions only
lnterventlons that target grovlders
Reminder vr reedi syslems Strongfy rewmme$ad
Assessment and feedback Strong& tewmmenc@d
Standing orden Strongly ritcomrner&d
Provider education alone Insufff*nt widence
l Adapted from Task Force on Community Preventive &wvfc+ Rbrnmandetions ~~~“~te~~~~~e to irnpbfe v&cfnation coveraga in chifdren,
adolescents, and adults. Am J Prev Med 2000;18~1 Supp&92-6.
.- -_--

28 MMWR February 8,2002


Vaccine information Sources Americqn Acidly arf’Family

In addition to these general recommendations, other Physicians FP) .--
sources are available that contain specific and,updatcd vac- Infdrmation from rhe prufessionai organization of family
cine information. physicians is available at httprJ/ (accessedNo-
vember 7,200l).
National Immunization Information
Hotline lrn~u~j~~t~~~ A&+ Clouli#ion
The National Immunization Information Hotline is sup- This source provides extensive free provider and patient
ported by CDC’s National Immunization Program and pro- information, including uanshxions of Vaccine Information
vides vaccination information for health-care providers and Statements into multiple .languages. The Internet address
the public, 8:OO am-l 1:00 pm, Monday-Friday: is (accessed November 7, 2001).
Telephone (English): 800-232-2522
Telephone (Spanish): 800-232-0233 Nathnaf Network. fo.r Immunization
Telephone (TTY): 800-243-7889 Informatign,
Internet: This information source is provided by the Infectious Dis-
(accessed November 7, 2001) easesSociety ofA.&xica, Pediatric Infectious DiseasesSociety,
W, American Nurses Association, and other professional
CDC’s National Immunization‘Program organizations. It provides objective, science-basedinformation
CDC’s National Immunization Program website provides regarding vaccines for the Pub&c and providers. The Internet
direct accessto immunization recommendations of the Advi- site is h~pJlwwvv.immu4izoni~fo.o~g (accessedNovember
sory Committee on Immunization Practices (ACIP), vaccina- 7,200l).
tion schedules, vaccine safety information, publications,
provider education and training, and links to other Vaccine Education C&n&r
immunization-related websites. Ic is located at http:// Located at the Chiidren’s HosPitaiofPhiladeiphii, this source (accessed November 7, 2001). provides Patient and provider information. The Internet ad-
dress is http:/ (accessedNovember 7,
Morbidity and Mortality Weekly Repoti 2001).
ACIP recommendations regarding vaccine use, statements
of vaccine policy as they are developed, and reports of specific hnstitufe for ccine Sufety
disease activity’ are published by CDC in the Mcwbiditj and Located atJohns Hopkins University School of Public
Mortality Weekly Report (MMWR) series.~ Electronic HeaIth, this source provides information regarding vaccine
subscriptions are free and available at http://wwwcdc.govl s&g cxmcems andobjectiire and timely infwmation to health-
subscribe.html (accessed November 7, 2001). Printed sub- care providers and .pacents. It is available at http://
scriptions are available at (accessedNovember 7,200 1).
Superintendent of Documents
U.S. Government Printing Office
Washington, D.C. 20402-9235
This national organization’encourages greater acceptanceand
use of vaccinations for al1agesthrough partnerships with pub-
American Academy of Pediairks (+P) lic and private organizations~ Their Internet address is http://
Every 3 years, AA.P issues the Red Book: Report oftbe Gm- (accessed November 7,
mittee on Infatious DiscaEcJ,which contains a composite sum- 2001).
mary ofAAP recommendations concerning infectious diseases
and immunizations for infants, children, and adolescents State und bcal Hed%h Depcwtments
Telephone: 888-227-1770
State and focal health dep~~e~~ provide technical advice
through hotlines, electronic mail, and Internet sites, includ-
(accessed November 7, 2001)
ing printed informacian regarding vaccines and immunization
schedules, posters, and otherr educational materials.
Vol. 51 I RR-2 Recommendations agd f%@po!ts 29

Acknowledgtnents 14. King GE, Hadk~:SC:Simuttanceus administration of childhood vat-

The members of the Advisory Committee on imporunt public heakh policy rhat is safeand e&acious.
Immunization Practices are grateful for the contributions PediatrInfcer DjsJ 1934;13:394&07.
1’5.Dash&&-B, Wald E, Guctra N, Bycrs C. Safety, tokrabiliry, and
of Margaret Hostetter, M.D., Yale Child Health Research
immw@ciry bf concuIcRt admiismdon of N@m&& inpumvrC
Center; Mary Swat, M.D., Childfen’s Hospital Medical type B conjugate,~cc&@n*nEngococzai protein conjugate) wirh ci-
Center of Cincinnati; Deborah Waler, M.D., Immunizwion d& mtislccmumps-Nbclli-va~e~nc or diphthrria-tcmnus-pert&s
Action Coalition; and John Grabenstein, Ph.D., U.S. Army and orltpolioviriis v&&es in 14- zo i3-month-otd irifanu. Pediatrics
Medical Command. 1990;85(4 Pr~i):@Z-9.
16. Giammancb G, Li V&i S, Ma? i, Immune rcsponx to simul-
Reterences ta&o&sadmi+aticmofa recombimmt DNA hepatitis B yrccine and
1. CDC. Standardsfor pediatric immunization practices:recommended multiple compultary vaccinesin infancy. Vaccine 1991;9:747-SO.
by rhc National Vaccine Advisory Committee; approved by the U.S. 17. Shin&& Hk Black SB, Siaehle SC& et al. Safety, tdcmbility and
Public Health Service.M M W R I 9Y3;42(No. RR-S): l-13.‘“” im~tmog&city
I ,” of ccncon&ant injections in separatelocations of
2. CDC. Health objectives for the narion public health burdin of vac- M-M-R@,,,VAR%VAX*and ~RAMUNE* in healthy childrm vs.
cine-preventablediseasesamong adults: scandardsfor adult irrimuni- comzomitantin&&oar ofI&M;R@,, and TETRAMUNE* followed
ation practice. M M W R 1990;39:725-9.‘** six WC& Iiecr by VARQXX~. I%d&tr f&-&t Dis ] 199& 17:9@l-5.
3. CDC. Poliomyelitis prevention in the United States:intraductionofa 18. CDC.Tshoid immunimdon: recommendationsoftheAdvisory Com-
sequentialvaccination schedule of inactivated poliovirus vaccine f& mirtee on ~Immukiaation Prjlaiccs (AC%?). M M W R 19%43(No.
lowed by oral poliovirus vaccine; recommendari~nr of the Advisory ,RR-14):1-7.
&nmittee qn Immunization Pm&es (ACIP). M M W R 1997;4G(No 19. DeS+o F, Goodman ,,m, Noble GR, McClary GD, Smirk SJ.
RR-3):1-25. Broome C\i, ?im,$tliatolrr a&n&trarion of inlluenaa and pncumo-
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mendations of the Advisory Committeecon Immunization Pncdao 20. Yvonnet B, Co-get %#De+lV# Diop-Mar l; Digourrc jP, Cl&on
(ACIP). M M W R ZOW,4Y(No, RR-5):1-22. J. Sit&taneous admi.nistticion of hepatitis B and yellow ferer vacci-
5. Plotkin SA. lmmun~logic correlatesof protection induced by vaccina- nations. J‘&&d ViroS 1986;19:307-I 1.
tion. Pcdiatr Infect Dis J 2001;20:63-75. 21. St&no I, Sate H& Panmati 9, cr al. Recent immunization against
6. CDC. MeaFles,mumps, and rubella--vaccine uso,and strategiesfor me&s doesnot intcrkre with ihc se&espouse to yellow &i vat-
elimination of mea&s. rubella, and congenital rubella syndrome and cink v&&c ~9~.17;1042-6.
control of mumps: recommendationsof the Advisory C&nmirtee on 22. CI.%; Yellow f&ver vaccinc:‘n~mendationr of the lmmuniaation
Immunization Practices(ACIP). M M W R 199&47(No. RR-&t-57. P&&es Advisory Committee (ACIP). M M W R 1990;S9(No. RR-
7. Watson JC, PearsonJA, Markowia LE, et al. Evaluation of ‘measles G&6.
revaccination among school-entry-aged children. Pediatrics 23. Shincficld HR, Black S, Ray‘P. et ai. S&y and immunogenicity of
19YGmGl3-8. hcptavalentpntimococcal CRM,, cettjugatc vaccine in infanti and
8. CDC. Prevenrionofvaricclla: recommendationsof the Advisory Com- roddkrs. P&a& I&t Dis J. 1999;18;757-63.
mittcc on Immuniaation Practices (ACIP). Mh$WR 1996;$5(Na. 24. CDC Hacmoph&~~@amjug&evaccina far preventionoff;/amropku
RR-I X):8. ;npMmzartype b,diseaseWang infanm an(! children two mot&s of
9. CDC. Human rabies prevention-Unit& States, IY99; rccommcn- ageand older: reconiti~dzricms cf rhc Immunization PracticesAdvi-
Ltions of chcAdvisory Committee on Immunization Practices(ACIP). sory C0m+.t& (AClP)i MMWKl991;4O(No. RR-l):l-7.
M M W R 1999;48(No. RR-l):l-21. 25. CDC. Percussisvac&~rlo~: use,ofac&dar percussisvaecincsamong
10. Levine L, EdsaIl G. Tetanus toxoid: what determines,reactionprone- inha and young children: recommendationsof the Advisory Com-
ness [Letter]! J I&cc Dis 1981;14~376., mircec on Immunization Pr;rctices (ACIP). M M W R 1997;46(No.
11. Edsall, G, Ellior M%! PeeblesTC, LevimeL, Eldrcd MC. Excessive RR-7)X1-25*
use of tetanustoxoid boosters.JAMA 1967;202:17-9. ’ 26. CDC, Ptmntiag pnettmoco+l die among i&nu and young
12. Hutchins SS,FscolanJ, Markowia LE, etaI. Measkseu~breakunong childntrc rymnmadad~maf the Advisety Committee on Immuniza-
unvaccinatedprcsrhool-agechildren: oppor&ies‘missed by he&b don Praeeicep(ACIP). MI\;NPR 2OW4Y(No. RR-Y):l-35.
care providers to administer measles vaccine. Pediatrics 27. CDC. CombiLtion ‘tic&es for childhood immunization: remm-
1989;83:369-74. mend+ons &f the Advisory Con&tree on Immunization Practices
13. Deforest A, Long SS, Lischncr I-i%! et al. Simuiraneousdmipisera- (ACID); the &nerican &dcmy o@cdia,criu (AAP), and the Amctian
tion of measles-mumps-rubella vaccine with bobstcr doses of Academy of Family Physicians(A!@). M M W R 1999;48l$Jo. RR-
diphtheria-tetanus-pertsis and poliovirus vaccines. Pediatrics 5):5. ’
1988;81:237-46. 28. Pet&i JK, Ma+pn TC, Wilb+ J% Ac$on of endogenoosinterferon
ag+st vatinic i&&on in &i&en. I.&cet 1965;2:401-5.
29. Perralli, JK, M&iganTC, Wilbur JR. Circulating interferon af&
masks vaccination. N Eng J ,Med 1965373: 198-201.
cp* Standards for pediatric,adolescent,
and adult immunizarionprsctice~spbbeiig 30. CDC.%m&aneaus adminismtion ofvaricellavatine and ochu rec-
revisedandwill k postedon CDC’sNational ImmunizacionPmgram In-c omm&fed chikih~od v&cinr+--Urdtcd States,1995-t 999. M M W R
site (http://wwwcdc.govfnip;accursedNovember7, ZODlt ti soon ei the 2001;50:1058-@.
-- .--

30 ~~WR February%2002

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MMWR February a, 2002

Abbreviations Used nical etrors in .vaecine preparation, handling, or adminis-

tration; 4) coincidental: associated temporally with .vacci-
in This Publication
natian by chance or caused by underlying illness. Special
AAFP American Academy of FamilyPhysicians studies are needed to determine if an adverse event is a reac-
American Academy of Pediatrics tion or the resulc,of another cause (Sources: Chen RT. Spe-
ACIP Advisory Committee on Immunization Practices cial method$ogical issues in ,pharmacoepidemiology studies
DT pediatric diphtheria-ten&s toxoid of vaccine safety In: Scroti EL, ed. Pharmacoepidemiology.
DTaP diphtheria and tetanus toxoids and acelfular 3d ed. Sussex, Engkpvk John Wiley & Sons, 2000:707-
pertussis vaccine 32; an+ FenicheI GM, Lane DA, Livengood JR, Horwin
D-l-P diphtheria and tetanus toxoids and whole-cell SJ, Menkes JH, Schwartz JF. Adverse events following im-
pert&s vaccine munization: assessing prbbabihty of causation. Pediatr
EWELISA enzyme immunoassay Neud 1989;5:2%7-90).
FDA Food and Drug Administration Adverse reaction. An undesirable medical condition that
GBS Guillain-Barre syndrome has been demonstrated to be caused by a vaccine. Evidence
HBIG hepatitis B immune globulin for the causal relationship is usually obtained through ran-
HbOC diphtheria CRM,,, (CRM, cross-reactive domized clinical trials, controlled epidetniologic studies,
material) protein conjugate isolation of the vaccine strain from the pathogenic site, or
HBsAg hepatitis B surface antigen recurrence of the condition with repeated vaccination (i.e.,
Hib Harmopbilus iny%azac type b rechaBenge)s synonyms include side effect and adverse ef-
HIV human immunodeficiency virus feet} .
HSCT hematopoietic stem cell transplant Immunobi&gi~ Antigenic substances (e.g., vaccines and
IgG immunoglobulin G toxoids) or antibody-containing preparations (e.g., gIobu-
IGN intravenous immune globulin Iins and antitoxins) from human or animal donors. These
IPV inactivated poliovirus vaccine producrs are used for active’ or passive immunization or
Jh jet injectors therapy. The foBowing are examples of immunobiologics:
MMR measles, mumps, rubella vaccine %tcciue. A suspension of live (usually attenuated) or
OPV oral poliovirus vaccine inactivared.microorganisms (e.g., bacteria or viruses) or
OSI-LA Occupational Safety and Health Adminisrration fractions thereof administered to induce immunity and
PCV pneumococcal conjugate vaccine prevent ir&+ious disease or its sequelae. Some vaccines
PPD purified,protein derivative contain l&My- defined antigens (e-g-, the polysaccha-
PRP-OMP polyribosylribitol phosphare-meningococcal ride of Wus~e#!~ i@tienzac type b or the surface
outer membrane protein antigen of hepatitis B}; others have antigens that are
PRP-T PRP-tetanus complex or incompletely defined (e.g., killed Bor&&z
PPV pneumococcal polysaccharide vaccine percussis or live arxenuated viruses).
Td adult tetanus-diphtheria toxoid Toxoid. A modified bacterial toxin that has been
VAERS Vaccine Adverse Event Reporting System made nontoxic; but retains the ability to stimulate the
VAPP vaccine-associated paralytic polio formation of antibodies to the toxin.
Immune globulin., A sterile sohttion containing an-
tibodies, which arc usually obtained from human blood.
Definitions Used in This Repoti It is obtained by co14 erhanol fractionation of large pools
Adverse event. An untoward event that occurs after a vac- of blood plasma and contains 15%-18% protein. In-
cination that might be caused by the vaccine product or tended for intramuscular administration, immune
vaccination process. It includes events that are 1) vaccine- glob& is primarily indicated for routine maintenance
induced: caused by the intrinsic characteristic of the vac- of immunity among certain immunodeficient persons
cine preparation and rhe individual response of rhe vaccinee; and for passive ‘protection against measles and
these events would not have occurred without vaccination hepatitis A.
(e.g.> vaccine-associated paralytic poliomyelitis); 2) vaccine- Intravenous immune giobulin. A product derived
potenriated: would have occurred anyway, but were pre- from btbod plasma from a donor pool similar to the
cipitated by the vaccination (e.g., first febrile seizure in a immune globulin pooh bur prepared so that it is suit-
predisposed child); 3) programmatic error: caused by tech-
Vol. 51 I RR-2 Recommendations and: Reporta 35

able for inrravenous use. Intravenous immune globulin V&ination and ~~rn~~~~~on. The terms vuc&c and
is used primarily for replacement therapy in primary vaccinatiorr- are derived from vacccIE,the Latin term for cow.
antibody-deficiency disorders, for treatment of Kawasaki Vaccine was the term used by Edward Jenner to describe
disease, immune thrombocytopenic purpura, material u&d (i.e., cowpox virus) to produce immunity to
hypogammaglobulinemia in chronic lymphocytic ,leu- smallpox. The term vti&r&~ we used by Louis Pasteur
kemia, and certain cases of human immunodeficiency in the lYh century to indude the physical act of adminis-
virus infection (Table 2). tering any vaccine or soxoid. ImJnlnrzation is a more inclu-
Hyperimmune globulin (specific), Special pmpara- sive term, -denoting .tbe process of inducing or providing
tions obtained from bIood plasma from donor pools immunity by ztdministering an immunobiologic. Immuni-
preselected for a high antibody content against a spe- zation carx be aaiv~. at passive. Active immunization is the
cific antigen (e.g., hepatitis B immune globulin, vati- production‘ofantibady or othet immune responses through
cella-zoster immune globulin, rabies immune globulin, administration‘ of a vacc& or toxoid. IJiuJive immunization
tetanus immune gIobdin, vaccinia immune giobuiin, means the ptovision of temporary immunity by the admin-
cytomegalovirus immune globulin, respiratory syncy- istration of prefoformed‘ antibodies. Four types of
tial virus immune globulin, botulism immune globu- immunobiologics are administered for passive immuniza-
lin). tion: 1) pooled human immune globulin or intravenous
Monocionll antibody. An antibody product prepared immune giobuli$ 2) hyperimmune globulin (specific)
from a single lymphocyte clone, which contains only prepa.rations, 3) ,monoc~onai antibody preparations, and 4)
antibody against a single microorganism. antitoxins &om no&man sources, Ahhough persons of-
Antitoxin. A sdution of antibodies against a toxin. ten use the terms v~ccir&en and immrrnization inter-
Antitoxin can be derived from either human (e.g., teta- change;lblyin rderetice to active immunization, the terms
nus antitoxin) or animal (usually equine) sources.(e.g., are.not synonymous b+xause the administration of an
diphtheria and botulism antitoxin). Antitoxins rim used imm&biologic cannot bt equated auto~aticaliy with de-
to confer passive immunity and for treatment. velopment of adequate immunity.
36 MMWR February 8,201)~