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Adverse events following live vaccines occur after one incubation period of the vaccine virus (except allergic reactions, which occur in minutes or hours). For example, the peak occurrence of fever and rash after measles vaccine is 7-10 days after vaccination.
Inactivated vaccines do not replicate, so adverse events are not similar to the natural disease. Since a large amount of antigen is given in the injection, the most common adverse events are local at the site of the injection, such as pain, swelling, and redness. Fever may occur, usually as a manifestation of inflammation at the site of injection. Local reactions to vaccines generally increase with increasing numbers of doses of the vaccine.
Adverse events from inactivated vaccines generally occur within 1-3 days of the dose of vaccine (i.e., unrelated to the incubation period of the disease).
In general, a contraindication is a condition in a recipient which is likely to result in a life-threatening problem if the vaccine were given. For example, administering influenza vaccine to a person with a true anaphylactic allergy to egg could cause serious illness or death in the recipient.
A precaution is a condition in a recipient which may result in a life-threatening problem if the vaccine is administered, or a condition which could compromise the ability of the vaccine to produce immunity. In general, when a precaution is present, a vaccine dose will not be given. However, there are circumstances when the benefit of the vaccine may outweigh the risk, and the practitioner may choose to administer the vaccine. For example, a hypotonic episode following a dose of pertussis vaccine is a precaution, and additional doses are usually not given. However, the benefit of pertussis immunity may outweigh the risk of another hypotonic episode if there is a high risk of pertussis infection (e.g., during an outbreak).
A severe allergic reaction following a dose of vaccine will virtually always contraindicate a subsequent dose of that vaccine. Severe allergies are those which are mediated by IgE, occur within minutes or hours of the vaccine, and require medical attention. Examples of severe allergic reactions are generalized urticaria (hives), wheezing, swelling of the mouth and throat, difficulty breathing, hypotension, or shock.
Persons may be allergic to the vaccine antigen, animal protein, antibiotics, preservatives, or stabilizers. The most common animal protein allergen is egg protein found in vaccines prepared using embryonated chicken eggs (e.g., yellow fever and influenza vaccines). Ordinarily, persons who are able to eat eggs or egg products safely can receive these vaccines; persons with histories of anaphylactic or anaphylactic-like allergy to eggs or egg proteins should not. Asking persons whether they can eat eggs without adverse effects is a reasonable way to screen for those who might be at risk from receiving measles, mumps, yellow fever, and influenza vaccines.
Several recent studies have shown that children who have a history of severe allergy to eggs rarely have reactions to MMR vaccine. This is probably because measles and mumps vaccine viruses are both grown in chick embryo fibroblasts, not actually in eggs. It appears now that it may be gelatin, not egg, that causes allergic reactions to MMR. As a result, in 1997, ACIP removed severe egg allergy as a contraindication to measles and mumps vaccines. Egg allergic children may be vaccinated with MMR without prior skin testing. Protocols have been developed for testing and vaccinating persons with anaphylactic reactions to egg protein. See the American Academy of Pediatrics Red Book for an example of a desensitization protocol.
Some vaccines contain trace amounts of antibiotics (e.g., neomycin) to which patients may be hypersensitive. No currently recommended vaccine contains penicillin or penicillin derivatives.
Encephalopathy without a known cause occurring within 7 days of a dose of pertussis vaccine is an absolute contraindication to subsequent doses of pertussis vaccine. Refer to the pertussis chapter (Chapter 4) for more information about encephalopathy following pertussis vaccine.
There are four vaccine contraindications which are generally temporary C pregnancy, immunosuppression, severe illness, and recent receipt of blood products. Live vaccines should not be given until these conditions are resolved.
Precaution: A condition in a recipient which may result in a life-threatening problem if vaccine is administered OR May compromise the ability of the vaccine to produce immunity.
Since inactivated vaccines cannot replicate, they cannot cause fetal infection. Inactivated vaccines should be administered to pregnant women for whom they are indicated.
Both diseases and drugs can cause significant immunosuppression. Persons with congenital immunodeficiency, leukemia, lymphoma, or generalized malignancy should not receive live vaccines. OPV should not be given if an immunosuppressed person is in the household. However, MMR and varicella vaccines may be given when an immunosuppressed person lives in the same house.
Certain drugs may cause immunosuppression. For instance, persons receiving cancer treatment with alkylating agents or antimetabolites, or radiation therapy should not be given live vaccines. Live vaccines can be given after chemotherapy has been discontinued for at least 3 months. Persons receiving large doses of corticosteroids should not receive live vaccines. This would include persons receiving 20 milligrams of prednisone daily or more than 2 milligrams per kilogram of body weight per day. Aerosolized steroids, such as inhalers for asthma, alternate day, rapidly tapering, and short (<14 days) high dose schedules, topical formulations, and physiologic replacement schedules are not contraindications to vaccination.
Inactivated vaccines are not contraindicated in immunosuppressed persons. However, response to the vaccine may be poor. A relatively functional immune system is required in order to develop an immune response to a vaccine. So an immunosuppressed person may not be protected, even if the vaccine has been given. Additional recommendations for vaccination of immunosuppressed persons are detailed in the General Recommendations and in a specific Altered Immunocompetence ACIP statement.
Oral polio vaccine should not be given to a person with HIV infection or AIDS or to a child whose household contact has HIV infection or AIDS. Varicella vaccine should not be given to a person known to be infected with HIV, but is recommended for healthy persons whose household contacts have HIV infection.
Measles can be a very severe illness in persons with HIV infection and is often associated with complications and death. Therefore, measles vaccine (as combination MMR vaccine) is recommended for persons with HIV infection who are asymptomatic or mildly immunosuppressed. However, persons with severe immunosuppression due to HIV infection should not receive measles vaccine or MMR.
The next table summarizes current recommendations for vaccination of HIV-infected persons.
Varicella, DTP/DTaP, unless severe immunodeficiency.
Mild, common illnesses (such as otitis media, upper respiratory infections, colds, and diarrhea) are NOT contraindications to vaccination.
MMR vaccine should be given 14 days prior to the blood product, or delayed until the antibody has degraded (see Table 8 in the ACIP's 1994 General Recommendations on Immunization, included in Appendix A). If MMR is given sooner than the minimum interval shown, the recipient should be tested for immunity or the dose repeated after the appropriate interval. Inactivated vaccines are not substantially affected by circulating antibody from blood products and are not contraindicated.
Several large studies have shown that young children with URI, otitis media, diarrhea, and/or fever respond to measles vaccine as well as those without these conditions. These large studies refute the results of an earlier small study (Krober, JAMA 1991) which suggested that minor infections such as URIs might impair the response to measles vaccine. Further, there is no evidence that mild diarrhea reduces the success of polio immunization of infants in this country.
Low-grade fever is not a contraindication to immunization. Temperature measurement is not necessary before immunization if the infant or child does not appear ill, does not feel hot to the touch, and the parent does not say he or she is currently ill.
Measles and mumps vaccine viruses produce a noncommunicable infection, and are not transmitted to household contacts. Rubella vaccine virus has been shown to be shed in breast milk, but transmission to an infant has rarely been documented (rubella is not transmitted by mouth). Transmission of varicella vaccine virus is uncommon, and most women are immune from prior chickenpox. Oral polio vaccine virus is shed and can spread, but pregnant contacts are at no greater risk than other household contacts in this situation, and OPV has not been shown to cause fetal defects.
Breast-feeding does not decrease the response to routine childhood vaccines, including OPV. Breast-feeding also does not extend or improve passive immunity to vaccine- preventable disease provided by maternal antibody.
Only one study has suggested decreased efficacy of measles vaccine in children with URI(upper respiratory infection such as bronchitis). Findings not replicated by multiple prior and subsequent studies. No evidence of increased adverse events .Minor illness
If a premature infant is still hospitalized, OPV should generally not be used. This could lead to contact transmission of OPV to other high-risk infants.
Routine hepatitis B vaccination should not be given until an infant weighs 2 kilograms or more. Infants born to women who are hepatitis B surface antigen positive (from acute or chronic infection) should be vaccinated and given hepatitis B immune globulin regardless of body weight. See Chapter 10 for more information on the prevention of perinatal transmission of hepatitis B virus.
MMR vaccine may decrease the response to a TB skin test, potentially causing a false negative response in someone who actually has an infection with tuberculosis. MMR can be given the same day as a TB skin test. If MMR has been given and one or more days have elapsed, in most situations it is recommended to wait 4-6 weeks before giving a routine TB skin test.
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