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Conditions Commonly Misperceived as Contraindications to Vaccination

Recommendations and Guidelines

Clinicians or other health care providers might misperceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they actually do not preclude vaccination. These misperceptions result in missed opportunities to administer recommended vaccines (ref 1). Among the most common conditions mistakenly considered to be contraindications are diarrhea, minor upper respiratory tract illnesses (including otitis media) with or without fever, mild to moderate local reactions to a previous dose of vaccine, current antimicrobial therapy, and being in the convalescent phase of an acute illness.

NOTE: The contents of this page were excerpted from the ACIP General Recommendations (January 28, 2011) and include corrections detailed in errata dated July 29, 2011 and any changes to recommendations as of October 2013.

TIP: Consult the main contraindications page for links to other contraindications and precautions materials.

 

Quick Guide to Conditions Commonly Misperceived as Contraindications to Vaccination
Vaccine Conditions commonly misperceived as contraindications
(i.e., vaccination may be administered under these conditions)
general for all vaccines, including DTaP, pediatric DT, adult Td, adolescent-adult Tdap, IPV, MMR, Hib, hepatitis A, hepatitis B, varicella, rotavirus, PCV, TIV, LAIV, PPSV, MCV4, MPSV4, HPV, and herpes zoster
  • Mild acute illness with or without fever
  • Mild-to-moderate local reaction (i.e., swelling, redness, soreness); low-grade or moderate fever after previous dose
  • Lack of previous physical examination in well-appearing person
  • Current antimicrobial therapy1
  • Convalescent phase of illness
  • Preterm birth (hepatitis B vaccine is an exception in certain circumstances)2
  • Recent exposure to an infectious disease
  • History of penicillin allergy, other nonvaccine allergies, relatives with allergies, or receiving allergen extract immunotherapy

DTaP

  • Fever of <105°F (<40.5°C), fussiness or mild drowsiness after a previous dose of DTP/DTaP
  • Family history of seizures
  • Family history of sudden infant death syndrome
  • Family history of an adverse event after DTP or DTaP administration
  • Stable neurologic conditions (e.g., cerebral palsy, well-controlled seizures, or developmental delay)

Tdap

  • Fever of ≥105°F (≥40.5°C) for 48 hours after vaccination with a previous dose of DTP or DTaP
  • Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP
  • Seizure <3 days after receiving a previous dose of DTP/DTaP

  • Persistent, inconsolable crying lasting >3 hours within 48 hours after receiving a previous dose of DTP/DTaP
  • History of extensive limb swelling after DTP/DTaP/Td that is not an arthus-type reaction
  • Stable neurologic disorder
  • History of brachial neuritis
  • Latex allergy that is not anaphylactic
  • Breastfeeding
  • Immunosuppression
IPV
  • Previous receipt of ≥1 dose of oral polio vaccine
MMR3,4
  • Positive tuberculin skin test
  • Simultaneous tuberculin skin testing5
  • Breastfeeding
  • Pregnancy of recipient's mother or other close or household contact
  • Recipient is female of child-bearing age
  • Immunodeficient family member or household contact
  • Asymptomatic or mildly symptomatic HIV infection
  • Allergy to eggs

Hepatitis B
  • Pregnancy
  • Autoimmune disease (e.g., systemic lupus erythematosis or rheumatoid arthritis)
Varicella
  • Pregnancy of recipient's mother or other close or household contact
  • Immunodeficient family member or household contact6
  • Asymptomatic or mildly symptomatic HIV infection
  • Humoral immunodeficiency (e.g., agammaglobulinemia)
TIV
  • Nonsevere (e.g., contact) allergy to latex, thimerosal, or egg
  • Concurrent administration of coumadin or aminophylline
LAIV
  • Health-care providers that see patients with chronic diseases or altered immunocompetence (an exception is providers for severely immunocompromised patients requiring care in a protected environment)
  • Breastfeeding
  • Contacts of persons with chronic disease or altered immunocompetence (an exception is contacts of severely immunocompromised patients requiring care in a protected environment)
PPSV
  • History of invasive pneumococcal disease or pneumonia
HPV
  • Immunosuppression
  • Previous equivocal or abnormal Papanicolaou test
  • Known HPV infection
  • Breastfeeding
  • History of genital warts
Rotavirus
  • Prematurity
  • Immunosuppressed household contacts
  • Pregnant household contacts
Zoster
  • Therapy with low-dose methotrexate (≤0.4 mg/kg/week), azathioprine (≤3.0 mg/kg/day), or 6-mercaptopurine (≤1.5 mg/kg/day) for treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease, or other conditions
  • Healthcare providers of patients with chronic diseases or altered immunocompetence
  • Contacts of patients with chronic diseases or altered immunocompetence
  • Unknown or uncertain history of varicella in a U.S.-born person

Abbreviations
DT = diphtheria and tetanus toxoids; DTP = diphtheria toxoid, tetanus toxoid, and pertussis; DTaP = diphtheria and tetanus toxoids and acellular pertussis; HBsAg = hepatitis B surface antigen; Hib = Haemophilus influenzae type b; HPV = human papillomavirus; IPV = inactivated poliovirus; LAIV = live, attenuated influenza vaccine; MCV4 = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV = pneumococcal conjugate vaccine; PPSV = pneumococcal polysaccharide vaccine; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; TIV = trivalent inactivated influenza vaccine.

Footnotes

  1. Antibacterial drugs might interfere with Ty21a oral typhoid vaccine, and certain antiviral drugs might interfere with varicella-containing vaccines and LAIV.
  2. Hepatitis B vaccination should be deferred for infants weighing <2,000 g if the mother is documented to be HBsAg-negative at the time of the infant's birth. Vaccination can commence at chronological age 1 month or at hospital discharge. For infants born to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered within 12 hours after birth, regardless of weight.
  3. MMR, LAIV, and varicella vaccines can be administered on the same day. If not administered on the same day, these vaccines should be separated by at least 28 days.
  4. HIV-infected children should receive immune globulin after exposure to measles. HIV-infected children can receive varicella and measles vaccine if CD4+ T-lymphocyte count is >15%. (Source: Adapted from American Academy of Pediatrics. Passive immunization. In: Pickering LK, ed. Red book: 2009 report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.)
  5. Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin testing. If testing cannot be performed until after the day of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need exists to skin test, do so with the understanding that reactivity might be reduced by the vaccine.
  6. If a vaccinee experiences a presumed vaccine-related rash 7 through 25 days after vaccination, the person should avoid direct contact with immunocompromised persons for the duration of the rash.

Reference:

  1. Szilagyi PG, Rodewald LE. Missed opportunities for immunizations: a review of the evidence. J Public Health Manag Pract 1996;2:18-25.

 

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