General Recommendations on Immunization Measlesand varicella can be very severe ein with HIV infection and are often sociated with endations for Therefore,measles vaccine(as combination MMR vaccine) nd vafce reymromic or millyimun MMB.or varicella vaccine.Susceptible household contacts Yes=vaccinete No do not vaccinate varice Vaccination of Hematopoietic Stem Cell Transplant Recipients Hematopoietic stem cell transplant(HSCT)is the infusion hamatopoetic stefomdnor into a patient who seace&apaotpHenmtat8epeme。 has received c emotherapy and o which are suall is rer immunodeficiency syndromes. enital enzyme deficiencies andutoune dore HSCTrecpnn rcve either their own cells(i.e.,autologous HSCT)or cells from other than the transplant(eic Antibody titers to vaccine-preventable diseases (e.g. tetanus,poliovirus,measles,mumps,rubella,and encapsulated s0eseoi9eaofpHsamtaReepcema olwnpnn at in ecpent5oteaccna IPV hopa PPV preventable diseases.As a result,HSCT recipients should be routinely revaccinated after HSCT,regardless of the source thereafter for the life of the recipient.MMR vaccine should be administered 24 months after transplantation if the HSCT recipient is presumed to be immunocomperent. aricella,meningococca al,and pneumococcal recipients among HSCT recipients. care for HSCT recipients and their contacts can be found in a CDC 一 21
2 Measles and varicella can be very severe illnesses in persons with HIV infection and are often associated with complications. Therefore, measles vaccine (as combination MMR vaccine) and varicella vaccine are 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, MMR, or varicella vaccine. Susceptible household contacts of persons with HIV infection should receive MMR and varicella vaccines. Persons with HIV infection should not receive LAIV; they should receive inactivated influenza vaccine. Vaccination of Hematopoietic Stem Cell Transplant Recipients Hematopoietic stem cell transplant (HSCT) is the infusion of hematopoietic stem cells from a donor into a patient who has received chemotherapy and often radiation, both of which are usually bone marrow ablative. HSCT is used to treat a variety of neoplastic diseases, hematologic disorders, immunodeficiency syndromes, congenital enzyme deficiencies, and autoimmune disorders. HSCT recipients can receive either their own cells (i.e., autologous HSCT) or cells from a donor other than the transplant recipient (i.e., allogeneic HSCT). Antibody titers to vaccine-preventable diseases (e.g., tetanus, poliovirus, measles, mumps, rubella, and encapsulated bacteria [i.e., Streptococcus pneumoniae and Haemophilus influenzae type b]) decline during the 1–4 years after allogeneic or autologous HSCT if the recipient is not revaccinated. HSCT recipients are at increased risk for certain vaccinepreventable diseases. As a result, HSCT recipients should be routinely revaccinated after HSCT, regardless of the source of the transplanted stem cells. Revaccination with inactivated vaccines should begin 12 months after HSCT. An exception to this recommendation is for influenza vaccine, which should be administered 6 months after HSCT and annually thereafter for the life of the recipient. MMR vaccine should be administered 24 months after transplantation if the HSCT recipient is presumed to be immunocompetent. Varicella, meningococcal, and pneumococcal conjugate vaccines are not currently recommended for HSCT recipients because of insufficient experience using these vaccines among HSCT recipients. Household and other close contacts of HSCT recipients and healthcare workers who care for HSCT recipients should be appropriately vaccinated, particularly against influenza, measles, and varicella. Additional details of vaccination of HSCT recipients and their contacts can be found in a CDC report on this topic available at http://www.cdc.gov/nip/publications/hsct-recs.pdf. 21 General Recommendations on Immunization
General Recommendations on Immunization Moderate or Severe Acute lllness There is no evidence that a concurrent acute illness reduces reaction（paric management of boh live vaccines should be delayed until the illness has improved contrain ations to vaccination. Invalid Contraindications ider certair contraindicat ns or are known as invalid co missed cy or im opportunities to administer needed vaccines.Some of the most common invalid contraindications are minor illnesses. o vaccine comp astfeeding,allergies nily histor t anaphy ctic in nature,and certain aspects of ed for TB skin testing the patient's family history. Invalid (URD. diarhea.can and should be vaccinated. Saveshown that young childrenh larrhea,and/c fever re pond to measles 10U these condi ese a11 e of d adverse reactio (Krober.JAMA 10011i d th such as URIs might impair the response to measles vaccine Further,there is no evidence that mild diarrhea reduces the success of immunization of infants in this country. the prent oeor thechlrl and Antimicrobial Therapy Antimicrobial agents do not have an effect on the immune response to a vaccine.No commonly used antibiotic or antiviral agent will inactivate a live-virus vaccine. 22
2 Moderate or Severe Acute Illness There is no evidence that a concurrent acute illness reduces vaccine efficacy or increases vaccine adverse events. The concern is that an adverse reaction (particularly fever) following vaccination could complicate the management of a severely ill person. If a person has a moderate or severe acute illness, vaccination with both live and inactivated vaccines should be delayed until the illness has improved. Minor, common illnesses (such as otitis media, upper respiratory infections, colds, and diarrhea) are NOT contraindications to vaccination. Invalid Contraindications to Vaccination Some healthcare providers inappropriately consider certain conditions or circumstances to be true contraindications or precautions to vaccinations. Such conditions or circumstances are known as invalid contraindications; they result in missed opportunities to administer needed vaccines. Some of the most common invalid contraindications are minor illnesses, conditions related to pregnancy and breastfeeding, allergies that are not anaphylactic in nature, and certain aspects of the patient’s family history. Minor Illness Children with mild acute illnesses, such as low-grade fever, upper respiratory infection (URI), colds, otitis media, and mild diarrhea, can and should be vaccinated. 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 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 and the parent does not say the child is currently ill. Antimicrobial Therapy Antimicrobial agents do not have an effect on the immune response to a vaccine. No commonly used antibiotic or antiviral agent will inactivate a live-virus vaccine. 22 General Recommendations on Immunization
General Recommendations on Immunization Disease Exnosure or Convalescence If a child is not moderately or severely ill,he or she should be vaccinated.There is no evidence that either disease exposure or convalescence will affect the response to a vaccine or increase the likelihood of an adverse event. 5eainoH8rgreaeenRg ession in the It is critical that healthy household contacts of pre Vaccination of healthy contacts reduces the chance of of pregnantw omen and immunMR essed per and vellcines, are household contacts of p persons,as well as to breastfeeding infants.Vaccinia (smallpox) vaccine is not recommended for household contacts of a pregnant or suppres onemergenc be s who have immunosuppressed persons who are hospitalized and require care in a protected environment (are in isoation LAIV may be administered Measles and mumps vaccine viruses produce a noncommu- nicable infection and are not transn itted to bousebold contacts.Rub a vaccine virus has been shown to be shed in human milk, on to an i ant has rarely cine virus is ed persons are immune from having had chickenpox.LAIV may be administered to a woman who is breastfeeding if she but is proba transmission of vaccine ng immunity to vaccine-preventable disease that is provided by maternal antibody. Premature Birth Vaccines should be started on schedule based on the child's been shown to Studies demonstrate that decreased seroconversion rates H )after all pre initial birthweight or gestational age are as likely to respond as adequately as older and larger infants. 23
2 Disease Exposure or Convalescence If a child is not moderately or severely ill, he or she should be vaccinated. There is no evidence that either disease exposure or convalescence will affect the response to a vaccine or increase the likelihood of an adverse event. Pregnancy or Immunosuppression in the Household or Breastfeeding It is critical that healthy household contacts of pregnant women and immunosuppressed persons be vaccinated. Vaccination of healthy contacts reduces the chance of exposure of pregnant women and immunosuppressed persons. Most vaccines, including live vaccines (MMR, varicella, and yellow fever), can be given to infants or children who are household contacts of pregnant or immunosuppressed persons, as well as to breastfeeding infants. Vaccinia (smallpox) vaccine is not recommended for household contacts of a pregnant or immunosuppressed person in nonemergency situations. Live attenuated influenza vaccine should not be administered to persons who have contact with severely immunosuppressed persons who are hospitalized and require care in a protected environment (i.e., who are in isolation because of immunosuppression). LAIV may be administered to contacts of persons with lesser degrees of immunosuppression. 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 human milk, but transmission to an infant has rarely been documented. Transmission of varicella vaccine virus is not common, and most women and older immunosuppressed persons are immune from having had chickenpox. LAIV may be administered to a woman who is breastfeeding if she is otherwise eligible. The risk of transmission of vaccine virus is not known but is probably low. Breastfeeding does not decrease the response to routine childhood vaccines. Breastfeeding also does not extend or improve the passive immunity to vaccine-preventable disease that is provided by maternal antibody. Premature Birth Vaccines should be started on schedule based on the child’s chronological age. Premature infants have been shown to respond adequately to vaccines used in infancy. Studies demonstrate that decreased seroconversion rates might occur among certain premature infants with low birth weights (less than 2,000 grams) after administration of hepatitis B vaccine at birth. However, by 1 month chronological age, all premature infants, regardless of initial birthweight or gestational age are as likely to respond as adequately as older and larger infants. 23 General Recommendations on Immunization
General Recommendations on Immunization All premature infants born to hepatitis Bsurface antigen tus mus D (HBIG) eig grams at birth,the initial vaccine dose should not be count. age The optimal timing of the first dose of hepatitis B vaccine Ag-negative mothers with a been series at i month of chronole cal age discharged from the hospital prior to 1 month chronological itis B vaccine at discharge if stent weight gain Non-Vaccine-Related Allergies 0a1 rlold be immumt中osca o vaccine avai tes contains lactic Allergy to Anaphylactic allergy to a vaccine et(such as egg or neomycin)is a true contraindication to vaccination. Nonanaphylactic allergy toa vaccine constituent is not a ation to that vaccine Family History of Adverse Events The only family histe vaccinate a child is immunosu pression.A family history of adverse reactions unrelated to immunosupression or family history of seizures or sudden infant death syndrome is not a virus vaccin odenve a fam first-degree relatives (e.g.,parents and siblings)unless the Tuberculosis Skin Test [PP o nee n and should on the same day as a TB skin test,or any time after a TB skin test is applied.For most vaccines,there are no TB skin test timing restrictions at all 24
2 All premature infants born to hepatitis B surface antigen (HBsAg)–positive mothers and mothers with unknown HBsAg status must receive immunoprophylaxis with hepatitis B vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours after birth. If these infants weigh less than 2,000 grams at birth, the initial vaccine dose should not be counted toward completion of the hepatitis B vaccine series, and three additional doses of hepatitis B vaccine should be administered beginning when the infant is 1 month of age. The optimal timing of the first dose of hepatitis B vaccine for premature infants of HBsAg-negative mothers with a birth weight of less than 2,000 grams has not been determined. These infants can begin the first dose of the hepatitis B vaccine series at 1 month of chronological age. Premature infants discharged from the hospital prior to 1 month chronological age may also be given hepatitis B vaccine at discharge if they are medically stable and showing consistent weight gain. Non–Vaccine-Related Allergies Infants and children with nonspecific allergies, duck or feather allergy, or allergy to penicillin, children who have relatives with allergies, and children taking allergy shots can and should be immunized. No vaccine available in the United States contains duck antigen or penicillin. Nonanaphylactic Allergy to Vaccine Component Anaphylactic allergy to a vaccine component (such as egg or neomycin) is a true contraindication to vaccination. Nonanaphylactic allergy to a vaccine constituent is not a contraindication to that vaccine. Family History of Adverse Events The only family history that is relevant in the decision to vaccinate a child is immunosuppression. A family history of adverse reactions unrelated to immunosupression or family history of seizures or sudden infant death syndrome is not a contraindication to vaccination. Varicella virus vaccine should not be administered to persons who have a family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents and siblings) unless the immune competence of the potential vaccine recipient has been clinically substantiated or verified by a laboratory. Tuberculosis Skin Test (PPD) Infants and children who need TB skin tests can and should be immunized. All vaccines, including MMR, can be given on the same day as a TB skin test, or any time after a TB skin test is applied. For most vaccines, there are no TB skin test timing restrictions at all. 24 General Recommendations on Immunization
General Recommendations on Immunization MMR vace cine may decrease the response to a TB skin causing a false-n se in s has an infection with tuberculosis.MMR can be given the ys nav ,in most situat No info or LAIV on a TB skin test is available.Until such information is vaccine and TE Screening for Contraindications and Precautions to Vaccination The key to preventing serious adverse reactions is screening. Every person who administers vaccines should screen every patient for ations and pre ot diff mplicated and can be acc mplished with just a few questions. Screening Questions acute illness .How is your child today? If the child has been examined,this question may not be necessary or may have already been asked. .Allergles to food or medication? .Any problem after last shots? re allergic reaction to a vaccine component is a contraindication to vaccination,so this question must always be asked.It may be more time-efficient to inquire about allergies in a generic way (i.e any food or medication) speciti .vaccme components. vaccine.but they should know if the child has had an allergic reaction to a food or medication that was severe enough to require medical attention. This open-ended qu stion explores for allergic reactions to previous doses and for conditions following pertussis vaccine that may be precautions to additional doses,such as high ever or a hypotonic episod 监aes 欢
2 MMR vaccine may decrease the response to a TB skin test, 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, but if MMR has been given and 1 or more days have elapsed, in most situations a wait of 4–6 weeks is recommended before giving a routine TB skin test. No information on the effect of varicella vaccine or LAIV on a TB skin test is available. Until such information is available, it is prudent to apply rules for spacing measles vaccine and TB skin testing to varicella vaccine and LAIV. Screening for Contraindications and Precautions to Vaccination The key to preventing serious adverse reactions is screening. Every person who administers vaccines should screen every patient for contraindications and precautions before giving the vaccine dose. Effective screening is not difficult or complicated and can be accomplished with just a few questions. How is your child (or how are you) today? This question screens for concurrent moderate or acute illness. If the child has been examined, this question may not be necessary or may have already been asked. Does your child have any allergies to any food or medication? A severe allergic reaction to a vaccine component is a contraindication to vaccination, so this question must always be asked. It may be more time-efficient to inquire about allergies in a generic way (i.e., any food or medication) rather than to inquire about specific vaccine components. Most parents will not be familiar with minor components of vaccine, but they should know if the child has had an allergic reaction to a food or medication that was severe enough to require medical attention. Did the child have any problems after his or her last shots? This open-ended question explores for allergic reactions to previous doses and for conditions following pertussis vaccine that may be precautions to additional doses, such as high fever or a hypotonic episode. Does the child have any problems with his or her immune system? This question will help identify children with immunodeficiency who generally should not receive live attenuated vaccines, particularly oral polio vaccine. continues 25 General Recommendations on Immunization