Almost all individuals can be safely vaccinated with all vaccines. In very few individuals, vaccination is contraindicated or should be deferred. Where there is doubt, rather than withholding vaccine, advice should be sought from an appropriate consultant paediatrician or physician, the immunisation co-ordinator or consultant in health protection.
All vaccines are contraindicated in those who have had:
Live vaccines may be temporarily contraindicated in individuals who are:
Some vaccines are contraindicated in specific groups. These are outlined in the relevant chapters.
Individuals with a confirmed anaphylactic reaction to egg should not receive influenza or yellow fever vaccines. MMR vaccine can be safely given to most children with a previous history of allergy after ingestion of egg or egg- containing food, and vaccination with MMR can be performed under normal circumstances. For the small number of individuals who have a history of confirmed anaphylactic reaction after any egg-containing food, specialist advice should be sought with a view to immunisation under controlled conditions.
Some pre-filled syringes may contain latex proteins in the tip cap and/or rub- ber plunger of the syringe. Similarly, the stoppers of some vaccines supplied in vials may contain latex proteins.
It is theoretically possible that latex protein from these tip caps, plungers or vial stoppers may cause allergic reactions when the vaccines are administered to latex-sensitive individuals. There is little evidence that such a risk exists and any such risk would be extremely small (Russell at al., 2004). Millions of doses of vaccines in pre-filled syringes are administered every year and the risk of anaphylaxis due to any allergen following immunisation is about one per million vaccine doses (see Chapter 8)
As a precaution, if an individual has a history of severe (i.e. anaphylactic) allergy to latex, vaccines supplied in vials or syringes that contain latex should not be administered, unless the benefit of vaccination outweighs the risk of an allergic reaction to the vaccine.
If possible, an alternative latex-free vaccine should be administered.
For latex allergies other than anaphylactic allergies (e.g. a history of contact allergy to latex gloves), vaccines supplied in vials or syringes that contain latex can be administered (ACIP, 2006).
There is a theoretical concern that vaccinating pregnant women with live vaccines may infect the foetus. There is no evidence that any live vaccine (including rubella and MMR) causes birth defects. However, since the theoretical possibility of foetal infection exists, live vaccines should generally be delayed until after delivery. Termination of pregnancy following inadvertent immunisation is not recommended.
Since inactivated vaccines cannot replicate they cannot cause infection in either the mother or the foetus. However, inactivated vaccines should be administered to pregnant women only if protection is required without delay.
Live vaccines can, in some situations, cause severe or fatal infections in immu- nosuppressed individuals due to extensive replication of the vaccine strain. For this reason, severely immunosuppressed individuals (see bullet list below) should not be given live vaccines, and vaccination in immuno- suppressed individuals should only be conducted in consultation with an appropriate specialist.
Inactivated vaccines cannot replicate and so may be administered to immuno- suppressed individuals, although they may elicit a lower response than in immunocompetent individuals.
The following individuals should not receive live vaccines:
Many patients with relatively minor immunodeficiencies can, and indeed should, receive all recommended vaccinations, including live vaccines. Where there is doubt or a relatively severe immunodeficiency is present, it is important to obtain individual specialist advice.
Some patients with 22q11 deletion syndromes, including partial DiGeorge syndrome, may be able to receive live vaccines safely provided that they have no evidence of severe immunocompromise (Perez et al., 2003). Specialist advice should be sought.
Non-systemic corticosteroids, such as aerosols or topical or intra-articular preparations, do not cause systemic immunosuppression. Therefore, administration of live vaccines is not contraindicated.
Live vaccines are likely to be safe in those receiving other immunomodulating drugs, for example interferon. However, advice should be sought from the specialist in charge of the therapy to ensure that the patient has not been immunosuppressed by the treatment. Deferral of immunisation may be suggested to avoid side effects of the drugs being confused with reactions to vaccination.
Replacement schedules of corticosteroids for people with adrenal insufficiency do not cause immunosuppression and are not, therefore, contraindications for administration of live vaccines.
For further information, please refer to the RCPCH Best Practice Statement (www.rcpch.ac.uk).
HIV-positive individuals should be given MMR vaccine according to national recommendations unless they have evidence of severe immunosuppression (Table 6.1). For children under 12 months of age, CD4 counts may not be an accurate representation of levels of immunosuppression and immune status should be assessed by an expert using a combination of laboratory and clinical criteria. Varicella vaccine is contraindicated for HIV-infected individuals with severe immunosuppression (Table 6.1). This guidance may be relaxed in the near future, as evidence is emerging that patients with moderate immunosuppression can be safely vaccinated and will make an adequate response (M Levine, pers.comm., 2005). For HIV-infected individuals with no immunosuppression who are susceptible to varicella, vaccine is indicated to reduce the risk of serious chickenpox or zoster should their condition deteriorate.
Because there have been reports of dissemination of Bacillus Calmette-Guérin (BCG) in HIV-positive individuals, such individuals should not receive BCG vaccine in the UK (Talbot et al., 1997; Fallo et al., 2005; Langley et al., 2004).
Infants born to HIV-positive mothers where the infant has an indeterminate HIV status may have an increased risk of contracting tuberculosis. Where indicated, BCG vaccine can be given after two appropriately timed negative postnatal PCR blood tests for HIV infection. Unless a mother is known to be at risk of HIV, it is not necessary to test her before giving BCG vaccine to her infant.
Yellow fever vaccine should not be given to HIV-positive individuals. If such individuals intend to visit countries where a yellow fever certificate is required for entry but where there is no risk of exposure, then they should obtain a letter of exemption from a medical practitioner. Fatal myeloencephalitis following yellow fever vaccination has been reported in an individual with severe HIV- induced immunosuppression (Kengsakul et al., 2002). There are limited data, however, suggesting that yellow fever vaccine may be given safely to HIV- infected persons with a CD4 count that is greater than 200 and a suppressed HIV viral load (Receveur et al., 2000; Tattevin et al., 2004). Therefore, if the yellow fever risk is unavoidable, specialist advice should be sought with a view to the vaccination of asymptomatic HIV-infected individuals.
Further guidance is provided by the Royal College of Paediatrics and Child Health (www.rcpch.ac.uk), the British HIV Association (BHIVA) Immunisation guidelines for HIV-infected adults (BHIVA, 2006) and the Children’s HIV Association of UK and Ireland (CHIVA) immunisation guidelines (www.bhiva.org/chiva).
Table 6.1 Measure of immunosuppression by CD4 count
| CD4 count/μl (% of total lymphocytes) | |||
| Age | 1–5 years | 6–12 years | >12 years |
| No suppression | ≥1000 | ≥500 | ≥500 | (≥25%) | (≥25%) |
| Moderate suppression | 500–999 | 200–499 | 200–499 | (15–24%) | (15–24%) |
| Severe suppression | <500 | <200 | <200 | (<15%) | (<15%) |
There will be very few occasions when deferral of immunisation is required. Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation. If an individual is acutely unwell, immunisation may be postponed until they have fully recovered. This is to avoid wrongly attributing any new symptom or the progression of symptoms to the vaccine.
In individuals with an evolving neurological condition, immunisation should be deferred until the neurological condition has resolved or stabilised.
Immunoglobulin may interfere with the immune response to live vaccine viruses because it may contain antibodies to measles, varicella and other viruses. Live virus vaccines should therefore be given at least three weeks before or three months after an injection of immunoglobulin. This does not apply to yellow fever vaccine, because immunoglobulin used in the UK is unlikely to contain high levels of antibody to this virus.
The following conditions are NOT contraindications to routine immunisa- tion (in some of these situations, additional precautions may be required – refer to the relevant chapter for further information):
Russell M, Pool V and Kelso JM et al. (2004) Vaccination of persons allergic to latex: a review of safety data in the Vaccine Adverse Event Reporting System (VAERS). Vaccine 23(5):664-7. www.hubmed.org/display.cgi?uids=15542187 British HIV Association (2006) Immunisation guidelines for HIV-infected adults: www. bhiva.org/pdf/2006/Immunisation506.pdf. Fallo A, De Matteo E, Preciado MV et al. (2005) Epstein-Barr virus associated with primary CNS lymphoma and disseminated BCG infection in a child with AIDS. Int J Infect Dis 9(2): 96–103. Kengsakul K, Sathirapongsasuti K and Punyagupta S (2002) Fatal myeloencephalitis following yellow fever vaccination in a case with HIV infection. J Med Assoc Thai 85(1): 131–4. Langley J, Ellis E and Deeks S (2004) National Advisory Committee on Immunization; Health Canada First Nations; Inuit Health Branch. Statement on Bacille Calmette-Guérin (BCG) vaccine. Can Commun Dis Rep 1(30): 1–11. English, French. Erratum in Can Commun Dis Rep (2005) Feb 1: 31(3):40. www.phac-aspc.gc.ca/publicat/ccdr-rmtc/04vol30/acs-dcc-5/index.html Perez EE, Bokszczanin A, McDonald-McGinn D et al. (2003) Safety of live viral vaccines in patients with chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/ velocardiofacial syndrome). Pediatrics 112(4): e325. Receveur MC, Thiebaut R, Vedy S et al. (2000) Yellow fever vaccination of human immunodeficiency virus-infected patients: report of two cases. Clin Infect Dis 31(3): E7–8. Advisory Committee on Immunization Practices (ACIP) (2006) MMWR 55(RR-15):30-31 www.cdc.gov/mmwr/PDF/rr/rr5515.pdf Talbot EA, Perkins MD, Silva SF and Frothingham R (1997) Disseminated Bacille Calmette-Guérin disease after vaccination: case report and review. Clin Infect Dis 24(6): 1139–46. Tattevin P, Depatureaux AG, Chapplain JM et al. (2004) Yellow fever vaccine is safe and effective in HIV-infected patients. AIDS 18(5): 825–7.