Guide to Vaccine Guide to Vaccine Contraindications 

and Precautions 
I

cy) 

NTRODUCTION
 

Guide to Vaccine Contraindications and 

Precautions 

This guide summarizes CDC’s recommendations regarding common symptoms and conditions that 

do and do not contraindicate vaccines licensed in the United States: 

Anthrax Human Papillomavirus (HPV) Rotavirus 

BCG Influenza (TIV & LAIV) Td 

DTaP Japanese Encephalitis (JE) Tdap 

DT MMR Typhoid 

Hepatitis A (HA) Meningococcal Vaccines (MPSV & MCV) Vaccinia (non-emergen

Hepatitis B (HB) Pneumococcal Vaccines (PPV &PCV) Varicella 

Haemophilus influenzae type b Polio (IPV) Yellow Fever (YF) 

(Hib) Rabies Zoster 

The guide is arranged alphabetically according to symptoms and conditions which may, correctly or 

not, be perceived as contraindications to vaccination. 

•Th e first column states the •The second column lists •The third column states whether 

symptom or condition. individual vaccines, when or not a person with that 

recommendations diff er by symptom or condition should be

vaccine. vaccinated. 

Notes describe exceptions and special situations, or provide additional information. 

When assessing a patient with multiple symptoms, if any one of them is a contraindication, 

do not vaccinate. 

If there is a contraindication to any component of a combination vaccine, 

do not use that combination. 

Contents: 

Contraindications & Precautions: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
 

Notes: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
 

Appendix A: Summary of Contents of Vaccines Licensed in the United States . . . . . . . . . . . . . . . .15
 

Appendix B: Latex in Vaccine Packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

Appendix C: Reaction After a Previous Dose of Diphtheria-, Tetanus-, or
 

Pertussis-Containing Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
 

Appendix D: Suggested Intervals Between Administration of Immune Globulin Preparations and 


Measles- or Varicella-Containing Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
 

Appendix E: Vaccinia (Smallpox) Vaccine (Routine, Non-Emergency Use) . . . . . . . . . . . . . . . . . .26
 

Appendix F: Quick Reference - Contraindications and Precautions to Routine Childhood and 


Adolescent Vaccinations, By Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
 

1
CONTRAINDICATIONS & PRECAUTIONS

Symptom or Condition Vaccine(s) Vaccinate? 

to any vaccine 

component (See All No 

Appendix A) 

HA (HAVRIX only) No to 2-phenoxyethanol All Others Yes 

HA No to alum All Others Yes 

HB No 

to yeast HPV No 

All Others Yes 

to duck meat or duck All Yes feathers 

Flu No (See note 1) 

to eggs YF No 

All Others Yes 

MMR See Note 2 

Varicella See Note 2 to gelatin Zoster No 

All Others Yes 

to latex All See Appendix B 

IPV No Allergy (anaphylactic) MMR No 

to neomycin Varicella No 

Zoster No 

All Others Yes 

to penicillin All Yes 

IPV No to polymyxin B All Others Yes 

to proteins of rodent or JE No 

neural origin All Others Yes 

IPV No to streptomycin All Others Yes 

nonspecifi c or All Yes nonanaphylactic 

in relatives All Yes 

DTaP See Note 3 

Flu (Inactivated) See Note 3 

HB See Note 3 

to thimerosal JE No 

MPSV See Note 3 

Td/DT See Note 3 

All Others Yes 

Anaphylactic (life-threatening) reaction to All No (See Note 4) previous dose of vaccine 

2
3

CONTRAINDICATIONS & PRECAUTIONS
 

Symptom or Condition Vaccine(s) Vaccinate? 

Anthrax, prior infection Anthrax 

All Others 

No 

Yes 

Antimicrobial therapy (current) 

Flu (LAIV only) 

Typhoid 

Varicella 

Zoster 

All Others 

Yes (See Note 5) 

Yes (See Note 6) 

Yes (See Note 7) 

Yes (See Note 8) 

Yes 

Asplenia (anatomic or functional) All Yes 

Aspirin or salicylate therapy (children or 

adolescents) 

Flu (LAIV only) 

All Others 

No 

Yes 

Bleeding Disorders All Yes (See Note 9) 

Breastfeeding 

Vaccinate nursing 

infant? All Yes 

Vaccinate lactating 

mother? All Yes 

Convalescing from illness All Yes 

Convulsions (fits, seizures), family history 

(including epilepsy) 

DTaP 

All Others 

Yes (See Note 10) 

Yes 

Diarrhea (See Illness: Concurrent) 

Encephalopathy (See “Reaction after a previous dose of DTaP,” Appendix C) 

Exposure to infectious disease (recent) All Yes 

Fever 

Low-grade fever with or 

without mild illness All Yes 

Fever with moderate to 

severe illness All See Note 11 

Guillain Barré Syndrome (GBS) (history of) 

DTaP 

Flu (LAIV) 

Flu (Inactivated) 

MCV 

Td 

Tdap 

All Others 

See Note 12 

No 

See Note 13 

No (See Note 14) 

See Note 15 

See Note 15 

Yes 

Heart Conditions Flu (LAIV only) 

All Others 

See Note 16 

Yes 

Hematopoietic Stem Cell Transplant (HSCT) All See Note 17 
CONTRAINDICATIONS & PRECAUTIONS
 

Symptom or Condition Vaccine(s) Vaccinate? 

HIV Infection 

in recipient 

(asymptomatic) 

BCG 

Flu (LAIV only) 

MMR 

Rotavirus 

Typhoid (Ty21a only) 

Varicella 

YF 

All Others 

No 

No 

See Note 18 

See Note 19 

No 

See Note 20 

No 

Yes 

in recipient 

(symptomatic) 

BCG 

Flu (LAIV only) 

MMR 

Rotavirus 

Typhoid (Ty21a only) 

Varicella 

YF 

Zoster 

All Others 

No 

No 

See Note 21 

See Note 19 

No 

See Note 20 

No 

See Note 22 

Yes 

in household contact Flu (LAIV only) 

All Others 

No 

Yes 

IG (Immune Globulin) administration, recent 

or simultaneous 

(Either intramuscular or intravenous) 

MMR 

Varicella 

All Others 

See Note 23 

See Note 24 

Yes 

Illness: Concurrent 

Acute: mild (with 

or without low-grade 

fever) 

Flu (LAIV only) 

All Others 

See Note 25 

Yes 

Acute: moderate to 

severe (with or without 

fever) 

Flu (LAIV only) 

All Others 

See Note 25 

See Note 11 

Chronic 

Flu (LAIV only) 

Rotavirus 

All Others 

See Note 26 

See Note 27 

See Note 28 

Immunodefi ciency 

(See also “HIV 

Infection” and 

“Hematopoietic Stem 

Cell Transplant” 

above) 

in recipient 

(hematologic and solid 

tumors, congenital 

immunodefi ciency, 

long-term 

immunosuppressive 

therapy, including 

steroids) 

BCG 

Flu (LAIV only) 

MMR 

PPV 

Rabies 

Rotavirus 

Typhoid (Ty21a only) 

Varicella 

YF 

Zoster 

All Others 

No 

No 

No 

Yes (See Note 29) 

See Note 30 

See Note 19 

No 

See Note 31 

No 

See Note 32 

Yes 

family history Varicella 

All Others 

See Note 33 

Yes 

in household contact Flu (LAIV only) 

All Others 

See Note 34 

Yes 

4
CONTRAINDICATIONS & PRECAUTIONS
 

Symptom or Condition Vaccine(s) Vaccinate? 

Intussusception, history of Rotavirus 

All Others 

See Note 35 

Yes 

Neurologic disorders, underlying (including 

seizure disorders, cerebral palsy, and 

developmental delay) 

DTaP 

Tdap 

All Others 

See Note 36 

See Note 37 

Yes 

Otitis media 

mild (with or without 

low-grade fever) All Yes 

moderate or severe (with 

or without fever) All See Note 11 

resolving All Yes 

Pregnancy 

in recipient 

Anthrax 

BCG 

Flu (LAIV only) 

HA 

HPV 

IPV 

JE 

MMR 

PPV 

Td 

Tdap 

Typhoid 

Varicella 

YF 

Zoster 

All Others 

No (See Note 38) 

No 

No 

See Note 39 

No (See Note 40) 

See Note 41 

See Note 42 

No (See Note 43) 

See Note 44 

See Note 45 

See Note 45 

See Note 44 

No (See Note 43) 

See Note 46 

No (See Note 43) 

Yes 

in mother or household 

contact of recipient All Yes 

Prematurity 

HB 

Rotavirus 

All Others 

Yes (See Note 47) 

Yes (See Note 48) 

Yes (See Note 49) 

Reaction to a previous 

dose of vaccine 

anaphylactic (lifethreatening) All No (See Note 50) 

local (mild-to-moderate 

soreness, redness, 

swelling) 

All Yes 

Reaction after a previous dose of diphtheria-, tetanus-, or pertussis-containing vaccine 

(See Appendix C) 

Sudden infant death syndrome (SIDS), family 

history All Yes 

Steroids (See “Immunodeficiency,” p. 4) 

Thrombocytopenia, or history of 

thrombocytopenic purpura 

MMR 

All Others 

See Note 51 

Yes 

5
CONTRAINDICATIONS & PRECAUTIONS

Symptom or Condition Vaccine(s) Vaccinate? 

Tuberculin skin testing, performed 

simultaneously with vaccination 

MMR 

Varicella 

YF 

All Others 

Yes (See Note 52) 

Yes (See Note 53) 

Yes (See Note 53) 

Yes 

Tuberculosis (TB) or positive PPD 

MMR 

Varicella 

Zoster 

All Others 

See Note 54 

See Note 55 

No 

Yes 

Unvaccinated household contact All Yes 

Vomiting 

mild (with or without 

low-grade fever) All Yes 

moderate or severe (with 

or without fever) All See Note 11 

Wheezing (recurrent) Flu (LAIV) 

All Others 

See Note 56 

Yes 

Zoster (history of) All Yes 

6
 

 

NOTES
 

Note 1:	 Protocols have been published for safely administering influenza vaccine to persons with 

egg allergies. See “Prevention and Control of Influenza,” MMWR 2008;57 (No. RR-7) 

References 222-224. 

Note 2:	 If vaccinating persons with a history of an anaphylactic reaction to gelatin or gelatincontaining products with MMR or its component vaccines, or with varicella vaccine, 

extreme caution should be exercised. Before administering these vaccines to such persons, 

skin testing for sensitivity to gelatin can be considered. However, no specific protocols for 

this purpose have been published. 

Note 3:	 Some brands or formulations still contain thimerosal as a preservative, or may contain 

trace amounts of thimerosal that are a remnant of the manufacturing process. Check the 

appropriate manufacturer’s package insert for more information. 

Note 4: Contraindicates vaccination only with vaccine to which reaction occurred. 

Note 5:	 It is not known whether administering influenza antiviral medications affects the safety 

or efficacy of live attenuated influenza vaccine (LAIV); LAIV should not be administered 

until 48 hours following cessation of influenza antiviral therapy, and infl uenza antiviral 

medications should not be administered for 2 weeks following receipt of LAIV. 

Note 6: The vaccine manufacturer advises that Ty21a should not be administered to persons 

receiving sulfonamides or other antimicrobial agents. Ty21a should be administered >24 

hours after an antimicrobial dose. Mefloquine can inhibit the growth of the live Ty21a 

strain in vitro; if this antimalarial is administered, vaccination with Ty21a should be delayed 

for 24 hours. 

Note 7:	 Antiviral drugs active against herpesviruses (e.g., acyclovir or valacyclovir) might reduce the 

efficacy of live attenuated varicella vaccine. These drugs should be discontinued >24 hours 

before the administration of varicella vaccine, if possible. 

Note 8:	 “Persons taking chronic acyclovir, famciclovir, or valacyclovir should discontinue these 

medications at least 24 hours before administration of zoster vaccine, if possible. Th ese 

medications should not be used for at least 14 days after vaccination, by which time the 

immunologic effect should be established.” 

Note 9:	 When [any] intramuscular vaccine is indicated for a patient with a bleeding disorder or a 

person receiving anticoagulant therapy, the vaccine should be administered intramuscularly 

if, in the opinion of a physician familiar with the patient’s bleeding risk, the vaccine can be 

administered with reasonable safety by this route. If the patient receives antihemophilia 

or similar therapy, intramuscular vaccinations can be scheduled shortly after such therapy 

is administered. A fine needle (<23 gauge) should be used for the vaccination and fi rm 

pressure applied to the site, without rubbing, for >2 minutes. The patient or family should 

be instructed concerning the risk for hematoma from the injection. 

Note 10:Consider giving acetaminophen before DTaP and every 4 hours thereafter for 24 hours 

to children who have a personal or a family history of convulsions. (If an underlying 

neurologic disorder is involved, also see page 5.) 

Note 11:Persons with moderate or severe illnesses, with or without fever, can be vaccinated as soon as 

they are recovering and no longer acutely ill. 

7
 

 

NOTES
 

Note 12: The decision to give additional doses of DTaP to children who developed GBS within 6 

weeks of a prior dose should be based on consideration of the benefits of further vaccination 

vs. the risk of recurrence of GBS. For example, completion of the primary series in children 

is justifi ed. 

Note 13: Whether influenza vaccination specifically might increase the risk for recurrence of GBS 

is not known; therefore, avoiding vaccinating persons who are not at high risk for severe 

influenza complications and who are known to have developed GBS within 6 weeks after 

a previous influenza vaccination is prudent. Although data are limited, for the majority of 

persons who have a history of GBS and who are at high risk for severe complications from 

influenza, the established benefits of influenza vaccination justify yearly vaccination. 

Note 14:CDC recommends that persons with a history of GBS not receive MCV, although persons 

with a history of GBS at especially high risk for meningococcal disease (i.e., microbiologists 

routinely exposed to isolates of Neisseria meningitidis) might consider vaccination. 

Note 15:Not a contraindication, but providers should evaluate the risks and benefits of administering 

Tdap or Td. If a decision is made to continue vaccination with tetanus toxoid, Tdap is 

preferred to Td if otherwise indicated. 

Note 16:Persons with chronic disorders of the cardiovascular system should not get live attenuated 

infl uenza vaccine. 

Note 17: Specific vaccines are recommended, or may be given, at varying times after transplant and 

under certain circumstances. For some vaccines, no data exist. Use of live vaccines is 

indicated only among immunocompetent persons and is contraindicated for recipients 

after HSCT who are not presumed immunocompetent. HSCT recipients are presumed 

immunocompetent at >24 months after HSCT if they are not on immunosuppressive 

therapy and do not have graft-versus-host disease. For more information, see “Guidelines 

for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant 

Recipients” (MMWR 2000; 49 [No RR-10]), especially Tables 4 and 6; and ACIP’s “General 

Recommendations on Immunization” (MMWR 2006; [No RR-15]:28). 

Note 18:MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not 

have evidence of severe immunosuppression and for whom measles vaccination would 

otherwise be indicated. [For definition of severe immunosuppression, see 2006 AAP Red 

Book, Table 3.25, p. 382.] 

Note 19:Consider the potential risks and benefits of administering rotavirus vaccine to infants 

with known or suspected altered immunocompetence. Children and adults who 

are immunocompromised because of congenital immunodefi ciency, hematopoietic 

transplantation, or solid organ transplantation sometimes experience severe, prolonged, and 

even fatal rotavirus gastroenteritis. However, no safety or efficacy data are available for the 

administration of rotavirus vaccine to infants who are potentially immunocompromised, 

including . . . infants with primary and acquired immunodeficiency states, including HIV/ 

AIDS or other clinical manifestations of infection with HIV. Data are insuffi cient from the 

clinical trials to support administration of rotavirus vaccine to infants with indeterminant 

HIV status who are born to mothers with HIV/AIDS. 

8
 

Note 20:Children aged 1-8: HIV-infected children with CD4+ T-lymphocyte percentage >15% 

should be considered for vaccination with the single-antigen varicella vaccine (2 doses 

administered 3 months apart). Adolescents and adults: Data are lacking; however, 

weighing the risk for severe disease from wild VZV and potential benefit of vaccination, 

vaccination may be considered (2 doses, administered 3 months apart) for HIV-infected 

persons with CD4+T-lymphocyte count >200 cells/μL in these age groups. Because data 

are not available on safety, immunogenicity or efficacy of MMRV vaccine in HIV infected 

children, MMRV should not be used when vaccinating these children. 

Note 21:MMR vaccination should be considered for all symptomatic HIV-infected persons who do 

not have evidence of severe immunosuppression or of measles immunity. [For defi nition of 

severe immunosuppression, see 2006 AAP Red Book, Table 3.25, p. 382.] 

Note 22:Zoster vaccine should not be administered to persons with primary or acquired 

immunodeficiency including persons with AIDS or other clinical manifestations of HIV, 

including persons with CD4+ T-lymphocyte values <200 per mm3

 or <15% of total 

lymphocytes. 

Note 23:Do not give immune globulin products and MMR simultaneously. If unavoidable, give 

at different sites and revaccinate or test for seroconversion in 3 months. If MMR is 

given first, do not give IG for 2 weeks. If IG is given first, the interval between IG and 

measles vaccination depends on the product, the dose, and the indication (see Appendix 

D). Because of the importance of rubella immunity among childbearing-age women, the 

postpartum vaccination of rubella-susceptible women with rubella or MMR vaccine should 

not be delayed because of receipt of anti-Rho(D) globulin or any other blood product 

during the last trimester of pregnancy or at delivery. These women should be vaccinated 

immediately after delivery and, if possible, tested >3 months later to ensure immunity to 

rubella and, if necessary, to measles. 

Note 24:Do not give varicella vaccine for 3-11 months (see Appendix D) after administration of 

blood (except washed red blood cells) or after plasma tranfusions or IG. Do not give 

antibody-containing products for 2 weeks after vaccination unless the benefits exceed those 

of vaccination. In such instances, either revaccinate or test for immunity at the appropriate 

intervals, and revaccinate if seronegative. 

Note 25:If nasal congestion is present that might impede delivery of the vaccine to the 

nasopharyngeal mucosa, deferral of administration should be considered until resolution of 

the illness, or TIV should be administered instead. 

Note 26:Persons with asthma, reactive airways disease or other chronic disorders of the pulmonary 

or cardiovascular systems and persons with other underlying medical conditions, including 

metabolic diseases such as diabetes, renal dysfunction, and hemoglobinopathies should not 

receive LAIV. 

NOTES
 

9
 

NOTES
 

Note 27:Consider the potential risks and benefits of administering rotavirus vaccine to infants with 

preexisting chronic gastrointestinal disease (e.g., congenital malabsorption syndromes, 

Hirschsprung’s disease, short-gut syndrome, persistent vomiting of unknown cause). Infants 

with chronic gastrointestinal conditions who are not undergoing immunosuppressive therapy 

should benefit from rotavirus vaccine, and the benefits outweigh the theoretical risks. 

However, the safety and efficacy of rotavirus vaccine have not been established for infants 

with these conditions. 

Note 28: The great majority of persons with chronic illnesses should be appropriately vaccinated. Th e 

decision whether or not to vaccinate these persons, and what vaccines to give, should be 

made on an individual basis. 

Note 29:When cancer chemotherapy or other immunosuppressive therapy is being considered 

(e.g., for patients with Hodgkins disease or those who undergo organ or bone marrow 

transplantation), the interval between vaccination and initiation of immunosuppressive 

therapy should be at least 2 weeks. Vaccination during chemotherapy or radiation therapy 

should be avoided. 

Note 30:Preexposure: Patients who are immunosuppressed by disease or medications should 

postpone preexposure vaccinations and consider avoiding activities for which rabies 

preexposure prophylaxis is indicated. When this course is not possible, immunosuppressed 

persons who are at risk for rabies should be vaccinated by the IM route and their antibody 

titers checked. Failure to seroconvert after the third dose should be managed in consultation 

with appropriate public health officials. Postexposure: Immunosuppressive agents should 

not be administered during postexposure therapy unless essential for treatment of other 

conditions. When postexposure prophylaxis is administered to an immunosuppressed 

person, it is especially important that a serum sample be tested for rabies antibody to ensure 

that an acceptable antibody response has developed. 

Note 31:Varicella vaccine should not be administered to persons who have cellular 

immunodeficiencies, but persons with impaired humoral immunity may be vaccinated. 

Vaccination of leukemic children who are in remission and who do not have evidence 

of immunity to varicella should be undertaken only with expert guidance and with the 

availability of antiviral therapy should complications ensue. Persons without evidence of 

immunity who are receiving systemic steroids for certain conditions (e.g., asthma) and who 

are not otherwise immunocompromised may be vaccinated if they are receiving <2 mg/kg of 

body weight or a total of <20 mg/day of prednisone or its equivalent. 

Note 32: Zoster vaccine should not be administered to: 

• 

• 

• 

• 

Persons with leukemia, lymphomas, or other malignant neoplasms affecting the bone 

marrow or lymphatic system. 

Persons on immunosuppressive therapy, including high-dose corticosteroids (>20 mg/day 

of prednisone or equivalent) lasting two or more weeks. Defer vaccination for at least 1 

months after discontinuation of such therapy. 

Persons with clinical or laboratory evidence of other unspecified cellular 

immunodeficiency. 

Persons receiving recombinant human immune mediators and immune modulators, 

especially the antitumor necrosis factor agents adalimumab, infliximab, and etanercept. If 

it is not possible to administer zoster vaccine to patients before initiation of therapy, assess 

the immune status of the recipient on a case-by-case basis to determine the relevant risks 

and benefits. Otherwise, defer vaccination for at least 1 month after discontinuation of 

such therapy. 10
 Zoster vaccine may be administered to: 

• Patients whose leukemia is in remission and who have not received chemotherapy or 

radiation for at least 3 months. 

• Persons on short-term corticosteroid therapy (<14 days); low to moderate dose (<20 mg/ 

day of prednisone or equivalent); topical; intra-articular, bursal, or tendon injections; or 

long-term alternate-day treatments with low to moderate doses of short-acting systemic 

corticosteroids. 

• Persons on therapy with low doses of 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, and other 

conditions. 

• Persons with impaired humoral immunity (e.g., hypogammaglobulinemia or 

dysgammaglobulinemia). 

Note 33:Varicella vaccine should not be administered to a person with a family history of congenital 

or hereditary immunocefidiency in parents or siblings unless that person’s immune 

competence has been clinically substantiated or verified by a laboratory. 

Note 34:TIV is preferred for vaccinating household members, healthcare personnel, and others who 

have close contact with severely immunosuppressed persons during those periods in which 

the immunosuppressed person requires care in a protective environment. No preference is 

indicated for TIV use by those who have close contact with persons with lesser degrees of 

immunosuppression. 

Note 35:Data suggest that infants with a history of intussusception might be at higher risk for a 

repeat episode than other infants. Therefore, until postlicensure data on safety of rotavirus 

vaccine is available, the risks and benefits of vaccination should be considered when 

vaccinating infants with a previous episode of intussusception. 

Note 36:Whether and when to administer DTaP to children with proven or suspected underlying 

neurologic disorders should be decided individually. Generally, infants and children with 

stable neurologic conditions, including well-controlled seizures, may be vaccinated. 

Note 37:ACIP recommends that children with progressive neurologic conditions not be vaccinated 

with Tdap until the condition stabilizes. Chronic progressive neurologic conditions that 

are stable in adults do not constitute a reason to delay Tdap; this is in contrast to unstable 

or evolving neurologic conditions (e.g., cerebrovascular events and acute encephalopathic 

conditions). 

Note 38:Pregnant women should be vaccinated against anthrax only if the potential benefi ts of 

vaccination outweigh the potential risks to the fetus. 

Note 39: The theoretical risk to the developing fetus is expected to be low. The risk associated with 

vaccination should be weighed against the risk for hepatitis A in women who may be at high 

risk for exposure to hepatitis A virus. 

NOTES
 

11
NOTES
 

Note 40:HPV vaccine is not recommended for use in pregnancy. It has not been causally associated 

with adverse outcomes of pregnancy or adverse events in the developing fetus. However, 

until additional information is available, initiation of the vaccine series should be delayed 

until after completion of the pregnancy. If a woman is found to be pregnant after initiating 

the vaccination series, the remainder of the 3-dose regimen should be delayed until after 

completion of the pregnancy. A vaccine in pregnancy registry has been established; report 

any exposure to HPV vaccine during pregnancy to 800-986-8999. No intervention is 

needed. 

Note 41:If a pregnant woman is at increased risk for infection and requires immediate protection 

against polio, IPV can be administered in accordance with the recommended schedules for 

adults. 

Note 42:Pregnant women who must travel to an area where risk of JE is high should be vaccinated 

when the theoretical risks of immunization are outweighed by the risk of infection to the 

mother and developing fetus. 

Note 43:Women should avoid becoming pregnant for 4 weeks following vaccination. 

Note 44:Vaccine is not contraindicated, but no data exist on its use among pregnant women. 

Note 45:ACIP recommends Td when tetanus and diphtheria protection is required during pregnancy. 

In some situations, health-care providers can choose to administer Tdap instead of Td to 

add protection against pertussis. When Td or Tdap is administered during pregnancy, the 

second or third trimester is preferred. Data on safety, immunogenicity and the outcomes of 

pregnancy are not available for pregnant women who receive Tdap. Providers who choose 

to administer Tdap to pregnant women should discuss the lack of data with the pregnant 

women and are encouraged to report Tdap administration, regardless of the trimester, to the 

appropriate manufacturer’s pregnancy registry (Boostrix to GlaxoSmithKline at 1-888-825­

5349; Adacel to sanofi pasteur at 1-800-822-2463). 

Note 46:Pregnant women should not be routinely vaccinated on theoretical grounds, and travel to 

areas where yellow fever is present should be postponed until after delivery. If international 

travel requirements constitute the only reason to vaccinate a pregnant woman, rather than an 

increased risk of infection, efforts should be made to obtain a waiver letter from the traveler’s 

physician. Pregnant women who must travel to areas where the risk of yellow fever is high 

should be vaccinated. 

Note 47:HBsAg-Negative Mother: Preterm infants weighing <2,000 g and born to HBsAg-negative 

mothers should have their first vaccine dose delayed until 1 month after birth or hospital 

discharge. For these infants, a copy of the original laboratory report indicating that the 

mother was HBsAg negative during this pregnancy should be placed in the infant’s medical 

record.

 HBsAg-Positive Mother: For preterm infants weighing <2,000 g, the initial vaccine dose 

(birth dose) should not be counted as part of the vaccine series because of the potentially 

reduced immunogenicity of hepatitis B vaccine in these infants; 3 additional doses of vaccine 

(for a total of 4 doses) should be administered beginning at age 1 or 2 months. 

12
Mother’s HBsAg Status Unknown: Preterm infants weighing <2,000 g should receive both 

single-antigen hepatitis B vaccine and HBIG (0.5 mL) if the mother’s HBsAg status cannot 

be determined within 12 hours of birth. The birth dose of vaccine should not be counted 

as part of the 3 doses required to complete the vaccine series; 3 additional doses of vaccine 

(for a total of 4 doses) should be administered according to a recommended schedule on the 

basis of the mother’s HBsAg test result. 

Note 48:ACIP supports vaccination of prematurely born infants with rotavirus vaccine if they are at 

least 6 weeks of age, are being or have been discharged from the hospital nursery, and are 

clinically stable. 

Note 49: The appropriate age for initiating vaccinations in the prematurely born infant is the usual 

chronological age (same dosage and indications as for normal, full-term infants). 

Note 50:Contraindicates vaccination only with vaccine to which reaction occurred. If tetanus toxoid 

is contraindicated for someone who has not completed a primary tetanus series and that 

person has a wound that is neither clean nor minor, give only passive vaccination, using 

tetanus immune globulin (TIG). 

Note 51:Consider the benefits of immunity to measles, mumps, and rubella vs. the risk of recurrence 

or exacerbation of thrombocytopenia after vaccination, or risk from natural infections of 

measles or rubella. In most instances, the benefits of vaccination will be much greater than 

the potential risks and will justify giving MMR, particularly in view of the even greater risk 

of thrombocytopenia following measles or rubella disease. However, if a prior episode of 

thrombocytopenia occurred near the time of vaccination, it might be prudent to avoid a 

subsequent dose. (Also applies to MMRV.) 

Note 52:Measles vaccination may temporarily suppress tuberculin reactivity. MMR vaccine may be 

given after, or on the same day as, TB testing. If MMR has been given recently, postpone 

the TB test until 4-6 weeks after administration of MMR. If giving MMR simultaneously 

with tuberculin skin test, use the Mantoux test, not multiple puncture tests, because the 

latter, if results are positive, require confirmation (and confirmation would then have to be 

postponed 4-6 weeks). 

Note 53:No data exist for the potential degree of PPD suppression that might be associated with 

other parenteral live attenuated virus vaccines. Nevertheless, in the absence of data, 

following guidelines for measles-containing vaccine when scheduling PPD screening and 

administering other parenteral live attenuated virus vaccines is prudent. 

Note 54:A theoretical basis exists for concern that measles vaccine might exacerbate tuberculosis. 

Consequently, before administering MMR to persons with untreated active tuberculosis, 

initiating antituberculosis therapy is advisable. 

Note 55:Although no data exist regarding whether either varicella or live varicella virus vaccine 

exacerbates tuberculosis, vaccination is not recommended for persons who have untreated, 

active tuberculosis. 

Note 56:LAIV should not be administered to children younger than 5 years of age with recurrent 

wheezing. 

NOTES
 

13
APPENDICES
 

Appendices: 

Appendix A: Summary of Contents of Vaccines Licensed in the United States . . . . . . . . . . . . . . . .15
 

Appendix B: Latex in Vaccine Packaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
 

Appendix C: Reaction After a Previous Dose of Diphtheria-, Tetanus-, or
 

Pertussis-Containing Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
 

Appendix D: Suggested Intervals Between Administration of Immune Globulin Preparations and 


Measles- or Varicella-Containing Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
 

Appendix E: Vaccinia (Smallpox) Vaccine (Routine, Non-Emergency Use) . . . . . . . . . . . . . . . . . .26
 

Appendix F: Quick Reference - Contraindications and Precautions to Routine Childhood and 


Adolescent Vaccinations, By Vaccine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
 

14
APPENDIX 

A
 

Summary of Contents of Vaccines Licensed in 

the United States 

The ACIP specifies that severe allergies to certain substances contraindicate specific vaccines (see 

“Allergies,” pages 1 & 2). But ACIP also makes the general statement that a “serious allergic reaction 

[e.g., anaphylaxis] to a vaccine component” is a contraindication to any vaccine containing that 

component. 

This table lists vaccine components (e.g., adjuvants and preservatives) found in all U.S. vaccines, as 

well as substances used during the manufacturing process, including vaccine-production media, that 

are removed from the final product and present only in trace quantities. 

If in doubt about the contents of a particular vaccine, check the current package insert. 

In addition to the substances listed, most vaccines contain Sodium Chloride (table salt). 

Vaccine Contains 

Aluminum Hydroxide, Amino Acids, 

Anthrax (BioTh rax) Benzethonium Chloride, Formaldehyde or 

Formalin, Inorganic Salts and Sugars, Vitamins 

Asparagine, Citric Acid, Lactose, Glycerin, 

BCG (Tice) Iron Ammonium Citrate, Magnesium Sulfate, 

Potassium Phosphate 

Aluminum Phosphate, Ammonium Sulfate, 

Casamino Acid, Dimethyl-beta-cyclodextrin, DTaP (Daptacel) Formaldehyde or Formalin, Glutaraldehyde, 

2-Phenoxyethanol 

Aluminum Hydroxide, Bovine Extract, 

DTaP (Infanrix) Formaldehyde or Formalin, Glutaraldhyde, 

2-Phenoxyethanol, Polysorbate 80 

Aluminum Potassium Sulfate, Ammonium 

Sulfate, Bovine Extract, Formaldehyde or DTaP (Tripedia) Formalin, Gelatin, Polysorbate 80, Sodium 

Phosphate, Th imerosal* 

Aluminum Potassium Sulfate, Ammonium 

Sulfate, Bovine Extract, Formaldehyde or DTaP/Hib (TriHIBit) Formalin, Gelatin, Polysorbate 80, Sucrose, 

Th imerosal* 

Aluminum Hydroxide, Bovine Extract, 

DTaP/IPV (Kinrix) Formaldehyde, Gluteraldehyde, Monkey Kidney 

Cells, Neomycin, Polymyxin B, Polysorbate 80 

15
APPENDIX A
 

Vaccine Contains 

Aluminum Hydroxide, Aluminum Phosphate, 

Bovine Protein, Lactalbumin Hydrolysate, 

Formaldehyde or Formalin, Glutaraldhyde, DTaP/HepB/IPV (Pediarix) Monkey Kidney Tissue, Neomycin, 

2-Phenoxyethanol, Polymyxin B, Polysorbate 80, Th imerosal*, Yeast Protein 

2-phenoxyethanol, Aluminum Phosphate, Bovine 

Serum Albumin, Casamino Acid, Formaldehyde, DTaP/Hib/IPV (Pentacel) Gluteraldehyde, MRC-5 Cellular Protein, 

Neomycin, Polymyxin B, Polysorbate 80 

Aluminum Potassium Sulfate, Bovine Extract, 

DT (sanofi ) Formaldehyde or Formalin, Th imerosal (multidose) or Th imerosal* (single-dose) 

DT (Massachusetts) Aluminum Hydroxide, Formaldehyde or Formalin 

Ammonium Sulfate, Formaldehyde or Formalin, Hib (ACTHib) Sucrose 

Hib (PedvaxHib) Aluminum Hydroxyphosphate Sulfate 

Amino Acids, Aluminum Hydroxyphosphate 

Sulfate, Dextrose, Formaldehyde or Formalin, Hib/Hep B (Comvax) Mineral Salts, Sodium Borate, Soy Peptone, Yeast 

Protein 

Aluminum Hydroxide, Amino Acids, 

Formaldehyde or Formalin, MRC-5 Cellular Hep A (Havrix) Protein, Neomycin Sulfate, 2-Phenoxyethanol, 

Phosphate Buff ers, Polysorbate 

Aluminum Hydroxyphosphate Sulfate, Bovine 

Albumin or Serum, DNA, Formaldehyde or Hep A (Vaqta) Formalin, MRC-5 Cellular Protein, Sodium 

Borate 

Aluminum Hydroxide, Phosphate Buff ers, Hep B (Engerix-B) Th imerosal*, Yeast Protein 

Aluminum Hydroxyphosphate Sulfate, Amino 

Acids, Dextrose, Formaldehyde or Formalin, Hep B (Recombivax) Mineral Salts, Potassium Aluminum Sulfate, Soy 

Peptone, Yeast Protein 

Aluminum Hydroxide, Aluminum Phosphate, 

Amino Acids, Dextrose, Formaldehyde or 

Formalin, Inorganic Salts, MRC-5 Cellular HepA/HepB (Twinrix) Protein, Neomycin Sulfate, 2-Phenoxyethanol, 

Phosphate Buffers, Polysorbate 20, Th imerosal*, 

Vitamins, Yeast Protein 16
APPENDIX A 

Vaccine Contains 

Amino Acids, Amorphous Aluminum 

Hydroxyphosphate Sulfate, Carbohydrates, Human Papillomavirus (HPV) (Gardasil) L-histidine, Mineral Salts, Polysorbate 80, Sodium 

Borate, Vitamins 

Beta-propiolactone, Calcium Chloride, 

Ovalbumin, Neomycin Sulfate, Polymyxin B, 

Infl uenza (Afl uria) Potassium Chloride, Potassium Phosphate, 

Sodium Phosphate, Sodium Taurodeoxycholate, 

Thimerosal (multidose containers) 

Egg Albumin (Ovalbumin), Egg Protein, 

Formaldehyde or Formalin, Gentamicin, 

Hydrocortisone, Octoxynol-10, α-Tocopheryl 

Hydrogen Succinate, Polysorbate 80, Sodium 

Deoxycholate, Sodium Phosphate, Th imerosal*

Infl uenza (Fluarix) 

Egg Albumin (Ovalbumin), Egg Protein, 

Infl uenza (Flulaval) Formaldehyde or Formalin, Sodium 

Deoxycholate, Phosphate Buff ers, Th imerosal 

Beta-Propiolactone , Egg Protein, Neomycin, 

Polymyxin B, Polyoxyethylene 9-10 Nonyl 

Infl uenza (Fluvirin) Phenol (Triton N-101, Octoxynol 9), Th imerosal 

(multidose containers), Th imerosal* (single-dose 

syringes) 

Egg Protein, Formaldehyde or Formalin, 

Infl uenza (Fluzone) Gelatin, Octoxinol-9 (Triton X-100), Th imerosal 

(multidose containers) 

Chick Kidney Cells, Egg Protein, Gentamicin 

Infl uenza (FluMist) Sulfate, Monosodium Glutamate, Sucrose 

Phosphate Glutamate Buff er 

Calf Serum Protein, Formaldehyde or 

IPV (Ipol) Formalin, Monkey Kidney Tissue, Neomycin, 

2-Phenoxyethanol, Polymyxin B, Streptomycin 

Formaldehyde or Formalin, Gelatin, Mouse Serum Japanese Encephalitis (JE-Vax) Protein, Polysorbate 80, Th imerosal 

Amino Acid, Bovine Albumin or Serum, Chick 

Embryo Fibroblasts, Gelatin, Glutamate, Human Measles (Attenuvax) Albumin, Neomycin, Phosphate, Sodium 

Phosphate, Sorbitol, Sucrose, Vitamins 

Meningococcal (Menactra) Formaldehyde or Formalin, Phosphate Buff ers 

Meningococcal (Menomune) Lactose, Thimerosal (10-dose vials only) 

17
APPENDIX 

A
 

Vaccine Contains 

Amino Acid, Bovine Albumin or Serum, Chick 

Embryo Fibroblasts, Human Serum Albumin, Mumps (Mumpsvax) Gelatin, Glutamate, Neomycin, Phosphate 

Buffers, Sorbitol, Sucrose, Vitamins 

Amino Acid, Bovine Albumin or Serum, Chick 

Embryo Fibroblasts, Human Serum Albumin, MMR (MMR-II) Gelatin, Glutamate, Neomycin, Phosphate 

Buffers, Sorbitol, Sucrose, Vitamins 

Bovine Albumin or Serum, Gelatin, Human 

Serum Albumin, Monosodium L-glutamate, 

MRC-5 Cellular Protein, Neomycin, Sodium MMRV (ProQuad) Phosphate Dibasic, Sodium Bicarbonate, Sorbitol, 

Sucrose, Potassium Phosphate Monobasic, 

Potassium Chloride, Potassium Phosphate Dibasic 

Pneumococcal (Pneumovax) Bovine Protein, Phenol 

Aluminum Phosphate, Amino Acid, Soy Peptone, Pneumococcal (Prevnar) Yeast Extract 

Human Serum Albumin, Beta-Propiolactone, 

Rabies (Imovax) MRC-5 Cellular Protein, Neomycin, Phenol Red 

(Phenolsulfonphthalein), Vitamins 

Amphotericin B, Beta-Propiolactone , 

Bovine Albumin or Serum, Chicken Protein, 

Rabies (RabAvert) Chlortetracycline, Egg Albumin (Ovalbumin), 

Ethylenediamine-Tetraacetic Acid Sodium 

(EDTA), Neomycin, Potassium Glutamate 

Cell Culture Media, Fetal Bovine Serum, 

Sodium Citrate, Sodium Phosphate Monobasic Rotavirus (RotaTeq) Monohydrate, Sodium Hydroxide Sucrose, 

Polysorbate 80 

Amino Acids, Calcium Carbonate, Dextran, 

Rotavirus (Rotarix) Dulbecco’s Modified Eagle Medium (DMEM), 

Sorbitol, Sucrose, Xanthan 

Bovine Albumin or Serum, Gelatin, Human 

Rubella (Meruvax II) Serum Albumin, Neomycin, Phosphate Buff ers, 

Sodium Phosphate, Sorbitol 

Aluminum Potassium Sulfate, Bovine Extract, 

Td (Decavac) Formaldehyde or Formalin, 2-Phenoxyethanol, 

Peptone, Th imerosal* 

18
APPENDIX 

A
 

Vaccine Contains 

Aluminum Hydroxide, Aluminum Phosphate, 

Td (Massachusetts) Formaldehyde or Formalin, Th imerosal (some 

multidose containers) 

Aluminum Phosphate, Formaldehyde or Formalin, Tdap (Adacel) Glutaraldehyde, 2-Phenoxyethanol 

Aluminum Hydroxide, Bovine Extract, 

Tdap (Boostrix) Formaldehyde or Formalin, Glutaraldehyde, 

Polysorbate 80 

Disodium Phosphate, Monosodium 

Typhoid (inactivated – Typhim Vi) Phosphate, Phenol, Polydimethylsilozone, 

Hexadecyltrimethylammonium Bromide 

Amino Acids, Ascorbic Acid, Bovine Protein, 

Typhoid (oral – Ty21a) Casein, Dextrose, Galactose, Gelatin, Lactose, 

Magnesium Stearate, Sucrose, Yeast Extract 

Glycerin, Human Serum Albumin, Neomycin, Vaccinia (ACAM2000) Phenol, Polymyxin B 

Bovine Albumin or Serum, EthylenediamineTetraacetic Acid Sodium (EDTA), Gelatin, 

Monosodium L-Glutamate, MRC-5 DNA and Varicella (Varivax) Cellular Protein, Neomycin, Potassium Chloride, 

Potassium Phosphate Monobasic, Sodium 

Phosphate Monobasic, Sucrose 

Yellow Fever (YF Vax) Egg Protein, Gelatin, Sorbitol 

Bovine Calf Serum, Hydrolyzed Porcine Gelatin, 

Monosodium L-glutamate, MRC-5 DNA and 

Zoster (Zostavax) Cellular Protein, Neomycin, Potassium Phosphate 

Monobasic, Potassium Chloride, Sodium 

Phosphate Dibasic, Sucrose 

August 2008 

*Where “thimerosal” is marked with an asterisk (*) it indicates that the product should be considered equivalent to thimerosal-free 

products. This vaccine may contain trace amounts (<3 mcg) of mercury left after post-production thimerosal removal, but these 

amounts have no biological eff ect. JAMA 1999;282(18) and JAMA 2000;283(16) 

Adapted from Grabenstein JD. ImmunoFacts: Vaccines & Immunologic Drugs. St. Louis, MO: Wolters Kluwer Health Inc.; 2006 

and individual products’ package inserts. All reasonable efforts have been made to ensure the accuracy of this information, but 

manufacturers may change product contents before that information is refl ected here. 

19
APPENDIX 

B
 

Latex in Vaccine Packaging 

If a person reports a severe (anaphylactic) allergy to latex, vaccines supplied in vials or syringes that 

contain natural rubber should not be administered, unless the benefit of vaccination outweighs the 

risk of an allergic reaction to the vaccine. 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 dry 

natural rubber or rubber latex can be administered. 

The following table is accurate, to the best of our knowledge, as of July 2008. If in doubt, check the 

package insert for the vaccine in question. 

Vaccine Latex? 

Anthrax (BioTh rax) YES – Vial. 

Comvax YES – Vial 

Daptacel YES – Vial 

YES – Syringe DTaP Infanrix NO – Vial 

Tripedia YES – Vial 

DT (Generic) YES – Vial 

PedvaxHIB Yes – Vial 

Hib YES – Diluent vial ActHIB NO – Lyophilized vaccine vial 

YES – Syringe Havrix NO – Vial 

Hepatitis A YES – Vial Vaqta YES – Syringe 

YES – Syringe Engerix-B Hepatitis B NO – Vial 

Recombivax HB YES – Vial 

HPV (Gardasil) NO 

Fluarix YES – Syringe 

Fluvirin NO 

Fluzone NO Infl uenza FluLaval NO 

FluMist NO 

Afl uria NO 

Japanese Encephalitis (JE-Vax) NO 

YES – Syringe Kinrix NO – Vial 

MMR (M-M-R II) NO 

MMRV (ProQuad) NO 

Measles (Attenuvax) NO 

Mumps (Mumpsvax) NO 20
 

APPENDIX 

B
 

21

Vaccine Latex? 

Rubella (Meruvax II) NO 

Meningococcal Menomune YES – Vial 

Menactra YES – Vial 

Pediarix YES – Syringe 

NO – Vial 

Pentacel NO 

Pneumococcal Pneumovax 23 NO 

Prevnar YES – Vial 

Polio (IPOL) YES – Syringe 

NO – Vial 

Rabies 

Imovax Rabies NO 

RabAvert NO 

Rotavirus 

RotaTeq NO 

Rotarix YES – Applicator 

NO– Vial & Transfer Adapter 

Td 

Decavac NO – Vial 

NO – Syringe 

Generic YES – Vial 

YES – Syringe 

Tdap 

Adacel NO 

Boostrix YES – Syringe 

NO – Vial 

TriHIBit YES – Vial 

Twinrix YES – Syringe 

NO – Vial 

Typhoid Typhim Vi NO 

Vivotif Berna N/A 

Varicella (Varivax) NO 

Vaccinia 

(Smallpox) ACAM2000 NO 

Yellow Fever (YF-Vax) YES – Vial 

Zoster (Shingles) (Zostavax) NO 

July 2008
 
APPENDIX 

C
 

Reaction After a Previous Dose of Diphtheria-, 

Tetanus- or Pertussis-Containing Vaccine 

Symptom or Condition Vaccine Vaccinate? 

Arthus reaction, following tetanus- and/ DTaP See Note C1 

or diphtheria toxoid-containing vaccine Tdap See Note C1 

(including MCV) Td/DT See Note C1 

DTaP See Note C2 Collapse or shock-like state within 48 hours of Tdap Yes dose Td/DT Yes 

DTaP No Encephalopathy within 7 days after dose, not Tdap No attributable to an identifi able cause Td/DT Yes 

DTaP Yes Extensive limb swelling that was not an Arthus Tdap Yes reaction Td/DT Yes 

DTaP Yes (See Note C3) Family history of any adverse event after a Tdap Yes dose Td/DT Yes 

DTaP Yes (See Note C3) Fever of <40.5°C (105°F) within 48 hours Tdap Yes after a dose Td/DT Yes 

DTaP See Notes C2 & C3 Fever of >40.5°C (105°F) within 48 hours Tdap Yes after a dose, not attributable to another cause Td/DT Yes 

DTaP See Note C4 Guillain-Barré syndrome (GBS) within 6 Tdap See Note C5 weeks after a dose Td/DT See Note C5 

Persistent, inconsolable crying lasting for 3 or DTaP See Note C2 

more hours, occurring within 48 hours of a Tdap Yes 

dose Td/DT Yes 

DTaP See Notes C2 & C3 

Seizures within 3 days after a dose Tdap Yes 

Td/DT Yes 

22
APPENDIX 

C
 

23

Note C1:	 Providers should carefully review the medical history to verify the diagnosis of an Arthus 

reaction, and can consult with an allergist or immunologist. If an Arthus reaction was 

likely, consider deferring DTaP, Tdap or Td vaccination until at least 10 years have elapsed 

since the last tetanus toxoid-containing and/or diphtheria toxoid-containing vaccine was 

received. If the Arthus reaction was associated with a vaccine that contained diphtheria 

toxoid without tetanus toxoid (e.g., MCV), deferring Tdap or Td might leave the patient 

inadequately protected against tetanus. In this situation, if the last tetanus toxoidcontaining vaccine was >10 years earlier, providers can obtain a serum antitetanus level to 

evaluate the need for tetanus vaccination (antitetanus levels >0.1 IU/mL are considered 

protective) or administer TT. 

Note C2: 	Not a contraindication, but a precaution. Consider carefully the benefits and risks of 

this vaccine under these circumstances. If the risks are believed to outweigh the benefi ts, 

withhold the vaccination; if the benefits are believed to outweigh the risks (for example, 

during an out-break or foreign travel), give the vaccine. 

Note C3:	 Consider giving acetaminophen before DTaP and every 4 hours thereafter for 24 hours. 

Note C4: 	The decision to give additional doses of DTaP should be based on consideration of the 

benefits of further vaccination vs. the risk of recurrence of GBS. For example, completion 

of the primary series in children is justifi ed. 

Note C5:	 Not a contraindication, but providers should evaluate the risks and benefi ts of 

administering Tdap or Td. If a decision is made to continue vaccination with tetanus 

toxoid, Tdap is preferred to Td if otherwise indicated. 
APPENDIX 

D
 

Suggested Intervals Between Administration of 

Immune Globulin Preparations and Measles- or 

Varicella-Containing Vaccine (Does not include zoster 

vaccine [Zostavax]) 

Recommended 

interval before Dose, including mg measles- or Product / Indication immunoglobulin G varicella- (IgG)/kg body weight containing 

vaccine 

RSV monoclonal antibody (SynagisTM)

1 15 mg/kg intramuscularly (IM) None 

Tetanus IG (TIG) 250 units (10 mg IgG/kg) IM 3 months 

Hepatitis A IG

 Contact prophylaxis 0.02 mL/kg (3.3 mg IgG/kg) IM 3 months 

 International travel 0.06 mL/kg (10 mg IgG/kg) IM 3 months 

Hepatitis B IG (HBIG) 0.06 mL/kg (10 mg IgG/kg) IM 3 months 

Rabies IG (HRIG) 20 IU/kg (22 mg IgG/kg) IM 4 months 

Measles prophylaxis IG 

Standard (i.e., non- 0.25 mL/kg (40 mg IgG/kg) IM 5 months 

 immunocompromised) contact

 Immunocompromised contact 0.50 mL/kg (80 mg IgG/kg) IM 6 months 

Blood tranfusion 

Red blood cells (RBCs), washed 10 mL/kg negligible IgG/kg

 intravenously (IV) None 

RBCs, adenine-saline added 10 mL/kg (10 mg IgG/kg) IV 3 months 

Packed RBCs (Hct 65%)2 10 mL/kg (60 mg IgG/kg) IV 6 months 

Whole blood (Hct 35%-50%)2 10 mL/kg (80-100 mg IgG/kg) IV 6 months 

 Plasma/platelet products 10 mL/kg (160 mg IgG/kg) IV 7 months 

Cytomegalovirus intravenous immune 150 mg/kg maximum 6 months 

globulin (IGIV) 

IGIV 

Replacement therapy for immune

 defi ciencies3 300-400 mg/kg IV3 8 months 

Immune thrombocytopenic purpura 400 mg/kg IV 8 months 

Immune thrombocytopenic purpura 1000 mg/kg IV 10 months 

Postexposure varicella prophylaxis4 400 mg/kg IV 8 months 

 Kawasaki disease 2 g/kg IV 11 months 

24
APPENDIX 

D
 

This table is not intended for determining the correct indications and dosages for using antibodycontaining products. Unvaccinated persons might not be fully protected against measles during the 

entire recommended interval, and additional doses of immune globulin or measles vaccine might 

be indicated after measles exposure. Concentrations of measles antibody in an immune globulin 

preparation can vary by manufacturer’s lot. Rates of antibody clearance after receipt of an immune 

globulin preparation also might vary. Recommended intervals are extrapolated from an estimated 

half-life of 30 days for passively acquired antibody and an observed interference with the immune 

response to measles vaccine for 5 months after a dose of 80 mg IgG/kg. 

Note 1: 	Contains antibody only to respiratory syncytial virus. 

Note 2: 	Assumes a serum IgG concentration of 16 mg/mL. 

Note 3: 	Measles and varicella vaccinations are recommended for children with asymptomatic 

or mildly symptomatic human immunodeficiency virus (HIV) infection but are 

contraindicated for persons with severe immunosuppression from HIV or any other 

immunosuppressive disorder. 

Note 4: 	The investigational product VariZIG, similar to licensed VZIG, is a purifi ed human 

immune globulin preparation made from plasma containing high levels of anti-varicella 

antibodies (immunoglobulin class G [IgG]). When indicated, health-care providers should 

make every effort to obtain and administer VariZIG. In situations in which administration 

of VariZIG does not appear possible within 96 hours of exposure, administration of 

immune globulin intravenous (IGIV) should be considered as an alternative. IGIV also 

should be administered within 96 hours of exposure. Although licensed IGIV preparations 

are known to contain anti-varicella antibody titers, the titer of any specific lot of IGIV 

that might be available is uncertain because IGIV is not routinely tested for antivaricella 

antibodies. The recommended IGIV dose for postexposure prophylaxis of varicella is 400 

mg/kg, administered once. For a pregnant woman who cannot receive VariZIG within 

96 hours of exposure, clinicians can choose either to administer IGIV or closely monitor 

the woman for signs and symptoms of varicella and institute treatment with acyclovir 

if illness occurs. (CDC. A new product for postexposure prophylaxis available under an 

investigational new drug application expanded access protocol. MMWR 2006;55:209-10.) 

Adapted from ACIP General Recommendations on Immunization, December 1, 2006 25
APPENDIX 

E
 

Vaccinia (Smallpox) Vaccine (Routine, non-emergency use*)
 

Symptom or Condition Vaccinate with Smallpox? 

Anaphylactic allergy to : No 

 neomycin No 

 polymyxin B 

Age

 <1 year No 

 <18 years Not recommended 

Antimicrobial therapy (current) Yes 

Breastfeeding (vaccinate lactating mother) No 

Convulsions (fits, seizures) in recipient, or Yes 

family history 

Eczema or atopic dermatitis (presence or history of) No 

Eye disease (inflammatory, requiring steroid treatment) See Note E1 

Guillain Barré syndrome (GBS), history of Yes 

Heart conditions No See Note E2 

HIV infection (symptomatic or asymptomatic) No 

IG administration, recent or simultaneous Yes 

Illness Yes 

Mild acute (with or without low-grade fever) See Note E3 

Moderate or severe acute (with or without fever) 

Reaction to previous dose of smallpox vaccine

 Anaphylactic (life-threatening) No 

Local (mild-to-moderate soreness, redness, swelling Yes 

Simultaneous administration with other vaccines 

With varicella vaccine No (See Note E4) 

With all other vaccines Yes (See Note E5) 

Skin condition (acute, chronic or exfoliative) in recipient or No (See Note E6) 

household contact 

Sudden infant death syndrome (SIDS), family history Yes 

* Vaccinia Vaccination During a Smallpox Emergency: No absolute contraindications exist regarding vaccination of a person with a 

high-risk exposure to smallpox. Persons at greatest risk for experiencing serious vaccination complications are also at greatest risk for 

death from smallpox. If a relative contraindication to vaccination exists, the risk for experiencing serious vaccination complications 

must be weighed against the risk for experiencing a potentially fatal smallpox infection. When the level of exposure risk is 

undetermined, the decision to vaccinate should be made after prudent assessment by the clinician and the patient of the potential 

risks versus the benefits of smallpox vaccination. 26
 

Symptom or Condition Vaccinate with Smallpox? 

Steroid eye drops No 

Thrombocytopenia, or history of thrombocytopenic purpura Yes 

Tuberculin skin testing, performed simultaneously with 

vaccination 

Yes (See Note E7) 

Household contact (i.e., can a person be vaccinated who has a household contact who):
 

- is allergic to a vaccine component? Yes 

- is breastfeeding? Yes 

- is a child or adolescent? Yes (See Note E8) 

- has (or has a history of) eczema or atopic dermatitis? No 

- has HIV infection? No 

- has altered immunocompetence? No 

- is pregnant? No 

- has an acute, chronic or exfoliative skin condition? No (See Note E6) 

- has a heart condition? Yes 

Note E1:	 Persons with inflammatory eye disease can be at increased risk for inadvertent inoculation 

as a result of touching or rubbing the eye. Therefore, deferring vaccination of persons with 

inflammatory eye diseases requiring steroid treatment is prudent until the condition resolves 

and the course of therapy is complete. 

Note E2:	 As a precaution, a patient who has been diagnosed by a doctor as having a heart condition 

with or without symptom should not get the smallpox vaccine at this time while experts 

continue their investigations. These conditions include known coronary disease including 

previous myocardial infarction or angina, congestive heart failure, cardiomyopathy, stroke 

or transient ischemic attack, chest pain or shortness of breath with activity, or other heart 

conditions under the care of a doctor. 

In addition, a patient should not get smallpox vaccine who has 3 or more of the following 

factors: 

- has been diagnosed with high blood pressure 

- has been diagnosed with high blood cholesterol 

- has been diagnosed with diabetes or high blood sugar 

- has a first degree relative who had a heart condition before the age of 50 

- smokes cigarettes 

Note E3:	 Persons with moderate or severe illnesses, with or without fever, can be vaccinated as soon as 

they are recovering and no longer acutely ill. 

Note E4:	 Varicella vaccine and smallpox vaccine should be administered >4 weeks apart. 

APPENDIX 

E
 

27
APPENDIX 

E
 

Note E5: There is a theoretical risk that the administration of multiple live virus vaccines within 4 

weeks of one another, if not given on the same day, will result in a suboptimal immune 

response. Parenterally administered live vaccines, and live attenuated infl uenza vaccine, 

when not administered on the same day, should be administered >4 weeks apart whenever 

possible. If these live vaccines are separated by <4 weeks, the vaccine administered second 

should not be counted as a valid dose and should be repeated >4 weeks after the last, 

invalid, dose. 

Note E6:	 Vaccination may be administered after condition resolves. (Recommendations diff er for 

eczema and atopic dermatitis. See page 23) 

Note E7:	 No data exist for the potential degree of PPD suppression that might be associated with 

parenteral live attenuated virus 

vaccines (other than measles). Nevertheless, in the absence of data, following guidelines 

for measles-containing vaccine 

when scheduling PPD screening and administering other parenteral live attenuated virus 

vaccines is prudent. 

Note E8:	 Not a contraindication, but ACIP recognizes that programs might defer vaccination of 

household contacts of infants <1 year of age because of data indicating a higher risk for 

adverse events among primary vacinees in this age group, compared with that among older 

children. 

28
APPENDIX 

F
 

Quick Reference 

Contraindications and Precautions to Routine Childhood & Adolescent

Vaccinations BY VACCINE 

For more complete and detailed information, see pages 2 through 6, or read the ACIP’s 

recommendations for the indivdual vaccines (www.cdc.gov/vaccines/pubs/acip-list.htm). 

Contraindications and Precautions to Routine Childhood & Adolescent 

Vaccinations BY VACCINE 

DTaP 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components • Underlying unstable, evolving neurologic 

• Encephalopathy within 7 days of a previous disorder 

dose of DTaP or DTP (use DT instead of • Any of these conditions within the specifi ed 

DTaP) time after a previous dose of DTaP or DTP 

- Fever of > 40.5°C (105°F) unexplained by 

another cause (within 48 hours) 

- Collapse or shock-like state (within 48 

hours) 

- Persistent, inconsolable crying lasting >3 

hours (within 48 hours) 

- Seizure or convulsion (within 72 hours) 

- Guillain-Barré syndrome (within 6 weeks) 

Tdap 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components • History of an Arthus reaction following a 

• Encephalopathy within 7 days of a previous previous dose of a tetanus-containing and/ 

dose of DTaP or DTP (use Td instead of or diphtheria toxoid-containing vaccine, 

Tdap) including meningococcal conjugate vaccine. 

Hepatitis A 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of • Moderate or severe acute illness 

the vaccine or any of its components (e.g., 

2-phenoxyethanol, alum) 

Hepatitis B 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components (e.g., baker’s 

yeast) 

29
APPENDIX 

F
 

Contraindications and Precautions to Routine Childhood & Adolescent 

Vaccinations BY VACCINE 

Hib 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components 

HPV 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components (e.g., yeast). 

• Pregnancy 

Infl uenza (inactivated) 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components (e.g., eggs) 

Infl uenza (LAIV) 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components (e.g., eggs) 

• Chronic illness of pulmonary system 

(including asthma or Reactive Airway 

Disease), or cardiovascular system; metabolic 

disorder (e.g., diabetes); hemoglobinopathies 

(e.g., sickle cell disease) 

• Immunodefi ciency 

• Aspirin or salicylate therapy (children & 

adolescents) 

• Pregnancy 

• History of Guillian-Barré syndrome 

IPV 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of • Moderate or severe acute illness 

the vaccine or any of its components (e.g., 

neomycin, streptomycin, polymyxin B) 

MCV 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components 

30
APPENDIX 

F

Contraindications and Precautions to Routine Childhood & Adolescent 

Vaccinations BY VACCINE 

MMR 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of • Moderate or severe acute illness 

the vaccine or any of its components (e.g., • Recent administration of antibodygelatin, neomycin) containing blood products 

• Pregnancy • Th rombocytopenia/ thrombocytopenic 

• Immunodefi ciency purpura (now or by history) 

• Untreated active tuberculosis 

PCV7 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness 

vaccine or any of its components (e.g., yeast) 

Rotavirus 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of the • Moderate or severe acute illness, including 

vaccine or any of its components gastroenteritis 

• Immune deficiency for any reason 

• Administration of antibody-containing 

blood products within the past 42 days 

• Preexisting chronic GI disease 

• History of intussusception 

Varicella 

Contraindications Precautions 

• Anaphylactic reaction to a prior dose of • Moderate or severe acute illness 

the vaccine or any of its components (e.g., • Recent administration of antibodygelatin, neomycin) containing blood products 

• Pregnancy 

• Immunodefi ciency 

• Untreated active tuberculosis 

Zoster 

Contraindications Precautions 

• History of anaphylactic reaction to any • Moderate or severe acute illness 

vaccine component (e.g., gelatin, neomycin) 

• Immunodefi ciency 

• Pregnancy 

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