General Best Practice Guidelines for Immunization: Special Situations 149

9. Special Situations

Updates

Major revisions to this section of the best practices guidance include the timing of 

intramuscular administration and the timing of clotting factor deficiency replacement.

 

Concurrent Administration of Antimicrobial Agents and 

Vaccines 

With a few exceptions, use of an antimicrobial agent does not interfere with the 

effectiveness of vaccination. Antibacterial agents have no effect on non-live vaccines. They 

also have no effect on response to live, attenuated vaccines, except live oral Ty21a typhoid 

vaccine and BCG vaccines. Ty21a typhoid vaccine should not be administered to persons 

receiving antimicrobial agents until 72 hours after the last dose of antimicrobial (1). If 

feasible, to avoid a possible reduction in vaccine effectiveness, antibacterial drugs should 

not be started or resumed until 1 week after the last dose of Ty21a. Antimicrobial or 

immunosuppressive agents may interfere with the immune response to BCG and should 

only be used under medical supervision (for additional information, see 

www.merck.com/product/usa/pi_circulars/b/bcg/bcg_pi.pdf).

Antiviral drugs used for treatment or prophylaxis of influenza virus infections have no 

effect on the response to inactivated influenza vaccine (2). However, live, attenuated 

influenza vaccine should not be administered until 48 hours after cessation of therapy 

with antiviral influenza drugs. If feasible, to avoid possible reduction in vaccine 

effectiveness, antiviral medication should not be administered for 14 days after LAIV 

administration (2). If influenza antiviral medications are administered within 2 weeks 

after receipt of LAIV, the LAIV dose should be repeated 48 or more hours after the last 

dose of zanamivir or oseltamivir. The LAIV dose should be repeated 5 days after peramivir 

and 17 days after baloxavir. Alternatively, persons receiving antiviral drugs within the 

period 2 days before to 14 days after vaccination with LAIV may be revaccinated with 

another approved vaccine formulation (e.g., IIV or recombinant influenza vaccine). 

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

the efficacy of vaccines containing live, attenuated varicella zoster virus (i.e., Varivax and 
General Best Practice Guidelines for Immunization: Special Situations 150

ProQuad) (3,4). These drugs should be discontinued at least 24 hours before 

administration, if possible. If clinically appropriate, delay use or resumption of antiviral 

therapy for 14 days after vaccination. No data exist to suggest that commonly used 

antiviral drugs have an effect on rotavirus vaccine or MMR.

Administration of Live Vaccines and Tuberculin Skin 

Tests (TSTs) and Interferon-gamma Release Assays 

(IGRAs)

Measles illness, severe acute or chronic infections, HIV infection, and malnutrition can 

create a relatively anergic state during which the TST might have a false-negative reaction 

(5-7). Although live, attenuated measles vaccine theoretically can suppress TST reactivity, 

the degree of suppression is likely less than that occurring from acute infection from wildtype measles virus. Screening children for tuberculosis exposure is accomplished by 

medical history rather than TST testing; universal TST screening of all children is no 

longer recommended, though TST screening is sometimes indicated (e.g., for persons at 

increased risk for tuberculosis exposure based on medical history, or for employees for 

occupational health reasons).

In a general screening situation, a provider may find that: both TST and live vaccine are 

recommended; live vaccine is recommended, and TST has already been administered 

more than one day previous; or TST is indicated, and the live vaccine has already been 

administered more than one day previous. TST may be administered simultaneously with 

live vaccines, and this is the preferred scenario. If live vaccine is indicated, and TST has 

been administered more than one day previous, the live vaccine can be administered at 

any interval after the TST. If TST is recommended, and the live vaccine has already been 

administered more than one day previous, providers should ensure a 28 day interval, in 

other words defer the TST for 28 days after vaccination. A delay in performing the TST 

removes the concern of any theoretical transient suppression of TST reactivity. Some 

providers choose to perform TST screening and then delay the vaccine until the patient 

returns to have the TST read. This option is less favored compared with simultaneous 

TST/live vaccination, because it delays receipt of the measles-containing vaccine.

While the above rationale is based on measles suppression of TST response, because of 

similar concerns about smallpox vaccine and TST suppression, a TST should not be 

performed until 4 weeks after smallpox vaccination (8). No data exist regarding the 
General Best Practice Guidelines for Immunization: Special Situations 151

potential degree of TST suppression that might be associated with other live, attenuated 

virus vaccines (e.g., varicella or yellow fever). However, in the absence of data, following 

guidelines for measles-containing vaccine when scheduling TST screening and 

administering other live, attenuated virus vaccines is prudent. 

If the opportunity to vaccinate might be missed, vaccination should not be delayed only 

because of these theoretical considerations. TST can be repeated 4 weeks after vaccination 

if it is negative and concern for TB infection persists.

Interferon gamma release assays (IGRAs), such as the QuantiFERON-TB Gold In-Tube 

test and the T-Spot TB test, are blood-test alternatives to the TST for 

detecting Mycobacterium tuberculosis infection. The IGRA requires only a single visit to 

complete and may be less effected by previous BCG vaccination (9). The same timing 

guidelines that apply to the interval between a live vaccine and TST apply to IGRA (i.e., 28 

days between live vaccine and IGRA if they do not occur on the same day), because IGRA 

(like TST) might be suppressed through immunologic mechanisms. The potential for a 

previous TST to cause boosting of future TST results should be considered in adults who 

have a negative initial TST (9). Two-step testing, in which TST is repeated in a short time 

frame (e.g., 1 to 3 weeks) after an initial negative TST, can illicit boosting and identify 

persons whose immune response may have waned with time since infection or BCG 

vaccination. For people undergoing serial screening for infection, for instance health care 

personnel who are tested yearly, differentiation of positive tests due boosting versus new 

infection is important (9). The 2-step test, in which the test is given twice in a short time 

frame, reduces the chance of these false negatives, which are important to identify among 

adults who may have had or plan to have repeat testing anyway—for example, healthcare 

personnel who are tested yearly (9). Because this test consists of 2 TSTs separated by an 

interval of 1-3 weeks, there is a greater window of time during which live vaccine 

replication could suppress reactivity. If a live vaccine is administered, the first dose of a 2-

step TST should be delayed for 4 weeks, and if additional doses of live vaccines are 

indicated thereafter, they should be delayed until the second TST is measured.

TST or IGRA reactivity in the absence of active tuberculosis is not a contraindication to 

administration of any vaccine, including live, attenuated virus vaccines.
General Best Practice Guidelines for Immunization: Special Situations 152

Note that TST screening of an asymptomatic individual is clinically different than testing a 

person suspected to have active tuberculosis. If a person is suspected to have active 

tuberculosis, MMR vaccine is typically not administered. Active tuberculosis should be 

considered severe acute illness, and moderate or severe acute illness is a precaution for 

vaccination.

Although no studies have reported on the effects of MMR vaccine on persons with active 

untreated tuberculosis, a theoretical basis exists for concern that measles vaccine might 

exacerbate active tuberculosis (10). As a result, before administering MMR to persons with 

untreated active tuberculosis, initiating antituberculosis therapy is advisable (10).

Considering whether concurrent immunosuppression (e.g., immunosuppression caused by 

HIV infection) is present before administering live, attenuated vaccines also is necessary, 

because immunosuppression is a contraindication to MMR vaccine.

Vaccination of Preterm Infants

In the majority of cases, preterm infants (infants born before 37 weeks’ gestation), 

regardless of birth weight, should be vaccinated at the same chronological age and 

according to the same schedule and using the same precautions as for full-term infants 

and children. Birth weight and size are not factors in deciding whether to vaccinate a 

clinically stable preterm infant (11-15), except for hepatitis B vaccination. The full 

recommended dose of each vaccine should be used. Divided or reduced doses are not 

recommended.

Decreased seroconversion rates might occur among certain preterm infants (i.e., those 

with low birth weights [<2,000 g]) after administration of hepatitis B vaccine at birth (16). 

However, by the chronological age of 1 month, all preterm infants, regardless of initial 

birth weight, are likely to respond as adequately as larger infants (17-19). Infants weighing 

<2,000 g born to HBsAg-negative mothers should receive the first dose of the hepatitis B 

vaccine series at chronological age 1 month or hospital discharge, if hospital discharge 

occurs when the infant is younger than one month of age. Preterm low-birth-weight–

infants born to HBsAg-positive mothers should receive immunoprophylaxis with hepatitis 

B vaccine within 12 hours after birth. The initial vaccine dose should not be counted 

toward completion of the hepatitis B series, and 3 additional doses of hepatitis B vaccine 
General Best Practice Guidelines for Immunization: Special Situations 153

should be administered, beginning when the infant is aged 1 month. For mothers with 

unknown HBsAg status, hepatitis B vaccine is recommended within 12 hours of birth 

regardless of low-birth-weight status.

In addition to hepatitis B vaccines, hepatitis B Immunoglobulin (HBIG) is recommended 

for infants whose mothers are HBsAg positive or unknown. 

If the mother is HBsAg positive, HBIG must be given within 12 hours of birth. If the 

mother’s HBsAg status is unknown, providers should first attempt to determine the 

mother’s status. Regardless, if the infant is preterm or low birth weight, HBIG must be 

given within 12 hours of birth. If the infant is neither preterm nor low birth weight, 

providers have up to 7 days from birth to determine if the mother is HBsAg negative; 

because the protective efficacy of HBIG declines the longer that administration is delayed, 

if results are unlikely to be known by day 7 of life, HBIG should be given no later than day 

7 if not earlier. If the mother is determined to be HBsAg positive, HBIG should be 

administered as soon as possible (20).

If a child aged at least 6 weeks has been in the hospital since birth, deferral of rotavirus 

vaccine is recommended until the time of discharge. If an infant were to be vaccinated 

with rotavirus vaccine while still needing care in the NICU or nursery, at least a theoretic 

risk exists for vaccine virus being transmitted to infants in the same unit who are acutely 

ill and to preterm infants who are not age-eligible for vaccine (21). The rotavirus vaccine 

series should not be initiated for infants aged ≥15 weeks, 0 days.

Breastfeeding and Vaccination

With 2 exceptions, neither non-live nor live-virus vaccines administered to a lactating 

woman affect the safety of breastfeeding for women or their infants. Although live viruses 

in vaccines can replicate in the mother, the majority of live viruses in vaccines have been 

demonstrated not to be excreted in human milk. Varicella vaccine virus has not been 

found in human milk (22). Although rubella vaccine virus has been excreted in human 

milk, the virus usually does not infect the infant. If infection does occur, it is well tolerated 

because the virus is attenuated (23). Non-live vaccines pose no risk for mothers who are 

breastfeeding or for their infants. Breastfeeding is a contraindication for smallpox 

vaccination of the mother because of the theoretical risk for contact transmission from 
General Best Practice Guidelines for Immunization: Special Situations 154

mother to infant. Yellow fever vaccine should be avoided in breastfeeding women, because 

2 cases (one confirmed, one probable) of yellow-fever vaccine associated acute neurotropic 

disease (YEL-AND) have been detected in infants whose mothers were vaccinated but 

were not vaccinated themselves. In both infants, vaccine virus was recovered from the 

cerebrospinal fluid of the infant, but the exact mode of transmission was not precisely 

determined because vaccine virus was not recovered from breast milk (24). 

However, when nursing mothers cannot avoid or postpone travel to areas endemic for 

yellow fever in which risk for acquisition is high, these women should be vaccinated.

Limited data indicate that breastfeeding can enhance the response to certain vaccine 

antigens (25). There are no data to suggest that passive transfer of antibodies in human 

milk can affect the efficacy of live-virus vaccines. Breastfed infants should be vaccinated 

according to the recommended schedule (26-28).

Vaccination During Pregnancy

No evidence exists of risk to the fetus from vaccinating pregnant women with non-live 

virus or bacterial vaccines (29,30). In spite of the lack of evidence of risk, HPV vaccine, a 

non-live vaccine, is not recommended during pregnancy. Live vaccines administered to a 

pregnant woman pose a theoretical risk to the fetus; therefore, live, attenuated virus and 

live bacterial vaccines generally are contraindicated during pregnancy. Women should 

avoid conception for 4 weeks after vaccination with live vaccines. However, benefits of 

vaccinating pregnant women usually outweigh potential risks when the likelihood of 

disease exposure is high, when infection would pose a risk to the mother or fetus, and 

when the vaccine is unlikely to cause harm. Recommendations for vaccination during 

pregnancy are developed using ACIP’s Guiding Principles for Development of ACIP 

Recommendations for Vaccination During Pregnancy and Breastfeeding (31).

Women who are pregnant should receive a dose of Tdap for the prevention of infant 

pertussis whether or not they have previously received Tdap. Vaccination of the mother 

generates antibodies that pass transplacentally to the fetus (32). Vaccination in the third 

trimester optimizes the duration of this antibody protection until after birth. Additionally, 

preventing pertussis in the mother reduces the risk that the infant is exposed to pertussis 
General Best Practice Guidelines for Immunization: Special Situations 155

after birth (33). Health care personnel should administer Tdap during pregnancy, 

preferably during the third trimester. If Tdap is not administered during pregnancy to 

women who have never received it, it should be administered immediately postpartum. 

Pregnant women who are not vaccinated or are only partially vaccinated against tetanus 

should complete the primary series (34). Women for whom Td is indicated but who did 

not complete the recommended 3-dose series during pregnancy should receive follow-up 

after delivery to ensure the series is completed. 

One dose of the tetanus vaccine series should be Tdap, if Tdap has not already been 

received.

Pregnant and postpartum women are at higher risk for severe illness and complications 

from influenza than women who are not pregnant (2, 35). Pregnant women have 

protective levels of anti-influenza antibodies after vaccination (36,37). Passive transfer of 

anti-influenza antibodies that might provide protection from vaccinated women to 

neonates has been reported (36, 38-41). Routine vaccination with inactivated influenza 

vaccine is recommended for all women who are or will be pregnant (in any trimester) 

during influenza season.

IPV can be administered to pregnant women who are at risk for exposure to wild-type 

poliovirus. This includes travelers to areas or countries where polio is epidemic or 

endemic; members of communities or specific population groups with disease caused by 

wild polioviruses; laboratory workers who handle specimens that might contain 

polioviruses; healthcare personnel who have close contact with patients who might be 

excreting wild polioviruses; and unvaccinated persons whose children will be receiving 

oral poliovirus vaccine (42). Hepatitis A, pneumococcal polysaccharide, meningococcal 

conjugate, and meningococcal polysaccharide vaccines should be considered for women at 

increased risk for those infections (43-45). Pregnant women who must travel to areas 

where there is a risk for acquiring yellow fever should receive yellow fever vaccine, because 

the limited theoretical risk from vaccination is outweighed substantially by the risk for 

yellow fever infection (24, 46). Hepatitis B vaccine is not contraindicated in pregnancy and 

should be given to a pregnant woman for whom it is indicated (20, 47).

Pregnancy is a contraindication for smallpox (vaccinia) vaccine and measles-, mumps-, 
General Best Practice Guidelines for Immunization: Special Situations 156

rubella-, and varicella-containing vaccines. Smallpox vaccine is the only vaccine known to 

harm a fetus when administered to a pregnant woman. In addition, smallpox vaccine 

should not be administered to a household contact of a pregnant woman (8). Women who 

are pregnant should not have close contact with anyone who has recently (within the last 

28 days) received the smallpox vaccine. Data from studies of children born to mothers 

inadvertently vaccinated with rubella vaccine during pregnancy demonstrate rubella 

antibody in unvaccinated infants. This could represent passive transfer of maternal 

antibody or a fetal antibody response to vaccine virus infection in the fetus. 

No cases of congenital rubella or varicella syndrome or abnormalities attributable to fetal 

infection have been observed among infants born to susceptible women who inadvertently 

received rubella or varicella vaccines during pregnancy (48-50). Because of the importance 

of protecting women of childbearing age against rubella and varicella, reasonable practices 

in any vaccination program include asking women if they are pregnant or might become 

pregnant in the next 4 weeks; not vaccinating women who state that they are or plan to 

become pregnant within that interval; explaining the theoretical risk for the fetus if MMR, 

varicella, or MMRV vaccine were administered to a woman who is pregnant; and 

counseling women who are vaccinated not to become pregnant during the 4 weeks after 

MMR, varicella, or MMRV vaccination (10, 48-51). MMRV is an unlikely option for a 

pregnant woman because the vaccine is only licensed through 12 years of age. Routine 

pregnancy testing of women of childbearing age before administering a live-virus vaccine 

is not recommended (3, 10). If a pregnant woman is inadvertently vaccinated or becomes 

pregnant within 4 weeks after MMR or varicella vaccination, she should be counseled 

about the theoretical basis of concern for the fetus; however, MMR or varicella vaccination 

during pregnancy should not be considered a reason to terminate pregnancy (3, 10, 50).

Persons who receive MMR vaccine do not transmit the vaccine viruses to contacts (10). 

Transmission of varicella vaccine virus to contacts is exceedingly rare (3). MMR and 

varicella vaccines should be administered when indicated to children and other household 

contacts of pregnant women (10). Infants living in households with pregnant women 

should be vaccinated with rotavirus vaccine according to the same schedule as infants in 

households without pregnant women.

Pregnant women should be evaluated for evidence of immunity to rubella and varicella 
General Best Practice Guidelines for Immunization: Special Situations 157

and be tested for the presence of HBsAg during every pregnancy (10, 20, 52). Women 

without evidence of immunity to rubella and varicella should be vaccinated immediately 

after delivery. A second dose of varicella vaccine should be administered 4-8 weeks later. A 

woman found to be HBsAg positive should be followed-up carefully to ensure that the 

infant receives HBIG and begins the hepatitis B vaccine series no later than 12 hours after 

birth and that the infant completes the recommended hepatitis B vaccine series on 

schedule (20). No known risk exists for the fetus from passive immunization of pregnant 

women with immune globulin preparations.

Persons Vaccinated Outside the United States

Clinicians have a limited ability to determine whether persons are protected on the basis of 

their country of origin and their vaccination records alone. Vaccines administered outside 

the United States generally can be accepted as valid if the schedule (i.e., minimum ages 

and intervals) is similar to that recommended in the United States. There are exceptions 

(providers should not accept documentation of these vaccines): Aimmugen, a hepatitis A 

vaccine; and Twinrix Jr., a combination vaccine containing hepatitis A and hepatitis B 

components (providers can accept the hepatitis B component but NOT the hepatitis A 

component). 

Only written documentation should be accepted as evidence of previous vaccination. There 

is one exception, influenza vaccine, for which self-report can be accepted. Written records 

are more likely to predict protection if the vaccines, dates of administration, intervals 

between doses, and age at the time of vaccination are comparable to U.S. 

recommendations. Although vaccines with inadequate potency have been produced in 

other countries (53,54), the majority of vaccines used worldwide are produced with 

adequate quality control standards and are potent. Medscape has a guide to pediatric 

vaccines used in other countries, available at 

https://emedicine.medscape.com/article/2500038-overview. Persons vaccinated outside 

of the United States can enter the country through a number of different mechanisms. 

Those seeking to immigrate to the United States may be vaccinated under the authority of 

a civil surgeon or a panel physician. Some enter the United States as refugees and are 

vaccinated under the authority of the Office of Refugee Resettlement, part of the 

Administration for Children and Families, in the Department of Health and Human 

Services.
General Best Practice Guidelines for Immunization: Special Situations 158

Adopted children’s birth countries often have vaccination schedules that differ from the 

recommended childhood vaccination schedule in the United States. Differences in the U.S. 

schedule and those used in other countries include the vaccines administered, the 

recommended ages of administration, and the number and timing of doses.

Data are inconclusive regarding the extent to which an internationally adopted child’s 

vaccination record reflects the child’s protection. 

A child’s record might indicate administration of MMR vaccine when only single-antigen 

measles vaccine was administered. A study of children adopted from orphanages in the 

People’s Republic of China, Russia, and countries in Eastern Europe determined that 67% 

of children with documentation of >3 doses of DTP before adoption had nonprotective 

titers to these antigens (54). 

In contrast, children adopted from these countries who received vaccination in the 

community (not only from orphanages) and had documentation of ≥1 doses of DTP 

exhibited protective titers 67% of the time (54). However, antibody testing was performed 

by using a hemagglutination assay, which tends to underestimate protection and cannot 

directly be compared with antibody concentration (55). Data are likely to remain limited

for areas other than the People’s Republic of China, Russia, and Eastern Europe. 

Healthcare providers should ensure that household contacts of international adoptees are 

vaccinated adequately, particularly for measles, hepatitis A, and hepatitis B (56). 

Healthcare providers may use one of multiple approaches if the immunogenicity of 

vaccines or the completeness of series administered to persons outside the United States is 

in question. Repeating the vaccinations is an acceptable option that usually is safe and 

prevents the need to obtain and interpret serologic tests. If avoiding unnecessary 

injections is desired, judicious use of serologic testing might help determine which 

vaccinations are needed. For some vaccines, the most readily available serologic tests 

cannot document protection against infection. This best practices document provides 

guidance on possible approaches to evaluation and revaccination for each vaccine 

recommended in the United States (Table 9-1).

DTaP Vaccine
General Best Practice Guidelines for Immunization: Special Situations 159

Vaccination providers can revaccinate children younger than 7 years of age with DTaP 

vaccine without regard to recorded doses; however, data indicate increased rates of local 

adverse reactions after the fourth and fifth doses of DTaP (57). If a revaccination approach 

is adopted and a severe local reaction occurs, serologic testing for specific IgG antibody to 

tetanus and diphtheria toxins can be measured before administering additional doses. 

Protective concentration(a) indicates that additional doses are unnecessary and subsequent 

vaccination should occur as age appropriate. No established serologic correlates exist for 

protection against pertussis.

For a child whose record indicates receipt of ≥3 doses of DTP or DTaP, serologic testing 

for specific IgG antibody to both diphtheria and tetanus toxin before additional doses is a 

reasonable approach. If a protective concentration is present, recorded doses are 

considered valid, and the vaccination series should be completed as age appropriate. 

An indeterminate antibody concentration might indicate immunologic memory but 

waning antibody; serologic testing can be repeated after a booster dose if vaccination 

providers or parents want to avoid revaccination with a complete series.

Alternately, for a child whose records indicate receipt of ≥3 doses, a single booster dose 

can be administered followed by serologic testing after 1 month for specific IgG antibody

to both diphtheria and tetanus toxins. If the child has a protective concentration, the 

recorded doses are considered valid, and the vaccination series should be completed as age 

appropriate. Children with an indeterminate concentration after a booster dose should be 

revaccinated with a complete series.

Hepatitis A Vaccine

Children aged 12-23 months without documentation of hepatitis A vaccination or serologic 

evidence of immunity should be vaccinated on arrival in the United States (45). Persons 

who have received 1 dose should receive the second dose if 6-18 months have passed since 

the first dose was administered.

Hepatitis B Vaccine

Persons not known to be vaccinated for hepatitis B should receive an age-appropriate 

series of hepatitis B vaccine. A person whose records indicate receipt of a complete series 
General Best Practice Guidelines for Immunization: Special Situations 160

of vaccine is considered protected(b), and additional doses are not needed if ≥1 dose was 

administered at age ≥24 weeks. Persons who received their last hepatitis B vaccine dose at 

an age <24 weeks should receive an additional dose at age ≥24 weeks. People who have 

received no doses or a partial series of vaccine should complete the series at the 

recommended intervals and ages.

All foreign-born persons and immigrants, refugees, and internationally adopted children 

born in Asia, the Pacific Islands, Africa, and other regions of high or intermediate hepatitis 

B endemicity should be tested for HBsAg, regardless of vaccination status (58). Those 

determined to be HBsAg positive should be monitored for development of liver disease. 

Household members of HBsAg-positive children or adults should be vaccinated if they are 

not already immune.

Hib Vaccine 

Interpretation of a serologic test to verify whether children who were vaccinated >2 

months previously are protected against Hib bacteria can be difficult. Because the number 

of vaccinations needed for protection decreases with age and because adverse events are 

rare (59), age-appropriate vaccination should be provided. Hib vaccination is not 

recommended routinely for persons aged ≥5 years (59).

Meningococcal Vaccine

Quadrivalent meningococcal conjugate vaccines are not routinely used in other countries 

in adolescents (the United Kingdom is the exception). Unless patients have documented 

receipt they should be considered unvaccinated and receive the age-appropriate doses.

MMR Vaccine

The simplest approach to resolving concerns about MMR vaccination is to revaccinate 

with 1 or 2 doses of MMR vaccine, depending on age. Serious adverse events after MMR 

vaccinations are rare (10). No evidence indicates that administering MMR vaccine 
General Best Practice Guidelines for Immunization: Special Situations 161

increases the risk for adverse reactions among persons who are already immune to 

measles, mumps, or rubella as a result of previous vaccination or natural disease. Doses of 

measles-containing vaccine administered before the first birthday should not be counted 

as part of the series (10). Alternatively, serologic testing for IgG antibody to vaccine viruses 

indicated on the vaccination record can be considered. Serologic testing is widely available 

for measles and rubella IgG antibody. 

A person whose record indicates receipt of monovalent measles or measles-rubella vaccine 

on or after the first birthday and who has protective antibody against measles and rubella 

should receive 1 or 2 doses of MMR or MMRV as age appropriate to ensure protection 

against mumps and varicella (and rubella if measles vaccine alone had been 

administered). If a person whose record indicates receipt of MMR at age ≥12 months has a 

protective concentration of antibody to measles, no additional vaccination is needed 

unless a second dose is required for school entry.

Pneumococcal Vaccines

Many industrialized countries now routinely use pneumococcal vaccines. Although 

recommendations for pneumococcal polysaccharide vaccine also exist in many countries, 

the pneumococcal conjugate vaccine might not be routinely administered. PCV13 and 

PPSV23 should be administered according to age-appropriate vaccination schedules or as 

indicated by the presence of underlying medical conditions (43, 60).

Poliovirus Vaccine

The simplest approach to vaccinating with poliovirus vaccine is to revaccinate persons 

aged <18 years with IPV according to the U.S. schedule. Adverse events after IPV are rare 

(42). Children appropriately vaccinated with 3 doses of OPV in economically developing 

countries might have suboptimal seroconversion, including to type 3 poliovirus (42).

Rotavirus Vaccine
General Best Practice Guidelines for Immunization: Special Situations 162

Rotavirus vaccination should not be initiated for infants aged ≥15 weeks, 0 days. Infants 

who began the rotavirus vaccine series outside the United States but who did not complete 

the series and who are still aged ≤8 months, 0 days, should follow the routine schedule 

and receive doses to complete the series. If the brand of a previously administered dose is 

live, reassortment pentavalent rotavirus vaccine or is unknown, a complete series of 

rotavirus vaccine should be documented for series completion(b). All doses should be 

administered by age 8 months, 0 days.

Td and Tdap Vaccines

Children aged ≥7 years who are not considered fully vaccinated for pertussis should 

receive Tdap vaccine. “Fully vaccinated” means at least 5 doses of DTaP before the seventh 

birthday or at least 4 doses of DTaP before the seventh birthday if the fourth dose is given 

after the fourth birthday. One dose of Tdap is recommended after the seventh birthday. If 

additional doses of vaccine are needed, Td should be administered as age appropriate.

Varicella Vaccine

Varicella vaccine is not available in most countries. A person who lacks evidence of 

varicella immunity should be vaccinated as age appropriate (3, 59).

Zoster Vaccine

In the United States, zoster vaccination is recommended for all persons aged ≥50 years 

who have no contraindications, including persons who report a previous episode of zoster 

or who have chronic medical conditions. For persons who do not have documentation of 

receipt of zoster vaccine, the vaccine should be offered at the patient’s first clinical 

encounter with the healthcare provider. Two doses of vaccine are recommended 2-6 

months apart, each dose a 0.5-mL intramuscular dose. Zoster vaccination is not indicated 

to treat acute zoster, to prevent persons with acute zoster from developing postherpetic 

neuralgia, or to treat ongoing postherpetic neuralgia. Patients do not need to be asked 

about their history of varicella or to have serologic testing conducted to determine zoster 

immunity prior to administration of zoster vaccine.
General Best Practice Guidelines for Immunization: Special Situations 163

Vaccinating Persons with Increased Bleeding Risk

Providers often avoid giving intramuscular injections or choose alternative routes for 

persons with bleeding disorders because of the risk for hematoma formation after 

injections. In one study, hepatitis B vaccine was administered intramuscularly to 153 

persons with hemophilia. The vaccination was administered with a 23-gauge or smaller 

caliber needle, followed by application of steady pressure to the site for 1-2 minutes. The 

vaccinations resulted in a low (4%) bruising rate, and no patients required factor 

supplementation (61). Whether antigens that produce more local reactions (e.g., pertussis) 

would produce an equally low rate of bruising is unknown.

When hepatitis B or any other intramuscularly administered vaccine is indicated for a 

patient with a bleeding disorder, the vaccine should be administered intramuscularly if a 

physician familiar with the patient’s bleeding risk determines that the vaccine can be 

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

similar therapy, intramuscularly administered vaccinations can be scheduled shortly after 

such therapy is administered. 

A fine-gauge needle (23-gauge or smaller caliber) should be used for the vaccination, 

followed by firm pressure on the site, without rubbing, for at least 2 minutes. The patient 

or family should be given information on the risk for hematoma from the injection. 

Patients receiving anticoagulation therapy presumably have the same bleeding risk as 

patients with clotting factor disorders and should follow the same guidelines for 

intramuscular administration. If possible, vaccination could be scheduled prior to the use 

of these medications, so that the patients’ risk of bleeding is not increased by their 

therapeutic action.

(a) Enzyme immunoassay tests are available. Physicians should contact the laboratory performing the test for interpretive 

standards and limitations. Protective concentrations for antibody to diphtheria and tetanus toxins are defined as >0.1 IU/mL.

(b) A complete series may consist of two or three doses, depending on the brand of vaccine used in the country of origin.
General Best Practice Guidelines for Immunization: Special Situations 164

TABLE 9-1. Approaches to evaluation and vaccination of persons 

vaccinated outside the United States who have no (or questionable) 

vaccination records

Vaccine Recommended 

approach

Alternative approach(a)

DTaP Revaccination with DTaP, 

with serologic testing for 

specific IgG antibody to 

tetanus and diphtheria 

toxins in the event of a 

severe local reaction

Persons whose records indicate 

receipt of ≥3 doses: serologic testing 

for specific IgG antibody to 

diphtheria and tetanus toxins before 

administering additional doses (see 

text), or administer a single booster 

dose of DTaP, followed by 

serological testing after 1 month for 

specific IgG antibody to diphtheria 

and tetanus toxins with 

revaccination as appropriate (see 

text)

HepA Age-appropriate 

revaccination

Serologic testing for IgG antibodies 

to hepatitis A

HepB Age-appropriate 

revaccination and serologic 

testing for HBsAg(b)

—

Hib Age-appropriate 

revaccination

—

HPV Age-appropriate 

revaccination

—

Meningococcal 

conjugate 

(MenACWY)

Age-appropriate 

revaccination

—

MMR Revaccination with MMR Serologic testing for IgG antibodies 

to measles, mumps, and rubella

Pneumococcal 

conjugate (or in 

some cases, both 

PCV13 and 

PPSV23)

Age-appropriate 

revaccination

—
General Best Practice Guidelines for Immunization: Special Situations 165

Poliovirus Revaccination with 

inactivated poliovirus 

vaccine

—

Rotavirus Age-appropriate 

revaccination

—

Tdap Age-appropriate 

revaccination of persons 

who are candidates for 

Tdap vaccine

—

Varicella Age-appropriate 

revaccination of persons 

who lack evidence of 

varicella immunity

—

Zoster Age-appropriate 

revaccination

—

Abbreviations: DTaP = diphtheria and tetanus toxoids and acellular pertussis; HBsAg = hepatitis B surface 

antigen; HepA = hepatitis A; HepB = hepatitis B; Hib = Haemophilus influenzae type b; HPV = human 

papillomavirus; IgG = immune globulin G; MMR = measles, mumps, and rubella; PCV13 = pneumococcal conjugate 

vaccine; PPSV23= pneumococcal polysaccharide vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and 

acellular pertussis.

(a) There is a recommended approach for all vaccines and an alternative approach for some vaccines.

(b) In rare instances, hepatitis B vaccine can give a false-positive HBsAg result up to 18 days after vaccination; 

therefore, blood should be drawn to test for HBsAg before vaccinating (20).
General Best Practice Guidelines for Immunization: Special Situations 166

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