General Best Practice Guidelines for Immunization: Contraindications and Precautions 51

4. Contraindications and Precautions

Updates

Major changes to the best practice guidance in this section include 1) enhancement of the 

definition of a “precaution” to include any condition that might confuse diagnostic 

accuracy and 2) recommendation to vaccinate during a hospitalization if a patient is not 

acutely moderately or severely ill.

General Principles

National standards for pediatric vaccination practices have been established and include 

descriptions of valid contraindications and precautions to vaccination (2). Persons who 

administer vaccines should screen patients for contraindications and precautions to the 

vaccine before each dose of vaccine is administered (Table 4-1). Screening is facilitated by 

consistent use of screening questionnaires, which are available from certain state 

vaccination programs and other sources (e.g., the Immunization Action Coalition, 

http://www.immunize.org).

Contraindications

Contraindications (conditions in a recipient that increases the risk for a serious adverse 

reaction) to vaccination are conditions under which vaccines should not be administered. 

Because the majority of contraindications are temporary, vaccinations often can be 

administered later when the condition leading to a contraindication no longer exists. A 

vaccine should not be administered when a contraindication is present; for example, 

MMR vaccine should not be administered to severely immunocompromised persons (1). 

However, certain conditions are commonly misperceived as contraindications (i.e., are 

not valid reasons to defer vaccination).

Severely immunocompromised persons generally should not receive live vaccines (3). 

Because of the theoretical risk to the fetus, women known to be pregnant generally should 

not receive live, attenuated virus vaccines (4). Persons who experienced encephalopathy 

within 7 days after administration of a previous dose of pertussis- containing vaccine not 

attributable to another identifiable cause should not receive additional doses of a vaccine 

that contains pertussis (4,5). 
General Best Practice Guidelines for Immunization: Contraindications and Precautions 52

Severe Combined Immunodeficiency (SCID) disease and a history of intussusception are 

both contraindications to the receipt of rotavirus vaccines (6).

Precautions

A precaution is a condition in a recipient that might increase the risk for a serious adverse 

reaction, might cause diagnostic confusion, or might compromise the ability of the 

vaccine to produce immunity (e.g., administering measles vaccine to a person with 

passive immunity to measles from a blood transfusion administered up to 7 months 

prior) (7). A person might experience a more severe reaction to the vaccine than would 

have otherwise been expected; however, the risk for this happening is less than the risk 

expected with a contraindication. In general, vaccinations should be deferred when a 

precaution is present. However, a vaccination might be indicated in the presence of a 

precaution if the benefit of protection from the vaccine outweighs the risk for an adverse 

reaction.

The presence of a moderate or severe acute illness with or without a fever is a 

precaution to administration of all vaccines (Table 4-1). The decision to administer or 

delay vaccination because of a current or recent acute illness depends on the severity of 

symptoms and etiology of the condition. The safety and efficacy of vaccinating persons 

who have mild illnesses have been documented (8-11). Vaccination should be deferred 

for persons with a moderate or severe acute illness. This precaution avoids causing 

diagnostic confusion between manifestations of the underlying illness and possible 

adverse effects of vaccination or superimposing adverse effects of the vaccine on the 

underlying illness. After they are screened for contraindications, persons with 

moderate or severe acute illness should be vaccinated as soon as the acute illness has 

improved. Studies indicate that failure to vaccinate children with minor illnesses can 

impede vaccination efforts (12–14). Among persons whose compliance with medical 

care cannot be ensured, use of every opportunity to administer appropriate vaccines is 

critical.

Hospitalization should be used as an opportunity to provide recommended vaccinations. 

Health-care facilities are held to standards of offering influenza vaccine for hospitalized 

patients, so providers are incentivized to vaccinate these patients at some point during 

hospitalization (15). Likewise, patients admitted for elective procedures will not be 

acutely ill during all times during their hospitalization. Most studies that have explored 
General Best Practice Guidelines for Immunization: Contraindications and Precautions 53

the effect of surgery or anesthesia on the immune system were observational, included 

only infants and children, and were small and indirect, in that they did not look at the

immune effect on the response to vaccination specifically (16-35). They do not provide 

convincing evidence that recent anesthesia or surgery significantly affect response to 

vaccines. Current, recent, or upcoming anesthesia/surgery/hospitalization is not a 

contraindication to vaccination, but certain factors might lead a provider to consider 

current, recent, or upcoming anesthesia/surgery/hospitalization as a precaution (16-35). 

Efforts should be made to ensure vaccine administration during the hospitalization or at 

discharge. For patients who are deemed moderately or severely ill throughout the 

hospitalization, vaccination should occur at the earliest opportunity (i.e., during 

immediate post-hospitalization follow-up care, including home or office visits) when 

patients’ clinical symptoms have improved.

A personal or family history of seizures is a precaution for MMRV vaccination; this is 

because a recent study found an increased risk for febrile seizures in children 12-23 

months who receive MMRV compared with MMR and varicella vaccine (36).

Neither Contraindications Nor Precautions

Clinicians or other health-care providers might misperceive certain conditions or 

circumstances as valid contraindications or precautions to vaccination when they 

actually do not preclude vaccination (2) (Table 4-2). These misperceptions result in 

missed opportunities to administer recommended vaccines (37).

Routine physical examinations and procedures (e.g., measuring temperatures) are not 

prerequisites for vaccinating persons who appear to be healthy. The provider should ask 

the parent or guardian if the child is ill. If the child has a moderate or severe illness, the 

vaccination should be postponed.
General Best Practice Guidelines for Immunization: Contraindications and Precautions 54

TABLE 4-1. Contraindications and precautions(a) to commonly used vaccines

Vaccine Citation Contraindications Precautions

Dengue–

ONLY use in 

persons who 

have 

laboratory 

confirmation 

of previous 

dengue 

infection 

AND reside 

in endemic 

dengue areas

(b)

(38) Lack of laboratory 

evidence of previous 

dengue infection

Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Severe

immunodeficiency (e.g.,

hematologic and solid 

tumors, receipt of 

chemotherapy, 

congenital 

immunodeficiency, 

long-term 

immunosuppressive 

therapy(c) or patients 

with HIV infection who 

are severely 

immunocompromised)

 

 

Pregnancy

HIV infection without evidence of 

severe immunosuppression

Moderate or severe acute illness 

with or without fever

DT, Td (4) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

GBS <6 weeks after previous dose of 

tetanus-toxoid–containing vaccine

History of Arthus-type 

hypersensitivity reactions after a 

previous dose of diphtheria-toxoid—

containing or tetanus-toxoid–

containing vaccine; defer vaccination 

until at least 10 years have elapsed 

since the last tetanus-toxoidcontaining vaccine

Moderate or severe acute illness with 

or without fever
General Best Practice Guidelines for Immunization: Contraindications and Precautions 55

DTaP (39) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Encephalopathy (e.g., 

coma, decreased level of 

consciousness, 

prolonged seizures), not 

attributable to another 

identifiable cause, 

within 7 days of 

administration of 

previous dose of DTP or 

DTaP

Progressive neurologic disorder, 

including infantile spasms, 

uncontrolled epilepsy, progressive 

encephalopathy; defer DTaP until 

neurologic status clarified and 

stabilized

GBS <6 weeks after previous dose of 

tetanus-toxoid–containing vaccine

History of Arthus-type 

hypersensitivity reactions after a 

previous dose of diphtheria-toxoid–

containing or tetanus-toxoid–

containing vaccine; defer vaccination 

until at least 10 years have elapsed 

since the last tetanus-toxoid–

containing vaccine

Moderate or severe acute illness with 

or without fever

Hepatitis A (40) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Moderate or severe acute illness with 

or without fever

Hepatitis B (41) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Hypersensitivity to yeast

Moderate or severe acute illness with 

or without fever

Hib (42) Severe allergic reaction 

(e.g., anaphylaxis) after

Moderate or severe acute illness with 

or without fever
General Best Practice Guidelines for Immunization: Contraindications and Precautions 56

a previous dose or to a 

vaccine component

Age <6 weeks

HPV(d) (43) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component, 

including yeast

Moderate or severe acute illness with 

or without fever

IIV(e) (44) Severe allergic reaction 

(e.g., anaphylaxis) after 

previous dose of 

influenza vaccine or to 

vaccine component

GBS <6 weeks after a previous dose of 

influenza vaccine

Moderate or severe acute illness with 

or without fever

IPV (45) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Pregnancy

Moderate or severe acute illness with 

or without fever
General Best Practice Guidelines for Immunization: Contraindications and Precautions 57

LAIV(f) (44) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Concomitant use of 

aspirin or salicylatecontaining medication 

in children and 

adolescents

LAIV4 should not be 

administered to persons 

who have taken 

oseltamivir or zanamivir 

within the previous 48 

hours, peramivir within 

the previous 5 days, or 

baloxavir within the 

previous 17 days.(h)

Pregnancy

Children aged 2 through 

4 years who have 

received a diagnosis of 

asthma or whose 

parents or caregivers 

report that a health care 

provider has told them 

during the preceding 12 

months that their child 

had wheezing or asthma 

or whose medical record 

indicates a wheezing 

episode has occurred 

during the preceding 12 

months.

Persons with active 

cerebrospinal 

fluid/oropharyngeal 

communications/leaks.

GBS <6 weeks after a previous dose of 

influenza vaccine

Asthma in persons aged 5 years old or 

older

Medical conditions which might 

predispose to higher risk of 

complications attributable to 

influenza(g)

Moderate or severe acute illness with 

or without fever
General Best Practice Guidelines for Immunization: Contraindications and Precautions 58

Close contacts and 

caregivers of severely 

immunosuppressed 

persons who require a 

protected environment.

Persons with cochlear 

implants (due to the 

potential for CSF leak, 

which might exist for 

some period of time 

after implantation. 

Providers might 

consider consultation 

with a specialist 

concerning risk of 

persistent CSF leak if an 

age-appropriate 

inactivated or 

recombinant vaccine 

cannot be used).

Altered 

Immunocompetence

Anatomic or functional 

asplenia (e.g. sickle cell 

disease

MenACWY (46) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component, 

including yeast

Moderate or severe acute illness with 

or without fever

Preterm birth (MenACWY-CRM)(i)

MenB (46,48) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Moderate or severe acute illness with 

or without fever

Pregnancy

Latex sensitivity (MenB-4c)
General Best Practice Guidelines for Immunization: Contraindications and Precautions 59

MMR(j),(k) (1) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Pregnancy 

Known severe

immunodeficiency (e.g.,

from hematologic and 

solid tumors, receipt of 

chemotherapy, 

congenital 

immunodeficiency, 

long-term 

immunosuppressive 

therapy(c) or patients 

with HIV infection who 

are severely 

immunocompromised)

Family history of altered 

immunocompetence(m)

Recent (≤11 months) receipt of 

antibody-containing blood product 

(specific interval depends on product)

History of thrombocytopenia or 

thrombocytopenic purpura

Need for tuberculin skin testing or 

interferon-gamma release assay 

(IGRA) testing(l)

Moderate or severe acute illness with 

or without fever

MPSV4 (49) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Moderate or severe acute illness with 

or without fever

PCV13, 

PCV15, 

PCV20

(50) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose of PCV 

or any diphtheriatoxoid– containing 

vaccine or to a 

component of a vaccine 

(PCV or any diphtheriatoxoid– containing 

vaccine)

Moderate or severe acute illness with 

or without fever

PPSV23 (51) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Moderate or severe acute illness with 

or without fever

RIV (44) Severe allergic reaction 

(e.g., anaphylaxis) to 

any component of the 

vaccine

GBS <6 weeks after a previous dose of 

influenza vaccine

Moderate or severe acute illness with 

or without fever
General Best Practice Guidelines for Immunization: Contraindications and Precautions 60

Rotavirus (6) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

SCID

History of 

intussusception

Altered immunocompetence other 

than SCID

Chronic gastrointestinal disease

Spina bifida or bladder exstrophy(n)

Moderate or severe acute illness with 

or without fever

Tdap (52) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Encephalopathy (e.g., 

coma, decreased level of 

consciousness, 

prolonged seizures), not 

attributable to another 

identifiable cause, within 

7 days of administration 

of previous dose of DTP, 

DTaP, or Tdap

GBS <6 weeks after a previous dose of 

tetanus-toxoid–containing vaccine

Progressive or unstable neurological 

disorder, uncontrolled seizures, or 

progressive encephalopathy until a 

treatment regimen has been 

established and the condition has 

stabilized

History of Arthus-type 

hypersensitivity reactions after a 

previous dose of diphtheria-toxoid—

containing or tetanus-toxoid–

containing vaccine; defer vaccination 

until at least 10 years have elapsed 

since the last tetanus-toxoid–

containing vaccine

Moderate or severe acute illness with 

or without fever

Varicella(j),(k

)

(53) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Known severe 

immunodeficiency (e.g., 

from hematologic and 

solid tumors, receipt of 

chemotherapy, 

congenital 

immunodeficiency, 

long-term 

immunosuppressive 

therapy(c) or patients 

with HIV infection who 

are severely

immunocompromised)(j)

Pregnancy

Family history of altered 

immunocompetence(m)

Recent (≤11 months) receipt of 

antibody-containing blood product 

(specific interval depends on product)

Moderate or severe acute illness with 

or without fever

Receipt of specific antiviral drugs 

(acyclovir, famciclovir, or 

valacyclovir) 24 hours before 

vaccination (avoid use of these 

antiviral drugs for 14 days after 

vaccination)

Use of aspirin or aspirin-containing 

products(o)
General Best Practice Guidelines for Immunization: Contraindications and Precautions 61

Zoster (54) Severe allergic reaction 

(e.g., anaphylaxis) after 

a previous dose or to a 

vaccine component

Moderate or severe acute illness with 

or without fever

Abbreviations: DT = diphtheria and tetanus toxoids; DTaP = diphtheria and tetanus toxoids and acellular pertussis; 

DTP = diphtheria toxoid, tetanus toxoid, and pertussis; GBS = Guillain-Barré syndrome; Hib = Haemophilus influenzae 

type b; HIV = human immunodeficiency virus; HPV = human papillomavirus; IIV = inactivated influenza vaccine; IPV = 

inactivated poliovirus; LAIV = live, attenuated influenza vaccine; MenACWY = quadrivalent meningococcal conjugate 

vaccine; MMR = measles, mumps, and rubella; MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV13 = 

pneumococcal conjugate vaccine; PPSV23= pneumococcal polysaccharide vaccine; SCID = severe combined 

immunodeficiency; RIV=recombinant influenza vaccine; Td = tetanus and diphtheria toxoids; Tdap = tetanus toxoid, 

reduced diphtheria toxoid, and acellular pertussis.

(a) Events or conditions listed as precautions should be reviewed carefully. Benefits of and risks for administering a 

specific vaccine to a person under these circumstances should be considered. If the risk from the vaccine is believed to 

outweigh the benefit, the vaccine should not be administered. If the benefit of vaccination is believed to outweigh the 

risk, the vaccine should be administered. Whether and when to administer DTaP to children with proven or suspected 

underlying neurologic disorders should be decided on a case-by-case basis.

(b) Only persons with laboratory confirmation of immunity according to strict guidance at

https://www.cdc.gov/dengue/vaccine/hcp/testing.html should receive dengue vaccination.

(c) Substantially immunosuppressive steroid dose is considered to be ≥2 weeks of daily receipt of 20 mg or 2 mg/kg body 

weight of prednisone or equivalent.

(d) HPV vaccine is not recommended during pregnancy

(e) When applying this contraindication to ccIIV, the history of severe allergic reaction (e.g., anaphylaxis) must be specific 

to the event occurring following a dose of ccIIV. Likewise, when applying this contraindication to RIV, the history of 

severe allergic reaction (e.g., anaphylaxis) must be specific to the event occurring following a dose of RIV. A history of 

severe allergic reaction (e.g., anaphylaxis) to a non-ccIIV vaccine or to a component specific to components not 

contained in ccIIV, is a precaution to ccIIV. A history of severe allergic reaction (e.g., anaphylaxis) to a non-RIV vaccine 

or to a component specific to components not contained in RIV is a precaution to RIV.

(f) In addition, ACIP recommends LAIV not be used for pregnant women, immunosuppressed persons, and children aged 

2-4 years who have asthma or who have had a wheezing episode noted in the medical record within the past 12 months, 

or for whom parents report that a health care provider stated that they had wheezing or asthma within the last 12 months. 

LAIV should not be administered to persons who have taken influenza antiviral medications within the previous 48 

hours. Persons who care for severely immunosuppressed persons who require a protective environment should not 

receive LAIV, or should avoid contact with such persons for 7 days after receipt.

(g) See reference: Grohskopf LA, Alyanak E, Ferdinands JM, et al. Prevention and Control of Seasonal Influenza with 

Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021-2022 Influenza 

Season. MMWR Recomm Rep 2021;70(No. RR-5):1-30.
General Best Practice Guidelines for Immunization: Contraindications and Precautions 62

(h) These values are based on the clearance of the particular antiviral. LAIV4 should not be administered to persons who 

have taken oseltamivir or zanamivir within the previous 48 hours, peramivir within the previous 5 days, or baloxavir 

within the previous 17 days. This “contraindication” is due to concern with reduced effectiveness of the vaccine. To obtain 

specific information, please refer to Grohskopf LA, Alyanak, E, Broder KR, et. al. Prevention and Control of Seasonal 

Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 

2020–21 Influenza Season. MMWR Recomm Rep 2020;69 (No. RR-8:1-26. Also at 

https://www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6908a1-H.pdf 

(i) This precaution applies to infants younger than 9 months old

(j) HIV-infected children may receive varicella vaccine if CD4+ T-lymphocyte count is ≥15% and should receive MMR 

vaccine if they are aged ≥12 months and do not have evidence of current severe immunosuppression (i.e., individuals 

aged ≤5 years must have CD4+T lymphocyte [CD4] percentages ≥15% for ≥6 months; and individuals aged >5 years must 

have CD4+percentages ≥15% and CD4+≥200 lymphocytes/mm3 for ≥6 months) or other current evidence of measles, 

rubella, and mumps immunity. In cases when only CD4+cell counts or only CD4+percentages are available for those 

older than age 5 years, the assessment of severe immunosuppression can be based on the CD4+values (count or 

percentage) that are available. In cases when CD4+percentages are not available for those aged ≤5 years, the assessment 

of severe immunosuppression can be based on age-specific CD4+counts at the time CD4+counts were measured; i.e., 

absence of severe immunosuppression is defined as ≥6 months above age-specific CD4+count criteria: CD4+count >750 

lymphocytes/mm3 while aged ≤12 months and CD4+count ≥500 lymphocytes/mm3 while aged 1 through 5 years.

Sources: (1,50).

(k) MMR and varicella-containing vaccines can be administered on the same day. If not administered on the same 

day, these vaccines should be separated by at least 28 days.

(l) If active tuberculosis is suspected, MMR should be delayed. Measles vaccination might suppress tuberculin reactivity 

temporarily. Measles-containing vaccine can be administered on the same day as tuberculin skin or IGRA testing. If 

testing cannot be performed until after the day of MMR vaccination, the test should be postponed for ≥4 weeks after the 

vaccination. If an urgent need exists to skin test or IGRA, do so with the understanding that reactivity might be reduced 

by the vaccine.

(m) family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents and siblings), 

unless the immune competence of the potential vaccine recipient has been substantiated clinically or verified by a 

laboratory

(n) For RV1 only, based on latex in product/packaging. Note that anaphylactic allergy to latex is covered in the 

contraindication, and would also be isolated to RV 1 in the case of latex. For more details, see (55).

(o) No adverse events associated with the use of aspirin or aspirin-containing products after varicella vaccination have 

been reported; however, the vaccine manufacturer recommends that vaccine recipients avoid using aspirin or aspirincontaining products for 6 weeks after receiving varicella vaccines because of the association between aspirin use and 

Reye syndrome after varicella. Vaccination with subsequent close monitoring should be considered for children who have 

rheumatoid arthritis or other conditions requiring therapeutic aspirin. The risk for serious complications associated with 

aspirin is likely to be greater in children in whom natural varicella develops than it is in children who receive the vaccine

containing attenuated VZV. No association has been documented between Reye syndrome and analgesics or antipyretics 

that do not contain aspirin.”
General Best Practice Guidelines for Immunization: Contraindications and Precautions 63

TABLE 4-2. Conditions incorrectly perceived as contraindications or 

precautions to vaccination (i.e., vaccines may be given under these 

conditions)

Vaccine Conditions commonly misperceived as 

contraindications or precautions

General for all 

vaccines, including 

DTaP, pediatric 

DT, adult Td, 

adolescent-adult 

Tdap, IPV, MMR,

Hib, hepatitis A, 

hepatitis B, 

varicella, rotavirus, 

PCV13, IIV, LAIV, 

PPSV23, 

MenACWY, MPSV4,

HPV, and herpes 

zoster

Mild acute illness with or without fever

Lack of previous physical examination in well-appearing 

person

Current antimicrobial therapy(a) 

Convalescent phase of illness

Preterm birth (hepatitis B vaccine is an exception in certain 

circumstances)(b)

Recent exposure to an infectious disease

History of penicillin allergy, other nonvaccine allergies, 

relatives with allergies, or receiving allergen extract 

immunotherapy

History of GBS(c)

DTaP Fever within 48 hours after vaccination with a previous dose of 

DTP or DTaP

Collapse or shock-like state (i.e., hypotonic hyporesponsive 

episode) within 48 hours after receiving a previous dose of 

DTP/DTaP

Seizure ≤3 days after receiving a previous dose of DTP/DTaP

Persistent, inconsolable crying lasting ≥3 hours within 48 

hours after receiving a previous dose of DTP/DTaP 

Family history of seizures

Family history of sudden infant death syndrome 

Family history of an adverse event after DTP or DTaP 

administration

Stable neurologic conditions (e.g., cerebral palsy, wellcontrolled seizures, or developmental delay)

Hepatitis B Pregnancy

Autoimmune disease (e.g., systemic lupus erythematosus or 

rheumatoid arthritis)

HPV Immunosuppression

Previous equivocal or abnormal Papanicolaou test 

Known HPV infection

Breastfeeding

History of genital warts

IIV Nonsevere (e.g., contact) allergy to latex, thimerosal, or egg 

Concurrent administration of Coumadin (generic: warfarin) or 

aminophylline

IPV Previous receipt of ≥1 dose of oral polio vaccine
General Best Practice Guidelines for Immunization: Contraindications and Precautions 64

LAIV Health-care providers that see patients with chronic diseases 

or altered immunocompetence (an exception is providers for 

severely immunocompromised patients requiring care in a 

protected environment)

Breastfeeding

Contacts of persons with chronic disease or altered 

immunocompetence (an exception is contacts of severely 

immunocompromised patients requiring care in a protected 

environment)

MMR(d),(e) Positive tuberculin skin test

Simultaneous tuberculin skin or interferon-gamma release 

assay (IGRA) testing(f)

Breastfeeding

Pregnancy of recipient’s mother or other close or household 

contact

Recipient is female of child-bearing age 

Immunodeficient family member or household contact 

Asymptomatic or mildly symptomatic HIV infection 

Allergy to eggs

PPSV23 History of invasive pneumococcal disease or pneumonia

Rotavirus Prematurity

Immunosuppressed household contacts 

Pregnant household contacts

Tdap History of fever of ≥40.5°C (≥105°F) for <48 hours after 

vaccination with a previous dose of DTP or DTaP 

History of collapse or shock-like state (i.e., hypotonic

hyporesponsive episode) within 48 hours after receiving a 

previous dose of DTP/DTaP

History of seizure <3 days after receiving a previous dose of 

DTP/DTaP

History of persistent, inconsolable crying lasting >3 hours 

within 48 hours after receiving a previous dose of DTP/DTaP 

History of extensive limb swelling after DTP/DTaP/Td that is 

not an Arthus-type reaction

History of stable neurologic disorder 

History of brachial neuritis

Latex allergy that is not anaphylactic 

Breastfeeding

Immunosuppression

Varicella Pregnancy of recipient’s mother or other close or household 

contact

Immunodeficient family member or household contact(g) 

Asymptomatic or mildly symptomatic HIV infection 

Humoral immunodeficiency (e.g., agammaglobulinemia)
General Best Practice Guidelines for Immunization: Contraindications and Precautions 65

Zoster Therapy with low-dose methotrexate (≤0.4 mg/kg/week), 

azathioprine (≤3.0 mg/kg/day), or 6-mercaptopurine (≤1.5 

mg/kg/day) for treatment of rheumatoid arthritis, psoriasis, 

polymyositis, sarcoidosis, inflammatory bowel disease, or other 

conditions

Health-care providers of patients with chronic diseases or 

altered immunocompetence

Contacts of patients with chronic diseases or altered 

immunocompetence

Unknown or uncertain history of varicella in a U.S.-born 

person

Abbreviations: DT = diphtheria and tetanus toxoids; DTP = diphtheria toxoid, tetanus toxoid, and pertussis; 

DTaP = diphtheria and tetanus toxoids and acellular pertussis; GBS = Guillain-Barré syndrome; HBsAg = hepatitis 

B surface antigen; Hib = Haemophilus influenzae type b; HIV = human immunodeficiency virus; HPV = human 

papillomavirus; IIV = inactivated influenza vaccine; IPV = inactivated poliovirus; LAIV = live, attenuated influenza 

vaccine; MenACWY = quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella; 

MPSV4 = quadrivalent meningococcal polysaccharide vaccine; PCV = pneumococcal conjugate vaccine; PPSV23= 

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

diphtheria toxoid, and acellular pertussis.

(a) Antibacterial drugs might interfere with Ty21a oral typhoid vaccine, and certain antiviral drugs might interfere 

with varicella-containing vaccines and LAIV4.

(b) Hepatitis B vaccination should be deferred for infants weighing <2,000 g if the mother is documented to be 

HBsAg negative. Vaccination should commence at chronological age 1 month or at hospital discharge. For infants 

born to HBsAg-positive women, hepatitis B immune globulin and hepatitis B vaccine should be administered 

within 12 hours after birth, regardless of weight.

(c) An exception is Guillain-Barré syndrome within 6 weeks of a dose of influenza vaccine or tetanus-toxoid–

containing vaccine, which are precautions for influenza vaccines and tetanus-toxoid containing vaccines, 

respectively.

(d) MMR and varicella vaccines can be administered on the same day. If not administered on the same day, these 

vaccines should be separated by at least 28 days.

(e) HIV-infected children should receive immune globulin after exposure to measles. HIV-infected children can 

receive varicella and measles vaccine if CD4+ T-lymphocyte count is >15%. (55).

(f) Measles vaccination might suppress tuberculin reactivity temporarily. Measles-containing vaccine can be 

administered on the same day as tuberculin skin or IGRA testing. If testing cannot be performed until after the day 

of MMR vaccination, the test should be postponed for at least 4 weeks after the vaccination. If an urgent need 

exists to skin test or IGRA, do so with the understanding that reactivity might be reduced by the vaccine.

(g) If a vaccinee experiences a presumed vaccine-related rash 7-25 days after vaccination, the person should avoid 

direct contact with immunocompromised persons for the duration of the rash.
General Best Practice Guidelines for Immunization: Contraindications and Precautions 66

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