No individual should be denied vaccination without serious consideration of the consequences, both for the individual and for the community. Where there is any doubt, seek advice from the individual’s general practitioner (GP), a public health medicine specialist, medical ofﬁcer of health or consultant paediatrician.
Live viral vaccines should not be given to pregnant women, nor, in general, to immunosuppressed individuals (see chapter 4).
Minor infection without signiﬁcant fever or systemic upset is not a reason to defer immunisation. The decision to administer or delay immunisation because of a current or recent acute illness depends on the severity of the illness and the aetiology of the disease. All vaccines can be administered to people with minor acute illness (eg, diarrhoea or mild upper respiratory tract infections), but should be postponed if the individual has a fever over 38oC.
Careful consideration will be needed depending on the nature of the reaction. If in doubt about the safety of future doses, seek specialist advice. A confirmed anaphylactic reaction to a previous dose is a contraindication to further doses of that vaccine.
Vaccinators need to be aware of the possibility that allergic reactions, including anaphylaxis, may occur after any vaccination without any apparent risk factors (see section 2.4).
Egg allergy, including anaphylaxis, is not a contraindication to MMR vaccine. Anaphylaxis to a prior dose of MMR is a contraindication to a further dose. Egg allergy, including anaphylaxis, is no longer considered a contraindication to influenza vaccination. However, a history of egg anaphylaxis warrants the first dose of influenza vaccine to be given in a supervised medical setting (see section 10.6.2).
Delayed hypersensitivity to a prior vaccine dose or a component of a vaccine is not a contraindication to further doses, but it is important to distinguish these from anaphylaxis. If an individual has had anaphylaxis to any component contained in a vaccine, seek specialist advice.
Intramuscular vaccines should be administered with caution to individuals with thrombocytopenia or a bleeding disorder, since a haematoma may occur following intramuscular administration. Vaccine administration should be coordinated with clotting factor replacement therapy, where appropriate. A 23-gauge or smaller needle should be used and firm pressure applied to the injection site (without rubbing) for at least two minutes.
In the past, the subcutaneous route was recommended for people with significant bleeding disorders, but guidelines are now moving to recommend the intramuscular route, providing the vaccine is administered by someone familiar with the individual’s bleeding risk. With the exception of hepatitis B vaccines, most Schedule vaccines may be given subcutaneously, but there is a risk of reduced immunogenicity and increased local reactions with subcutaneous administration. (See section 2.3 for information on vaccine administration.)
If two different live parenteral virus vaccines are given within four weeks of each other, the antibody response to the first may interfere with the response to the second. They may be given on the same day without interference. There are no dose interval restrictions for inactivated/ subunit vaccines (see section 2.6.1 and chapter 3). Live virus vaccines should be given at least 3 weeks before, or deferred for up to 11 months after, doses of human normal immunoglobulin or other blood products. The interval will be determined by the blood product and dose received (see Table 1.3). Note that this does not apply to rotavirus vaccine, which is a non-parenteral vaccine.
|Indications or product||Route||Dose||Interval (months) a|
|U or mL||mg IgG/kg|
|Tetanus prophylaxis (as TIG)||IM||250 U||10||3|
|Hepatitis A prophylaxis |
| ||IM||0.02 mL/kg||3.3||3|
| ||IM||0.06 mL/kg||10||3|
|Hepatitis B prophylaxis |
|Rabies prophylaxis (as RIG)||IM||20 IU/kg||22||4|
|Varicella prophylaxis |
|IM||125 U/10 kg |
(max 625 U)
|Measles prophylaxis (as IG):|
| ||IM||0.25 mL/kg||40||5|
| ||IM||0.50 mL/kg||80||6|
|RSV-prophylaxis (palivizumab monoclonal antibody)b||IM||15 mg/kg |
|Cytomegalovirus immunoglobulind||IV||3 mL/kg||150||6|
| ||IV||10 mL/kg||Negligible||0|
| ||IV||10 mL/kg||10||3|
| ||IV||10 mL/kg||20–60||5|
| ||IV||10 mL/kg||80–100||6|
| ||IV||10 mL/kg||160||7|
|Replacement (or therapy) of immune deﬁciencies |
|Therapy for ITP (as IVIG)||IV||400||8|
|Therapy for ITP||IV||1000||10|
|Therapy for ITP or Kawasaki disease |
Key: MMR = measles, mumps, rubella; MMRV = measles, mumps, rubella, varicella; TIG = tetanus immunoglobulin; IM= intramuscular; IG = immunoglobulin; HBIG = hepatitis B immunoglobulin; RIG = rabies immunoglobulin; ZIG = zoster immunoglobulin; RSV = respiratory syncytial virus; IV = intravenous; RBCs = red blood cells; IVIG = intravenous immunoglobulin; ITP = immune (formerly termed ‘idiopathic’) thrombocytopenic purpura.
Source: Adapted from American Academy of Pediatrics. 2012. Active and passive immunization. In: Pickering LK, Baker CJ, Kimberlin DW, et al (eds). Red Book: 2012 report of the Committee on Infectious Diseases (29th edition). Elk Grove Village, IL: American Academy of Pediatrics, Table 1.9.