Overview of Immunization

With rare exceptions, simultaneous administration of vaccines is safe, effective, and convenient; it is particularly recommended when children may be unavailable for future vaccination or when adults require multiple vaccines before international travel. An exception is simultaneous administration of pneumococcal conjugate vaccine and the meningococcal conjugate vaccine MenACWY-D (Menactra) to children with functional or anatomic asplenia; these vaccinations should not be given during the same visit but should be separated by ≥ 4 weeks. If vaccination against both meningococcal serotypes B and serotypes A, C, W, and Y is indicated (previously available separately), the newly licensed MenACWY-TT/MenB-FHbp is recommended.

Simultaneous administration may involve combination vaccines (see table Vaccines Available in the United States) or use of ≥ 1 single-antigen vaccines. More than one vaccine may be given at the same time using different injection sites and syringes.

If live-virus vaccines (eg, varicella and measles-mumps-rubella [MMR]) are not given at the same time, they should be given ≥ 4 weeks apart.

1. 1. Barnes MG, Ledford C, Hogan K: A "needling" problem: Shoulder injury related to vaccine administration. J Am Board Fam Med 25(6):919–922, 2012. doi: 10.3122/jabfm.2012.06.110334

For many vaccines, the only contraindication is a serious allergic reaction (eg, anaphylactic reaction) to the vaccine or to one of its components.

Egg allergy is common in the United States. Some vaccines produced in cell culture systems, including most influenza vaccines, contain trace amounts of egg antigens. CDC guidelines for the influenza vaccine state patients with a history of egg allergy should be given the influenza vaccine. An egg allergy necessitates no additional safety measures for influenza vaccination beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. Any influenza vaccine that is otherwise recommended based on the recipient’s age and health status can be used. (See CDC: Summary: ‘Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2023-24’.)

Patients who developed Guillain-Barré syndrome (GBS) within 6 weeks after a previous influenza or diphtheria-tetanus-acellular pertussis (DTaP) vaccination may be given the vaccine if the benefits of vaccination are thought to outweigh the risks. For example, for patients who developed the syndrome after a dose of DTaP, clinicians may consider giving them a dose of the vaccine if a pertussis outbreak occurs; however, such decisions should be made in consultation with an infectious disease specialist.

The Advisory Committee on Immunization Practices no longer considers a history of GBS to be a contraindication or precaution for use of the meningococcal conjugate vaccine, although it remains listed as a precaution in the package insert (see CDC: Meningococcal Vaccines Safety Information).

A significant fever (temperature of > 39° C) or severe illness without fever requires delaying vaccination, but minor infections, such as the common cold (even with low-grade fever), do not. This precaution prevents confusion between manifestations of the underlying illness and possible adverse effects of the vaccine and prevents superimposition of adverse effects of the vaccine on the underlying illness. Vaccination is postponed until the illness resolves, if possible.

Pregnancy is a contraindication to vaccination with measles/mumps/rubella vaccines, intranasal influenza vaccine (live), varicella-zoster virus vaccine, and other live-virus vaccines.Pregnancy is a contraindication to vaccination with measles/mumps/rubella vaccines, intranasal influenza vaccine (live), varicella-zoster virus vaccine, and other live-virus vaccines.

The Advisory Committee on Immunization Practices recommends delaying vaccination with human papillomavirus 9-valent vaccine and recombinant zoster vaccine until after pregnancy (see The Advisory Committee on Immunization Practices recommends delaying vaccination with human papillomavirus 9-valent vaccine and recombinant zoster vaccine until after pregnancy (seeAdult Immunization Schedule by Medical Condition and Other Indication).

Immunocompromised patients should, in general, not receive live-microbial vaccines, which could provoke severe or fatal infections. If immunocompromise is caused by immunosuppressive therapy (eg, high-dose corticosteroids [≥ 20 mg prednisone or equivalent for ≥ 2 weeks], antimetabolites, immune modulators, alkylating compounds, radiation), live-virus vaccines should be withheld until the immune system recovers after treatment (the interval of time varies depending on the therapy used). Patients taking immune-suppressing medications for any of a wide variety of disorders, including dermatologic, gastrointestinal, rheumatologic, and lung disorders, should not receive live-virus vaccines. For patients receiving long-term immunosuppressive therapy, clinicians should discuss risks and benefits of vaccination and/or revaccination with an infectious disease specialist.Immunocompromised patients should, in general, not receive live-microbial vaccines, which could provoke severe or fatal infections. If immunocompromise is caused by immunosuppressive therapy (eg, high-dose corticosteroids [≥ 20 mg prednisone or equivalent for ≥ 2 weeks], antimetabolites, immune modulators, alkylating compounds, radiation), live-virus vaccines should be withheld until the immune system recovers after treatment (the interval of time varies depending on the therapy used). Patients taking immune-suppressing medications for any of a wide variety of disorders, including dermatologic, gastrointestinal, rheumatologic, and lung disorders, should not receive live-virus vaccines. For patients receiving long-term immunosuppressive therapy, clinicians should discuss risks and benefits of vaccination and/or revaccination with an infectious disease specialist.

Patients with HIV infection should generally receive inactivated vaccines (eg, diphtheria-tetanus-acellular pertussis [Tdap], polio [IPV], Hib) according to routine recommendations. Despite the general caution against giving a live-virus vaccine, patients who have CD4 counts ≥ 200/mcL (ie, are not severely immunocompromised) can be given certain live-virus vaccines, including measles-mumps-rubella (MMR). Patients with HIV infection who have not received a conjugate pneumococcal vaccine or whose previous vaccination history is unknown should be given PCV15 or PCV20; if PCV15 is given, follow with PPSV23 ≥ 8 weeks after the PCV15 dose. should generally receive inactivated vaccines (eg, diphtheria-tetanus-acellular pertussis [Tdap], polio [IPV], Hib) according to routine recommendations. Despite the general caution against giving a live-virus vaccine, patients who have CD4 counts ≥ 200/mcL (ie, are not severely immunocompromised) can be given certain live-virus vaccines, including measles-mumps-rubella (MMR). Patients with HIV infection who have not received a conjugate pneumococcal vaccine or whose previous vaccination history is unknown should be given PCV15 or PCV20; if PCV15 is given, follow with PPSV23 ≥ 8 weeks after the PCV15 dose.

Asplenic patients are predisposed to overwhelming bacteremic infection, primarily due to encapsulated organisms such as Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae type b (Hib). Asplenic adults should be given the following vaccines (before splenectomy if possible):

• Hib conjugate vaccine: Patients are given a single dose and no booster.

• Meningococcal conjugate vaccine (MenACWY): Patients are given 2 doses at least 8 weeks apart and a booster every 5 years.

• Meningococcal B vaccine (MenB): Patients are given a 2-dose series of MenB-4C ≥ 1 month apart or a 3-dose series of MenB-FHbp at 0, 1 to 2, and 6 months (if dose 2 was given at least 6 months after dose 1, dose 3 is not needed; if dose 3 was given < 4 months after dose 2, a fourth dose should be given at least 4 months after dose 3); MenB-4C and MenB-FHbp are not interchangeable (use same product for all doses in series); 1 dose MenB booster 1 year after primary series and revaccinate every 2 to 3 years if risk remains. Pregnancy: Delay MenB until after pregnancy unless at increased risk and vaccination benefits outweigh potential risks.

• Pneumococcal conjugate (PCV15, PCV20, and PCV21) and pneumococcal polysaccharide (PPSV23) vaccines: Patients are given one dose of either PCV20 or PCV21 or one dose of PCV15 followed by a dose of PPSV23 one year apart if they have not previously received a pneumococcal conjugate vaccine or if their vaccination history is unknown. A shorter minimum interval of 8 weeks between PCV15 and PPSV23 can be considered for adults with an immunocompromising condition (including congenital or acquired asplenia), cochlear implant, or cerebrospinal fluid (CSF) leak.

Additional doses may be given based on clinical judgment.

Before solid organ transplantation, patients should receive all appropriate vaccines. Patients who have had allogeneic or autogeneic hematopoietic stem cell transplantation should be considered unimmunized and should receive repeat doses of all appropriate vaccines. Care of these patients is complex, and vaccination decisions for these patients should involve consultation with the patient's hematologist-oncologist and an infectious disease specialist.

Live-microbial vaccines should not be given simultaneously with blood or plasma transfusions or immune globulin; these products can interfere with development of desired antibodies. Ideally, live-microbial vaccines should be given 2 weeks before or 6 to 12 weeks after the immune globulins.

Live-microbial vaccines include the following:

• Bacille Calmette-Guérin (BCG) live (for Bacille Calmette-Guérin (BCG) live (fortuberculosis)

• Cholera vaccineCholera vaccine

• Ebola vaccine

• Influenza virus vaccine (LAIV)Influenza virus vaccine (LAIV)

• Measles/mumps/rubella vaccines (MMR)Measles/mumps/rubella vaccines (MMR)

• Measles virus/mumps virus/rubella virus/varicella virus vaccine (MMRV)Measles virus/mumps virus/rubella virus/varicella virus vaccine (MMRV)

• Polio (oral preparation only; no longer licensed or available in the United States)

• Rotavirus vaccineRotavirus vaccine

• Smallpox and monkeypox vaccine, live, nonreplicatingSmallpox and monkeypox vaccine, live, nonreplicating

• Typhoid vaccine Typhoid vaccine

• Varicella-zoster virus vaccine (no longer available in the United States)Varicella-zoster virus vaccine (no longer available in the United States)

• Yellow fever vaccineYellow fever vaccine

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2. 2. Institute of Medicine Immunization Safety Review Committee: Immunization safety review: Vaccines and autism. Washington DC, National Academies Press, 2004.

3. 3. Spencer JP, Trondsen Pawlowski RH, Thomas S: Vaccine adverse events: Separating myth from reality. Am Fam Physician 95(12):786–794, 2017. PMID: 28671426