Contraindications and Special Considerations

All vaccines are contraindicated in those who have had a confirmed anaphylactic reaction to:

• a previous dose of a vaccine containing the same antigens, or
  
• another component contained in the relevant vaccine, e.g. neomycin, streptomycin or polymyxin B (which may be present in trace amounts in some vaccines).
  

Live vaccines may be temporarily contraindicated in individuals who are:

• immunosuppressed
  
• pregnant
  

Some vaccines are contraindicated in specific groups:

Egg allergy: As of 2017, it has been recommended that egg allergic individuals may be safely vaccinated with the measles mumps rubella (MMR), the measles mumps rubella varicella (MMR-V) vaccine (which contains no egg protein) and the influenza vaccine (which may contain minute traces of egg protein).

Special precautions such as split dosing, prior allergy testing with the vaccines, allergy specialist review before vaccination or prolonged waiting times after administration are not required.

The yellow fever and Q fever vaccines potentially contain higher amounts of egg protein and an allergy specialist evaluation is recommended before vaccination.

Severe latex allergy: While it is theoretically possible that latex protein in the tip cap and/or rubber plunger or vial stoppers may cause allergic reactions, there is little evidence that such a risk exists and any such risk would be extremely small (around 1 per 1 million vaccine doses). Even so, as a precaution, vaccines supplied in vials or syringes that contain latex 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 latex can be administered.

Pregnancy: There is no evidence that any live vaccine (including rubella and MMR) causes direct foetal injury or birth defects. However, since the theoretical possibility of foetal infection still exists, live vaccines should generally be delayed until after delivery. Women should avoid conception for 4 weeks after vaccination with live vaccines. Termination of pregnancy following inadvertent immunisation is not recommended.

Even though inactivated vaccines cannot replicate and cause infection in either the mother or the foetus, they should be administered to pregnant women only if protection is required without delay.

Immunosuppression: Live vaccines can, in some situations, cause severe or fatal infections in immunosuppressed individuals (including the HIV-infected) due to extensive replication of the vaccine strain. For this reason, severely immunosuppressed individuals (see section on Immunocompromised Patients on page 248) should not be given live vaccines.

Killed or recombinant vaccines and toxoids may be administered to immunosuppressed individuals since they cannot replicate. Since they may elicit a lower immune response than in immunocompetent individuals, a double dose may be required.

Other Considerations:

Adults on stable long term low dose corticosteroid therapy (up to 20mg prednisolone per day for more than 14 days) either alone, or in combination with other low dose immunosuppressive drugs or low dose non-biological oral immune-modulating drugs (e.g. methotrexate, azathioprine, 6-mercapto (purine), are not considered sufficiently immunosuppressed. These patients can therefore receive live vaccines.

Non-systemic corticosteroids, such as aerosols or topical or intra- articular preparations, do not cause systemic immunosuppression. Neither does replacement schedule of corticosteroids for people with adrenal insufficiency. Therefore, administration of live vaccines is not contraindicated.

Live vaccines should not be given to the following:

Patients receiving immunosuppressive treatment including radiotherapy or systemic high-dose steroids.

Patients with evidence of primary or secondary immunodeficiency.

Contact with an individual with immunodeficiency, on current/recent immunosuppressive therapy:

Historically, smallpox and oral polio were contraindicated in healthy household contacts of immunocompromised patients.

For most of the current live vaccines in use, transmission through contacts does not occur or can be minimised by simple precautions (e.g. MMR, varicella. See vaccine specific advice).

In addition, vaccination of close contacts of vulnerable people has a major benefit by reducing the risk of exposure to wild-type infection. Thus, some vaccines should be actively encouraged in family and household contacts of those at risk.

Organ transplant candidates should complete the recommended full vaccination schedule as early as possible because of the problem of reduced immune response to vaccines following transplantation as a result of immunosuppressive treatment.

Temporary Deferral of Immunisation

The following are situations where temporary deferral of immunisation is required:

Individuals with immunosuppression from malignant disease on chemotherapy should not receive live attenuated vaccines until at least 3 months after chemotherapy has finished.

Patients who received a hematopoietic stem cell transplant may be given inactivated vaccine or toxoid from 6 to 12 months after completing all immunosuppressive treatment, or longer if the patients developed graft versus-host disease.

For those on high dose systemic corticosteroids (for adults; daily doses in excess of 20mg for more than 2 weeks or 60mg of prednisolone), live attenuated vaccines should be postponed until at least 3 months after treatment has stopped.

Live virus vaccines, with the exception of yellow fever vaccine, generally should not be given during the 3 months following injection of immunoglobulin because the immune response may be inhibited. For MMRV vaccine, refer to Table 10.1 on page 113.

The following are NOT contraindications to routine vaccinations (in some of these situations, additional precautions may be required – refer to the relevant chapter for further information):

Minor self-limiting illness without fever.

Asthma, eczema, or hay fever.

Treatment with antibiotics or locally-acting (e.g. topical or inhaled) steroids.

Contact with an infectious disease.

Family history of any adverse reactions following immunisation.

Previous history of the disease (with the exception of BCG for people who have evidence of past exposure to tuberculosis).

Someone in the household being pregnant.

Personal or family history of febrile convulsions or epilepsy.

Being a sibling or close contact of an immunosuppressed individual.

Recent or imminent elective surgery.

Imminent general anaesthesia.

Unknown or inadequately documented immunisation history.

Food intolerances.

Treatment with interferons & other non-immunosuppressing immunomodulatory.

Route and Site of Administration

By mouth :

Sugar lumps, if used, should be prepared with oral polio vaccine (OPV) immediately before administration. By allowing them to stand at room temperature for any length of time, may decrease the potency of the vaccine.

Cholera and typhoid vaccines are also to be given orally. Food and drink should be avoided for 1 hour before and 1 hour after vaccination. Oral administration of other medicinal products should be avoided within 1 hour before and after administration of the vaccine.

Intranasal (Currently no intranasal vaccines are available in Malaysia):

The live attenuated influenza vaccine (LAIV) is administered by the intranasal route (Fluenz®) and is supplied in an applicator that allows a divided dose to be administered in each nostril (total dose of 0.2ml, 0.1ml in each nostril). The device allows intranasal administration to be performed without the need for additional training.

Administration of either dose does not need to be repeated if the patients sneeze or blow their nose following administration. As heavy nasal congestion might impede delivery of the vaccine to the nasopharyngeal mucosa, defer administration of the vaccine until resolution of the nasal congestion has occurred. Alternatively, an appropriate intramuscularly administered influenza vaccine should be considered.

Subcutaneous (SC) and intramuscular (IM) injections:

Most vaccines are given by IM injections, rather than deep SC, as the former are less likely to cause local reactions. However, for individuals with a bleeding disorder, vaccines normally given by an IM route should be given by deep subcutaneous injection to reduce the risk of bleeding. Vaccines should never be given intravenously.

The preferred site for IM and SC immunisation is the deltoid area of the upper arm. The upper outer quadrant of the buttock (ventrogluteal) area is an alternative injection site.