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 Symptoms and Conditions

This guide is for childhood (pre-adolescent) vaccinations only.

Allergies 2

Anaphylactic reaction to previous dose of vaccine . . . . . . . . . . . . . . . . 2

Antimicrobial therapy (current) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . 3

Cerebral palsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14

Convalescing from illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Convulsions, family history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Convulsions within 3 days of previous dose of DTP or DTaP 4

Developmental delay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 14

Diarrhea. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Encephalopathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19

DTP/DTaP Hib IPV OPV MMR HB Var

Epilepsy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Exposure (recent) to infectious disease. . . . . . . . . . . . . . . . . . . . . . . 6
Fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Fits (see "Convulsions") ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Gastroenteritis (see "Diarrhea"). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Genetic disorders (see "Neurologic disorders") . . . . . . . . . . . . . . . . . 14
Guillain-Barre syndrome (GBS) ". . . . . . . . . . . . . . . . . . . 20
HIV infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
IG administration, recent or simultaneous. . . . . . . . . . . . . . . . . . . . . 9-10
Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Immunodeficiency 12-13
Neurologic disorders, underlying. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Otitis media. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Pr~gnancy, mother or household contact of recipient. . . . . . . . . . . . 16

DTP/DTaP Hib IPV OPV MMR HB Var

Prematurity . 16
Reactions to a previous dose of any vaccine . 17
Reactions to a previous dose of DTP or DTaP . 18-20
. res (see lieonvu I'
Selzu slons ") . 4
Simultaneous administration of vaccines . 21
Steroids (see "Immunodeficienct) . 12-13
Sudden infant death syndrome (SIDS), family history . 21
Thrombocytopenia . 22
Tuberculin skin testing, performed simultaneously with vaccination. 23
Tuberculosis (TB) or positive PPD . 23
Unvaccinated household contact . 24
Vomiting . 25

DTP/DTaP Hib IPV OPV MMR HB Var

This guide is designed to help providers of childhood vaccinations decide what
common symptoms and conditions should be considered contraindications to
vaccination and which ones should not. It covers all of the routine pre-adolescent
childhood vaccinations (DTP/DTaP, MMR, hepatitis B, Hib, OPV, IPV, and varicella).

Following is a checklist of events in a patient's medical history that are contraindications

to or precautions for childhood vaccines.

The rest of the guide, beginning on page 1, is arranged alphabetically according to

symptoms and conditions that are often considered contraindications to vaccina­
tion. The first column states the symptom or condition. The second column lists
individual vaccines when recommendations differ by vaccine; and the third column
states whether or not vaccination of a child with that symptom or condition is
recommended. Footnotes describe exceptions and special situations.

When assessing a child with multiple symptoms, consider all of the symptoms, and
if anyone of them is a contraindication, do not vaccinate.

DTP/DTaP Hib IPV OPV MMR HB Var

The Guide to Contraindications to Childhood Vaccinations was developed by the

National Immunization Program, Centers for Disease Control and Prevention, using
information derived from the Standards for Pediatric Immunization Practices,
recommendations of the Advisory Committee on Immunization Practices (ACIP),
and those of the Committee on Infectious Diseases (Red Book Committee) of the
American Academy of Pediatrics (AAP). Some of these recommendations may
differ from those stated in manufacturers' package inserts.

For more details, consult the published recommendations of the ACIP, the AAP,
and the American Academy of Family Physicians (AAFP), and manufacturers'
package inserts.

DTP/DTaP Hib IPV OPV MMR HB Var

Use the following checklist when reviewing a child's history for contraindications to
any of the childhood vaccines.

Check for Reason Page

Anaphylactic allergy to
baker's yeast Contraindicates HB 1
gelatin Contraindicates Varicella & MMR 1
neomycin Contraindicates MMR, IPV & Varicella 1
streptomycin Contraindicates IPV 2
Anaphylactic reaction to previous dose of
any vaccine Contraindicates that vaccine 2
Encephalopathy within 7 days of previous
dose of DTP Contraindicates DTP/DTaP 19

DTP/DTaP Hib IPV OPV MMR HB Var

Check for Reason Page

Any of these conditions after previous dose of Precaution for DTP/DTaP 18-20
DTP or DTaP:
• Fever of .?40.5° C (105° F) within 48 hours
• Collapse or shocklike state within 48 hours
• Convulsions (seizures) within 3 days
• Persistent, inconsolable crying lasting

~3 hours within 48 hours

• Guillain-Barre syndrome (GBS) within 6 weeks

HIV (in recipient) Contraindicates OPV & Varicella 8
HIV (in household contact) Contraindicates OPV 8
Immune globulin (I G) administration, recent Precaution for MMR & Varicella 9
Immunodeficiency (family history or household contact) Contraindicates OPV 12
Immunodeficiency (in recipient) Contraindicates MMR, OPV & Varicella 13
Neurologic disorder, underlying Precaution for DTP/DTaP 14
Thrombocytopenic purpura (history) Precaution for MMR 22

DTP/DTaP Hib IPV OPV MMR HB Var

 Symptom or Condition Vaccine(s) Vaccinate?
Allergies

to baker's yeast (anaphylactic) HB No

All others
Yes
to duck meat or duck feathers All
Yes
to eggs All
Yes
to gelatin (anaphylactic) Varicella See Note 1
MMR See Note 1
All others Yes
to neomycin (anaphylactic) MMR No
IPV No
Varicella No
All others Yes
Note 1: In vaccinating persons with a history of an anaphylactic reaction to gelatin or gelatin-containing products with MMR or
its component vaccines, or with varicella vaccine, extreme caution should be exercised. Before administering these vaccines to
such persons, skin testing for sensitivity to gelatin can be considered. However, no specific protocols for this purpose have
been published.
 Symptom or Condition Vaccine(s) Vaccinate?
Allergies (continued)

to penicillin All Yes

to streptomycin (anaphylactic) IPV No

All others Yes

nonspecific or nonanaphylactic All Yes

in relatives All Yes

Anaphylactic (life-threatening) reaction to All No

previous dose of vaccine See Note 2

Antimicrobial therapy (current) All Yes

Note 2: Contraindicates vaccination only with vaccine to which reaction occurred. (Also, see "Allergies,"
pages 1 and 2.)
 Symptom or Condition Vaccine('s) Vaccinate?
Convalescing from illness All Yes

Convulsions (fits, seizures), family history All Yes

(including epilepsy) See Note 3

Convulsions (fits, seizures) within 3 days of DTP/DTaP See Note 4

previous dose of DTP or DTaP All others Yes

Note 3: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours to
children who have a personal or a family history of convulsions. (If an underlying neurologic disorder is
involved, also see page 14.)

Note 4: Not a contraindication, but a precaution. Consider carefully the benefits and risks of this vaccine
under these circumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the
benefits are believed to outweigh the risks (for example, during an outbreak or foreign travel), give the
vaccine. (If convulsions are accompanied by encephalopathy, also see page 19. If an underlying neuro­
logic disorder is involved, also see page 14.)
 Symptom or Condition Vaccine(s) Vaccinate?
Diarrhea

mild (with or without low-grade fever) All Yes

moderate to severe (with or without fever) All No

 Symptom or Condition Vaccine(s) Vaccinate?
Fever

low-grade fever with or without mild illness All Yes

fever with moderate-to-severe illness All See Note 5

Note 5: Children with moderate or severe febrile illnesses can be vaccinated as soon as they are
recovering and no longer acutely ill.
 Symptom or Condition Vaccine(s) Vaccinate?
HIV infection

in household contact OPV No

All others Yes

in recipient (asymptomatic) OPV No

Varicella No
MMR See Note 6
All others Yes

in recipient (symptomatic) OPV No

Varicella No
MMR See Note 7
All others Yes
Note 6: MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not have
evidence of severe immunosuppression* for whom measles vaccination would otherwise be indicated.

Note 7: MMR vaccination should be considered for all symptomatic HIV-infected persons who do not have
evidence of severe immunosuppression* or of measles immunity.
"For definition of severe immunosuppression, see 1997 AAP "Red Book," Table 3.22, p. 282.
 Symptom or Condition Vaccine(s) Vaccinate?
IG administration (intramuscular or intravenous), recent MMR See Note 8
or simultaneous (see suggested intervals on next page) Varicella See Note 9
All others Yes

Note 8: Do not give immune globulin products and MMR simultaneously. If unavoidable, give at different
sites and revaccinate or test for seroconversion in 3 months. If MMR is given first, do not give IG for 2
weeks. If IG is given first, the interval between IG and measles vaccination depends on the product, the
dose, and the indication. (See page 10.)

Note 9: Do not give varicella vaccine for at least 5 months after administration of blood (except washed red
blood cells) or after plasma transfusions, IG, or VZIG. Do not give IG or VZIG for 3 weeks after vaccination
unless the benefits exceed those of the vaccination. In such instances, either revaccinate 5 months later or
test for immunity 6 months later and revaccinate if seronegative.
 Months before
measles vaccination
TIG for tetanus prophylaxis 3
IG for hepatitis A contact prophylaxis or foreign travel 3
HBIG for hepatitis B prophylaxis 3
HRIG for rabies prophylaxis 4
VZIG for varicella prophylaxis 5
IG for measles prophylaxis (normal contact) 5
IG for measles prophylaxis (immunocompromised contact) 6
Blood transfusion (red blood cells [RBCs], washed) 0
Blood transfusion (RBCs, adenine-saline added) 3
Blood transfusion (packed RBCs [Hct 65%]) 6
Blood transfusion (whole blood [Hct 35% - 50%]) 6
Blood transfusion (plasma/platelet products) 7
Cytomegalovirus prophylaxis (CMV IGIV) 6
Replacement therapy for humoral immune deficiencies (given as IGIV) 8
Respiratory syncytial virus prophylaxis (RSV IGIV) 9
Treatment of immune thrombocytopenic purpura (400 mg/kg IV) 8
Treatment of immune thrombocytopenic purpura (1000 mg/kg IV) 10
Kawasaki disease 11
(For guidelines, see J Pediatr 1993; 122:204-11.) Also, see General Recommendations on Immunization: Advisory
Committee on Immunization Practices, Jan. 18, 1994, for a more detailed version of this table.
 Symptom or Condition Vaccine(s) Vaccinate?
Illness

mild acute (with or without low-grade fever) All Yes

moderate-to-severe acute (with or without fever) All No

chronic All See Note 10

Note 10: The great majority of children with chronic illnesses should be appropriately vaccinated. The
decision whether or not to vaccinate these children, and what vaccines to give, should be made on an
individual basis.
 Symptom or Condition Vaccine(s) Vaccinate?
Imm unodeficiency*

family history OPV See Note 11

Varicella See Note 11
All others Yes

in household contact OPV No

All others Yes

* See "HIV infection" (page 8); recommendations differ slightly for that condition.

Note 11: Do not give OPV or varicella vaccine to a member of a household with a family history of immuno­
deficiency until the immune status of the recipient and other children in the family is documented.
 Symptom or Condition Vaccine(s) Vaccinate?
Immunodeficiency (continued)

in recipient (hematologic and solid tumors, congenital OPV No

immunodeficiency, long-term immunosuppressive MMR No
therapy, including steroids) Varicella No
See Note 12
All others Yes

Note 12: A protocol exists for use of varicella vaccine in patients with acute lymphoblastic leukemia (ALL).
See Varicella Prevention: Recommendations of the Advisory Committee on Immunization Practices.
 Symptom or Condition Vaccine(s) Vaccinate?
Neurologic disorders, underlying (including seizure disor­ DTP/DTaP See Note 13
ders, cerebral palsy, and developmental delay) All others Yes

Note 13: Whether and when to administer DTP or DTa P to children with proven or suspected underlying
neurologic disorders should be decided individually. Generally, infants and children with stable neurologic
conditions, including well-controlled seizures, may be vaccinated.

u.
 Symptom or Condition Vaccine(s) Vaccinate?
Otitis media

mild (with or without low-grade fever) All Yes

moderate to severe (with or without fever) All No

resolving All Yes
 Symptom or Condition Vaccine(s) Vaccinate?
Pregnancy, mother or household contact All Yes
of recipient

Prematurity All Yes

See Notes 14
and 15

Note 14: The appropriate age for initiating vaccinations in the prematurely born infant is the usual
chronologie age (same dosage and indications as for normal, full-term infants).

Note 15: For hepatitis B vaccine, if the mother is antigen-positive, use the vaccine schedule in which the
first dose is given at birth.
 Symptom or Condition Vaccine(s) Vaccinate?
Reactions to a previous dose of any vaccine

anaphylactic (life-threatening) All No

See Note 16

local (mild-to-moderate soreness, redness,

All Yes
swelling)

Note 16: Contraindicates vaccination only with vaccine to which reaction occurred. If tetanus toxoid is
contraindicated for a child who has not completed a primary series of tetanus toxoid immunization and
that child has a wound that is neither clean nor minor, give only passive vaccination, using tetanus im­
mune globulin (TIG).
 Symptom or Condition Vaccine(s) Vaccinate?
Reactions to a previous dose of DTP/DTaP

collapse or shocklike state within 48 hours of dose DTP/DTaP See Note 17

persistent, inconsolable crying lasting for 3 or more

hours, occurring within 48 hours of dose DTP/DTaP See Note 17

Note 17: Not a contraindication, but consider carefully the benefits and risks of this vaccine under these
circumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the benefits are
believed to outweigh the risks (for example, during an outbreak or foreign travel), give the vaccine.
 Symptom or Condition Vaccine(s) Vaccinate?
Reactions to a previous dose of DTP/DTaP (continued)

encephalopathy* within 7 days after dose DTP/DTaP No

family history of any adverse event after a dose DTP/DTaP Yes

See Note 18

fever of <40.5 0 C (105 0 F) within 48 hours after a dose DTP/DTaP Yes

See Note 18

* An acute, severe central nervous system disorder, generally consisting of major alterations in conscious­
ness, unresponsiveness, or generalized or focal seizures that persist more than a few hours, with failure
to recover within 24 hours.

Note 18: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours to
children who have a personal or a family history of convulsions.
 Symptom or Condition Vaccine(s) Vaccinate?
Reactions to a previous dose of DTP/DTaP (continued)

fever of >40.5° C (105° F) within 48 hours after a dose DTP/DTaP See Notes
19 and 20

Guillain-Barre syndrome (GBS) within 6 weeks after a DTP/DTaP See Note 21

dose

seizures within 3 days after a dose DTP/DTaP See Notes

19 and 20

Note 19: Not a contraindication, but consider carefully the benefits and risks of this vaccine under these
circumstances. If the risks are believed to outweigh the benefits, withhold the vaccination; if the benefits are
believed to outweigh the risks (for example, during an outbreak or foreign travel), give the vaccine.

Note 20: Consider giving acetaminophen before DTP or DTaP and every 4 hours thereafter for 24 hours.

Note 21: The decision to give additional doses of DTP/DTaP should be based on consideration of the ben­
efit of further vaccination vs. the risk of recurrence of GBS. For example, completion of the primary series in
children is justified.
 Symptom or Condition Vaccine(s) Vaccinate?
Simultaneous administration of vaccines All Yes
See Note 22

Sudden infant death syndrome (SIDS), family history All Yes

Note 22: There is a theoretical risk that the administration of multiple live virus vaccines (OPV, MMR, and
varicella) within 30 days of one another if not given on the same day will result in a suboptimal immune
response. There are no data to substantiate this with current vaccines.

-'­
 Symptom or Condition Vaccine(s) Vaccinate?
Thrombocytopenia MMR See Note 23
All others Yes

Thrombocytopenic purpura (history) MMR See Note 23

All others Yes

Note 23: Consider the benefits of immunity to measles, mumps, and rubella vs. the risk of recurrence or
exacerbation of thrombocytopenia after vaccination, or risk from natural infections of measles or rubella. In
most instances, the benefits of vaccination will be much greater than the potential risks and will justify giving
MMR, particularly in view of the even greater risk of thrombocytopenia following measles or rubella disease.
However, if a prior episode of thrombocytopenia occurred near the time of vaccination, it might be prudent
to avoid a subsequent dose.
 Symptom or Condition Vaccine(s) Vaccinate?
Tuberculin skin testing, performed simultaneously with MMR See Note 24
vaccination Varicella See Note 24
All others Yes

Tuberculosis (T8) or positive PPD All Yes

Note 24: Measles vaccination may temporarily suppress tuberculin reactivity. MMR vaccine may be given
after, or on the same day as, TB testing. If MMR has been given recently, postpone the TB test until 4 - 6
weeks after administration of MMR. If giving MMR simultaneously with tuberculin skin test, use the Mantoux
test, not multiple puncture tests, because the latter, if results are positive, require confirmation (and confir­
mation would then have to be postponed 4 - 6 weeks).

While no data are available on the effect of varicella vaccination on tuberculin reactivity, it is prudent to
apply the same precautions when using varicella vaccine.
Unvaccinated household contact* OPV Yes
See Note 25
All others Yes

* Parent or other household contact who has not been vaccinated with a vaccine the child is receiving.

Note 25: If the parent or other adult household contact of a child receiving OPV has never received polio
vaccine, this person should consider being vaccinated with IPV before or at the same time as the child.
Vaccination of the child should not be delayed.
 Symptom or Condition Vaccine(s) Vaccinate?
Vomiting

mild (with or without low-grade fever) All Yes

moderate to severe (with or without fever) All No

NOTE: Vomiting and OPV

Infants sometimes do not swallow OPV. If, in the judgment of the vaccinator, a substantial
amount of the vaccine is spit out or vomited within 5 - 10 minutes after administration, another
dose can be given at the same visit. If this repeat dose is not retained, neither dose should be
counted, and the vaccine should be readministered at the next visit.