Yes. All adolescents should receive one dose of Tdap vaccine to protect them from pertussis, even if they have already received Td. It is important to do this right away (no minimal interval is required), especially if they are in contact with an infant younger than age 12 months, work in a healthcare setting where they have direct contact with patients, or live in a community where pertussis is occurring.
Last reviewed:
March 31, 2022
If you cannot verify a healthcare employee’s history of chickenpox, the employee should receive 2 doses of varicella vaccine at least 4 weeks apart. For details, refer to pages 16 and 26 of the CDC recommendations Prevention of Varicella at www.cdc.gov/mmwr/pdf/rr/rr5604.pdf.
Last reviewed:
May 16, 2023
A dose of MMR vaccine administered up to 4 days before the first birthday may be counted as valid. However, school entry requirements in some states may mandate administration on or after the first birthday. The 4-day “grace period” also may be applied to the 28-day minimum interval between two doses of MMR if the interval is inadvertently shorter than 28 days, although you should never plan to administer the second dose earlier than the 28-day minimum interval. This 4-day “grace period” does not apply to the strict 28-day minimum interval between two different live vaccines (e.g., MMR and varicella vaccines), if not administered at the same visit.
Last reviewed:
June 19, 2023
Screening should be done with the hepatitis B surface antigen (HBsAg) test only. This blood test will tell whether a mother has current HBV infection that can be transmitted to the infant. Ordering a total antibody to hepatitis B core antigen (total anti-HBc) and/or anti-HBs are not useful when screening to prevent perinatal HBV infections and should not be included in screening during pregnancy for risk of perinatal HBV infection. Total anti-HBc will be positive in all HBsAg-positive people and anti-HBs is rarely positive in an HBsAg-positive person. Pregnant people who are found to be positive should be tested for HBV DNA to guide the use of maternal antiviral therapy during pregnancy for the prevention of perinatal HPV transmission (see MMWR 2018;67 [RR-1]:13).
An infant born to a mother for whom HBsAg screening test results during pregnancy are not available but other evidence suggesting maternal HBV infection exists (e.g., presence of HBV DNA, HBeAg-positive, or mother known to be chronically infected with HBV) should be managed as if born to an HBsAg-positive mother. The infant should receive both HepB and HBIG within 12 hours of birth. The mother should also be referred to their jurisdiction’s Perinatal Hepatitis B Prevention Program for case management to ensure that the infant receives timely prophylaxis and follow-up.
Last reviewed:
July 21, 2023
Although not at increased risk for hepatitis A virus (HAV) infection, people with chronic liver disease are at increased risk for fulminant hepatitis A, hospitalization, and death if they become infected with HAV. For this reason, HepA vaccination is recommended for them.
Last reviewed:
June 25, 2023
No. If there is no longer a CSF leak, neither vaccine is recommended, unless there is another risk factor for invasive pneumococcal disease or an age-based indication.
Last reviewed:
April 5, 2024
They need just one dose of any appropriate influenza vaccine annually.
Last reviewed:
September 10, 2023
You should use separate alcohol wipes to clean the vial top and the patient’s skin.
Last reviewed:
December 28, 2022
Inactivated vaccines can be administered to people who take immunosuppressive drugs or who have a condition that causes them to be immunocompromised. The vaccines might not be as effective as they would be when given to a person with an intact immune system. If possible, the immunosuppressive drug should be discontinued for a month prior to vaccination, then allow the vaccine 2–3 weeks to generate an immune response before restarting the immunosuppressive treatment, but obviously, this is not always possible.
Determination of altered immunocompetence is important because incidence or severity of some vaccine-preventable diseases is greater in people with altered immunocompetence. As a result, certain vaccines (e.g., inactivated influenza vaccine and pneumococcal vaccines) are recommended specifically for people with altered immunocompetence.
More information can be found in ACIP’s “General Best Practices Guidelines for Immunization” available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
Last reviewed:
August 29, 2022
Valacyclovir, acyclovir, and famciclovir are antiviral medications that are active against herpesviruses, including varicella zoster virus. The risk of shingles risk is reduced during antiviral treatment. Since Shingrix is not a live virus vaccine, Shingrix may be administered while patients are taking antiviral medications if indicated.
A patient who is taking a prophylactic antiviral for a fixed period of time while their immune system recovers from HCT, should ideally initiate vaccination with Shingrix about 2 months prior to discontinuation of antiviral therapy.
Regardless of the duration of antiviral therapy after HCT, CDC recommends that autologous HCT recipients wait at least 3 months after transplant before initiating Shingrix vaccination. Allogenic HCT recipients should wait at least 6 months after transplantation. For additional details on timing after HCT, see www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#clinical-guidance.
Last reviewed:
March 9, 2022
Twinrix is licensed as a 3-dose series for people age 18 years and older (minimum interval between dose 1 and dose 2 is 4 weeks; minimum interval between dose 2 and dose 3 is 5 months). It is also approved for use in an accelerated 4-dose schedule in adults, with doses given at 0, 7, and 21-30 days, followed by a booster dose at 12 months. There is no accelerated schedule for single antigen HepA or HepB vaccines, so the recommendations below presume the use of the Twinrix 3-dose routine schedule, with a minimum interval between dose 1 and dose 2 of 4 weeks.
If Twinrix is not available or if you choose not to use Twinrix to complete the hepatitis A (HepA) and hepatitis B (HepB) series, you should do the following:
- If 1 dose of Twinrix was given, complete the series with 2 adult doses of HepA and 2 adult doses of HepB.
- If 2 doses of Twinrix were given, complete the schedule with 1 adult dose of HepA and 1 adult dose of HepB.
Another way to consider this is as follows:
- A dose of Twinrix contains a standard adult dose of HepB and a pediatric dose of HepA. So, a dose of Twinrix can be substituted for any dose of the HepB series but not for any dose of the HepA series.
- Any combination of 3 doses of adult HepB or 3 doses of Twinrix is a complete series of HepB vaccine
- One dose of Twinrix and 2 doses of adult HepA is a complete series of HepA
- Two doses of Twinrix and 1 dose of adult HepA is a complete series of HepA
Last reviewed:
June 3, 2024
Some American Indian or Alaska Native (AI/AN) children experience higher rates of severe RSV disease than the general population. A recent study found that the incidence of hospitalization due to RSV among some AI/AN children in their second year of life was four to ten times higher than that of similar-aged children in multiple study sites in the United States. Also, some AI/AN communities live in remote regions, making transportation of children with severe RSV to obtain medical care more challenging. Although the available data are limited and may not apply to all AI/AN children in all settings, ACIP recommends nirsevimab for AI/AN children entering their second RSV season.
Last reviewed:
January 22, 2024
No. Beta thalassemia minor is a hemoglobinopathy, but compared to sickle cell disease, these patients have less risk for functional asplenia, and therefore do not have a significantly increased risk of invasive pneumococcal disease.
Last reviewed:
April 5, 2024
No. You should only use the (0.4% NaCl) diluent provided with the Dengvaxia vaccine vial. Contact your immunization program or the manufacturer for additional guidance.
Last reviewed:
February 16, 2022
Yes. There is no need to observe any minimum interval between doses of Td and Tdap except when administered as part of a catch-up primary series of tetanus vaccine.
Last reviewed:
March 31, 2022
No. Documented receipt of 2 doses of varicella vaccine supersedes results of subsequent serologic testing. Most commercially available tests for varicella antibody are not sensitive enough to detect vaccine-induced antibody, which is why CDC does not recommend post-vaccination testing. For more information, see page 24 of ACIP’s Immunization of Health-Care Personnel, available at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.
Last reviewed:
May 16, 2023
Yes. COVID-19 vaccination is recommended for people who are lactating.
Last reviewed:
March 19, 2024
Yes. Mothers who have received HepB should still be screened for HBsAg early in each pregnancy. Just because a pregnant person has been vaccinated does not mean they are HBsAg negative. Since postvaccination testing is not performed for most vaccinated people, the mother could have been vaccinated when already actively infected.
Last reviewed:
July 21, 2023
In published reports of three serologic surveys conducted among United States wastewater workers and appropriate comparison populations, no substantial or consistent increase in the prevalence of anti-HAV was identified among wastewater workers. No work-related instances of hepatitis A transmission have been reported among wastewater workers in the United States. In addition, in the United States, outbreaks of hepatitis A caused by flooding, which can carry raw sewage, have not been reported.
Last reviewed:
June 25, 2023
Yes. However, if two parenteral or intranasal live vaccines (MMR, varicella, LAIV and/or yellow fever) are not administered on the same day, they should be separated by an interval of at least 28 days.
Last reviewed:
June 19, 2023
The two doses may be the same or different products.
Last reviewed:
September 10, 2023
The stopper of a single-dose vial is often assumed to be sterile. However, not all vaccine manufacturers guarantee the tops of unused vials are sterile, and the manner in which the cover over the stopper is removed can potentially contaminate the stopper. Therefore, using friction and a sterile alcohol pad to swab the stopper may help to assure aseptic technique in preparing the single-dose vial prior to inserting a sterile syringe. Alcohol evaporates quickly and will dry while the needle is being prepared for insertion into the vial.
Last reviewed:
December 28, 2022
No. Twinrix contains 50% less hepatitis A antigen component than Havrix, GSK’s monovalent HepA vaccine [720 vs. 1440 EL.U.], so the patient would not receive the recommended dose of HepA vaccine antigen.
Last reviewed:
July 15, 2023
The risk for zoster and its severe morbidity and mortality is much greater for immunosuppressed people. A 2-dose series of Shingrix should be administered as soon as possible while the person’s immune system is intact. In cases such as this, depending upon the timing of chemotherapy initiation, you may wish to consider a shorter interval of at least 4 weeks (1 month) in order to complete the series as soon as possible.
Last reviewed:
March 9, 2022
ProQuad was licensed in 2005 for use in children ages 12 months through 12 years. It combines the measles-mumps-rubella (MMR) and varicella vaccines and therefore can be used in place of the individual MMR and varicella vaccines given at ages 12–15 months and 4–6 years. For more information, consult the package insert at www.merck.com/product/usa/pi_circulars/p/proquad/proquad_pi_4171.pdf.
Last reviewed:
July 15, 2023
There is no specific indication for meningococcal vaccine in this patient. He is older than 21 years, and the risk–based recommendations are restricted to specific forms of altered immunocompetence (persistent complement component deficiency, functional or anatomic asplenia, use of complement inhibitors such as eculizumab [Soliris] or ravulizumab [Ultomiris], and HIV infection) and do not include other forms of altered immunocompetence.
Last reviewed:
March 24, 2024
Palivizumab (Synagis, AstraZeneca) is another injectable monoclonal antibody recommended by the American Academy of Pediatrics (AAP) for use in certain infants and children with underlying medical conditions that put them at high risk of severe RSV infection. It is not long-acting and must be administered once monthly, up to 5 doses, through the RSV season. The cost of palivizumab is much higher than the cost of nirsevimab. Nirsevimab should be used for children eligible for either product.
Once a single dose of nirsevimab is given for the season, palivizumab is not needed for that season. In circumstances where nirsevimab is unavailable, a high-risk infant or toddler who is also eligible for palivizumab should receive palivizumab. If palivizumab is administered initially during a season and nirsevimab becomes available before 5 monthly doses of palivizumab have been given, discontinue palivizumab and administer one dose of nirsevimab (at least a month after the most recent dose of palivizumab).
AAP recommendations for use of palivizumab and nirsevimab are found at: https://publications.aap.org/redbook/resources/25379 and https://publications.aap.org/pediatrics/article/152/1/e2023061803/192153/Palivizumab-Prophylaxis-in-Infants-and-Young.
Last reviewed:
January 22, 2024
Adults 65 years and older that received PCV13 should complete the pneumococcal series with either PCV20 or PPSV23 vaccination at least 1 year after PCV13. PCV15 is not recommended in this situation.
Last reviewed:
April 5, 2024
The earlier the evaluation is done, the better. Consultation with or referral to a liver disease specialist (such as a hepatologist, gastroenterologist, or infectious disease specialist) should be done. The consulting/referral physician should be aware of the patient’s obstetrical status. In addition, the patient’s sex partner and children or other household contacts should be tested for HBV infection (total anti-HBc and HBsAg) as soon as possible. If any are susceptible to HBV infection (total anti-HBc and HBsAg negative), they should be vaccinated. If any are HBsAg positive, they should be referred to or have consultation with a liver disease specialist.
Last reviewed:
July 21, 2023
Store both the vaccine antigen and the diluent in a refrigerator at 36°F–46°F (2°C–8°C). Do not freeze. Protect from light. After reconstitution, administer Dengvaxia immediately or store refrigerated at 36°F–46°F (2°C–8°C) and use within 30 minutes.
Do not use the vaccine if it has been reconstituted for over 30 minutes. Contact your public health immunization program or the manufacturer for advice if vaccination occurs using vaccine that has been reconstituted more than 30 minutes, or in the event of other storage or handling errors.
The manufacturer package insert contains additional information and can be found at www.fda.gov/media/124379/download.
For complete information on vaccine storage and handling best practices and recommendations, please refer to CDC’s Vaccine Storage and Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.
Last reviewed:
February 16, 2022
The recommended minimum interval between two doses of varicella vaccine for children 12 months through 12 years of age is 12 weeks. However, the second dose of varicella vaccine does not need to be repeated if records show it was separated from the first dose by at least 4 weeks. See www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html, Table 3-2.
Last reviewed:
May 16, 2023
The second dose of MMR may be given as early as 4 weeks after the first dose, and be counted as a valid dose, if both doses were given after the first birthday. The second dose is not a booster, but rather it is intended to produce immunity in the small number of people who fail to respond to the first dose. The risk of measles is higher in school-age children than those of preschool age, so it is important to receive the second dose by school entry. It is also convenient to give the second dose at this age, since the child will have an immunization visit for other school entry vaccines.
Last reviewed:
June 19, 2023
People with clotting factor disorders were originally recommended to receive hepatitis A vaccine (HepA) in 1996. At that time, the process used to make clotting factor supplements did not reliably inactivate hepatitis A viruses and recipients of these products had an increased risk of hepatitis A virus (HAV) infection. Modern blood donor screening and virus reduction steps have drastically reduced that risk. In addition, more than 80% of people with clotting factor disorders now receive recombinant clotting factor concentrates that are sterilized and have no risk of HAV transmission. As a result of these factors, people with clotting factor disorders now have no greater risk of hepatitis A than the general population and are no longer recommended to receive HepA vaccine unless it is otherwise indicated.
Last reviewed:
June 25, 2023
The child should always receive the dose appropriate for his or her age at the time of the clinic visit; at age 37 months that would be a 0.5 mL dose of Afluria Quadrivalent.
Last reviewed:
September 10, 2023
Using a pre-packaged sterile alcohol prep pad is recommended to maintain aseptic technique. Not only are cotton balls not sterile, but neither is a bottle of sterile alcohol, once it’s opened.
Last reviewed:
December 28, 2022
The IDSA guidelines indicate that persons receiving rituximab should be considered to have high-level immunosuppression. Both inactivated and live vaccines should be withheld at least 6 months following treatment with lymphocyte depleting medications such as rituximab. As for the IG, the interval to live vaccination depends on the dose. For guidance, please refer to the Timing and Spacing of Immunobiologics section of the ACIP’s “General Best Practices Guidelines for Immunization”, table 3-5: “Recommended intervals between administration of antibody-containing products and measles- or varicella-containing vaccine, by product and indication for vaccination” at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html. This interval could be as long as 11 months, depending on the dose he receives.
Last reviewed:
August 29, 2022
A person who was on immunosuppressive chemotherapy in the past but is not expected to be immunocompromised again may follow routine recommendations for shingles vaccination at age 50 years or older. If the patient is age 19 or older and expected to require repeated exposure to immunosuppressive chemotherapy in the future, then it is preferable to vaccinate now while the patient’s immune system is more robust.
Last reviewed:
March 9, 2022
Yes. Adolescents and adults who started the HPV vaccine series prior to the 15th birthday and who are not immunocompromised are considered to be adequately vaccinated with just one additional dose of HPV vaccine.
Last reviewed:
March 2, 2024
Please see CDC’s Interim Clinical Considerations for the Use of COVID-19 Vaccines for dosage guidance: www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#immunocompromised..
People who are moderately or severely immunocompromised, who have not been vaccinated against COVID-19 in the past, and who are receiving the 2023–2024 Formula Novavax COVID-19 Vaccine should receive 2 doses spaced 3 to 8 weeks apart. They may receive a third dose at least 2 months after dose 2. As with mRNA COVID-19 vaccine recipients, they may receive additional doses at the discretion of their healthcare provider, based on their individual circumstances. CDC recommends that any additional doses be administered at least 2 months after the most recent 2023–2024 Formula dose.
Immunocompromised people should be counseled that they may have a reduced immune response to COVID-19 vaccination. They should be advised to continue other recommended infection prevention measures, such as wearing a face mask and avoiding crowds, to limit their risk of exposure to the SARS-CoV-2 virus.
Last reviewed:
March 19, 2024
You should use DTaP to catch up children younger than age 7 years. In addition, ACIP recommends giving one dose of Tdap to children age 7–10 years who were not fully vaccinated against pertussis before their seventh birthday. Children age 7–10 who require more than one dose of tetanus-containing vaccine to be up to date with diphtheria or tetanus immunization may be given either Td or Tdap for doses needed after the initial Tdap dose. Although this is an off-label use of the vaccines, it’s important that you vaccinate these unvaccinated or undervaccinated older children with Tdap as well as any other adolescent or adult who hasn’t received Tdap previously.
Last reviewed:
May 30, 2024
- Infants born to mothers for whom HBsAg testing results during pregnancy are not available but other evidence suggestive of maternal HBV infection exists (for example presence of HBV DNA, HBeAg-positive, or mother known to be chronically infected with HBV) should be managed as if born to an HBsAg-positive mother.
- Mothers admitted for delivery without documentation of HBsAg test results should have blood drawn and tested as soon as possible after admission.
- While test results are pending, all infants with birth weights of 2,000 grams or more born to mothers without documentation of HBsAg test results should receive the first dose of single-antigen HepB (without HBIG) within 12 hours of birth. Only single antigen HepB vaccine should be used for the birth dose.
- If the mother is determined to be HBsAg positive, the infant should receive HBIG as soon as possible but no later than age 7 days, and the vaccine series should be completed according to a recommended schedule for infants born to HBsAg-positive mothers.
- If the mother is determined to be HBsAg negative, the vaccine series should be completed according to a recommended schedule for infants born to HBsAg-negative mothers.
Last reviewed:
July 21, 2023
Although second-hand smoke and other environmental conditions have been identified as risk factors for meningococcal disease, ACIP does not include them as indications for MenACWY vaccination. Providers may always use their clinical judgment in situations not addressed by ACIP.
Last reviewed:
March 24, 2024
If you are unable to obtain prenatal records or verify receipt of maternal RSV vaccine, CDC recommends that the baby receive nirsevimab, particularly if it is shortly before or during the RSV season. Don’t forget to check the state immunization information system (IIS) for the mother’s vaccination record. It is also important to attempt to verify from the birthing facility records whether this baby received nirsevimab prior to discharge to avoid giving a second dose.
Last reviewed:
January 22, 2024
What you describe is an excellent strategy for administration of pneumococcal vaccines to people age 65 years and older. ACIP does not define “one year” but this is assumed to be one calendar year. Receiving PPSV23 a few days or weeks earlier than one calendar year after PCV13 or PCV15 is not a medical problem. However, it could be a problem for reimbursement since Medicare will only pay for both a PCV vaccine and a PPSV23 vaccine if they are given at least 11 months apart. Private insurance may have similar rules. Here is the wording from the Centers for Medicare and Medicaid (CMS): “An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered).”
Last reviewed:
April 5, 2024
Yes. Multi-dose vials of inactivated influenza vaccine contain a small amount of thimerosal to prevent bacterial and fungal growth in the vial. Thimerosal-containing vaccines are safe to use in children. No scientific evidence indicates that thimerosal in vaccines causes adverse events unless the patient has a severe allergy to thimerosal. Despite this, a few states have enacted legislation that restricts the use of thimerosal-containing vaccines in children. To find out if your state has such restrictions, check with your state immunization program (see www.immunize.org/coordinators for contact information).
Last reviewed:
September 10, 2023
The conditions and treatments that CDC specifies may result in moderate or severe immunocompromise include but are not limited to:
- Active treatment for solid tumor and hematologic malignancies
- Hematologic malignancies associated with poor responses to COVID-19 vaccines regardless of current treatment status (e.g., chronic lymphocytic leukemia, non-Hodgkin lymphoma, multiple myeloma, acute leukemia)
- Receipt of solid-organ transplant or an islet transplant and taking immunosuppressive therapy
- Receipt of chimeric antigen receptor (CAR)-T-cell therapy or hematopoietic cell transplant (HCT) (within 2 years of transplantation or taking immunosuppressive therapy)
- Moderate or severe primary immunodeficiency (e.g., common variable immunodeficiency disease, severe combined immunodeficiency, DiGeorge syndrome, Wiskott-Aldrich syndrome)
- Advanced HIV infection (people with HIV and CD4 cell counts less than 200/mm³, history of an AIDS-defining illness without immune reconstitution, or clinical manifestations of symptomatic HIV) or untreated HIV infection
- Active treatment with high-dose corticosteroids (i.e., 20 mg or more of prednisone or equivalent per day when administered for 2 or more weeks), alkylating agents, antimetabolites, transplant-related immunosuppressive drugs, cancer chemotherapeutic agents classified as severely immunosuppressive, tumor necrosis factor (TNF) blockers, and other biologic agents that are immunosuppressive or immunomodulatory (e.g., B-cell-depleting agents)
Additional factors to consider in assessing the general level of immune competence in a patient include disease severity, duration, clinical stability, complications, comorbidities, and any potentially immune-suppressing treatment. A patient’s clinical care team is in the best position to evaluate the degree of immunocompromise and timing of vaccination.
See CDC’s interim clinical considerations for this population: www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#immunocompromised.
Last reviewed:
March 19, 2024
People who have received 2 doses of HPV vaccine separated by less than 5 months should receive a third dose 6–12 months after dose #1 and at least 12 weeks after dose #2, regardless of their age at the time of the first dose. The recommended interval for the second dose in the 2-dose schedule (indicated when the first dose is given before age 15) is 6 months and the minimum interval is 5 months.
Last reviewed:
March 2, 2024
This child needs to complete the primary series with 1 dose of Td or Tdap, administered no earlier than 6 months after the Tdap dose given at age 11 years. After that, the child needs a booster dose of Td or Tdap every 10 years. An easy way to determine how to catch up a child is to consult “Recommended Immunization Schedules for Persons Aged 0 Through 18 Years, U.S.” The schedule is approved by CDC, AAP, and AAFP and is released early in each calendar year. It includes a catch-up schedule for children who have fallen behind (see www.cdc.gov/vaccines/schedules/index.html).
Last reviewed:
March 31, 2022
Because of measles. Measles is highly communicable and poses a serious threat to the health of unvaccinated infants. For this reason, all infants age 6 through 11 months who travel internationally are recommended to receive a dose of measles, mumps, and rubella vaccine (MMR) to reduce the risk of measles infection during travel.
The antibodies in immune globulin (IG) typically used to prevent HAV infection in infants before the first birthday can interfere with the effectiveness of MMR vaccine. An infant who is given IG should not be vaccinated with MMR or varicella vaccines for at least 6 months after IG administration. If an infant age 6 through 11 months is traveling to a destination where protection from infection with HAV is desired, ACIP recommends off-label use of HepA vaccine (not IG) in addition to MMR. The HepA and MMR doses administered before the first birthday do not count toward the routine vaccination series of either vaccine: these infant travelers will still need two doses of HepA and two doses of MMR when age appropriate.
Last reviewed:
June 25, 2023
ACIP recommends that children who travel or live abroad should be vaccinated at an earlier age than that recommended for children who reside in the United States. Before their departure from the United States, children age 6 through 11 months should receive 1 dose of MMR. The risk for measles exposure can be high in high-, middle- and low-income countries. Consequently, CDC encourages all international travelers to be up to date on their immunizations regardless of their travel destination and to keep a copy of their immunization records with them as they travel. For additional information on the worldwide measles situation, and on CDC’s measles vaccination information for travelers, go to wwwnc.cdc.gov/travel.
Last reviewed:
June 19, 2023
In general the entire volume should be used even if it is a little more than 0.5 mL. Discarding the excess vaccine is not required or recommended. An exception to this is recombinant zoster vaccine (RZV; Shingrix, GSK). The RZV adjuvant solution may contain up to 0.75 mL of liquid. The entire volume of the adjuvant solution should be withdrawn and used to reconstitute the lyophilized vaccine. After mixing, withdraw the recommended dose of 0.5 mL. Any reconstituted vaccine left in the vial should be discarded.
Last reviewed:
December 28, 2022
Post-licensure studies of MMRV suggested that, during the 5–12 days after vaccination, approximately one additional febrile seizure occurred among every 2,600 children ages 12 through 23 months vaccinated with a first dose of MMRV vaccine compared with children in the same age group vaccinated with separate first doses of MMR vaccine and varicella vaccine administered during a single office visit.
For this reason, the recommendations for use of MMRV vaccine are as follows:
- The routinely recommended ages for measles, mumps, rubella, and varicella vaccination are age 12 through 15 months for the first dose and age 4 through 6 years for the second dose.
- For the first dose of measles, mumps, rubella, and varicella vaccines at age 12 through 47 months, providers may use either MMR vaccine and varicella vaccine or MMRV vaccine. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, CDC recommends that providers administer MMR vaccine and varicella vaccine for the first dose in this age group.
- For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months through 12 years) and for the first dose at age 48 months and older, use of MMRV vaccine generally is preferred, if available, over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine).
- A personal or family (e.g., sibling or parent) history of seizures of any etiology (i.e., cause) is a precaution for MMRV vaccination, and such children generally should be vaccinated with MMR vaccine and varicella vaccine.
The complete recommendations for the use of MMRV vaccine are available on CDC’s website at www.cdc.gov/mmwr/pdf/rr/rr5903.pdf.
Last reviewed:
July 15, 2023
Hepatitis C infection is not a contraindication for Shingrix vaccination. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider to discuss the clinical considerations for the timing of vaccination. Detailed guidance is available at www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#clinical-guidance.
Last reviewed:
March 9, 2022
Contraindications:
- History of a serious allergic reaction (e.g., anaphylaxis) after a previous dose of varicella vaccine or to a varicella vaccine component. For information on vaccine components, refer to the manufacturer’s package insert (www.immunize.org/fda) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf.
- Pregnancy
- Severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy [e.g., two weeks or more of daily receipt of 20 mg or more, or 2 mg/kg body weight or more, of prednisone or equivalent] or patients with HIV infection who are severely immunocompromised [a child age 1 through 5 years with CD4+ T-lymphocyte percentage less than 15% or a person age 6 years or older with a CD4+ T-lymphocyte count less than 200 cells per microliter])
- Family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents, siblings) unless the immune competence of the potential vaccine recipient has been clinically substantiated or verified by a laboratory
Precautions:
- Recent receipt (within the previous 11 months) of antibody-containing blood product (specific interval depends on product)
- Moderate or severe acute illness with or without fever (defer until recovery)
- Use of aspirin or aspirin-containing products
- Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
Precautions for combination MMRV (ProQuad, Merck) only (approved for children 1 through 12 years of age) also include: history of thrombocytopenia or thrombocytopenic purpura, a personal or family history of seizures of any etiology, and a need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing.
For additional information, see the “General Best Practice Guidelines for Immunization” section on contraindications and precautions, table 4–1 and associated footnotes, at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html.
Last reviewed:
February 19, 2024
ACIP recommends adolescents age 11 or 12 years should be routinely vaccinated with MenACWY and receive a booster dose at age 16 years. Adolescents who receive the first dose at age 13 through 15 years should receive a one-time booster dose, preferably at age 16 through 18 years, just before the peak in incidence of meningococcal disease among adolescents occurs. Teens who receive their first dose of MenACWY at or after age 16 years do not need a booster dose, as long as they have no additional risk factors.
Last reviewed:
March 24, 2024
Yes. The ACIP recommends that pregnant people at risk for hepatitis A virus (HAV) infection during pregnancy or at risk for a severe outcome from HAV infection should be vaccinated during pregnancy if not previously vaccinated. Pregnant people should be vaccinated for the same indications as non-pregnant people. For additional information, see page 20 of the recommendations: www.cdc.gov/mmwr/volumes/69/rr/pdfs/rr6905a1-H.pdf.
Last reviewed:
June 25, 2023
Yes. Infants born less than 14 days after the mother received RSV vaccine should receive nirsevimab. Infants born within 14 days after maternal vaccination may not have had sufficient time in utero to receive adequate protection from maternal RSV antibodies produced after vaccination. Infants born 14 days or more after maternal vaccination are not recommended to receive nirsevimab.
Last reviewed:
January 22, 2024
Studies have shown that administering a pneumococcal conjugate vaccine first leads to a better immune response to serotypes common to both vaccines when the polysaccharide vaccine (PPSV23) is given at a later date. For this reason, CDC recommends that pneumococcal vaccine-naive adults receive pneumococcal conjugate vaccines either alone (PCV20) or first in a sequence (PCV15 first, followed by PPSV23). A provider who stocks only PPSV23 should consider purchasing a recommended pneumococcal conjugate vaccine or referring such patients elsewhere to receive a conjugate vaccine, if feasible. A patient due for a conjugate vaccine who receives PPSV23 first may receive either the PCV15 or PCV20 vaccine at least one year later.
Last reviewed:
April 5, 2024
Yes. See all information about vaccination of immunocompromised people, including revaccination considerations after HCT and for those on B-cell depleting therapies, at www.cdc.gov/vaccines/covid-19/clinical-considerations/interim-considerations-us.html#immunocompromised. This is the most current statement from CDC on COVID-19 vaccination after HCT:
Recipients of HCT or CAR-T-cell therapy who received 1 or more doses of COVID-19 vaccine prior to or during treatment should be revaccinated. Revaccination should start at least 3 months (12 weeks) after transplant or CAR-T-cell therapy and should follow the currently recommended schedule for immunocompromised people who are unvaccinated.
A patient’s clinical team is best positioned to determine the degree of immune compromise, need for revaccination, and appropriate timing of revaccination.
Last reviewed:
March 19, 2024
Since the first DTaP was received before 12 months of age and one Tdap dose has been given, this person needs one dose of Td or Tdap 6 calendar months after the Tdap dose. A routine Td or Tdap booster should be administered every 10 years. See Immunize.org’s handout: DTaP, Tdap, and Td Catch-up Vaccination Recommendations by Prior Vaccine History and Age: www.immunize.org/catg.d/p2055.pdf.
Last reviewed:
March 31, 2022
Immunize.org has developed suggested standing orders for all vaccines commonly given to children and adults. They are based on CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations. You can find the standing orders and protocols for medical management of vaccine reactions at www.immunize.org/standing-orders.
Last reviewed:
December 28, 2022
Preterm infants weighing less than 2,000 grams (4.4 pounds) at birth have a decreased response to HepB administered before age 1 month. By age 1 month, medically stable preterm infants, regardless of initial birth weight or gestational age, have an immunologic response to HepB vaccination that is comparable to that of full-term infants. For preterm infants weighing less than 2,000 grams at birth:
- If maternal HBsAg status is positive:
- Give hepatitis B immune globulin (HBIG) plus HepB vaccine within 12 hours of birth. The birth dose (the initial HepB dose) should not be counted as part of the vaccine series.
- Give 3 additional HepB doses (for a total of 4 doses) at ages 1, 2 to 3, and 6 months, or HepB-containing combination vaccine (Pediarix or Vaxelis) at ages 2, 4, and 6 months. The final dose should not be administered before 24 weeks of age.
- Test for HBsAg and anti-HBs at age 9–12 months, or 1–2 months after the final dose of the vaccine series if completion of the series is delayed. Testing should not be performed before age 9 months (anti-HBs resulting from use of HBIG might still be positive and therefore misleading) or within 1 month of the most recent HepB dose (testing for HBsAg sooner than 1 month of a vaccine dose might produce a transient HBsAg-positivity).
- If maternal HBsAg status is unknown:
- If the mother’s HBsAg status cannot be determined within 12 hours of birth give HBIG plus HepB vaccine. The birth dose of vaccine should not be counted as part of the 3 doses required to complete the HepB series.
- Three additional doses of vaccine (for a total of 4 doses) should be administered according to the recommended schedule on the basis of the mother’s HBsAg test result. The final dose in the series should not be administered before 24 weeks of age.
- If it is not possible to determine the mother’s HBsAg status:
- The vaccine series should be completed according to a recommended schedule for infants born to HBsAg positive mothers.
- If the maternal HBsAg status is negative:
- If you are certain that appropriate maternal testing was done and a copy of the mother’s original laboratory report indicating that she was HBsAg negative during this pregnancy is placed on the infant’s chart, delay the first dose of HepB vaccine until age 1 month or hospital discharge (even if weight is still less than 2,000 grams), whichever comes first. Complete the vaccine series per the recommended schedule.
For preterm infants weighing 2,000 grams or more at birth, follow the recommendations for full-term infants including a HepB dose within 24 hours of birth.
Last reviewed:
July 21, 2023
The CDC “General Best Practice Guidelines for Immunization” section on altered immunocompetence recommends varicella vaccination of children with humoral (but not cellular) immunodeficiencies. In addition, single-antigen varicella vaccine should be considered for HIV-infected children age 1 through 5 years with CD4+ T-lymphocyte percentages greater than or equal to 15% for at least 6 months or for children age 6 years and older with CD4+ T-lymphocytes count greater than or equal to 200 cells per microliter for at least 6 months. Eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses. Additional details of these recommendations can be found in table 8-1 and associated footnotes at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
Last reviewed:
May 16, 2023
