Active and Passive Immunization

A polio vaccine worker visits a mother and child in Pakistan.

Image from: UNICEF. "Polio vaccination campaigns resume in Pakistan and Afghanistan after COVID-19 disruptions leave 50 million children unimmunized." August 11, 2020. Accessed June 28, 2023. https://www.unicef.org/pakistan/press-releases/polio-vaccination-campaigns-resume-pakistan-and-afghanistan-after-covid-19

1. Which live-virus vaccines are contraindicated for household members living with an immunocompromised contact?

Answer below.

Oral polio vaccine (OPV) and live attenuated influenza vaccine (LAIV) are contraindicated. Specifically, LAIV is contraindicated in caregivers of immunocompromised persons requiring a protected environment.

MMR, varicella, MMRV, Zostavax, rotavirus, oral typhoid vaccine, and yellow fever vaccines are all safe for household members with immunocompromised contacts. It is simply recommended that members of the household should wash their hands after changing the diaper of an infant who received rotavirus vaccine, as shedding of the virus can last up to 1 month after the last dose. I would add that you should wash your hands after changing anybody's diaper, regardless of their immunization history.

Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP: Contraindications and Precuations. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html Page last Reviewed Oct 18, 2022. Page accessed June 12, 2023.

American Academy of Pediatrics. Poliovirus Infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 601-607

Jackson BR, Iqbal S, Mahon B. Updated Recommendations for the Use of Typhoid Vaccine — Advisory Committee on Immunization Practices, United States, 2015. MMWR Morb Mortal Wkly Rep 2015;64:305-308

2. What dosage and duration of systemic steroids is considered a contraindication for live-virus vaccination?

Answer below.

The ACIP recommends that MMR and varicella vaccination is contraindicated in those receiving ≥2 weeks of daily receipt of 20 mg or 2 mg/kg body weight of prednisone or equivalent.

3. How long after discontinuation of high-dose steroids does an individual need to wait before receiving live-virus vaccines like varicella and MMR?

Answer below.

The recommended interval between stopping high-dose corticosteroids and live-virus immunizations is at least 4 weeks/1 month.

American Academy of Pediatrics. Immunization in Special Clinical Circumstances. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 67-105

4. How many donors are used when creating immune globulin preparations (like IGIV and IGIM)?

Answer below.

1,000-60,000.

American Academy of Pediatrics. Passive Immunization. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 54-67

5. How long before initiating immune suppression, biologic response-modifying drugs, solid organ transplantation, conditioning for hematopoietic stem cell transplantation, or starting chemotherapy should an individual receive live and inactivated vaccines?

Answer below.

Inactivated vaccines should be given at least 2 weeks prior; live vaccines should be given at least 4 weeks prior.

6. If a child requires administration of an immune globulin preparation (like IGIV or IGIM) after receiving measles- or varicella-containing vaccine, what is the time interval between these events that would necessitate repeating the vaccines later?

Answer below.

14 days

Centers for Disease Control and Prevention. CDC Yellow Book 2024: Vaccination and Immunoprophylaxis--General Principles. https://wwwnc.cdc.gov/travel/yellowbook/2024/preparing/vaccination-and-immunoprophylaxis-general-principles Page last Reviewed May 1, 2023. Page accessed June 12, 2023.

7. Which patients with selective immunoglobulin deficiency may suffer anaphylaxis with IGIV administration?

Answer below.

Patients with IgA deficiency. Very rarely, some individuals with CVID can develop IgE antibodies to IgA. Overall, such reactions are extremely rare and routine screening for such is not recommended.

8. Which adjuvant can rarely cause sterile abscesses in certain susceptible individuals at the site of inactived vaccine administration?

Answer below.

Aluminum salts, like alum (potassium aluminum sulfate), or aluminum hydroxide. These are not technically contraindications against future vaccination with products containing aluminum salts, unless they are especially severe

American Academy of Pediatrics. Active Immunization. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 13-54

9. Which vaccines are produced in chicken eggs?

Answer below.

Influenza, MMR, Rabies, and Yellow Fever. Of note, influenza and MMR vaccines are very well tolerated by individuals with egg allergies. Yellow fever vaccine contains larger amounts of egg protein with fewer reports of administration to individuals with egg allergy. It is recommended that individuals with egg protein allergy who need to receive the yellow fever vaccine may benefit from an allergist's consultation.

Cox JE. Egg-based vaccines. Pediatr Rev. 2006 Mar;27(3):118-9. doi: 10.1542/pir.27-3-118.

10. Name all of the live and attenuated vaccines licensed in the United States (Hint: there are 12).

Answer below.

Live:

Oral adenovirus vaccine (used primarily in the military; covers types 4 and 7)

Live attenuated:

ACAM2000 smallpox vaccine

Bacille Calmette Guerin (BCG) vaccine
Dengue vaccine
Ebola vector vaccine
Live attenuated influenza vaccine (LAIV)
Live oral typhoid vaccine (Ty21a)
Measles-mumps-rubella – containing (MMR, MMRV)
Oral cholera vaccine
Rotavirus vaccines (RV1, RV5)
Varicella (Var) vaccine

Yellow Fever vaccine

Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP: Timing and Spacing of Immunobiologics. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html Page last Reviewed April 7, 2023. Page accessed June 12, 2023.

11. As a general principle, if live virus vaccines are not going to be administered simultaneously and instead will be given on different days, how far apart should they be spaced?

Answer below.

Live virus vaccines should be given at least 28 days apart whenever possible. It is believed if they are given in closer spacing the immunogenicity of either vaccine may be compromised. This restriction does not apply to the intranasal live attenuated influenza vaccine, nor does it apply to live oral vaccines.

12. What should be done if an infant regurgitates or spits out a dose of rotavirus vaccine?

Answer below.

The dose should not be readministered and the remaining doses should be given following the routine schedule.

American Academy of Pediatrics. Rotavirus. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 644-648

13. How should rotavirus vaccine be given to infants exposed or infected with HIV?

Answer below.

Rotavirus vaccine should be given according to schedule irrespective of HIV viral load or CD4 percentage or count.

14. What is the risk of embryopathy or congenital disease for fetuses of pregnant women inadvertently subjected to MMR or varicella-containing vaccines?

Answer below.

These live-attenuated vaccines pose a theoretical risk to the fetus and are contraindicated in pregnancy. However, no cases of emrbyopathy due to rubella in the MMR vaccine has ever been reported. There is also a small, theoretical risk for congenital varicella that cannot be completely ruled out, but surveillance suggests there is no increased risk.

15. Under what circumstances can children and adolescents with HIV receive live MMR, varicella, or MMRV vaccines?

Answer below.

In order to receive the MMR and varicella vaccines, they must be clinically stable and asymptomatic, and for those 1-13 years of age, CD4+ T-lymphocyte percentage must be ≥15%, and for the those ≥14 years of age, the CD4+ T-lymphocyte count must be ≥200 lymphocytes/mm3.

MMRV is not recommended due to a lack of safety data for this population.

16. What is the minimum age for live oral typhoid (Ty21a) vaccine? What about the polysaccharide (ViCPS) IM vaccine?

Answer below.

6 years old for the live oral vaccine; 2 years old for the polysaccharide IM vaccine.

American Academy of Pediatrics. Salmonella Infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 655-663

17. What is the recommended booster frequency for live oral typhoid (Ty21a) vaccine? What about the polysaccharide (ViCPS) IM vaccine?

Answer below.

Every 5 years for the live oral vaccine (although efficacy for 7 years after immunization has been demonstrated); every 2 years for the polysaccharide IM vaccine.

18. Which children are at highest risk of complications from a vaccinia-based live-virus vaccine, like ACAM2000? What are the complications?

Answer below.

Immunocompromised children and children with atopic skin disease. They could be at risk for progressive vaccinia and eczema vaccinatum.

American Academy of Pediatrics. Smallpox (Variola). In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 672-675

19. Name some adverse effects of measles vaccination.

Answer below.

Body temperature >39.4 C, transient rash, febrile seizure, transient thrombocytopenia.

American Academy of Pediatrics. Measles. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 503-519

20. How long should PPD/Interferon gamma testing be delayed following measles immunization?

Answer below.

4-6 weeks. Measles immunization temporarily suppresses tuberculin skin test reactivity. Reportedly the effect of measles vaccination on interferon gamma release assay characteristics are yet to be determined, so the same recommendation applies.

21. How effective is one dose of mumps vaccine? Two doses?

Answer below.

78%. 88%.

American Academy of Pediatrics. Mumps. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2018Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2018: 570

22. How long can Hepatitis B antigen be detected after a hepatitis B vaccine?

Answer below.

As early as 24 hours following vaccine administration, and as long as 3 weeks following administration.

American Academy of Pediatrics. Hepatitis B. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 381-399

23. What is the preferred postexposure prophylaxis method in non-immune, healthy individuals (12 months through 40 years) exposed to Hepatitis A??

Answer below.

Hepatitis A vaccine should be given, as long as they are healthy and present within 2 weeks of exposure.

American Academy of Pediatrics. Hepatitis A. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 373-381

24. What is the preferred postexposure prophylaxis method in non-immune individuals younger than 12 months exposed to Hepatitis A??

Answer below.

IGIM, as long they present within 2 weeks of exposure.

25. What is the preferred postexposure prophylaxis method in non-immune individuals older than 40 years exposed to Hepatitis A??

Answer below.

Hepatitis A vaccine should be given, and IGIM may be considered, as long they present within 2 weeks of exposure.

26. Name the mild and severe adverse reactions of IGIV administration.

Answer below.

Mild: fever, headache, chills, nausea, vomiting. About 25% of patients will experience one of these, and for the most part they seem to be related to the rate of infusion.

Severe: anaphylactoid reactions, thrombosis, isoimmune hemolysis, renal insufficiency and failure, aseptic meningitis, noncardiogenic pulmonary edema, transfusion-related acute lung injury.

27. Preterm infants in the NICU can receive all vaccines normally indicated at 2 months of chronologic age except _________.

Answer below.

Oral rotavirus vaccine, which is deferred until discharge to avoid theoretical nosocomial spread.

Centers for Disease Control and Prevention. Vaccine Recommendations and Guidelines of the ACIP: Special Situations. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html Page last Reviewed July 12, 2022. Page accessed June 13, 2023.

28. What are the severe adverse events reported with yellow fever vaccine?

Answer below.

Viscerotropic disease (multiple organ system failure); neurologic disease (postvaccinal encephalitis); Guillan-Barre Syndrome; meningoencephalitis; acute disseminated encephalomyelitis; bulbar palsy. Also infants exposed to breastfeeding mothers who have received the vaccine have had reports of meningoencephalitis.

Staples JE, Gershman M, Fischer M. Yellow Fever Vaccine: Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2010;59:1-27

29. Name the US-approved live-attenuated bacterial vaccines.

Answer below.

Bacille Calmette Guerin (BCG) vaccine
Live oral typhoid vaccine (Ty21a)
Oral cholera vaccine

30. How should an individual who needs both oral cholera vaccine and oral typhoid vaccine receive these immunizations?

Answer below.

When both vaccines are administered, the oral cholera vaccine should be given first, at least 8 hours before the first dose of oral typhoid. The reason is as follows: "The expert opinion of the ACIP work group postulated that CVD 103-HgR buffer might interfere with the enteric-coated Ty21a formulation and concluded that taking the first Ty21a dose ≥8 hours after ingestion of CVD 103-HgR might decrease potential interference of the vaccine buffer with the Ty21a vaccine."

Collins JP, Ryan ET, Wong KK, et al. Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022. MMWR Recomm Rep 2022;71(No. RR-2):1–8.

31. Who is the oral cholera vaccine recommended for?

Answer below.

Individuals 2-64 years of age travelling to cholera-affected regions. "CVD 103-HgR is a single-dose, live attenuated oral cholera vaccine derived from V. cholerae O1. In June 2016, FDA approved CVD 103-HgR for the prevention of cholera caused by V. cholerae O1 in adults aged 18–64 years traveling to cholera-affected areas. In December 2020, FDA extended the approved usage to include children and adolescents aged 2–17 years (3). CVD 103-HgR is the only cholera vaccine licensed for use in the United States."

Collins JP, Ryan ET, Wong KK, et al. Cholera Vaccine: Recommendations of the Advisory Committee on Immunization Practices, 2022. MMWR Recomm Rep 2022;71(No. RR-2):1–8.

32. What percentages of children develop serum measles antibodies after vaccination (by age)?

Answer below.

95% with immunization at 12 months of age. 98% of children immunized at 15 months of age. More than 99% of people who receive 2 doses separated by at least 28 days with the first dose on or after the first birthday develop serologic evidence of immunity.

33. Why shouldn't the MenACWY-D (Menactra) vaccine be used routinely before 2 years of age?

Answer below.

It may interfere with the immune response to pneumococcal conjugate vaccine.

American Academy of Pediatrics. Meningococcal Infections. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 519-532

34. What is the minimum age requirement for yellow fever vaccine?

Answer below.

Infants 9 months and older living in or traveling to endemic regions are recommended to receive the vaccine. Infants younger than 6 months should not be immunized with the yellow fever vaccine due to an increased risk of vaccine-associated encephalitis. Those between 6 and 9 months must have a risks-versus-benefits discussion regarding the utility of vaccination.

American Academy of Pediatrics. Arboviruses. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 202-209

35. Which vaccine can suppress tuberculin reactivity for 4-6 weeks?

Answer below.

Measles immunization temporarily suppresses tuberculin skin test reactivity. Reportedly the effect of measles vaccination on interferon gamma release assay characteristics are yet to be determined, so the same recommendation applies.

36. Which vaccine is most frequently or classically associated with whole limb swelling?

Answer below.

DTaP, Td, DTP.

Woo EJ, Burwen DR, Gatumu SN, Ball R; Vaccine Adverse Event Reporting System Working Group. Extensive limb swelling after immunization: reports to the Vaccine Adverse Event Reporting System. Clin Infect Dis. 2003 Aug 1;37(3):351-8.

37. In order to receive the Dengvaxia vaccine, what must you have laboratory evidence of?

Answer below.

Serologic proof of prior Dengue infection.

Paz-Bailey G, Adams L, Wong JM, et al. Dengue Vaccine: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021. MMWR Recomm Rep 2021;70(No. RR-6):1–16.

38. What should be used if TIG is not available to treat clinical tetanus?

Answer below.

IGIV--although the quantity of antitetanus antibody could be different in any given lot.

American Academy of Pediatrics. Tetanus. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 750-755

39. What prophylaxis is indicated for a fully-immunized child with nonoccupational exposure (such as a needlestick, sexual assault, or bite) to a Hepatitis B positive source?

Answer below.

The child should undergo a hepatitis B booster dose.

40. Boosters from which vaccine may cause a serum sickness-like reaction in 6% of recipients, thought to be due to sensitization to human albumin?

Answer below.

Rabies.

American Academy of Pediatrics. Rabies. In: Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH, eds. Red Book: 2021 Report of the Committee on Infectious Diseases. Itasca, IL: American Academy of Pediatrics. 2021: 619-627