Special Considerations in Immunization Practices: A Refresher for the New Year

Column Author:   Yvonne M Carter, MSN, APRN II, FNP-C | Nurse Practitioner, Division of Hematology/Oncology/BMT      

Column Editor: Angela Myers, MD, MPH | Pediatric Infectious Diseases; Division Director, Infectious Diseases; Medical Director, Center for Wellbeing; Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

What precautions should be taken when immunizing a patient with a bleeding disorder? Should vaccines be held in a child with respiratory symptoms? When is a vaccine truly contraindicated? The start of a new year provides a valuable opportunity to revisit the Advisory Committee on Immunization Practices (ACIP) best practice guidelines for vaccination practices, including valid instances when deferring vaccination is necessary—and commonly misperceived instances when it is not. The comprehensive list of ACIP’s contraindications and precautions for commonly used vaccines, along with conditions often incorrectly perceived as contraindications or precautions, can be found here.¹

To review: Prior to receiving any vaccine, patients should be screened for contraindications and precautions. Per the ACIP, a contraindication is a condition in which a vaccine should not be administered. Many contraindications are temporary, allowing vaccination to take place once this condition has expired. However, providers should be cautious about the presence of conditions that may increase the risk for serious adverse reaction to a vaccine, cause diagnostic confusion, or compromise the ability of the vaccine to produce immunity. While vaccinations should be deferred when such conditions exist, they may be indicated if the benefit of protection from the vaccine outweighs the risk for adverse reaction.¹ Here we will focus on two scenarios that may have historically given providers pause when it comes to immunizations, along with guidance for each.^1,2

When it comes to patients with bleeding disorders, providers may be hesitant to administer immunizations in the form of intramuscular injections due to the risk for hematoma formation. However, the Medical and Safety Advisory Council (MASAC) for the National Bleeding Disorders Foundation (NBDF) agrees that patients with bleeding disorders should continue to follow Centers for Disease Control and Prevention (CDC) vaccine recommendations and schedule for their age.³ Recent ACIP guidelines state that a vaccine can be administered intramuscularly if it is deemed safe by the physician most familiar with the patient’s bleeding risk. If the patient is receiving antihemophilic factor, an intramuscular vaccine can be scheduled shortly after such therapy is administered. Details on timing of administration depend on diagnosis.³ For all bleeding disorder patients, and presumably those receiving anticoagulation therapy (due to similar risk), the following precautions can be taken:

• Use of a fine-gauge needle (23-gauge or smaller caliber)
• Firm pressure applied to the injection site for at least two minutes—without rubbing
• Education on risk of hematoma development at the injection site, and anticipatory guidance regarding when to contact a provider for signs such as fever, redness and warmth
• Directions to avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) for fever and/or pain relief following vaccination, due to potential risk of bleeding^2,3

The most recent ACIP best practice guidelines also include recommendations to vaccinate during hospitalization if a patient is not acutely moderately to severely ill.¹ Although providers should be cautious about vaccination in the presence of an acute moderate to severe illness (with or without fever), they should take into account the severity of symptoms and etiology of the patient’s condition before making decisions to delay or administer vaccination. In most instances, persons with moderate or severe acute illness may be vaccinated as soon as the acute illness has abated. In many cases, hospitalizations can actually serve as opportunities to provide recommendations for vaccinations in patients. While many health care facilities may be accustomed to offering influenza vaccines to hospitalized patients during flu season, other routine vaccinations may be recommended to patients as well, provided they have been screened for any contraindications.¹

In outpatient practices, there was once a common misunderstanding that any cough or cold should result in deferred vaccination, which would often occur during winter months due to respiratory virus season. However, studies have shown that failure to vaccinate children due to minor illnesses can hinder vaccination efforts. Providers should take any and every opportunity to administer developmentally appropriate vaccines, including vaccinating a patient who is taking antibiotics, as antibacterial agents have no effect on non-live vaccines. With the exception of live oral Ty21a typhoid vaccine and BCG vaccines, antibiotics also have no effect on live, attenuated vaccines.² Other special considerations related to the concurrent administration of antimicrobial agents and vaccines can be found on the CDC website.

Whether in patients with bleeding disorders or other special populations, extra precautions can be taken to minimize risk when administering routine vaccinations. In 2024, as in years prior, we as health care providers can continue to weigh risk vs. benefit when making clinical decisions such as when to vaccinate our pediatric patients. We can also be sure to take advantage of every opportunity to ensure that patients and their families are provided with proper protection against common illnesses. The ACIP guidelines remain available to practitioners caring for all age groups.

References:

1. Contraindications and precautions: general best practices guidelines for immunization. Centers for Disease Control and Prevention. Updated August 1, 2023. Accessed January 11, 2024. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html
2. Special situations: general best practice guidelines for immunization. Centers for Disease Control and Prevention. Last reviewed June 20, 2023. Accessed January 11, 2024. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html
3. MASAC Recommendations on Administration of Vaccines to Individuals with Bleeding Disorders. National Bleeding Disorders Foundation. Published May 2, 2023. Accessed January 12, 2024. https://www.hemophilia.org/healthcare-professionals/guidelines-on-care/masac-documents/masac-document-278-masac-recommendations-on-administration-of-vaccines-to-individuals-with-bleeding-disorders