Proquad (Pf) (measles, mumps, rubella, and varicella vaccine live/PF)

Single-antigen varicella virus vaccine live (Varivax(R)) is administered in 0.5-mL doses.

When the single-antigen varicella vaccine (Varivax(R)) is administered within 30 minutes following reconstitution as specified, each 0.5-mL dose contains at least 1350 plaque-forming units (PFU) of Oka/Merck varicella virus.

Fixed-combination vaccines containing measles, mumps, and rubella vaccine live (MMR) are administered by IM injection or subcutaneous injection depending on the preparation. There are currently 2 preparations of the MMR vaccine in the US (M-M-R(R) II and Priorix(R)). A fixed-combination vaccine preparation containing measles, mumps, rubella, and varicella vaccine live (ProQuad(R)) is also commercially available for use when such vaccines are indicated in children 12 months through 12 years of age; consult the prescribing information for ProQuad(R) for additional details.

MMR vaccines are supplied as single-dose vials of lyophilized antigen component that must be reconstituted with the accompanying sterile diluent (supplied in a vial or prefilled syringe) prior to administration. If the diluent is supplied in a vial, withdraw the entire volume of diluent from the vial and inject into the lyophilized vaccine vial. If the diluent is supplied as a prefilled syringe, transfer the entire contents of the prefilled syringe into the vial containing the lyophilized antigen component. A single dose of MMR vaccine after reconstitution is approximately 0.5 mL. See the manufacturer's prescribing information for additional details on preparation of individual vaccine preparations. After reconstitution, withdraw and administer the entire volume immediately.

Varicella virus vaccine live (Varivax(R)) is administered by subcutaneous or IM injection.

A fixed-combination vaccine preparation containing measles, mumps, rubella, and varicella vaccine (ProQuad(R)) is also commercially available for use when such vaccines are indicated in children 12 months through 12 years of age; consult the prescribing information for ProQuad(R) for additional details.

Varicella virus vaccine live (Varivax(R)) is supplied as a single-dose vial of lyophilized vaccine that must be reconstituted with the accompanying sterile diluent (supplied in a vial or prefilled syringe) prior to administration. If the diluent is supplied in a vial, withdraw the entire volume of diluent from the vial and slowly inject into the lyophilized vaccine vial; gently agitate to dissolve completely. If the diluent is supplied as a prefilled syringe, reconstitute the vaccine by slowly injecting the entire contents of the prefilled syringe into the lyophilized vaccine vial; gently agitate to dissolve completely. A single dose of varicella virus vaccine live is approximately 0.5 mL. See the manufacturer's prescribing information for additional details on preparation of individual vaccine preparations. After reconstitution, withdraw and administer the entire volume immediately after reconstitution; discard if not used within 30 minutes after reconstitution..

Store the lyophilized vaccine component of varicella virus vaccine live between -50degreesC and -15degreesC prior to use. Before reconstitution, the lyophilized vaccine component may be stored at 2-8degreesC for up to 72 continuous hours; protect from light.

Varicella vaccine may be given simultaneously with other age appropriate vaccines. When multiple vaccines are administered during a single health-care visit, each vaccine should be given with a different syringe and at different injection sites. Injection sites should be separated by at least 1 inch, if possible. If multiple vaccines must be given into a single limb, the deltoid may be used in older children and adults, but the anterolateral thigh is preferred in infants and younger children.

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Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

Live Vaccines/Bevacizumab

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Systemic bevacizumab suppresses the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency. Intravitreal injections of small doses of bevacizumab for macular degeneration or macular edema are not expected to suppress immune function.

PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) Intravitreal injections of small doses of bevacizumab for macular degeneration or macular edema are not expected to suppress immune function. For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)

Live Vaccines/Rebisufligene Etisparvovec

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Rebisufligene etisparvovec therapy may suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained.(1) The vaccine may result in illness.(1,2)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of rebisufligene etisparvovec states that vaccines should be avoided 30 days prior to rebisufligene etisparvovec administration.(1)

DISCUSSION: Rebisufligene etisparvovec therapy may pose a risk for vaccine-derived infections and decrease the effectiveness of vaccines.(1)

Live Vaccines/Vusolimogene Oderparepvec

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: The interaction potential of live virus vaccines with vusolimogene oderparepvec is unknown.

CLINICAL EFFECTS: Concurrent administration of live vaccines with vusolimogene oderparepvec may alter the effectiveness or toxicities of either agent.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The manufacturer of vusolimogene oderparepvec states that vaccines containing live attenuated viruses should be avoided during vusolimogene oderparepvec therapy.(2) Patients should be advised that their cancer gene therapy may be delayed due to administration of vaccines.(3)

DISCUSSION: The concomitant use of live attenuated vaccines and vusolimogene oderparepvec has not been evaluated. The manufacturer's recommendation is based on vaccine guidance used in clinical trials.(2)

Live Vaccines; Live Bcg/Selected Immunosuppressive Agents

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: A variety of disease modifying agents suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(2)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1) Patients who receive anti-B cell therapies should not receive live vaccines for at least 6 months after such therapies due to a prolonged duration of immunosuppression. An exception is the Zoster vaccine, which can be given at least 1 month after receipt of anti-B cell therapies.(1) The US manufacturer of abatacept states live vaccines should not be given during or for up to 3 months after discontinuation of abatacept.(2) The US manufacturer of live BCG for intravesicular treatment of bladder cancer states use is contraindicated in immunosuppressed patients.(3) The US manufacturer of daclizumab states live vaccines are not recommended during and for up to 4 months after discontinuation of treatment.(4) The US manufacturer of guselkumab states that live vaccines should be avoided during treatment with guselkumab.(5) The US manufacturer of inebilizumab-cdon states that live vaccines are not recommended during treatment and after discontinuation until B-cell repletion. Administer all live vaccinations at least 4 weeks prior to initiation of inebilizumab-cdon.(6) The US manufacturer of ocrelizumab states that live vaccines are not recommended during treatment and until B-cell repletion occurs after discontinuation of therapy. Administer all live vaccines at least 4 weeks prior to initiation of ocrelizumab.(7) The US manufacturer of ozanimod states that live vaccines should be avoided during and for up to 3 months after discontinuation of ozanimod.(8) The US manufacturer of siponimod states that live vaccines are not recommended during treatment and for up to 4 weeks after discontinuation of treatment.(9) The US manufacturer of ustekinumab states BCG vaccines should not be given in the year prior to, during, or the year after ustekinumab therapy.(10) The US manufacturer of satralizumab-mwge states that live vaccines are not recommended during treatment and should be administered at least four weeks prior to initiation of satralizumab-mwge.(11) The US manufacturer of ublituximab-xiiy states that live vaccines are not recommended during treatment and until B-cell recovery. Live vaccines should be administered at least 4 weeks prior to initiation of ublituximab-xiiy.(12) The US manufacturer of etrasimod states that live vaccines should be avoided during and for 5 weeks after treatment. Live vaccines should be administered at least 4 weeks prior to initiation of etrasimod.(13) The US manufacturer of emapalumab-lzsg states that live vaccines should not be administered to patients receiving emapalumab-lzsg and for at least 4 weeks after the last dose of emapalumab-lzsg. The safety of immunization with live vaccines during or following emapalumab-lzsg therapy has not been studied.(14) The US manufacturer of sibeprenlimab-szsi states live vaccines should not be given within 30 days prior to initiation or during treatment with sibeprenlimab-szsi.(15)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)

Selected Live Viral Vaccines/Selected Immunoglobulins

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Immune globulin(IG) products may prevent the immune system from properly responding to the vaccine.(1-19)

CLINICAL EFFECTS: Administration of selected live viral vaccines after immunoglobulins may impair the efficacy of the vaccine.(1-19) Administration of immunoglobulins within 2-4 weeks after selected live viral vaccines impair the efficacy of the vaccine.(1-4,15)

PREDISPOSING FACTORS: The amount of antigen-specific antibody present in the administered immunoglobulin product determines the duration of this interaction.(15)

PATIENT MANAGEMENT: The recommendations regarding this interaction are conflicting. The Centers for Disease Control and Prevention(CDC) immunization recommendations for spacing of live vaccines and antibody-containing products include the following(15): - Live attenuated influenza vaccine, rotavirus, zoster and Ty21a typhoid vaccines may be given any time before, concurrent, with, or after administration of any immune globulin. Yellow fever vaccine may also be given in areas where donor blood products are unlikely to contain a substantial quantity of yellow fever antibody. - Administration of measles or varicella containing vaccines should be postponed for the following intervals after immunoglobulin therapy: Hepatitis B IG, Tetanus IG - 3 months Rabies IG - 4 months Varicella IG - 5 months Measles prophylaxis IG - 6 months if nonimmunocompromised Botulinum IG Intravenous, CMV IG Intravenous, Hepatitis A IG - 6 months Intravenous Immune Globulin(IVIG) - 8 to 11 months depending upon the dose Monoclonal antibody to RSV F protein (palivizumab) - none - Administration of antibody-containing products should be delayed 2 weeks after administration of live vaccines, except for influenza, rotavirus, zoster and typhoid vaccines as noted above. CDC guidelines state that in circumstances where there is high-risk of vaccine-preventable disease, it is acceptable to administer a dose of vaccine prior to completion of these intervals.(16) Manufacturer recommendations are as follows: Administration of a live viral vaccine should be postponed for at least three months in patients who have received the following immunoglobulin therapy: anthrax immunoglobulin,(19) cytomegalovirus immunoglobulin,(1) hepatitis B immunoglobulin,(5,6) rabies immunoglobulin,(7) tetanus immunoglobulin,(8-11) vaccinia immunoglobulin,(18) and zoster immunoglobulin.(2) Administration of a live viral vaccine should be postponed for at least six months in patients who have received the following immunoglobulin therapy: botulinum neurotoxin a/b immune globulin.(17) The US manufacturer of human immunoglobulin states that live viral vaccines should be postponed for three months in patients who have received human immunoglobulin. The Australian and Canadian manufacturers of human immunoglobulin advise postponing live viral vaccines for 3-6 months in patients who have received human immunoglobulin.(6,12,13,18) The UK manufacturer states that vaccines may be compromised for one year and vaccines should be postponed in children for at least seven months.(14) The US manufacturer of immune globulin-hyaluronidase states that immune response to live attenuated vaccines may be impaired for up to 6 months, or for a year or more in the case of measles vaccine.(15) Cytomegalovirus immunoglobulin(1) or human immunoglobulin(3) should not be administered to patients who have received a live vaccine in the previous two weeks. If a live viral vaccine is given within two weeks of zoster immunoglobulin,(1) repetition of the vaccination three months after the completion of immunoglobulin should be considered.

DISCUSSION: CDC Immunization Recommendations(15)provide discussion, charts, and further details regarding appropriate use and timing of vaccine therapy.(16)

Vaccines/Pariglasgene Brecaparvovec

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Pariglasgene brecaparvovec therapy may decrease the effectiveness of vaccines. The mechanism is not known.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of pariglasgene brecaparvovec states that vaccines should be avoided for 1 month prior to pariglasgene brecaparvovec administration.(1)

DISCUSSION: Pariglasgene brecaparvovec therapy may decrease the effectiveness of vaccines.(1)

Varicella; Zoster Live Vaccine/Famciclo; Val; Acyclovir

SEVERITY LEVEL: 1-Contraindicated Drug Combination: This drug combination is contraindicated and generally should not be dispensed or administered to the same patient.

MECHANISM OF ACTION: Acyclovir, famciclovir, and valacyclovir inhibit varicella zoster virus activity and may prevent the body from developing an immune response to the live vaccine.

CLINICAL EFFECTS: Administration of antiviral agents active against varicella zoster virus may decrease the efficacy of live, attenuated varicella or zoster vaccines.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: CDC immunization guidelines recommend acyclovir, famciclovir or valacyclovir discontinuation at least 24 hours prior to administration of varicella or zoster vaccines, if possible. Delay use or resumption of antiviral therapy for 14 days after vaccination.(1)

DISCUSSION: Acyclovir, famciclovir, valacyclovir inhibit varicella zoster virus activity and may prevent the body from developing an immune response to the live vaccine, decreasing the efficacy of efficacy of live, attenuated varicella or zoster vaccines.(1)

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Live Vaccines/Brensocatib

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Brensocatib may suppress the immune system by inhibiting dipeptidyl peptidase-1 (DPP-1). Brensocatib prevents the activation of neutrophil serine proteases (NSPs) during neutrophil maturation in the bone marrow.(1) Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(2)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained. The vaccine may result in illness. Immune response to live vaccines may be decreased during periods of immunocompromise.(2)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: The coadministration of live vaccines and brensocatib should be avoided.(1) The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live-attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(2)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(2) The concomitant use of live attenuated vaccines and brensocatib has not been evaluated. Brensocatib may suppress the immune system by inhibiting dipeptidyl peptidase-1 (DPP-1).(1)

Live Vaccines/Leniolisib

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Leniolisib modifies the immune system. Immune response to live vaccines may be decreased during treatment with leniolisib.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained.(1)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: The manufacturer of leniolisib states live, attenuated vaccinations may be less effective if administered during leniolisib treatment.(1)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)

Live Vaccines/Live Vaccines

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: The immune response to an injectable or nasally administered live vaccine may be impaired if it is administered within 28 days of another injectable or nasally administered live vaccine.(1)

CLINICAL EFFECTS: Non-simultaneous administration (i.e. given on different days) of an injectable or nasally administered live vaccine to an individual who has received another injectable or nasally administered live vaccine in the previous 28 days may result in the second vaccine being ineffective.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The CDC states that multiple injectable or nasal live vaccines (e.g. MMR and varicella) may be administered on the same day. However, injectable or nasally administered live vaccines not administered on the same day should be administered at least 4 weeks apart whenever possible. If injectable or nasal live vaccines are administered less than 4 weeks apart and not on the same day, the vaccine administered second should be considered invalid and be repeated at least 4 weeks after the last, invalid dose.(1)

DISCUSSION: The immune response to a live vaccine may be impaired if it is administered within 28 days of another live vaccine. In a study, patients who received varicella vaccine less than 28 days after MMR vaccination had an increased risk for varicella vaccine failure (i.e., varicella disease in a vaccinated person) of 2.5-fold compared with those who received varicella vaccine before or more than 28 days after MMR.(1)

Live Vaccines/Methotrexate (Low Strength Injection, Oral)

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: A variety of disease modifying agents such as methotrexate suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines. Immune response to vaccines may be decreased during periods of immunocompromise.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: The Centers for Disease Control(CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) CDC recommendations for zoster vaccine state it may be administered to patients receiving methotrexate if the dose is < or = to 0.4 mg/kg/week for treatment of rheumatoid arthritis, psoriasis, inflammatory bowel disease or other conditions.(1) For patients scheduled to receive chemotherapy, vaccination should ideally precede the initiation of chemotherapy by 14 days. Patients vaccinated while on immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated at least 3 months after discontinuation of therapy.(1)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(1)

Live Vaccines/Systemic Corticosteroids; Corticotropin (Acth)

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Corticosteroids and corticotropin suppress the immune system. In severely immunocompromised patients, virus replication after administration of live, attenuated-virus vaccines can be enhanced and/or the immune response to the vaccine may be decreased.(1)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(1)

PREDISPOSING FACTORS: Patients receiving immunosuppressive doses of corticosteroids or corticotropin for equal to or greater than 14 consecutive days.(1)

PATIENT MANAGEMENT: The Centers for Disease Control's (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are severely immunosuppressed, including those who are receiving or have received high-dose, systemic steroids for greater than or equal to 14 consecutive days. Live vaccines should be deferred for at least 1 month after discontinuation of high-dose systemic steroids administered for 14 consecutive days. When initiating immunosuppressives doses of corticosteroids, wait 4 weeks after a live vaccines is administered. However, if patients require therapy for chronic inflammatory conditions, do not delay therapy due to past vaccines. Patients who are vaccinated within the 14 days prior to initiating immunosuppressive therapy should be considered unvaccinated and should be revaccinated at least 3 months after immunosuppressive therapy is discontinued.(1) The US manufacturer of corticotropin(2) and triamcinolone(3) and the Australian manufacturer of dexamethasone(4) state that administration of live or live-attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids or corticotropin. The manufacturer of deflazacort states that live or live-attenuated vaccines should be administered at least 4 to 6 weeks prior to initiation of therapy with deflazacort.(5)

DISCUSSION: Many clinicians consider a dose equivalent to either 2 mg/kg of body weight or a total of 20 mg/day of prednisone as sufficiently immunosuppressive to raise safety concerns about live-virus vaccines.(1) Immunization procedures may be undertaken in patients receiving corticosteroids when the therapy is short term (less than 2 weeks); low to moderate dose; long-term, alternate-day treatment with short-acting preparations; maintenance physiologic doses (replacement therapy); or administered topically (skin or eyes), by aerosol, or by intra-articular, bursal, or tendon injection.(1) Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)

Live Vaccines/Tuberculin Testing

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Measles infection and severe acute and chronic infections may induce an anergic state resulting in a false-negative tuberculin test. The live measles vaccine, as well as other live vaccines (e.g. smallpox, varicella, yellow fever) theoretically may also suppress response to tuberculin testing, though the degree of suppression may be less than that expected from acute infection with wild-type virus.(1-4)

CLINICAL EFFECTS: Tuberculin testing that is performed more than one day but less than 28 days after administration of a live vaccine may result in a false negative tuberculin response. Tuberculin testing may be administered simultaneously with live vaccines.(1-4)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The CDC states that live vaccines (e.g. MMR and varicella) and tuberculin testing may be administered within one day of each other at separate administration sites. If it has been more than one day since tuberculin testing has been administered, the live vaccine can be given at any interval after the tuberculin test. However, if the live vaccine has been administered more than one day previously and tuberculin testing is indicated, tuberculin testing should be deferred for at least 4-6 weeks.(1-4)

DISCUSSION: Suppression of response to tuberculin testing has been observed following measles infection, live measles vaccination, and live smallpox vaccination. The degree of suppression after live virus vaccination is likely to be less than that from an acute infection with wild-type virus. There is no data on suppression of response to tuberculin testing with other live vaccines. In the absence of data, the CDC recommends tuberculin testing within one day that a live vaccine is administered. Otherwise the tuberculin test should be deferred for at least 4-6 weeks.(1-4)

Live Vaccines; Live Bcg/Hydroxyurea

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Hydroxyurea may suppress the immune system.(1) Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(2)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained and/or the vaccine may result in illness.(2) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(3)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies), treatments (e.g. radiation) and cytotoxic drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: Recommendations for administration of live vaccines in patients on hydroxyurea are dependent on the indication. The US manufacturers of hydroxyurea recommend avoiding live vaccine use in patients taking hydroxyurea. Evaluate hematologic status prior to and during treatment with hydroxyurea. Provide supportive care and modify the dose or discontinue hydroxyurea as needed.(1) The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live, attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician. Patients who are vaccinated within the 14 days prior to initiating immunosuppressive therapy should be considered unvaccinated and should be revaccinated at least 3 months after immunosuppressive therapy is discontinued.(2) The ACIP recommendations state that routine vaccinations patients with secondary immunodeficiency such as sickle cell disease are likely effective. Live viral and bacterial vaccines are contraindicated in patients with generalized malignant neoplasm, immunosuppressive, or radiation therapy, depending on immune status.(4)

DISCUSSION: Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(2) Patients with a history of leukemia who are in remission and have not received chemotherapy for at least 3 months are not considered to be immunocompromised.(2) A multicenter, randomized, double-blind, placebo-controlled trial in infants and young children with sickle cell disease (BABY HUG) studied the response to pneumococcal and measles, mumps, and rubella vaccines in patients using hydroxyurea. The authors concluded that hydroxyurea does not appear to have significant deleterious effects on the immune function of infants and children with sickle cell disease. Additional assessments of lymphocyte parameters of hydroxyurea-treated children may be warranted. No changes in current immunization schedules are recommended; however, for endemic disease or epidemics, adherence to accelerated immunization schedules for the measles, mumps, and rubella vaccine should be reinforced.(5)

Live Vaccines; Live Bcg/Teplizumab

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Teplizumab may cause lymphopenia and suppress the immune system. Immunocompromised patients may be at increased risk for uninhibited replication after administration of live, attenuated vaccines or intravesicular BCG. Immune response to vaccines may be decreased during periods of immunocompromise.(1,2)

CLINICAL EFFECTS: The expected serum antibody response may not be obtained. The vaccine may result in illness.(1,2) After instillation of intravesicular BCG, immunosuppression may interfere with local immune response, or increase the severity of mycobacterial infection following inadvertent systemic exposure.(3)

PREDISPOSING FACTORS: Immunosuppressive diseases (e.g. hematologic malignancies, HIV disease), treatments (e.g. radiation) and drugs may all increase the magnitude of immunodeficiency.

PATIENT MANAGEMENT: The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) states that live-virus and live-attenuated vaccines should not be administered to patients who are immunocompromised. The magnitude of immunocompromise and associated risks should be determined by a physician.(1) Vaccination should ideally precede the initiation of teplizumab therapy by 8 weeks. Live vaccines are not recommended within the 8 weeks prior to, during, or for 52 weeks after stopping teplizumab therapy.(2)

DISCUSSION: Vaccinations may be less effective if administered within 8 weeks before, during, and for 52 weeks following teplizumab therapy.(2) Killed or inactivated vaccines do not pose a danger to immunocompromised patients.(1)

Varicella Virus Vaccine Live/Salicylates

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Use of salicylates during natural varicella infection has been associated with Reye's Syndrome.(1-4)

CLINICAL EFFECTS: Use of the live varicella virus vaccine in patients receiving salicylate therapy or use of salicylates within 6 weeks after vaccination with the live varicella virus vaccine may increase the risk of Reye's Syndrome.(1-4) Symptoms of Reye's syndrome include drowsiness, confusion, seizures, coma. In severe cases, Reye's syndrome can result in death.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The Canadian, UK, and US manufacturers of live varicella virus vaccine indicated for the prevention of chicken pox state that vaccine recipients should avoid the use of salicylates for 6 weeks after vaccination.(1-4) There is no such restriction in the labeling for live varicella virus vaccine indicated for the prevention of shingles, which is only indicated for patients age 60 and older.(5)

DISCUSSION: Because the use of salicylates during natural varicella infection has been associated with Reye's Syndrome, the use of salicylates for 6 weeks following vaccination with live varicella virus vaccine should be avoided.(1-4)

Moderate Interaction: Assess the risk to the patient and take action as needed.

Rubella Vaccine/Rho Immunoglobulin

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Immune globulin products may prevent the immune system from properly responding to the vaccine.(1-6)

CLINICAL EFFECTS: Administration of live rubella vaccine after immunoglobulins may impair the efficacy of the vaccine.(1-6) Administration of immunoglobulins within 2-4 weeks after a live viral vaccine impair the efficacy of the vaccine.(1-6)

PREDISPOSING FACTORS: The amount of antigen-specific antibody present in the administered immunoglobulin product determines the duration of the interaction.(7)

PATIENT MANAGEMENT: Due to the importance of rubella immunity in women of child-bearing age, and the low dose of anti-Rho immunoglobulin administered, postpartum vaccination of rubella-susceptible women with rubella or MMR should not be delayed.(7) CDC recommendations state the low dose of anti-Rho globulin administered to postpartum women has not been demonstrated to reduce the response to the RA27/3 strain of rubella vaccine.(7) Vaccination should be performed immediately after delivery. If possible, test for immune response to rubella and measles three or more months after vaccination and repeat the vaccine if necessary.(6,7) Administration of live rubella vaccine should be postponed for 3 to 11 months in patients who have received other types of immunoglobulin therapy.(1-7) If live rubella vaccine is given and administration of an immune globulin becomes necessary within 14 days, vaccination should be repeated unless serologic testing indicates a protective antibody response.(7)

DISCUSSION: CDC Immunization Recommendations(7) provide discussions, charts, and further details regarding appropriate use and timing of vaccine therapy.

Vaccines/Hepatitis B Vaccine (Fendrix)

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: No data is available on the concurrent administration of the hepatitis B vaccine Fendrix and other vaccines.(1)

CLINICAL EFFECTS: It is unknown if concurrent administration of the hepatitis B vaccine Fendrix and other vaccines will affect the efficacy of either vaccine.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The Swedish manufacturer of Fendrix states that since there is no data available for the concurrent administration of Fendrix with other vaccines, the administration of Fendrix and other vaccines should be separated by 2 to 3 weeks.(1)

DISCUSSION: No data is available on the concurrent administration of the hepatitis B vaccine Fendrix with other vaccines.(1)

*Individuals with a history of hypersensitivity to any component of the MMR vaccine (including gelatin) or after a previous dose of any measles, mumps, and rubella virus-containing vaccine.

*Individuals with a history of anaphylaxis to neomycin.

*Individuals who are immunodeficient or immunosuppressed due to disease or medical therapy. Disseminated measles, mumps, and rubella virus infection have been reported in such individuals.

*Individuals with an active febrile illness with fever (>38.5degreesC).

*Individuals with active untreated tuberculosis.

*Individuals who are pregnant or who are planning on becoming pregnant within the next month.

*History of severe allergic reaction to any component of the varicella virus live vaccine (including neomycin and gelatin) or to a previous dose of varicella vaccine.

*Immunosuppression.

*Moderate or severe febrile illness (>38.5degreesC).

*Active untreated tuberculosis.

*Individuals who are pregnant or who are planning on becoming pregnant within the next 3 months.

• Dysgammaglobulinemia
• HIV infection
• Hypogammaglobulinemia
• Immunosuppression
• Leukemia
• Malignant lymphoma
• Malignant neoplasm of bone marrow
• Pregnancy
• Primary immune deficiency disorder
• Secondary malignant neoplasm of bone marrow
• Secondary malignant neoplasm of lymph nodes
• Untreated active tuberculosis

• Cerebral trauma
• Febrile convulsions
• Seizure disorder

• High fever >101 degrees fahrenheit
• Thrombocytopenic disorder

Common adverse effects reported in individuals receiving M-M-R(R) II: injection site reactions (erythema, pain, and swelling), fever.

Common adverse effects reported in individuals 12 through 15 months of age receiving Priorix(R): local reactions including pain and redness, and systemic reactions including irritability, loss of appetite, drowsiness, and fever.

Common adverse effects reported in individuals 4 through 6 years of age receiving Priorix(R): local reactions including pain, redness, and swelling, and systemic reactions including loss of appetite, drowsiness, and fever.

Common adverse effects reported in individuals 7 years of age and older receiving Priorix(R): local reactions including pain and redness.

Common adverse effects reported in individuals 1-12 years of age receiving Varivax(R) included fever >=38.9degreesC (oral) and injection site complaints.

Common adverse effects reported in individuals >=13 years of age receiving Varivax(R) included fever >=37.8degreesC (oral) and injection site complaints.

Common adverse effects reported in all individuals receiving Varivax(R) included varicella-like rash at the injection site and generalized varicella-like rash.

More Frequent

• High fever >101 degrees fahrenheit

Less Frequent

• Optic neuritis

Rare or Very Rare

• Acute retinal necrosis
• Anaphylaxis
• Angioedema
• Aplastic anemia
• Bell's palsy
• Bronchospastic pulmonary disease
• Encephalitis
• Epididymitis
• Erythema multiforme
• Facial edema
• Febrile convulsions
• Guillain-barre syndrome
• Hearing disorder
• Herpes zoster
• IgA vasculitis
• Influenza
• Interstitial pneumonitis
• Myelitis
• Neuroretinitis
• Non-infective meningitis
• Orchitis
• Pneumonia
• Polyneuropathy
• Pulmonary congestion
• Seizure disorder
• Stevens-johnson syndrome
• Thrombocytopenic disorder

More Frequent

• Erythema
• Fever
• Injection site sequelae
• Irritability
• Lymphadenopathy
• Skin rash

Less Frequent

• Acute abdominal pain
• Arthralgia
• Arthritis
• Cough
• Diarrhea
• Ecchymosis
• Headache disorder
• Rhinorrhea
• Sore throat
• Upper respiratory infection
• Vomiting

Rare or Very Rare

• Agitation
• Ataxia
• Dizziness
• Earache
• Epistaxis
• Eyelid edema
• Flatulence
• Hypersomnia
• Induration of skin
• Myalgia
• Nervousness
• Paresthesia
• Parotitis
• Peripheral neuropathy
• Pruritus of skin
• Stomatitis
• Tremor
• Wheezing

No enhanced messaging available.

Measles, mumps, and rubella virus vaccine live is not approved for use in individuals less than 12 months of age; however, the vaccine has been used for postexposure prophylaxis and outbreak control in infants as young as 6 months of age+. Safety and efficacy of MMR in infants younger than 6 months of age have not been established.

Safety and efficacy of varicella virus vaccine live (Varivax(R)) in pediatric patients younger than 12 months of age have not been established.

MMR and MMRV vaccines are contraindicated in pregnant women; infection during pregnancy with the wild-type viruses has been associated with adverse maternal and fetal outcomes such as spontaneous abortion, stillbirth, premature delivery, and congenital defects. In pregnant women with no evidence of immunity to rubella, ACIP recommends that a dose of MMR be administered after pregnancy, but before discharge from the healthcare facility.

Varicella virus vaccine live is contraindicated in pregnant women; infection during pregnancy with the wild-type varicella virus has been associated with adverse outcomes, including congenital varicella syndrome.

It is not known whether measles, mumps, or varicella vaccine virus is secreted in human milk. Studies have shown that lactating postpartum women vaccinated with live attenuated rubella vaccine may secrete the virus in breast milk and transmit it to breast-fed infants. In breastfed infants with serological evidence of rubella virus vaccine strain antibodies, none exhibited severe disease; however, one infant exhibited mild clinical illness typical of acquired rubella.

ACIP states that it is safe for breastfeeding women to receive MMR vaccination. Breastfeeding does not interfere with the response to MMR vaccine and the nursing infant will not be affected by vaccine present in breastmilk.

The developmental and health benefits of breastfeeding should be considered along with the mother's clinical need for these vaccines, and any potential adverse effects on the breastfed child from the vaccine or from the underlying maternal condition. For preventive vaccines, the underlying maternal condition is susceptibility to disease prevented by the vaccine.

It is not known whether varicella virus vaccine live is secreted in human milk. Consider the developmental and health benefits of breast-feeding along with the mother's clinical need for the varicella virus vaccine live and any potential adverse effects on the breast-fed child from the vaccine or from susceptibility to varicella.

The manufacturers make no specific dosage recommendations for geriatric patients.

The manufacturer makes no specific dosage recommendations for geriatric patients.

Clinical studies of MMR did not include sufficient numbers of individuals 65 years of age or older to determine whether these individuals respond differently than younger individuals.

Clinical studies of varicella virus vaccine live did not include sufficient numbers of seronegative adults 65 years of age and older to determine whether geriatric adults respond differently than younger individuals.