Vaccine Education Center

Vaccines: Practical Considerations and Special Situations

Getting vaccines can sometimes be complicated by special circumstances, such as when someone in the home was born prematurely, has recently been adopted, is being treated for cancer, or is breastfeeding an infant. Further, sometimes individuals have experienced reactions following a vaccine. Each of these scenarios might lead to questions about vaccination. This page addresses these and other more practical aspects of vaccination:

Adoptees
Adults
Breastfeeding
Childcare workers
Fevers
Healthcare workers
Lessening the pain of vaccines
Living with someone with weakened immunity
Missed vaccines
Pregnancy
Premature babies
Previous severe reactions
Steroids
Travelers
Weakened immunity

Adoptees

For children who have received vaccines outside of the United States, you should be aware that doses are often missed and records may or may not be accurate, even when written. Therefore, your child's doctor may suggest beginning all immunizations again or testing for immunity if a blood test is available. Even if your child received some vaccines before arriving in the U.S., repeat doses are not dangerous.

The American Academy of Pediatrics offers a helpful brochure, A Healthy Beginning: Important Information for Parents of Internationally Adopted Children.

The Immunization Action Coalition provides a list of multiple resources for families who have or are considering international adoption.

Families of adoptees

Adopting a child is an exciting time for a family; however, amid all of the preparations, one aspect of preparation should not be overlooked.

Prospective parents should talk with their healthcare provider before it is time to get the child because anyone traveling to pick up the child is likely to need certain vaccines, and some family members at home may also need vaccines, such as the hepatitis A vaccine.

Watch as one family prepares to bring home their adopted children.

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Adults

Some adults incorrectly assume that the vaccines they received as children will protect them for the rest of their lives. Generally this is true, except that:

Vaccines all adults need

Additional vaccines needed

Some adults are at higher risk of contracting vaccine-preventable diseases or suffering complications due to their short- or long-term health status (examples include pregnancy, cancer treatment, lack of a spleen, asthma), type of employment (working in healthcare or childcare) or activities (smoking, international travel). This list is not an exhaustive list, so you should talk with your healthcare provider about whether there are vaccines that you need.

Vaccines and Adults: A Lifetime of Health is a 46-page booklet developed by the Vaccine Education Center that can help you and other adults in your life stay informed of your vaccine needs. Download a copy today:

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Breastfeeding

Baby

Infants who are being breastfed may receive all 14 vaccines routinely recommended for infants. Antibodies in breast milk do not interfere with any of the currently recommended vaccines.

Sometimes parents wonder whether they can forego immunizations for their baby because the baby is being breastfed; however, this is not the safest decision because antibodies in human breast milk bathe the intestinal surface but are not absorbed. Therefore, breast milk antibodies never enter the lymphatics or circulation where they would be needed to protect against diseases for which infection in the blood (circulation) is an important part of how viruses and bacteria cause disease. Examples of these types of diseases include diphtheria, tetanus, pertussis, measles, mumps, rubella, varicella (chickenpox), pneumococcus, Haemophilus influenzae type b, polio, hepatitis A and hepatitis B.

Mom

Women who are breastfeeding can receive any vaccines they need during this time. Although some live viral vaccines may replicate and cause viruses to be excreted in breast milk, the viruses are weakened sufficiently that they will not harm the baby.

In most cases women are recommended to have received the live viral vaccines (specifically, MMR and chickenpox) prior to becoming pregnant because the diseases they prevent may be harmful to a developing fetus if the woman is infected during pregnancy.

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Childcare workers

Anyone who works with children, especially in childcare centers, is at high risk of coming into contact with a number of bacteria or viruses. Therefore, childcare workers should be up to date on vaccines including measles-mumps-rubella (MMR), tetanus-diphtheria (Td) or tetanus-diphtheria-pertussis (Tdap), varicella, influenza, and hepatitis B. Because infants are at increased risk of suffering complications and death from pertussis infections (whooping cough), adults and teens who will be around them, including childcare providers, should have a single dose of the Tdap vaccine.

Young children in childcare centers are commonly infected with hepatitis A virus. Whereas young children infected with hepatitis A virus often do not develop any symptoms of infection, the same cannot be said for adults who get infected. Childcare workers who have not previously had the hepatitis A vaccine may be recommended to get the vaccine or treatment if hepatitis A cases are diagnosed in their center. Hepatitis A virus can occasionally cause severe and rarely fatal infection of the liver.

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Fevers

Questions about vaccines and fever typically fall into two categories: receiving vaccines during a fever and fevers caused by vaccines. Before addressing either of these, it is important to understand why we have fever.

What is fever?

Fevers are part of the body’s innate, or non-specific, immune response. Because fevers play a role in protecting against pathogens, they are generally considered to be beneficial. In fact, specific cytokines, or chemicals produced during an immune response are meant to increase body temperature. Increased temperatures help fight infection in two ways. First, some bacteria, like Neisseria gonorrhea, reproduce most efficiently at body temperature, so increasing the temperature limits infection. Second, fever actually enhances the body’s immune response; cells of the immune system actually work better at the higher temperature.

Should children with a fever get vaccines?

Children with minor illnesses are generally able to get vaccines even if they have a low-grade fever; however, vaccines should be delayed for children with moderate or severe illness, regardless of whether they have a fever or not. The reasons for the delay during moderate or severe illness are two-fold. First, the child is likely not to be feeling well and would probably prefer to be left alone. Second, if the child’s symptoms worsen, it may be difficult to discern whether the symptoms are from the pre-existing illness or the vaccinations. If your child’s vaccines are delayed due to illness, be sure to make another appointment, so your child does not fall behind on scheduled vaccines.

What should I do if my child gets a fever after getting a vaccine?

Because fevers indicate an immune response and may, in fact, enhance immune responses, a fever following vaccination is not a bad sign. As long as the child is not uncomfortable and his fever does not rise too quickly, use of medications to reduce fever should be used conservatively. This approach is supported by the findings of a study published in The Lancet, which found that children who received fever-relieving medications, called antipyretics, had lower levels of immunity than those who did not. The good news was that in both cases, the immunity was protective, so if your child is uncomfortable, it is reasonable to offer medication. However, it is important not to offer aspirin-containing medications as aspirin-containing medication given to children can cause Reye’s syndrome, particularly in those recovering from viral infections, such as influenza or chickenpox.

It is also important to monitor children with fever closely because if a fever rises too quickly, a child can experience febrile seizures. While these fever-induced seizures do not usually recur, are not usually indicative of a seizure disorder, and do not cause permanent harm, they can be frightening for both children and parents.

Children with fevers should also be encouraged to rest and drink fluids.

References:

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Healthcare workers

People who work in hospitals are at higher risk of catching certain infections than those who don't work in hospitals. Specifically, hospital workers are at high risk of catching influenza and hepatitis B infections. Therefore, in addition to the vaccines recommended for all adults (measles-mumps-rubella (MMR) vaccine, influenza, tetanus-diphtheria (Td) or tetanus-diphtheria-pertussis (Tdap) vaccine, and varicella vaccine), all healthcare workers are recommended to have the hepatitis B vaccine.

In addition, healthcare workers who are ill can unintentionally infect their patients, including those who are at risk of suffering severe complications and death because of weakened immunity. Therefore, medical institutions might require their employees to be immunized. In the case of the annual influenza vaccine, these practices have generated debate about the individual rights of the employee versus the safety of patients.

Read more about this issue in an article about the ethics of mandating influenza vaccine for healthcare workers.

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Lessening the pain of vaccines

For most children, getting vaccines simply means the pain of getting a shot. Although pain is to some extent unavoidable, there are a few things worth trying in older children.

Blowing away the pain

One technique is called "blowing away the pain." Just before the shot, take out a feather, tell the child to take a deep breath, closing his eyes if he wants, and then to blow out...blow, and blow on the feather until you or the nurse tells them to stop. The distraction of blowing on the feather has been shown in one study to lessen the amount of pain perceived by the child.

Cold versus pain

Another idea is to swab a small amount of alcohol on the forearm of the opposite arm that will receive the vaccine. The child then blows on the alcohol before and during the shot. Our bodies don't feel cold and pain in the same place at the same time. Rather, when confronted with the choice of cold or pain, the body picks cold. So the feeling of pain from the shot will be reduced.

EMLA cream

For older children with severe phobias to needles, you might consider the use of an EMLA patch applied to the skin. The limitation of this technique is that the patch (which helps to numb the area) must be applied at least one hour before the injection. Also, EMLA cream works to decrease pain caused by injections under the skin (called subcutaneous injections), but doesn't lessen the pain of vaccines given in the muscles.

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Living with someone with weakened immunity

The only vaccine that wasn't given to a child who was living in the home of someone with weakened immunity was the oral polio vaccine. The oral polio vaccine was contagious and was potentially dangerous to someone suffering from a weakened immune system. However, this vaccine is no longer recommended for use.

The MMR, rotavirus, shingles, intranasal influenza and varicella vaccines can all be given to people who are living in the same home as someone with weakened immunity. Although trace amounts of these live vaccine viruses can be detected for about two weeks in the throat of a vaccinated child, they are not contagious. The viruses that show up are so weakened, and exist in such miniscule amounts, that they do not endanger family members.

Children receiving the hepatitis B, Hib, hepatitis A, polio (shot), influenza (shot), pneumococcus, and diphtheria, tetanus and pertussis vaccines are not contagious to someone with weakened immunity.

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Missed vaccines

Vaccines are given as a series of shots over a scheduled period of time (see Vaccine Schedule). However, if a shot is missed, you do not need to start the series of doses all over again. The series can be continued as usual, simply picking up where you left off. Part of the immunization schedule is titled the “catch-up” schedule to help doctors most efficiently get kids who missed multiple vaccines back on schedule.

Pregnancy

Important vaccines during pregnancy

Vaccines to avoid during pregnancy

If you have inadvertently received any of these vaccines during pregnancy, you should be aware that none has been proven to be harmful to your unborn baby. The recommendation to avoid these vaccines is theoretical. In some cases, databases are maintained by the manufacturers to track these occurrences, so if you receive one of these vaccines, you or your doctor should report it to the manufacturer:

Children in the home of someone who is pregnant

Children living in the home of a pregnant woman can receive all recommended vaccines.

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Premature babies

Most premature infants, including those with low birth weights, can be immunized at the usual chronological age. In other words, a child born two months early should still receive his or her first immunizations at 2 months of age (not at 4 months of age).

An exception to this rule is the hepatitis B vaccine. Premature infants (children born within 36 weeks of conception with a birth weight of less than 4.4 pounds) whose mothers are not infected with hepatitis B virus should receive the hepatitis B vaccine at 1 month of age or at hospital discharge, whichever comes first. However, premature infants whose mothers are infected with hepatitis B virus should receive the vaccine at birth, independent of birth weight.

If an infant is at least 6 weeks old and has been hospitalized since birth, the first dose of rotavirus vaccine should be delayed until the infant is discharged from the hospital unless discharge occurs after 15 weeks of age. Due to a lack of safety data, the rotavirus vaccine cannot be started after an infant is more than 15 weeks old.

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Previous severe reactions

People with severe allergic reactions to a vaccine should not receive another dose of that vaccine. Some children have severe hypersensitivity (or anaphylactic) reactions to vaccines. Although these are extremely rare, you should watch out for the following reactions, which usually occur within 15 to 30 minutes of receiving a vaccine:

Many healthcare providers will request you stay at the office for 15 to 30 minutes after receipt of vaccines, so that if a reaction occurs, you are near medical treatment.

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Steroids

Steroids, which can weaken the immune system, are often given to people with diseases such as asthma, rheumatologic diseases and poison ivy. If people are taking steroids for any reason, they should discuss with their doctor whether it is safe to proceed with the vaccination schedule. In general, the following rules apply:

Steroid creams or sprays (aerosols)

It is safe to be vaccinated. The use of topical or inhaled steroids does not prevent the administration of vaccines.

Steroids taken by mouth for less than two weeks

It is safe to be vaccinated.

High doses of steroids taken by mouth for more than two weeks

People should not receive live, "weakened" vaccines if they have been taking high doses of steroids by mouth for more than two weeks. (A high dose is considered to be that greater than 2 milligrams (mg) per kilogram [2.2 pounds] of prednisone per day). The live viral vaccines include measles, mumps, rubella, varicella (chickenpox), shingles, rotavirus and the intranasal version of influenza. These vaccines can be given about three months after steroids have been stopped, although the rotavirus vaccine has age restrictions and the influenza vaccine is seasonal, so patients should discuss their situation with their healthcare provider.

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Vaccines for Travelers

In 1996 a man from Tennessee came back from a trip to South America and died of yellow fever. Although he was advised to receive the yellow fever vaccine, he chose not to get it. The decision cost him his life. Because unusual infectious diseases such as typhoid, yellow fever or cholera rarely or never occur in the United States, we don't often think about them. However, in some parts of the world, these diseases are common and often fatal.

When traveling, protect yourself and your family by considering the following four-step plan:

Step 1: Consult resources on disease risks and vaccines available for international travel

Resources available include travel clinics, doctors, travel agencies, airlines, cruise lines, missionary organizations, and academic institutions. The following is a list of organizations that provide up-to-date information on disease risks (and the necessity of vaccines) based on where you are traveling:

Step 2: Prepare for the possibility of vaccines at least eight weeks before leaving

In most developed countries such as Japan, Canada, Australia, New Zealand and Western Europe, the risk of various infectious diseases is the same as that in the United States. However, when traveling to developing countries or regions such as Africa, South America, Asia, the Mediterranean Basin, Mexico, the Caribbean, Central America or Oceania, various vaccines, as well as preventive measures against diseases such as malaria, must be considered.

Prepare for the health risks that you may encounter on your trip at least eight weeks before you leave. Some vaccines require more than one dose to be effective, and all vaccines require several weeks before they are fully effective.

Step 3: Know the five vaccines recommended before traveling to developing countries

Five vaccines are often recommended for travel to developing countries: hepatitis A, cholera, typhoid, yellow fever and Japanese Encephalitis. For more information on specific vaccines see A Look at Each Vaccine.

The five vaccines can be divided into two groups.
The first group consists of hepatitis A virus, cholera and typhoid.

All of these infections are transmitted by contaminated food or contaminated water. Two of these diseases, cholera and typhoid, can be avoided by staying in standard tourist accommodations and drinking only bottled or boiled water and avoiding uncooked meat, unpeeled fruits, shellfish, beverages with ice, salads, and food from street vendors. However, hepatitis A virus is so prevalent and so easily transmitted that even standard tourist accommodations and careful avoidance of various foods and beverages may not protect against infection! The hepatitis A vaccine is recommended for all children in the U.S. beginning at 1 year of age. If your child did not receive this vaccine yet, be sure to get at least one dose prior to traveling.

The second group consists of yellow fever and Japanese encephalitis virus. Both of these diseases are transmitted by the bite of a mosquito. The yellow fever vaccine has a very low rate of side effects and is required or recommended for entry into a number of countries. On the other hand, the Japanese Encephalitis vaccine has a fairly high rate of severe side effects, and the disease can be avoided by not engaging in high-risk activities.

Step 4: Consider other vaccines

You should also consider the meningococcal vaccine and, depending on where and when you are traveling, the rabies vaccine.

All routinely recommended vaccines including DTaP, MMR, varicella, Hib, polio, hepatitis B, hepatitis A, rotavirusinfluenza and pneumococcus should be up-to-date. Preferably at least two doses of vaccines that require more than one dose should be given prior to travel.

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Weakened immunity

If a child or adult has leukemia, lymphoma, other types of cancers or AIDS, they should not receive vaccines made with what is known as the "live, weakened" viruses — that is, they should not receive the measles, mumps, rubella (MMR), intranasal influenza (FluMist®), rotavirus or varicella vaccines.

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Reviewed by: Paul A. Offit, MD
Date: April 2013

Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.

 

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