News & Views: How Familiar Are You with the “General Best Practice Guidelines for Immunization?”

If you administer vaccines, you are likely familiar with the vaccine-specific recommendations published in the Morbidity and Mortality Weekly Report (MMWR). However, you should also be familiar with the “General Best Practice Guidelines for Immunization.” This 195-page document provides supporting guidance for vaccine administration. While it has some vaccine-specific information, this document should be used in concert with the vaccine-specific recommendations because each offers its own important information:

• Vaccine-specific recommendations — These guidelines discuss the disease and its epidemiology and provide detailed information about the vaccine or vaccines available to protect against a particular disease. The documents provide information about vaccine safety and effectiveness as well as the specific vaccine recommendations, including who should get the vaccine, dosing, precautions, contraindications, and other special considerations.
• Comprehensive recommendations — These guidelines provide “the big picture” considerations related to each topic addressed, meaning that they offer a context for understanding how vaccine recommendations are similar or diverse when it comes to topics, such as timing and spacing of immunobiologics, vaccine administration and more. This document is helpful for someone just starting in immunizations because it provides a good overview of the immunization landscape. However, it is also helpful for those with years of experience giving vaccines because sometimes a nuanced question comes up, and this resource is a good place to start sorting out details. The combination of helping you know which vaccine-specific recommendations to check as well as the numerous citations make this document a vital resource.

Current and archived vaccine-specific recommendations are compiled on the “Vaccine-Specific Recommendations” section of the ACIP website. The comprehensive recommendations and guidelines are also available in a dedicated section of the ACIP recommendations website. They can also be downloaded (PDF) by section or in their entirety.

So, let’s take a closer look at what you can find in the “General Best Practice Guidelines for Immunization.”

Timing and spacing of immunobiologics

This 38-page section includes information about spacing related to multiple doses of the same vaccine as well as in relation to antibody-containing products. Simultaneous and nonsimultaneous administration as well as how to approach unknown or uncertain vaccination status and interchangeability of products from different manufactures are also covered.

Section tidbit!
Even though the oral typhoid, Ty21, and rotavirus vaccines are live weakened viral vaccines, they can be given at any interval before or after other live vaccines. The minimum 28-day interval between live vaccines does not apply for these two orally administered vaccines.

Go to this section of the recommendations.

Contraindications and precautions

In addition to text describing contraindications and precautions, as well as commonly mistaken issues, this 20-page section includes summary tables of this information.

Section tidbit!
History of Guillain-Barré syndrome (GBS) is only a precaution for two vaccines — influenza and tetanus-containing vaccines — and only when it occurred within six weeks of the dose.

Go to this section of the recommendations.

Preventing and managing adverse reactions

This 18-page section addresses risk communication and preventing and managing adverse events, with a significant amount of space related to allergic reactions. The section also describes how to report adverse events and provides tables for managing anaphylactic responses in children and adults.

Section tidbit!
The mandated reporting requirements for healthcare providers and vaccine manufacturers differ slightly. Healthcare providers are required to report events that appear in the VAERS reportable events table. However, it is also suggested that they report events listed as contraindications in package inserts as well as clinically significant adverse events, even if they do not appear to have a causal association with the vaccination.

Go to this section of the recommendations.

Vaccine administration

Vaccine preparation and disposal, exposure of healthcare workers to vaccine components and safety when using needles and syringes, routes of administration, appropriate needle length by age, administering multiple injections, alleviating pain and discomfort, clinical implications of administration errors, and several related tables and figures are included in this 26-page section.

Section tidbit!
The administration route for injectable vaccines is in part related to whether the vaccine contains an adjuvant. Typically, a vaccine that includes an adjuvant is administered intramuscularly to reduce the severity of local reactions that can follow intradermal or subcutaneous administration.

Go to this section of the recommendations.

Storage and handling of immunobiologics

This section is rather short compared with other sections (6 pages) because readers are directed to the CDC’s “Vaccine Storage and Handling Toolkit” for more detailed information; however, the section includes general information related to storage temperatures, expiration dates and what to do when a storage unit has an out-of-range reading. The section also includes a table that compiles recommended vaccine storage temperatures.

Section tidbit!
If live, weakened viral vaccines need to be repeated due to a vaccine administration issue (e.g., expiration or storage temperature issue), the repeat dose should not be administered sooner than 28 days after the invalid dose to decrease the chance for interference from interferon. Likewise, even though it is not a live vaccine, repeat doses of the current shingles vaccine should also be delayed by at least 28 days to decrease the potential for side effects. On the other hand, inactivated vaccines should be re-administered as soon as feasible.

Go to this section of the recommendations.

Altered immunocompetence

This 25-page section addresses various topics, including considerations for determining immune competence, vaccines that may need to be considered outside of the typical age range because of immune compromise, vaccination of close contacts of people with compromised immunity, safety and effectiveness of various types of vaccines related to immune status, and vaccines that may be contraindicated. A summary table is also included in this section.

Section tidbit!
Smallpox vaccine is the only vaccine that close contacts of someone with compromised immunity may not be able to receive. All other vaccines can be administered to close contacts. If the recipient of a varicella vaccine develops a chickenpox rash, they should avoid direct contact with the individual until the rash has resolved. Additionally, individuals changing the diaper of an infant who received rotavirus vaccine should be advised to wash their hands thoroughly since the virus can be shed in the stools for up to one month after the last dose. LAIV can be administered to contacts, unless they will be visiting an individual with an immune-compromising condition who is being treated in a positive-airflow medical environment.

Go to this section of the recommendations.

Special situations

Several special circumstance situations are described in this 25-page section, including considerations related to screening tests for tuberculosis, preterm birth, breastfeeding and pregnancy, vaccination in other countries, and individuals with conditions that put them at higher risk of bleeding.

Section tidbit!
Breastfed infants can get all age-appropriate vaccines according to the schedule. Likewise, women who are breastfeeding can typically get vaccinated as indicated with two exceptions. Breastfeeding women should not get smallpox or yellow fever vaccine if possible; however, it is noted that if a breastfeeding woman cannot avoid or postpone travel to a yellow-fever-endemic area, she should be vaccinated.

Go to this section of the recommendations.

Vaccination records

This short section (4 pages) addresses recordkeeping by healthcare offices, educating families about the importance of maintaining immunization records, and immunization information systems (IIS).

Section tidbit!
Healthcare provider records are mandated for all routinely recommended childhood vaccines, even if they are given to adults (e.g., influenza vaccine) and should be considered for all vaccine doses administered. Records should include the vaccine administration date; manufacturer and lot number; name, address, and title of the person administering the vaccine; edition date of the Vaccine Information Statement (VIS) and the date it was administered. Providers are also recommended to record adverse events and any vaccine-preventable-disease-related blood tests.

Go to this section of the recommendations.

Other sections

In addition to the aforementioned sections, the document also includes sections on how the guidelines were developed, vaccination programs, vaccine information sources, and two appendices. One appendix includes a glossary of terminology, and the other reviews ACIP committee members who were serving when the current iteration of the guidelines was developed.

Staying updated

So, now that you are up to date on this guidance, how do you know when changes have been made? You can register for email notifications using the box on the left side of the errata page, or you can periodically check the page directly.