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  • CLASSES

    Vaccine Combinations with Measles/Mumps Component

    DEA CLASS

    Rx

    DESCRIPTION

    Combination of three live virus vaccinations intended to confer immunity against measles (rubeola), mumps, and rubella (German measles); commonly used in routine childhood vaccinations.

    COMMON BRAND NAMES

    M-M-R II

    HOW SUPPLIED

    M-M-R II Subcutaneous Inj Pwd F/Sol

    DOSAGE & INDICATIONS

    For measles prophylaxis, mumps prophylaxis, and rubella prophylaxis.
    NOTE: Vaccination with MMR is recommended for persons susceptible to measles, mumps, and rubella. Adults born before 1957 are considered immune.
    For post-exposure measles prophylaxis†.
    Subcutaneous dosage
    Children and Adolescents

    0.5 mL subcutaneously within 72 hours of measles exposure. The vaccine may provide some protection against infection or modify the clinical course of the disease. Additionally, in patients who have received only 1 dose of vaccine prior to measles exposure, revaccination with 0.5 ml subcutaneously within 72 hours of exposure may prevent disease.

    Infants 6 to 11 months

    0.5 mL subcutaneously within 72 hours of measles exposure. Infants who receive the vaccination prior to 12 months of age may not achieve immunity to all three diseases; therefore, revaccination with 2 MMR doses (first dose at 12 to 15 months, second dose at least 28 days later) is recommended.

    Subcutaneous dosage
    Adults

    0.5 mL subcutaneously for patients born during or after 1957 unless one of the following exists: a contraindication, documented receipt of a live measles/mumps/rubella-containing vaccine, or laboratory evidence of immunity/disease. A second MMR dose (given at least 28 days after the first dose) is recommended for adults who have been recently exposed (within 72 hours) to measles, live in a community experiencing a measles or mumps outbreak and are in an affected age group, have been previously vaccinated with inactivated or unknown type of measles vaccine, have been vaccinated with killed or unknown type of mumps vaccine before 1979, have close contact with immunocompromised persons, are infected with HIV but not severely immunocompromised (CD4 count more than 200 lymphocytes/mm3), are students in postsecondary educational institutes, work in a health care facility, or plan to travel internationally. Further, for unvaccinated health care workers born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, consider 2 doses of the MMR vaccine (separated by at least 28 days) for measles and mumps or 1 dose of the MMR vaccine for rubella; during outbreaks of measles or mumps, give 2 doses, and during an outbreak of rubella, give 1 dose. One dose of MMR is recommended for all non-pregnant women of childbearing age without laboratory evidence of rubella immunity or with an unreliable rubella vaccination history; do not administer the MMR vaccine during pregnancy. Pregnant women without evidence rubella immunity should be administered the MMR vaccine upon completion or termination of pregnancy and before discharge from the health-care facility.

    Children and Adolescents

    0.5 mL subcutaneously. The Advisory Committee on Immunization Practices (ACIP) recommends a 2-dose vaccine schedule during childhood for MMR. For routine immunization, the recommended schedule is administration of the first dose at age 12 to 15 months and the second dose at age 4 to 6 years. For catch-up immunization, the 2 doses should be administered at least 28 days apart. The 2-dose vaccination series is also recommended for HIV-infected pediatric patients who do not have evidence of immunity unless they are severely immunosuppressed. Severe immunosuppression is defined as CD4 percentage less than 15% (all ages) or CD4 count less than 200 lymphocytes/mm3 (ages 5 years and older). Pediatric patients with perinatal HIV infection who received the MMR vaccine prior to beginning effective antiretroviral therapy (ART) and do not have evidence of immunity, should be vaccinated with 2 appropriately spaced doses once effective ART is established.

    Infants 6 to 11 months†

    Although safety and efficacy have not been established, the Centers for Disease Control and Prevention (CDC) recommends administering 0.5 mL subcutaneously to infants 6 to 11 months of age who plan to travel or live internationally. The same dose (0.5 mL subcutaneously) is also recommended during measles outbreaks involving infants less than 12 months of age. Infants who receive the vaccination prior to 12 months of age may not achieve immunity to all three diseases; therefore, revaccination with 2 MMR doses (first dose at 12 to 15 months, second dose at least 28 days later) is recommended.

    MAXIMUM DOSAGE

    Adults

    0.5 ml/dose SC.

    Geriatric

    0.5 ml/dose SC.

    Adolescents

    0.5 ml/dose SC.

    Children

    0.5 ml/dose SC.

    Infants

    >= 6 months: Safety and efficacy not established; however, 0.5 ml/dose SC is recommended in certain situations.
    < 6 months: Safety and efficacy not established.

    DOSING CONSIDERATIONS

    Hepatic Impairment

    Specific guidelines for dosage adjustments in hepatic impairment are not available; it appears that no dosage adjustments are needed.

    Renal Impairment

    Specific guidelines for dosage adjustments in renal impairment are not available; it appears that no dosage adjustments are needed.

    ADMINISTRATION

     
    NOTE: Health care professionals administering vaccines should take appropriate precautions to prevent allergic reactions in vaccine recipients (see Contraindications).
     
    NOTE: According to U.S. federal laws, the health care provider must record the manufacturer, lot number, date of administration, and the name and address of the person administering the vaccine in the patient's permanent record.

    Injectable Administration

    NOTE: Use sterile syringes that are free of preservatives, antiseptics, and detergents for each injection or reconstitution of the vaccine. Preservatives, antiseptics, or detergents may inactivate the live virus vaccine.
    Administer subcutaneously.
    Do not give immune globulin (IgG, etc.) concurrently with MMR vaccine.
    Visually inspect parenteral products for particulate matter and discoloration prior to administration whenever solution and container permit.

    Subcutaneous Administration

    Reconstitution:
    Use only the sterile vaccine diluent supplied with this vaccine. This diluent is free from preservatives or anti-viral substances that might inactivate the vaccine virus.
    Single-dose vial: Withdraw the entire volume of the supplied diluent and inject into the vial containing the lyophilized vaccine. Agitate to mix thoroughly. Discard the vaccine if it cannot be dissolved. The reconstituted vaccine should be clear yellow.
    Ten (10) dose vial (available only to government agencies/institutions): Withdraw the entire volume of the supplied diluent and inject into the vial containing the lyophilized vaccine. Agitate to mix thoroughly; discard the vaccine if it cannot be dissolved. The reconstituted vaccine should be clear yellow. Reconstituted vaccine may be used with separate sterile syringes or in a Jet Injector.
    Aseptic technique must be observed because the products do not contain preservatives.
    Storage of reconstituted vaccine: Immediate use of the reconstituted vaccine is recommended, but the product may be stored at 2—8 degrees C (36—46 degrees F) if protected from light and used within 8 hours. Discard unused portions.
     
    Injection:
    Using a 25-gauge 5/8' needle, inject subcutaneously into the outer aspect of the upper arm. Care should be taken to avoid intradermal injection.

    STORAGE

    M-M-R II:
    - Discard product if it contains particulate matter, is cloudy, or discolored
    - Protect from light
    - Store diluent separately at room temperature (68 to 77 degrees F) or in the refrigerator (36 to 46 degrees F)
    - Store reconstituted product in refrigerator (36 to 46 degrees F), discard if not used within 8 hours
    - Store unreconstituted product in refrigerator (36 to 46 degrees F)

    CONTRAINDICATIONS / PRECAUTIONS

    General Information

    NOTE: Excretion of small amounts of the live attenuated rubella virus from the nose or throat has occurred in most susceptible patients 7—28 days after vaccination. However, transmission of the disease through close personal contact is not regarded as a significant risk, as there is no confirmed evidence to indicate viral transmission to susceptible persons who are in contact with the vaccinated individuals.
     
    Rumors that MMR vaccine may be causally related to increased cases of autism in children have caused substantial parental concern about MMR vaccination. Previous studies have found no relationship between autism and MMR administration. In 2001, two important studies were released that concluded that vaccination with MMR is not associated with an increased risk of autism.

    Intramuscular administration, intravenous administration

    Do not give MMR vaccine via intravenous administration or intramuscular administration. The vaccine is for subcutaneous use only. Prior to administration, health care personnel should inform the patient, parent, guardian, or responsible adult of the vaccine's benefits and risks. This should include the provision of the vaccine information statement from the manufacturer. The responsible adult should report any adverse reaction following vaccine administration to the health care provider. The U.S. Department of Health and Human Services has established a Vaccine Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events after the administration of any vaccine. This includes, but is not limited to, the reporting of events required by the National Childhood Vaccine Injury Act of 1986. The toll-free number for VAERS is 800—822—7967.

    Egg hypersensitivity, neomycin hypersensitivity

    Because measles and mumps viruses are cultured from chick embryos, and each vaccine dose contains 25 mcg of neomycin, it is generally regarded that patients with a history of egg hypersensitivity or neomycin hypersensitivity are more likely to develop an allergic reaction if given the MMR vaccine. According to CDC recommendations and the manufacturer, persons who have experienced an anaphylactic reaction to topically or systemically administered neomycin should not receive MMR vaccine. However, a history of contact dermatitis to neomycin is not a contraindication to receiving MMR vaccination; in these patients, the adverse reaction to neomycin in the vaccine is usually an erythematous, pruritic nodule or papule appearing 48—96 hours after vaccination. In persons allergic to eggs, the risk for serious allergic reactions following administration of measles- or mumps-containing vaccines is extremely low, but patients with a history of anaphylactic, anaphylactoid, or other immediate reactions subsequent to egg ingestion may be at an enhanced risk of an immediate-type hypersensitivity reaction. In a study of 54 children with documented egg allergy, a single 0.5 ml SC dose of the MMR vaccine was administered safely, despite the confirmation of egg allergy with a food challenge. Thus, according to the CDC, skin testing is not required before administering MMR to persons allergic to eggs. Data indicate that most anaphylactic reactions to measles- and mumps-containing vaccines are not associated with hypersensitivity to egg antigens but to other components of the vaccines. Carefully evaluate the potential risk to benefit ratio and have adequate treatment for anaphylaxis readily available if the decision is made to administer the vaccine.

    Albumin hypersensitivity, gelatin hypersensitivity

    The MMR vaccine is contraindicated for use by patients with gelatin hypersensitivity or hypersensitivity to any vaccine component. Several case reports appear in the literature of persons with an anaphylactic sensitivity to gelatin (i.e., gelatin hypersensitivity) who had an anaphylactic reaction after receiving MMR vaccine. MMR vaccine contains hydrolyzed gelatin as a stabilizer. Each dose of the vaccine also contains no more than 0.3 mg of recombinant human albumin. Patients with albumin hypersensitivity may not be appropriate vaccine candidates.

    Idiopathic thrombocytopenic purpura (ITP), infection, thrombocytopenia

    Patients with thrombocytopenia may develop more severe thrombocytopenia after vaccination. In addition, patients who experience thrombocytopenia with the first dose of the MMR vaccine or any vaccine component may develop thrombocytopenia with repeat doses. Consider the potential risks and benefits of further vaccine receipt; evaluation of serologic status may help determine the need for additional doses. In children, a causal association of MMR vaccine and immune thrombocytopenia/idiopathic thrombocytopenic purpura (ITP) has been demonstrated. In one study, the absolute risk of ITP in children aged 12—23 months within 6 weeks of immunization was 1 in 22,300 doses (two of every three cases of ITP were vaccine-attributed). The MMR-related cases tended to be milder and of shorter-duration than non-vaccine associated cases. Children with ITP before MMR vaccine had no vaccine-associated recurrences of purpura; the authors concluded that a history of previous ITP did not contraindicate the administration of the vaccine. The decision to vaccinate children with MMR should depend on the benefits of immunity to measles, mumps, and rubella and the risks for recurrence or exacerbation of thrombocytopenia after vaccination or during natural infection with measles or rubella. According to the CDC, the benefits of primary immunization are usually greater than the potential risks, especially when the incidence of thrombocytopenia after measles or rubella disease is considered.

    Seizure disorder

    Children with a personal or family history of a seizure disorder may be at an increased risk of developing febrile seizures after MMR vaccination. The risk of this complication, however, appears to be low. In addition, febrile seizures occur commonly among children in whom measles disease develops. Therefore, according to the CDC, the benefits of administering MMR vaccine to children with a history of convulsions substantially outweighs the risks.

    Infants, neonates

    Safety and effectiveness of measles vaccine in neonates and infants below the age of 6 months have not been established, and the safety and effectiveness of mumps and rubella vaccine in patients less than 12 months of age have not been established. The MMR vaccine is only indicated in patients at least 12 months of age, but receipt in infants may be acceptable in certain conditions (see Dosage). The vaccine may not be as immunogenic in infants. If vaccination first occurred before the age of 12 months, revaccinate between 12 and 15 months of age and again before elementary school entry.

    Acquired immunodeficiency syndrome (AIDS), agammaglobulinemia, bone marrow suppression, chemotherapy, human immunodeficiency virus (HIV) infection, hypogammaglobulinemia, IgA deficiency, immunosuppression, leukemia, lymphoma, neoplastic disease, radiation therapy, severe combined immunodeficiency (SCID)

    Recommendations and precautions for patients with immunosuppression are complex, but the measles virus; mumps virus; rubella virus (MMR) live vaccine is contraindicated in any person with a primary immunodeficiency state (e.g., severe combined immunodeficiency (SCID), IgA deficiency, hypogammaglobulinemia, agammaglobulinemia, or dysgammaglobulinemia) or an acquired immunodeficiency state. Measles inclusion body encephalitis, pneumonitis, and death as a direct consequence of disseminated measles vaccine virus infection have been reported in immunocompromised patients inadvertently vaccinated with measles-containing vaccine; additionally, disseminated mumps and rubella virus infection has occurred in immunosuppressed patients who were inadvertently given the MMR vaccine. A family history of congenital or hereditary immunodeficiency is also a contraindication for MMR vaccine unless the immune competence of the potential vaccine recipient is demonstrated. In persons with human immunodeficiency virus (HIV) infection, MMR vaccination is recommended for all asymptomatic and mildly symptomatic (adult/adolescent category A or pediatric category A1 or A2) patients who do not have evidence of severe immunosuppression (age specific CD4 percentages >= 15%). Patients infected with HIV who have met diagnostic criteria of acquired immunodeficiency syndrome (AIDS) should not receive the vaccine. The MMR vaccine should also not be administered to those with cellular immune deficiency or those patients on immunosuppressive therapy such as high-dose corticosteroid therapy. However, corticosteroid therapy usually is not a contraindication to administering live-virus vaccines when administration is short-term (< 2 weeks); a low-to-moderate dose (< 2 mg/kg of body weight or 20 mg/day of prednisone or equivalent for persons who weigh > 10 kg when administered for < 2 weeks); long-term, alternate-day treatment with short-acting preparations; maintenance physiologic doses (replacement therapy); or when administered topically (skin, eyes), inhaled, or by local injection. Healthcare providers should wait at least 1 month after discontinuation of high-dose corticosteroid therapy given for more than 2 weeks before administering MMR vaccine. The vaccine is also contraindicated in patients with blood dyscrasias or any neoplastic disease that causes bone marrow suppression or affects the lymphatic system such as leukemia or lymphoma, including patients currently receiving chemotherapy or radiation therapy. Patients with leukemia, lymphoma, or other malignancies whose disease is in remission and whose chemotherapy or radiation therapy has been terminated for at least 3 months can receive live-virus vaccines.

    Pregnancy

    The MMR vaccine is classified by the FDA as pregnancy risk category C and is contraindicated in pregnancy. Although controlled studies have not been done to evaluated the effects on the fetus, pregnant women or females likely to become pregnant within 3 months after administration should not be given live, attenuated-virus vaccines because of the theoretical risk to the developing fetus. Advise women of child-bearing potential to avoid becoming pregnant for 3 months after receiving the MMR vaccine; explain the need for pregnancy avoidance. All females of child-bearing age should be tested for rubella immunity. In non-immune women, administration of the MMR vaccine is recommended as protection against rubella infection during pregnancy. Pregnant women without evidence of immunity should be vaccinated upon completion of pregnancy. Although there is no evidence of congenital rubella syndrome in infants born to susceptible mothers who inadvertently were given rubella vaccine during pregnancy, persons given measles, mumps, or rubella vaccines can shed these viruses.

    Breast-feeding

    According to the CDC, live-virus vaccines administered to a lactating woman do not affect the safety of breast-feeding for women or their infants. Although live viruses in vaccines can replicate in vaccine recipients (i.e., the mother), the majority of live viruses in vaccines have been demonstrated not to be excreted in human milk. The rubella vaccine virus may be excreted in human milk; however, the virus usually does not infect the infant. If infection does occur, it is well tolerated because the virus is attenuated. There are no data to suggest that passive transfer of antibodies in human milk can affect the efficacy of live-virus vaccines. Breastfed infants should be vaccinated according to the recommended schedule. The manufacturer of the measles/mumps/rubella (MMR) vaccine states that caution should be used when the vaccine is administered to a breast-feeding woman; lactating women immunized with live attenuated rubella vaccine may secrete the virus in breast milk and transmit it to breast-feeding infants. In the infants with serological evidence of rubella infection, none exhibited severe disease; however, one exhibited mild clinical illness typical of acquired rubella. The ability of either the measles or mumps vaccine virus to be secreted in human milk is unknown. Consider the benefits of breast-feeding, the risk of infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally administered drug, health care providers are encouraged to report the adverse effect to the FDA.

    Fever, respiratory infection, tuberculosis

    Patients with active, untreated tuberculosis should not be vaccinated with MMR. The MMR vaccine is contraindicated in patients with a febrile respiratory illness such as a respiratory infection or other active infection associated with a fever. The ACIP, however, recommends that all vaccines can be given to patients with minor illnesses such as diarrhea, mild upper respiratory infection, or other low-grade febrile illnesses.

    ADVERSE REACTIONS

    Severe

    seizures / Delayed / 0-1.0
    Guillain-Barre syndrome / Delayed / Incidence not known
    vasculitis / Delayed / Incidence not known
    optic neuritis / Delayed / Incidence not known
    aseptic meningitis / Delayed / Incidence not known
    bronchospasm / Rapid / Incidence not known
    angioedema / Rapid / Incidence not known
    anaphylactic shock / Rapid / Incidence not known
    erythema multiforme / Delayed / Incidence not known
    anaphylactoid reactions / Rapid / Incidence not known
    Stevens-Johnson syndrome / Delayed / Incidence not known

    Moderate

    thrombocytopenia / Delayed / 0-1.0
    encephalopathy / Delayed / 0-0.1
    acute disseminated encephalomyelitis / Delayed / 0-0.1
    neuritis / Delayed / Incidence not known
    ataxia / Delayed / Incidence not known
    conjunctivitis / Delayed / Incidence not known
    erythema / Early / Incidence not known

    Mild

    arthralgia / Delayed / 0-26.0
    fever / Early / 1.0-10.0
    maculopapular rash / Early / 5.0-5.0
    purpura / Delayed / 0-1.0
    syncope / Early / Incidence not known
    paresthesias / Delayed / Incidence not known
    pruritus / Rapid / Incidence not known
    urticaria / Rapid / Incidence not known
    musculoskeletal pain / Early / Incidence not known
    myalgia / Early / Incidence not known
    headache / Early / Incidence not known
    malaise / Early / Incidence not known
    vomiting / Early / Incidence not known
    diarrhea / Early / Incidence not known
    nausea / Early / Incidence not known
    irritability / Delayed / Incidence not known
    injection site reaction / Rapid / Incidence not known

    DRUG INTERACTIONS

    Abatacept: (Severe) If possible, administer all needed vaccines before abatacept initiation. Live vaccines should not be given concurrently with abatacept or within 3 months of its discontinuation. The immune response of the immunocompromised patient to vaccines may be decreased and adjusted doses or boosters that are more frequent may be required. The immune response to an inactive vaccine may still be suboptimal. Live virus vaccines may induce the illness they are intended to prevent and are contraindicated for use during immunosuppressive treatment. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Abciximab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Adalimumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Aldesleukin, IL-2: (Severe) Aldesleukin, IL-2 is associated with impaired neutrophil function. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Alefacept: (Severe) The safety and efficacy of administering attenuated virus vaccines or live vaccines to patients receiving alefacept have not been studied. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Alemtuzumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Alkylating agents: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Alpha interferons: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient, including those receiving Interferon therapy. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Altretamine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Anakinra: (Severe) No data are available on the effects of vaccination with live virus vaccines in patients receiving anakinra. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Anthracyclines: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Antimetabolites: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Antithymocyte Globulin: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Antitumor antibiotics: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Arsenic Trioxide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Azathioprine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Basiliximab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Belatacept: (Severe) Avoid the use of live vaccines such as the intranasal influenza vaccine; measles/mumps/rubella vaccines, MMR; Bacillus Calmette-Guerin Live, BCG; yellow fever vaccine; oral polio vaccine; varicella virus vaccine live; and TY21a typhoid vaccine during belatacept treatment. Further, inactive vaccine receipt may not illicit an acceptable response; belatacept may blunt the effectiveness of some immunizations. Consult the most current CDC guidances for vaccination recommendations.
    Belimumab: (Major) Live vaccines should not be given for 30 days before or concurrently with belimumab, as clinical safety has not been established. Because of its mechanism of action, belimumab may interfere with the response to immunizations. No data are available on the secondary transmission of infection from persons receiving live vaccines. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Bevacizumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Bexarotene: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Bortezomib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Brodalumab: (Major) Avoid administration of live vaccines to brodalumab recipients. Before initiation of brodalumab therapy, consider completion of all age appropriate vaccinations per current immunization guidelines. No data are available on the response to live or inactive vaccines in patients receiving brodalumab therapy.
    Busulfan: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Canakinumab: (Major) Do not administer live vaccines to a patient who is receiving canakinumab; other vaccination schedules should be complete as recommended prior to initiating canakinumab treatment. No data are available regarding the risk of secondary transmission of infection by live vaccines, and the efficacy and safety of live vaccines have not been established in patients receiving canakinumab. The immune response to vaccines or toxoids may be decreased, as canakinumab may interfere with normal immune response to new antigens. Limited data are available on the effectiveness of vaccination with inactivated antigens in patients receiving canakinumab. Because interleukin-1 blockade may interfere with immune response to infections, it is recommended that prior to initiation of therapy with canakinumab, adult and pediatric patients receive any recommended vaccination (including pneumococcal vaccine and inactivated influenza vaccines).
    Carmustine, BCNU: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Certolizumab pegol: (Severe) Do not administer live vaccines concurrently with certolizumab. No data are available on the response to vaccinations or to the secondary transmission of infection by live vaccines in patients receiving certolizumab. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Chlorambucil: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Clofarabine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system
    Corticosteroids: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system. Children who are receiving high doses of systemic corticosteroids (i.e., greater than or equal to 2 mg/kg prednisone orally per day) for 2 weeks or more may be vaccinated after steroid therapy has been discontinued for at least 3 months in accordance with general recommendations for the use of live-virus vaccines. The CDC has stated that discontinuation of steroids for 1 month prior to varicella virus vaccine live administration may be sufficient. Budesonide may affect the immunogenicity of live vaccines. An open-label study examined the immune responsiveness to varicella vaccine in 243 pediatric asthma patients who were treated with budesonide inhalation suspension 0.251 mg daily (n = 151) or non-corticosteroid asthma therapy (n = 92). The percentage of patients developing a seroprotective antibody titer of at least 5 (gpELISA value) in response to the vaccination was slightly lower in patients treated with budesonide compared to patients treated with non-corticosteroid asthma therapy (85% vs. 90%). Even though no patient treated with budesonide inhalation suspension developed chicken pox because of vaccination, live-virus vaccines should not be given to individuals who are considered to be immunocompromised until more information is available.
    Cyclophosphamide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Cyclosporine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Cytomegalovirus Immune Globulin, CMV-IGIV: (Major) Rubella Virus Vaccine or Measles/mumps/rubella vaccines, MMR should not be given for at least 3 months following administration of immunoglobulins because antibodies in these products can neutralize the vaccine.
    Dacarbazine, DTIC: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Dasatinib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Denileukin Diftitox: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Dupilumab: (Major) Avoid administration of live vaccines to dupilumab recipients. Before initiation of dupilumab therapy, consider completion of all age appropriate vaccinations per current immunization guidelines. No data are available on the response to live vaccines in patients receiving dupilumab therapy.
    Efalizumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Estramustine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Etanercept: (Severe) Etanercept has not been found to act as a general immunosuppressant; however, the patient's underlying disease state may result in the immunosuppression. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune syste
    Fingolimod: (Severe) Do not administer live vaccines to a patient who is receiving fingolimod or has discontinued the drug in the last 2 months because of the risk of infection. No data are available regarding the risk of secondary transmission of infection by live vaccines, and the efficacy and safety of live vaccines have not been established in patients receiving fingolimod. Before fingolimod initiation, test patients without a history of chickenpox or without vaccination against varicella zoster virus (VZV) for antibodies to VZV. Consider VZV vaccination of antibody-negative patients before fingolimod initiation, and do not start fingolimod for 1 month to allow the full effect of vaccination to occur. In addition to the concerns with live virus vaccines, the immune response to inactive vaccines or toxoids may be decreased, as fingolimod may interfere with normal immune response to new antigens. No data are available on the effectiveness of vaccination with inactivated antigens in patients receiving fingolimod. Vaccination may be less effective during and for up to 2 months after fingolimod discontinuation. For example, as compared with the response of placebo recipients, the capacity to mount a skin delayed-type hypersensitivity reaction to Candida and to tetanus toxoid was decreased by approximately 30% among fingolimod 0.5 mg daily recipients. Further, in healthy patients, antigen-specific IgM titers were decreased by 25% in response to pneumococcal polysaccharide vaccine (PPV-23) immunization as compared with the response by placebo recipients. Similarly, IgG titers were decreased by 50% among fingolimod recipients as compared with placebo.
    Folate analogs: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Gefitinib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Golimumab: (Severe) Do not administer live vaccines to golimumab recipients. No data are available on the response to live vaccination or on the risk of infection or infection transmission after the administration. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Guselkumab: (Major) Avoid use of live vaccines in patients being treated with guselkumab; no data are available regarding the risk of secondary transmission of infection by live vaccines in patients receiving guselkumab. In addition, guselkumab may decrease the vaccine-induced immune response. Before initiation of guselkumab therapy, consider completion of all age appropriate vaccinations per current immunization guidelines.
    Hepatitis B Immune Globulin, HBIG: (Major) The manufacturers advise deferral of live virus vaccine receipt such as measles/mumps/rubella vaccines, MMR and varicella virus vaccine live until approximately 3 months after hepatitis B immune globulin, HBIG administration. Of note, the Advisory Committee on Immunization Practices states that Ty21a typhoid; yellow fever; live, attenuated influenza vaccine; zoster; and rotavirus vaccines may be administered at any time before, concurrent with, or after administration of HBIG. For all other live vaccines, do not administer simultaneously with HBIG, as HBIG may interfere with live virus vaccines. If simultaneous administration of measles-containing vaccine or varicella-containing vaccine (except zoster) is unavoidable, administer the products at different sites and revaccinate or test for seroconversion after recommended interval of at least 3 months between HBIG administration and any measles or varicella-containing vaccine except the zoster vaccine. It may be necessary to revaccinate persons who received HBIG shortly after live virus vaccination. If HBIG was administered less than 14 days after live virus vaccination, revaccinate 3 months after HBIG administration unless serologic test results indicate antibody production. Administering inactivated vaccines and toxoids either simultaneously with or at any interval before or after receipt of an antibody-containing product should not substantially impair development of a protective antibody response. Administer the inactivated vaccine or toxoid and HBIG at different sites using the standard recommended doses.
    Hyaluronidase, Recombinant; Immune Globulin: (Major) Rubella virus vaccine or Measles/mumps/rubella vaccines, MMR should not be given for at least 3 months following administration of blood, plasma, and/or immunoglobulins because antibodies in these products can neutralize the vaccine.
    Hydroxychloroquine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Ibritumomab Tiuxetan: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Ifosfamide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Imatinib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Immune Globulin IV, IVIG, IGIV: (Major) Rubella virus vaccine or Measles/mumps/rubella vaccines, MMR should not be given for at least 3 months following administration of blood, plasma, and/or immunoglobulins because antibodies in these products can neutralize the vaccine.
    Infliximab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Ixabepilone: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Ixekizumab: (Major) Do not administer live vaccines to ixekizumab recipients. Before initiation of ixekizumab therapy, consider completion of all age appropriate vaccinations per current immunization guidelines. No data are available on the response to live or inactive vaccines in patients receiving Ixekizumab therapy.
    Lapatinib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Leflunomide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Lenalidomide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Lomustine, CCNU: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Mechlorethamine, Nitrogen Mustard: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Mitotane: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Monoclonal antibodies: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Muromonab-CD3: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Natalizumab: (Severe) The immune response to vaccines or toxoids may be decreased in patients who receive natalizumab; however, no data are available. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Natural Antineoplastics: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Nelarabine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Nilotinib: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Ocrelizumab: (Major) Due to the lack of clinical information related to the safety and efficacy of vaccine administration during ocrelizumab use, concomitant vaccination with live vaccines or live-attenuated vaccines is not recommended. Withhold vaccination with live or live-attenuated virus vaccines to patients during ocrelizumab treatment and until B-cell repletion. Administer all vaccinations according to current vaccination guidelines and CDC recommendations at least 6 weeks before starting treatment with ocrelizumab. The ability to generate a primary or anamnestic humoral response to any vaccine following ocrelizumab has not been studied. ACIP recommends that patients receiving any vaccination during immunosuppressive therapy or in the 2 weeks prior to starting therapy should be considered unimmunized and should be revaccinated a minimum of 3 months after discontinuation of therapy. Passive immunoprophylaxis with immune globulins may be indicated for immunocompromised persons instead of, or in addition to, vaccination.
    Ofatumumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Palivizumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Procarbazine: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Purine analogs: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Rabies Immune Globulin, human RIG: (Major) Persons administered rabies immune globulin, human RIG should wait 4 months before receiving immunization with a measles virus vaccine. Antibodies contained within RIG may interfere with the immune response to the live virus vaccine. According to the Advisory Committee on Immunization Practices, if the measles vaccine is administered less than 4 months after receipt of the RIG, the vaccine dose should be repeated unless serologic testing is feasible and indicates a response to the vaccine. The repeat dose and serologic tests must be performed 4 months or more after administration of RIG. (Major) The manufacturers of the rabies immune globulin, human RIG recommend persons administered the RIG wait 3 months before receiving immunization with a live-virus vaccine, such as mumps virus vaccine. Antibodies contained within RIG may interfere with the immune response to the live virus vaccine. According to the Advisory Committee on Immunization Practices, if the mumps virus vaccine is administered < 3 months after receipt of the RIG, the vaccine dose should be repeated unless serologic testing is feasible and indicates a response to the vaccine. The repeat dose and serologic tests must be performed >= 3 months after administration of RIG. (Major) The manufacturers of the rabies immune globulin, human RIG recommend persons administered the RIG wait 3 months before receiving immunization with a live-virus vaccine, such as rubella virus vaccine live. Antibodies contained within RIG may interfere with the immune response to the live virus vaccine. According to the Advisory Committee on Immunization Practices, if the rubella virus vaccine is administered < 3 months after receipt of the RIG, the vaccine dose should be repeated unless serologic testing is feasible and indicates a response to the vaccine. The repeat dose and serologic tests must be performed >= 3 months after administration of RIG.
    Rh0 [D] Immune Globulin: (Major) Rubella virus vaccine or Measles/mumps/rubella vaccines, MMR should not be given for at least 3 months following administration of immunoglobulins because antibodies in these products can neutralize the vaccine.
    Rilonacept: (Severe) Do not administer live vaccines to a patient who is receiving rilonacept. No data are available regarding the use of live vaccines during rilonacept treatment. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Rituximab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Rituximab; Hyaluronidase: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Sarilumab: (Major) Avoid concurrent use of live vaccines during treatment with sarilumab due to potentially increased risk of infections; clinical safety of live vaccines during sarilumab treatment has not been established. No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving sarilumab. The interval between live vaccinations and initiation of sarilumab therapy should be in accordance with current vaccination guidelines regarding immunosuppressive agents.
    Secukinumab: (Major) Do not administer live vaccines to secukinumab recipients; no data are available regarding the risk of secondary transmission of infection by live vaccines in patients receiving secukinumab. Before initiation of secukinumab therapy, consider completion of all age appropriate vaccinations per current immunization guidelines. Secukinumab recipients may receive inactivated vaccines, but the immune response to vaccines or toxoids may be decreased. Similar antibody responses were seen when healthy individuals who received a single 150 mg dose of secukinumab 2 weeks before vaccination with a non-US approved group C meningococcal polysaccharide conjugate vaccine and a non-US approved inactivated seasonal influenza vaccine. The efficacy of meningococcal and influenza vaccines has not been evaluated in patients undergoing treatment with secukinumab.
    Sorafenib: (Major) Concomitant administration of immunosuppressives such as antineoplastic agents can decrease an individual's immunological response to live vaccines or can result in more extensive vaccine-associated adverse events. Refer to the most recent CDC guidelines regarding vaccination of immunosuppressed patients.
    Streptozocin: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Sunitinib: (Major) Concomitant administration of immunosuppressives such as antineoplastic agents can decrease an individual's immunological response to live vaccines or can result in more extensive vaccine-associated adverse events. Refer to the most recent CDC guidelines regarding vaccination of immunosuppressed patients.
    Taxanes: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Temozolomide: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Temsirolimus: (Severe) The use of live vaccines should be avoided during treatment with temsirolimus. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Teriflunomide: (Major) Due to the lack of clinical information related to the safety and efficacy of vaccine administration during teriflunomide use, concomitant vaccination with live vaccines is not recommended. The long half-life of teriflunomide should be considered when contemplating administration of a live vaccine after stopping the medication if the teriflunomide drug elimination procedure has not been performed.
    Tetanus Immune Globulin, Human, TIG: (Major) Do not vaccinate patients with live virus vaccines for 3 months following administration of tetanus immune globulin. TIG contains antibodies that can interact with live virus vaccines. If is necessary to administer TIG simultaneously with live vaccines, administer at different sites and revaccinate or test for sero-conversion after 3 months.
    Thalidomide: (Severe) No data are available on the response to vaccination with live vaccines or on the secondary transmission of infection by live vaccines in patients receiving thalidomide. Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Thiotepa: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Tocilizumab: (Major) Avoid concurrent use of live vaccines during treatment with tocilizumab due to potentially increased risk of infections; clinical safety of live vaccines during tocilizumab treatment has not been established. No data are available on the secondary transmission of infection from persons receiving live vaccines to patients receiving tocilizumab. The interval between live vaccinations and initiation of tocilizumab therapy should be in accordance with current vaccination guidelines regarding immunosuppressive agents.
    Tofacitinib: (Major) Do not administer live virus vaccines to patients taking tofacitinib, as no data are available on the secondary transmission of infection by live vaccines. Also, no data are available on the response to vaccination with any vaccine during tofacitinib receipt. Before tofacitinib initiation, review the vaccination status of patients, and update immunizations in agreement with current immunization guidelines.
    Tositumomab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Trastuzumab: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Tretinoin, ATRA: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Tuberculin Purified Protein Derivative, PPD: (Minor) Temporary suppression to the tuberculin purified protein derivative, PPD with the rubella virus vaccine live has been demonstrated. If a tuberculin test is to be done, it is recommended to place the PPD either before or at the same time as the vaccine. (Minor) The measles vaccine live can temporarily suppress tuberculin purified protein derivative, PPD, skin sensitivity. Administer a tuberculin test either before or simultaneously with vaccine receipt.
    Ustekinumab: (Severe) If possible, administer all recommended vaccines before ustekinumab initiation. Ustekinumab recipients may receive inactive vaccines, but the elicited immune response may be insufficient to prevent disease. Do not administer live vaccines to a ustekinumab recipient. Furthermore, do not administer BCG live vaccines for either 1 year before or 1 year after ustekinumab receipt, due to the infectious risk for Mycobacteria. No data are available on the response to live vaccination or on the risk of infection or infection transmission after the administration of other live vaccines to ustekinumab recipients. Cautious administration of ustekinumab to household contacts of ustekinumab recipients may be warranted due to the potential risk for shedding from the household contact and transmission to the patient. Practitioners should also refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.
    Varicella-Zoster Immune Globulin: (Major) Efficacy of live attenuated virus vaccines such as measles/mumps/rubella Vaccines, MMR; rotavirus vaccine; and varicella virus vaccine live may be impaired by varicella-zoster immune globulin administration; revaccination may be necessary. As the passive transfer of antibodies may impair the efficacy of live attenuated virus vaccines, defer vaccination with live virus vaccines until approximately 3 months after varicella-zoster immune globulin administration. Inform the immunizing physician of recent therapy with varicella-zoster immune globulin, so that appropriate measures can be taken.
    Vorinostat: (Severe) Live virus vaccines should generally not be administered to an immunosuppressed patient. Live virus vaccines may induce the illness they are intended to prevent and are generally contraindicated for use during immunosuppressive treatment. The immune response of the immunocompromised patient to vaccines may be decreased, even despite alternate vaccination schedules or more frequent booster doses. If immunization is necessary, choose an alternative to live vaccination, or, consider a delay or change in the immunization schedule. Practitioners should refer to the most recent CDC guidelines regarding vaccination of patients who are receiving drugs that adversely affect the immune system.

    PREGNANCY AND LACTATION

    Pregnancy

    The MMR vaccine is classified by the FDA as pregnancy risk category C and is contraindicated in pregnancy. Although controlled studies have not been done to evaluated the effects on the fetus, pregnant women or females likely to become pregnant within 3 months after administration should not be given live, attenuated-virus vaccines because of the theoretical risk to the developing fetus. Advise women of child-bearing potential to avoid becoming pregnant for 3 months after receiving the MMR vaccine; explain the need for pregnancy avoidance. All females of child-bearing age should be tested for rubella immunity. In non-immune women, administration of the MMR vaccine is recommended as protection against rubella infection during pregnancy. Pregnant women without evidence of immunity should be vaccinated upon completion of pregnancy. Although there is no evidence of congenital rubella syndrome in infants born to susceptible mothers who inadvertently were given rubella vaccine during pregnancy, persons given measles, mumps, or rubella vaccines can shed these viruses.

    According to the CDC, live-virus vaccines administered to a lactating woman do not affect the safety of breast-feeding for women or their infants. Although live viruses in vaccines can replicate in vaccine recipients (i.e., the mother), the majority of live viruses in vaccines have been demonstrated not to be excreted in human milk. The rubella vaccine virus may be excreted in human milk; however, the virus usually does not infect the infant. If infection does occur, it is well tolerated because the virus is attenuated. There are no data to suggest that passive transfer of antibodies in human milk can affect the efficacy of live-virus vaccines. Breastfed infants should be vaccinated according to the recommended schedule. The manufacturer of the measles/mumps/rubella (MMR) vaccine states that caution should be used when the vaccine is administered to a breast-feeding woman; lactating women immunized with live attenuated rubella vaccine may secrete the virus in breast milk and transmit it to breast-feeding infants. In the infants with serological evidence of rubella infection, none exhibited severe disease; however, one exhibited mild clinical illness typical of acquired rubella. The ability of either the measles or mumps vaccine virus to be secreted in human milk is unknown. Consider the benefits of breast-feeding, the risk of infant drug exposure, and the risk of an untreated or inadequately treated condition. If a breast-feeding infant experiences an adverse effect related to a maternally administered drug, health care providers are encouraged to report the adverse effect to the FDA.

    MECHANISM OF ACTION

    Mechanism of Action: Many epidemiological studies suggest that people who develop disease-specific antibodies to the measles, mumps, and rubella viruses are immune to the virus upon reexposure for 10 to 30 years (with rare exception). Active immunization with the MMR vaccine stimulates the immune system to produce disease-specific antibodies by inducing a subclinical and noncommunicable infection with attenuated virus particles. Clinical studies indicate that MMR is highly immunogenic, with one injection stimulating measles antibodies (hemagglutination inhibition) in 95% of recipients; mumps-neutralizing antibodies in 96% of recipients; and rubella antibodies (hemagglutination inhibition) in 95% of vaccinees, although vaccine-induced antibody levels are generally lower than for natural rubella infection. These vaccine-induced antibodies are capable of virus neutralization by opsonization, complement activation, and induction of cell-mediated immunity.

    PHARMACOKINETICS

    The MMR vaccine is administered subcutaneously. Following subcutaneous injection of the measles vaccination, antibodies are detectable in about 12 days in 95% of vaccinees, and immunity occurs within 10 days. Immunity persists at least 15 years. Permanent immunity occurs in most individuals. Following subcutaneous injection of the mumps vaccine, a serologic response is observed in 95% of vaccinees. The mumps vaccine also induces a cell-mediated response that is difficult to quantify. The immunity conferred from the mumps vaccine persists at least 20 years. Permanent immunity occurs in most individuals. Following subcutaneous injection of the rubella vaccine, a serologic response is observed in 95% of vaccinees, conferring immunity within 2 to 6 weeks. This immunity persists at least 15 years. Permanent immunity occurs in most individuals.