Blood products, human immunoglobulin and timing of immunization: Canadian Immunization Guide

Notice

This CIG chapter has not been updated to contain any information regarding COVID-19 vaccines, refer to the COVID-19 vaccine chapter.

Last complete chapter revision: December 2013

General considerations
MMR, MMRV, and monovalent varicella vaccines
- Table 1: Guidelines for the interval between administration of immunoglobulin (Ig) preparations or blood products and measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV) or monovalent varicella vaccine to maximize immunization effectiveness
Yellow fever vaccine
Selected references

General considerations

Blood products of human origin contain significant amounts of antibodies to infectious agents that are prevalent in the general population, such as measles virus and varicella zoster virus (VZV); these antibodies are present either because of natural disease or following vaccination. Therefore, administration of Ig preparations and certain blood products can interfere with the immune response to parenteral live virus vaccines if given concomitantly with or shortly before or after the vaccine. The duration of the interference with the immune response to the vaccine is related to the amount of antibody in the Ig preparation or blood product. Exceptions are respiratory syncytial virus monoclonal antibody (RSVAb) and transfusion of washed red blood cells (which is infrequently used). These products do not interfere with live vaccines because RSVAb contains only antibody to respiratory syncytial virus and washed red blood cells contain a negligible amount of antibody.

There is minimal or no interaction between blood products or Ig preparations, and:

inactivated vaccines
live oral vaccines (rotavirus, oral typhoid vaccines)
live intranasal vaccine (live attenuated influenza vaccine)
Bacille Calmette-Guerin (BCG) vaccine
yellow fever vaccine

These vaccines may be given concomitantly with, or at any time before or after, an Ig preparation or blood product has been administered. If a parenteral vaccine and intramuscular Ig are given concomitantly, administer the vaccine and Ig preparation at different anatomic injection sites, using separate needles and syringes.

Refer to vaccine specific chapters in Part 4 for additional information

Measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV) and monovalent varicella vaccines

Guidelines for the interval between administration of Ig preparations or blood products and MMR, MMRV or monovalent varicella vaccines have been developed because of the potential for reduced effectiveness of the vaccine if Ig is administered with, or shortly before or after the vaccine; it should be noted that there are no additional safety concerns if Ig is inadvertently administered with, or shortly before or after the vaccine. For an optimum immune response to MMR, MMRV or monovalent varicella vaccine, the vaccine should be administered at least 14 days prior to administration of an Ig preparation or blood product, or the vaccine administration delayed until the antibodies in the Ig preparation or blood product have degraded (refer to Table 1). If the interval between the administration of any of these vaccines and subsequent administration of an Ig preparation or blood product is less than 14 days, or if these vaccines are administered before the antibody has degraded, repeat the vaccine dose after the recommended interval. The recommended interval between administration of Ig preparation or blood product and subsequent vaccination varies, depending on the Ig preparation or blood product (refer to Table 1). The recommended intervals between live parenteral vaccines should also be respected when repeating vaccine doses.

Individuals with chronic conditions requiring continuous subcutaneous Ig therapy should not be immunized with MMR, MMRV or monovalent varicella vaccine (refer to footnote 1 in Table 1). Individuals who have undergone cardiac surgery with cardiopulmonary bypass would have received packed red blood cells and platelets and may have received frozen plasma. They may have received subsequent blood products in the ICU after their surgery. They should delay receiving MMR, MMRV or monovalent varicella vaccine until 7 months after the date they were discharged from the ICU.

Table 1: Guidelines for the interval between administration of immunoglobulin (Ig) preparations or blood products and measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV) or monovalent varicella vaccine to maximize immunization effectiveness
Immunoglobulin or blood product	Dose, route	Interval between receipt of Ig or blood product and subsequent administration of MMR, MMRV or monovalent varicella vaccine (months)
Standard immunoglobulin (human)^{Table 1 - Footnote 1}
Immunoglobulin (Ig)	0.02 - 0.06 mL/kg, IM	3
	0.25 mL/kg, IM	5
	0.50 mL/kg, IM	6
Intravenous immunoglobulin (IVIg)	300 - 400 mg/kg, IV	8
	1,000 mg/kg, IV	10
	2,000 mg/kg, IV	11
Blood transfusion products
Plasma and platelet products	10 mL/kg, IV	7
Whole blood	10 mL/kg, IV	6
Packed red blood cells	10 mL/kg, IV	5
Reconstituted red blood cells	10 mL/kg, IV	3
Washed red blood cells^{Table 1 - Footnote 2}	10 mL/kg, IV	0
Specific immunoglobulin (human)
Cytomegalovirus immunoglobulin (CMVIg)	150 mg/kg, IV	6
Hepatitis B immunoglobulin (HBIg)	0.06 mL/kg, IM	3
Rabies immunoglobulin (RabIg)	20 IU/kg, IM	4
Rh immunoglobulin (RhIg)	300 mcg, IM	3^{Table 1 - Footnote 3}
Tetanus immunoglobulin (TIg)	250 units, IM	3
Varicella immunoglobulin (VarIg)	125 IU/10 kg, IM	5
Specific immunoglobulin (humanized monoclonal antibody)
Respiratory syncytial virus monoclonal antibody (palivizumab) (RSVAb)	15 mg/kg/4 weeks, IM	0
Table 1 - Footnote 1 Ig can also be administered subcutaneously (SCIg). SCIg is primarily indicated as life-long replacement therapy in patients with primary antibody deficiencies for whom immunization with live vaccines is contraindicated. However, potential alternative indications for SCIg therapy may result in temporary use and discontinuation of therapy. Because pharmacokinetic properties of Ig G following SCIg administration have been shown to resemble those following IVIg administration, the recommended interval between the administration of SCIg and MMR, MMRV or monovalent varicella vaccines should be considered equivalent to the recommended interval after the corresponding IVIg monthly dosing. Return to footnote 1 referrer Table 1 - Footnote 2 washed red blood cells are infrequently used Return to footnote 2 referrer Table 1 - Footnote 3 refer to Rh immunoglobulin for additional information Return to footnote 3 referrer

Rh immunoglobulin (RhIg)

A risk-benefit assessment is needed for post-partum women who have received RhIg and require MMR or monovalent varicella vaccine. The risk of lowered vaccine efficacy due to potential interference from the RhIg needs to be weighed against the need for protection against the vaccine preventable disease. To optimize response to vaccine, rubella-, measles- or varicella-susceptible women who receive RhIg in the peri-partum period should generally wait 3 months before being vaccinated with MMR or varicella vaccine.

However, if there is a risk of: exposure to rubella, measles, or varicella; recurrent pregnancy in the 3 months post-partum period; or a risk that vaccines may not be received later, either MMR or monovalent varicella vaccine or both may be given prior to discharge. In this context, serologic testing for antibodies to the vaccine antigens should be done 3 months after vaccination and non-immune women should be revaccinated. In the event that a post-partum woman receives either MMR or varicella vaccine or both vaccines in the 14 days prior to receiving RhIg, serologic testing for MMR or varicella should be done 3 months later and the woman revaccinated if non-immune.

Yellow fever vaccine

The background antibody level for yellow fever is low in North America; therefore, an Ig or blood product produced from blood donated in Canada or the United States is unlikely to interfere with vaccination with yellow fever vaccine.

Selected references

Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(RR-02):1-61.
Centers for Disease Control and Prevention. Health Information for International Travel 2012. The Yellow Book. Accessed August 2012 at: http://wwwnc.cdc.gov/travel/page/yellowbook-2012-home.htm

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