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Canadian Immunization Guide

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Part 1
Key Immunization Information 2013

Blood products, human immune globulin and timing of immunization

This chapter provides guidance on the timing of administration of live vaccines and human immune globulin (Ig) preparations and blood products.

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 Passive Immunizing Agents in Part 5 and and vaccine specific chapters in Part 4 for additional information

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

Guidelines for the interval between administration of Ig preparations or blood products and MMR, MMRV or univalent 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 univalent 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 univalent 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 univalent varicella vaccine until 7 months after the date they were discharged from the ICU.

Table 1: Guidelines for the interval between administration of immune globulin (Ig) preparations or blood products and measles-mumps-rubella (MMR), measles-mumps-rubella-varicella (MMRV) or univalent varicella vaccine to maximize immunization effectiveness
Immune globulin or blood product Dose, route Interval between receipt of Ig or blood product and subsequent administration of MMR, MMRV or univalent varicella vaccine (months)
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 univalent varicella vaccines should be considered equivalent to the recommended interval after the corresponding IVIg monthly dosing.
Table 1 - Footnote 2
washed red blood cells are infrequently used
Table 1 - Footnote 3
refer to Rh immune globulin for additional information
Standard immune globulin (human)Footnote 1
Immune globulin (Ig) 0.02 - 0.06 mL/kg, IM 3
0.25 mL/kg, IM 5
0.50 mL/kg, IM 6
Intravenous immune globulin (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 cellsFootnote 2 10 mL/kg, IV 0
Specific immune globulin (human)
Cytomegalovirus immune globulin (CMVIg) 150 mg/kg, IV 6
Hepatitis B immune globulin (HBIg) 0.06 mL/kg, IM 3
Rabies immune globulin (RabIg) 20 IU/kg, IM 4
Rh immune globulin (RhIg) 300 mcg, IM 3Footnote 3
Tetanus immune globulin (TIg) 250 units, IM 3
Varicella immune globulin (VarIg) 125 IU/10 kg, IM 5
Specific immune globulin (humanized monoclonal antibody)
Respiratory syncytial virus monoclonal antibody (palivizumab) (RSVAb) 15 mg/kg/4 weeks, IM 0

Rh immune globulin (RhIg)
A risk-benefit assessment is needed for post-partum women who have received RhIg and require MMR or univalent 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 univalent 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.

Herpes zoster vaccine

Although no safety or efficacy data are available for the administration of herpes zoster vaccine to individuals who have recently received Ig preparations or other blood products, the vaccine is known to be immunogenic in adults with pre-existing antibody to VZV. In theory, administration of Ig should not interfere with the vaccine response; therefore, some experts do not consider recent administration of Ig or blood products as a reason to delay the administration of herpes zoster vaccine.

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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