Drug Interactions between measles virus vaccine / rubella virus vaccine and vaccinia immune globulin

ADJUST DOSING INTERVAL: Administration of vaccinia immune globulin intravenous, human (VIGIV) with, or shortly before, or shortly after live viral vaccines may impair the immune response to the vaccination(s). Injected live, attenuated virus vaccines, particularly measles/mumps/rubella (MMR), measles/mumps/rubella/varicella (MMRV), or monovalent varicella, may be affected by circulating antibodies present in VIGIV. The passive transfer of these antibodies may prevent replication of the vaccine virus, potentially reducing the vaccine's efficacy. In general, there appears to be minimal to no interaction between immune globulin (Ig) preparations or blood products and the yellow fever vaccine, some live oral vaccines (e.g., rotavirus, typhoid), the live attenuated influenza vaccine (LAIV), and the Bacille Calmette-Guerin (BCG) vaccine. As this interaction is dependent upon the antibodies present in VIGIV, it may be affected by the source used to develop the VIGIV product. Additionally, the vaccinations impacted may vary from country to country. Data on the immunogenicity and safety of all vaccinations (e.g., dengue vaccine) given concurrently with or shortly before or after the administration of VIGIV are not available.

MANAGEMENT: Immunization with live virus vaccines should be deferred until approximately 3 months after the administration of VIGIV. People who received VIGIV shortly after live virus vaccination should be revaccinated 3 months after the administration of the Ig. In general, most immunization guidelines indicate that live virus vaccines can be safely administered 2 to 3 weeks prior to Ig products. Local immunization guidelines and prescribing information for the specific products involved should be consulted for further recommendations.

ADJUST DOSING INTERVAL: Administration of vaccinia immune globulin intravenous, human (VIGIV) with, or shortly before, or shortly after live viral vaccines may impair the immune response to the vaccination(s). Injected live, attenuated virus vaccines, particularly measles/mumps/rubella (MMR), measles/mumps/rubella/varicella (MMRV), or monovalent varicella, may be affected by circulating antibodies present in VIGIV. The passive transfer of these antibodies may prevent replication of the vaccine virus, potentially reducing the vaccine's efficacy. In general, there appears to be minimal to no interaction between immune globulin (Ig) preparations or blood products and the yellow fever vaccine, some live oral vaccines (e.g., rotavirus, typhoid), the live attenuated influenza vaccine (LAIV), and the Bacille Calmette-Guerin (BCG) vaccine. As this interaction is dependent upon the antibodies present in VIGIV, it may be affected by the source used to develop the VIGIV product. Additionally, the vaccinations impacted may vary from country to country. Data on the immunogenicity and safety of all vaccinations (e.g., dengue vaccine) given concurrently with or shortly before or after the administration of VIGIV are not available.

MANAGEMENT: Immunization with live virus vaccines should be deferred until approximately 3 months after the administration of VIGIV. People who received VIGIV shortly after live virus vaccination should be revaccinated 3 months after the administration of the Ig. In general, most immunization guidelines indicate that live virus vaccines can be safely administered 2 to 3 weeks prior to Ig products. Local immunization guidelines and prescribing information for the specific products involved should be consulted for further recommendations.

ADJUST DOSING INTERVAL: If multiple live, attenuated parenteral viral or bacterial vaccines are not given on the same day, but are administered within 28 days of each other, the immune response to the second live parenteral vaccine may be diminished by the immune response to the first. The exact mechanism of this interaction is unknown, but may involve competition for cellular receptors, competition for molecular substrates required for replication, and/or induction of inhibitory host proteins like interferon. Clinical data are limited and sometimes conflicting. One randomized clinical trial in Brazil was conducted in 12-month-old children (n=1769) receiving routine vaccinations. Volunteers were randomized to receive simultaneous yellow fever (YF) and measles, mumps, rubella (MMR) vaccines or to receive YF 30 days after the MMR vaccine. Subjects who received both vaccines simultaneously had lower seroconversion rates for rubella, YF, and mumps than those vaccinated 30 days apart (90% vs. 97%, 70% vs. 87%, and 62% vs. 71%, respectively). Seroconversion rates for measles were unaffected (>98% in both groups). Geometric mean titers (GMT) for rubella and YF were approximately three times higher in those who were vaccinated 30 days apart. However, a different randomized, non-inferiority trial in healthy one-year-old children in Argentina (n=738), which evaluated coadministration of MMR and YF vaccines compared to MMR followed by the YF vaccine 28 to 35 days later, or YF followed by the MMR vaccine 28 to 35 days later, reported that effective seroconversion was achieved when the two vaccines were administered concurrently. This study did note that antibody levels for rubella and YF were significantly lower following co-administration. A separate study conducted in two U.S. health maintenance organizations found that the risk for varicella vaccine failure (defined as varicella disease in a vaccinated individual) was three times higher in those who received the varicella vaccine within 28 days of the MMR vaccine, when compared to those who received the varicella vaccine more than 28 days after MMR vaccination. Clinical data are not available for all possible live vaccine combinations in all age groups.

MANAGEMENT: The U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices generally recommends that doses of live, attenuated parenteral viral or bacterial vaccines that are not administered simultaneously (using different injection sites and separate needles and syringes for injectable products not formulated as combinations) should be separated by an interval of at least 28 days. If the live vaccines involved are separated by less than 4 weeks, the second vaccine administered should not be counted and the dose should be repeated at least 4 weeks later. Oral vaccines (e.g., Ty21a typhoid vaccine and rotavirus) can be administered simultaneously with or at any interval before or after other live vaccines if indicated. The United Kingdom's Green Book recommends always separating the YF and MMR vaccines by at least 4 weeks, unless rapid protection is required in which case they advise considering an additional dose of the MMR vaccine. Additionally, the Canadian Immunization Guide recommends avoiding simultaneous administration of a first-generation smallpox vaccine with a varicella-containing vaccine; suggesting that if both are needed, the varicella-containing vaccine should be given at least 4 weeks before or after the first-generation smallpox vaccine. Current local immunization guidelines and prescribing information for individual vaccines should be consulted for specific recommendations.