Ask the Experts: Administering live vaccines in conjunction with antibody-containing products

Circulating antibodies can inhibit the virus replication process, leading to decreased vaccine efficacy.

Question. What are your recommendations regarding administration of zoster vaccine after a patient has received a blood transfusion? In the past, I have told our pharmacists to wait at least 6 months based on the recommendations for measles–mumps–rubella and varicella vaccines. However, I recently looked it up in the latest edition of the Pink Book, which stated that no time period is recommended.

Answer. When considering administration of live vaccines, concern exists regarding timing around administration of antibody-containing products (e.g., whole blood, packed red blood cells, plasma, immune globulin, specific hyperimmune globulin). To stimulate the immune response and create protective immunity, live vaccines require virus replication within the patient. If antibodies are circulating in the patient at the time of vaccination or within 2 weeks after vaccination, the replication process can be inhibited, leading to decreased vaccine efficacy.1 In the case of the measles and rubella vaccines, this interference with immunity has been seen for more than 3 months following administration of antibody-containing products.2 The Advisory Committee on Immunization Practices (ACIP) recommends specific dose-dependent intervals between measles- or varicella-containing vaccines and antibody-containing products. In addition, it recommends waiting 2 weeks following administration of some live vaccines before giving an antibody-containing product. Literature suggests that antibody-containing products do not affect the efficacy of several live vaccines. ACIP advises that the Ty21a typhoid, yellow fever, live-attenuated influenza vaccine (LAIV), zoster, and rotavirus vaccines can be given without regard to the administration of antibody-containing products.2

Literature regarding the zoster vaccine supports the stance that antibody-containing products are permissible in conjunction with vaccination. Levin et al.3 demonstrated that patients with a history of varicella will have elevated varicella–zoster virus (VZV) antibody titers that do not substantially decline over time. The amount of VZV antibodies in these patients is similar to that found in antibody-containing products, making it unlikely that the antibody-containing products would have a measurable effect on vaccine efficacy. Further, VZV antibodies are not primarily responsible for protection from herpes zoster. The immune response necessary to provide herpes zoster protection is cell-mediated immunity, which has been correlated with vaccine efficacy.3

Similarly, literature on the oral Ty21a typhoid vaccine has shown comparable vaccine efficacy in patients with and without typhoid antibody before vaccination. In a study of 634 Thai children aged 2 to 6 years, 22% had anti–Salmonella typhi antibodies at baseline.4 However, the difference in seroconversion rates between these children and those without antibodies was not statistically significant. Therefore, any typhoid antibody present in blood products should not have an effect on vaccination.

A study of yellow fever vaccination by Kaplan et al.5 revealed no effect of immune globulin on seroconversion rates when given 7 days before or concurrently with the vaccine. In addition, ACIP recommendations note that products available in the United States “are unlikely to contain a substantial amount of antibody to yellow fever vaccine virus.”2 Thus, providers may safely consider administration of yellow fever vaccine concomitantly with blood products.

In the case of LAIV, mumps, varicella, and rotavirus vaccines, little information exists to offer insight into the appropriate administration of these vaccines in conjunction with antibody-containing products. The current ACIP recommendations state that immune globulin products do contain antibodies to mumps and varicella. The only vaccine available in the United States that contains the combination of measles, mumps, and rubella antigens is M-M-R II (Merck Vaccines). Single-antigen vaccines are not available in the United States; therefore, the recommended intervals outlined by ACIP for measles-containing vaccines should be followed for M-M-R II.2 For the LAIV and rotavirus vaccines, current recommendations are that these vaccines may be given without regard to antibody-containing products. The ACIP statement specific to rotavirus acknowledges a possible decrease in vaccine efficacy if given with antibody-containing products, but the risk is offset by the one to two additional vaccine doses in the series.6 More research will be needed to determine the true effects associated with use of antibody-containing products in conjunction with LAIV and rotavirus vaccine.

Nicole H. McClellan

Student Pharmacist
College of Pharmacy
University of Tennessee Health Sciences Center


Stephan L. Foster, PharmD, FAPhA

Professor and Vice Chair
College of Pharmacy
University of Tennessee Health Sciences Center
APhA Liaison Representative to the Advisory Committee on Immunization Practices (ACIP)
CAPT (Ret) U.S. Public Health Service



  1. Centers for Disease Control and Prevention. General recommendations on immunization: epidemiology and prevention of vaccine-preventable diseases. Accessed at, April 24, 2012.
  2. National Center for Immunization and Respiratory Diseases. General recommendations on immunization --- recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60:1–64.
  3. Levin MJ, Oxman MN, Zhang JH, et al. Varicella-zoster virus-specific immune responses in elderly recipients of a herpes zoster vaccine. J Infect Dis. 2008;197:825–35.
  4. Cryz SJ Jr, Vanprapar N, Thisyakorn U, et al. Safety and immunogenicity of Salmonella typhi Ty21a vaccine in young Thai children. Infect Immun. 1993;61:1149–51.
  5. Kaplan JE, Nelson DB, Schonberger LB, et al. The effect of immune globulin on the response to trivalent oral poliovirus and yellow fever vaccinations. Bull World Health Organ. 1984;62:585–90.
  6. Cortese MM, Parashar UD, Centers for Disease Control and Prevention. Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2009;58(RR-2):1–25.