The Australian Immunisation Handbook 10th Edition 2013

3.3.5 Vaccination of persons with bleeding disorders
Persons who are receiving anticoagulant therapy may develop haematomas in
IM injection sites. The length of anticoagulant therapy should be clarified and
immunisation delayed if therapy is going to be of short-term duration. Unless
warfarin or low molecular weight heparin (LMWH) doses are known to be
stable, persons receiving anticoagulants should have appropriate levels checked
before vaccine administration, if possible. Intramuscular injections should be
deferred if the INR is >2.0 (warfarin) or the anti-Xa (LMWH) level 4 hours post
dose is >0.5 Units/mL.
If a person has haemophilia and is receiving clotting factor replacement or similar
therapy, IM vaccine administration should be conducted as soon as possible after
the medication is received. 163 The site should not be rubbed post administration,
but firm pressure applied for approximately 5–10 minutes. Vaccine recipients
and/or carers should be informed about the possibility of haematoma formation.
Ice and immobilisation may be used in the case of a small haematoma. The
subcutaneous route could be considered as an alternative in a person with
haemophilia or on anticoagulant therapy; however, the intramuscular route is
preferred if that is the usual recommended mode of vaccine administration –
seek expert advice. If a vaccine is administered subcutaneously, there may be
diminished immune response (e.g. requirement to check anti-HBs antibodies)
and additional vaccine doses may be required. 164,165
3.3.6 Vaccination before or after anaesthesia/surgery
Recent or imminent surgery is not a contraindication to vaccinations, and
recent vaccination is not a contraindication to surgery (see 2.1.4 Pre-vaccination
screening). There are no randomised controlled trials providing evidence of
adverse outcomes with anaesthesia and surgery in recently vaccinated children.
It is possible that the systemic effects from recent vaccination, such as fever and
malaise, may cause confusion in the post-operative period. As the evidence
is limited, it is possible to administer vaccines as per the routine schedule,
or electively during a procedure for a person in a special risk group, if the
appropriate vaccine delivery safety mechanisms are in place. 166
If elective surgery and anaesthesia are to be postponed, some guidelines
recommend postponing for 1 week after inactive vaccination and for 3 weeks
after live attenuated viral vaccination in children. Routine vaccination may be
deferred for 1 week after surgery. 167
A person who receives any blood products during surgery will need to be
informed of the need to delay some vaccinations (see Table 3.3.6 Recommended
intervals between either immunoglobulins or blood products and MMR, MMRV or
varicella vaccination).
168 The Australian Immunisation Handbook 10th edition