Which of the Hepatitis A (Hep A) and Hepatitis B (Hep B) vaccines and the Measles, Mumps, and Rubella (MMR) and Varicella vaccines can be administered together?

Hepatitis A, Hepatitis B, MMR, and Varicella Vaccines: Simultaneous Administration Guidelines

All four vaccines (Hepatitis A, Hepatitis B, MMR, and Varicella) can be safely and effectively administered together at the same visit at different anatomic sites. 1

Evidence for Simultaneous Administration

Hepatitis A with Other Vaccines

• Hepatitis A vaccine can be safely administered simultaneously with:
  • DTaP (diphtheria, tetanus, acellular pertussis)
  • Poliovirus vaccines (oral and inactivated)
  • Haemophilus influenzae type b (Hib)
  • Hepatitis B
  • MMR vaccines 1

MMR and Varicella

• MMR and varicella vaccines can be administered on the same day
• Response to MMR and varicella vaccines administered on the same day is identical to vaccines administered a month apart 1
• When not given on the same day, MMR and varicella vaccines should be separated by at least 4 weeks 1

Hepatitis B with Other Vaccines

• Hepatitis B vaccine can be administered simultaneously with other vaccines, including Hepatitis A 1
• The combined Hepatitis A and B vaccine (Twinrix) is available for adults 18 years and older in the US 1

Practical Administration Guidelines

1. Same-day administration: All four vaccines can be given during the same visit

   • Each vaccine should be administered at a different anatomic site
   • Use separate syringes for each vaccine
   • Document each injection site

2. Injection site recommendations:

   • For multiple injections in the same limb, separate injection sites by at least 1 inch
   • For children 12-15 months: Consider deltoid and anterolateral thigh for multiple injections
   • For older children and adults: Both deltoids and anterolateral thighs can be used

3. If not administered simultaneously:

   • Inactivated vaccines (Hepatitis A and B) can be given at any interval before or after other inactivated or live vaccines
   • Live vaccines (MMR and Varicella) should be given either on the same day OR separated by at least 4 weeks 1

Special Considerations

Immune Globulin Interactions

• If immune globulin (IG) is administered for hepatitis A prophylaxis:
  • MMR administration should be delayed for >3 months
  • Varicella vaccine should be delayed for >5 months 1
  • If MMR or varicella vaccine is given <2 weeks before IG administration, revaccination should occur after the appropriate interval 1

Combined Vaccines

• For adults, consider the combined Hepatitis A and B vaccine (Twinrix), which provides dual protection with fewer injections 2, 3, 4
• Twinrix has shown immunogenicity comparable to separate vaccines with potentially better compliance 5, 6

Common Pitfalls to Avoid

1. Delaying vaccines unnecessarily:

   • There is no medical basis for administering MMR components separately 1
   • Delaying vaccines increases the risk of missed vaccination opportunities 1

2. Incorrect spacing of live vaccines:

   • If MMR and varicella are not given on the same day, they must be separated by at least 4 weeks 1
   • Administering live vaccines less than 4 weeks apart may result in suboptimal immune response

3. Forgetting documentation:

   • Carefully document all vaccines administered to avoid unnecessary revaccination or missed doses
   • Record vaccine lot numbers, administration sites, and dates

By following these guidelines, healthcare providers can ensure optimal protection against hepatitis A, hepatitis B, measles, mumps, rubella, and varicella while minimizing the number of visits required for complete vaccination.