Varicella (Chickenpox) Vaccine


Article Author:
Vasudha Kota
Carlee Lenehan


Article Editor:
Marc Grella


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
9/3/2019 10:46:59 AM

Indications

Varicella or chickenpox is a common and highly contagious exanthematic disease caused by the varicella-zoster virus (VZV) that during primary infection can establish latency. VZV reactivation, even decades after primary infection, causes herpes zoster.  Varicella still represents the most widespread vaccine-preventable childhood infectious disease in industrialized countries; due to its relevant burden on healthcare resources, several countries have introduced varicella vaccination into the recommended routine childhood national immunization schedule.[1] Varicella-zoster virus (chickenpox)  was very common in children in the United States before the universal vaccination program came into existence.[2] The varicella-zoster virus manifestations are usually very mild and self-limited, but in young infants and adults, the complications can be life-threatening. Luckily, the varicella-zoster virus is a vaccine-preventable disease, and the FDA approves the use of the live varicella virus vaccine to provide immunity for the prevention of varicella in individuals 12 months and older.  Current vaccines against varicella and herpes zoster are not 100% efficacious. Specifically, studies have shown that one dose of varicella vaccine can lead to breakthrough varicella, albeit rarely, in children and a 2-dose regimen is now recommended.[3] The varicella vaccine is used routinely in children with two doses.

The first dose is given to children between 12 to 15 months of age, and administration of the second dose is for children between 4 to 6 years old.[4][5] If three months have passed since the first dose, one may opt to give the second dose earlier. If a child has never been vaccinated or had chickenpox, the practitioner should give the two doses at least 28 days apart. One may give the varicella vaccine at the same time as other vaccines; however, evidence demonstrates that there is an increase in the breakthrough disease when the varicella vaccine adminsitration is within four weeks of the measles-mumps-rubella (MMR) vaccine. The recommendation is to give the vaccines simultaneously in different injection sites or to give them four weeks apart. There also exists a quadrivalent combination vaccine called MMRV, which consists of MMR and varicella and may be provided in place of the two individual doses if the child is younger than 12 years old. The FDA has not approved the use of this vaccine in pregnancy and requires intense immune status evaluation in individuals with a family history of congenital immunodeficiencies.[6][7] The varicella vaccine is now FDA approved to give as postexposure use and for outbreak control. The vaccine should be given as soon as possible after exposure, but when it is given within three or five days post-exposure, it has shown effectiveness in preventing or modifying disease. Oral acyclovir administered in the incubation period of the virus may also modify varicella disease in a healthy child. However, this practice has not yet been FDA approved and needs further evaluation. There also exists a high-titer anti-varicella virus immune globulin which can be used as prophylaxis in immunocompromised children, pregnant women, and newborns exposed to varicella. Another indication for prophylaxis with the immune globulin is in close contact with a high-risk susceptible individual and someone who has herpes zoster.[8][9][10]

You can demonstrate evidence of immunity to varicella by showing documentation. The following documentation will prove age-appropriate vaccination with varicella vaccine:

  • Preschool-age children (older than 12 months): one dose
  • School-age children, adolescents, and adults: two doses
  • Laboratory evidence or confirmation of the disease
  • Birth in the United States before 1980; unless one is immunocompromised, a pregnant woman, or a health care worker (born before 1980 does not count as evidence of immunity in this population)
  • Diagnosis or verification of a history of varicella disease by a healthcare provider
  • Diagnosis or verification of a history of herpes zoster by a healthcare provider

Mechanism of Action

The varicella-zoster vaccine contains live attenuated varicella-zoster vaccine (Oka strain). This vaccine induces both humoral and cell-mediated immune response. It produces an IgG humoral immune response in individuals, and the cell-mediated immune response is by varicella-zoster-specific activation of both CD4+ T-helper and CD8+ T-lymphocyte cells. The duration of protection currently still unknown; however, there is evidence shown in some efficacy trials that the vaccine can offer continued protection for up to ten years after vaccination. 

Administration

The varicella vaccine is only available to be administered subcutaneously. It is best when practitioners inject the vaccine in the outer aspect of the upper arm in the deltoid region or anterolateral thigh.

The FDA has not yet approved intravenous (IV) or intramuscular (IM) use.

Adverse Effects

Varicella vaccine is safe and well-tolerated. According to some sources, the incidence of injection site complaints after vaccination was slightly higher after the second dose than the first. The most commonly reported adverse effect is soreness or swelling at the injection site.

Some other mild reported reactions include fever and mild vaccine-associated varicelliform rash. The rash comprises six to ten papular, vesicular, erythematous lesions which peak around eight to 21 days after injection. It is rare, but when an individual has this rash after getting the vaccine, other household members are susceptible to transmission.

Some of the moderate reported reactions include a fever that causes a low-grade seizure (showing jerking or staring), but this is rare and more frequently reported with the MMRV vaccine five to 12 days after the vaccine, and upper respiratory infection which can include a cough, chest pain, and difficulty breathing.

Serious reported reactions include pneumonia, low blood cell count, and severe brain reactions. These are all extremely rare, and researchers still do not understand if the vaccine causes these reactions.

After administration of the vaccine, it is recommended to avoid salicylates for five weeks due to the risk of Reyes syndrome and to avoid contact with susceptible high-risk individuals.

Contraindications

The varicella vaccine is contraindicated in individuals who have a severe allergy or have had an anaphylactic reaction to neomycin or gelatin, which are components of this vaccine, or to the previous dose of a varicella-containing vaccine.[11][12]

It is also contraindicated in individuals who are immunosuppressed or immunodeficient in any of the following ways:

  • Severe combined immunodeficiency, lymphoma, leukemia, AIDS, blood dyscrasias, hypogammaglobulinemia, agammaglobulinemia, IgA deficiency, malignant neoplasms affecting the bone marrow or lymphatic system, patients receiving steroids, chemotherapy, or X-rays as a treatment for cancer or X-rays
  • Any patient showing clinical signs of infection with HIV
  • Any person who has a family history of congenital or hereditary immunodeficiency in first-degree relatives unless there is demonstrable immunocompetence of the potential vaccine recipient

Patients can not receive the vaccine if they present with febrile illness or have active, untreated tuberculosis.

Vaccination is contraindicated in pregnant females, and women should delay pregnancy for three months after vaccination with the use of effective birth control. Maternal varicella infection has shown to harm the fetus, but the vaccination effects have not had testing on pregnant women, and the effects on fetal development are currently unknown. It is also not known whether the varicella vaccine virus is passed in breast milk and is best to avoid vaccination during breastfeeding for that reason.

There is currently no clinical data available on the efficacy or the safety of administration of the varicella vaccine in children younger than 12 months old.

Enhancing Healthcare Team Outcomes

All healthcare workers, including the nurse and pharmacist, are frontline professionals when it comes to the prevention of chickenpox. Because of the anti-vaccination hysteria, healthcare professionals must educate the public on the importance of vaccination. For children who do develop an infection, the parents should receive education on trimming the child's fingernails to minimize excoriation marks and bacterial superinfections. The pharmacist should warn the parents not to administer aspirin to young children with fever because of the risk of Reye syndrome. All pregnant women who develop chickenpox should obtain a referral to an infectious disease specialist regarding treatment. Further, postpartum women with chickenpox should be encouraged to breastfeed if they desire because it is safe.[10][13][14] (Level V)

Outcomes

Chickenpox in a healthy individual is a self-limiting illness with an excellent outcome. However, in immunocompromised individuals, the infection can be associated with very high morbidity and mortality. The currently available Varicella vaccine is safe and well-tolerated. According to some sources, the incidence of injection site complaints after vaccination was slightly higher after the second dose than the first. The most commonly reported adverse effect is soreness or swelling at the injection site.[15][16] [Level V]

Varicella/herpes zoster vaccines require the collaboration of the entire interprofessional healthcare team. In many states, pharmacists are empowered to administer the vaccine in the pharmacy, and they must let the patient's physician know so records can be updated appropriately. Physicians, nurses, and pharmacists all bear responsibility for patient counseling, as well as ensuring the patient is a viable vaccine candidate, in line with the restrictions outlined above. Should they encounter any of these contraindications, they must communicate them to the entire healthcare team, so all members are on the same page and patient records can be updated. This interprofessional approach ensures maximal effectiveness for varicella/herpes zoster vaccination strategies. [Level V]


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Varicella (Chickenpox) Vaccine - Questions

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A 7-year-old boy comes to the clinic with symptoms of mild fever and flu-like symptoms from the past four days. He plays with his neighbor who had similar symptoms. They recently immigrated from India and the mother is not aware of the immunization history of the child. She noticed a few fluid-filled blisters on his chest today. Which of the following vaccine could have prevented this child's condition?



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A 4-year-old boy comes to the clinic with his mother to receive his vaccines. His mother is concerned that the child developed mild fever and soreness of the arm following his first dose of varicella vaccine. She enquires whether her child can receive the booster dose of varicella today. Which of the following is the best step regarding this child's vaccination?



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A 23-year-old female college student comes to the student health center with to 2 weeks of "not feeling well." She has not attended classes for the past several days due to myalgia and fatigue. The patient has also had intermittent fever, headache, dry cough, and malaise. Due to weak appetite and frequent episodes of diarrhea, she has lost a significant amount of weight over the same period. The patient has also had excessive dandruff and scaly facial rash despite using the same shampoo and cosmetic products as before. She has a history of unprotected sexual intercourse with three male partners in the past. Physical examination shows pallor and white lesions over the tongue and buccal mucosa. Which of the following vaccines is contraindicated in this patient?



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A 17-year-old woman who works in a daycare presents to the outpatient clinic with symptoms of low-grade fever and itchy rashes over her body. On examination, the rashes are in different stages showing few papules, few blisters, and few scabs. She has not received her childhood immunizations due to religious beliefs. What is the mode of administration of the vaccine that is used to prevent this condition?



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A 23-year-old female college student comes to the student health center due to 2 weeks of "not feeling well." She has not attended classes for the past several days due to myalgia and fatigue. The patient has also had intermittent fever, headache, dry cough, and malaise. Due to weak appetite and frequent episodes of diarrhea, she has lost a significant amount of weight over the same period. The patient has also had excessive dandruff and scaly facial rash despite using the same shampoo and cosmetic products as before. She also mentions having unprotected sexual intercourse with 3 male partners in the past. Physical examination shows pallor and white lesions over the tongue and buccal mucosa. Her initial labs reveal a positive HIV test. Which of the following vaccines is contraindicated in this patient?



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An 11-year-old boy is brought to the clinic by his mother with symptoms of low-grade fever, headache, and fatigue for 3 days. Today morning his mother noticed a few red bumps and small fluid-filled blisters on his chest. The patient complains that the rash is itchy. Which of the following is the likely cause of his symptoms?



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A healthy 12-month-old boy is brought for a routine examination. He started walking last week and can say "mama," "dada," "night-night," and "go." He eats a well-rounded diet and drinks whole milk twice a day. The patient lives with his mother, who is 17 weeks pregnant. His growth parameters and physical examination are normal. He is scheduled to receive measles-mumps-rubella, varicella, inactivated poliovirus, and pneumococcal conjugate vaccinations today. Which of the following is the best next step in the management of this patient?



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A 12-month-old child has received vaccination for a disease that causes itchy rashes, fever, malaise, and fluid-filled blisters. Which of the following medications is contraindicated in this child for a short term period?



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A 4-year-old girl is brought to the clinic by her father for a routine well-child visit. She is scheduled for her age-appropriate vaccinations today. Her father complains that the child developed life-threatening anaphylactic reaction following her first dose of varicella immunization which required epinephrine administration. He is concerned about the booster dose of the vaccine today. Which of the following would be the best approach?



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A 13-month-old boy is brought to the office for a routine checkup. The patient has no other past medical history and has met all developmental milestones. He takes no medications, and his immunizations are up-to-date. The patient is allergic to penicillin, which causes a rash. His older sister was diagnosed with infantile-type polycystic kidney disease and underwent kidney transplantation two months ago. She is receiving immunosuppressive therapy. The patient is scheduled to receive the varicella vaccine today. Which of the following is the most accurate statement regarding varicella vaccination in this patient?



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A 23-year-old G1P0 presents for a first-trimester prenatal visit. The standard first-visit tests included blood type and screen, Rh type, CBC, urinalysis, Pap smear, and vaccine status. You find that the patient is Varicella nonimmune. What is the next best step to perform in this patient?



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Varicella (Chickenpox) Vaccine - References

References

Walker TY,Elam-Evans LD,Yankey D,Markowitz LE,Williams CL,Mbaeyi SA,Fredua B,Stokley S, National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13-17 Years - United States, 2017. MMWR. Morbidity and mortality weekly report. 2018 Aug 24     [PubMed]
Gray SJ,Cathie K, Fifteen-minute consultation: Chickenpox vaccine-should parents immunise their children privately? Archives of disease in childhood. Education and practice edition. 2018 Aug 4     [PubMed]
Ong CY,Low SG,Vasanwala FF,Baikunje S,Low LL, Varicella infections in patients with end stage renal disease: a systematic review. BMC nephrology. 2018 Jul 24     [PubMed]
Lo Presti C,Curti C,Montana M,Bornet C,Vanelle P, Chickenpox: An update. Medecine et maladies infectieuses. 2018 May 19     [PubMed]
Chan DYW,Edmunds WJ,Chan HL,Chan V,Lam YCK,Thomas SL,van Hoek AJ,Flasche S, The changing epidemiology of varicella and herpes zoster in Hong Kong before universal varicella vaccination in 2014. Epidemiology and infection. 2018 Apr     [PubMed]
Varicella and herpes zoster vaccines: WHO position paper, June 2014--Recommendations. Vaccine. 2016 Jan 4     [PubMed]
Doret M,Marcellin L, [Vaccination in the early post-partum: Guidelines]. Journal de gynecologie, obstetrique et biologie de la reproduction. 2015 Dec     [PubMed]
Baracco GJ,Eisert S,Saavedra S,Hirsch P,Marin M,Ortega-Sanchez IR, Clinical and economic impact of various strategies for varicella immunity screening and vaccination of health care personnel. American journal of infection control. 2015 Oct 1     [PubMed]
Malaiya R,Patel S,Snowden N,Leventis P, Varicella vaccination in the immunocompromised. Rheumatology (Oxford, England). 2015 Apr     [PubMed]
Dolan SB,Libby TE,Lindley MC,Ahmed F,Stevenson J,Strikas RA, Vaccination policies among health professional schools: evidence of immunity and allowance of vaccination exemptions. Infection control and hospital epidemiology. 2015 Feb     [PubMed]
Updated recommendations for use of VariZIG--United States, 2013. MMWR. Morbidity and mortality weekly report. 2013 Jul 19     [PubMed]
Lopez AS,Cardemil C,Pabst LJ,Cullen KA,Leung J,Bialek SR, Two-dose varicella vaccination coverage among children aged 7 years--six sentinel sites, United States, 2006-2012. MMWR. Morbidity and mortality weekly report. 2014 Feb 28     [PubMed]
Ackerson BK,Li BH,Sy LS,Cheetham TC,Jacobsen SJ, Association of the use of MMRV in infants by pediatric infectious disease specialists with that of other affiliated providers. Vaccine. 2014 Apr 1     [PubMed]
Szucs TD,Pfeil AM, A systematic review of the cost effectiveness of herpes zoster vaccination. PharmacoEconomics. 2013 Feb     [PubMed]
Gabutti G,Franchi M,Maniscalco L,Stefanati A, Varicella-zoster virus: pathogenesis, incidence patterns and vaccination programs. Minerva pediatrica. 2016 Jun;     [PubMed]
Haberthur K,Engelmann F,Park B,Barron A,Legasse A,Dewane J,Fischer M,Kerns A,Brown M,Messaoudi I, CD4 T cell immunity is critical for the control of simian varicella virus infection in a nonhuman primate model of VZV infection. PLoS pathogens. 2011 Nov;     [PubMed]

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