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For the first dose, CDC recommends that MMR and varicella vaccines be given separately in children age 12 months through age 15 months unless the parent or caregiver expresses a preference for MMRV vaccine. Both vaccines may be given at the same time as other vaccines for children age 12 months through 15 months and age 4 years through 6 years. People who got varicella vaccine but should not have because of contraindications should be monitored for adverse reactions. People who had varicella or a positive serologic test for varicella in the past are less likely to develop serious adverse reactions to the vaccine, unless they have had a prior serious allergic reaction to any ingredient of a vaccine.
For more information about potential adverse reactions, see Vaccine Safety. Pregnant women should not get vaccinated. To report administration of VZV-containing vaccines to a pregnant woman, call the manufacturer at During this period, no cases of congenital varicella syndrome and no increased prevalence of other birth defects were detected.
Recently vaccinated healthcare personnel do not require any restriction in their work activities. However, healthcare personnel who develop varicella-like rash after vaccination should stay away from people who do not have evidence of immunity and are at risk for severe varicella.
They should wait until all lesions resolve crust over. If they develop lesions that do not crust macules and papules only , they should wait until no new lesions appear within a hour period. The Advisory Committee on Immunization Practices ACIP recommends that after being exposed to varicella or herpes zoster, people who do not have evidence of immunity and are eligible for vaccination should get varicella vaccine.
People who previously got the first dose should get a second dose at the appropriate time interval. For more information, see About the Varicella Vaccines. Varicella vaccination is recommended for controlling outbreaks. People who do not have evidence of immunity should get a first or second dose as needed. For information about chickenpox varicella outbreaks, see Outbreak Identification, Investigation, and Control. See Managing People at Risk of Severe Varicella for information on prevention and treatment options for people at risk of severe varicella who cannot get vaccinated.
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ACIP recommends giving a dose of MMR to infants age 6 through 11 months before international travel, but not varicella vaccine. Varicella vaccine is neither approved nor recommended for children younger than age 12 months in any situation.
Can varicella vaccine be used as postexposure prophylaxis for a 9-month-old who was exposed to herpes zoster? Varicella vaccine is neither approved nor recommended for children younger than age 12 months. Assuming that the child is not immunocompromised, varicella zoster immune globulin VariZIG is also not recommended. If the child had a condition which was considered to place the child at greater risk for complications than the general population, then VariZIG could be considered see the Varicella Zoster Immune Globulin section below and www.
ACIP does not have a recommendation for acyclovir for varicella postexposure prophylaxis. The American Academy of Pediatrics provide some guidance on this issue in the current edition of the Red Book.
If a healthcare worker does not have a history of varicella vaccination or disease but has had a clinically diagnosed case of shingles, does she or he still need varicella vaccination? A healthcare provider's diagnosis or verification of a history of shingles is acceptable evidence of immunity to varicella.
According to ACIP, acceptable evidence of varicella immunity in healthcare personnel includes 1 documentation of 2 doses of varicella vaccine given at least 28 days apart, 2 history of varicella or herpes zoster based on clinician diagnosis, 3 laboratory evidence of immunity, or 4 laboratory confirmation of disease.
I have a patient who is 62 years old and is immigrating to the U. She received a dose of live zoster vaccine at age The immigration requirements state she should receive 2 doses of varicella vaccine. Does she need additional varicella vaccine? To meet the immigration requirements, the dose of live zoster vaccine counts as the first dose of the varicella vaccine series. You should give a dose of varicella vaccine now since it has been more than 4 weeks since the dose of live zoster vaccine.
The varicella vaccine dose may not be needed, but it will not be harmful and will allow your patient to meet the regulatory requirement. Concerning the recommendation for a second dose of varicella vaccine, does CDC recommend that a teen who received only one varicella vaccine when they were preschool age get a second dose now?
The current recommendation is for 2 doses regardless of age, for anyone school age and older without evidence of immunity. For everyone whose varicella immunity is based on vaccination, 2 doses of varicella vaccine are recommended.
Originally, ACIP only recommended one dose of varicella vaccine for children. Why did ACIP later revise its recommendations to add a second dose of varicella vaccine for all children? In the ten years following vaccine licensure in , there was a significant decline in varicella disease, as well as varicella-related hospitalizations and deaths. A 2-dose regimen was adopted in to further reduce the risk of disease among vaccinated people whose numbers would accumulate over time, which could lead to varicella disease later in life when it can be more severe.
Should a child who has had chickenpox prior to the first birthday get the first dose of varicella vaccine at age 1 year? If the child had confirmed varicella disease or laboratory evidence of prior disease, it is not necessary to vaccinate regardless of age at infection. If there is any doubt that the illness was actually varicella, the child should be vaccinated. How important is it to vaccinate older children and adults? It is critical to vaccinate susceptible older children and adults whenever the opportunity arises.
With younger children being routinely vaccinated, the chance of being exposed to cases of chickenpox is decreasing. Older children, adolescents, and adults who have not had chickenpox now have a greater chance of remaining susceptible.
These older individuals, when they contract chickenpox, are more likely to become seriously ill and have disease complications than younger children. If an adult or child has not had documented chickenpox but has had shingles, is varicella vaccination recommended? Shingles is caused by varicella zoster virus, the same virus that causes chickenpox. A history of shingles based on a healthcare provider diagnosis is evidence of immunity to chickenpox.
A person who has had shingles does not need to be vaccinated against varicella. Can we accept receipt of a single documented dose of live zoster vaccine as proof of varicella immunity in a healthcare employee who has no other evidence of immunity? Receipt of live zoster vaccine is not proof of prior varicella disease.
According to CDC, acceptable evidence of varicella immunity in healthcare personnel includes 1 documentation of 2 doses of varicella vaccine given at least 28 days apart, 2 history of varicella or herpes zoster based on clinician diagnosis, 3 laboratory evidence of immunity, or 4 laboratory confirmation of disease.
If a healthcare employee has received a dose of live zoster vaccine in the past but has no other evidence of immunity to varicella, the live zoster dose can be considered the first dose of the 2-dose varicella series. Note that recombinant zoster vaccine RZV, Shingrix cannot be counted as the first dose in a 2-dose varicella vaccination series. Should a person who received 2 doses of varicella vaccine be vaccinated for herpes zoster when they turn 50?
In its recommendations for the prevention of herpes zoster, ACIP states that Shingrix may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine Zostavax, Merck.
For details, see www. A mild case of chickenpox produces immunity to varicella as does a moderate or severe case. A child with a reliable history of chickenpox does not need to receive varicella vaccine.
However, if there is any doubt that the mild illness really was chickenpox, it is best to vaccinate the child. There is no harm in vaccinating a child who is already immune. I understand that varicella vaccine can be used in postexposure settings. How soon after exposure does the vaccine need to be administered? Varicella vaccine is effective in preventing chickenpox or reducing the severity of the disease if used within 72 hours 3 days , and possibly up to 5 days after exposure.
However, not every exposure to varicella leads to infection, so for future immunity, varicella vaccine should be given, even if more than 5 days have passed since an exposure. A healthcare worker with no history of chickenpox, and unknown serologic immunity, was exposed to a patient with zoster. She received varicella vaccine two days later. She developed a pruritic maculopapular rash 11 days after vaccination.
Is the rash from the vaccine or from her zoster exposure? The only way to determine whether the rash is caused by wild-type varicella or vaccine virus is to try to isolate virus from the rash and send it to a laboratory that is capable of differentiating wild and vaccine-type virus.
This is generally not practical. Given the history, the conservative approach is to assume she has an active case of chickenpox and act according to your infection control guidelines. Does varicella vaccine affect tuberculosis skin test readings in the same way that MMR does?
There is currently no information on the effect of varicella vaccine on reactivity to a tuberculin skin test TST. Until information is available, it is prudent to apply the same rules to varicella vaccine as are applied to MMR: a TST i. If vaccine has been given, delay the TST for at least 4 weeks. How has widespread use of varicella vaccine in children impacted disease? Substantial reductions in varicella morbidity and mortality have occurred following the licensure of vaccine.
For more information on the impact of varicella vaccination see the CDC varicella webpage at www. What are the recommendations for varicella vaccination before and after pregnancy? Live varicella vaccine should not be given to a woman who is known to be pregnant or who plans to become pregnant within one month.
If a woman who is planning to become pregnant in the future comes in for a visit or an annual exam, her varicella history should be obtained and if indicated, 2 doses of vaccine should be given, spaced 4 to 8 weeks apart.
Pregnant women should be assessed for evidence of varicella immunity and if non-immune, should receive the first dose of varicella vaccine following completion of the pregnancy and prior to hospital discharge. A second dose should be given 4 to 8 weeks later. Can a pregnant healthcare worker with a history of varicella infection care for a patient with varicella? Is it possible for her to have a declining titer, thus making her susceptible to the virus again? People with a reliable history of varicella can be considered to be immune.
A reliable history for healthcare personnel consists of 1 a healthcare provider's diagnosis of varicella or verification of history of varicella disease; 2 a history of herpes zoster, based on healthcare provider diagnosis; or 3 laboratory evidence of immunity or laboratory confirmation of disease.
Immunity following disease or vaccination is probably life-long. More than one primary infection with varicella is unusual. Should all pregnant women have serology screening for varicella? Serologic testing for varicella should be considered only for women who do not have evidence of immunity reliable history of chickenpox or documented vaccination. Once a person has been found to be seropositive, it is not necessary to test again in the future.
If a woman receives varicella vaccine, how long should she wait before becoming pregnant? Contrary to the information provided in the vaccine package insert, which states that pregnancy should be avoided for 3 months, the ACIP recommends that a wait of 1 month is sufficient. If a woman receives varicella vaccine and subsequently finds out that she is pregnant, what should she be told about the risk to the fetus? To date, no adverse outcomes of pregnancy or in a fetus have been reported among women who inadvertently received varicella vaccine shortly before or during pregnancy.
The risk of congenital varicella syndrome following varicella disease is small, so the risk of congenital anomalies following vaccination with live attenuated varicella zoster virus VZV -containing vaccine is probably very small.
Merck and the Centers for Disease Control and Prevention CDC jointly operated a pregnancy registry for women exposed to VZV-containing vaccines for seventeen years after the licensure of varicella vaccine. The registry was discontinued in , having found no signals to indicate a risk of Congenital Varicella Syndrome or pattern of birth defects related to vaccination with VZV-containing vaccines.
Healthcare providers may continue to report exposure to VZV-containing vaccines within 3 months of conception or during pregnancy by contacting Merck's call center at Scheduling Vaccines Back to top What is the recommended schedule for vaccinating a child?
What about adults? For children, the first dose should be given at age 12 months with a second dose given at age 4 through 6 years. The second dose could be given earlier, if necessary, as long as there is a 3-month interval between doses. All children age 13 years and older as well as adults without evidence of immunity should also have documentation of 2 doses of varicella vaccine, separated by a minimum interval of 4 weeks. Some children in my practice have had only 1 dose of varicella vaccine.
Is there a problem waiting until the to year-old visit to give them the second dose? Don't delay giving the second dose of varicella vaccine.
Give the second dose the next time the child is in your office. In what circumstances should I obtain a varicella titer after vaccination? Postvaccination serologic testing is not recommended in any group, including healthcare personnel. A child received only one dose of varicella vaccine and subsequently tests positive for varicella IgG antibody.
Does the child still need a second dose of varicella vaccine? If a person tests positive for varicella antibody 28 days or more after vaccination, the Advisory Committee on Immunization Practices ACIP considers the person to be immune. CDC prefers that the child receive a second dose to assure long-term immunity, but doing so is not absolutely necessary. You can access the ACIP varicella vaccine recommendations, which include evidence of immunity page 16 at www.
Should I test women for varicella immunity at their first prenatal visit? Test pregnant women who lack either 1 documentation of receipt of 2 doses of varicella vaccine or 2 healthcare provider diagnosis or verification of varicella or herpes zoster disease. Women who are not immune should begin the 2-dose vaccination series immediately postpartum. What is the appropriate lab test to use to determine whether there has been previous chickenpox disease? Commercially available laboratory tests for varicella antibody are usually based on a technique called EIA enzyme immunoassay.
Though these tests are sufficiently sensitive to detect antibody resulting from varicella zoster virus infection, they are generally not sensitive enough to detect vaccine-induced antibody. The more sensitive assays needed to detect vaccine-induced antibody are not widely available. This is why CDC does not recommend antibody testing after varicella vaccination.
I work in employee health. Several hospital employees have told me they have had chickenpox, but their titers show no antibodies. Should I offer varicella vaccination to them even though they insist they've had the illness? If you cannot verify a healthcare employee's history of chickenpox, the employee should receive 2 doses of varicella vaccine at least 4 weeks apart.
A nursing student received 2 valid, documented doses of varicella vaccine. For whatever reason, she subsequently had a titer drawn.
The titer was negative. Do you recommend revaccination with 2 doses of varicella vaccine? Documented receipt of 2 doses of varicella vaccine supersedes results of subsequent serologic testing.
Most commercially available tests for varicella antibody are not sensitive enough to detect vaccine-induced antibody, which is why CDC does not recommend post-vaccination testing.
A child in our practice received her first dose of varicella vaccine when she was 12 months old and her second dose when she was 14 months old. The second dose was only 2 months after the first. Is the second dose valid or does it need to be repeated? The recommended minimum interval between two doses of varicella vaccine for children 12 months through 12 years of age is 12 weeks.
However, the second dose of varicella vaccine does not need to be repeated if it was separated from the first dose by at least 4 weeks.
See www. Contraindications and Precautions Back to top What are the precautions and contraindications to varicella vaccine? For information on vaccine components, refer to the manufacturer's package insert www.
What are the recommendations for the use of varicella vaccine in children with HIV or other immunodeficiencies? The ACIP General Best Practice Guidelines for Immunization section on altered immunocompetence recommends varicella vaccination of children with humoral but not cellular immunodeficiencies. Eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses. Additional details of these recommendations can be found in table and associated footnotes at www.
We have a 40 lb six-year-old patient who has been taking 15 mg of methotrexate weekly for arthritis for 12 months. Can we give the child MMR and varicella vaccine based on this methotrexate dosage? Administration of both varicella and MMR vaccines are contraindicated until such time as the methotrexate dosage can be reduced.
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