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November 28, 2006

Advisory No. 4. Updated Recommendations on the Prevention of Varicella

The goal of the Vaccine Advisory is to disseminate, in a timely manner, practical information related to vaccines, vaccine-preventable diseases, and the vaccine programs managed by the Immunization Branch. The Immunization Branch welcomes readers’ input to improve the contents of this document.

November 28, 2006

Advisory No. 4. Updated Recommendations on the Prevention of Varicella

In June 2005 and June 2006, the ACIP made policy changes for use of live, attenuated varicella-containing vaccines for prevention of varicella. Changes include routine two dose varicella vaccination of children and second dose catch-up varicella vaccination for children, adolescents and adults who previously had received only one dose. The ACIP also expanded recommendations for varicella-containing vaccines to promote wider use of the vaccine for adolescents, adults, and HIV-infected children and approved new criteria for evidence of immunity to varicella. In August 2006, the ACIP published the Provisional Recommendations for Prevention of Varicella.

This advisory contains:

1. Background information
2. Summary of ACIP‘s provisional recommendations for the varicella vaccine
3. Texas Vaccines for Children program
4. ImmTrac
5. Texas school and child-care facilities requirements for the varicella vaccine
6. Epidemiology and surveillance
7. Reporting vaccine adverse events
8. Resources (Vaccines)
9. Resources (Disease)

1) Background
In August 2006, the ACIP posted provisional recommendations, for use of live, attenuated varicella-containing vaccines for prevention of varicella.  These incorporate the June 2005 and June 2006 changes, and supersede the 1999 recommendations.  The tentative date for publication of the final recommendations is January 2007. 

2) Summary of ACIP Recommendations
Changes include a routine two dose varicella vaccination of children and a second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received only one dose. The ACIP also expanded recommendations for varicella-containing vaccines to promote wider use of the vaccine for adolescents, adults, and HIV-infected children and approved new criteria for evidence of immunity to varicella.   Highlights follow:

• All children < 13 years of age should be administered routinely two doses of varicella-containing vaccine, with the first dose administered at 12-15 months of age and the second dose at 4-6 years of age (i.e. before a child enters kindergarten or first grade). 
• A second dose catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose.   The ACIP now recommends that all people >= 13 years of age without evidence of immunity be vaccinated with two doses of varicella vaccine.
• Revised criteria for evidence of immunity include changes for people reporting a history of varicella or presenting with atypical and/or mild cases.  Please refer to the ACIP recommendations for details.

3) Texas Vaccines for Children (TVFC) Program
Beginning October 20, 2006, the second dose varicella recommendations were added to the Texas Vaccines for Children (TVFC) Program. 

Providers should use the current ordering process, the TVFC Biological Order Form (C-68), to order the additional varicella doses needed to provide the recommended second dose for children 4 to 18 years of age.

Children eligible for TVFC varicella vaccine must meet TVFC eligibility criteria, be between 12 months and 18 years of age, and not have evidence of varicella immunity. 

The two-dose varicella vaccination schedule is similar to the measles, mumps, and rubella (MMR) vaccination schedule. Measles, mumps, rubella, and varicella (MMRV) vaccine is licensed and indicated for simultaneous vaccination against measles, mumps, rubella, and varicella among children 12 months through 12 years of age.  The minimum interval for the MMRV vaccine, ProQuad®, is three months.

Contraindications and precautions to the use of varicella vaccine.

For other questions or information, please contact your health service region, or TVFC consultant.

4) ImmTrac
ImmTrac users can report varicella vaccines administered using the ImmTrac code: “VAR.”  ImmTrac users can report evidence of varicella disease or immunity to varicella using the code:  “VAR-HadVar.”  The code “HAR-HadVAR” will appear adjacent to “VAR” (Varicella Vaccine) on the vaccine drop-down box when adding immunizations to a client record.  When "VAR-HadVAR" is selected, the description: “Had Chickenpox” will appear on the client’s Immunization History Report.  Although ImmTrac can record varicella vaccine doses administered and doses will be reflected on the client immunization history, the ImmTrac immunization scheduler will not currently generate recommendations for routine two-dose varicella vaccination for children <13 years of age.  Modifications to the ImmTrac scheduler will be implemented after CDC publication of recommendations. For more information about ImmTrac, please refer to: www.ImmTrac.com.

5) Texas school requirements for the second varicella vaccine
The immunization requirements for school and child-care facilities remain the same. 

6) Epidemiology and Surveillance
In 2005, Texas reported 8,336 cases of varicella.  Fifty-two percent of the cases had previously been vaccinated with one dose of varicella vaccine. The majority of cases occurred among children five to nine years of age (61percent).

Laboratory confirmation of varicella zoster virus is not normally required, because varicella diagnosis is most commonly made by clinical assessment. Laboratory testing has been recommended to confirm the diagnosis of severe or unusual cases or to determine susceptibility to varicella. However, as varicella incidence continues to decline, the likelihood of clinical misdiagnosis increases. Varicella in vaccinated persons is usually mild or atypical and can pose particular challenges for clinical diagnosis. Therefore, laboratory confirmation of varicella cases is becoming more important, as fewer cases are seen and a higher proportion of these few are vaccinated.  The ideal testing for confirmation of varicella is a culture of a skin lesion.  For instructions on how to obtain this type of specimen, please watch the video produced by the CDC.  

In addition to the culture, serological specimens can be obtained and tested for IgG and IgM antibodies to varicella.  Ideally an acute and convalescent specimen should be obtained. Both serological and virological specimens should be submitted to the state lab for testing. 

7) Reporting adverse vaccine events
Clinically significant adverse events following vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS).  

Adverse events from privately purchased vaccine may be reported directly to VAERS. Secure web-based reporting is available on the VAERS website.  Contact 800-VAC-RXNS for forms and information.

A copy of the VAERS form is also available in the Texas Vaccines for Children toolkit. To request a VAERS form or additional information, call the VAERS contact in your area: 

• In Texas: 800.252.9152
• For Bexar County: 210.207.2087
• For City of Houston: 713.558.3518

8) Resources (Vaccines)

CDC Varicella webpage   

VARIVAX® package insert

ProQuad® package insert

CDC Varicella Vaccine Information Statement

The DSHS Addendum to varicella VIS (Scroll down to number 2)

Immunization Action Coalition: Ask the Experts.  

9) Resources (Diseases)

DSHS Infectious Disease Control Unit varicella webpage  (includes reporting information)
Medline Plus

We hope you generously forward this advisory to others who may benefit from this information.  

Texas Department of State Health Services Immunization Branch
P.O. Box 149347, Austin, Texas, 78714-9347. 1-800.252.9152
www.ImmunizeTexas.com

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Last Updated September 20, 2007