Routine Varicella Vaccination

The Advisory Committee on Immunization Practices (ACIP) recommends that healthy people who do not have evidence of immunity to varicella should get vaccinated against this disease.

Routine 2-dose vaccination

• First dose at 12 through 15 months old
• Second dose at 4 through 6 years old

Second dose catch-up vaccination

• Give ≥3 months after first dose for children <13 years of age

Adolescents and Adults (≥13 years old)

• Give 2 doses 4 to 8 weeks apart
• If it has been more than 8 weeks since the first dose, the second dose may be given without restarting the schedule

Varicella vaccination is especially important for—

• Healthcare professionals
• People who care for or are around immunocompromised people
• Teachers
• Child care workers
• Residents and staff in nursing homes and residential settings
• College students
• Inmates and staff of correctional institutions
• Military personnel
• Women of childbearing age who are not pregnant (women should not get pregnant for 1 month after being vaccinated.)
• Adolescents and adults living with children
• International travelers

For more information, see the ACIP recommendations for varicella vaccination.

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Contraindications for Varicella Vaccination

People with contraindications for varicella vaccine should not receive varicella vaccine, including anyone who—

• has a history of anaphylactic/anaphylactoid reaction to gelatin, neomycin, or any other component of the vaccine
• has blood dyscrasias, leukemia, lymphomas, or malignant neoplasms affecting bone marrow or lymphatic system
• is receiving prolonged, high-dose systemic immunosuppressive therapy (≥2 weeks), including large doses of oral steroids (≥2mg/kg of body weight or a total of 20mg/day of prednisone or its equivalent for people who weigh >10kg)
• has a moderate or severe concurrent illness
• has received blood products (such as whole blood, plasma, or immune globulin) during the previous 3 to 11 months, depending on dosage
• has a family history (first degree relatives) of congenital hereditary immunodeficiency, unless the person is immunocompetent
• is or may be pregnant. For more information, see Guidelines for Vaccinating Pregnant Women: Varicella and Vaccination Recommendations for Specific Groups

Some people with contraindications for varicella vaccine may receive varicella zoster immune globulin after being exposed to varicella. For more information, see Managing People at Risk for Severe Varicella.

 

Precautions for Varicella Vaccination

People with Acute Illness

• People with acute severe illness, including untreated, active tuberculosis, should postpone vaccination until they recover. The decision to delay vaccination depends on the severity of symptoms and the etiology of disease.

 

People with Thrombocytopenia

• Thrombocytopenia is not a contraindication for vaccination with single-antigen varicella vaccine (Varivax®).
• For vaccination of thrombocytopenic children with combination MMRV vaccine (ProQuad®), healthcare providers should refer to the Advisory Committee on Immunization Practices recommendation on MMR vaccination.

 

Recipients of Blood Products

• People who have recently received (within 3 to 11 months depending on dosage) blood, plasma, or immune globulin products should not be vaccinated.
  • Blood, including whole blood, packed red blood cells, and plasma, and other antibody-containing blood products may interfere with the effectiveness of the vaccine.
• People who have received varicella vaccine should not receive blood products for 14 days after being vaccinated unless the benefits of blood product outweigh the need for protection from vaccination.

 

People Receiving Salicylates

• People should avoid using salicylates for 6 weeks after getting varicella vaccine. This is because of the association between aspirin use and Reye syndrome following varicella, and also the potential risk of Reye syndrome if a person is given aspirin after varicella vaccination.
• Take caution when vaccinating children who are receiving salicylates. However, no adverse events have been reported.
• Children with rheumatoid arthritis or other conditions that require therapeutic aspirin should be monitored closely after they get vaccinated.

For more information, see Chart of Contraindications and Precautions for varicella vaccination.

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Varicella Vaccination Recommendations for Specific Groups

Healthcare providers should consider vaccinating people in the following groups who do not have evidence of immunity against varicella—

HIV-infected People

• HIV-infected children ≥12 months old with CD4+ T-lymphocyte percentages ≥15%
• HIV-infected people >8 years old with CD4+ T-lymphocyte counts ≥200 cells/µL
  • There is a lack of data on the use of varicella vaccine in HIV-infected adolescents and adults. The immunogenicity may be lower in these groups compared to children 1 to 8 years old. The benefits of varicella vaccination may outweigh the risk of severe disease from wild-type varicella infection. Therefore, vaccination may be considered in these groups.
  • If vaccination of HIV-infected person results in clinical disease, acyclovir may be used to help prevent severe disease.

HIV-infected people eligible for vaccination should get 2 doses of single-antigen varicella vaccine (Varivax®) separated by 3 months.

HIV-infected children, adolescents, or adults should not get the combination measles, mumps, rubella, and varicella vaccine (ProQuad®).

 

People Who May Have Some Degree of Immunodeficiency

• People with impaired humoral immunity
• People receiving systemic steroids for certain conditions, such as asthma, and who are receiving steroids <2 mg/kg of body weight or total of <20 mg/day of prednisone or its equivalent and are not otherwise immunocompromised
  • There is a lack of data on whether people who use inhaled, nasal, or topical steroids can be vaccinated safely. However, based on clinical experience, these people can generally tolerate vaccination well
  • Some experts suggest withholding steroids for 2 to 3 weeks after vaccination if that can be done safely
• People receiving high doses of systemic steroids (≥2 mg/kg/day or ≥20 mg/day prednisone or its equivalent, for ≥2 weeks) if steroid therapy has been discontinued for ≥1 month
• People with leukemia, lymphoma, or other malignancies that are in remission and who have not received chemotherapy for ≥3 months
  • Children with leukemia that is in remission and who do not have evidence of immunity to varicella should only be vaccinated with expert guidance and access to antiviral therapy in case complications occur

People who may have some degree of immunodeficiency should not get the combination measles, mumps, rubella, and varicella vaccine (ProQuad).

Household Contacts of People with Compromised Immune Systems

• Healthy people who are living with immunocompromised people
  • Healthy people who get vaccinated against varicella can protect immunocompromised people from being exposed to the disease
  • If the vaccinated person develops a vaccine-related rash, they should stay away from immunocompromised people who do not have evidence of immunity against varicella until all lesions resolve or no new lesions appear within a period of 24 hours.

Postpartum and Nursing Mothers without Evidence of Immunity

• Postpartum mothers should get 2 doses of varicella vaccine after their pregnancy
  • The first dose should be given after delivery and before they are discharged from the medical facility. A second dose should be given at 4 to 8 weeks after the first dose. This dose can be given during the postpartum visit (6 to 8 weeks after delivery)
  • There is no need to delay postpartum vaccination because of breastfeeding.
  • Women who get varicella vaccine may continue to breastfeed.

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Varicella Vaccination Recommendations of Healthcare Personnel

The Advisory Committee on Immunization Practices (ACIP), with support from the Hospital Infection Control Practices Advisory Committee (HICPAC), recommends that healthcare institutions ensure that all healthcare personnel have evidence of immunity against varicella. They should receive 2 doses of varicella vaccine given 4 to 8 weeks apart.

For more information, see

• Management of Healthcare Personnel Exposed to Varicella or Herpes Zoster
• Immunization of Health-Care Personnel

Testing for Immunity

Healthcare personnel without evidence of immunity against varicella may get serologic screening before being vaccinated. This is likely to be cost effective since 70% to 90% of adults who do not remember having varicella actually have antibodies in their blood.

ACIP or HICPAC do not recommend that healthcare personnel get tested for immunity to varicella after 2 doses of vaccine. Commercial assays are not sensitive enough in all instances to detect antibodies after vaccination

 

Transmission

It is rare for vaccinated people to spread varicella vaccine virus, especially if they do not have rash. Since the varicella vaccine program started, only 8 vaccinated people have been documented as spreading vaccine virus to others. All of these vaccinated people had rash after vaccination. As a result, 9 people, including household members and people in long-term care facilities, got infected with varicella.

There has not been any documented transmission of varicella from vaccinated healthcare personnel.

 

Work Restrictions

Recently vaccinated healthcare personnel do not require any restriction in their work activities. However, healthcare personnel who develop varicella-like rash after getting vaccinated should stay away from people who do not have evidence of immunity and who are at risk for severe varicella. They should wait until all lesions resolve (crusted over). If they develop lesions that do not crust (macules and papules only), they should wait until no new lesions appear within a 24 hour period.

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Post-exposure Varicella Vaccination

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.

• Ideally, the vaccine should be given within 3 to 5 days after the person is exposed. This may prevent varicella or make it less severe.
• Even if it has been more than 5 days, the vaccine should still be offered. This will provide protection against varicella if a person is exposed again in the future.

People who previously got the first dose should get a second dose at the appropriate time interval. For more information, see Routine Vaccination.

There are no data available on the use of the combination measles, mumps, rubella, and varicella vaccine (ProQuad®) for post-exposure vaccination.

Varicella vaccination is recommended for controlling outbreaks. People who do not have adequate evidence of immunity should get a first or second dose as needed. For information about outbreak surveillance, investigation, and control, see Chickenpox (Varicella) Outbreaks.

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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