Again, we talked about catch-up immunization of the 11-12 year old age group. When they come into the office, pay attention to see if they’ve gotten hepatitis B vaccine in the past and then they should get three doses if they haven’t. In California, this is the first year that requires hepatitis B vaccine for school entry for junior high school.
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Now we will move on and talk about common varicella vaccine. Varicella vaccine is a live virus vaccine, administered subcutaneously. It may result in some reactions. The most common reaction is a local reaction similar to other vaccines; pain, redness at the injection site, mild and goes away in a few days. But it also may result in very subclinical varicella. You can see a papulovesicular rash. This can be either localized to the injection site, or it can be generalized. In general, this is a very small number of lesions and this is what it looks like. This is localized to the injection site. You can just see this is at the injection site. This is ten days following immunization. A few papules. That one actually looks a little bit like a vesical to me, and that goes away in a few days. That’s the vaccine virus multiplying. The vaccine is immunogenic, greater than 95% immunogenicity and the efficacy – I split this up into two kinds of efficacy. One is absolute efficacy; 85% of subjects have prevention of varicella. The other 15% may have breakthrough disease but the breakthrough disease is also … there is some efficacy in breakthrough disease, in which case it’s milder than routine chicken pox which occurs in unvaccinated individuals. The rash is atypical. You get a reduction in skin lesions. Half the patients don’t even have vesicles and only a minority have fever. Recovery is more rapid in children who have chicken pox who have been previously vaccinated, compared to those who haven’t.
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Contraindications and precautions to varicella vaccine are shown on this slide. Live virus vaccine; again, immunocompromised host – you need to think about that – pregnancy, neomycin anaphylactic or gelatin allergy that is in the vaccine, presence of passive antibody will interfere with vaccine take, and aspirin should be avoided after vaccination because of a theoretical risk of Reye’s syndrome which may occur with aspirin and wild type chicken pox.
The recommendations are for routine vaccination at 12-18 months of age. Catch-up immunization for subjects who are out of that age range who are still susceptible to chicken pox; one dose can be given 1-12 years of age. Older than 12 years of age you need two doses to achieve the same immunogenicity. A lot of issues have come up regarding duration of immunity to varicella vaccine. How long will subjects remain immune after vaccination? That’s not known, but ten year follow-up in this country, twenty year follow-up in Japan, so this vaccine does have a long duration of immunity. Further studies are in progress to determine if booster doses are needed. But it’s very reassuring that there has been no severity in breakthrough varicella over time, which would indicate waning immunity.
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Next we’ll move on and talk about passive antibody and prevention of varicella. We’ll talk briefly about VZIG because really active vaccination with varicella is the way to go, but VZIG(Varicella Zoster Immune Globulin) may be administered as soon as possible, definitely within four days of exposure to varicella to subjects who meet three criteria. The three criteria are: susceptible to chicken pox, significant exposure, and high risk for complications. Susceptible to chicken pox means they have never had chicken pox in the past. Significant exposure, shown on this slide, household contact, face-to-face play, hospital roommate or newborn with maternal varicella five days prior to delivery, up to two days postpartum. Those subjects who are at increased risk for complications include those who are immunocompromised, a newborn with the above situation, and premature infants.
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