Varicella vaccine

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Varicella vaccine
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Varicella vaccine
Vaccine description
Target Varicella
Vaccine type Attenuated
Clinical data
Trade names Varivax, Varilrix, others
AHFS/Drugs.com Monograph
MedlinePlus a607029
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administration 		subcutaneous
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Varicella vaccine, also known as chickenpox vaccine, is a vaccine that protects against chickenpox. [9] One dose of vaccine prevents 95% of moderate disease and 100% of severe disease. [10] Two doses of vaccine are more effective than one. [10] If given to those who are not immune within five days of exposure to chickenpox it prevents most cases of disease. [10] Vaccinating a large portion of the population also protects those who are not vaccinated. [10] It is given by injection just under the skin. [10] Another vaccine, known as zoster vaccine, is used to prevent diseases caused by the same virus – the varicella zoster virus. [11]

Contents

The World Health Organization (WHO) recommends routine vaccination only if a country can keep more than 80% of people vaccinated. [10] If only 20% to 80% of people are vaccinated it is possible that more people will get the disease at an older age and outcomes overall may worsen. [10] Either one or two doses of the vaccine is recommended. [10] In the United States two doses are recommended starting at twelve to fifteen months of age. [9] As of 2017, twenty-three countries recommend all non-medically exempt children receive the vaccine, nine recommend it only for high risk groups, three additional countries recommend use in only parts of the country, while other countries make no recommendation. [12] Not all countries provide the vaccine due to its cost. [13] In the United Kingdom, Varilrix, a live viral vaccine [14] is approved from the age of 12 months, but only recommended for certain at risk groups.

Minor side effects may include pain at the site of injection, fever, and rash. [9] Severe side effects are rare and occur mostly in those with poor immune function. [10] Its use in people with HIV/AIDS should be done with care. [10] It is not recommended during pregnancy; however, the few times it has been given during pregnancy no problems resulted. [9] [10] The vaccine is available either by itself or along with the MMR vaccine, in a version known as the MMRV vaccine. [10] It is made from weakened virus. [9]

A live attenuated varicella vaccine, the Oka strain, was developed by Michiaki Takahashi and his colleagues in Japan in the early 1970s. [15] American vaccinologist Maurice Hilleman's team developed a chickenpox vaccine in the United States in 1981, based on the "Oka strain" of the varicella virus. [16] [17] [18] The chickenpox vaccine first became commercially available in 1984. [10] It is on the WHO Model List of Essential Medicines. [19] [20]

Medical uses

Varicella vaccine is 70% to 90% effective for preventing varicella and more than 95% effective for preventing severe varicella. [21] Follow-up evaluations have taken place in the United States of children immunized that revealed protection for at least 11 years. Studies were conducted in Japan which indicated protection for at least 20 years. [21]

People who do not develop enough protection when they get the vaccine may develop a mild case of the disease when in close contact with a person with chickenpox. In these cases, people show very little sign of illness. [22] This has been the case of children who get the vaccine in their early childhood and later have contact with children with chickenpox. Some of these children may develop a mild chickenpox also known as breakthrough disease. [23]

Another vaccine, known as zoster vaccine, is simply a larger-than-normal dose of the same vaccine used against chickenpox, and is used in older adults to reduce the risk of shingles (also called herpes zoster) and postherpetic neuralgia, which are caused by the same virus. [11] The recombinant zoster (shingles) vaccine is recommended for adults aged 50 years and older. [24]

Duration of immunity

The long-term duration of protection from varicella vaccine is unknown, but there are now persons vaccinated twenty years ago with no evidence of waning immunity, while others have become vulnerable in as few as six years. Assessments of duration of immunity are complicated in an environment where natural disease is still common, which typically leads to an overestimation of effectiveness. [25]

Some vaccinated children have been found to lose their protective antibody in as little as five to eight years. [26] However, according to the World Health Organization (WHO): "After observation of study populations for periods of up to 20 years in Japan and 10 years in the United States, more than 90% of immunocompetent persons who were vaccinated as children were still protected from varicella." However, since only one out of five Japanese children were vaccinated, the annual exposure of these vaccinees to children with natural chickenpox boosted the vaccinees' immune system. In the United States, where universal varicella vaccination has been practiced, the majority of children no longer receive exogenous (outside) boosting, thus, their cell-mediated immunity to VZV (varicella zoster virus) wanes – necessitating booster chickenpox vaccinations. [27] As time goes on, boosters may be necessary. Persons exposed to the virus after vaccination tend to experience milder cases of chickenpox if they develop the disease. [28]

Catching "wild" chickenpox as a child has been thought to commonly result in lifelong immunity. Indeed, parents have deliberately ensured this in the past with "pox parties". Historically, exposure of adults to contagious children has boosted their immunity, reducing the risk of shingles. [29] [ better source needed ] The US Centers for Disease Control and Prevention (CDC) and corresponding national organizations are carefully observing the failure rate which may be high compared with other modern vaccines –large outbreaks of chickenpox having occurred at schools which required their children to be vaccinated. [30]

Chickenpox

Prior to the widespread introduction of the vaccine in the United States in 1995 (1986 in Japan and 1988 in Korea [31] ), there were around 4,000,000 cases per year in the United States, mostly in children, with typically 10,500–13,000 hospital admissions (range, 8,000–18,000), and 100–150 deaths each year. [31] [27] [10] [32] Most of the deaths were among young children. [33]

During 2003, and the first half of 2004, the CDC reported eight deaths from varicella, six of whom were children or adolescents. These deaths and hospital admissions have substantially declined in the US due to vaccination, [34] [35] though the rate of shingles infection has increased as adults are less exposed to infected children (which would otherwise help protect against shingles). [36] [37] [38] Ten years after the vaccine was recommended in the US, the CDC reported as much as a 90% drop in chickenpox cases, a varicella-related hospital admission decline of 71% [32] and a 97% drop in chickenpox deaths among those under 20. [39]

Vaccines are less effective among high-risk patients, as well as being more dangerous because they contain attenuated live virus. In a study performed on children with an impaired immune system, 30% had lost the antibody after five years, and 8% had already caught wild chickenpox in that five-year period. [40]

Herpes zoster

Herpes zoster (shingles) most often occurs in the elderly and is only rarely seen in children. The incidence of herpes zoster in vaccinated adults is 0.9/1000 person-years, and is 0.33/1000 person-years in vaccinated children; this is lower than the overall incidence of 3.2–4.2/1000 person-years. [41] [42]

The risk of developing shingles is reduced for children who receive the varicella vaccine, but not eliminated. [43] The CDC stated in 2014: "Chickenpox vaccines contain weakened live VZV, which may cause latent (dormant) infection. The vaccine-strain VZV can reactivate later in life and cause shingles. However, the risk of getting shingles from vaccine-strain VZV after chickenpox vaccination is much lower than getting shingles after natural infection with wild-type VZV." [44]

The risk of shingles is significantly lower among children who have received varicella vaccination, including those who are immunocompromised. The risk of shingles is approximately 80% lower among healthy vaccinated children compared to unvaccinated children who had wild-type varicella. [43] [45] A population with high varicella vaccination also has lower incidence of shingles in unvaccinated children, due to herd immunity. [45]

Schedule

The WHO recommends one or two doses with the initial dose given at 12 to 18 months of age. [10] The second dose, if given, should occur at least one to three months later. [10] The second dose, if given, provides the additional benefit of improved protection against all varicella. [46] This vaccine is a shot given subcutaneously (under the skin). It is recommended for all children under 13 and for everyone 13 or older who has never had chickenpox. [47]

In the United States, two doses are recommended by the CDC. For a routine vaccination, the first dose is administered at 12 to 15 months of age and a second dose at age 4–6 years. However, the second dose can be given as early as 3 months after the first dose. If an individual misses the timing for the routine vaccination, the individual is eligible to receive a catch-up vaccination. For a catch-up vaccination, individuals between 7 and 12 years old should receive a two-dose series 3 months apart (a minimum interval of 4 weeks). For individuals 13–18 years old, the catch-up vaccination should be given 4 to 8 weeks apart (a minimum interval of 4 weeks). [48] The varicella vaccine did not become widely available in the United States until 1995. [49]

In the UK, the vaccine is only available on the National Health Service for those who are in close contact with someone who is particularly vulnerable to chickenpox. [50] As there is an increased risk of shingles in adults due to possible lack of contact with chickenpox-infected children providing a natural boosting to immunity, and the fact that chickenpox is usually a mild illness, the NHS cites concerns about unvaccinated children catching chickenpox as adults when it is more dangerous. [50] However, the vaccine is approved for 12 months and up and is available privately, with a second dose to be given a year after the first. [14]

Contraindications

The varicella vaccine is not recommended for seriously ill people, pregnant women, people who have tuberculosis, people who have experienced a serious allergic reaction to the varicella vaccine in the past, people who are allergic to gelatin, people allergic to neomycin, people receiving high doses of steroids, people receiving treatment for cancer with x-rays or chemotherapy, as well as people who have received blood products or transfusions during the past five months. [51] [52] Additionally, the varicella vaccine is not recommended for people who are taking salicylates (e.g. aspirin). [52] After receiving the varicella vaccine, the use of salicylates should be avoided for at least six weeks. [52] The varicella vaccine is also not recommended for individuals who have received a live vaccine in the last four weeks, [52] because live vaccines that are administered too soon within one another may not be as effective. [52] It may be usable in people with HIV infections who have a good blood count and are receiving appropriate treatment. [10] Specific antiviral medication, such as acyclovir, famciclovir, or valacyclovir, are not recommended 24 hours before and 14 days after vaccination. [53]

Side effects

Serious side effects are very rare. From 1998 to 2013, only one vaccine-related death was reported: an English child with pre-existent leukemia. On some occasions, severe reactions such as meningitis and pneumonia have been reported (mainly in inadvertently vaccinated immunocompromised children) as well as anaphylaxis. [41]

The possible mild side effects include redness, stiffness, and soreness at the injection site, as well as fever. A few people may develop a mild rash, which usually appears around the injection site. [54]

There is a short-term risk of developing herpes zoster (shingles) following vaccination. However, this risk is less than the risk due to a natural infection resulting in chickenpox. [55] : 378  Most of the cases reported have been mild and have not been associated with serious complications. [56]

Approximately 5% of children who receive the vaccine develop a fever or rash. Adverse reaction reports for the period 1995 to 2005 found no deaths attributed to the vaccine despite approximately 55.7 million doses being delivered. [57] Cases of vaccine-related chickenpox have been reported in patients with a weakened immune system, [58] [59] but no deaths.

The literature contains several reports of adverse reactions following varicella vaccination, including vaccine-strain zoster in children and adults. [60]

History

The varicella zoster vaccine is made from the Oka/Merck strain of live attenuated varicella virus. The Oka virus was initially obtained from a child with natural varicella, introduced into human embryonic lung cell cultures, adapted to and propagated in embryonic guinea pig cell cultures, and finally propagated in a human diploid cell line originally derived from fetal tissues (WI-38). [4] [5] [6] Takahashi and his colleagues used the Oka strain to develop a live attenuated varicella vaccine in Japan in the early 1970s. [15] This strain was further developed by pharmaceutical companies such as Merck & Co. and GlaxoSmithKline. [61] American vaccinologist Maurice Hilleman's team at Merck then used the Oka strain to prepare a chickenpox vaccine in 1981. [16] [17] [18]

Japan was among the first countries to vaccinate for chickenpox. The vaccine developed by Hilleman was first licensed in the United States in 1995. [16] [62] Routine vaccination against varicella zoster virus is also performed in the United States, and the incidence of chickenpox has been dramatically reduced there (from four million cases per year in the pre-vaccine era to approximately 390,000 cases per year as of 2014). [63]

As of 2019, standalone varicella vaccines are available in all 27 European Union member countries, and 16 countries also offer a combined measles, mumps, rubella and varicella vaccine (MMRV). [64] Twelve European countries (Austria, Andorra, Cyprus, Czech Republic, Finland, Germany, Greece, Hungary, Italy, Latvia, Luxembourg and Spain) have universal varicella vaccination (UVV) policies, though only six of these countries have made it available at no cost via government funding. [64] EU member states that have not implemented UVV cite reasons such as "a perceived low disease burden and low public health priority," the cost and cost-effectiveness, the possible risk of herpes zoster when vaccinating older adults, and rare fevers leading to seizures after the first dose of the MMRV vaccine. [64] "Countries that implemented UVV experienced decreases in varicella incidence, hospitalizations and complications, showing overall beneficial impact." [64]

Varicella vaccination is recommended in Canada for all healthy children aged 1 to 12, as well as susceptible adolescents and adults 50 years of age and younger; "may be considered for people with select immunodeficiency disorders; [22] and "should be prioritized" for susceptible individuals, including "non-pregnant women of childbearing age, household contacts of immunocompromised individuals, members of a household expecting a newborn, health care workers, adults who may be exposed occupationally to varicella (for example, people who work with young children), immigrants and refugees from tropical regions, people receiving chronic salicylate therapy (for example, acetylsalicylic acid [ASA])," and others. [65]

Australia has adopted recommendations for routine immunization of children and susceptible adults against chickenpox. [66]

Other countries, such as the United Kingdom, have targeted recommendations for the vaccine, e.g., for susceptible health care workers at risk of varicella exposure. In the UK, varicella antibodies are measured as part of the routine of prenatal care, and by 2005 all National Health Service personnel had determined their immunity and been immunized if they were non-immune and have direct patient contact. Population-based immunization against varicella is not otherwise practised in the UK. [67]

Since 2013, the MMRV vaccine is offered for free to all Brazilian citizens. [68]

Society and culture

Catholic Church

The Roman Catholic Church is opposed to abortion. Nevertheless, the Pontifical Academy for Life stated in 2017 that "clinically recommended vaccinations can be used with a clear conscience and that the use of such vaccines does not signify some sort of cooperation with voluntary abortion". [69] On 21 December 2020, the Vatican's doctrinal office, the Congregation for the Doctrine of the Faith, further clarified that it is "morally licit" for Catholics to receive vaccines derived from fetal cell lines or in which such lines were used in testing or development, because "passive material cooperation in the procured abortion from which these cell lines originate is, on the part of those making use of the resulting vaccines, remote" and "does not and should not in any way imply that there is a moral endorsement of the use of cell lines proceeding from aborted fetuses". [70]

Related Research Articles

<span class="mw-page-title-main">Vaccination</span> Administration of a vaccine to protect against disease

Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating the body's adaptive immunity, they help prevent sickness from an infectious disease. When a sufficiently large percentage of a population has been vaccinated, herd immunity results. Herd immunity protects those who may be immunocompromised and cannot get a vaccine because even a weakened version would harm them. The effectiveness of vaccination has been widely studied and verified. Vaccination is the most effective method of preventing infectious diseases; widespread immunity due to vaccination is largely responsible for the worldwide eradication of smallpox and the elimination of diseases such as polio and tetanus from much of the world. However, some diseases, such as measles outbreaks in America, have seen rising cases due to relatively low vaccination rates in the 2010s – attributed, in part, to vaccine hesitancy. According to the World Health Organization, vaccination prevents 3.5–5 million deaths per year.

<span class="mw-page-title-main">MMR vaccine</span> Any of several combined vaccines against measles, mumps, and rubella

The MMR vaccine is a vaccine against measles, mumps, and rubella, abbreviated as MMR. The first dose is generally given to children around 9 months to 15 months of age, with a second dose at 15 months to 6 years of age, with at least four weeks between the doses. After two doses, 97% of people are protected against measles, 88% against mumps, and at least 97% against rubella. The vaccine is also recommended for those who do not have evidence of immunity, those with well-controlled HIV/AIDS, and within 72 hours of exposure to measles among those who are incompletely immunized. It is given by injection.

<span class="mw-page-title-main">Varicella zoster virus</span> Herpes virus that causes chickenpox and shingles

Varicella zoster virus (VZV), also known as human herpesvirus 3 or Human alphaherpesvirus 3 (taxonomically), is one of nine known herpes viruses that can infect humans. It causes chickenpox (varicella) commonly affecting children and young adults, and shingles in adults but rarely in children. VZV infections are species-specific to humans. The virus can survive in external environments for a few hours.

<span class="mw-page-title-main">Shingles</span> Viral disease caused by the varicella zoster virus

Shingles, also known as herpes zoster, is a viral disease characterized by a painful skin rash with blisters in a localized area. Typically the rash occurs in a single, wide mark either on the left or right side of the body or face. Two to four days before the rash occurs there may be tingling or local pain in the area. Other common symptoms are fever, headache, and tiredness. The rash usually heals within two to four weeks; however, some people develop ongoing nerve pain which can last for months or years, a condition called postherpetic neuralgia (PHN). In those with poor immune function the rash may occur widely. If the rash involves the eye, vision loss may occur.

<span class="mw-page-title-main">DPT vaccine</span> Combination vaccine

The DPT vaccine or DTP vaccine is a class of combination vaccines against three infectious diseases in humans: diphtheria, pertussis, and tetanus (lockjaw). The vaccine components include diphtheria and tetanus toxoids, and either killed whole cells of the bacterium that causes pertussis or pertussis antigens. The term toxoid refers to vaccines which use an inactivated toxin produced by the pathogen which they are targeted against to generate an immune response. In this way, the toxoid vaccine generates an immune response which is targeted against the toxin which is produced by the pathogen and causes disease, rather than a vaccine which is targeted against the pathogen itself. The whole cells or antigens will be depicted as either "DTwP" or "DTaP", where the lower-case "w" indicates whole-cell inactivated pertussis and the lower-case "a" stands for "acellular". In comparison to alternative vaccine types, such as live attenuated vaccines, the DTP vaccine does not contain any live pathogen, but rather uses inactivated toxoid to generate an immune response; therefore, there is not a risk of use in populations that are immune compromised since there is not any known risk of causing the disease itself. As a result, the DTP vaccine is considered a safe vaccine to use in anyone and it generates a much more targeted immune response specific for the pathogen of interest.

Postherpetic neuralgia (PHN) is neuropathic pain that occurs due to damage to a peripheral nerve caused by the reactivation of the varicella zoster virus. PHN is defined as pain in a dermatomal distribution that lasts for at least 90 days after an outbreak of herpes zoster. Several types of pain may occur with PHN including continuous burning pain, episodes of severe shooting or electric-like pain, and a heightened sensitivity to gentle touch which would not otherwise cause pain or to painful stimuli. Abnormal sensations and itching may also occur.

<span class="mw-page-title-main">Influenza vaccine</span> Vaccine against influenza

Influenza vaccines, colloquially known as flu shots, are vaccines that protect against infection by influenza viruses. New versions of the vaccines are developed twice a year, as the influenza virus rapidly changes. While their effectiveness varies from year to year, most provide modest to high protection against influenza. Vaccination against influenza began in the 1930s, with large-scale availability in the United States beginning in 1945.

<span class="mw-page-title-main">Childhood immunizations in the United States</span>

The schedule for childhood immunizations in the United States is published by the Centers for Disease Control and Prevention (CDC). The vaccination schedule is broken down by age: birth to six years of age, seven to eighteen, and adults nineteen and older. Childhood immunizations are key in preventing diseases with epidemic potential.

The MMRV vaccine combines the attenuated virus MMR vaccine with the addition of the varicella (chickenpox) vaccine. The MMRV vaccine is typically given to children between one and two years of age.

<span class="mw-page-title-main">Mumps vaccine</span> Vaccine which prevents mumps

Mumps vaccines are vaccines which prevent mumps. When given to a majority of the population they decrease complications at the population level. Effectiveness when 90% of a population is vaccinated is estimated at 85%. Two doses are required for long term prevention. The initial dose is recommended between 12 and 18 months of age. The second dose is then typically given between two years and six years of age. Usage after exposure in those not already immune may be useful.

A breakthrough infection is a case of illness in which a vaccinated individual becomes infected with the illness, because the vaccine has failed to provide complete immunity against the pathogen. Breakthrough infections have been identified in individuals immunized against a variety of diseases including mumps, varicella (Chickenpox), influenza, and COVID-19. The characteristics of the breakthrough infection are dependent on the virus itself. Often, infection of the vaccinated individual results in milder symptoms and shorter duration than if the infection were contracted naturally.

<span class="mw-page-title-main">Zoster vaccine</span> Vaccine to prevent shingles

A zoster vaccine is a vaccine that reduces the incidence of herpes zoster (shingles), a disease caused by reactivation of the varicella zoster virus, which is also responsible for chickenpox. Shingles provokes a painful rash with blisters, and can be followed by chronic pain, as well as other complications. Older people are more often affected, as are people with weakened immune systems (immunosuppression). Both shingles and postherpetic neuralgia can be prevented by vaccination.

<span class="mw-page-title-main">Hepatitis B vaccine</span> Vaccine against hepatitis B

Hepatitis B vaccine is a vaccine that prevents hepatitis B. The first dose is recommended within 24 hours of birth with either two or three more doses given after that. This includes those with poor immune function such as from HIV/AIDS and those born premature. It is also recommended that health-care workers be vaccinated. In healthy people, routine immunization results in more than 95% of people being protected.

<span class="mw-page-title-main">Hepatitis A vaccine</span> Vaccine to prevent hepatitis A

Hepatitis A vaccine is a vaccine that prevents hepatitis A. It is effective in around 95% of cases and lasts for at least twenty years and possibly a person's entire life. If given, two doses are recommended beginning after the age of one. It is given by injection into a muscle. The first hepatitis A vaccine was approved in Europe in 1991, and the United States in 1995. It is on the World Health Organization's List of Essential Medicines.

<span class="mw-page-title-main">Chickenpox</span> Human viral disease

Chickenpox, or chicken pox, also known as varicella, is a highly contagious, vaccine-preventable disease caused by the initial infection with varicella zoster virus (VZV), a member of the herpesvirus family. The disease results in a characteristic skin rash that forms small, itchy blisters, which eventually scab over. It usually starts on the chest, back, and face. It then spreads to the rest of the body. The rash and other symptoms, such as fever, tiredness, and headaches, usually last five to seven days. Complications may occasionally include pneumonia, inflammation of the brain, and bacterial skin infections. The disease is usually more severe in adults than in children.

<span class="mw-page-title-main">Measles vaccine</span> Vaccine used to prevent measles

Measles vaccine protects against becoming infected with measles. Nearly all of those who do not develop immunity after a single dose develop it after a second dose. When the rate of vaccination within a population is greater than 92%, outbreaks of measles typically no longer occur; however, they may occur again if the rate of vaccination decreases. The vaccine's effectiveness lasts many years. It is unclear if it becomes less effective over time. The vaccine may also protect against measles if given within a couple of days after exposure to measles.

<span class="mw-page-title-main">Rubella vaccine</span> Vaccine used to prevent rubella

Rubella vaccine is a vaccine used to prevent rubella. Effectiveness begins about two weeks after a single dose and around 95% of people become immune. Countries with high rates of immunization no longer see cases of rubella or congenital rubella syndrome. When there is a low level of childhood immunization in a population it is possible for rates of congenital rubella to increase as more women make it to child-bearing age without either vaccination or exposure to the disease. Therefore, it is important for more than 80% of people to be vaccinated. By introducing rubella containing vaccines, rubella has been eradicated in 81 nations, as of mid-2020.

<span class="mw-page-title-main">Yellow fever vaccine</span> Vaccine that protects against yellow fever

Yellow fever vaccine is a vaccine that protects against yellow fever. Yellow fever is a viral infection that occurs in Africa and South America. Most people begin to develop immunity within ten days of vaccination and 99% are protected within one month, and this appears to be lifelong. The vaccine can be used to control outbreaks of disease. It is given either by injection into a muscle or just under the skin.

Live recombinant vaccines are biological preparations that stimulate immune responses to a pathogen through the use of genetically modified live bacteria or viruses. These live pathogens are biologically engineered to express exogenous antigens in the cytoplasm of target cells, thereby triggering immune responses. This form of vaccine combines the beneficial features of attenuated and recombinant vaccines, providing the long-lasting immunity of attenuated vaccines’ with recombinant vaccines’ genetically engineered precision and safety.

Anne Gershon is an infectious disease researcher and professor of pediatrics at Columbia University. She is best known for her work on the varicella-zoster virus, the causative agent for chickenpox. In the 1970s, she ran clinical trials for the varicella vaccine which showed that the vaccine was safe for children with leukemia. She also developed the first sensitive test for chickenpox.

References

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