Title: Varicella Vaccine 2 dose schedule A natural evolution
1Varicella Vaccine 2 dose scheduleA natural
evolution?
And other things you wanted to know
-
- Dennis A. Clements MD PhD MPH
- NC Immunization Conference
- 2007
2Why ask the question ?
- Varicella vaccine was the first vaccine approved
that required follow-up studies of up to 15
years. - What is the natural epidemiology of varicella
after beginning routine varicella vaccination - Are we better off with one or two doses?
- What else do we need to think about?
3 Observations Since Introduction of 1-Dose
Regimen
- Reduction in severe varicella disease and its
related complications in healthy children in the
US1 - 88 decline in varicella-related hospital
discharges, 1994 20022 - Reduction in varicella-related mortality
- 100 deaths per year reported prior to 1995
vaccine licensure3 - From 2003 through mid-2004, 8 varicella-related
deaths were reported 6 occurred in unvaccinated
persons4 - Primary vaccine effectiveness (835 866)
- Pool of varicella susceptibles remains after
administration of a single injection of vaccine1 - Insufficient herd immunity to prevent outbreaks2
4Potential Impact from Accumulation of Susceptibles
- The CDC estimates the total number of
susceptibles is rising, including persons
vaccinated with 1 dose and unvaccinated persons1
- Varicella outbreaks are occurring in elementary
and middle school and are likely to occur in high
school and college in the future unless students
are protected1 - Increased risk for outbreaks later in life when
disease can be more severe2 - Risk of complication and death from varicella is
1020 times higher for adolescents and adults
than for children ages 142 - Significant cost to public health and other
institutions3
5Varicella History
- 1767 Differentiation of varicella from smallpox
- 1875 Demonstration of infectious nature of
varicella - 1892 Varicella noted after exposure to herpes
zoster - 1943 Consideration of herpes zoster as
varicella reactivation - 1943 Varicella isolated in tissue culture
- 1972 Varicella vaccine first used by Takahashi
- 1981 First trials USA in immuno-compromised in
remission - 1986 First trials in Durham
- 1995 Vaccine licensed in USA
- 2002 88 decline in hospital varicella-related
discharges
6Varicella Pathogenesis and Clinical Features
- Varicella virus enters through the respiratory
tract and conjunctiva - Replication likely in nasopharynx and regional
lymph nodes - Repeated episodes of viremia
- Multiple tissues, including sensory ganglia,
infected during viremia
- Incubation period 1416 days (range 1021 days)
- Mild prodrome for 12 days
- Rash generally appears first on head most
concentrated on trunk - Successive crops (24) of pruritic vesicles
Centers for Disease Control and
Prevention. 9th ed. Washington DC Public Health
Foundation, 2006.
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8VZV Latency
Dorsal root
VZV moves along the sensory nerve to the
dorsal root ganglia
ganglion
Spinal cord
Varicella
rash
Skin
VZV established latency in the dorsal root
ganglion
Viral latency is established during primary
infection (varicella).1 Transport of virus up
sensory nerve from infected dermal sites2
Dormant in dorsal root ganglion2
.
1. Straus SE, Oxman MN. Varicella and
herpes zoster. In Freedberg IM, Eisen AZ, Wolff
K, et al, eds. Fitzpatricks Dermatology in
General Medicine. 5th ed. Vol 2. New York, NY
McGraw-Hill 199924272450. 2. Silvertsein S,
Straus SE. In Arvin AM, Gershon AA, eds.
Varicella-Zoster Virus Virology and Clinical
Management. Cambridge, UK Cambridge University
Press 2000123-141.
9Varicella Epidemiology
- Reservoir Humans only
- Transmission Airborne droplet Direct contact
with lesions - Temporal pattern Peak in winterearly spring
(US) - Communicability 12 days before to 45
days after onset of rash May be longer
in immunocompromised
Centers for Disease Control and
Prevention. 9th ed. Washington DC Public Health
Foundation, 2006.
10Varicella Epidemiology
- Before Vaccination
- 4 million cases a year
- 11,000 hospitalizations
- 100 deaths
- 50 children
- 50 adults
- 10 of adults non-immune
- Primarily a Childhood disease
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12- Varicella Age-Specific Incidence United States,
199019941
Rate per 100,000 population. National Health
Interview Survey data
Centers for Disease Control and
Prevention. Washington DC Public Health
Foundation, 2006.
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14- Varicella Fatality Rate in Healthy Persons
Deaths per 100,000 cases
Centers for Disease Control and
Prevention. Washington DC Public Health
Foundation, 2006.
15Groups at Increased Risk of Complications of
Varicella
- Healthy adults
- Immunocompromised persons
- Newborns of women with rash onset within 5 days
before to 2 days after delivery
16Complications of Varicella in Healthy Children
- Secondary Skin infections Impetigo or less
commonly fasciitis - Staphylococcus aureus
- Group A ß-hemolytic streptococcus
- CNS Disease
- Acute Cerebellar Ataxia
- Encephalitis
- Secondary bacterial meningitis
- Pneumonia
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25Complications of varicella in Healthy Adults
- Pneumonia
- Skin Infections
- Encephalitis
- Acute Glomerulonephritis
- Herpes Zoster (common in older age group)
26Varicella Zoster
27Complications in Immunocompromised
- Dissemination
- Slower healing of lesions
- Visceral involvement
- Death
28Varicella Zoster Complications
29Complications of Varicella in Pregnancy
- During Pregnancy
- Fetal abnormalities
- Rash
- Limb hypoplasia
- Peripartum Disease
- Devastating disease 5 to 2 days of delivery
- Baby gets virus but no antibodies
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33Varicella requirements
- For Day care entry gradually expanding in all
states - For School entry gradually expanding in all
states - For University entry gradually expanding in all
states
34Varicella Vaccine Immunogenicity
- Seroconversion in Clinical Trials
- Children (lt13 years) 97
- 2 doses 99
- Adults Adolescents (gt12years)
- 1st dose 75-94
- 2nd dose 99
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36Varicella vaccine Effectiveness
- Study Method Dose/Population Results
- Double-blind Single dose in 100 1st year
- Placebo controlled Children (491/163) 96 2nd
year - After household Single dose in 77 reduction
- Exposure Children (259) in attack rate
- After household Adolescent/Adults 70 reduction
- Exposure 2 doses (64) in attack rate
37Clements paper
38Post-vaccination Rash
39Breakthrough Disease
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41Clinical Features of Wild Type and Breakthrough
Varicella Disease
Wild-type varicella
Breakthrough disease
Photo courtesy of Barbara Watson, MD2
Photo courtesy of American Academy of Pediatrics,
Red Book Online, 2003
- Lesions predominantly maculopapular and usually
lt50 - Frequency and severity of fever are generally
lower - Rash averages 5 days
- Lesions are predominantly vesicular and
250-500 in number - Fever is generally higher
- Rash averages 12 days
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43North Carolina Day Care Study
- OBJECTIVES
- To document the change in varicella epidemiology
in day care centers after the implementation of
varicella vaccination. - To document the rate of uptake of varicella
vaccine in day care children.
44Age specific Vaccination coverage
45Proportion of children susceptible to varicella
46Disease incidence in vaccinated children
47Disease incidence in unvaccinated children
48Cumulative incidence of varicella vs. percent
vaccinated
49Discussion point
- By age 48 months, only 80 of children are
immune to varicella due to vaccination or from
wild type disease. - As varicella disease becomes increasingly
infrequent, there may be a decreased motivation
to obtain vaccine for eligible children.
50Conclusions stated in 2004
- Partial uptake is sufficient to produce herd
immunity. - Even though school entry requires varicella
vaccine there is a cohort of aging children who
are unvaccinated and who have not had the disease.
51What is happening elsewhere?
- Disease incidence
- Zoster incidence
- Disease in infants and adults
- Vaccination rates
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53Incidence of VaricellaAntelope Valley, CA
Seward JF et al. JAMA 2002287(5)606-611
54Varicella Active Surveillance Project West
Philadelphia 1995-1999
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56Varicella Epidemiology
- Before Vaccination
- 100 deaths
- 50 children
- 50 adults
- Primarily a childhood disease
- After Vaccination
- 20-26 deaths total since 2000
- Will it become a more common adult disease?
57Varicella zoster rate
- After vaccination significant decrease
- 21 million doses distributed
- 1.5/100,000 zoster cases actual
- 110/100,000 expected lt5 yrs.
- 23 cases vaccine strain
- 15 cases wild type
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60Michigan Outbreak
- 85 protective against all disease
- 98 protective against moderate to severe disease
- 5x risk of breakthrough if vaccinated gt4 years
before - Vaccinated - 85 had mild disease, unvaccinated -
20 with mild disease
61Varicella Outbreaks 2001-2005
- Occurred in elementary schools
- Vaccine effectiveness 72-85
- Highest attack rates occurred among the younger
students. - Outbreaks lasted about two months
- Vaccinated children played a role in transmission
although their disease was mild - Overall attack rates among vaccinated children
11-17
62Successes
- 85 reduction in disease
- Less Zoster
- Mild disease is common when breakthrough occurs
- Few outbreaks
- Vaccination coverage high
- Varicella deaths declined 78
- Varicella hospitalizations down gt60
63So what are the issues ?(From 2005 presentation)
- Varicella outbreaks in highly vaccinated cohorts
like day care/school why? - Will lack of wild type disease change
epidemiology? More adult disease both varicella
and zoster? - How to vaccinate those who missed vaccination?
- Do we need a second dose? At what cost?
- Should it be combined with MMR?
- If the disease burden shifts to older patients
there will be more complications. - Need refrigerator stability
64Rate of Breakthrough Disease 1-Dose and 2-Dose
Regimens of VARIVAX Varicella Virus Vaccine
Live (Oka/Merck) Over 10 Years
2,216 children 12 months to 12 years of age with
a negative history of varicella were randomized
to receive either 1 dose of VARIVAX or 2 doses
given 3 months apart. Subjects were followed on
an annual basis for 10 years after vaccination.
94 98 7.5 2.2
Plt0.001 Breakthrough infection was defined
as any case of varicella occurring gt42 days
postvaccination.
Kuter B et al. Pediatr Infect Dis J.
200423132137.
65Factors about vaccination
- There was a 3.4-fold lower risk of developing
breakthrough disease in children who received
2 doses of varicella vaccine compared with
children who received 1 dose of varicella
vaccine. - The duration of protection from varicella
obtained using VARIVAX in the absence of
wild-type boosting is unknown.
66Varicella Vaccine Recommendations MMWR - 22 June
2007
- Implement a routine 2 dose varicella schedule
12-15 months 4-6 years - A second catch-up dose for anyone who had only
one dose in the past. - Routine immunization of varicella naïve healthy
people gt12 years of age - Prenatal assessment and postpartum vaccination
- Expand use in HIV patients
- Children CD4T lymphs 15-24
- Adol adults with CD4T lymphs gt200cells/uL.
- Establish middle high school and college entry
vaccination requirement.
67Things to remember
- These are the issues to remember
- Disease epidemiology
- Vaccine type
- Vaccine storage
- Breakthrough
68Skin lesions
69Complications
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72Deaths are declining
73Deaths per 1 million by age
74Deaths by age by time period
75So why is this happening?
- Immunization generally cannot provide the
protection that surviving natural disease can. - Time since vaccination appears to play some part
in the process - Age of exposed is a factor also.
76Varicella Vaccines
- All three vaccines contain the same live
Oka-Merck varicella vaccine virus but in
different concentrations - -Varivax - 1,400 pfu
- ProQuad - 9,800 pfu (7x Varivax)
- Zostavax - 19,000 pfu (14x Varivax)
77Varicella Vaccine (Varivax)
- Live virus (Oka-Merck strain)
- Efficacy
- Infection 70-90
- Severe disease 95
- Duration of immunity At least 10 yrs
- Schedule 2 doses
78Varicella Breakthrough Disease
- Varicella in a previously vaccinated person
- Breakthrough disease much milder than in
unvaccinated persons - Can occur in up to 30 of recipients of one dose
of varicella vaccine
79Clinical Features of Wild Type and Breakthrough
Varicella Disease
Wild-type varicella
Breakthrough disease
Photo courtesy of Barbara Watson, MD2
Photo courtesy of American Academy of Pediatrics,
Red Book Online, 2003
- Lesions predominantly maculopapular and usually
lt50 - Frequency and severity of fever are generally
lower - Rash averages 5 days
- Lesions are predominantly vesicular and
250-500 in number - Fever is generally higher
- Rash averages 12 days
80Breakthrough Infection
- Retrospective cohort study of 115,000 children
vaccinated in 2 HMOs during January 1995 through
December 1999 - Risk of breakthrough varicella 2.5 times higher
if varicella vaccine administered less than 30
days following MMR - No increased risk if varicella vaccine given
simultaneously or more than 30 days after MMR
MMWR 200150(47)1058-61
81Nonsimultaneous Administrationof Live Virus
Vaccines
- If varicella vaccine is not administered on the
same day as MMR or live attenuated influenza
vaccine, the vaccines should be separated by at
least 4 weeks - If separated by less than 4 weeks the vaccine
given second should be repeated
82Varicella VaccinePostexposure Prophylaxis
- Varicella vaccine is recommended for use in
persons without evidence of varicella immunity
after exposure to varicella - 70-100 effective if given within 72 hours of
exposure - not effective if administered more than 5 days
after exposure but will produce immunity if not
infected
83Zoster Following Vaccination
- Most cases in children
- Risk from vaccine virus appears to be less than
from wild-type virus - Usually a mild illness without complications
84Transmission of Varicella Vaccine Virus
- Asymptomatic transmission of vaccine virus may
occur - Risk of transmission is increased if the
recipient develops a rash
85Varicella VaccineStorage and Handling
- Store frozen at 5F (-15C ) or lower at all
times - May be stored up to 72 hours at 35o-46o F
- Unused vaccine must be discarded after 72 hours
at this temperature - Discard if not used within 30 minutes of
reconstitution
86MMRV Storage and Handling
- Store frozen at 5F (-15C ) or lower at all
times - May NOT be stored at refrigerator temperature AT
ANY TIME - Discard if not used within 30 minutes of
reconstitution
87Herpes Zoster Vaccine (Zostavax)
- Contains the same live attenuated varicella virus
as Varivax but at a much higher titer of vaccine
virus - Approved by FDA for persons 60 years of age and
older - Administered by the subcutaneous route
88Herpes Zoster Vaccine Efficacy
- Compared to the placebo group the vaccine group
had - 51 fewer episodes of zoster
- Less severe disease
- 66 less postherpetic neuralgia
- No significant safety issues were identified
NEJM 2005352(22)2271-84.
89What do I do with the teen who is not sure if
they had Varicella?
- Draw a varicella titer/elisa
- Give a dose of vaccine
- Wait for lab data to return
- If neg then get a second dose
- If pos then congratulations you have had your
booster.
90National Immunization ProgramContact Information
- Telephone 800.CDC.INFO
- Email nipinfo_at_cdc.gov
- Website www.cdc.gov/nip
91- Varicella Vaccination in Pregnancy Registry
800.986.8999
92- Varicella Vaccine Information
800-9VARIVAX
93U.S. National Immunization Survey Estimated
Coverage by State Among Children 1935 Mos. (2005)
Rates vary from state to state (6896)
82.9 (NH)
76.6
68.5 (VT)
84.2
75.5
87.2
83.3
76.2
95.4(MA)
77.4
87.0
85.7
87.6
96.2 (RI)
93.4
77.2
91.0(CT)
89.2
83.4
89.9
84.4
83.8(NJ)
86.3
86.3
82.8
81.2
89.5(DE)
87.2
90.7 (MD)
81.1
89.5
89.9
87.9
81.5
90.6(DC)
83.3
91.3
89.8
83.6
85.8
85.9
86.3
87.4
85.9
91.9
93.5
88.4
88.9
91.1
89.0
89.4 (HI)
81.2
2005 national varicella vaccination coverage
levels among children 1935 months of age
(?1 dose) ? 87.9
Adapted from Centers for Disease Control and
Prevention. MMWR. 2006 55(36)988993.
94- THE END
- Thank you for your attention