Ask the Experts: Varicella (Chickenpox)

Results (63)

Prior to the availability of varicella vaccine there were approximately 4 million cases of varicella a year in the U.S. Though usually a mild disease in healthy children, an estimated 150,000 to 200,000 people developed complications, about 11,000 people required hospitalization and 100 people died each year from varicella. Varicella tends to be more severe in infants, adolescents and adults than in young children. The most common complications from varicella include bacterial superinfection of skin lesions, pneumonia, central nervous system involvement, and thrombocytopenia.

Last reviewed: May 16, 2023

The varicella zoster virus (VZV) spreads from person to person by direct contact or through the air by coughing or sneezing. It is highly contagious. It can also be spread through direct contact with fluid from a blister of a person infected with varicella, or from direct contact with a skin lesion from a person with zoster (shingles). People with varicella are infectious 1 to 2 days before skin lesions appear until all lesions have crusted over, usually 4 to 7 days after the appearance of skin lesions.

Last reviewed: March 16, 2023

ACIP recommends administration of varicella zoster immune globulin (VariZIG, Saol Therapeutics) to certain people up to 10 days following exposure to varicella or herpes zoster. People for whom VariZIG is recommended are those without evidence of immunity to varicella who are at high risk of severe disease and complications of varicella illness and are ineligible for varicella vaccination. VariZIG given up to 10 days after an exposure can modify or prevent clinical varicella disease. See the varicella zoster immune globulin section below, and www.cdc.gov/mmwr/pdf/wk/mm6228.pdf, pages 574–6, for more information on this topic.

 

Patients recommended by ACIP to receive VariZIG include:

  • Immunocompromised patients without evidence of immunity
  • Newborn infants whose mothers have signs and symptoms of varicella around the time of delivery (i.e., 5 days before to 2 days after)
  • Hospitalized premature infants born at 28 weeks (or more) of gestation whose mothers do not have evidence of immunity to varicella
  • Hospitalized premature infants born at less than 28 weeks of gestation or who weigh 1,000 grams or less at birth, regardless of their mothers’ evidence of immunity to varicella
  • Pregnant people without evidence of immunity

If a susceptible person exposed to varicella or zoster is age 12 months or older, and has no contraindications to varicella vaccination, varicella vaccine can prevent or reduce the severity of infection when administered as post-exposure prophylaxis (PEP) as soon as possible, within 5 days after exposure. There is no evidence that vaccination after infection increases the risk of vaccine-associated adverse reactions. If the patient’s exposure does not result in infection, vaccination can protect against future exposures. See the MMWR for details: www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm.

Last reviewed: May 16, 2023

The minimum age for varicella vaccine is 12 months. Vaccination is not recommended for infants younger than 12 months of age even as post-exposure prophylaxis. CDC recommends that a healthy infant should receive no specific treatment or vaccination after exposure to VZV. The child can be treated with an appropriate antiviral medication if chickenpox occurs.

See the Varicella Zoster Immune Globulin section for details on the recommended use of VariZIG in immunocompromised children, infants exposed to varicella around the time of birth and some hospitalized preterm infants.

Last reviewed: May 16, 2023

Two vaccines containing varicella virus are licensed for use in the United States. Both vaccines contain live, attenuated varicella zoster virus (VZV) derived from the Oka strain.

  • Varivax (VAR, Merck) contains only varicella vaccine virus.
  • ProQuad (MMRV, Merck) is a combination measles, mumps, rubella, and varicella vaccine

Both vaccines may be administered either by subcutaneous injection or intramuscular injection. VAR is approved by the Food and Drug Administration (FDA) for people 12 months of age and older. MMRV is approved for people 12 months through 12 years of age. MMRV should not be administered to people age 13 years or older.

Last reviewed: May 16, 2023

All children, beginning at age 12 months, as well as adults without other evidence of immunity should be vaccinated with 2 doses of varicella vaccine. Special consideration should be given to vaccinating adults who (1) have close contact with people at high risk for severe disease (e.g., healthcare workers and family contacts of immunocompromised people), or (2) are at high risk for exposure or transmission (e.g., teachers of young children; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; non-pregnant women of childbearing age; and international travelers).

Last reviewed: May 16, 2023

The Advisory Committee on Immunization Practices (ACIP) considers evidence of immunity to varicella to be:

  • Written documentation of 2 doses of varicella vaccine given no earlier than age 12 months with at least 4 weeks between doses.
  • U.S.-born before 1980*
  • A healthcare provider’s diagnosis of varicella or verification of history of varicella disease
  • History of herpes zoster, based on healthcare provider diagnosis or verification of disease history
  • Laboratory evidence of immunity or laboratory confirmation of disease

    *Note: Although there is only a very small chance of susceptibility, due to the potential for severe consequences from varicella infection, year of birth is not accepted as evidence of varicella immunity for healthcare personnel, immunosuppressed people, and pregnant people.

Last reviewed: May 16, 2023

No. ACIP recommends giving a dose of MMR to infants age 6 through 11 months before international travel, but not varicella vaccine. Varicella vaccine is neither approved nor recommended for children younger than age 12 months in any situation.

Last reviewed: May 16, 2023

Varicella vaccine is neither approved nor recommended for children younger than age 12 months. Assuming that the child is not immunocompromised, varicella zoster immune globulin (VariZIG) is also not recommended.

ACIP does not have a recommendation for acyclovir for varicella postexposure prophylaxis. The American Academy of Pediatrics provide some guidance on this issue in the current edition of the Red Book.

Last reviewed: May 16, 2023

No. A healthcare provider’s diagnosis or verification of a history of shingles is acceptable evidence of immunity to varicella. According to ACIP, acceptable evidence of varicella immunity in healthcare personnel includes (1) documentation of 2 doses of varicella vaccine given at least 28 days apart, (2) history of varicella or herpes zoster based on clinician diagnosis, (3) laboratory evidence of immunity, or (4) laboratory confirmation of disease.

Last reviewed: May 16, 2023

Recombinant zoster vaccine (RZV, Shingrix, GSK) does not count as the first of two doses of varicella vaccine. Shingrix is not licensed and has not been evaluated for the prevention of primary varicella infection. To meet the immigration requirements, you should give a dose of varicella vaccine now and a second dose at least 4 weeks later. The varicella vaccine doses will not be harmful and will allow your patient to meet the regulatory requirement.

Last reviewed: May 16, 2023

Yes. For everyone whose varicella immunity is based on vaccination, 2 doses of varicella vaccine are recommended.

Last reviewed: May 16, 2023

In the ten years following vaccine licensure in 1995, there was a significant decline in varicella disease, as well as varicella-related hospitalizations and deaths. Although a 1-dose regimen was estimated to be 80% to 85% effective, breakthrough disease was still occurring in highly vaccinated populations. A 2-dose regimen was adopted in 2006 to further reduce the risk of disease among vaccinated people whose numbers would accumulate over time, which could lead to varicella disease later in life when it can be more severe.

Last reviewed: May 16, 2023

If the child had confirmed varicella disease or laboratory evidence of prior disease, it is not necessary to vaccinate regardless of age at infection. If there is any doubt that the illness was actually varicella, the child should be vaccinated.

Last reviewed: May 16, 2023

It is critical to vaccinate susceptible older children and adults whenever the opportunity arises. With younger children being routinely vaccinated, the chance of being exposed to cases of chickenpox is decreasing. Older children, adolescents, and adults who have not had chickenpox now have a greater chance of remaining susceptible. These older individuals, when they contract chickenpox, are more likely to become seriously ill and have disease complications than younger children.

Last reviewed: May 16, 2023

No. Shingles is caused by varicella zoster virus, the same virus that causes chickenpox. A history of shingles based on a healthcare provider diagnosis is evidence of immunity to chickenpox. A person who has had shingles does not need to be vaccinated against varicella. The person should still receive zoster vaccine, however, if it is not contraindicated and the person is age 50 or older or is age 19 or older and immunocompromised.

Last reviewed: May 16, 2023

No. Receipt of one dose of live zoster vaccine is not proof of varicella immunity. According to CDC, acceptable evidence of varicella immunity in healthcare personnel includes (1) documentation of 2 doses of varicella vaccine given at least 28 days apart, (2) history of varicella or herpes zoster based on clinician diagnosis, (3) laboratory evidence of immunity, or (4) laboratory confirmation of disease. If a healthcare employee has received a dose of live zoster vaccine in the past but has no other evidence of immunity to varicella, the live zoster dose can be considered the first dose of the 2-dose varicella series. Note that recombinant zoster vaccine (RZV, Shingrix) cannot be counted as the first dose in a 2-dose varicella vaccination series because Shingrix is not licensed and has not been evaluated for the prevention of primary varicella infection (chickenpox).

Last reviewed: May 16, 2023

Yes. In its 2018 recommendations for the prevention of herpes zoster, ACIP states that Shingrix may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine (Zostavax, Merck). Shingrix is also recommended for adults age 19 and older who are immunocompromised due to disease or treatment if they have a history of varicella illness or vaccination.

Last reviewed: May 16, 2023

A mild case of chickenpox produces immunity to varicella as does a moderate or severe case. A child with a reliable history of chickenpox does not need to receive varicella vaccine. However, if there is any doubt that the mild illness really was chickenpox, it is best to vaccinate the child. There is no harm in vaccinating a child who is already immune.

Last reviewed: May 16, 2023

Varicella vaccine is most effective in preventing chickenpox or reducing the severity of the disease if used within 72 hours (3 days), and may still be helpful up to 5 days after exposure. However, not every exposure to varicella leads to infection, so for future immunity, varicella vaccine should be given to a person age 12 months or older who does not have a contraindication to vaccination, even if more than 5 days have passed since an exposure.

Last reviewed: May 16, 2023

The only way to determine whether the rash is caused by wild-type varicella or vaccine virus is to try to isolate virus from the rash and send it to a laboratory that is capable of differentiating wild and vaccine-type virus. This is generally not practical. Given the history, the conservative approach is to assume she has an active case of chickenpox and act according to your infection control guidelines.

Last reviewed: May 16, 2023

There is currently no information on the effect of varicella vaccine on reactivity to a tuberculin skin test (TST). Until information is available, it is prudent to apply the same rules to varicella vaccine as are applied to MMR: a TST (i.e., PPD) may be applied before (preferably) or simultaneously with varicella vaccine. If vaccine has been given, delay the TST for at least 4 weeks.

Last reviewed: May 16, 2023

Live varicella vaccine should not be given to anyone known to be pregnant. If a person who is planning to become pregnant in the future comes in for a visit or an annual exam, the varicella history should be obtained and if indicated, 2 doses of vaccine should be given, spaced 4 to 8 weeks apart. Vaccine recipients capable of becoming pregnant should be counseled to avoid pregnancy for one month following each dose of varicella vaccine. A person who is inadvertently vaccinated while pregnant or becomes pregnant within a month of vaccination should be counseled about the theoretical risk to the fetus; however, it should not be considered a reason to terminate a pregnancy. Pregnant people should be assessed for evidence of varicella immunity and if non-immune, should receive the first dose of varicella vaccine following completion of the pregnancy and prior to hospital discharge. A second dose should be given 4 to 8 weeks later.

Last reviewed: May 16, 2023

People with a reliable history of varicella can be considered to be immune. A reliable history for healthcare personnel consists of (1) a healthcare provider’s diagnosis of varicella or verification of history of varicella disease; (2) a healthcare provider’s diagnosis of herpes zoster or verification of a history of herpes zoster; or (3) laboratory evidence of immunity or laboratory confirmation of disease. Immunity following disease or vaccination is probably life-long. More than one primary infection with varicella is unusual.

Last reviewed: May 16, 2023

No. Serologic testing for varicella should be considered only for pregnant people who do not have evidence of immunity (reliable history of chickenpox or documented vaccination). Once a person has been found to be seropositive, it is not necessary to test again in the future.

Last reviewed: May 16, 2023

Contrary to the information provided in the vaccine package insert, which states that pregnancy should be avoided for 3 months, the ACIP recommends that a wait of 1 month is sufficient.

Last reviewed: May 16, 2023

To date, no adverse outcomes of pregnancy or in a fetus have been reported among people who inadvertently received varicella vaccine shortly before or during pregnancy. The risk of congenital varicella syndrome following varicella disease is small, so the risk of congenital anomalies following vaccination with live attenuated varicella zoster virus (VZV)-containing vaccine is probably very small.

Merck and the Centers for Disease Control and Prevention (CDC) jointly operated a pregnancy registry for women exposed to VZV-containing vaccines for seventeen years after the licensure of varicella vaccine. The registry was discontinued in 2013, having found no signals to indicate a risk of Congenital Varicella Syndrome or pattern of birth defects related to vaccination with VZV-containing vaccines. Healthcare providers may continue to report exposure to VZV-containing vaccines within 3 months of conception or during pregnancy by contacting Merck’s call center at 1-877-888-4231.

Last reviewed: May 16, 2023

For children, the first dose should be given at age 12 months with a second dose given at age 4 through 6 years. The second dose could be given earlier, if necessary, as long as there is a 3-month (12-week) interval between doses. Although a 3-month minimum interval is recommended in children younger than age 13, the second dose does not need to be repeated if separated from the first dose by a shorter interval of at least 4 weeks.

All children age 13 years and older as well as adults without evidence of immunity should also have documentation of 2 doses of varicella vaccine, separated by a minimum interval of 4 weeks.

Last reviewed: May 16, 2023

Don’t delay giving the second dose of varicella vaccine. Give the second dose the next time the child is in your office. The recommendation to routinely give a second dose at age 4 through 6 years is intended to provide improved protection in the 15% to 20% of children who do not adequately respond to the first dose.

Last reviewed: May 16, 2023

Postvaccination serologic testing for varicella immunity is not recommended in any group, including healthcare personnel.

Last reviewed: May 16, 2023

Varicella postvaccination serologic testing is not recommended; however, if a person tests positive for varicella antibody 28 days or more after vaccination, the Advisory Committee on Immunization Practices (ACIP) considers the person to be immune. Studies have shown that a second dose boosts antibody titers and indicators of cell-mediated immunity significantly above the levels produced by a single dose. A second dose may be required to comply with school entry or institutional immunization requirements, regardless of serologic test results. You can access the ACIP varicella vaccine recommendations, which include evidence of immunity (page 16) at www.cdc.gov/mmwr/pdf/rr/rr5604.pdf.

Last reviewed: September 5, 2023

Test pregnant people who lack either (1) documentation of receipt of 2 doses of varicella vaccine or (2) healthcare provider diagnosis or verification of varicella or herpes zoster disease. Those who are not immune should begin the 2-dose vaccination series immediately postpartum.

Last reviewed: May 16, 2023

Commercially available laboratory tests for varicella antibody are usually based on a technique called EIA (enzyme immunoassay). Though these tests are sufficiently sensitive to detect antibody resulting from varicella zoster virus infection, they are generally not sensitive enough to detect vaccine-induced antibody. The more sensitive assays needed to detect vaccine-induced antibody are not widely available. This is why CDC does not recommend antibody testing after varicella vaccination.

Last reviewed: May 16, 2023

If you cannot verify a healthcare employee’s history of chickenpox, the employee should receive 2 doses of varicella vaccine at least 4 weeks apart. For details, refer to pages 16 and 26 of the CDC recommendations Prevention of Varicella at www.cdc.gov/mmwr/pdf/rr/rr5604.pdf.

Last reviewed: May 16, 2023

No. Documented receipt of 2 doses of varicella vaccine supersedes results of subsequent serologic testing. Most commercially available tests for varicella antibody are not sensitive enough to detect vaccine-induced antibody, which is why CDC does not recommend post-vaccination testing. For more information, see page 24 of ACIP’s Immunization of Health-Care Personnel, available at www.cdc.gov/mmwr/pdf/rr/rr6007.pdf.

Last reviewed: May 16, 2023

The recommended minimum interval between two doses of varicella vaccine for children 12 months through 12 years of age is 12 weeks. However, the second dose of varicella vaccine does not need to be repeated if records show it was separated from the first dose by at least 4 weeks. See www.cdc.gov/vaccines/hcp/imz-best-practices/timing-spacing-immunobiologics.html, Table 3-2.

Last reviewed: May 16, 2023

Contraindications:

  • History of a serious allergic reaction (e.g., anaphylaxis) after a previous dose of varicella vaccine or to a varicella vaccine component. For information on vaccine components, refer to the manufacturer’s package insert (www.immunize.org/fda).
  • Pregnancy
  • Severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy [e.g., two weeks or more of daily receipt of 20 mg or more, or 2 mg/kg body weight or more, of prednisone or equivalent] or patients with HIV infection who are severely immunocompromised [a child age 1 through 5 years with CD4+ T-lymphocyte percentage less than 15% or a person age 6 years or older with a CD4+ T-lymphocyte count less than 200 cells per microliter])
  • Family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents, siblings) unless the immune competence of the potential vaccine recipient has been clinically substantiated or verified by a laboratory

Precautions:

  • Recent receipt (within the previous 11 months) of antibody-containing blood product (specific interval depends on product)
  • Moderate or severe acute illness with or without fever (defer until recovery)
  • Use of aspirin or aspirin-containing products
  • Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)

Precautions for combination MMRV (ProQuad, Merck) only (approved for children 1 through 12 years of age) also include: history of thrombocytopenia or thrombocytopenic purpura, a personal or family history of seizures of any etiology, and a need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing.

For additional information, see the “General Best Practice Guidelines for Immunization” section on contraindications and precautions, table 4–1 and associated footnotes, at www.cdc.gov/vaccines/hcp/imz-best-practices/contraindications-precautions.html.

Last reviewed: July 26, 2024

The CDC “General Best Practice Guidelines for Immunization” section on altered immunocompetence recommends varicella vaccination of children with humoral (but not cellular) immunodeficiencies. In addition, single-antigen varicella vaccine should be considered for HIV-infected children age 1 through 5 years with CD4+ T-lymphocyte percentages greater than or equal to 15% for at least 6 months or for children age 6 years and older with CD4+ T-lymphocytes count greater than or equal to 200 cells per microliter for at least 6 months. Eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses. Additional details of these recommendations can be found in table 8-1 and associated footnotes at www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html.

Last reviewed: May 16, 2023

The IDSA guidelines indicate that persons receiving rituximab should be considered to have high-level immunosuppression. Both inactivated and live vaccines should be withheld at least 6 months following treatment with lymphocyte depleting medications such as rituximab. As for the IG, the interval to live vaccination depends on the dose. For guidance, please refer to the Timing and Spacing of Immunobiologics section of CDC’s “General Best Practices Guidelines for Immunization”, table 3–6: “Recommended intervals between administration of antibody-containing products and measles- or varicella-containing vaccine, by product and indication for vaccination” at www.cdc.gov/vaccines/hcp/imz-best-practices/timing-spacing-immunobiologics.html. This interval could be as long as 11 months, depending on the dose he receives.

Last reviewed: May 16, 2023

The ACIP’s varicella vaccine recommendations state that no adverse events associated with the use of salicylates after varicella vaccination have been reported, however, the vaccine manufacturer recommends that vaccine recipients avoid using salicylates for 6 weeks after receiving varicella vaccines because of the association between aspirin use and Reye syndrome after varicella disease (chickenpox). Vaccination with subsequent close monitoring should be considered for children who have rheumatoid arthritis or other conditions requiring therapeutic aspirin. The risk for serious complications associated with aspirin is likely to be greater in children in whom natural varicella develops than it is in children who receive the vaccine containing attenuated varicella zoster virus. In other words, the benefit of varicella vaccine likely outweighs the theoretical risk of Reye syndrome. See the ACIP varicella recommendations at www.cdc.gov/mmwr/PDF/rr/rr5604.pdf, page 29.

Last reviewed: May 16, 2023

This is not necessary unless the person who was vaccinated develops a rash.

Last reviewed: May 16, 2023

ACIP recommends varicella vaccine for healthy household contacts of pregnant people and immunosuppressed people. Although there may be a small risk of transmission of varicella vaccine virus to household contacts, the risk is much greater that the susceptible child will be infected with wild-type varicella, which could present a more serious threat to household contacts.

Last reviewed: September 5, 2020

Because the surgeon is immune, the child’s rash is not a problem and there is no need for the surgeon to restrict activity. In comparing a vaccine rash to wild-type chickenpox infection, transmission is less likely with a vaccine rash and, in general, there are fewer skin lesions.

Last reviewed: May 16, 2023

There has been only one published report of mother to child transmission of varicella vaccine virus. If the susceptible woman were to be infected with wild varicella virus, the risk of transmission to the infant would be much higher. Breastfeeding is not a contraindication or a precaution to varicella vaccination of the mother when vaccination is indicated.

Last reviewed: May 16, 2023

A previous history of chickenpox disease, even recent disease, is not known to interfere with the immune response to different vaccines. To review the true contraindications and precautions to vaccination, consult the appendix of the CDC Recommended Child and Adolescent Immunization Schedule (www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html).

CDC’s “General Best Practice Guidelines for Immunization” also contains the table of contraindications and precautions, in addition to a useful table titled “Conditions incorrectly perceived as contraindications or precautions to vaccination (i.e., vaccines may be given under these conditions)”. Both tables are available at www.cdc.gov/vaccines/hcp/imz-best-practices/contraindications-precautions.html, Tables 4-1 and 4-2.

Last reviewed: February 19, 2024

There is no known risk associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. It is possible that the immune response may be weaker, but the vaccines are likely effective.

Last reviewed: May 16, 2023

Varicella vaccine is very safe. About 20% of vaccine recipients will have minor injection site complaints, such as pain, swelling, or redness. Fewer than 5% of recipients develop a localized or generalized varicella-like rash 5 to 26 days after vaccination. These rashes have an average of 2 to 5 lesions, and may be maculopapular rather than vesicular. Fever following varicella vaccine is uncommon.

Last reviewed: May 16, 2023

If you believe the child had varicella disease (that is, breakthrough varicella) after the first dose, the child does not need another dose. If you are uncertain whether the child had varicella or a rash related to varicella vaccination, the second dose should be administered on schedule. If in doubt, give the second dose. If this was a case of breakthrough varicella, a second dose will not be harmful.

Last reviewed: May 16, 2023

Transmission of varicella vaccine virus is a rare event, and appears to occur only when the vaccinated person develops a vesicular rash. A maculopapular rash 2 weeks after varicella vaccine may not have been caused by the vaccine. If the rash were caused by the vaccine, the risk of transmission is very small; however, the child should avoid close contact with people who do not have evidence of varicella immunity and who are at high risk of complications of varicella, such as immunocompromised people, until the rash has resolved.

Last reviewed: May 16, 2023

You cannot distinguish a mild case of varicella disease from a rash caused by the vaccine. The child may have been infected with varicella at about the same time s/he was vaccinated. The conservative approach would be to treat the child as if s/he had chickenpox and restrict her/his activities until all the lesions crust.

Last reviewed: May 16, 2023

Breakthrough varicella represents replication of wild varicella virus in a vaccinated person. Although most breakthrough disease is very mild, the child is contagious and activities should be restricted to the same extent as an unvaccinated person with varicella disease.

Last reviewed: May 16, 2023

Available data suggest that healthy children are unlikely to transmit vaccine virus. Transmission of vaccine virus to a household contact has rarely been documented. It appears that transmission of vaccine virus occurs mostly, or perhaps even exclusively, when the vaccinated person develops a rash following vaccination.

Last reviewed: May 16, 2023

Transmission of varicella vaccine virus is rare. However, if a pregnant or immunosuppressed household contact of a vaccinated person is known to be susceptible to varicella, and if the vaccinee develops a rash 7 to 21 days following vaccination, it is prudent that they avoid prolonged close contact with the susceptible person until the rash resolves.

Last reviewed: May 16, 2023

Based on the weight and dosage provided (40 lbs and 15 mg/week), the child is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Infectious Disease Society of America (IDSA) definition of high-level immunosuppression. Administration of both varicella and MMR vaccines are contraindicated until such time as the methotrexate dosage can be reduced. The 2013 IDSA definition of low-level immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. For additional details, see the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf.

As a general rule, whenever feasible, it is recommended that non-live and live vaccines be administered 2 or more weeks before initiating immunosuppressive medications include human immune mediators like interleukins and colony-stimulating factors, immune modulators, and medicines like tumor necrosis factor-alpha inhibitors and anti-B cell agents. See CDC General Best Practice Guidelines for Immunization section on altered immunocompetence: www.cdc.gov/vaccines/hcp/imz-best-practices/altered-immunocompetence.html.

Last reviewed: June 19, 2023

An 8-month-old is likely to have residual passive varicella antibody from his or her mother. The vaccine probably will have no effect, and no action is necessary. The dose should not be counted, and the child should be revaccinated on schedule at 12 through 15 months of age.

Last reviewed: May 16, 2023

Varicella zoster immune globulin (VariZIG, Saol Therapeutics) is a human blood product prepared from plasma obtained from healthy, volunteer blood donors identified by routine screening to have high antibody titers to varicella-zoster virus. The first varicella zoster immune globulin, VZIG, became available in 1978. In a study of immunocompromised children who were administered VZIG within 96 hours of exposure, approximately one in five exposed children developed clinical varicella, and one in 20 developed subclinical disease compared with 65%—85% attack rates among historical controls. In 2006, VZIG was discontinued and a new product, VariZIG, became available.

Last reviewed: May 16, 2023

Varicella zoster immune globulin, VariZIG (Saol Therapeutics), is recommended for patients without evidence of immunity to varicella who are at high risk for severe varicella and complications, who have been exposed to varicella or herpes zoster, and for whom varicella vaccine is contraindicated. Patient groups recommended by CDC to receive VariZIG include the following:

  • Immunocompromised patients without evidence of immunity
  • Newborn infants whose mothers have signs and symptoms of varicella around the time of delivery (i.e., 5 days before to 2 days after)
  • Hospitalized preterm infants born at 28 weeks or more of gestation whose mothers do not have evidence of immunity to varicella
  • Hospitalized preterm infants born at less than 28 weeks of gestation or who weigh 1,000 grams or less at birth, regardless of their mothers’ evidence of immunity to varicella
  • Pregnant people without evidence of immunity

CDC recommends administration of VariZIG as soon as possible after exposure to varicella-zoster virus, ideally within 96 hours, but not beyond 10 days after exposure. The most recent recommendations for the use of VariZIG were published in 2013 and are available at www.cdc.gov/mmwr/pdf/wk/mm6228.pdf on pages 574—576.

Last reviewed: May 16, 2023

VariZIG is supplied in 125-IU vials and should be administered intramuscularly as directed by the manufacturer. The recommended dose is 125 IU/10 kg of body weight, up to a maximum of 625 IU (five vials). The minimum dose is 62.5 IU (0.5 vial) for patients weighing 2.0 kg or less and 125 IU (one vial) for patients weighing 2.1–10.0 kg. VariZIG is available from Saol Therapeutics. For ordering information see varizig.com/liquid-product_info.html.

Last reviewed: September 5, 2020

There is no evidence that healthy full-term infants born to women in whom varicella occurs more than 48 hours after delivery are at increased risk for serious complications such as pneumonia or death. Varicella zoster immune globulin, VariZIG, can be given up to 10 days after exposure but is only recommended for newborn infants whose mothers have signs and symptoms of varicella around the time of delivery (5 days before to 2 days after), hospitalized premature infants born at 28 or more weeks of gestation whose mothers do not have evidence of immunity to varicella, or hospitalized premature infants born at less than 28 weeks of gestation or who weigh 1,000 grams or less at birth regardless of their mothers’ evidence of immunity to varicella. Assuming this is an infant at home, VariZIG would not be recommended. Varicella, if it develops, would be managed as for any child.

Last reviewed: May 16, 2023

Live varicella-containing vaccines (varicella, MMRV) must be stored in a freezer at a temperature between -50°C and -15°C (between -58°F and +5°F) until reconstitution and administration. These vaccines can deteriorate rapidly after they are removed from the freezer. A separate stand-alone freezer or a combination refrigerator-freezer purpose-built for vaccine storage (sometimes called “pharmaceutical grade”) should be used to store frozen vaccines that require storage temperatures between -50°C and -15°C (between -58°F and +5°F). A stand-alone storage unit that is frost-free or has an automatic defrost cycle is preferred. Frozen vaccines should not be stored in the freezer compartment of a household-type combination unit because household freezers in combination units cannot reliably maintain proper storage temperatures for frozen vaccines. This applies to both temporary and long-term storage of frozen vaccines. The diluents should be kept separately in the refrigerator or at room temperature. Live varicella-containing vaccines must be administered within 30 minutes of reconstitution.

Last reviewed: May 16, 2023

Vaccine may lose potency rapidly if not stored according to the manufacturer’s instructions. However, it may still be permissible to use vaccine that has not been properly stored. Put the affected vaccine vials into the freezer after you have marked them so they are not confused with the unaffected vials, then call the manufacturer at 1-800-9-VARIVAX (1-800-982-7482) for further guidance about whether the vaccine is still usable. Unreconstituted varicella vaccine may be stored in the refrigerator for up to 72 hours before use. If refrigerated varicella vaccine is not used within 72 hours, it should be discarded.

If you have inadvertently left your vaccine at room temperature instead of in the freezer or have experienced a power failure, label the affected vaccine to keep it separated from unaffected vaccine and return it to recommended storage conditions in a freezer promptly, then contact the manufacturer for further guidance. Do not administer the vaccine until you have consulted with Merck.

Last reviewed: May 16, 2023

The vaccine manufacturer does not recommend transporting varicella-containing vaccines (varicella, MMRV). If these vaccines must be transported (for example during an emergency), CDC recommends use of a portable vaccine freezer unit or qualified container and packout that maintains temperatures between -50°C and -15°C (- 8°F and +5°F). Do not use dry ice, even for temporary storage. Dry ice might expose the vaccines to temperatures colder than -50°C (-58°F), resulting in compromise of the vial stopper material.

Follow these steps for transporting frozen vaccines:

  • Place a temperature monitoring device (preferably with a buffered probe) in the container as close as possible to the vaccines.
  • Immediately upon arrival at the destination, unpack the vaccines and place them in a freezer at a temperature range between -50°C and -15°C (-58°F and +5°F). Any stand-alone freezer or freezer purpose built for vaccine storage that maintains these temperatures is acceptable.
  • Record the time vaccines are removed from the storage unit and placed in the transport container, the temperature during transport, and the time at the end of transport when vaccines are placed in a stable storage unit.

If necessary, varicella-containing vaccines may be transported or stored at refrigerator temperature between 2°C and 8°C (between 36°F and 46°F) for up to 72 continuous hours prior to reconstitution. To do so, follow the steps above using a portable vaccine refrigerator unit or a qualified container and packout designed to maintain vaccine storage temperatures between 2°C and 8°C (between 36°F and 46°F).

Transport of varicella-containing vaccine at temperatures other than the recommended range between -50°C and -15°C (-58°F and +5°F) is considered a temperature excursion, so contact Merck at (800) 982-7482 for further guidance. Do not discard vaccines without contacting the manufacturer and/or your immunization program for guidance.

For additional guidance, see the CDC Vaccine Storage and Handling Toolkit at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf.

Last reviewed: May 16, 2023

Yes. According to the manufacturer, unreconstituted varicella vaccine may be stored at refrigerator temperature (2°C to 8°C, 36°F to 46°F) for up to 72 continuous hours prior to reconstitution. Vaccine stored at 2°C to 8°C that is not used within 72 hours of removal from -15°C (+5°F) storage should be discarded. See www.merck.com/product/usa/pi_circulars/v/varivax/varivax_pi.pdf.

Last reviewed: May 16, 2023

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