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Varicella (Chickenpox) Vaccine

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ACIP Recommendations for Use of Combination Measles-Mumps-Rubella-Varicella Vaccine

May 13, 2010 -- The Bureau of Immunization is pleased to bring to your attention an important report published by the Centers for Disease Control and Prevention (CDC) on May 7, 2010, in the Morbidity and Mortality Weekly Report (MMWR Weekly / Vol. 59 / No. RR3). The report, Use of Combination Measles, Mumps, Rubella, and Varicella Vaccine - Recommendations of the Advisory Committee on Immunization Practices (ACIP) (page 1 - 12), presents the recommendations and use of the combination measles-mumps- rubella-varicella vaccine (MMRV, ProQuad, Merck & Co., Inc.).

We encourage providers to read these recommendations and guidance carefully, since we include only excerpts here.

In June 2009, the CDC's Advisory Committee on Immunization Practices (ACIP) adopted new recommendations regarding use of the combination MMRV vaccine. MMRV vaccine was licensed in the U.S. in September 2005 and may be used instead of measles-mumps-rubella vaccine (MMR, M-M-RII, Merck & Co., Inc.) and varicella vaccine (VARIVAX, Merck & Co., Inc.) to implement the recommended 2-dose vaccine schedule for prevention of measles, mumps, rubella, and varicella among children 12 months through 12 years of age. At the time of its licensure, use of MMRV vaccine was preferred for both the first and second doses over separate injections of equivalent component vaccines (MMR vaccine and varicella vaccine), which was consistent with the ACIP's 2006 general recommendations on use of combination vaccines (CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2006;55;[No. RR-15]). Since July 2007, supplies of MMRV vaccine have been temporarily unavailable as a result of manufacturing constraints unrelated to efficacy or safety. MMRV vaccine is now available in the U.S. again.

After consideration of the postlicensure data and other evidence, the ACIP adopted the following summized new recommendations regarding use of MMRV vaccine for the first and second doses and identified a personal or family (i.e., sibling or parent) history of seizure as a precaution for use of MMRV vaccine:

• The routinely recommended ages for measles, mumps, rubella and varicella vaccination continue to be 12 to 15 months of age for the first dose and 4 to 6 years of age for the second dose.
• For the first dose of measles, mumps, rubella, and varicella vaccines at 12 to 47 months of age, either measles, mumps, and rubella (MMR) vaccine and varicella vaccine or MMRV vaccine may be used. Providers who are considering administering MMRV vaccine should discuss the benefits and risks of both vaccination options with the parents or caregivers. Unless the parent or caregiver expresses a preference for MMRV vaccine, the CDC recommends that MMR vaccine and varicella vaccine should be administered for the first dose in this age group.
• For the second dose of measles, mumps, rubella, and varicella vaccines at any age (15 months to 12 years) and for the first dose at greater than 48 months of age, use of MMRV vaccine generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and varicella vaccine). Considerations should include provider assessment, patient preference, and the potential for adverse events.
• A personal or family (i.e., sibling or parent) history of seizures of any etiology is a precaution for MMRV vaccination. Children with a personal or family history of seizures of any etiology generally should be vaccinated with MMR vaccine and varicella vaccine.

MMRV vaccine may be administered simultaneously with other vaccines recommended for children 12 to 15 months of age and 4 to 6 years of age. If simultaneous administration is not possible, MMRV vaccine may be administered at any time before or after an inactivated vaccine but at least 28 days before or after another live, attenuated vaccine, except varicella vaccine, for which a minimum interval of 3 months is recommended.

Effective Monday, May 10, 2010, Merck ProQuad, MMR-V, NDC 00006-4999-00, 10-pack single dose vial became available for ordering through the Vaccines for Children (VFC) Program. A separate Vaccine Information Statement (VIS) for MMRV is in draft form and is expected to be available later this year. Both MMR and varicella VISs include information about MMRV and are available at: http://www.cdc.gov/vaccines/pubs/vis/.

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Update on Supply of Merck & Co., Inc. Vaccines

-- SUPERSEDED INFORMATION -- HISTORICAL USE ONLY -- SEE UPDATED INFORMATION ABOVE --

November 16, 2007 -- The Centers for Disease Control and Prevention (CDC) maintains a webpage with the latest national information about vaccine supplies and provides guidance to healthcare providers who are facing vaccine shortages or delays at: http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm.

Varicella

Merck is continuing to experience a vaccine supply interruption and shipping delays of 6 to 8 weeks for varicella orders. While there is no change in the routine recommendation, provision of Temporary Medical Exemptions may still be necessary.

Please be assured that the Florida Vaccines for Children (VFC) Program has sufficient Haemophilus influenzae type B, Varicella, and Hepatitis A vaccine available. The bureau will provide vaccine supply updates as indicated.

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Update on Supply of Vaccines Containing Varicella-Zoster Virus

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October 29, 2007 -- We are continuing to experience extended delivery timelines for vaccines containing varicella-zoster virus. Shipments of varicella vaccines are anticipated to be delivered within 30 to 35 business days, or six to seven calendar weeks. However, there is no change in the routine recommendation for vaccines containing varicella-zoster virus. Providers should plan on recalling any children or adolescents who have been given temporary medical exemptions as soon as the vaccine supply is sufficient.

Questions regarding the supply of these Merck products should be addressed to Merck's National Service Center at (800) 637-2590. Updates on vaccine shortages and delays are available from the Centers for Disease Control and Prevention (CDC) at: http://www.cdc.gov/vaccines/vac-gen/shortages/default.htm. We will continue to provide updates about the supply of varicella-zoster-containing vaccines as new information becomes available.

For further information regarding adult immunization recommendations, prevention of hepatitis A after exposure, or the supply of vaccines containing varicella-zoster virus, please contact the Bureau of Immunization at (850) 245-4342.

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Varicella Recommendations

-- SUPERSEDED INFORMATION -- HISTORICAL USE ONLY -- SEE UPDATED INFORMATION ABOVE --

The Centers for Disease Control and Prevention (CDC) published Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP) in the June 22, 2007 / 56(RR04);1-40 Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports. These recommendations were available online previous to this publication, but were considered provisional until now. The new recommendations include:

• Implementation of a routine 2-dose varicella vaccination program for children, with the first dose administered at age 12-15 months and the second dose at age 4-6 years;
• A second dose catch-up varicella vaccination for children, adolescents, and adults who previously had received 1 dose;
• Routine vaccination of all healthy persons aged >=13 years without evidence of immunity;
• Prenatal assessment and postpartum vaccination;
• Expanding the use of the varicella vaccine for HIV-infected children with age-specific CD4+T lymphocyte percentages of 15%-24% and adolescents and adults with CD4+T lymphocyte counts >=200 cells/microliter; and
• Establishing middle school, high school, and college entry vaccination requirements. ACIP also approved criteria for evidence of immunity to varicella.

Note: The PDF version ( linked below) includes a free CDC-sponsored continuing-education activity that can be completed online or submitted by U.S. mail for CME, CEU, or CNE credit. To access a web-text (HTML) version of the recommendations, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm.

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Provisional Recommendations for Varicella Vaccine 2nd Dose

-- SUPERSEDED INFORMATION -- HISTORICAL USE ONLY -- SEE UPDATED INFORMATION ABOVE --

The Advisory Committee for Immunization Practices (ACIP) updated the provisional recommendations for the prevention of varicella on August 3, 2006. The provisional recommendations were first posted in November 2005. In June 2005 and June 2006, the ACIP made policy changes for use of live, attenuated varicella-containing vaccines for prevention of varicella.

Changes include routine two dose varicella vaccination of children and second dose catch-up varicella vaccination for children, adolescents and adults who previously had received only one dose. The ACIP also expanded recommendations for varicella-containing vaccines to promote wider use of the vaccine for adolescents, adults, and HIV-infected children and approved new criteria for evidence of immunity to varicella.

Provisional recommendations for prevention of varicella include but are not limited to:

• All children <13 years of age should be administered routinely two doses of varicella with the first dose administered at 12-15 months of age and the second dose at 4-6 years of age (i.e., before a child enters kindergarten or first grade). The second dose can be administered at an earlier age, provided the interval between the first and second dose is at least 3 months. However, if the second dose is administered at least 28 days following the first dose, the second dose does not need to be repeated.
• A second dose catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose to improve individual protection against varicella and for more rapid impact on school outbreaks. Catch-up vaccination can be implemented during routine healthcare provider visits and through school and college entry requirements. Catch-up second dose can be administered at any interval longer than 3 months after the first dose.

The ACIP revised criteria for evidence of immunity to varicella is detailed in the new provisional recommendations. The criteria for proof of immunity includes any of the following: documentation of age-appropriate vaccination; laboratory evidence of immunity; laboratory confirmation of disease; born in the U.S. before 1980; healthcare provider diagnosis of varicella or healthcare provider verification of history of varicella disease; or history of herpes zoster based on healthcare provider diagnosis.

Please note: current school immunization requirements, as referenced in Chapter 64D F.A.C., allows schools to accept parental history of disease for entry to childcare facilities and schools in Florida. Changes to update school requirements regarding proof of varicella immunity will be considered in the coming months.

Second dose of varicella is not required for entry to school or child care at this time. The provisional recommendations can be accessed at the following link: http://www.cdc.gov/vaccines/recs/provisional/downloads/varicella-june-2006.pdf [PDF 96 KB].

Measles, mumps, rubella and varicella (MMRV) vaccine is licensed and indicated for simultaneous vaccination against measles, mumps, rubella, and varicella among children 12 months through 12 years of age. For routine immunization, use of licensed combination vaccines, such as MMRV vaccine, is preferred over separate injection of equivalent component vaccines-- SUPERSEDED INFORMATION -- HISTORICAL USE ONLY -- SEE UPDATED INFORMATION ABOVE --