Review: varicella vaccination

Preamble

The National Advisory Committee on Immunization (NACI) provides the Public Health Agency of Canada with ongoing and timely medical, scientific and public health advice relating to immunization. The Public Health Agency of Canada acknowledges that the advice and recommendations set out in this statement are based upon the best current available scientific knowledge and is disseminating this document for information purposes. People administering the vaccine should also be aware of the contents of the relevant product monograph(s). Recommendations for use and other information set out herein may differ from that set out in the product monograph(s) of the Canadian manufacturer(s) of the vaccine(s). Manufacturer(s) have sought approval of the vaccine(s) and provided evidence as to its safety and efficacy only when it is used in accordance with the product monographs. NACI members and liaison members conduct themselves within the context of the Public Health Agency of Canada's Policy on Conflict of Interest, including yearly declaration of potential conflict of interest.

Introduction

In 2006 the Advisory Committee on Immunization Practices (ACIP) approved a routine 2-dose varicella vaccination schedule for children. They determined that the first dose should be administered at 12-15 months of age, and the second dose between 4 and 6 years of age. The purpose of this document is to review information on the epidemiology of varicella, compare the effectiveness of one dose of varicella vaccine with two doses, and to consider a potential change to the current National Advisory Committee on Immunization (NACI) recommendation for a one-dose childhood varicella vaccination program.

Methods

A variety of strategies were used to obtain literature for this review. A search of the Medline database was conducted for articles published in English prior to May 1, 2008. The search terms "varicella vaccination" and "varicella immunization" were used. Additionally, previous NACI recommendation statements, and the U.S. comprehensive review published in the Morbidity and Mortality Weekly Review in June 2007 by ACIP were used and then checked for relevant references. Relevant studies will be assigned a level of evidence and assessed for quality in the forthcoming NACI statement on Varicella Vaccination Two-Dose Recommendations (to be posted at: NACI Recommendations, Statements and Updates).

National Goals for Varicella Disease

The National Consensus Conference for Vaccine-Preventable Diseases in Canada convened in June, 2005. The purpose of the conference was to achieve consensus on national immunization coverage and disease reduction goals and targets for six vaccine-preventable diseases (VPDs) and to identify the process for their adoption and implementation at the national level. The goal established for varicella disease was to reduce illness and death due to complications from varicella through immunization. Recommendations for achievement of this goal included: 1) immunization coverage with varicella vaccine in 85% of children by their 2nd birthday, and in 85% of susceptible individuals by their 7th and 17th birthdays, by 2010; 2) 80% reductions in varicella-related hospitalization rates and varicella-related deaths by 2010, and 3) sustained reduction of 70 and 90% in varicella incidence by 2010 and 2015 respectively^{Footnote 1}.

Results

1. Disease Agent

Varicella-zoster virus (VZV) is a DNA virus of the herpes virus family. VZV causes a primary illness of varicella (chickenpox) and establishes latency in the sensory nerve ganglia which may reactivate later as herpes zoster (shingles). VZV can be spread through air or by direct contact with the virus shed from skin lesions and humans are the only reservoir known to transmit disease. The incubation period ranges from 10 to 21 days with a typical range of 14 to 16 days. Infectiousness begins 1 to 2 days before rash onset and lasts until the last lesion has crusted. The attack rate among susceptible contacts in household settings is estimated at 65%- 87% ^{Footnote 2}. Healthy children typically have 200 to 500 vesicular skin lesions. Acute varicella is typically mild and self-limiting, however varicella-related complications have been observed. Complications include secondary bacterial infections (e.g. Group A Streptococci), dehydration, pneumonia, and central nervous system involvement. Complications are more common in adolescents, adults and the immunocompromised ^{Footnote 3}.

2. Epidemiology of varicella and zoster in the pre-vaccine era

Prior to the introduction of extensive VZV vaccination programs, varicella (chickenpox) was deemed to be primarily a benign disease in healthy children less than 13 years of age. Approximately 50% and 90% of children were expected to have had an infection by the age of 5 years and 12 years respectively ^{Footnote 4}.

In Canada there were about 350,000 cases of chickenpox each year in the pre-vaccine era (estimated incidence, 11.7 per 1,000 population). A study published in 1999 estimated the total direct costs (i.e. hospitalizations, physician consults, and medical and surgical procedures) and productivity costs (e.g. time missed from work and caregiver activities) related to childhood varicella illness to be approximately $122 million annually ^{Footnote 5}. While risk of hospitalization was low (~1 in 200-400), children accounted for 90% of the annual 1500 to 2000 varicella-related hospitalizations each year. Providing care for children who were ill and lost productivity accounted for 81% of the annual cost of disease ^{Footnote 6}. Furthermore, nearly 20% of those hospitalized experienced some type of neurological complication and 8% had life-threatening infections such as necrotizing fasciitis or septicaemia ^{Footnote 6}. Prior to the introduction of their universal immunization program in 1995, the United States estimated an annual incidence rate of 15 cases per 1,000 ^{Footnote 7}, and 11,000 hospitalizations and 100 deaths related to varicella annually ^{Footnote 8,Footnote 9}.

Chickenpox was a nationally notifiable disease between 1924 and 1958, and was reintroduced on the list of notifiable diseases in 1986. Unfortunately, less than 10% of all varicella infections are reported to the Notifiable Diseases Reporting System (NDRS) in a given year as only laboratory-confirmed cases or clinical cases linked to laboratory-confirmed cases are captured by the case definition. Furthermore, not all provinces and territories participate in routine reporting at the national level ^{Footnote 10}.

Available supplementary surveillance information from the Immunization Monitoring Program, Active (IMPACT), a paediatric hospital-based network of 11 hospitals accounting for approximately 90% of available tertiary care paediatric beds in Canada revealed that Varicella Zoster Virus was responsible for a total of 3,681 paediatric hospitalizations between 1991-1996 and 1999-2005 (Table 1) ^{Footnote 10,Footnote 11}. Between 1999 and 2005, 55% of paediatric cases were male, with children ages 1 to 4 years accounting for the largest percentage of hospitalizations (45%), while children aged 5 to 9 years accounted for 30% of hospitalizations. Paediatric deaths among infants less than one year of age were relatively uncommon (7 deaths per 100,000 population) and of the 53 deaths attributed to varicella between 1987 and 1996, 70% occurred in those >15 years of age. Also, according to the 2006 Canadian National Report on Immunization, seven deaths due to varicella and one death attributed to herpes zoster were reported to IMPACT between 1999 and 2005 ^{Footnote 10}.

Table 1. Number and Yearly Average of VZV cases reported in IMPACT, 1991-2005

Time Period	Number of varicella cases	Average number of  varicella cases per year
1991-1996	1,326	221
1999-2005	2,358 (includes both varicella + zoster cases)	337

3. History of Varicella vaccination, indications, and dosage recommendations in Canada

Varivax® III (live attenuated, [Oka/Merck]) produced by Merck Frosst Canada Ltd. and Varilrix® (live attenuated, [Oka-strain]) produced by GlaxoSmithKline Inc are the two varicella vaccines authorized for use in Canada. Varivax® received its first authorization for use in Canada in 1999, and Varilrix® in 2002. Each vaccine consists of lyophilized, live attenuated varicella virus designated the Oka strain, which was developed in Japan in the mid 1970s. Each 0.5 mL dose of Varivax® III contains a minimum of 1350 Plaque Forming Units (PFU) (Product monograph Varivax® III MerckFrosst, revised September 21, 2007) ^{Footnote 12}. Each dose of Varilrix® contains a minimum of 1995 PFU (Product monograph Varilrix®, GSK amended January 3, 2007) ^{Footnote 13}.

Table 2. Historical review of NACI varicella vaccination recommendations, 1999-2004

Category	1999 NACI recommendation	2002 NACI recommendation	2004 NACI recommendation
Routine Childhood Schedule	1 dose at 12-18 months of age	No change	No change
Susceptible persons ≥ 13 years of age	2 doses > 28 days apart	No change	No change
Contraindications	Hypersensitivity History of hypersensitivity to any vaccine component including gelatin and neomycin (history of contact dermatitis to neomycin is not a contraindication) Immunocompromised Persons Not authorized for use in persons who are immunosuppressed Pregnancy	Addition of details related to Immunocompromised Persons Any persons with blood dyscrasis, leukemia (except acute lymphoblastic leukemia), lymphomas of any type, or other malignant neoplasms affecting the bone marrow or lymphatic system, or persons with other defects in cell mediated immunity or treatment associated with T-cell abnormalities (e.g., intensive chemotherapy, high dose steroids, cyclosporine, azathioprine, methotrexate, tacrolimus)	No change
High Risk Target Groups	None stated	∙ Children and adolescents on chronic salicylic acid therapy ∙ Persons with cystic fibrosis ∙ Susceptible household contacts of immunocompromised persons ∙ Susceptible health care workers ∙ Susceptible women of child-bearing age (vaccine should not be given during pregnancy) ∙ Solid organ transplant recipients (vaccine should be given a minimum of 4-6 weeks prior to transplantation) ∙ HIV infected person	No change
Immunocompromised persons: special considerations	Not authorized for use	∙ HIV-infected persons with normal immune status and solid organ transplant recipients. Some HIV infected children should be considered for immunization if asymptomatic or mildly symptomatic in CDC class N1 or A1 with age-specific CD4+ T-lymphocyte percentages of ≥ 25%. These children should receive 2 doses 3 months apart.	No change
Post-exposure Use	No conclusive data supporting post-exposure efficacy of varicella vaccine, however it is not harmful. Where post-exposure prophylaxis is being considered for outbreak control, consultation with the local public-health department is recommended.	3-5 days post exposure	No change

Prince Edward Island was the first province to introduce a universal childhood immunization program in April 2000. Since then all other provinces and territories have implemented universal varicella vaccination programs (Table 3).

Table 3. Comparison of Canadian Provincial and Territorial Varicella Vaccination Programs

	Year Implemented	Target Population	Catch-Up Programs
NACI recommendation	N/A	12 months,-18months (1 dose)	-
Province/ Territory
BC	Jan 2005	12 mths	- 4-6 year olds - Gr. 6 - Susceptible 18-47 months (ended 2007)
AB	Mar 2001	12 mths	- 4-6 year olds (ended 2007) Gr. 5 (ended  2007)
SK	Jan 2005	12 mths	Gr. 6 (ongoing until 2015)
MB	Oct 2004	12 mths	- 4-6 yrs - Gr. 4
ON	Sep 2004	15 mths	- unimmunized, susceptible 5 year olds
QC	Jan 2006	12 mths	- 4-6 yrs - Gr. 4 - Non-immune health care workers
NB	Sep 2004	12 mths	- 4 year olds (ended 2007)
NS	Sep 2002	12 mths	- 1-6 yrs old - Gr. 4 (ended 2007)
PE	Apr 2000	12 mths	-
NL	Jan 2005	12 mths	- 4-6 year olds
NT	Sep 2001	12 mths	- Children <5 yrs
YT	Sep 2007	12 mths	-
NU	Sep 2002	15 mths	-

4. Varicella Immunization Coverage

The United States introduced universal one-dose varicella immunization in 1995. Between 1997 and 2005, state-specific coverage rates increased from 27% to 88% among children 19-35 months of age. In spite of relatively high coverage rates, several varicella outbreaks have been recorded in vaccinated populations in settings ranging from child care centres and schools to households ^{Footnote 14,Footnote 16} (also see Table 7).

In Canada, universal varicella immunization programs were not implemented in all provinces and territories until 2007. The National Immunization Coverage Survey (NICS) conducted in Canada in 2004 reported a coverage rate of 32% among children 24-36 months of age. (The margin of error for the 2004 NICS is estimated to be from 4.2% to 4.4%) ^{Footnote 10}. Unpublished data from the 2006 NICS reveals a coverage rate of 57.8% by the second birthday (95% CI: 52-62). Unpublished data from the 2006 Adult NICS reveals a coverage rate in adults 18-64 years of age with a chronic medical condition (who report not having had "prior immunity" to varicella—based on recall of having had disease or having been tested for immunity) of 14% (95% CI: 4.4-23.6), and a coverage rate in health care workers in close contact with patients and no prior history of disease of 22.5% (95% CI: 20.1-24.9). Data from the 2009 NICS is not yet available. Data from Saskatchewan, where a provincial immunization registry captures all vaccinations provided by public health (which is close to 95% of all vaccination services in the province) showed 71% of children received one-dose of vaccine by two years of age in 2006 (unpublished data).

5. Post-Exposure Vaccination as a Strategy for Controlling Varicella Disease

Ideally, vaccinating persons susceptible to VZV prior to any exposure is the best method of preventing or decreasing the severity of disease should exposure occur. The NACI 2004 Update on Varicella statement ^{Footnote 4} defines exposure for children as: living in same household for > 5 minutes (some experts say >60 minutes) of face to face contact with another contagious child. In health care workers, having more than 15 minutes of face to face contact or spending > 60 minutes in a room with an infected patient is considered significant exposure.

The theoretical basis for post-exposure prophylaxis relates to the ability of the varicella Oka-derived vaccines to induce cell-mediated and antibody responses within 5 to 7 days ^{Footnote 17}. Pre-licensure studies showed that vaccination with single-antigen vaccine was 90% effective in preventing varicella in healthy persons ≥ 12 months if administered within 3 days of exposure to rash and roughly 70% effective if administered within 5 days, and 100% effective in modifying severe disease ^{Footnote 7}. A post-licensure study with  67 people reported vaccine effectiveness of 95% for prevention of any disease and 100% for preventing moderate or severe disease in children <13 years of age after exposure to VZV ^{Footnote 18}. Another study that looked at 10 siblings receiving post-exposure vaccination within 3 days demonstrated that the vaccine prevented disease in 5 out of 10 of these children and prevented moderate or severe disease among 9 out of 10 children ^{Footnote 19}. The five children who developed mild illness were described as having between 5 and 83 skin lesions.

In some instances post-exposure varicella vaccination may not be possible for persons with contraindications (i.e. pregnant women, immunocompromised persons, newborn infants of mothers developing varicella during the 5 days before to 48 hours after delivery) if significant exposure has occurred. When this is the case, passive immunization with Varicella-Zoster Immune Globulin VariZIG™ is the recommended course of treatment. VariZIG™ administration within 96 hours VariZIG™ may prolong the incubation period of VZV from 21 to 28 days. Protection after one dose lasts for approximately three weeks ^{Footnote 20}.

The 2007 ACIP Varicella Prevention statement ^{Footnote 7} states that VariZIG™ is not indicated for persons who have received 2 doses of varicella vaccine and subsequently become immunocompromised as a result of disease or treatment later in life. They instead advise treatment with acylclovir.

6. Varicella Epidemiology in the Post-Vaccine Era

Follow-up data since the introduction of universal vaccination programs in Canada is not currently available, however it is likely that similar trends will be observed here as those seen in the United States where universal programs have been in effect for over 10 years. The U.S. data is described below.

6.1 Changes in Varicella Epidemiology in the United States after Introduction of Universal Immunization Program

A large scale Varicella Active Surveillance Project was set up in Antelope Valley, California, West Philadelphia, Pennsylvania and Travis County, Texas to evaluate changes in varicella epidemiology after the introduction of universal vaccination programs in these communities. The surveillance project receives information from over 600 reporting sites across the three communities, who have a combined population of approximately 576,000. Several papers reported results on changing epidemiology, hospitalization and other varicella associated events over an 11-year surveillance period from 1995-2005 ^{Footnote 21-Footnote 23}.

Population-based disease surveillance in three U.S. communities after the introduction of universal varicella vaccination programs between 1995 and 2005 reported a 90% decline in incidence case reports ^{Footnote 22} while achieving immunization coverage levels of 74% to 84% in children aged 19 to 35 months ^{Footnote 24}. Children ages 1 to 4 years experienced the greatest decline in disease incidence.

The numerator and the denominator refer to adults with chronic medical conditions who report not having "prior immunity" to varicella. "Prior immunity" is assessed based on recall of having had the disease (varicella or chickenpox) or having been tested for immunity. However, since this value is heavily based on recall of having had the disease, it is possible that the denominator is increased due to participants not recalling have had varicella/chickenpox.

Incidence and Outbreak Epidemiology
Incidence rates decreased significantly in two ongoing VASP sites (surveillance in Travis County, Texas ended earlier) between 1995 and 2005 (p<0.001). The decrease was from 10.3 cases per 1000 population (2934 cases) to 1.1 cases per 1000 population (362 cases) in AV, and from 4.1 cases per 1000 population (1197) to 0.4 cases per 1000 population (108 cases) in WP. This represents a 90% decrease in the incidence of cases. Age-specific rates decreased significantly for all age groups from their 1995 baseline levels (Table 4). However an earlier published study that assessed data up to 2004 in Antelope Valley showed that while the overall varicella incidence rate had declined from baseline levels there was no substantial reduction in disease since 2001 despite vaccine coverage rates of approximately 90% ^{Footnote 25}.

Table 4. Reported Number of Varicella cases and Incidence Rates (per 1000 population) by age group in Sentinel Surveillance sites in Antelope Valley, California and West Philadelphia, Pennsylvania- 1995 and 2005

	No. of Cases		Rate per 1000		2005 vs. 1995
Antelope Valley	1995	2005	1995	2005	% Change
Age Group (yrs)
<1	134	16	19.7	3.2	-83.9
1-4	1127	50	48.8	2.5	-94.9
5-9	1228	122	54.9	4.6	-91.6
10-14	235	128	10.8	3.9	-63.9
15-19	65	15	3.1	0.5	-85.5
≥ 20	145	31	0.8	0.1	-82.0
Total	2934	362	10.3	1.1	-89.8
West Philadelphia
Age Group (yrs)
<1	38	7	8.8	1.9	-78.7
1-4	358	30	20.8	2.0	-90.3
5-9	534	29	27.3	1.6	-94.2
10-14	162	13	8.9	0.7	-92.8
15-19	39	6	1.9	0.2	-87.8
≥ 20	60	23	0.3	0.1	-57.3
Total	1197	108	4.1	0.4	-90.4

Source: Guris D et al. (2008) Changing Varicella Epidemiology in Active Surveillance Sites- United States, 1995-2005; Journal of Infectious Disease: 197 (Suppl 2) S71-S75

Overall since the introduction of universal varicella vaccination in the U.S., the number of outbreaks (characterized as ≥5 epidemiologically linked cases within 1 incubation period) decreased on average from 59 to 12 per year (p<.001) and the proportion of outbreaks with 25 or more cases also decreased significantly from 28% to 4% ^{Footnote 21}. Additionally, research from these surveillance sites also reported a decrease in the duration of outbreaks from 45 to 30 days (p<.001), an increase in the proportion of mild cases (less than 50 lesions) from 35% to 46% (p<.001) and a decrease from 9.3% to 3.6% (p<.001) in the number of cases with complications ^{Footnote 21}.

Age at Disease Onset
The median age at disease onset shifted upwards for both cases with and without history of vaccination. For vaccinated case patients, the median age increased from 5 years to 8 years in vaccinated cases and from 5 years to 13 years in unvaccinated case patients in Antelope Valley. In West Philadelphia the median age at disease onset increased from 3 years to 6 years in vaccinated cases and from 6 years to 19 years in unvaccinated cases ^{Footnote 22}.

Vaccination Status of Case Patients In the active surveillance sites between 1995 and 2005 there was an increase in the proportion of varicella cases with a previous history of vaccination. This proportion decreased as age increased. By 2005 the proportion of vaccinated cases ≥1 year of age ranged from 57 to 64%. A history of vaccination among case patients was observed in approximately 87-97% of those ages 5-9 years, 38-45% for those 10-14 years, 17-31% for those 15-19 years and 7-9% for those patients ≥20 years of age ^{Footnote 22}. The majority of these cases would have received only one vaccination prior to disease onset. Earlier data from this population revealed that the attack rate was 15% if contacts were vaccinated and 71.5% if the contact was unvaccinated (risk ratio 0.21; 95%CI 0.15-0.30).

Overall, vaccinated cases were half as contagious as unvaccinated cases, however vaccinated cases with 50 lesions or more were as contagious as unvaccinated cases whereas those with fewer than 50 lesions were only one third as contagious (Table 5)^{Footnote 16}. Specimen analysis using Polymerase Chain Reaction (PCR) from 33 vaccinated children found that 76% of those with adequate lesion sample were positive for wild-type VZV ^{Footnote 26}. Oka vaccine virus was not identified in any specimens.

Table 5. Secondary Attack Rate and Lesion Severity of Secondary Cases Ages 1 to 14 years by Varicella Vaccination Status and Disease History exposed to previously vaccinated primary cases, Antelope Valley, CA, 1997-2001

	Secondary Contacts of Primary Cases Previously Vaccinated for Varicella
	No History of Vaccination or Varicella (n=70)	History of Vaccination (n=94)	History of Varicella (n=38)
Secondary Attack Rate, No. (%)	26 (37)	21 (22.3)	1 (2.6)
Secondary cases with ≥50 lesions, No. (%)	16 (61.5)	4 (10.2)	0

Source: Seward J, Zhang J, Maupin T, et al. Contagiousness of Varicella in Vaccinated Cases A Household Contact Study. JAMA 2006; 292:704-708

Hospitalizations and Mortality
A varicella-related hospitalization (VRH), defined as an admission to an inpatient ward or an emergency room for >8 hours is a recognized complication of varicella^{Footnote 27}. A comprehensive prospective longitudinal study found that overall between 1995 and 2005, VRH rates per 100,000 population decreased significantly from 2.54 (95% CI, 2.1-3.0) during the early vaccination period (1995-1998) to 0.6 (95% CI 0.4- 1.0) during the late vaccination period (2002-2005), p<0.01. Among those <20 years of age, rates decreased by 77% from 6.42 (95% CI, 5.3-7.8) to 1.51 (95% CI, 0.6-1.2) per 100,000 population and by 60% among adults ≥ 20 years of age from 0.85 (95% CI, 0.6-1.2) to 0.34 (95% CI, 0.2-0.6) per 100,000 population. There was also a change in the age distribution in VRH case patients. In the early vaccination period, children <10 years of age accounted for 69% of all VRHs, those 10-19 years of age accounted for 7.8% of VRHs, and those ≥ 20 years of age accounted for 23.3% of VRHs. In the years following 1998, children <10 years accounted for only 48.8% of VRHs, while those 10-19 years made up 19.5% and adults ≥ 20 years accounted for 31.7% of VRHs. The median age for VRH case patients also increased from 4 years to 10 years, however this increase was not statistically significant. Additionally, the number of deaths where varicella was noted as an underlying cause decreased from 115 to 16 between 1995 and 2003 ^{Footnote 7}. A similar decreasing trend in varicella-related hospitalization was observed in a large scale Market-Scan database which included information from approximately 40 self-insured employers from across the U.S. with about 4 million people. They reported overall hospitalization rates decreased from 2.3 to 0.3 per 100,000 population between 1994 and 2002 with the greatest declines among infants younger than one year of age ^{Footnote 28}.

A restrospective chart review of a 144 patients conducted in a children's hospital in Chicago from 1993 to 2001 reported a significant decrease (p<0.01) in the number of varicella-related Invasive Group A Streptococcal (IGAS) infections--one of the most common complications associated with varicella-hospitalization in their patient population^{Footnote 29}. While varicella infection was the most common pre-disposing factor to IGAS, as the vaccine coverage rate increased, the percent of IGAS cases associated with varicella decreased from 27% to 2%^{Footnote 29}. It should be noted that four studies (8;24;30;31) with shorter lengths of follow-up (two to four years) did not observe significant declines in paediatric IGAS after the introduction of varicella vaccination programs, however they did not exclusively examine changes in IGAS.

Varicella in Adults
It has been hypothesized that with the implementation of child varicella vaccination programs, a shift in the age distribution of varicella cases would result in an increase in incidence and morbidity in adults. However, from 1995-2005 varicella incidence rates declined significantly from 0.50 per 100,000 population to 0.13/100,000 (p<0.0001). Disease was more severe in unvaccinated adults compared to unvaccinated children. Adults had a 1.8 and 1.9 times higher risk of >500 skin lesions, a 2.0 times greater risk of developing complications, and a 6.2 times higher chance of hospitalization compared to unvaccinated children. Furthermore, non-specific general symptoms including nausea, vomiting, headache, fatigue, dizziness and appetite loss were more prevalent in adults (1 in 17 adult cases vs. 1 in 116 child cases). Dehydration and pneumonia also occurred more frequently in adults than children (RR 5.4 and 10.6, p<0.001) ^{Footnote 23}.

7. Vaccine Modified (or Breakthrough) Disease

The typical incubation period for wild-type varicella is 14 to 16 days, hence rashes that occur within 14 days after vaccination are usually due to infection that occurred from exposure before vaccination. Between 14 and 42 days after vaccination, a vesicular rash may be due to wild virus or vaccine-strain virus; the distinction would need to be made through molecular typing or PCR testing at the National Microbiological Laboratory in Winnipeg, MB. Vaccine modified (breakthrough) disease is defined as a case of infection with wild-type VZV occurring >42 days after vaccination. Vaccinated children typically tend to have milder cases of disease with fewer lesions, shorter duration of illness and lower incidence of fever. Mild disease is defined as < 50 lesions, moderate disease as 50-500 lesions and severe disease >500 lesions or the occurrence of serious complications such as varicella-associated pneumonia, encephalitis, hospitalization or death.

The VASP in the U.S. where universal vaccination programs have been in place for over 10 years observed that the percent of cases with vaccine modified disease increased from 3.5% in 1997 to 24% in 2000 to 72% in 2005 in spite of increasing vaccination coverage rates ^{Footnote 32}.

8. Laboratory Testing for Immunogenicity

There are a variety of assays used for the detection of varicella antibody. In pre-licensure trials, fluorescent antibody to membrane antigen (FAMA) assay, which is a research laboratory tool, is highly correlated with neutralizing antibody titers to VZV. The later commercially developed whole-cell ELISA and glycoprotein (gp) ELISA tests developed by Merck Frosst Canada Inc. were developed to be more sensitive in detecting vaccine-induced immune response ^{Footnote 4}. However, during outbreaks PCR rather than serology is often used for rapid detection of infection ^{Footnote 33-Footnote 35}.

9. Immunogenicity and Vaccine Effectiveness

The robustness of primary varicella antibody response six weeks after vaccination is inversely correlated with vaccine modified (breakthrough) disease rates ^{Footnote 34}. In the original clinical trials, detectable levels of antibody response >0.6 gpELISA units were used as an endpoint measurement and was observed in 97% of recipients 1-12 years of age who received one-dose of varicella vaccine, and within 4 to 6 weeks post-vaccination. Later long term follow up data found children with varicella antibody titres <5 gpELISA units were 3.5 times more likely to have breakthrough disease than those with titres ≥5 gpELISA units. This threshold level of antibody response 6 weeks after vaccination was detected in 99.6% of children receiving two doses of vaccine but only in 85.7% of children receiving one dose of vaccine ^{Footnote 36}. Additionally a FAMA titer >1:4 at the time of VZV exposure and as long as 1 year after exposure in healthy individuals is highly correlated with protection against chickenpox after either vaccination or natural infection ^{Footnote 37}. A post-authorization study found only 76% of healthy children had FAMA seroconversion titre ratios >1:4 16 weeks after one-dose of vaccination ^{Footnote 7}. In susceptible adults, conversion rates were 82% after one-dose of vaccine and 94% after two doses ^{Footnote 38}.

Population Based Studies
Assessment of the vaccine effectiveness (VE) in preventing disease in real-world conditions is extremely important. It is typically estimated for preventing varicella disease of any severity, and for preventing moderate to severe disease (typically > 50 lesions).

Population surveillance from Antelope Valley reported VE of 89.5%, with time since vaccination greater than five years identified as a risk factor for moderate to severe disease (risk ratio, 2.6; 95% CI 1.2-5.8) ^{Footnote 25}.

A six-year case-control study from 1997 to 2003 which assessed one-dose vaccine effectiveness against laboratory-confirmed varicella in paediatric practice centres in Connecticut reported a vaccine effectiveness of 97% (95% CI 91, 99) in the first year after vaccination and an overall VE of 87% (95%CI 81-91). Vaccine effectiveness was significantly higher in the first year post-vaccination than at 2 to 8 years post vaccination--97% (95%CI 91,99) vs. 84% (95% CI 76, 89) (Figure 1). Vaccine effectiveness measured one year post-vaccination was significantly lower for those receiving vaccine at <15 months of age than in those ≥15 months of age -73% (95% CI -43, 95) vs 99% (95% CI 93, 100), p<0.01. However, VE was similar for those vaccinated at <15 months as for those vaccinated at ≥ 15 months of age when time since vaccination was greater than 1 year 81% (95% CI 62, 90) vs. 85% (95% CI 77, 90), p=0.47 ^{Footnote 39}.

Figure 1. Effectiveness of Varicella Vaccine (by Percent) as a Function of Length of Time since Vaccination

Source: Vazquez M, LaRussa PS, Gershon AA et al (2004). Effectiveness over  time of varicella vaccine. JAMA; 291: 851-855

In Israel, a retrospective cohort study followed 169,801 children for 31 months after the introduction of a voluntary one-dose vaccination program. Close to 27,000 children between the ages of one and ten years without a prior history of varicella disease were vaccinated between 2000 and 2002. The investigators found that the disease incidence decreased from 86.6 to 44.6 per 1000 population, representing nearly a 50% decline in disease incidence after authorization of varicella vaccine in that country; and VE was estimated at 92% ^{Footnote 40}.

A retrospective cohort study conducted in Canada of 431 children who received one-dose of vaccine between the ages of ≥12 months to 12 years and were followed up to three-years post-vaccination reported an average breakthrough rate of 3.1% per year based on definite or probable case definition, and 2.4% breakthrough rate per year when based on a suspect case definition ^{Footnote 41}.

These studies likely yielded higher than expected vaccine effectiveness rates, as vaccine coverage in these populations were relatively low at the time of analysis and vaccinees would have the potential for immunological boosting from exposure to wild-type varicella (Table 6).

Table 6. Summary of Population-Based Varicella Studies, 1998- 2004

Author & Year Published	Population	Study Period	Case Ascertainment	Cases (n)	% cases vaccinated	VE (%)	Risk Factors for Breakthrough Disease
Chaves, 2007 Footnote 25	350,000 persons in Antelope Valley, CA	1995-2004	Phone interview collecting demographic, clinical & epi data. Vaccination status obtained via self-report with 80% of reports verified against health record	11,356	9.5% N=1,080 1% in 1996 18% in 2000 60% in 2004	89.5	≥ 5 years since vaccination for children 8-12 years (severe-moderate disease) RR= 2.6 (95% CI: 1.2-5.8)
Vazquez, 2004 Footnote 39	20 group practices in Connecticut	1997-2003	Clinical diagnosis confirmed with Polymerase Chain Reaction test result	n=339 (cases) n=669 (controls)	n/a	87% (81,91)	Not Reported in Study
Passwell, 2004 Footnote 40	161,557 children age 1-10 years in Maccabi HMO Israel	1998-2002	Chart Review with varicella diagnosis code	n=373 (immunized) n=35,573 (non-immunized)	1.0%	92.0%	Not Reported in Study
Scheifele, 2002 Footnote 41	Three urban Canadian centres (Halifax, Ottawa, Vancouver)	1999	Definite Case: vesicles present and physician Confirmation Probable Case: vesicles present but no physician diagnosis	431 vaccinated children	n/a	3.1% per year break-through rate	Not Reported in Study

Outbreak Studies
There have been multiple varicella outbreaks in populations with high coverage rates for one-dose of varicella vaccination (Table 7). A meta-analysis of 14 varicella outbreak studies reported an overall vaccine effectiveness (VE) of 72.5% (95% CI 69.5 – 76.0) in 3,157 children vaccinated with one-dose of attenuated OKA strain vaccine ^{Footnote 42}. Some of the studies identified risk factors for vaccine modified disease. Four studies found that time since vaccination of ≥3 years increased the risk of disease by 2.6 to 6.7 times^{Footnote 15 Footnote 35 Footnote 43 Footnote 44}.

Table 7. Summary of Findings from Varicella Outbreak Studies, 1999-2006

Author & Year Published	Population	Setting	Population Vaccination Coverage rate%	Attack Rate in Vaccinated (%)	Attack Rate in Unvaccinated (%)	Vaccination History of Index Case	VE% Overall, Moderate/Severe	Other Findings
CDC, 2006 Footnote 45	N=142 (K-Gr. 7) 33 cases (age 5-13 yrs, median 8 yrs)	Elementary School in Nebraska, Aug- Dec, 2004	81 (69-100)	13	67	Unvaccinated Kindergarten Student	81 (66,89) 93 (82,97)	Vaccinated student more likely to have mild disease (67% vs 11%) fewer days of rash (5 vs. 7.3) and miss fewer days of school (3 vs. 5.2)
CDC, 2004 Footnote 35	N=455 (K- Gr 3) 66 cases	Elementary School in Michigan, Sep-Dec, 2003	97.1	11.8	76.9	Vaccinated 3rd grade student	84.7 (77.4, 89.7) 97.6 (95.0, 99.9)	Vaccinated students more likely to have mild disease (84.6% vs 20.0%), less likely to have fever (44.2% vs 88.9%) and missed fewer days of school (1.3 vs. 3.5). Vaccination ≥ 4 years before outbreak, more likely to acquire varicella (RR= 4.65; 95% CI 1.48, 14.61)
Buchholz, 1999 Footnote 46	N=39 12 cases (31-66 months, mean 50 months)	Child Care Centre in Los Angeles County, March 1998	87.2	24	80	Not reported	71 (38, 86) 93 (33,99)
	N=20 12 cases (41-64 months, mean 53 months)	Child Care Centre in Los Angeles County, March 1998	30.0	0	86	Not reported	100 (67,100) 100 (0, 100)
Hadad, 2005 Footnote 44	N=289 26 cases (age 5-12 yrs)	Elementary school in Utah, Oct.- Dec. 2002	77.2	4	27	Unvaccinated 1st Grade student	87 (71, 94) 90 (76, 96)	Vaccinated children more likely to have mild disease (15% vs. 69%), shorter duration of illness (1.5 vs. 3 days). Children with eczema 3.8 (CI 1.8-7.1) times more likely to develop breakthrough disease. Vaccination ≥ 5 years before outbreak  more likely to acquire varicella (RR=3.0; 95% CI:1.4-6.4) Vaccination at ≤ 18 months more likely to develop breakthough disease (RR=2.6; 95% CI:1.2-5.6)
	N=422 48 cases (age 5-12 yrs)	Elementary School in Utah, , Oct 2002- Feb 2003	82.5	5	40.5		87 (78, 92) 99 (94, 99)
Marin, 2005Footnote 33	N=197 48 cases (K-Gr 3)	Elementary School in Maine, Dec 2002- Jan 2003	74 (60-90)	8.2	70.6	Not reported	89 (79, 94) 96 (88, 99)	Vaccinated cases less likely to have moderate or severe disease (25% vs 78%), had shorter duration of illness (5 vs 7 days), missed fewer days of school (3 vs 5 days). Eczema associated with non-significant increased risk of breakthrough disease (RR: 4.3; 95%CI: 0.8-23.5) *Attack rate was 5% among students with history of disease (VE 93%; 95%CI:83-97)
Miron, 2005Footnote 47	N=242 116 cases (age 3-6 yrs)	100 Day Care Centres in Northern Israel (approx 30-40 children in each DCC), Jan 2003- Jun 2003	37	52	41.5	Not reported	20 (0,40) 93.4 (75,98)	Vaccination ≥ 2 year before outbreak is a risk factor for breakthrough disease
Galil, 2002 Footnote 43	N=88 25 cases (age 6 mnths to 8 yrs; median 4.1 yrs)	Day Care Centre in New Hampshire, Dec 2000- Jan 2001	73.1 (49 of 67 eligible)	34.7	44.4	Vaccinated 4.5 year old	44.0 (6.9, 66.3) 86.0 (38.7, 96.8)	Vaccination ≥ 3 yrs before outbreak increased risk for vaccine failure RR=2.6; 95%CI: 1.3-5.3) *Index case was healthy vaccinated child who infected more than 50% of susceptibles, suggesting breakthrough disease can be highly infectious
Izurieta, 1997 Footnote 14	N=148 81 cases	Child Care centre in Georgia, Jan 1996- May 1996	44.6	14	88	Unvaccinated 4 year old	86 (73, 92) 100 (96,100)	Vaccinated children with asthma or other respiratory illness at increased risk for disease compared to vaccinated children without the same underlying condition
Tugwell, 2004 Footnote 15	N=159 21 cases (age 5-11 yrs; median 7 yrs)	Elementary school in Oregon Oct 2001- Jan 2002	96.8	12	42.9	3 unvaccinated & 1 vaccinated	72 (3, 87)	Vaccination > 5yrs prior to outbreak associated with increase risk of breakthrough disease RR=6.7;95%CI: 2.2-22.9 Early age at vaccination  ≤15 months NOT associated with increased risk of breakthrough disease
Arnedo-Pena, 2006 Footnote 48	N=269 148 cases (age 2-12 yrs, mean 5.7 yrs)	Day Care & School in Spain, Dec 2004-Apr 2005	35.7	22.9	72.8	Unvaccinated 4 year old	70(51, 82) 97(78, 100)	RR of disease (in vaccinated population)= 0.31(CI95% 0.21-0.46) compared to unvaccinated population Vaccinated cases had shorter duration of disease (4.5 vs. 7.8 days), fewer cases with >500 vesicles (0% vs 15.2%), were younger (4.0 vs. 6.0 years), and less likely to have fever ≥ 38.5C (14.3% vs 39.0%)
Dworkin, 2002 Footnote 49	N=209 35 cases (age 4-8 yrs)	Two schools in Illinois; Jan 2001- May 2001	69.9	5.5	42.9	Not reported	88 (77, 93)	Vaccination ≤ 15 months associated with increased risk of breakthrough disease; RR=3.7;95%CI, 1.1-13.1
Galil, 2002Footnote 50	N=100 31 cases (age 3.2 mnths – 11 yrs; median age 3.7 yrs)	Day Care Centre Pennsylvania; Nov 1999-Apr 2000	80	17.5	85	Vaccinated 4 year old	79 (66, 88) 95 (84, 98)	Children vaccinated at <14 months of age more likely to develop breakthrough disease (RR=3.0; 95%CI 0.9-9.9)
Lee, 2004 Footnote 51	N=154 49 cases (age 5-11 yrs; median age 7 yrs)	Elementary School Minnesota; July 2003- Jan 2003	76.7	24.6	55.5	Vaccinated 6 year old	56 (30, 72)	Increased risk of breakthrough disease if vaccine received ≥12 months and <16 months (RR=2.1; 95%CI, 1.4-4.1) - Chronic ear infection not associated with breakthrough (RR=1.9;95%CI 1.0-3.5) - History of respiratory syncytial virus, pneumonia or similar lung condition associated with increased risk of disease (RR=3.0; 95%CI 1.5-5.8)
Lopez et al, 2006Footnote 52	N=395 44 cases (age 5-12 yrs)	Elementary School Arkansas; Sep 2003-Nov 2003	96	11.3	37.5	Vaccinated 2nd grader	82 (76,87)

Vaccine-Modified Disease in Canada
At the time of writing, there was no published information on breakthrough cases in Canada. Data from IMPACT regarding previously vaccinated children hospitalized with varicella is being analyzed.

10. Herpes Zoster

Herpes Zoster (HZ or shingles) results from reactivation of latent varicella zoster virus in the sensory nerve ganglia and is characterized by painful vesicular dermatomal rash and may result in debilitating chronic pain known as post-herpetic neuralgia. Risk factors for HZ have been found to be greatest for immunocompromised persons and those older than 50 years of age ^{Footnote 53-Footnote 55}. Other risk factors for Herpes Zoster include sex (higher for females), race (higher for Caucasians), and psychological stress (higher for those with recent stressful life events) ^{Footnote 56}. Factors that reduce risk of HZ are exposure to varicella, or childhood vaccination with varicella vaccine as opposed to wild-type infection ^{Footnote 56}. The lifetime risk of zoster from wild-type VZV is estimated to be around 10-30% and incidence increases markedly with age, affecting up to 50% of people who live to 85 years ^{Footnote 57-Footnote 58}. A systematic review of population based studies in the pre-vaccination era reported overall annual HZ incidence rates ranging from 1.2 to 7.2 per 1000 population. The rate in the oldest individuals of the populations tested (from > 60 years to > 75 years) was higher at 3.6 to 14.2 per 1000 ^{Footnote 59}.

Local surveillance of HZ incidence in the U.S. reported differential findings. A study in Massachusetts reported a significant increase in HZ incidence rates from 2.99/1,000 population to 5.25/1,000 population from 1999 to 2003, p=0.0009  ^{Footnote 55}. Data from Washington State reported that the incidence of HZ remained stable between 1992 and 2003 (3.71 to 4.05 cases per 1,000 person-years) while varicella vaccination coverage rates increased to 45-65% for children between the ages of 2 and 6 years, and varicella incidence decreased from 2.63 to 0.92 cases per 1,000 person-years. However, HZ incidence was lower in vaccinated children age 0-9 years than in unvaccinated children ^{Footnote 54}.

Baseline surveillance data from Alberta and British Columbia demonstrated that HZ incidence was increasing prior to the implementation of universal varicella vaccination programs. In BC the HZ incidence rate increased from 3.2 to 3.7 per 1,000 population between 1994 and 2003 and from 2.8 to 4.4 per 1,000 population in Alberta between 1986 and 2002 ^{Footnote 60-Footnote 61}. As varicella vaccination coverage rates increase, the median age of acquiring wild-type varicella may increase, hence decreasing the risk for infection in early childhood and subsequently reducing a risk factor for childhood HZ. Older age of varicella disease onset is associated with decreased risk of herpes zoster ^{Footnote 62}.

It has been hypothesized that widespread varicella vaccination may alter the risk of HZ in the population and increase the annual incidence of HZ cases as opportunity for humoral immune boosting will decrease as circulating virus dwindles ^{Footnote 63}. Model estimates predict that shingles rates will increase for the first 20 years after the elimination of varicella transmission peaking at an incidence 51% (95% CI 28-60) higher than in the pre-vaccine era. The incidence of zoster will gradually begin to decrease as the vaccinated cohorts begin to reach the older ages at which most zoster cases occur but would remain above the pre-vaccination level for approximately 46 years (95% CI 35-47) after the introduction of vaccination. The mathematical model used for these predictions did not take into account the possibility of immunization of adults to boost immunity against zoster. In 2006 the United States Food and Drug Administration licensed Zostavax™ for the prevention of herpes zoster in persons 60 years of age and older. In August 2008 a live, injectable, attenuated herpes zoster vaccine (Zostavax™, Merck Frosst Canada Ltd.) was approved for use in Canada for the prevention of herpes zoster (shingles) infection in adults aged 60 years and older. NACI recommendations on the use of this vaccine are forthcoming. The use of this vaccine may reduce the incidence of zoster in this country.

11. Two Dose Post-Authorization Studies

To date there is one clinical trial that compares the efficacy of a one dose vaccination regimen with a two dose regimen. With 10-years of follow up data it was found that children receiving 2 doses had significantly higher vaccine efficacy rates than the children who received one dose [98.3% (CI95% 97.3, 99.0) vs 94.4%(CI95% 92.9, 95.7),  p<0.001] and a 3.3 fold lower risk of breakthrough disease than those who received one dose (Figure 2) ^{Footnote 36}.

Figure 2. Cumulative Varicella Disease Breakthrough rates (per 100 person years at risk) for One and Two Doses of single antigen Varicella Vaccine in Children 12 months to 12 years by number of years after vaccination- United States, 1993-2003

Source: Kuter B, Matthews H, Shinefield H, et al. Ten year follow-up of healthy children who received one or two injections of varicella vaccine. Pediatr Infect Dis J 2004;23:132-137

Two cases of zoster were reported during the 10 years of follow-up. Both cases occurred in recipients of a single dose of vaccine. The first child was vaccinated at 22 months and developed zoster 30 months post vaccination and the second child was 13 months at vaccination and developed zoster 46 months after having been vaccinated.

The two-dose group had slightly higher Geometric Mean Titres (GMTs) in the first two years after vaccination and a larger percentage of subjects with antibody titres ≥5 gpELISA units/ml than the one-dose group in the first 3 years. The varicella antibody persistence rate was close to 100% throughout the 9-year follow-up for both groups and the cumulative rate of antibody persistence with both regimens remained high 9 years post-vaccination [99.0% (one-dose group), 99.8% (two-dose group)]. A summary of the clinical trial is outlined in Table 8.

Table 8. Summary of Findings From 2-Dose Varicella Vaccination Clinical Trials

Author, (Year) :	Kuter et al. (2004)
Study Design :	Design: Randomized Control Trial Population: N=2196 children age ≥12 months to 12 years n= 1103 (1 dose of vaccine) (Mean Age 3.6 years range 1 year- 12.9 years) n= 1093 (2 doses of vacc ine) (Mean Age 3.9 years range 1 year- 12.9 years) (Oka/Merck Varivax®) Participants enrolled Dec 1991- Jan 1993 Setting: 18 multi-centre sites Inclusion Criteria Healthy children 12 months to 12 years with no history of varicella and/or zoster Exclusion Criteria Significant exposure to varicella or zoster (>1 hour of contact indoors) in the 4 weeks before entry into the study; received another vaccination within a month before or planning to receive another vaccine during the month after injection; or received any blood products during preceding 3 months. Also excluded if history of anaphylactoid reaction to neomycin, known immune deficiency or neoplastic disease or depressed immunity from disease or drugs Intervention: Administration of either 1 dose or 2 doses of vaccine (2nd dose three months after 1st ) containing 2,900-9,000 PFUs of attenuated Oka/Merck Varivax® Outcomes Analyzed: - Persistence of varicella antibodies (as measured by gpELISA, titers ≥ 5 considered positive) - Lab-confirmed varicella cases occurring >42 days post-vaccination (acute and convalescent titres were ≥200 gpELISA units/ml) Suspect case if there was a 4-fold rise between acute and convalescent samples and at least one titre was between 50 and 199 gpELISA units/ml  -Vaccine Efficacy- Based on person-years at risk to calculate annual and cumulative breakthrough disease, only subjects actively followed as of March 2002 by questionnaire and/or annual blood sample contribute estimate) Follow-up: 10 years of follow-up with measurements taken each year
Outcomes and Results	Variable 1-Dose Regimen 2-Dose Regimen No. of varicella cases 60 17 Median days duration of rash (range) 4 (1-18) 5 (1-14) Median of the daily maximum # of lesions (range) 26 (2-272) 20 (2-100) % with >50 lesions 22.8 18.8 % with 1 or more vesicle 77.2 68.8 Median of the daily maximum no. of vesicles (range) 13 (1-272) 5 (1-80) % with temperature ≥ 38.9°C, oral equivalent 2.4 0 Vaccine Efficacy (1 dose vs 2 doses) 94.4%(CI95% 92.9, 95.7),  98.3% (CI95% 97.3, 99.0) p<.001 Risk of developing varicella >42 days post-vaccination during 10-year period was 3.3 fold lower in children receiving 2 doses as opposed to one (p< .001) VE for Prevention of Varicella after Household Exposure (1 vs. 2 doses) 90.2%(CI95% 83.7, 96.7) vs. 96.4% (CI95% 92.4, 100) p=0.112 Persistence of Varicella antibody (gpELISA) 1 to 9 years post-vaccination 1 dose- Regimen 2 dose Regimen (0 and 3 mo) Time Post- Vaccination N Persistence rate (%) % ≥5 gpELISA units/ml GMT N Persistence rate (%) % ≥5 gpELISA units/ml GMT 6 wk 881 NA 85.7 12.5 768 NA 99.6 142.6 1 yr 657 100 86.9 20.8 588 99.8 97.4 32.0 2 yr 384 100 90.9 23.6 318 100 95.0 24.6 3 yr 458 99.8 93.2 44.7 398 100 98.2 50.9 4 yr 452 99.6 92.0 45.3 395 100 92.9 36.8 5 yr 400 100 95.5 50.3 376 100 98.1 44.3 6 yr 399 99.7 93.7 49.5 392 100 96.7 49.7 7 yr 424 100 94.3 54.2 392 100 96.2 54.2 8 yr 381 100 94.5 56.5 347 99.1 96.0 52.8 9 yr 277 99.6 95.3 57.8 237 99.6 97.0 61.0

Data on immune responses from the study by Kuter et al were combined with a different study by Reisinger et al who administered a second dose of varicella vaccine to previously vaccinated healthy 4 to 6 year old children, and are presented in Table 9. Reisinger et al reported similar immunological responsiveness six weeks post-second dose of a combination MMRV (Table 9) ^{Footnote 64}.

Table 9. Immune Response Among Children Aged 12 Months to 12 Years, Measured 6 Weeks after 1 or 2 Doses of Varicella Vaccination, United States, 1988–2002

	6 weeks after Receiving ONE dose	6 weeks after Receiving TWO doses with three months between doses	6 weeks after receiving 2nd  doses at age 4-6 yrs
VZV IgG gpELISA ≥5 SA units	85.7%Table 9 note *	99.6%Table 9 note *	99.4%Table 9 note **
GMT	12.5Table 9 note *	142.6Table 9 note *	212.4Table 9 note **

Table 9 note *

Source: Kuter B, Matthews H, Shinefield H, et al. Ten year follow-up of healthy children who received one or two injections of varicella vaccine. Pediatr Infect Dis J 2004;23:132-137

Return to table 9 note * referrer

Table 9 note **

Reisinger K, Hoffman-Brown M, Xu J, et al. A Combination Measles, Mumps, Rubella, and Varicella Vaccine (ProqUAD) Given to 4-to 6-Year-Old Healthy Children Vaccinated Previously with M-M-RII and Varivax..Pediatrics;117:265-272

Return to table 9 note ** referrer

12. Adverse Events

CDC Vaccine Adverse Event Reporting System
Pre-licensure clinical trials of varicella vaccine showed little or no increase in rates of fever, varicella-like rash or local reactions at the injection site in children or adults receiving varicella vaccine compared with placebo ^{Footnote 65}.

The Vaccine Adverse Event Reporting System (VAERS) is a passive surveillance system managed by the United States Centers for Disease Control and Prevention and the US Food and Drug Administration. It receives reports from health care providers, vaccine manufacturers and the public concerning adverse events temporally related to immunization. VAERS reports that between 1995 and 2005 nearly 48 million doses of varicella vaccine were distributed in the U.S. and 25,306 adverse events associated with this vaccine were reported ^{Footnote 66}. Overall the adverse events rate per 100,000 doses distributed was 52.7 (0.06%). The rate steadily declined during this time period from 245 per 100,000 in 1995 to 20.8 per 100,000 in 2005. Of all the reports, 1276 (5.0%) were classified as serious (2.6 per 100,000 doses). The rate of serious adverse events (defined as adverse events resulting in hospitalization, death, life-threatening illness, permanent disability or certain other medically important conditions) also declined between 1995 and 2005 from 5.8 to 1.4 per 100,000 doses. There were more AE reports from those receiving varicella vaccine alone (14,780 incidents) relative to those receiving varicella vaccine in combination with another vaccine (10,526 incidents). However a larger percentage of AE were classified as serious in the group receiving varicella vaccine in conjunction with another vaccine relative to those receiving varicella alone (7.8% vs. 3.2%) ^{Footnote 66}.

The five most commonly reported AEs were: rash (8,262 cases or 32.6%), fever (5,451 cases or 21.5%), injection-site reaction (3,291 or 13.0%), urticaria (1047 cases or 4.1%) and herpes zoster (981 cases or 3.9%). Sixty deaths following vaccination with varicella vaccine were reported; 23 (38.3%) followed administration of varicella vaccine alone. The median interval between vaccination and death was 9 days (range, <1 day to 6.8 years). The most common fatal events reported were septicaemia and multi-organ failure (11 cases or 18.3%). All deaths were in individuals with severe congenital anomalies or who had disorders that affect the immune system and 10 deaths were described as "crib-deaths".

Laboratory testing from 338 patients with suspected adverse events after varicella vaccination found that 26% of specimens were positive for wild-type varicella, while 18% tested positive for vaccine-strain VZV. The remaining specimens either tested negative or were inadequate for laboratory testing. In 118 specimens from patients with HZ rashes, wild-type VZV was detected in 20% and vaccine-strain VZV was observed in 41%.

13. MMR and Varicella Vaccine Administration

NACI recommends the Measles, Mumps, Rubella (MMR) vaccine at twelve months of age. This coincides with the recommendation for when varicella vaccine should be administered. Currently, 8 provinces and 2 territories provide a schedule whereby MMR and varicella are administered concomitantly with the expectation that decreasing the number of visits required for immunization will increase compliance. A study evaluated whether co-administration of vaccinations given 6 weeks apart in two separate groups of subjects would yield differences in immune responses, persistence of antibody, duration of protection against varicella, or safety profiles. They found that seroconversion rates and the percent of those with glycoprotein ELISA titres ≥ 5.0 units were the same for the two groups (99.5% and 92.5% for the group with co-administered vaccines vs. 100% and 94.8% for the group given the vaccines six weeks apart, respectively (p>0.05). However, while the seroconversion rates were similar, a statistically significant difference was observed in the Geometric Mean Titres (GMTs) between the two groups. GMTs were slightly but significantly lower in the group with concomitant MMR and varicella vaccine administration (13.2 in the co-administered groups vs. 17.9 group given the vaccines six weeks apart, respectively (p<0.05) (Table 10) ^{Footnote 67}.

Table 10. Seroconversion Rate and Geometric Mean Titer for Initially Sero-Negative Varicella Subjects (gpELISA) 6 Weeks After Vaccination

	MMR II + Varicella Vaccine co-administered	MMR II + Varicella Vaccine Given Six weeks Apart	Fold Difference in GMT's Between the two groups (95% CI)
Sero-Conversion Rate (%)	99.5 (199/200)	100 (174/174)	-
Geometric Mean Titre	13.2	17.9	0.74 (0.63, 0.87)

Source: Shinefield HR et al (2002) Vaccination with measles, mumps and rubella vaccine and varicella vaccine: safety, tolerability, immunogenicity, persistence of antibody and duration of protection against varicella in health children; Pediatr Infect Dis J; 21: 555-61

Varicella antibody persistence rates were >98% to 100% during 6 years of follow-up for the two groups, and vaccine efficacy during 5 years of follow-up were similar between the two groups 90.5% (95% CI 86.2 – 95.0) and 88.9% (95% CI 83.7 – 93.7), respectively (Table 11) ^{Footnote 67} .

Table 11. Varicella Antibody Persistence Rates and GMTs for Subjects Who Seroconverted 6 Weeks after Vaccination

	MMR II + varicella vaccine co-administered		MMR II + varicella vaccine given 6 weeks apart
	Persistence rate %	GMT (95% CI)	Persistence rate %	GMT (95% CI)
1 year	100 (143/143)	35.3 (28.4, 44.0)	98.2 (109/111)	25.7 (20.0, 33.0)
3 years	98.8 (82/83)	40.0 (28.7, 55.9)	99.1 (112/113)	36.8 (27.4, 49.3)
4 years	99.0 (95/96)	34.4 (25.6, 46.4)	100 (76/76)	29.1 (20.1, 42.3)
5 years	100 (91/91)	49.5 (35.5, 69.0)	100 (77/77)	40.2 (27.9, 57.9)
6 years	100 (91/91)	42.9 (31.9, 57.7)	98.6 (70/71)	31.3 (20.9, 46.8)

Source: Shinefield HR et al (2002) Vaccination with measles, mumps and rubella vaccine and varicella vaccine: safety, tolerability, immunogenicity, persistence of antibody and duration of protection against varicella in health children; Pediatr Infect Dis J; 21: 555-61

14. Cost-Effectiveness

In addition to intervention effectiveness studies, economic analysis is a critical factor for consideration when making population-based recommendations for vaccine use. Benefit-cost ratio is an indicator that attempts to summarize the overall value for money of a project or intervention. A value greater than 1 would indicate that the benefits of an intervention outweigh its cost. A 2008 U.S. study ^{Footnote 68} conducted a comparative economic assessment of 3 scenarios: 1) no varicella vaccination program, 2) a 1-dose, or 3) a 2-dose program. Compared to no vaccination program, both 1 and 2-dose programs were found to be cost-saving with a benefit-cost ratio (BCR) of 4.37 and 2.73 respectively. However, compared with the 1-dose program, a 2nd dose was not cost saving either in terms of direct costs (BCR 0.13) or societal costs (BCR 0.56).

Discussion

One dose of varicella vaccine has been relatively effective at decreasing the burden of varicella associated illness. However, breakthrough disease continues to occur as one dose has been shown to illicit a minimum threshold level of adequate immunologic protection in only about 85% of vaccine recipients. Ninety-nine percent of vaccine recipients have sufficient immune response after a second dose of vaccine is administered. A second dose is required to address primary vaccine failure and waning immunity. A similar occurrence was the reason for administering two doses of measles vaccine ^{Footnote 69}. The strain on public health resources in the mumps outbreak that occurred in populations who were either unvaccinated or vaccinated with only one dose of mumps vaccine in Nova Scotia and New Brunswick in 2007 provide some insight into what could occur in the future with varicella disease if the one-dose regimen continues.

While follow-up data show the overall incidence of varicella disease decreases with a one-dose universal child program, the evidence shows that incidence of breakthrough disease is significantly greater in those receiving one dose of varicella as compared to those receiving two doses after 10 years of follow-up. Additionally, the incidence of moderate-to severe breakthrough disease cases increased as time since vaccination increased. The data also indicates that previously vaccinated persons serve as good vectors of disease transmission for those susceptible to disease (no varicella vaccination or no previous history of varicella disease) after having received only one-dose of vaccine. The index case in 5 out of 10 of the outbreak studies had a previous history of vaccination. The same occurrence of this phenomenon with those receiving two doses of vaccine, while possible, has not been reported in any studies to date. This is important since the age distribution of varicella cases has shifted upwards since the introduction of universal vaccination and the frequency of moderate to severe disease has been shown to increase with increasing age regardless of vaccination status of the infected case. Furthermore, data from the U.S. surveillance sites showed that with time there were a greater number of cases with previous history of vaccination. This can contribute to the perception that the vaccine is ineffective in preventing varicella disease. Should this occur, parents and adults alike may be less likely to choose vaccination as an option which would erode all the previous gains of decreased disease incidence.

Timing of the second dose will need to be considered. Currently, provinces and territories administer the first dose of varicella vaccine at either 12 or 15 months of age. A second dose would be optimally provided at either 18 months or at 4 to 6 years of age as these are the times at which the child is due for their next visit for a vaccination. Administering the dose to the 4-6 year age group would provide children with a boosting of immunity approximately three years after the first vaccination. This is the point in which breakthrough rates begin to increase substantially. Additionally, immune response to a second dose provided 4-6 years after the first dose has been comparable to the response observed when the second dose is administered 3 months after the first. Unfortunately, individuals who did not mount a sufficient response to the first vaccination would have an elevated risk of disease during the time between receiving their first and second dose, however virus circulation would likely be sufficiently reduced thereby reducing the risk of disease in any case. Furthermore, while this is a safe vaccine with relatively few reports of adverse events it is likely there will be some increase in number due to the administration of a second dose.

Concern has been raised that varicella vaccination could potentially result in increased risk of herpes zoster which is generally a more severe disease that typically impacts older populations because people previously infected with varicella will have decreased opportunities for boosting immunity by exposure to wild-type varicella zoster virus. Any protective advantage exposure to wild-type varicella may produce would be short lived as vaccinated cohorts become older. Additionally, a vaccine for herpes zoster was recently licensed in the U.S. (and more recently in Canada) and is recommended for use in those over the age of 60 years in the U.S. If used in Canada, it would be expected that HZ incidence and severity would decrease.

While Canada has not recommended the elimination of varicella as a national goal as is the case for rubella, the purpose of a vaccination program should be to achieve the lowest levels of morbidity and mortality possible. This will not be achieved with the current one-dose child schedule. Furthermore, breakthrough disease would likely increase in frequency and this could have a negative impact on public perception of the varicella vaccine's (and possibly other vaccines) effectiveness and utility.

Search CCDR