Varicella Vaccination Recommendations Based on ACIP Guidelines
Based on current CDC Advisory Committee on Immunization Practices (ACIP) recommendations, varicella vaccination is indicated for the 36-year-old person with diabetes mellitus and chronic liver disease who received one dose of the vaccine about 2 years ago and has no evidence of immunity to the virus.
Analysis of Each Patient Scenario
36-year-old with diabetes and chronic liver disease (INDICATED)
- This patient received only one dose of varicella vaccine 2 years ago
- According to ACIP guidelines, adults who previously received one dose should receive a second dose (catch-up vaccination) 1
- The patient has chronic liver disease, but this is not a contraindication for vaccination
- Studies have shown that varicella vaccine is safe and immunogenic in patients with chronic liver disease 2
- The patient should receive the second dose to complete the recommended vaccination series
38-year-old pregnant individual with HIV (NOT INDICATED)
- Varicella vaccine is contraindicated during pregnancy due to theoretical risk to the fetus 1
- Although this patient has HIV with a CD4 count >200 cells/μL (584 cells/mm³), which would normally allow vaccination, pregnancy is an absolute contraindication
- Vaccination should be deferred until after delivery 1
48-year-old post-transplant patient (NOT INDICATED)
- This patient underwent cardiac and renal transplantation 6 months ago
- Varicella vaccine is contraindicated in severely immunocompromised persons, including recent transplant recipients 1
- Transplant recipients require immunosuppressive therapy, which makes live vaccines contraindicated
- The risk of vaccine-strain viral infection is significant in this population 3
- Instead, this patient should be considered for VariZIG (Varicella Zoster Immune Globulin) if exposed to varicella 4
42-year-old with leukemia on chemotherapy (NOT INDICATED)
- This patient has leukemia and is currently receiving chemotherapy
- ACIP guidelines explicitly state that vaccination of leukemic patients who are receiving chemotherapy should only be undertaken with expert guidance and with antiviral therapy available 1
- Patients with leukemia must be in remission and off chemotherapy for at least 3 months before receiving live virus vaccines 1
- Current chemotherapy makes this patient severely immunocompromised and at risk for disseminated vaccine-strain infection
Key Considerations for Varicella Vaccination
Evidence of Immunity
According to ACIP, evidence of immunity to varicella includes:
- Documentation of age-appropriate vaccination
- Laboratory evidence of immunity or laboratory confirmation of disease
- Birth in the U.S. before 1980 (except for healthcare workers and pregnant women)
- Diagnosis or verification of a history of varicella or herpes zoster by a healthcare provider
Two-Dose Recommendation
- ACIP recommends a 2-dose varicella vaccination regimen for all persons without evidence of immunity 1
- For adults who previously received one dose, a second catch-up dose is recommended regardless of the time elapsed since the first dose 1
Contraindications
- Pregnancy
- Severe immunodeficiency, including:
- Patients receiving immunosuppressive therapy
- Patients with malignant conditions affecting bone marrow or lymphatic systems
- Patients receiving high-dose systemic steroids (≥20 mg/day of prednisone or equivalent)
- Recent transplant recipients
Special Considerations
- HIV-infected patients with CD4+ counts ≥200 cells/μL may be considered for vaccination when not pregnant 1
- Patients with chronic conditions like diabetes without significant immunocompromise can be safely vaccinated
Conclusion
The 36-year-old with diabetes and chronic liver disease who received one dose of varicella vaccine is the only patient among those listed for whom varicella vaccination is currently indicated according to ACIP guidelines. This patient should receive a second dose to complete the recommended vaccination series.