Varicella Vaccination Indication
The patient with diabetes mellitus and chronic liver disease who received one dose of the vaccine 2 years ago and has no evidence of immunity should receive a second dose of varicella vaccine.
Analysis of Each Patient Scenario
Patient with Diabetes Mellitus and Chronic Liver Disease (One Prior Dose, No Evidence of Immunity)
This patient qualifies for vaccination and should receive a second dose. 1
- Diabetes mellitus and chronic liver disease are not contraindications to varicella vaccination 1
- All adults without evidence of immunity should receive 2 doses of single-antigen varicella vaccine 4-8 weeks apart 1
- Second dose catch-up vaccination is specifically recommended for persons who previously received 1 dose 1, 2
- The minimum interval between doses for adults (≥13 years) is 4 weeks, though longer intervals are acceptable 1, 2
- Persons with impaired humoral immunity may be vaccinated safely 1
Pregnant Individual with HIV (CD4 Count Specified, No Immunity)
This patient has two absolute contraindications: pregnancy and active immunosuppression.
- Pregnancy is an absolute contraindication to varicella vaccination because it is a live-attenuated vaccine 1, 3
- Varicella vaccine should not be administered to pregnant women, although no pattern of malformation has been identified after inadvertent immunization 1
- Women should be counseled to avoid conception for 1 month after each dose of varicella vaccine 1
- HIV-infected persons may be considered for vaccination only if they have CD4+ T-lymphocyte count >200 cells/mm³ AND are not pregnant 1
- Vaccination may be considered (2 doses, administered 3 months apart) for HIV-infected persons with CD4+ T-lymphocytes count >200 cells/µL 1
- The vaccine should be administered postpartum before discharge from the health care facility if the patient lacks evidence of immunity 1
Patient Post-Cardiac and Renal Transplantation (6 Months Ago, No Immunity)
This patient is contraindicated for vaccination due to ongoing immunosuppression from transplant medications.
- Live vaccines should not be given to immunocompromised persons, including solid-organ transplant recipients 1
- Transplant recipients require ongoing immunosuppressive therapy to prevent organ rejection, making them severely immunocompromised 1
- Varicella vaccine is not licensed for use in immunocompromised patients because of its potential to cause severe disease in patients who lack sufficient T-cell-mediated immune responses 1
- The ideal time for vaccination would have been ≥4 weeks before transplantation 1
Patient with Leukemia on Chemotherapy (One Prior Dose at Younger Age, No Immunity)
This patient is contraindicated for vaccination while actively receiving chemotherapy.
- Vaccination of leukemic children who are in remission and who do not have evidence of immunity should be undertaken only with expert guidance and with the availability of antiviral therapy 1
- Patients with leukemia whose disease is in remission can receive live-virus vaccines only after chemotherapy has been terminated for at least 3 months 1
- Varicella vaccine should not be administered routinely to children with leukemia receiving chemotherapy 1
- When immunizing persons in whom some degree of immunodeficiency might be present, only single-antigen varicella vaccine should be used 1
Critical Clinical Pitfalls to Avoid
- Do not vaccinate pregnant women under any circumstances—defer until postpartum 1
- Do not assume that one prior dose provides adequate protection—all adults need 2 doses for optimal immunity 1
- Do not vaccinate patients on active immunosuppressive therapy—wait until therapy has been discontinued for at least 1-3 months depending on the condition 1
- Do not use MMRV vaccine in adults—only single-antigen varicella vaccine is licensed for persons ≥13 years 1, 3, 2