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Morbidity and Mortality Weekly Report

Morbidity and Mortality Weekly ReportRecommendations and ReportsJune 22, 2007 / Vol. 56 / No. RR-4 INSIDE: Continuing Education Examinationdepardepardepardepardepartmen t of health and human sertment of health and human sertment of health and human sertment of health and human sertment of health and human servicesvicesvicesvicesvicesCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionPrevention of VaricellaRecommendations of the Advisory Committeeon Immunization Practices (ACIP) 2 Epidemiology of Varicella .. 2 Prenatal and Perinatal 7 Herpes Zoster 7 Use of Acyclovir to Treat and Prevent 8 Vaccines for Prevention of Varicella .. 9 Immune Response to 10 Vaccine Efficacy and Vaccine 13 Breakthrough 14 Evidence of 16 Simultaneous Administration of 17 Economic Analysis of 17 Storage, Handling, and Transportation of VaricellaVaccines.

Proposed recommendations and a draft statement were pre-sented to the full ACIP in June 2005 and June 2006. After deliberations, final ACIP recommendations were approved in 2005 and 2006. Modifications to the draft statement were made following CDC and external review process to update and clarify wording in the document. Epidemiology of ...

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Transcription of Morbidity and Mortality Weekly Report

1 Morbidity and Mortality Weekly ReportRecommendations and ReportsJune 22, 2007 / Vol. 56 / No. RR-4 INSIDE: Continuing Education Examinationdepardepardepardepardepartmen t of health and human sertment of health and human sertment of health and human sertment of health and human sertment of health and human servicesvicesvicesvicesvicesCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionPrevention of VaricellaRecommendations of the Advisory Committeeon Immunization Practices (ACIP) 2 Epidemiology of Varicella .. 2 Prenatal and Perinatal 7 Herpes Zoster 7 Use of Acyclovir to Treat and Prevent 8 Vaccines for Prevention of Varicella .. 9 Immune Response to 10 Vaccine Efficacy and Vaccine 13 Breakthrough 14 Evidence of 16 Simultaneous Administration of 17 Economic Analysis of 17 Storage, Handling, and Transportation of VaricellaVaccines.

2 18 Adverse Events After 19 Transmission of Vaccine 21 Summary of Rationale for Varicella 22 recommendations for the Use of Varicella 23 Special Considerations for 24 Health-Care 26 Vaccination for Outbreak Control .. 27 Contraindications .. 27 Precautions .. 28 Postexposure 29 Acknowledgments .. 38 Continuing Education CE-1 Centers for Disease Control and PreventionJulie L. Gerberding, MD, MPHD irectorTanja Popovic, MD, PhDChief Science OfficerJames W. Stephens, PhD(Acting) Associate Director for ScienceSteven L. Solomon, MDDirector, Coordinating Center for Health Information and ServiceJay M. Bernhardt, PhD, MPHD irector, National Center for Health MarketingB. Kathleen Skipper, MA(Acting) Director, Division of Health Information Dissemination (Proposed)Editorial and Production StaffFrederic E. Shaw, MD, JDEditor, MMWR SeriesSuzanne M. Hewitt, MPAM anaging Editor, MMWR SeriesTeresa F.

3 RutledgeLead Technical Writer-EditorJeffrey D. Sokolow, MAProject EditorBeverly J. HollandLead Visual Information SpecialistLynda G. CupellMalbea A. LaPeteVisual Information SpecialistsQuang M. Doan, MBAE rica R. ShaverInformation Technology SpecialistsEditorial BoardWilliam L. Roper, MD, MPH, Chapel Hill, NC, ChairmanVirginia A. Caine, MD, Indianapolis, INDavid W. Fleming, MD, Seattle, WAWilliam E. Halperin, MD, DrPH, MPH, Newark, NJMargaret A. Hamburg, MD, Washington, DCKing K. Holmes, MD, PhD, Seattle, WADeborah Holtzman, PhD, Atlanta, GAJohn K. Iglehart, Bethesda, MDDennis G. Maki, MD, Madison, WISue Mallonee, MPH, Oklahoma City, OKStanley A. Plotkin, MD, Doylestown, PAPatricia Quinlisk, MD, MPH, Des Moines, IAPatrick L. Remington, MD, MPH, Madison, WIBarbara K. Rimer, DrPH, Chapel Hill, NCJohn V. Rullan, MD, MPH, San Juan, PRAnne Schuchat, MD, Atlanta, GADixie E. Snider, MD, MPH, Atlanta, GAJohn W.

4 Ward, MD, Atlanta, GAThe MMWR series of publications is published by the CoordinatingCenter for Health Information and Service, Centers for DiseaseControl and Prevention (CDC), Department of Health andHuman Services, Atlanta, GA Citation: Centers for Disease Control and Prevention.[Title]. MMWR 2007;56(No. RR-#):[inclusive page numbers].Disclosure of RelationshipCDC, our planners, and our content experts wish to disclose theyhave no financial interests or other relationships with themanufacturers of commercial products, suppliers or commercialservices, or commercial supporters. Presentations will not includeany discussion of the unlabeled use of a product or a product underinvestigational 56 / RR-4 recommendations and Reports1 Prevention of VaricellaRecommendations of the Advisory Committeeon Immunization Practices (ACIP)Prepared byMona Marin, MD, Dalya G ris, MD,* Sandra S.

5 Chaves, MD, Scott Schmid, PhD, Jane F. Seward, MBBSD ivision of Viral Diseases, National Center for Immunization and Respiratory Diseases, CDCS ummaryTwo live, attenuated varicella zoster virus containing vaccines are available in the United States for prevention of varicella:1) a single-antigen varicella vaccine (VARIVAX, Merck & Co., Inc., Whitehouse Station, New Jersey), which was licensed inthe United States in 1995 for use among healthy children aged >12 months, adolescents, and adults; and 2) a combinationmeasles, mumps, rubella, and varicella vaccine (ProQuad, Merck & Co., Inc., Whitehouse Station, New Jersey), which waslicensed in the United States in 2005 for use among healthy children aged 12 months 12 years. Initial Advisory Committee onImmunization Practices (ACIP) recommendations for prevention of varicella issued in 1995 (CDC. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices [ACIP].

6 MMWR 1996;45[No. RR-11]) includedroutine vaccination of children aged 12 18 months, catch-up vaccination of susceptible children aged 19 months 12 years, andvaccination of susceptible persons who have close contact with persons at high risk for serious complications ( , health-carepersonnel and family contacts of immunocompromised persons). One dose of vaccine was recommended for children aged12 months 12 years and 2 doses, 4 8 weeks apart, for persons aged >13 years. In 1999, ACIP updated the recommendations (CDC. Prevention of varicella: updated recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR1999;48[No. RR-6]) to include establishing child care and school entry requirements, use of the vaccine following exposure andfor outbreak control, use of the vaccine for certain children infected with human immunodeficiency virus, and vaccination ofadolescents and adults at high risk for exposure or June 2005 and June 2006, ACIP adopted new recommendations regarding the use of live, attenuated varicella vaccines forprevention of varicella.

7 This Report revises, updates, and replaces the 1996 and 1999 ACIP statements for prevention of new recommendations include 1) implementation of a routine 2-dose varicella vaccination program for children, with thefirst dose administered at age 12 15 months and the second dose at age 4 6 years; 2) a second dose catch-up varicella vaccinationfor children, adolescents, and adults who previously had received 1 dose; 3) routine vaccination of all healthy persons aged>13 years without evidence of immunity; 4) prenatal assessment and postpartum vaccination; 5) expanding the use of thevaricella vaccine for HIV-infected children with age-specific CD4+T lymphocyte percentages of 15% 24% and adolescentsand adults with CD4+T lymphocyte counts >200 cells/ L; and 6) establishing middle school, high school, and college entryvaccination requirements. ACIP also approved criteria for evidence of immunity to is a highly infectious disease caused by the vari-cella-zoster virus (VZV).

8 Secondary attack rates for this virusmight reach 90% for susceptible household contacts. VZVcauses a systemic infection that results typically in lifetimeimmunity. In otherwise healthy persons, clinical illness afterreexposure is 1995, a vaccine to prevent varicella (VARIVAX, Merck& Co., Inc., Whitehouse Station, New Jersey) was licensed inthe United States for use among healthy children aged>12 months, adolescents, and adults; recommendations of theAdvisory Committee on Immunization Practices (ACIP)* During the preparation of this Report , Dalya G ris was an employee withthe Division of Viral Diseases, National Center for Immunization andRespiratory Diseases, CDC. She presently is employed by Merck, Inc.,Whitehouse Station, New material in this Report originated in the National Center forImmunization and Respiratory Diseases, Anne Schuchat, MD, Director;and the Division of Viral Diseases, Larry Anderson, MD, preparer: Mona Marin, MD, National Center forImmunization and Respiratory Diseases, CDC, 1600 Clifton RoadNE, MS A-47, Atlanta, GA 30333.

9 Telephone: 404-639-8791;Fax: 404-639-8665; E-mail: 22, 2007regarding use of the varicella vaccine have been published pre-viously (1,2) This Report revises, updates, and replaces earlierACIP statements (Table 1).MethodsIn response to increasing reports of varicella outbreaks amonghighly vaccinated populations (3 6), ACIP s measles-mumps-rubella and varicella (MMRV) workgroup first met inFebruary 2004 to review data related to varicella vaccine usein the United States since implementation of the vaccinationprogram in 1995 and to consider recommendation optionsfor improving control of varicella disease. The workgroup heldmonthly conference calls and met in person three times a workgroup reviewed data on the impact of the 1-dosevaricella vaccination program, including data on vaccinationcoverage, changes in varicella epidemiology, transmission fromvaccinated persons with varicella, vaccine effectiveness,immune response to vaccination, evidence of immunity, andpotential risk factors for vaccine failure.

10 Published andunpublished data related to correlates of protection, safety,immunogenicity, and efficacy of the new quadrivalentMMRV vaccine and the immunogenicity and efficacy of asecond dose of varicella vaccine also were reviewed. Cost-benefit and cost-effectiveness analyses were considered, includ-ing revised cost-benefit analysis of both the 1- and 2-doseprograms for children compared with no vaccination programand the incremental benefit of a second dose. Presentationswere made to the full ACIP meetings in October 2004,February 2005, June 2005, and June 2006. Recommenda-tion options were developed and discussed by the MMRV workgroup. When definitive research evidence was lacking,the recommendations incorporated expert opinion of theworkgroup members. The workgroup sought input from part-ner organizations ( , the American Academy of Pediatrics[AAP], the American Academy of Family Physicians [AAFP],the American College of Obstetricians and Gynecologists, theCouncil of State and Territorial Epidemiologists, and theAssociation of Immunization Managers) and from state pub-lic health professionals and immunization program recommendations and a draft statement were pre-sented to the full ACIP in June 2005 and June 2006.


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