Correspondence
Universal Vaccination against Varicella
N Engl J Med 1998; 338:683-684March 5, 1998
- Article
To the Editor:
Historically, chickenpox has been largely a benign disease affecting predominantly preschool and school-aged children. Times are changing: in Massachusetts, children enrolled in day-care programs will soon be required to be vaccinated against varicella (or have evidence of having had the disease).1 Although it is generally held that immunizing children is axiomatic for public health, vaccinating all children against chickenpox is a bad idea.
It is unknown whether long-term immunity to varicella arises from an attack of the disease in childhood or from the virus's repeatedly (and naturally) boosting immunity because it is maintained in our communities. Furthermore, it is unknown how long immunity will last after vaccination. Yet policies of universal vaccination of children will serve, over time, to eradicate most, but not all, naturally occurring varicella and its immeasurable booster effect.
In most children, varicella is a self-limited illness lasting five to seven days. Only rarely does a child die from its complications. In fact, most deaths attributed to varicella occur among adults.2 To prevent deaths and severe illness, the proponents of vaccination argue that universal vaccination of children should be instituted to eliminate the presence of contagious children.3
Universal vaccination means that many, but not all, children will be inoculated. If the protective immunity of the immunized children wanes as they age or if noninoculated children escape disease because contagion becomes rarer, outbreaks of life-threatening varicella may occur as these children become older. Since the morbidity and mortality associated with chickenpox are increased in fetuses and after childhood,4 a considerable problem may develop even if the rates of childhood immunization against varicella are high: an ever-expanding population of adults, including pregnant women, with nonboosted (even waning) immunity may inadvertently be created.
Proponents of universal immunization argue that waning immunity will be countered by providing adults with booster immunizations. Yet adults are notoriously underimmunized in the United States, as illustrated by the large number of pregnant women who lack immunity to rubella. Similarly, although there were 36 cases of tetanus reported in 1996, none occurred in children.5 Relying on adults to obtain booster vaccinations should their immunity to chickenpox wane is folly.
Hence, it makes good sense to immunize only vulnerable adults, susceptible children as they become young adults, and younger children at high risk for complications should they acquire the disease. A dialogue about universal vaccination of toddlers against varicella might make sense only if it could clearly be demonstrated that susceptible adults could be successfully immunized.
5 ReferencesRoger W. Spingarn, M.D., M.P.H.
Jonathan A. Benjamin, M.D.
1400 Centre St., Newton Centre, MA 021591
Immunization guidelines. Boston: Massachusetts Department of Public Health, August 1997.
2
Varicella-related deaths among adults -- United States, 1997
Medline3
Plotkin SA . Varicella vaccine. Pediatrics 1996;97:251-253
Web of Science | Medline4
Wharton M . The epidemiology of varicella-zoster virus infections. Infect Dis Clin North Am 1996;10:571-581
CrossRef | Web of Science | Medline5
Status report on the Childhood Immunization Initiative: reported cases of selected vaccine-preventable diseases -- United States, 1996
Medline
Dr. H. Cody Meissner, who has advised the Massachusetts Department of Health on the varicella-vaccine program, was asked to respond:
To the Editor: Spingarn and Benjamin express the concern of some physicians regarding universal use of the varicella–zoster virus vaccine in children — namely, the duration of immunity when circulation of wild-type virus becomes less common. Nearly 7 million doses of the varicella–zoster virus vaccine have been distributed in the United States since the vaccine was licensed by the Food and Drug Administration in March 1995. The postlicensure experience has confirmed the results of initial clinical trials, demonstrating both the safety and the efficacy of the vaccine. Furthermore, seroconversion occurs in more than 95 percent of vaccinated healthy children, with antibody titers maintained for at least 10 years.1 Even the small number of vaccinated persons in whom the titer falls maintain some immunity to varicella.2 Among healthy vaccinated persons, mean antibody titers are similar in those with a history of exposure to varicella and in those without such a history,3 which suggests that ongoing exposure to exogenous varicella–zoster virus is unnecessary to maintain immunity. Moreover, breakthrough varicella in vaccinated persons is almost exclusively mild.3 Exposure to wild-type varicella–zoster virus will probably diminish with increasing rates of immunization, which underscores the necessity of ensuring optimal immunization of children to reduce the numbers of seronegative adults in the future.
Spingarn and Benjamin hold the misconception that varicella is such a benign illness that a vaccine is not needed. The consequences of varicella–zoster virus infection are not always mild. Among approximately 4 million cases a year in the United States, there are about 100 deaths due to complications of varicella. The rate of hospitalization due to complications of varicella among members of a health maintenance organization in Massachusetts was 0.4 percent.4 Among children under 13 years of age, the hospitalization rate is as high as 1 per 200 cases of varicella.5 Varicella is now recognized as a major preceding event in the development of group A streptococcal cellulitis, necrotizing fasciitis, and streptococcal toxic shock syndrome.
A reduction in the severity of zoster appears to be another benefit of immunization against varicella. Vaccinated children with leukemia have a reduced risk of zoster as compared with children with leukemia who have had natural varicella.6 Furthermore, vaccinated healthy children and adults appear to have reductions in both the incidence and the severity of zoster.7
Spingarn and Benjamin propose the immunization of “vulnerable adults.” Even if susceptible adults could be reliably identified, the vaccine is less protective in adults (even after two doses) than in children. Furthermore, the average age of a child who has complications of varicella is 3.8 years.1 Spingarn and Benjamin also propose the immunization of “younger children at high risk for complications,” but the live attenuated vaccine is not approved for use in immunocompromised patients. One of the objectives of the Massachusetts guidelines in requiring vaccination for attendance at day-care programs is to ensure immunization before an immunocompromised state is likely to develop. The most effective route to the eradication of varicella and its complications is to require immunization early in life. There is no reason that varicella should still be viewed as an inevitable infection of childhood.
7 ReferencesH. Cody Meissner, M.D.
New England Medical Center, Boston, MA 02111-15261
Johnson CE ,Stancin T ,Fattlar D ,Rome LP ,Kumar ML . A long-term prospective study of varicella vaccine in healthy children. Pediatrics 1997;100:761-766
CrossRef | Web of Science | Medline2
Clements DA ,Armstrong CB ,Ursano AM ,Moggio MM ,Walter EB ,Wilfert CM . Over five-year follow-up of Oka/Merck varicella vaccine recipients in 465 infants and adolescents. Pediatr Infect Dis J 1995;14:874-879
CrossRef | Web of Science | Medline3
Watson BM ,Piercy SA ,Plotkin SA ,Starr SE . Modified chickenpox in children immunized with Oka/Merck varicella vaccine. Pediatrics 1993;91:17-22
Web of Science | Medline4
Choo PW ,Donahue JG ,Manson JE ,Platt R . The epidemiology of varicella and its complications. J Infect Dis 1995;172:706-712
CrossRef | Web of Science | Medline5
Yawn BP ,Yawn RA ,Lydick E . Community impact of childhood varicella infections. J Pediatr 1997;130:759-765
CrossRef | Web of Science | Medline6
Hardy I, Gershon AA, Steinberg SP, LaRussa P, Varicella Vaccine Collaborative Study Group
Full Text | Web of Science | Medline7
Gershon AA, Steinberg SP, NIAID Varicella Vaccine Collaborative Study Group
CrossRef | Web of Science | Medline
- Citing Articles (8)
Citing Articles
1
Matthew M Davis. (2006) Successes and remaining challenges after 10 years of varicella vaccination in the USA. Expert Review of Vaccines 5:2, 295-302
CrossRef2
Gary Goldman. (2005) Universal Varicella Vaccination: Efficacy Trends and Effect on Herpes Zoster. International Journal of Toxicology 24:4, 205-213
CrossRef3
Michiaki Takahashi. (2004) Effectiveness of live varicella vaccine. Expert Opinion on Biological Therapy 4:2, 199-216
CrossRef4
Michael Rothberg, Michael L. Bennish, Jack S. Kao, John B. Wong. (2002) Do the Benefits of Varicella Vaccination Outweigh the Long‐Term Risks? A Decision‐Analytic Model for Policymakers and Pediatricians. Clinical Infectious Diseases 34:7, 885-894
CrossRef5
LAWRENCE RHEIN, GARY R. FLEISHER, MARVIN B. HARPER. (2001) Lack of reduction in hospitalizations and emergency department visits for varicella in the first 2 years post-vaccine licensure. Pediatric Emergency Care 17:2, 101-103
CrossRef6
Philip R. Krause, Stephen E. Straus. (1999) HERPESVIRUS VACCINES. Infectious Disease Clinics of North America 13:1, 61-81
CrossRef7
Hitoshi Kamiya, Masahiro Ito. (1999) Update on varicella vaccine. Current Opinion in Pediatrics 11:1, 3-8
CrossRef8
Wack, Robert P., . (1998) More on Varicella Immunization. New England Journal of Medicine 338:26, 1927-1927
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