Correspondence

More on Varicella Immunization

N Engl J Med 1998; 338:1927June 25, 1998

Article

To the Editor:

The letter by Spingarn and Benjamin and the reply by Meissner (March 5 issue)1,2 highlight problems with the discussion about the merits of universal varicella immunization. All parties agree that the vaccine is safe and effective and that nonimmune adults and high-risk children require immunization. Beyond that, both sides expend considerable energy talking past one another. For example, with regard to the morbidity and mortality associated with varicella, the authors cite the same statistics to support opposite claims: that childhood varicella infection does or does not merit a universal immunization program. This “yes, it is” “no, it isn't” debate is unproductive and should be dropped, because in this case, severity is in the eyes of the beholder.

Meissner attempts to address Spingarn and Benjamin's concern about waning immunity, citing data on titers in vaccinated subjects after 10 years. Although certainly of interest, the data Spingarn and Benjamin require do not exist yet and will not be available for several decades. We do not know what role periodic reexposure to wild varicella has in maintaining immunity.3 The epidemiology of pertussis since the introduction of universal vaccination is not reassuring on this score.4 Meissner also does not address the concern about poor rates of vaccination in adults. Since there are currently no “one series for life” vaccines in use, it is not unreasonable to assume, in the absence of solid long-term data to the contrary, that persons receiving the varicella vaccine will require a booster at some point in the future.

The discussions of social costs and savings are not terribly compelling, because efforts to quantify the costs of increased cases of varicella in adults are incomplete at best. None of the widely cited studies supporting the cost effectiveness of varicella immunization looked at the costs of varicella in adults.5,6 A recent study found that the incidence of adult varicella in Japan is increasing, with substantial social costs.7

What the argument really boils down to is this: the proponents of universal vaccination admit that the long-term effect on the epidemiology of varicella in adults is unknown, but the potential decreases in morbidity and mortality in children are worth the risk. The skeptics believe that given the mildness of the disease, an attempt at universal vaccination, with its uncertain long-term risks, is not warranted. Until data are available to address these points, it is perfectly reasonable to allow parents to weigh the risks and benefits of vaccination for their own families, in the context of their finances, work situation, and child-care arrangements.

Robert P. Wack, M.D.
Carroll County General Hospital, Westminster, MD 21157

7 References

1. 1

   Spingarn RW, Benjamin JA. Universal vaccination against varicella. N Engl J Med 1998;338:683-683
   Full Text | Web of Science | Medline

2. 2

   Meissner HC. Universal vaccination against varicella. N Engl J Med 1998;338:684-684
   Full Text | Web of Science | Medline

3. 3

   Committee on Infectious Diseases, American Academy of Pediatrics. Recommendations for the use of live attenuated varicella vaccine. Pediatrics 1995;95:791-796[Erratum, Pediatrics 1995;96(1).]
   Web of Science | Medline

4. 4

   Bass JW, Stephenson SR. The return of pertussis. Pediatr Infect Dis J 1987;6:141-144
   CrossRef | Web of Science | Medline

5. 5

   Lieu TA, Cochi SL, Black SB, et al. Cost-effectiveness of routine varicella vaccination program for US children. JAMA 1994;271:375-381
   CrossRef | Web of Science | Medline

6. 6

   Preblud SR, Orenstein WA, Koplan JP, Bart KJ, Hinman AR. A benefit-cost analysis of a childhood varicella vaccination programme. Postgrad Med J 1985;61:Suppl 4:17-22
   Web of Science | Medline

7. 7

   Takayama N, Ajisawa A, Negishi M, Masuda G, Minamitani M. Varicella in adulthood: clinical features, severity scores, source of infection and complications. Kansenshogaku Zasshi 1997;11:1113-1119
   

Citing Articles (2)

Citing Articles

1. 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
   CrossRef

2. 2

   Gary Goldman. (2005) Universal Varicella Vaccination: Efficacy Trends and Effect on Herpes Zoster. International Journal of Toxicology 24:4, 205-213
   CrossRef