Natural Immunity and Varicella Vaccination in Immunocompromised Patients

Key Clinical Considerations

Live attenuated varicella vaccine should not be administered to highly immunocompromised patients due to the risk of severe disease from the vaccine strain itself, as recommended by the Centers for Disease Control and Prevention 1, 2, 3
The vaccine contains live-attenuated VZV that can cause life-threatening complications in patients lacking sufficient T-cell-mediated immune responses, according to the Infectious Diseases Society of America 2, 3
Vaccine virus given to immunocompromised patients has been associated with death and reactivation of VZV that became resistant to antiviral drugs, as reported by the Clinical Infectious Diseases journal 2, 3
Evidence of natural immunity includes documented history of varicella or zoster, laboratory-proven varicella or zoster, or serologic evidence of immunity, as stated by the American Academy of Pediatrics 1, 2, 4

HIV-infected patients with CD4+ T-lymphocyte count ≥200 cells/µL can receive 2 doses of single-antigen VAR administered 3 months apart, as recommended by the Centers for Disease Control and Prevention 5, 6, 4
Patients with primary immune deficiency disorders without defective T-cell-mediated immunity may receive VAR, according to the Infectious Diseases Society of America 1, 2, 4
Patients receiving long-term, low-level immunosuppression (<2 mg/kg prednisone or <20 mg/day total) may be considered for vaccination, as stated by the American College of Rheumatology 5, 6

If vaccination is appropriate, VAR must be administered ≥4 weeks before initiating highly immunosuppressive therapy, as recommended by the American Society of Transplantation 1, 2, 4
A 2-dose schedule is required: separated by >4 weeks for patients ≥13 years, or by ≥3 months for patients aged 1-12 years, according to the Centers for Disease Control and Prevention 1, 2, 3

Never administer VAR to patients already on significant immunosuppressive therapy, including elderly patients with impaired immune function from disease or medications, as warned by the American Geriatrics Society 1, 2, 7
Avoid using combination MMRV vaccine in any immunocompromised patient; if vaccination is appropriate, use single-antigen VAR only, as recommended by the Infectious Diseases Society of America 1, 2, 4