Contraindications:
- History of a serious allergic reaction (e.g., anaphylaxis) after a previous dose of varicella vaccine or to a varicella vaccine component. For information on vaccine components, refer to the manufacturer’s package insert (www.immunize.org/fda) or go to www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/B/excipient-table-2.pdf.
- Pregnancy
- Severe immunodeficiency (e.g., from hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy [e.g., two weeks or more of daily receipt of 20 mg or more, or 2 mg/kg body weight or more, of prednisone or equivalent] or patients with HIV infection who are severely immunocompromised [a child age 1 through 5 years with CD4+ T-lymphocyte percentage less than 15% or a person age 6 years or older with a CD4+ T-lymphocyte count less than 200 cells per microliter])
- Family history of congenital or hereditary immunodeficiency in first-degree relatives (e.g., parents, siblings) unless the immune competence of the potential vaccine recipient has been clinically substantiated or verified by a laboratory
Precautions:
- Recent receipt (within the previous 11 months) of antibody-containing blood product (specific interval depends on product)
- Moderate or severe acute illness with or without fever (defer until recovery)
- Use of aspirin or aspirin-containing products
- Receipt of specific antiviral drugs (acyclovir, famciclovir, or valacyclovir) 24 hours before vaccination (avoid use of these antiviral drugs for 14 days after vaccination)
Precautions for combination MMRV (ProQuad, Merck) only (approved for children 1 through 12 years of age) also include: history of thrombocytopenia or thrombocytopenic purpura, a personal or family history of seizures of any etiology, and a need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing.
For additional information, see the “General Best Practice Guidelines for Immunization” section on contraindications and precautions, table 4–1 and associated footnotes, at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html.
Last reviewed:
February 19, 2024
The CDC “General Best Practice Guidelines for Immunization” section on altered immunocompetence recommends varicella vaccination of children with humoral (but not cellular) immunodeficiencies. In addition, single-antigen varicella vaccine should be considered for HIV-infected children age 1 through 5 years with CD4+ T-lymphocyte percentages greater than or equal to 15% for at least 6 months or for children age 6 years and older with CD4+ T-lymphocytes count greater than or equal to 200 cells per microliter for at least 6 months. Eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses. Additional details of these recommendations can be found in table 8-1 and associated footnotes at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
Last reviewed:
May 16, 2023
The IDSA guidelines indicate that persons receiving rituximab should be considered to have high-level immunosuppression. Both inactivated and live vaccines should be withheld at least 6 months following treatment with lymphocyte depleting medications such as rituximab. As for the IG, the interval to live vaccination depends on the dose. For guidance, please refer to the Timing and Spacing of Immunobiologics section of CDC’s “General Best Practices Guidelines for Immunization”, table 3–6: “Recommended intervals between administration of antibody-containing products and measles- or varicella-containing vaccine, by product and indication for vaccination” at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html. This interval could be as long as 11 months, depending on the dose he receives.
Last reviewed:
May 16, 2023
The ACIP’s varicella vaccine recommendations state that no adverse events associated with the use of salicylates after varicella vaccination have been reported, however, the vaccine manufacturer recommends that vaccine recipients avoid using salicylates for 6 weeks after receiving varicella vaccines because of the association between aspirin use and Reye syndrome after varicella disease (chickenpox). Vaccination with subsequent close monitoring should be considered for children who have rheumatoid arthritis or other conditions requiring therapeutic aspirin. The risk for serious complications associated with aspirin is likely to be greater in children in whom natural varicella develops than it is in children who receive the vaccine containing attenuated varicella zoster virus. In other words, the benefit of varicella vaccine likely outweighs the theoretical risk of Reye syndrome. See the ACIP varicella recommendations at www.cdc.gov/mmwr/PDF/rr/rr5604.pdf, page 29.
Last reviewed:
May 16, 2023
This is not necessary unless the person who was vaccinated develops a rash.
Last reviewed:
May 16, 2023
ACIP recommends varicella vaccine for healthy household contacts of pregnant people and immunosuppressed people. Although there may be a small risk of transmission of varicella vaccine virus to household contacts, the risk is much greater that the susceptible child will be infected with wild-type varicella, which could present a more serious threat to household contacts.
Last reviewed:
September 5, 2020
Because the surgeon is immune, the child’s rash is not a problem and there is no need for the surgeon to restrict activity. In comparing a vaccine rash to wild-type chickenpox infection, transmission is less likely with a vaccine rash and, in general, there are fewer skin lesions.
Last reviewed:
May 16, 2023
There has been only one published report of mother to child transmission of varicella vaccine virus. If the susceptible woman were to be infected with wild varicella virus, the risk of transmission to the infant would be much higher. Breastfeeding is not a contraindication or a precaution to varicella vaccination of the mother when vaccination is indicated.
Last reviewed:
May 16, 2023
A previous history of chickenpox disease, even recent disease, is not known to interfere with the immune response to different vaccines. To review the true contraindications and precautions to vaccination, consult the appendix of the CDC Recommended Child and Adolescent Immunization Schedule (www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html).
CDC’s “General Best Practice Guidelines for Immunization” also contains the table of contraindications and precautions, in addition to a useful table titled “Conditions incorrectly perceived as contraindications or precautions to vaccination (i.e., vaccines may be given under these conditions)”. Both tables are available at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html, Tables 4-1 and 4-2.
Last reviewed:
February 19, 2024
There is no known risk associated with MMR or varicella vaccination in someone with selective IgA or IgM deficiency. It is possible that the immune response may be weaker, but the vaccines are likely effective.
Last reviewed:
May 16, 2023
Based on the weight and dosage provided (40 lbs and 15 mg/week), the child is currently receiving more than 0.4 mg/kg/week of methotrexate. This meets the Infectious Disease Society of America (IDSA) definition of high-level immunosuppression. Administration of both varicella and MMR vaccines are contraindicated until such time as the methotrexate dosage can be reduced. The 2013 IDSA definition of low-level immunosuppression for methotrexate is a dosage of less than 0.4 mg/kg/week. For additional details, see the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host: cid.oxfordjournals.org/content/early/2013/11/26/cid.cit684.full.pdf.
As a general rule, whenever feasible, it is recommended that non-live and live vaccines be administered 2 or more weeks before initiating immunosuppressive medications include human immune mediators like interleukins and colony-stimulating factors, immune modulators, and medicines like tumor necrosis factor-alpha inhibitors and anti-B cell agents. See CDC General Best Practice Guidelines for Immunization section on altered immunocompetence: www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html.
Last reviewed:
June 19, 2023
