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Abstract & Commentary
Synopsis: A study of 41 children who were mildly affected by HIV infection showed that varicella vaccination is safe and also immunogenic in the majority of these children. Varicella vaccination should be given to asymptomatic or mildly symptomatic HIV-infected children.
Source: Levin MJ, et al. Immunization of HIV-infected children with varicella vaccine. J Pediatr. 2001;139:305-310.
Two doses of the live attenuated varicella vaccine were administered to 41 HIV-infected children who were seronegative for varicella-zoster virus infection and who were in CDC class 1 (no evidence of immune suppression, with CD4 cell percentage of > 25% and normal CD4 cell number for age), either N1 (no signs or symptoms) or A1 (mild signs or symptoms). Local reactions occurred with 20% of first vaccinations and 10% of second vaccinations. Minor systemic reactions occurred with 37% of first vaccinations and 25% of second vaccinations. Vaccine-related rash occurred only twice after first vaccinations and only once after the second. The CD4 cell percentage and CD4 cell count were minimally decreased at 4 weeks after the first vaccination, but no effect was present at 8 weeks. Two months after immunization, 60% of children were seropositive for varicella antibodies, and 83% had positive lymphocyte proliferation assays to varicella. Vaccination had no effect on HIV RNA plasma load, and no patient experienced a change in CDC clinical category within 1 month after the first vaccination or within 2 months after the second.
Comment by Hal B. Jenson, MD, FAAP
At the time of licensure in 1995, varicella vaccine was contraindicated for HIV-infected children and all persons with primary or acquired immunodeficiencies. On the basis of the unpublished results from this study, and after considering the potential risks and benefits, the Advisory Committee on Immunization Practices (ACIP) of the CDC revised the varicella vaccination guidelines in 1999 and recommended varicella vaccine for HIV-infected children in CDC class N1 or A1 with age-specific CD4 T lymphocyte percentages of > 25%. In contrast to the single varicella vaccination recommended for healthy children < 13 years of age, HIV-infected children who are candidates for varicella vaccination should receive 2 doses with a 3-month interval between doses. The use of varicella vaccine in HIV-infected children with more significant immunologic impairment is being studied.
The updated ACIP guidelines in 1999 and updated American Academy of Pediatrics guidelines in 2000 recommended that in addition to mildly affected HIV-infected children, varicella vaccine be given to persons with impaired humoral immunity.1,2 However, varicella vaccine continues to be contraindicated for persons with cellular immunodeficiencies including blood dyscrasia, leukemia, lymphoma of any type, other malignancies affecting bone marrow or lymphatic systems, and congenital T cell abnormalities. One exception is children with acute lymphocytic leukemia who have been in continuous remission for 1 year with lymphocyte counts > 700/mm3 and platelet counts > 100,000/mm3 who may receive varicella vaccine through a research protocol sponsored by the manufacturer (Merck).
Dr. Jenson, Chief, Pediatric Infectious Diseases, University of Texas Health Science Center, San Antonio, TX, is Associate Editor of Infectious Disease Alert.
1. American Academy of Pediatrics, Committee on Infectious Diseases: Varicella vaccine update. Pediatrics. 2000;105:136-141.
2. Centers for Disease Control and Prevention: Prevention of varicella. Update recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 1999;48(RR-6):1-5.