Varicella-Zoster

Varivax, an approved live, attenuated varicella-zoster vaccine, is recommended in the United States for immunocompetent pediatric patients older than 12 months with no history of previous infection with varicella-zoster virus (VZV). A second dose is given when the child is between 4 and 6 years of age. For patients older than 13 years, 2 doses of vaccine are given 4–8 weeks apart. Health care workers who have not been exposed to chickenpox (varicella) should also be vaccinated. Varivax is safe and provides immunity for up to 20 years. Data from the CDC confirmed a dramatic decline (87%) in the incidence of varicella in the United States from 1995 to 2000.

Shingrix, an inactivated recombinant zoster vaccine given in 2 doses, is recommended by the FDA for adults aged 50 or older to reduce the incidence of VZV infection. This vaccine, approved in 2017, decreases the risk of VZV by 90% and may be safe to use in immunocompromised patients. Zostavax, a live, attenuated vaccine, was previously recommended to reduce the risk of VZV infection and postherpetic neuralgia. However, Zostavax appears to be less effective than Shingrix, and Zostavax cannot be used in adults receiving high-level immunosuppressive therapy. Neither Zostavax nor Shingrix may be used in place of Varivax in younger persons. Also see Chapter 14.

Ophthalmic considerations The incidence of varicella-zoster virus (VZV) infection increases with increasing age; it has a rate of 11 cases per 1000 person-years for patients in their 80s. In the United States, 1.2 million new cases of varicella-zoster infections are diagnosed each year in adults, 20% of which have ophthalmic involvement. Ophthalmologists should encourage their patients over age 50 to receive the new VZV vaccine (Shingrix) even if they have previously received the Zostavax vaccine.

• Cornea Society and American Academy of Ophthalmology Secretariat, Hoskins Center for Quality Eye Care. Clinical Statements. Recommendations for Herpes Zoster Vaccine for Patients 50 Years of Age and Older—2018. San Francisco: American Academy of Ophthalmology; 2018. www.aao.org/clinical-statement/recommendations-herpes-zoster-vaccine-patients-50-. Accessed February 22, 2019.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.