There is a lack of data on whether people who use inhaled, nasal, or topical steroids can be vaccinated safely. Interference from live viral vaccine could reduce vaccine effectiveness. 3-component positive antibody titer Varicella (Chickenpox)* 1. The risk of congenital abnormalities from primary maternal varicella infection is very low (less than 2%). This is likely to be cost effective since 70% to 90% of adults who do not remember having varicella actually have antibodies in their blood. Children with HIV infection are at increased risk for morbidity from varicella and herpes zoster. Zhang L, Ma W, Liu Y, Wang Y, Sun X, Hu Y, Deng X, Lu P, Tang F, Wang Z, Zhou M. BMC Infect Dis. Unable to load your collection due to an error, Unable to load your delegates due to an error. Most persons with breakthrough infection do not have fever. 2018 Nov 14;18(1):563. doi: 10.1186/s12879-018-3496-8. COVID-19 vaccine primary series (submitted as one upload) AND 2. doi: 10.1089/088282402760312377. Accumulated evidence supports that healthy, vaccinated persons have minimal risk for transmitting the varicella vaccine virus to contacts; through 2018 only 13 cases from 11 immunocompetent vaccine recipients have been documented, most commonly among household contacts. Essentials of diagnostic virology. Methods: VZV-seronegative adult SOT patients with no history of varicella/shingles vaccine or disease were given 2 doses of RZV vaccine 2-6 mo apart. Persons with severe cellular immunodeficiency resulting from infection with HIV, including persons diagnosed with acquired immunodeficiency syndrome (AIDS) should not receive varicella vaccine. and transmitted securely. Especially if youve limited that series to just one or two vaccinations, the last being after 16 weeks of age. However, if dose 2 is administered at least 4 weeks after dose 1, it does not need to be repeated. Ann Clin Lab Sci. If they develop lesions that do not crust (macules and papules only), they should wait until no new lesions appear within a 24-hour period. Leung J, Marin M. Update on trends in varicella mortality during the varicella vaccine era, United States 1990-2016. Prior history of varicella is not a contraindication to varicella vaccination, so when in doubt as to history, varicella vaccine should be administered. Simple, right? WebIf the Hepatitis B Surface Antibody test is negative (titer less than 10 mIU/mL) after a primary and repeat vaccine series, vaccine non-responders should be counseled and evaluated appropriately. ACIP recommends that documentation of 2 valid doses of MMR vaccine supersedes any subsequent serologic testing, even if titers are negative. The editors would like to acknowledge Valerie Morelli, Ginger Redmon, Cindy Weinbaum, and Skip Wolfe for their contributions to this chapter. The incubation period is 14 to 16 days after exposure, with a range of 10 to 21 days. New cases of exposure immediately before or during pregnancy or other adverse events after vaccination with VAR vaccine or MMRV vaccine should be reported to Merck (telephone, 1-877-888-4231) and to VAERS. It contains no adjuvant or preservative. 2018 Jan 23;9:46. doi: 10.3389/fimmu.2018.00046. If varicella and MMR vaccines are not administered at the same visit, they should be separated by at least 4 weeks. WebRoutine testing for varicella immunity following vaccination is not recommended because commercially available VZV IgG assays are not sensitive enough to detect all Expert Rev Vaccines 2017;16(4):391400. Speth F, Hinze CH, Andel S, Mertens T, Haas JP. -, Smith-Norowitz TA, Josekutty J, Lev-Tov H, Kohlhoff S, Norowitz KB, Silverberg JI, Chice S, Durkin HG, Bluth MH. Dose 1 is recommended for children age 12 through 15 months. In 1954, Thomas Weller used cell culture to isolate VZV from vesicular fluid of patients with varicella or zoster. All information these cookies collect is aggregated and therefore anonymous. WebPeople who have received varicella vaccine should not receive blood products for 14 days after being vaccinated unless the benefits of blood product outweigh the need for protection from vaccination. We want you to gain immunity as soon as possible. MMWR 2011;60(RR-7):145. -. doi: 10.1056/NEJMcp013211. Antiviral therapy Varicella vaccine virus is susceptible to acyclovir, valacyclovir, and famciclovir. Transmission of vaccine virus was reported only from vaccine recipients who developed a varicella-like or herpes zoster rash after vaccination. MMRV vaccine may be used for both dose 1 and dose 2 of measles, mumps, and rubella vaccination and varicella vaccination in children younger than age 13 years. The https:// ensures that you are connecting to the Primary viral pneumonia is uncommon among immunocompetent children but is the most common complication in adults. Webnot recommend checking titers after vaccination. However, no adverse events have been reported. The vaccine is reconstituted with sterile water and contains gelatin. Isolation guidance for these persons is to restrict contact with others until no new lesions appear within a 24-hour period. Please complete titers as soon as possible after the vaccinations are done, but at least 6 weeks after the last vaccination of a series, so that if the results are negative (i.e., you are not immune), you can be re-vaccinated with a booster. 1998;95:70807085. For example, macular lesions may be observed in the same area of skin as mature vesicles. Therefore, routine testing for varicella immunity following vaccination is not recommended. For storage and handling specifics, please refer to the manufacturer. If the result is positive, proof of negative Chest X-Ray is required. ACIP or HICPAC do not recommend that healthcare personnel get tested for immunity to varicella after 2 doses of vaccine. Each dose of MMRV vaccine contains neomycin as an antibiotic. Children infected with VZV in utero may develop herpes zoster early in life without having had extrauterine varicella. Transmission may also occur from infected respiratory tract secretions of patients with varicella that might also be aerosolized. Clinical practice. At six months after IVIG therapy, 9% and 6% of the subjects were seropositive for measles and varicella titers, respectively, but were seronegative for the mumps and rubella titers. Marin M, Marti M, Kambhampati A, et al. Thank you for taking the time to confirm your preferences. COVID-19* 1. This may prevent varicella or make it less severe. The risk of complications from varicella varies with age. Certain institutions may request signing an acknowledgement of non-responder status document before clinical placements. HIV-infected children, adolescents, or adults should not get the combination measles, mumps, rubella, and varicella vaccine (ProQuad). -, Gnann JW, Jr, Whitley RJ. Some experts recommend longer than 6 months following anti-B cell antibodies. These cookies perform functions like remembering presentation options or choices and, in some cases, delivery of web content that based on self-identified area of interests. The interval between the antibody-containing blood product and receipt of VAR, MMR, or MMRV vaccine is determined by the type of product administered. Web2. Impact of a routine two-dose varicella vaccination program on varicella epidemiology. Although a small risk for congenital varicella syndrome cannot be ruled out, the low number of exposures being registered each year in addition to the rarity of the outcome, were too low to improve on the estimate of the risk within a reasonable timeframe. (Attach the lab report to your completed Immunization Form) If the Quantitative Serum We want you to gain immunity as soon as possible. These agents should be avoided from 1 day before until 14 days after receipt of varicella vaccine [ 53 ]. 2021 Jan 2;17(1):211-216. doi: 10.1080/21645515.2020.1769395. 2001;(17):161-72. doi: 10.1007/978-3-7091-6259-0_17. Crusts from lesions are also excellent specimens for PCR. The .gov means its official. For more information, see Managing People at Risk for Severe Varicella. The Advisory Committee on Immunization Practices (ACIP), with support from the Hospital Infection Control Practices Advisory Committee (HICPAC), recommends that healthcare institutions ensure that all healthcare personnel have evidence of immunity against varicella. Rapid VZV identification techniques are indicated for a case with severe or unusual disease to initiate specific antiviral therapy. Keywords: However, treatment with low-dose (e.g., less than 2 milligrams per kilogram of body weight per day), alternate-day, topical, replacement, or aerosolized steroid preparations is not a contraindication to vaccination. For the second dose of measles, mumps, rubella, and varicella vaccines at any age and for the first dose at age 48 months or older, the use of MMRV generally is preferred over separate injections of its equivalent component vaccines (i.e., MMR vaccine and VAR vaccine). Severe allergic reaction to vaccine component or following a prior dose, Immunosuppression due to leukemia, lymphoma, generalized malignancy, immune deficiency disease, or immunosuppressive therapy, Family history of congenital or heredity immunodeficiency in first-degree relatives, Hematopoietic stem cell transplant (wait 24 months), Alpha-gal allergy (consult with physician), Receipt of antibody-containing blood products (wait 3 to 11 months to vaccinate), Receipt of specific antiviral drugs 24 hours before vaccination, Simultaneous use of aspirin or aspirin-containing products, Personal or family history of seizures of any etiology*, 1 additional per 2,300 to 2,600 children age 12 through 23 months. WebQuantitative numerical value Titers available include: Hepatitis A, Hepatitis B, Varicella (Chickenpox), Measles, Mumps and Rubella. Not so fast. Hospitalizations for varicella in the United States, 1988 to 1999. This severe disease is the result of fetal exposure to VZV without the benefit of passive maternal antibody. The most frequent complications in immunocompromised persons are pneumonia and encephalitis. Evidence of immunity to varicella includes any of the following: Data from the United States and Japan in a variety of settings indicate that varicella vaccine is 70% to 100% effective in preventing illness or modifying the severity of illness if used within 3 days, and possibly up to 5 days, after exposure. The vesicles are superficial and delicate and contain clear fluid on an erythematous base. See Managing People at Risk of Severe Varicellafor information on prevention and treatment options for people at risk of severe varicella who cannot get vaccinated. MMRV vaccine is administered by the subcutaneous route. Pediatrics 2013;132(5):e1134-40. If the exposure results in infection, there is no evidence that administration of varicella vaccine during the incubation period or prodromal stage of illness increases the risk for vaccine-associated adverse reactions. FOIA 8600 Rockville Pike Varicella vaccine is recommended for vaccinating people in the following groups who do not have evidence of immunity against varicella: HIV-infected people eligible for vaccination should get 2 doses of single-antigen varicella vaccine (Varivax) separated by 3 months. WebI have received 2 doses of the Varicella-Zoster Vaccine. CDC. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. The occurrence of HZ within the time window 1-21 days after vaccination defined for increased risk and the reported T cell-mediated immunity involvement suggest Some investigations have identified asthma, use of steroids, and vaccination at younger than age 15 months as risk factors for breakthrough varicella, but other investigations did not. As a result, the number of cases occurring annually was estimated to approximate the birth cohort, or about 4 million per year. Blood was drawn prevaccination (V1), before the second dose (V2), and 4 wk after the second dose (V3). Polymerase chain reaction (PCR) is the method of choice for laboratory diagnosis of varicella. Updated Recommendations for Use of VariZIG-United States, 2013. People receiving systemic steroids for certain conditions, such as asthma, and who are receiving steroids <2 mg/kg of body weight or total of <20 mg/day of prednisone or its equivalent and are not otherwise immunocompromised. Because viral proteins persist after cessation of viral replication, PCR and DFA may be positive when viral cultures are negative. The majority of cases (approximately 90%) occurred among children younger than age 15 years. The odds are youve just conferred lifetime immunity to your youngster. NCI CPTC Antibody Characterization Program. IAC Handouts web section gives users free access to hundreds of vaccination-related handouts and fact sheets for healthcare professionals and the public. Women who get varicella vaccine may continue to breastfeed. After re-immunization, VZV IgG Ab levels were positive (690.70 Ab index), VZV IgM Ab levels were negative ( 0.90), and VZV IgE levels remained undetectable. In this report, we describe a case of a previously healthy immunocompetent boy who had received two doses of varicella vaccine at 1 and 4 years. In otherwise healthy persons, a second occurrence of varicella is uncommon; it is more common in immunocompromised persons. Because the virulence of the attenuated virus used in the vaccine is less than that of the wild-type virus, the risk to the fetus, if any, should be even lower from vaccine virus. Seroconversion does not always result in full protection against disease, although no data regarding correlates of protection are available for adults. WebThe antibody titers to measles, rubella, mumps and varicella viruses were measured in 1,139 students (417 men, 722 women, average age 21.3+/-2.7 yr old)including 510 medical Analysis of sero-epidemiological characteristics of varicella in healthy children in Jiangsu Province, China. Seward J, Zhang J, Maupin T, et al. When antibody titer is negative, they are advised to be inoculated two more doses of vaccine. Galil K, Brown C, Lin F, et al. Although findings of some studies have suggested otherwise, most investigations have not identified time since vaccination as a risk factor for breakthrough varicella. Web2. The most useful time to run a titer test is after your youngster has received her initial series of vaccinations. Cases declined in all age groups, including infants who are not eligible for vaccination and adults whose rates of vaccination are low, indicating community protection benefits of the vaccination program. PCR testing that discriminates between vaccine and wild-type VZV is available free of charge through the specialized reference laboratories at CDC and the American Public Health Laboratory Association Vaccine Preventable Diseases Reference Centers. The fatality rate for varicella was approximately 1 per 100,000 cases among children age 1 through 14 years, 6 per 100,000 cases among persons age 15 through 19 years, and 21 per 100,000 cases among adults. Certain institutions may request signing an acknowledgement of non-responder status document before clinical placements. Would you like email updates of new search results? VariZIG is a purified human immune globulin preparation made from plasma containing high levels of anti-varicella antibodies (IgG) that is lyophilized. The manufacturer recommends that vaccine recipients avoid the use of salicylates for 6 weeks after receiving VAR or MMRV vaccine because of the association between aspirin use and Reye syndrome following varicella. Ten year follow-up of healthy children who received one or two injections of varicella vaccine. WebThe chickenpox (varicella) vaccine was licensed in . Varicella-containing vaccines may be administered a minimum of 24 months after hematopoietic stem cell transplant to patients who do not have graft versus host disease, are considered immunocompetent, and whose last dose of intravenous immunoglobulin (IVIG) was 8 to 11 months previously. Antibody persisted for at least 1 year in 97% of recipients after the second dose. Documentation of age-appropriate vaccination: Preschool-aged children (age 12 months or older): 1 dose, School-aged children, adolescents, and adults: 2 doses. One additional case had a mechanism other than direct transmission from a vaccine recipient, possibly exposure to vaccine aerosol during preparation of the vaccine for administration. Quantitative titer lab report showing negative/non-immune result to Rubella followed by 1 dose of MMR If a child receives the second dose of MMR vaccine before the 4th birthday (i.e. 5. Adults may have more severe disease and have a higher incidence of complications. Dose 2 is recommended at age 4 through 6 years at the same visit as the second dose of MMR vaccine, but may be given as early as 3 months after dose 1 (the minimum interval for children younger than age 13 years). It contains no adjuvant or preservative. You will be subject to the destination website's privacy policy when you follow the link. Studies have shown that a second dose of varicella vaccine boosts immunity and reduces the risk of breakthrough disease in children. VAR vaccine has been shown to be safe and effective in healthy children when administered at the same time as MMR vaccine at separate sites and with separate syringes. Varicella is highly contagious. High rates of vaccination coverage in the United States have eliminated discernible seasonality of varicella. For information about chickenpox (varicella) outbreaks, see Outbreak Identification, Investigation, and Control. Skin lesions are considered the major source of transmissible VZV. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. Recommendations of the Advisory Committee on Immunization Practices (ACIP). If there is a lapse of more than 4 weeks after the first dose, the second dose may be administered at any time without repeating the first dose. Laboratory evidence of immunity: commercial assays can be used to assess disease-induced immunity, but they lack adequate sensitivity to reliably detect vaccine-induced immunity (i.e., they may yield false-negative results). Merck continues to monitor pregnancy outcomes after inadvertent exposures to VZV-containing vaccines during pregnancy or within 3 months before conception. Antibody levels after vaccination may be up to 10-fold lower than levels induced by natural infection. VZV is a DNA virus and is a member of the herpesvirus group. As a safeguard, medical facilities should consider precautions for personnel in whom rash occurs after vaccination. Accessibility Covid-19: Students must receive a Covid-19 vaccineboth doses of a two-dose vaccine or the single dose of a one-dose vaccineapproved for use in the U.S. or accepted by the CDC. The need for tuberculin skin testing or interferon-gamma release assay (IGRA) testing is a precaution for MMRV vaccine. Antibody-containing products should not be given for 2 weeks following vaccination unless the benefits exceed those of the vaccine. An official website of the United States government. First, it is used to determine if a person has been previously exposed to the varicella zoster virus (VZV) through vaccination or previous infection and has developed immunity to the disease. Varicella is an acute infectious disease caused by varicella-zoster virus (VZV). All health care personnel should be immune to varicella. This will provide protection against varicella if a person is exposed again in the future and the previous exposure did not result in infection. A varicella-like rash at injection site is reported by 3% of children and by 1% of adolescents and adults following the second dose. Serologic testing of children prior to vaccination is not warranted because the majority of children between age 12 months and 12 years without a clinical history of varicella are not immune. Nonpregnant women who are vaccinated should avoid becoming pregnant for 1 month after each injection. 2-dose vaccine series OR 2. Vaccine-specific recommendations may be outdated. PNAS USA. Varicella zoster virus (VZV) causes chicken pox and herpes zoster and is a self-limiting disease in healthy children. Quantitative titer lab report showing negative/non-immune result to Measles or Mumps followed by 2 MMR vaccine doses (minimum of 28 days between doses) OR. The decision to delay vaccination depends on the severity of symptoms and the etiology of disease. Varicella disease after introduction of varicella vaccine in the United States, 19952000. Lesions also can occur on mucous membranes of the oropharynx, respiratory tract, vagina, conjunctiva, and the cornea. Adriana Lopez, MHS; Theresa Harrington, MD, MPH&TM; and Mona Marin, MD. The onset of maternal varicella from 5 days before to 2 days after delivery may result in overwhelming infection of the neonate, with a fatality ratio as high as 30% if antivirals are not given. There is evidence to suggest that the latex agglutination method, another method to test for serologic IgG, may give false-positive results that could mistakenly categorize a susceptible person as immune. WebOnce vaccinated, titers should not be drawn until 6-8 weeks after the vaccination. MMRV vaccine was licensed on the basis of non-inferiority of immunogenicity of the antigenic components rather than the clinical efficacy. People who may have some degree of immunodeficiency should not get the combination measles, mumps, rubella, and varicella vaccine (ProQuad). This page was reviewed on December 2, 2022. eCollection 2018. The patients were followed for 2 years after vaccination and no adverse reactions or episodes of primary varicella or HZ were reported. MeSH Total serum IgG was low (757 mg/dl), and total serum IgE was normal (30 IU/ml). The minimum interval between doses of MMRV is 3 months. A generalized varicella-like rash is reported by 4% to 6% of recipients of varicella vaccine (1% after the second dose in adolescents and adults), with an average of five lesions. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. Negative IGRA (T-Spot, QuantiFERON-TB test) within 6 months. From inception of the registry in 1995 through March 2012, no cases of congenital varicella syndrome and no increased prevalence of other birth defects have been detected among women vaccinated within 3 months before or during pregnancy. CDC. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). WebPeople receiving high-dose corticosteroids can receive varicella-containing vaccines after they have stopped corticosteroid therapy for at least 1 month (see Contraindications ). 2009;39:4350. National Library of Medicine Zoster is much less infectious as varicella, i.e., about 1/5 as infectious as varicella. WebA negative result does not rule out acute infection. These persons may receive MMR vaccine and VAR vaccine, but should not receive MMRV vaccine. RR-4):140. Testing for varicella immunity following 2 doses of vaccine is not necessary because 99% of persons are seropositive after the second dose. Although one-dose vaccination coverage has been high and varicella morbidity and mortality has diminished, the one-dose program did not prevent varicella Before Varicella vaccine has been used successfully to control these outbreaks. The Advisory Committee on Immunization Practices (ACIP) recommends that after being exposed to varicella or herpes zoster, people who do not have evidence of immunityand are eligible for vaccination should get varicella vaccine. In this report, we describe a case of a previously healthy immunocompetent boy who had received two doses of varicella vaccine at 1 and 4 years. Antibody resulting from vaccination is generally of lower titer than antibody resulting from varicella disease and commercially available serologic IgG tests are not sufficiently sensitive to detect low levels of antibody following vaccination. VAR vaccine and MMRV vaccine both contain minute amounts of neomycin and gelatin but do not contain egg protein. These cookies may also be used for advertising purposes by these third parties. Specimens are best collected by unroofing a vesicle, preferably a fresh fluid-filled vesicle, and then rubbing the base of a skin lesion with a polyester swab. Bialek S, Perella D, Zhang J, et al. CDC. The benefits of varicella vaccination may outweigh the risk of severe disease from wild-type varicella infection. Pediatrics 2016;137:110. In MMRV vaccine prelicensure studies conducted among children age 12 to 23 months, fever (reported as abnormal or elevated greater than or equal to 102F oral equivalent) was observed 5 to 12 days after vaccination in 21.5% of MMRV vaccine recipients compared with 14.9% of MMR vaccine and VAR vaccine recipients. WebIf the Hepatitis B Surface Antibody test is negative (titer less than 10 mIU/mL) after a primary and repeat vaccine series, vaccine non-responders should be counseled and evaluated appropriately. In such cases, vaccine recipients should either be revaccinated later at the appropriate intervals (ranging 3 to 11 months), or tested for immunity and revaccinated if seronegative. Isolated case-reports of congenital varicella syndrome have been reported in women infected after 20 weeks of gestation with the latest occurring at 28 weeks of gestation. ACIP does not recommend serologic testing after vaccination because commercial tests may not be sensitive enough to reliably detect vaccine-induced immunity. Zhu H, Zhao H, Ou R, Zeng Q, Hu L, Qiu H, Sharma M, Ye M. Int J Environ Res Public Health. Conclusion: Certain institutions may request signing an acknowledgement of non-responder status document before clinical placements. Transmission of VZV would cause varicella, not zoster, in a VZV-nave person. The rash usually appears first on the scalp, face or trunk, and then spreads to the extremities; the highest concentration of lesions is on the trunk. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. Even if it has been more than 5 days, the vaccine should still be offered. The vaccine virus was developed from virus isolated by Michiaki Takahashi from vesicular fluid from an otherwise healthy child with varicella disease. Primary varicella infection (chickenpox) was not reliably distinguished from smallpox until the end of the 19th century. There are no data available on the use of the combination measles, mumps, rubella, and varicella vaccine (ProQuad) for post-exposure vaccination. Fever within 42 days of vaccination is reported by 15% of children and 10% of adolescents and adults. As with other vaccines, a history of a severe allergic reaction (anaphylaxis) to a vaccine component or following a prior dose is a contraindication to further doses. Saving Lives, Protecting People, Epidemiology and Prevention of Vaccine-Preventable Diseases, Advisory Committee on Immunization Practices Vaccine Recommendations and Guidelines, Contraindications and Precautions to Vaccination, Manual for the Surveillance of Vaccine-Preventable Diseases, National Center for Immunization and Respiratory Diseases, Chapter 2: General Recommendations on Immunization, Chapter 3: Immunization Strategies for Healthcare Practices and Providers, Appendix A: Schedules and Recommendations, Appendix C: Vaccine Information Statements, U.S. Department of Health & Human Services, Acute infectious disease caused by varicella-zoster virus (VZV), Distinguished from smallpox at the end of the 19th century, Live, attenuated varicella vaccine developed in 1970s, Varicella and MMRV vaccines licensed for use in the U.S. in 1995 and 2005, respectively, Primary infection results in varicella (chickenpox), Reactivation of latent infection results in herpes zoster (shingles), Enters through respiratory tract and conjunctiva, Replication in nasopharynx and regional lymph nodes, Primary viremia 4 to 6 days after infection, Secondary viremia with viral skin infection after replication, Incubation period 14 to 16 days (range, 10 to 21 days), Prolonged incubation period if received postexposure prophylaxis with varicella specific immune globulin, Rash often first sign of disease in children; adults may have 1 to 2 days of fever and malaise before rash, In unvaccinated individuals, generalized and pruritic rash progresses rapidly, Clinical course in healthy children is mild; adults may have more severe disease, Recovery usually results in lifetime immunity, Results from maternal infection in the first 20 weeks of gestation, Associated with newborn limb hypoplasia, skin scarring, localized muscular atrophy, encephalitis, cortical atrophy, chorioretinitis, microcephaly, and low birth weight, Direct contact with vesicular fluid or inhalation of aerosols, 1 to 2 days before onset of rash until all lesions have formed crusts, Virtually all persons acquired varicella by adulthood before vaccine, Since vaccine, varicella incidence has declined an average of 97%, 2-dose series at age 12 through 15 months and age 4 through 6 years, 3 months for children age 12 months12 years (although a 4-week interval is valid), 4 weeks for persons age 13 years and older (VAR only), Discuss risks and benefits of MMRV versus separate VAR, Separate MMR and VAR vaccines preferred for dose 1 in ages 12 through 47 months, MMRV preferred for dose 2 and dose 1 at age 48 months or older, Documentation of age-appropriate vaccination, Exception: Health care personnel, pregnant women, and immunocompromised persons, Health care provider diagnosis or verification of varicella disease, History of herpes zoster based on health care provider diagnosis or verification of disease history. 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