Outbreak of varicella in preschool children despite one-dose vaccination

In Turkey, a single-dose varicella vaccine was introduced into the NationalImmunization Program in 2013. Before this implementation, varicella vaccinehad been available in the private sector since 2000. However, varicella outbreakscontinued to occur in preschools and elementary schools. We investigated avaricella outbreak to estimate the effectiveness of 1-dose varicella vaccine andto evaluate potential risk factors for breakthrough disease. This study wascarried out during a varicella outbreak in 3 preschools in İzmir, Turkey, in April2016. Using questionnaires, data including children’s medical and vaccinationhistories were collected from their parents. Attack rates in vaccinated andunvaccinated children were calculated and the analyses of vaccine effectivenessand of risk factors for breakthrough disease were conducted.A total of 124 children were enrolled in the study. Of the 124 children, 77(62%) had received 1-dose varicella vaccine before the outbreak. Varicelladeveloped in 34 of 124 children during the outbreak, and 18 of them (53%)had breakthrough varicella. The attack rate was 23.4% among vaccinatedchildren and 34% among unvaccinated children. The effectiveness of singledose varicella vaccine was 33.6% against varicella disease of any severity and82.5% against moderate or severe varicella. Children vaccinated 5 or moreyears before the outbreak had 3.5 times the risk of disease than those whohad been vaccinated more recently (OR 3.5 [95% CI, 1.08-11.5]); p= 0.046).Age at vaccination (

PDF

___

1. Takahashi M. Effectiveness of live varicella vaccine. Expert Opin Biol Ther 2004; 4: 199-216.

2. Vázquez M, LaRussa PS, Gershon AA, Steinberg SP, Freudigman K, Shapiro ED. The effectiveness of the varicella vaccine in clinical practice. N Engl J Med 2001; 344: 955-960.

3. Tugwell BD, Lee LE, Gillette H, Lorber EM, Hedberg K, Cieslak PR. Chickenpox outbreak in a highly vaccinated school population. Pediatrics 2004; 113: 455-459.

4. Galil K, Fair E, Mountcastle N, Britz P, Seward J.Younger age at vaccination may increase risk of varicella vaccine failure. J Infect Dis 2002; 186: 102-105.

5. Lopez AS, Guris D, Zimmerman L, et al. One dose of varicella vaccine does not prevent school outbreaks: is it time for a second dose? Pediatrics 2006; 117: e1070-e1077.

6. Marin M, Güris D, Chaves SS, Schmid S, Seward JF; Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56(RR-4): 1-40.

7. Rentier B, Gershon AA; European Working Group on Varicella. Consensu: varicella vaccination of healthy children-a challenge for Europe. Pediatr Infect Dis J 2004; 23: 379-389.

8. Kattan JA, Sosa LE, Bohnwagner HD, Hadler JL. . Impact of 2-dose vaccination on varicella epidemiology: Connecticut--2005-2008. J Infect Dis 2011; 203: 509- 512.

9. European Centre for Disease Prevention and Control (ECDC) Guİdance Varicella vaccination in the European Union. www.ecdc.europa.eu

10. Orenstein WA, Bernier RH, Hinman AR. Assessing vaccine efficacy in the field. Epidemiol Rev 1988; 10: 221-241.

11. Marin M, Marti M, Kambhampati A, Jeram SM, Seward JF. Global Varicella Vaccine Effectiveness: A Meta-analysis. Pediatrics 2016; 137: e20153741.

12. WHO. Strategic Advisory Group of Experts on Immunization (SAGE) Working Group on Varicella and Herpes Zoster Vaccines. SAGE on Immunization, 2 April 2014, Geneva.

13. Galil K, Lee B, Strine T, et al. Outbreak of varicella at a day care center despite vaccination. N Engl J Med 2002; 347: 1909-1915.

14. Lee BR, Feaver SL, Miller CA, Hedberg CW, Ehresmann KR. An elementary school outbreak of varicella attributed to vaccine failure: policy implications. J Infect Dis 2004; 190: 477-483.

15. Miron D, Lavi I, Kitov R, Hendler A. Vaccine effectiveness and severity of varicella among previously vaccinated children during outbreaks in day-care centers with low vaccination coverage. Pediatr Infect Dis J 2005; 24: 233-236.

16. Spackova M, Wiese-Posselt M, Dehnert M, MatysiakKlose D, Heininger U, Siedler A. Comparative varicella vaccine effectiveness during outbreaks in day-care centres. Vaccine 2010; 28: 686-691.

17. Arnedo-Pena A, Puig-Barberà J, Aznar-Orenga MA, et al. Varicella vaccine effectiveness during an outbreak in a partially vaccinated population in Spain. Pediatr Infect Dis J 2006; 25: 774-778.

18. Bayer O, Heininger U, Heiligensetzer C, von Kries R. Metaanalysis of vaccine effectiveness in varicella outbreaks. Vaccine 2007; 17: 6655-6660.

19. Chaves SS, Zhang J, Civen R, et al. Varicella disease among vaccinated persons: clinical and epidemiological characteristics, 1997-2005. J Infect Dis 2008; 197(Suppl 2): S127-S131.

20. Lu L, Suo L, Li J, et al. A varicella outbreak in a school with high one-dose vaccination coverage, Beijing, China. Vaccine 2012; 20: 5094-5098.

21. Haddad MB, Hill MB, Pavia AT, et al. Vaccine effectiveness during a Varicella outbreak among schoolchildren: Utah, 2002-2003. Pediatrics 2005; 115: 1488-1493.

22. Kurugol Z, Halicioglu O, Koc F, Koturoglu G, Aksit S. Varicella rates among unvaccinated and one-dose vaccinated healthy children in Izmir, Turkey. Int J Infect Dis 2011; 15: e475-e480.

23. Fu J, Wang J, Jiang C, Shi R, Ma T. Outbreak of varicella in a highly vaccinated preschool population. Int J Infect Dis 2015; 37: 14-18.

24. Kuter B, Matthews H, Shinefield H; Study Group for Varivax. Ten year follow-up of healthy children who received one or two injections of varicella vaccine. Study Group for Varivax. Pediatr Infect Dis J 2004; 23: 132-137.

25. Bonanni P, Gershon A, Gershon M, et al. Primary versus secondary failure after varicella vaccination: Implications for interval between 2 doses. Pediatr Infect Dis J 2013; 32: e305-e313.

26. Redondo Granado MJ, Vizcaino Lopez I, Garcia Saseta P, Torres Hinojal C, Nieto Sánchez R. Early presentation of breakthrough varicella in vaccinated children. An Pediatr (Barc) 2013; 78: 330-334.

27. Dworkin MS, Jennings CE, Roth-Thomas J, Lang JE, Stukenberg C, Lumpkin JR. An Outbreak of Varicella among children attending preschool and elementary school in Illinois. Clin Infect Dis 2002; 35: 102-104.

28. Verstraeten T, Jumaan AO, Mullooly JP; Vaccine Safety Datalink Research Group. A retrospective cohort study of the association of varicella vaccine failure with asthma, steroid use, age at vaccination, and measles-mumps-rubella vaccination. Pediatrics 2003; 112: 98-103.

29. Bernstein HH, Rothstein EP, Watson BM, et al. Clinical survey of natural varicella compared with breakthrough varicella after immunizationwith live attenuated Oka/ Merck varicella vaccine. Pediatrics 1993; 92: 833-837.

30. Aslan A, Kurugol Z, Gokben S. Acute transverse myelitis complicating breakthrough varicella infection. Pediatr Infect Dis J 2014; 33: 1196-1198.

31. Schwab J, Ryan M. Varicella zoster virus meningitis in a previously immunized child. Pediatrics 2004; 114: e273-e274.

32. Kelley J, Tristram D, Yamada M, Grose C. Failure of a Single Varicella Vaccination to Protect Children With Cancer From Life-Threatening Breakthrough Varicella. Pediatr Infect Dis J 2015; 34: 1027-1029.

33. Dinleyici EC, Kurugol Z, Kara A, et al; VARICOMP Study Group. Children with breakthrough varicella infection requiring hospitalization in Turkey (VARICOMP Study 2008-2013). Vaccine 2015; 33: 3983-3987.