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Varicella virus vaccine (VAR): Drug information

Varicella virus vaccine (VAR): Drug information
2024© UpToDate, Inc. and its affiliates and/or licensors. All Rights Reserved.
For additional information see "Varicella virus vaccine (VAR): Patient drug information" and "Varicella virus vaccine (VAR): Pediatric drug information"

For abbreviations, symbols, and age group definitions show table
Brand Names: US
  • Varivax
Brand Names: Canada
  • Varilrix;
  • Varivax III
Pharmacologic Category
  • Vaccine;
  • Vaccine, Live (Viral)
Dosing: Adult
Varicella immunization

Varicella immunization:

US labeling: IM or SUBQ: Two doses of ~0.5 mL (entire contents of reconstituted vial) separated by ≥4 weeks (4 to 8 weeks apart per ACIP). Note: The ACIP recommends that all children and adults without evidence of immunity receive 2 doses of the vaccine; those who received only 1 dose of a varicella-containing vaccine receive a second dose (Ref).

Canadian labeling: Note: The NACI recommends that adolescents (≥13 years of age) and adults (<50 years of age) who received only 1 dose of vaccine receive a second dose (Ref).

Varilrix: SUBQ: Two single doses 0.5 mL separated by ≥6 weeks.

Varivax III: SUBQ: Two single doses ~0.5 mL (entire contents of reconstituted vial) separated by 4 to 8 weeks.

Varicella postexposure prophylaxis

Varicella postexposure prophylaxis (healthy, previously unvaccinated individuals) (off-label use): IM, SUBQ: ~0.5 mL (entire contents of reconstituted vial) administered ideally within 72 hours postexposure but may be used up to 120 hours (5 days) postexposure (Ref).

Dosing: Kidney Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling

Dosing: Hepatic Impairment: Adult

There are no dosage adjustments provided in the manufacturer's labeling

Dosing: Older Adult

Refer to adult dosing.

Dosing: Pediatric

(For additional information see "Varicella virus vaccine (VAR): Pediatric drug information")

Note: Consult CDC/ACIP annual immunization schedules for additional information including specific detailed recommendations for catch-up scenarios and/or care of patients with high-risk conditions. According to ACIP, doses administered ≤4 days before minimum interval or age are considered valid; however, local or state mandates may supersede this timeframe (Ref).

Primary immunization

Primary immunization:

CDC/ACIP recommendations: Children ≥12 months: IM, SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for a total of 2 doses administered as follows: 12 to 15 months of age and 4 to 6 years of age. The second dose may be administered earlier provided ≥3 months have elapsed after the first dose. If the second dose was administered ≥4 weeks after the first dose, it may be considered as valid (Ref).

Canadian labeling: National Advisory Committee on Immunization (NACI) recommends 2 doses of 0.5 mL with first dose administered at 12 to 15 months of age. Separate doses by ≥3 months; however, if rapid protection is necessary, may administer second dose after ≥4 weeks (Ref).

Children:

Varilrix: SUBQ: 2 doses of 0.5 mL separated by ≥6 weeks.

Varivax III: SUBQ: ~0.5 mL (entire contents of reconstituted vial) as a single dose.

Adolescents: Note: The NACI recommends that adolescents should receive 2 doses (Ref).

Varilrix: SUBQ: 2 doses of 0.5 mL separated by ≥6 weeks.

Varivax III: SUBQ: 2 doses of ~0.5 mL (entire contents of reconstituted vial) separated by 4 to 8 weeks.

Catch-up immunization

Catch-up immunization: Children and Adolescents: ACIP recommendations (Ref): Note: Do not restart the series. If doses have been given, begin the below schedule at the applicable dose number. IM, SUBQ: ~0.5 mL (entire contents of reconstituted vial) per dose for a total of 2 doses administered as follows:

First dose given on the elected date.

Second dose given at least 3 months after the first dose (if age <13 years) or at least 4 weeks after the first dose (if age ≥13 years).

Varicella postexposure prophylaxis

Varicella postexposure prophylaxis (healthy, previously unvaccinated individuals): Children (≥12 months) and Adolescents: IM, SUBQ: ~0.5 mL (entire contents of reconstituted vial) administered ideally within 72 hours postexposure but may be used up to 120 hours (5 days) postexposure (Ref).

Dosing: Kidney Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified. Reported adverse reactions are for children, adolescents, and adults.

>10%:

Local: Injection-site reaction (19% to 33%; including erythema at injection site, hematoma at injection site, induration at injection site, injection-site numbness, injection-site pruritus, pain at injection site, rash at injection site, swelling at injection site, and stiffness)

Miscellaneous: Fever (10% to 15%)

1% to 10%:

Dermatologic: Pruritus, skin rash, varicella-like rash (≤6%; at injection site and generalized)

Gastrointestinal: Abdominal pain, anorexia, diarrhea, nausea, vomiting

Hematologic & oncologic: Lymphadenopathy

Hypersensitivity: Hypersensitivity reaction

Nervous system: Chills, fatigue, headache, irritability, malaise, sleep disturbance

Neuromuscular & skeletal: Arthralgia, myalgia, neck stiffness

Otic: Otitis

Respiratory: Cough, lower respiratory signs and symptoms, upper respiratory system symptoms

<1%:

Infection: Herpes zoster infection

Nervous system: Febrile seizures (children)

Respiratory: Pneumonitis

Postmarketing:

Cardiovascular: Peripheral edema, syncope

Dermatologic: Erythema multiforme, secondary skin infection (including cellulitis and impetigo), Stevens-Johnson syndrome

Hematologic & oncologic: Aplastic anemia, Henoch-Schönlein purpura, immune thrombocytopenia, thrombocytopenia

Hypersensitivity: Anaphylactic shock, anaphylaxis, angioedema, facial edema

Nervous system: Aseptic meningitis, ataxia, Bell palsy, cerebrovascular accident, dizziness, encephalitis, Guillain-Barré syndrome, meningitis, paresthesia, seizure, transverse myelitis

Ophthalmic: Anterior uveitis (children; Krall 2014), keratitis (children; Krall 2014), necrotizing retinitis (immunocompromised patients)

Respiratory: Pharyngitis, pneumonia

Contraindications

Severe allergic or anaphylactic reaction to the vaccine, a previous dose of a varicella-containing vaccine, or any component of the formulation, including neomycin and gelatin; immunosuppressed or immunodeficient individuals due to disease or medical therapy; untreated tuberculosis (TB) disease (active TB); active febrile illness with fever >38.5°C (>101.3°F); pregnancy or planning to become pregnant within the next 3 months.

Canadian labeling: Additional contraindications (not in US labeling): Varivax III: Blood dyscrasias, leukemia, lymphomas (any type), or other malignancies affecting the bone marrow or lymphatic system; concomitant use with immunosuppressive therapy (including high-dose corticosteroids); primary or acquired immunodeficiency, including immunosuppression associated with AIDS or other clinical manifestations of infection with HIV (excludes immunosuppression in asymptomatic children with CD4 T-lymphocyte percentages ≥25%); family history of congenital or hereditary immunodeficiency (unless immune competence of vaccine recipient is demonstrated). Varilrix: Primary or acquired immunodeficiency with a total lymphocyte count <1,200/mm3.

Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (ACIP [Kroger 2023]).

• CNS infection: Cases of encephalitis or meningitis caused by vaccine strain varicella virus have been reported in immunocompetent individuals previously vaccinated with varicella virus vaccine months to years after vaccination. Cases are often associated with preceding or concurrent herpes zoster rash.

• Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescents and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (ACIP [Kroger 2023]).

Disease-related concerns:

• Acute illness: Although fever is a contraindication per the manufacturer, current guidelines allow for administration to patients with mild acute illness with or without low grade fever (CDC/ACIP [Marin 2007]). Defer administration in patients with moderate or severe acute illness (with or without fever) (ACIP [Kroger 2023).

• Altered immunocompetence: Use of this vaccine is contraindicated in persons who are immunosuppressed or immunodeficient. Household and close contacts of persons with altered immunocompetence may receive most age-appropriate vaccines (ACIP [Kroger 2023]). Live vaccines should be administered ≥4 weeks prior to planned immunosuppression and avoided within 2 weeks of immunosuppression when feasible; live vaccines should not be administered for at least 3 months after immunosuppressive therapy (ACIP [Kroger 2023]; IDSA [Rubin 2014]).

• HIV: Children ≤8 years of age with HIV infection with age-specific CD4+ T-lymphocyte percentages ≥15% may receive live attenuated varicella vaccine. Vaccination may also be considered for children >8 years of age, adolescents, and adults with CD4+ T-lymphocyte counts ≥200 cells/microliter; refer to guidelines for specific information (CDC/ACIP [Marin 2007]).

Concurrent drug therapy issues:

• Antibody-containing products: Varicella vaccine and antibody-containing products (eg, immune globulin, blood products) should not be administered simultaneously. Guidelines with suggested administration intervals are available (ACIP [Kroger 2023]).

• Antiviral drugs: Medications active against the herpesvirus family (eg, acyclovir, famciclovir, valacyclovir) may interfere with the varicella vaccine; avoid varicella vaccination to a patient who has received these antivirals 24 hours before vaccination; avoid use of these antiviral agents for 14 days after varicella vaccination (ACIP [Kroger 2023]).

• Salicylates: Avoid salicylates in children and adolescents 12 months through 17 years of age for 6 weeks after vaccination; varicella may increase the risk of Reye syndrome.

• Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or non-live) for which a person is eligible at a single visit, unless contraindications exist. The use of combination vaccines is generally preferred over separate injections, taking into consideration provider assessment, patient preference, and adverse events. When using combination vaccines, the minimum age for administration is the oldest minimum age for any individual component; the minimum interval between dosing is the greatest minimum interval between any individual components (ACIP [Kroger 2023]).

Dosage form specific issues:

• Albumin: Products may contain albumin.

• Gelatin: Products may contain gelatin. Use is contraindicated in patients with a history of anaphylactic/anaphylactoid reaction to gelatin.

• Neomycin: Products may contain neomycin. Use is contraindicated in patients with history of anaphylactic/anaphylactoid reactions to neomycin. Contact dermatitis due to neomycin is not a contraindication to the vaccine (CDC/ACIP [Marin 2007]).

Other warnings/precautions:

• Appropriate use:

- Use of this vaccine for specific medical and/or other indications (eg, immunocompromising conditions, hepatic or kidney disease, diabetes) is also addressed in the annual ACIP Recommended Immunization Schedules (refer to the Centers for Disease Control and Prevention [CDC] schedule for detailed information). Specific recommendations for use of this vaccine in immunocompromised patients with asplenia, cancer, HIV infection, cerebrospinal fluid leaks, cochlear implants, hematopoietic stem cell transplant (prior to or after), sickle cell disease, solid organ transplant (prior to or after), or those receiving immunosuppressive therapy for chronic conditions as well as contacts of immunocompromised patients are available from the IDSA (Rubin 2014).

- Varilrix and Varivax III [Canadian products]: Canadian National Advisory Committee on Immunization (NACI) suggests that Varivax III and Varilrix may also be used for select groups (NACI 2017). Consult product labeling and/or NACI for specific recommendations regarding appropriate use in high risk patients.

• Antipyretics: Antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (ACIP [Kroger 2023]). One study reported that routine prophylactic administration of acetaminophen prior to vaccination to prevent fever decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).

• Congenital or hereditary immunodeficiency: Defer use in patients with a family history of congenital or hereditary immunodeficiency until immune competence in the vaccine recipient is demonstrated (CDC/ACIP [Marin 2007]).

• Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (ACIP [Kroger 2023]).

• Transmission of virus: Transmission of varicella vaccine virus resulting in varicella infection may occur (rare) between vaccine recipients (with or without varicella-like rash) and contacts susceptible to varicella (including healthy and high-risk individuals). The manufacturer notes that vaccinated individuals should not have close association with susceptible high-risk individuals for up to 6 weeks following vaccination. High-risk individuals include immunocompromised persons, pregnant women without evidence of immunity, newborns of mothers without evidence of immunity, and all infants born <28 weeks' gestation (regardless of maternal immunity). However, the CDC recommends that vaccine recipients who develop a vaccine-related rash avoid contact with susceptible individuals at high risk for complications until the lesions are resolved (crusted over or fade away) or until no new lesions appear for 24 hours. According to the CDC guidelines, having a pregnant household member is not a contraindication to vaccination (CDC/ACIP [Marin 2007]).

Warnings: Additional Pediatric Considerations

Herpes zoster caused by vaccine-strain varicella zoster virus (VZV) has been reported rarely in children postvaccination with varicella virus vaccine; in patients with herpes zoster caused by vaccine-strain VZV, the rash was more likely to correspond to site of vaccine injection than in patients with herpes zoster caused by wild-type VZV (Guffey 2017; Weinmann 2013). Onset of rash at previous injection site occurred between 6 and 61 months postvaccination in a case series describing 7 patients (age range: 1 to 6 years) with herpes zoster; precipitating factors and symptoms varied (Song 2018).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Injectable, Subcutaneous [preservative free]:

Varivax: 1350 PFU/0.5 mL (1 ea) [contains albumin bovine, edetic acid (edta), neomycin]

Generic Equivalent Available: US

No

Pricing: US

Injection (Varivax Subcutaneous)

1350 pfu/0.5 mL (per each): $209.04

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Injectable, Subcutaneous:

Varilrix: 2000 PFU/0.5 mL (0.5 mL) [contains lactose, neomycin sulfate]

Varivax III: 1350 PFU/0.5 mL (0.5 mL) [contains albumin bovine, neomycin]

Administration: Adult

Note: Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection. To prevent syncope related injuries, patients should be vaccinated while seated or lying down (Ref). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, Vaccine Information Statement (VIS) edition date and date it was provided, and the administering person's name, title, and address be recorded.

US labeling:

IM, SUBQ: For IM or SUBQ injection only. Administer immediately following reconstitution.

Canadian labeling:

SUBQ: For SUBQ injection only; do not administer IM, IV, intravascularly or intradermally. Varilrix is to be administered SUBQ in the deltoid region only. Varivax III should preferentially be administered SUBQ in the deltoid region or anterolateral thigh. Administer immediately following reconstitution.

Administration: Pediatric

Parenteral:

IM, SUBQ: Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection. To prevent syncope-related injuries, adolescents should be vaccinated while seated or lying down (Ref). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, Vaccine Information Statement (VIS) edition date and date it was provided, and the administering person's name, title, and address be recorded.

US labeling:

IM, SUBQ: For IM or SUBQ injection only; do not administer IV. Administer immediately following reconstitution. Administer SUBQ over the anterolateral thigh or into the upper arm (over the triceps area) or administer IM into the anterolateral aspect of the thigh or the outer aspect of the upper arm (deltoid muscle) (Ref).

Canadian labeling:

SUBQ: For SUBQ injection only; do not administer IM, IV, intravascularly, or intradermally. Varilrix is to be administered SUBQ in the deltoid region only. Varivax III should preferentially be administered SUBQ in the deltoid region or anterolateral thigh. Administer immediately following reconstitution.

Medication Guide and/or Vaccine Information Statement (VIS)

In the US, the appropriate CDC-approved Vaccine Information Statement (VIS) must be provided to the patient/caregiver before administering each dose of this vaccine; the VIS edition date and date it was provided to the patient/caregiver should be recorded as required by US law; VIS is available at http://www.cdc.gov/vaccines/hcp/vis/vis-statements/varicella.html.

Use: Labeled Indications

Varicella prevention: For the prevention of varicella in persons 12 months and older

The Advisory Committee on Immunization Practices (ACIP) recommends vaccination for all children, adolescents, and adults who do not have evidence of immunity (CDC/ACIP [Marin 2007]). Vaccination is especially important for:

• Health care personnel

• Household contacts of immunocompromised persons

• Persons living or working in environments where transmission is likely (teachers, child-care workers, residents and staff of institutional settings)

• Persons in environments where transmission has been reported

• Nonpregnant persons who may become pregnant

• Adolescents and adults in households with children

• International travelers

Varilrix (Canadian product): Also approved for use in high-risk patients (eg, acute leukemia [complete remission and lymphocyte count ≥1,200/mm3 or that no other evidence of lack of cellular immune competence exists], planned organ transplantation [6 to 8 weeks prior to], receiving immunosuppressive treatment [with lymphocyte count ≥1,200/mm3], or other chronic diseases); approved for use in susceptible healthy contacts of high-risk patients.

Use: Off-Label: Adult

Varicella postexposure prophylaxis

Medication Safety Issues
Sound-alike/look-alike issues:

Varicella virus vaccine has been given in error (instead of the indicated varicella immune globulin) to pregnant women exposed to varicella.

VAR (varicella vaccine) may be confused with HZV (herpes zoster vaccine)

Varivax may be confused with VZIG

High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs (contraindicated in pregnancy) which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Community/Ambulatory Care Settings).

Other safety concerns:

Both varicella vaccine and zoster vaccine are live, attenuated strains of varicella-zoster virus. Their indications, dosing, and composition are distinct. Varicella is indicated in children to prevent chickenpox, while zoster vaccine is indicated in older individuals to prevent reactivation of the virus which causes shingles. Zoster vaccine is not a substitute for varicella vaccine and should not be used in children.

Varivax may be supplied with a prefilled diluent syringe. After reconstitution of the vial contents, withdraw vaccine back into a syringe; relabel the syringe with the vaccine name to prevent mix-ups with other prefilled syringes (ISMP [Gaunt 2023]).

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.

5-Aminosalicylic Acid Derivatives: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. The primary concern is the potential development of Reye's Syndrome, a condition that has been associated with the use of salicylates in children with varicella infections. Management: Avoid administration of salicylates for at least 6 weeks after adminstration of a varicella virus-containing vaccine. Risk D: Consider therapy modification

Acetaminophen: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of acetaminophen before or during vaccine administration when possible. Acetaminophen is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modification

Acyclovir-Valacyclovir: May diminish the therapeutic effect of Varicella Virus Vaccine. Management: When possible, avoid use of acyclovir or valacyclovir within the 24 hours prior to administration of the varicella vaccine, and avoid use of these antiviral agents for 14 days after vaccination. Risk X: Avoid combination

Anti-CD20 B-Cell Depleting Therapies: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Anti-CD20 B-Cell Depleting Therapies may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Atidarsagene Autotemcel: May enhance the adverse/toxic effect of Vaccines. Atidarsagene Autotemcel may diminish the therapeutic effect of Vaccines. Risk X: Avoid combination

Corticosteroids (Systemic): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Corticosteroids (Systemic) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Dimethyl Fumarate: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, Dimethyl Fumarate may increase the risk of vaccinal infection. Dimethyl Fumarate may diminish the therapeutic effect of Vaccines (Live). Management: Non-US labeling for dimethyl fumarate states that live attenuated vaccine administration is not recommended during treatment. US labeling states that safety and effectiveness of live vaccines administered with dimethyl fumarate has not been assessed. Risk C: Monitor therapy

Dinutuximab Beta: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Dinutuximab Beta may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Dinutuximab Beta: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Dinutuximab Beta may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Dupilumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination

Elivaldogene Autotemcel: May enhance the adverse/toxic effect of Vaccines. Specifically, there may be a greater risk for contracting an infection from any live vaccine. Elivaldogene Autotemcel may diminish the therapeutic effect of Vaccines. Management: Administration of vaccines is not recommended in the 6 weeks before myeloablative conditioning, and until hematologic recovery after elivaldogene autotemcel treatment. Risk X: Avoid combination

Etrasimod: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Etrasimod may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Famciclovir: May diminish the therapeutic effect of Varicella Virus Vaccine. Management: When possible, avoid use of famciclovir within the 24 hours prior to administration of the varicella vaccine, and avoid use of famciclovir for 14 days after vaccination. Risk X: Avoid combination

Immune Globulins: May diminish the therapeutic effect of Vaccines (Live). Management: Live organism vaccination should be withheld for as long as 6 to 11 months following immune globulin administration. Recommendations vary by product and immune globulin dose, see full monograph for details. Risk D: Consider therapy modification

Immunosuppressants (Cytotoxic Chemotherapy): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Cytotoxic Chemotherapy) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Immunosuppressants (Miscellaneous Oncologic Agents): Mumps- Rubella- or Varicella-Containing Live Vaccines may enhance the adverse/toxic effect of Immunosuppressants (Miscellaneous Oncologic Agents). Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Miscellaneous Oncologic Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Immunosuppressants (Therapeutic Immunosuppressant Agents): May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Immunosuppressants (Therapeutic Immunosuppressant Agents) may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Lebrikizumab: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccine-associated infection may be increased. Lebrikizumab may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Leniolisib: May diminish the therapeutic effect of Vaccines (Live). Risk C: Monitor therapy

Methotrexate: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Methotrexate may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Ozanimod: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. The risk of developing a clinical infection from the live vaccine may be increased. Ozanimod may diminish the therapeutic effect of Varicella Virus-Containing Vaccines. Risk X: Avoid combination

Propacetamol: May diminish the therapeutic effect of Vaccines. Management: Consider avoiding routine prophylactic use of propacetamol before or during vaccine administration when possible. Propacetamol is still recommended to treat fevers and/or pain that occurs after vaccination. Risk D: Consider therapy modification

Rabies Immune Globulin (Human): May diminish the therapeutic effect of Vaccines (Live). Management: Avoid administering the measles vaccine within 4 months after administration of rabies immune globulin. Avoid administering other live vaccines within 3 months after administration of rabies immune globulin. Risk D: Consider therapy modification

Rho(D) Immune Globulin: May diminish the therapeutic effect of Varicella Virus Vaccine. Management: Do not delay administration of the varicella virus vaccine in women who have recently received Rho (D) immune globulin. If possible, women should be tested 3 or more months after vaccine administration to ensure immunity. Risk D: Consider therapy modification

Salicylates: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. Specifically, the risk for Reye's syndrome may increase. Risk X: Avoid combination

Smallpox Vaccine Live: May enhance the adverse/toxic effect of Varicella Virus Vaccine. It may be difficult to determine which vaccine caused skin lesions or other adverse effects. Management: Separate the administration of smallpox and varicella vaccines by at least 4 weeks. Risk D: Consider therapy modification

Teplizumab: May enhance the adverse/toxic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Specifically, the risk of vaccine-associated infection may be increased. Teplizumab may diminish the therapeutic effect of Mumps- Rubella- or Varicella-Containing Live Vaccines. Risk X: Avoid combination

Teplizumab: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of vaccines-associated infection may be increased. Teplizumab may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Tezepelumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination

Tildrakizumab: May enhance the adverse/toxic effect of Vaccines (Live). The risk for contracting an infection from the vaccine may be increased. Tildrakizumab may diminish the therapeutic effect of Vaccines (Live). Risk X: Avoid combination

Tralokinumab: May enhance the adverse/toxic effect of Vaccines (Live). Risk X: Avoid combination

Tuberculin Tests: Vaccines (Live) may diminish the diagnostic effect of Tuberculin Tests. Management: It is preferable to administer live vaccines simultaneously with tuberculin tests. If a live vaccine has been recently administered, the tuberculin skin test should be administered 4 to 6 weeks following the administration of the vaccine. Risk D: Consider therapy modification

Vaccines (Live): May diminish the therapeutic effect of other Vaccines (Live). Management: Two or more injectable or nasally administered live vaccines not administered on the same day should be separated by at least 28 days (ie, 4 weeks). If not, the vaccine administered second should be repeated at least 4 week later. Risk C: Monitor therapy

Reproductive Considerations

Varicella virus vaccine is contraindicated for use in patients planning to become pregnant within 3 months (per manufacturer labeling); pregnancy should be avoided for 1 month (per ACIP) following vaccination (CDC/ACIP [Marin 2007]).

Pregnancy Considerations

Varicella virus vaccine is contraindicated for use in pregnant patients.

Information related to pregnancy and fetal outcomes following inadvertent exposure to the varicella virus vaccine was collected from 1995-2013 using the manufacturer's pregnancy registry. Data was available from 905 women who received a varicella containing vaccine (30% within 3 months prior to conception) and who had known pregnancy outcomes. Among these women, the rates of miscarriage and birth defects was not increased above background rates, and there were no infants born with abnormalities consistent with congenital varicella syndrome. Postmarketing data collected since closure of the pregnancy registry has not detected new safety concerns or an increased risk of major birth defects following inadvertent varicella vaccine exposure during pregnancy (Woodward 2019).

Varicella disease during the first or second trimesters may result in congenital varicella syndrome. The onset of maternal varicella infection from 5 days prior to 2 days after delivery may cause varicella infection in the newborn. All women should be assessed for immunity during a prenatal visit; those without evidence of immunity should be vaccinated upon completion or termination of pregnancy (CDC/ACIP [Marin 2007]).

Although the pregnancy registry is closed, any exposures to the vaccine during pregnancy or within 3 months prior to pregnancy should be reported to the manufacturer (Merck & Co, 877-888-4231) or to VAERS (800-822-7967) as suspected adverse reactions.

Breastfeeding Considerations

It is not known if varicella virus vaccine is present in breast milk.

Following immunization, varicella virus was not detected in the milk samples of 12 breastfeeding women and none of the breastfed infants seroconverted (Bohlke 2003; CDC/ACIP [Marin 2007]). According to the manufacturer, the decision to breastfeed following immunization should consider the risk of infant exposure, the benefits of breastfeeding to the infant, and benefits of treatment to the mother. Guidelines note that immunization should not be delayed due to breastfeeding and vaccinated women may continue to breastfeed (CDC/ACIP [Marin 2007]). Breastfed infants should be vaccinated according to the recommended schedules (ACIP [Kroger 2023]).

Monitoring Parameters

Rash, fever; monitor for anaphylaxis and syncope for 15 minutes following administration (ACIP [Kroger 2023]). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.

Mechanism of Action

As a live, attenuated vaccine, varicella virus vaccine offers active immunity to disease caused by the varicella-zoster virus by inducing cell mediated and humoral immune responses

Pharmacokinetics (Adult Data Unless Noted)

Onset of action: Seroconversion occurred in 97% of healthy children ~4 to 6 weeks following a one dose regimen; using a two dose regimen, the seroconversion rate was 99.9% 6 weeks after the second dose. In adolescents≥13 years of age and adults, the seroconversion rate was ~75% 4 weeks after the first dose and 99% 4 weeks after the second dose

Duration: Antibody titers detectable at 10 years postvaccination. Actual antibody titers vary by year and age group, but are ~99% to 100% for children at 10 years and 100% for adolescents and adults at 6 years postvaccination. Exposure to wild-type varicella may boost antibody levels.

Brand Names: International
International Brand Names by Country
For country code abbreviations (show table)

  • (AE) United Arab Emirates: Varilrix | Varivax | Zostavax;
  • (AR) Argentina: Varilrix | Varivax | Zostavax;
  • (AT) Austria: Varilrix | Varivax;
  • (AU) Australia: Varilrix | Varivax ii | Varivax refrigerated | Zostavax;
  • (BD) Bangladesh: Varilrix;
  • (BE) Belgium: Provarivax | Varilrix | Varivax | Zostavax;
  • (BG) Bulgaria: Varivax;
  • (BR) Brazil: Vacina varicela (atenuada) | Varilrix | Zostavax;
  • (CH) Switzerland: Varilrix;
  • (CL) Chile: Varicela biken | Varilrix | Varivax | Zostavax;
  • (CN) China: Varilrix;
  • (CO) Colombia: Varilrix | Varivax | Zostavax;
  • (CZ) Czech Republic: Varilrix | Varivax | Zostavax;
  • (DE) Germany: Varilrix | Varilrix docpharm | Varivax;
  • (DO) Dominican Republic: Varilrix | Varivax;
  • (EC) Ecuador: Varilrix | Varivax;
  • (EE) Estonia: Varilrix | Varivax | Zostavax;
  • (EG) Egypt: Varilrix | Varivax;
  • (ES) Spain: Varilrix | Varivax | Zostavax;
  • (FI) Finland: Varilrix | Zostavax;
  • (FR) France: Varilrix | Varivax;
  • (GB) United Kingdom: Varilrix | Varivax | Zostavax;
  • (GR) Greece: Varilrix | Varivax | Zostavax;
  • (HK) Hong Kong: Varilrix | Zostavax;
  • (HR) Croatia: Varilrix;
  • (HU) Hungary: Varivax;
  • (ID) Indonesia: Okavax | Varicella vaccine | Varilrix | Varivax | Zostavax;
  • (IE) Ireland: Varivax;
  • (IL) Israel: Varilrix;
  • (IN) India: Varilrix | Variped | Varivax | Zostavax;
  • (IT) Italy: Varilrix | Varivax | Zostavax;
  • (JO) Jordan: Varivax;
  • (KE) Kenya: Varilrix;
  • (KR) Korea, Republic of: Vanrimune | Varicella biken | Varicella vaccine | Varicella zoster h | Varilrix | Varivax | Zostavax;
  • (KW) Kuwait: Varivax;
  • (LB) Lebanon: Varilrix | Varivax;
  • (LT) Lithuania: Varilrix | Varivax | Zostavax;
  • (LU) Luxembourg: Provarivax | Varilrix | Varivax;
  • (LV) Latvia: Varilrix | Varivax;
  • (MA) Morocco: Varilrix | Varivax;
  • (MX) Mexico: Varilrix | Varivax | Varivax iii | Zostavax;
  • (MY) Malaysia: Okavax | Varilrix | Varivax | Zostavax;
  • (NL) Netherlands: Provarivax | Zostavax;
  • (NO) Norway: Varilrix | Varivax | Zostavax;
  • (NZ) New Zealand: Varilrix | Varivax | Zostavax;
  • (PE) Peru: Varilrix | Varivax | Zostavax;
  • (PH) Philippines: Okavax | Varilrix | Zostavax;
  • (PK) Pakistan: Varilrix;
  • (PL) Poland: Varilrix | Varivax;
  • (PR) Puerto Rico: Varivax | Zostavax;
  • (PT) Portugal: Varilrix | Varivax | Zostavax;
  • (PY) Paraguay: Varilrix | Varivax;
  • (QA) Qatar: Varilrix | Varivax Refrigerated;
  • (RO) Romania: Varilrix | Varivax;
  • (RU) Russian Federation: Varilrix | Varivax;
  • (SA) Saudi Arabia: Varilrix | Varivax;
  • (SE) Sweden: Varilrix | Varivax | Zostavax;
  • (SG) Singapore: Varilrix | Varivax | Zostavax;
  • (SI) Slovenia: Varilrix | Zostavax;
  • (SK) Slovakia: Varivax | Zostavax;
  • (SV) El Salvador: Varivax;
  • (TH) Thailand: Varilrix | Varivax | Zostavax;
  • (TR) Turkey: Varilrix | Varivax | Zostavax;
  • (TW) Taiwan: Varilrix | Varivax;
  • (UY) Uruguay: Varilrix;
  • (VE) Venezuela, Bolivarian Republic of: Varilrix;
  • (ZA) South Africa: Onvara | Varilrix | Zostavax
  1. Bernstein HH, Rothstein EP, Watson BM, et al. Clinical Survey of Natural Varicella Compared With Breakthrough Varicella After Immunization With Live Attenuated Oka/Merck Varicella Vaccine. Pediatrics. 1993;92(6):833-837. [PubMed 8233746]
  2. Bohlke K, Galil K, Jackson LA, et al. Postpartum varicella vaccination: is the vaccine virus excreted in breast milk? Obstet Gynecol. 2003;102(5, pt 1):970-977. [PubMed 14672472]
  3. Centers for Disease Control and Prevention (CDC). Vaccination guidance during a pandemic. Updated October 20, 2020. https://www.cdc.gov/vaccines/pandemic-guidance/index.html
  4. Chaves SS, Gargiullo P, Zhang JX, et al. Loss of Vaccine-Induced Immunity to Varicella Over Time. N Engl J Med. 2007;356(11):1121-1129. [PubMed 17360990]
  5. Gaunt MJ, Cohen M, Bertagnoli S, Shastay A, eds. New error-prone situations after vaccines approved with prefilled diluent syringes. ISMP Medication Safety Alert! Community/Ambulatory Care Edition. 2023;22(10):1-3.
  6. Guffey DJ, Koch SB, Bomar L, Huang WW. Herpes zoster following varicella vaccination in children. Cutis. 2017;99(3):207-211. [PubMed 28398421]
  7. Krall P, Kubal A. Herpes zoster stromal keratitis after varicella vaccine booster in a pediatric patient. Cornea. 2014;33(9):988-989. [PubMed 25062334]
  8. Kroger A, Bahta L, Hunter P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Accessed April 30, 2021.
  9. Kroger A, Bahta L, Long S, Sanchez P. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf. Updated February 10, 2023. Accessed May 1, 2023.
  10. Kuter BJ, Weibel RE, Guess HA, et al. Oka/Merck Varicella Vaccine in Healthy Children: Final Report of a 2-Year Efficacy Study and 7-Year Follow-up Studies. Vaccine. 1991;9(9):643-647. [PubMed 1659052]
  11. Marin M, Guris 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. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm. [PubMed 17585291]
  12. National Advisory Committee on Immunization (NACI), "Active Vaccines: Varicella Vaccine,” from Public Health Agency of Canada, Ottawa, ONT: Minister of Public Works and Government Services Canada. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-24-varicella-chickenpox-vaccine.html. Accessed September 2017.
  13. Prymula R, Siegrist CA, Chlibek R, et al. Effect of Prophylactic Paracetamol Administration at Time of Vaccination on Febrile Reactions and Antibody Responses in Children: Two Open-Label, Randomised Controlled Trials. Lancet. 2009;374(9698):1339-1350. [PubMed 19837254]
  14. Refer to manufacturer's labeling.
  15. Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-e100. [PubMed 24311479]
  16. Song H, Morley KW, Trowbridge RM, et al. Herpes zoster at the vaccination site in immunized healthy children. Pediatr Dermatol. 2018;35(2):230-233. [PubMed 29405375]
  17. Tomblyn M, Chiller T, Einsele H et al. Guidelines for preventing infectious complications among hematopoietic cell transplant recipients: a global perspective. Biol Blood Marrow Transplant. 2009;15(10):1143-1238. doi:10.1016/j.bbmt.2009.06.019 [PubMed 19747629]
  18. Varilrix (varicella virus vaccine) [product monograph]. Mississauga, Ontario, Canada: GlaxoSmithKline Inc; August 2019.
  19. Varivax (varicella virus vaccine) [prescribing information]. Whitehouse Station, NJ: Merck & Co; August 2023.
  20. Varivax (varicella virus vaccine) [product monograph]. Kirkland, Quebec, Canada: Merck Canada Inc; February 2014.
  21. Varivax III (varicella virus vaccine) [product monograph]. Kirkland, Quebec, Canada: Merck Canada Inc; January 2023.
  22. Weinmann S, Chun C, Schmid DS, et al. Incidence and clinical characteristics of herpes zoster among children in the varicella vaccine era, 2005-2009. J Infect Dis. 2013;208(11):1859-1868. [PubMed 23922376]
  23. Woodward M, Marko A, Galea S, Eagel B, Straus W. Varicella virus vaccine live: a 22-year review of postmarketing safety data. Open Forum Infect Dis. 2019;6(8):ofz295. doi:10.1093/ofid/ofz295 [PubMed 31392326]
  24. World Health Organization (WHO). Guiding principles for immunization activities during the COVID-19 pandemic: interim guidance, 26 March 2020. Published March 26, 2020. https://apps.who.int/iris/handle/10665/331590
Topic 10038 Version 272.0

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