The changing epidemiology of varicella and herpes zoster in Hong Kong before universal varicella vaccination in 2014

AbstractIn Hong Kong, universal varicella vaccination started in July 2014. Before this, children could receive varicella vaccine via the private market. We analysed the epidemiology of varicella and zoster before universal vaccination. We estimated varicella vaccination coverage through surveys in preschool children. We estimated the burden of varicella and zoster with varicella notifications from 1999/00 to 2013/14, Accident and Emergency Department (A&E) attendance and inpatient admissions to public hospitals from 2004/05 to 2013/14. We fitted a catalytic model to serological data on antibodies against varicella-zoster virus to estimate the force of infection. We found that varicella vaccination coverage gradually increased to about 50% before programme inception. In children younger than 5 years, the annual rate of varicella notifications, varicella admission and zoster A&E attendance generally declined. The annual notification, A&E attendance and hospitalisation rate of varicella and zoster generally increased for individuals between 10 and 59 years old. Varicella serology indicated an age shift during the study period towards a higher proportion of infections in slightly older individuals, but the change was most notable before vaccine licensure. In conclusion, we observed a shift in the burden of varicella to slightly older age groups with a corresponding increase in incidence but it cannot necessarily be attributed to private market vaccine coverage alone. Increasing varicella vaccination uptake in the private market might affect varicella transmission and epidemiology, but not to the level of interrupting transmission.

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Universal varicella vaccination in the Sicilian paediatric population: rapid uptake of the vaccination programme and morbidity trends over five years

Eurosurveillance ◽

10.2807/ese.14.35.19321-en ◽

2009 ◽

Vol 14 (35) ◽

Author(s):

G Giammanco ◽

S Ciriminna ◽

I Barberi ◽

L Titone ◽

M Lo Giudice ◽

...

Keyword(s):

Vaccination Programme ◽

Vaccine Coverage ◽

Varicella Vaccine ◽

Age Groups ◽

Vaccination Strategy ◽

Paediatric Population ◽

Incidence Rates ◽

Universal Vaccination ◽

Varicella Vaccination ◽

Local Health

Following the licensure of the Oka/Merck varicella vaccine in Italy in January 2003, the Sicilian health authorities launched a universal vaccination programme in all nine Local Health Units. A two-cohort vaccination strategy was adopted to minimise the shift of the mean age of varicella occurrence to older age groups, with the goal of vaccinating with one dose at least 80% of children in their second year of life and 50% of susceptible adolescents in their 12th year of life. Two studies were implemented in parallel to closely monitor vaccination coverage as well as varicella incidence. Overall, the programme achieved its target, with 87.5% vaccine coverage for the birth cohort 2005 and 90.2% for adolescents born in 1995 and 1996. Varicella surveillance data obtained from a total of 28,188 children (0-14 years-old) monitored by family paediatricians showed a decline in incidence rates from 95.7 (95% confidence interval (CI): 72.2-126.8) for 1,000 person-years (PY) in 2004 to 9.0 (95% CI: 6.4-12.6) for 1,000 PY in 2007. In Europe, the only similar experience is the routine childhood varicella vaccination programme in Germany that started in 2004 with a single dose at the age of 11-14 months. The two-cohort universal vaccination programme implemented in Sicily, as well as the network for the surveillance study, can offer a model to other European countries that are considering introducing universal childhood varicella vaccination.

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Modelling the impact of varicella vaccination on varicella and zoster

Epidemiology and Infection ◽

10.1017/s0950268809990768 ◽

2009 ◽

Vol 138 (4) ◽

pp. 469-481 ◽

Cited By ~ 38

Author(s):

M. KARHUNEN ◽

T. LEINO ◽

H. SALO ◽

I. DAVIDKIN ◽

T. KILPI ◽

...

Keyword(s):

Large Scale ◽

Vaccine Coverage ◽

Varicella Vaccine ◽

Age Groups ◽

Varicella Vaccination ◽

Negative Consequences ◽

Serological Data ◽

Notification Data ◽

The Impact ◽

Case Notification

SUMMARYIt has been suggested that the incidence of herpes zoster may increase due to lack of natural boosting under large-scale vaccination with the varicella vaccine. To study the possibility and magnitude of such negative consequences of mass vaccination, we built a mathematical model of varicella and zoster epidemiology in the Finnish population. The model was based on serological data on varicella infection, case-notification data on zoster, and new knowledge about close contacts relevant to transmission of infection. According to the analysis, a childhood programme against varicella will increase the incidence of zoster by one to more than two thirds in the next 50 years. This will be due to increase in case numbers in the ⩾35 years age groups. However, high vaccine coverage and a two-dose programme will be very effective in stopping varicella transmission in the population.

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Varicella Vaccination Coverage among Adolescents Ages 13–17 Years, United States, National Immunization Survey, 2007–2014

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.765 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S324-S325

Author(s):

Jessica Leung ◽

Sarah Reagan-Steiner ◽

Adriana S Lopez ◽

Jenny Jeyarajah ◽

Mona Marin

Keyword(s):

Vaccination Coverage ◽

Varicella Vaccine ◽

Age Groups ◽

Varicella Vaccination ◽

Missed Opportunities ◽

National Immunization ◽

Adolescents And Adults ◽

Catch Up ◽

Well Child Visit ◽

To Receive

Abstract Background Varicella is typically a self-limiting disease but it can be more severe in adolescents and adults. In 2007, 2-doses of varicella vaccine were routinely recommended for children, with a catch-up second dose for persons who received 1 prior dose. Methods We used 2007–2014 NIS-Teen data to examine trends in ≥2 dose varicella vaccination coverage and proportions of adolescents with/without evidence of immunity to varicella. Evidence of immunity included receipt of ≥2 doses of varicella vaccine or varicella disease history. Additionally, using 2014 data, we assessed characteristics of ≥2 dose varicella vaccination coverage: 1) factors associated with ≥2 dose vaccination, 2) timing of receipt of second dose and 3) missed opportunities for second dose vaccination among adolescents who had received 1 prior dose of varicella vaccine. Results During 2007–2014, the proportion of adolescents with ≥2 doses of varicella vaccine increased from 8.3% to 66.9% in 13–15 year olds, and from 3.6% to 56.7% in 16–17 year olds. The proportion of adolescents with evidence of varicella immunity also increased for both age groups, from 68.0% to 84.1% in 13–15 year olds and from 78.6% to 83.4% in 16–17 year olds. Among adolescents who received ≥2 doses of varicella vaccine by 2014, a higher proportion of 13–15 year olds received their second dose at 4–6 years compared with 16–17 year olds (13.4% vs. 3.2%). Factors significantly associated with lower ≥2 dose coverage included non-Hispanic White race/ethnicity; rural residence; living at >133% of the income-to-poverty ratio; no 11- to 12-year well-child visit; not receiving an adolescent vaccine; and residence in a state with no 2-dose immunization school entry requirement. Among the 2,478 adolescents who received only 1-dose of varicella vaccine, 77.1% (1,922) had at least 1 missed opportunity to receive their second dose; potentially 2-dose coverage could have increased from 79.5% to 94.8%. Conclusion The ≥2-dose varicella vaccination coverage and the proportion of adolescents with evidence of immunity to varicella increased during 2007 to 2014, though 16% lacked evidence of immunity in 2014. Though catch-up campaigns have succeeded, decreasing missed vaccination opportunities will help with further improvement. Disclosures All authors: No reported disclosures.

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2767. Variation in Incidence of Pediatric Herpes Zoster by First- and Second-Dose Varicella Vaccine Formulations

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2444 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S975-S976

Author(s):

Sheila Weinmann ◽

Stephanie Irving ◽

Padma Koppolu ◽

Allison Naleway ◽

Edward Belongia ◽

...

Keyword(s):

Herpes Zoster ◽

Varicella Vaccine ◽

Vaccine Dose ◽

Varicella Vaccination ◽

Vaccine Formulation ◽

Wild Type ◽

Varicella Zoster ◽

Dose Formulation ◽

Using Data ◽

Rate Ratios

Abstract Background Varicella (VAR) and measles-mumps-rubella (MMR) vaccines are recommended for children at ages 12–15 months and 4–6 years. These are administered as separate MMR and VAR vaccines (MMR+VAR) or as combined measles-mumps-rubella-varicella (MMRV) vaccine. Herpes zoster (HZ), caused by wild-type or vaccine-strain varicella-zoster virus, can occur in children after varicella vaccination. It is unknown whether HZ incidence after varicella vaccination varies by vaccine formulation or simultaneous receipt of MMR. Methods Using data from six integrated health systems, we examined HZ incidence among children who turned 12 months old during 2003–2008 and received varicella and MMR vaccines according to routine recommendations. All HZ cases ≥ 21 days after first varicella vaccination were identified using ICD-9 codes from inpatient, outpatient, emergency room encounters, and claims data, through 2014. HZ incidence was examined by vaccine formulation (MMR+VAR, MMRV, or VAR without same-day MMR) and doses received and compared using incidence rate ratios (IRR). Results Among 199,797 children, we identified 601 HZ cases. Crude HZ incidence after first-dose MMR+VAR (18.6 [95% CI 11.1–29.2] cases/100,000 person-years) was similar to the rate after first-dose MMRV (17.9 [95% CI 10.6–28.3] cases/100,000 person-years), but approximately double the rate among those with first-dose VAR without same-day MMR (7.5 [95% CI 3.1–15.0] cases/100,000 person-years); see Table 1. The IRR for HZ after first-dose MMR+VAR or MMRV, compared with VAR, was 2.5 (95% CI 1.4–4.4; P = 0.002). When examining any first or second dose formulation, crude HZ incidence was lower after the second varicella vaccine dose (13.9 cases/100,000 person-years), than in the period before the second dose (i.e., between first and second doses or after the first dose in children with only one dose; 21.8 cases/100,000 person-years, P < 0.0001). HZ incidence was also lower after two varicella vaccine doses in each of the three first-dose formulation groups. Conclusion HZ incidence among children varied by first-dose varicella vaccine formulation and number of varicella vaccine doses. Regardless of the first-dose varicella vaccine formulation, children who received two vaccine doses had lower HZ incidence after the second dose. Disclosures All authors: No reported disclosures.

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Seroepidemiology of varicella-zoster virus in Korean adolescents and adults using fluorescent antibody to membrane antigen test

Epidemiology and Infection ◽

10.1017/s0950268814002441 ◽

2014 ◽

Vol 143 (8) ◽

pp. 1643-1650 ◽

Cited By ~ 3

Author(s):

S. B. HAN ◽

K. R. KANG ◽

D. H. HUH ◽

H. C. LEE ◽

J. H. KIM ◽

...

Keyword(s):

Varicella Zoster Virus ◽

Fluorescent Antibody ◽

Age Groups ◽

Varicella Vaccination ◽

Enzyme Linked Immunosorbent Assay ◽

Study Cohort ◽

Cross Sectional ◽

Entire Study ◽

Varicella Zoster ◽

Adolescents And Adults

SUMMARYWe conducted a cross-sectional seroepidemiological study in 2012–2013 to determine the seroprevalence of varicella-zoster virus (VZV) in adolescents and adults living in Korea, where varicella vaccination has been recommended universally at age 12–15 months since 2005. Residual serum samples were collected from 1196 healthy adults and adolescents aged ⩾10 years between November 2012 and March 2013. The fluorescent antibody to membrane antigen (FAMA) test and enzyme-linked immunosorbent assay (ELISA) were performed to determine the seroprevalence of VZV. The seroprevalences of VZV were compared between six age groups: 10–19, 20–29, 30–39, 40–49, 50–59, and ⩾60 years. The seroprevalence of VZV in the entire study cohort was 99·1% according to the FAMA test and 93·1% as determined by ELISA. The seroprevalences of the six age groups were as follows: 96·0%, 99·5%, 99·5%, 99·5%, 100%, and 100%, respectively, by the FAMA test, and 83·3%, 93·0%, 93·0%, 97·5%, 94·5%, and 97·5%, respectively, by ELISA. Seroprevalence increased significantly with age (P< 0·001); moreover, the seroprevalence in subjects aged 10–19 years was significantly lower than in other age groups (P< 0·001), as measured by both the FAMA test and ELISA. Thus, strategies to increase protective immunity against VZV in teenagers are necessary.

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Validity of Self-Reported Varicella Disease History in Pregnant Women Attending Prenatal Clinics

Public Health Reports ◽

10.1177/003335490712200411 ◽

2007 ◽

Vol 122 (4) ◽

pp. 499-506 ◽

Cited By ~ 18

Author(s):

Barbara Watson ◽

Rachel Civen ◽

Meredith Reynolds ◽

Karl Heath ◽

Dana Perella ◽

...

Keyword(s):

Pregnant Women ◽

Strong Predictor ◽

Varicella Vaccine ◽

Routine Care ◽

Varicella Vaccination ◽

Enzyme Linked Immunosorbent Assay ◽

Igg Antibodies ◽

Serological Evidence ◽

Varicella Zoster ◽

Cell Enzyme

Objective. The purpose of this study was to assess the validity of self-reported history for varicella disease relative to serological evidence of varicella immunity in pregnant women attending antenatal care at clinics located in two diverse geographical locations in the U.S. (Antelope Valley, California, and Philadelphia) with high varicella vaccination coverage. Methods. Pregnant women attending prenatal care appointments who needed blood drawn as part of their routine care were eligible to participate. Self-reported varicella disease history was obtained via questionnaire. Varicella serostatus was determined using a whole-cell enzyme-linked immunosorbent assay to test for varicella zoster virus-specific immunoglobulin G (VZV IgG) antibodies. Results. Of the 309 study participants from Antelope Valley and the 528 participants from Philadelphia who self-reported having had chickenpox disease, 308 (99.7%; 95% confidence interval [CI]: 98.2, 100) and 517 (97.9%; 95% CI: 96.3, 99.0), respectively, had serological evidence of immunity to varicella. Only 6.8% (95% CI: 3.9, 11.0) and 17.4% (95% CI: 13.1, 22.5) of women who self-reported having a negative or uncertain varicella disease history in Antelope Valley and Philadelphia, respectively, were seronegative for varicella antibodies. Conclusion. Despite the dramatic changes in the epidemiology of varicella that have occurred since 1995 due to the introduction and subsequent widespread use of the varicella vaccine, self-reported history of varicella continues to be a strong predictor of VZV IgG antibodies in pregnant women. Negative or uncertain history remains poorly predictive of negative serostatus.

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Varicella vaccination as useful strategy for reducing the risk of varicella-related hospitalizations

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.1258 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

A Marrella ◽

A Casuccio ◽

E Amodio ◽

F Vitale

Keyword(s):

Vaccination Coverage ◽

Age Groups ◽

Incidence Rates ◽

Varicella Vaccination ◽

Age Group ◽

Annual Percent Change ◽

High Coverage ◽

Joint Point ◽

Hospitalization Rates ◽

The Impact

Abstract Introduction The present study summarizes evidences of the impact of varicella vaccination (VV) on hospitalization rates attributable to this infectious disease in Italy. Methods We have carried out a retrospective observational study that analysed hospital discharge records and VV coverage at 24 months collected from 2003 to 2018 by the Italian Health Ministry. All hospitalizations with the presence of an ICD-9 CM 059.X code in the principal diagnosis or in any of the five secondary diagnoses were considered as related to varicella. The hospitalization rate reduction was evaluated by calculating average annual percent change (AAPC) through joint-point analysis. Results Hospitalization rates showed a decreasing risk by age: children aged <1 year were the most affected age group in each region (42.56/100,000 per year), whereas lower incidence rates were found in older age groups (23.76/100,000 in 1 to 5 years age group and <4/100,000 in the following groups). Varicella hospitalization rates decreased significantly after the introduction of VV (3.42 vs. 2.67 per 100,000; P < 0.001). During the first five years after vaccination introduction hospitalization rates showed a statistically significant decrease especially for infants aged <1 year (AAPC -34.98%; p < 0.001) and 1 to 5 years old (AAPC -35.22%; P < 0.01). VV coverage was strongly correlated with hospitalization rates decrease over each paediatric age group (R-squared 0.38 in aged <1 year, p < 0.001; 0.71 in 1 to 5 years old, p < 0.001; 0.93 in 6 to 14 years old, p < 0.0001). Conclusions All the previously reported findings confirm that hospitalization rates are strictly related to both the number of years since vaccination introduction and the vaccination coverage. VV confirms to be an important step in public health strategies and the introduction of universal vaccination, with high vaccination coverage, should be considered as an extremely powerful tool for reducing the risk of complications. Key messages This study adds update findings to the literature and shows that varicella hospitalizations in Italy, from 2003 to 2018, have reduced their burden, that was high in years before varicella vaccination. Varicella vaccination introduction and high coverage are powerful tools for reducing the risk of varicella complications and related hospitalizations in the general population.

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Evaluation of Varicella Zoster Prophylaxis after Allogeneic Hematopoietic Cell Transplantation Using Valacyclovir Followed By Vaccination

Blood ◽

10.1182/blood.v126.23.1963.1963 ◽

2015 ◽

Vol 126 (23) ◽

pp. 1963-1963

Author(s):

Kareem Jamani ◽

Andrew Daly ◽

Jan Storek

Keyword(s):

Competing Risks ◽

Cumulative Incidence ◽

Hematopoietic Cell Transplantation ◽

Conflicts Of Interest ◽

Varicella Vaccine ◽

Varicella Vaccination ◽

Strategy Group ◽

Cns Disease ◽

Varicella Zoster ◽

New Strategy

Rationale: Varicella zoster virus (VZV) disease occurs frequently post allo-HCT. While cutaneous disease is often complicated by debilitating post-herpetic neuralgia (PHN), visceral or CNS disease can be fatal. Studies have demonstrated that VZV disease is reduced during prophylaxis with acyclovir; however, patients frequently develop VZV disease after discontinuation of acyclovir. Recently, the varicella vaccine has been found to be safe and immunogenic post allo-HCT. The optimal prophylactic strategy for VZV disease post allo-HCT has not been established. Here we present a retrospective single-center study, comparing pre-2007 prophylaxis, which consisted of less than 2 years of post allo-HCT acyclovir, with post-2007 prophylaxis, which consisted of 2 years of valacyclovir prophylaxis followed by live attenuated varicella vaccination. Objective: To evaluate the hypothesis that the cohort treated with the pre-2007 strategy ("old strategy") had a higher cumulative incidence of VZV disease and PHN compared to the cohort treated with the post-2007 strategy ("new strategy"). Methodology: Charts of patients undergoing allo-HCT in Calgary between January 2004 and June 2011 were reviewed. VZV disease was defined as clinical zoster or visceral/CNS disease confirmed by immunostain or PCR. PHN was defined as pain in the affected dermatome persisting more than 3 months after the onset of the rash. Cumulative incidence of VZV disease and PHN were compared using competing risks regression (Fine-Gray), treating relapse, graft failure, second malignancy and death as competing risks. Results: 482 patients underwent first allo-HCT in Calgary during the review period. 21 were excluded due to inadequate data. 119 were treated with the new strategy, 116 with the old strategy and 226 experienced a competing event while on prophylaxis. Some patients in the old strategy group received late VZV vaccination (at >2 years). The old strategy was associated with a trend towards higher cumulative incidence of VZV disease (sHR 1.57, 95% CI 0.95-2.62, p=0.08) and with significantly higher cumulative incidence of PHN (sHR 9.94, 95% CI 1.24-80.05, p=0.03). 3 episodes of VZV disease in the old strategy group and 7 episodes in the new strategy group were associated with deviation from protocol (most associated with medication noncompliance). When events associated with protocol deviation were excluded, the old strategy led to a significantly higher cumulative incidence of VZV disease (HR 2.40, 95% CI 1.32-4.38, p=0.004) and PHN was not observed in the new group (p= <0.01). Vaccination was safe; however 10% of patients developed immediate or late cutaneous VZV disease. PHN was not observed in the patients who developed the VZV disease post vaccination. Conclusions: The new strategy was associated with a trend towards less VZV disease and significantly less PHN. Noncompliance was a significant contributor to VZV disease in the new strategy group. If compliance is ensured, the new strategy significantly reduces VZV disease and eliminates PHN. Disclosures No relevant conflicts of interest to declare.

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P033 POPULATION-LEVEL HPV VACCINATION COVERAGE AMONG U.S. ADULT IBD PATIENTS: STILL NOT ENOUGH

Inflammatory Bowel Diseases ◽

10.1093/ibd/zaa010.167 ◽

2020 ◽

Vol 26 (Supplement_1) ◽

pp. S65-S65

Author(s):

Ryan Suk ◽

Heetae Suk ◽

Keith Sigel ◽

Kalyani Sonawane ◽

Ashish Deshmukh

Keyword(s):

Vaccination Coverage ◽

Hpv Vaccine ◽

Vaccine Coverage ◽

Hpv Vaccination ◽

Age Groups ◽

Population Level ◽

Vaccine Uptake ◽

Population Estimate ◽

Age Group ◽

Old Patients

Abstract Background Evidence suggests that the inflammatory bowel disease (IBD) patients may have an elevated risk of Human papillomavirus (HPV)-associated cancers when compared with those without IBD. HPV vaccination has been recommended for 11 to 26 years old males and females. Recently, the Centers for Disease Control and Prevention (CDC) has updated the guideline to include adults aged 27 to 45 who are not adequately vaccinated. To the best of our knowledge, population-level HPV vaccine uptake rates among patients with IBD remains unknown. Methods We used 2015–2016 National Health Information Survey (NHIS) data to assess the HPV vaccination coverage among people with IBD in the US. Weighted counts and percentages were estimated using survey design for the population-level results. We identified those who reportedly were told by a doctor or healthcare professional that they have IBD. Then we stratified the patients into two age groups: HPV-vaccine eligible age group (age 18–26) and newly approved age group (age 27–45). Our outcome was vaccine coverage status assessed as vaccine initiation age and number of doses. When the initiation age was less than 15, two doses were defined as “completed” and when the age was 15 and older, three doses were defined as “completed”. When the participants had initiated the vaccine but have not completed all the required doses according to their initiation age, it was defined as “incomplete” while no dose was defined as “no vaccine”. We estimated the coverage rate by age group and sex. We used Wald chi-square test to examine differences in completion rate by sex. Results We identified 951 participants (population estimate: 3,121,387) who self-reportedly had IBD. Among those, 51 persons (population estimate: 191,830) were HPV vaccine-eligible aged and 219 persons (population estimate: 859,711) were newly approved aged. Only 3.2% men while 63.2% of eligible women completed vaccination series as recommended. Eligible men had higher rates of incompletion compared to women (13.8% vs 1.3%). A higher proportion of vaccine-eligible men (83.0%) did not initiate the HPV vaccine compared to women (35.5%) (p=0.001). Among the newly approved age group, only 0.5% of men completed vaccine and 1.3% did not complete their doses. In women, 2.3% was complete with the doses and 9.6% initiated but did not complete the vaccine (p <0.001). Conclusion IBD patients might greatly benefit from receiving HPV vaccination given the possibly high risk of HPV-associated cancers. However, the coverage for vaccine-eligible IBD patients was not enough and much lower than the goal of 80% coverage in Healthy People 2020. Moreover, according to the updated guideline, 27 to 45 years old patients who are not adequately vaccinated would be able to catch up their vaccination. Further study needs to be focused on promoting and informing HPV vaccination in IBD patients, for both currently vaccine-eligible patients and those who are aged between 27 and 45 and not adequately vaccinated.

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Vaccination to prevent varicella

Human & Experimental Toxicology ◽

10.1177/0960327113512340 ◽

2013 ◽

Vol 33 (8) ◽

pp. 886-893 ◽

Cited By ~ 2

Author(s):

GS Goldman ◽

PG King

Keyword(s):

United States ◽

Varicella Vaccine ◽

Cost Effective ◽

Target Population ◽

The United States ◽

Incidence Rates ◽

Varicella Vaccination ◽

Cell Mediated Immunity ◽

Varicella Zoster ◽

Control And Prevention

Background: There is increasing evidence that herpes zoster (HZ) incidence rates among children and adults (aged <60 years) with a history of natural varicella are influenced primarily by the frequency of exogenous exposures, while asymptomatic endogenous reactivations help to cap the rate at approximately 550 cases/100,000 person-years when exogenous boosting becomes rare. The Antelope Valley Varicella Active Surveillance Project was funded by the Centers for Disease Control and Prevention in 1995 to monitor the effects of varicella vaccination in one of the three representative regions of the United States. The stability in the data collection and number of reporting sites under varicella surveillance from 1995–2002 and HZ surveillance during 2000–2001 and 2006–2007 contributed to the robustness of the discerned trends. Discussion: Varicella vaccination may be useful for leukemic children; however, the target population in the United States is all children. Since the varicella vaccine inoculates its recipients with live, attenuated varicella–zoster virus (VZV), clinical varicella cases have dramatically declined. Declining exogenous exposures (boosts) from children shedding natural VZV have caused waning cell-mediated immunity. Thus, the protection provided by varicella vaccination is neither lifelong nor complete. Moreover, dramatic increases in the incidence of adult shingles cases have been observed since HZ was added to the surveillance in 2000. In 2013, this topic is still debated and remains controversial in the United States. Summary: When the costs of the booster dose for varicella and the increased shingles recurrences are included, the universal varicella vaccination program is neither effective nor cost-effective.

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