“Oh, don’t be so nervous,” Virginia’s mom said to the apprehensive ten-year-old. “I already promised you that you wouldn’t be getting any shots today. This is just your annual physical. So please answer all of the doctor’s questions.” Up until that time Virginia was a bit quiet and not very conversant, simply answering my questions with guarded, one-word responses. After her mom made that proclamation Virginia opened up and was the pleasant cheerful girl I had known over the years. She became animated. Her eyes lit up as she told me about how well she was doing in dance and soccer. The exam went well, and I told her she couldn’t be any healthier.
When the nurse knocked on the door and walked in a panicked look loomed over Virginia’s face. I was handed a lab slip with the results of her urinalysis--all completely normal. Virginia exhaled a sigh of relief. Mom again stated, “Would you please relax. We are almost done and you are NOT getting any shots!” She went on to explain, “Every time the door opens or she sees a nurse Virginia is convinced that she’s being set up for a shot.” My nurse smiled and didn’t say anything which elevated the level of anxiety in the room. There followed a brief period of silence which must have been painful for Virginia as the color left her face. She looked at her mom almost with contempt.
At this point I intervened. Virginia would definitely NOT be getting any shots today. But I did continue to tell her that things had changed recently. She would need another chicken pox vaccine, but we just wouldn’t do it today. The color returned to her cheeks and we finished the exam without incident.
Until very recently, the schedule for the chicken pox vaccines was as such: the Varivax vaccine was given at one year of age. For those children not immunized up until 12 years of age one Varivax was needed. For those individuals 12 years of age and older who had not been immunized, two Varivax vaccines were needed at least one month apart. This was the routine immunization schedule since the Varivax had been licensed and used.
Over the years it was discovered that of those patients who had received only one Varivax vaccine, as many as 15 percent or more were found to get chicken pox as they got older. Some reached young adulthood and had severe cases of chicken pox with serious complications. It is widely known that chicken pox can be a devastating disease in older patients.
This year the American Academy of Pediatrics adopted the recommendations of the Advisory Committee on Immunization Practices. This states that anyone who has had only one Varivax vaccine should receive a second vaccine to enhance their chances of being fully protected. The exception to this would be an individual who had only one vaccine but subsequently got a mild case of chicken pox or developed a case of shingles. It is safely assumed that in these cases the patient would have sufficient natural antibodies to protect them in the future. As it now stands, the immunization schedule will call for a Varivax at one year of age followed by another between 4-6 years of age, usually given before kindergarten entrance.
It is important to note that this second vaccine is NOT a booster. It is merely to pick up those individuals who did not mount a protective response with a single vaccine. This is the same situation with the MMR, measles, mumps and rubella, vaccine. We have known for years that a single MMR vaccine provides protection for around 94-96 percent. Although this is good, it was recommended to give a second MMR to capture the 4-6 percent who were not fully protected. For years now we have been giving the MMR at one year of age, and a second at around age five. This has proven to be extremely successful. The Varivax will now follow the same schedule, hopefully with the same success.
If a young person had only one Varivax, and the parents think that he or she might have had a mild case of chicken pox but aren’t entirely sure, a blood test can be done to determine the exact status of his protection. Varicella titers measure the immunoglobulins lgM and lgG. When a person has had a case of chicken pox or has received the vaccine with a good response, the level of lgG will be high. This will remain elevated for the rest of his life. This is what prevents him from getting chicken pox again. In certain cases it might be reasonable to measure Varicella titers before giving the second Varivax vaccine.
Getting back to Virginia--she was thrilled to learn that IN FACT she would not get any shots. I had to confess that I was not being magnanimous in not giving her a shot. The truth of the matter was that our office was out of the vaccine, and that it was on back order. Since the new guidelines came out to give the second Varivax, demand for the vaccine has been incredible. We have had to change the way it is ordered. Mom chuckled, and Virginia could not have cared less as long as she was granted a reprieve from the dreaded shot. We agreed that she would stop by the office the following Saturday on the way home from her soccer game, just to get the vaccine. She was perfectly amenable with that.