Transmission of Vaccine-Strain Varicella-Zoster Virus: A Systematic Review

We reviewed the published experience with the use of live VZV vaccines to assess characteristics of secondary transmission of the vaccine-strain virus. CONTEXT:Live vaccines usually provide robust immunity but can transmit the vaccine virus.OBJECTIVE:To assess the characteristics of secondary transmission of the vaccine-strain varicella-zoster virus (Oka strain; vOka) on the basis of the published experience with use of live varicella and zoster vaccines.DATA SOURCES:Systematic review of Medline, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and Scopus databases for articles published through 2018.STUDY SELECTION:Articles that reported original data on vOka transmission from persons who received vaccines containing the live attenuated varicella-zoster virus.DATA EXTRACTION:We abstracted data to describe vOka transmission by index patient's immune status, type (varicella or herpes zoster) and severity of illness, and whether transmission was laboratory confirmed.RESULTS:Twenty articles were included. We identified 13 patients with vOka varicella after transmission from 11 immunocompetent varicella vaccine recipients. In all instances, the vaccine recipient had a rash: 6 varicella-like and 5 herpes zoster. Transmission occurred mostly to household contacts. One additional case was not considered direct transmission from a vaccine recipient, but the mechanism was uncertain. Transmission from vaccinated immunocompromised children also occurred only if the vaccine recipient developed a rash postvaccination. Secondary cases of varicella caused by vOka were mild.LIMITATIONS:It is likely that other vOka transmission cases remain unpublished.CONCLUSIONS:Healthy, vaccinated persons have minimal risk for transmitting vOka to contacts and only if a rash is present. Our findings support the existing recommendations for routine varicella vaccination and the guidance that persons with vaccine-related rash avoid contact with susceptible persons at high risk for severe varicella complications.