Varicella Virus Vaccine
(var i SEL a VYE rus vak SEEN)
- Chickenpox Vaccine
- Varicella-Zoster Virus (VZV) Vaccine (Varicella)
- VZV Vaccine (Varicella)
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)
Brand Names: U.S.
- Vaccine, Live (Viral)
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
Onset of Action
Seroconversion occurred in 97% of healthy children ~4-6 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 of Action
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.
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 women of childbearing age
• 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.
Off Label Uses
Varicella postexposure prophylaxis
Based on the Centers for Disease Control and Prevention "Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP)", varicella virus vaccine given within 3 days (possibly 5 days) after exposure to varicella rash is effective in preventing illness or modifying severity of disease in persons without other evidence of immunity.
Severe allergic or anaphylactic reaction to the vaccine, neomycin, gelatin, or any component of the formulation; immunosuppressed or immunodeficient individuals including individuals with leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic systems; persons with AIDs or other clinical manifestations of HIV; those receiving immunosuppressive therapy (including immunosuppressive doses of corticosteroids); history of primary and acquired immunodeficiency states; active, untreated tuberculosis; current febrile illness (per manufacturer labeling); pregnancy
Canadian labeling: Additional contraindications (not in US labeling): Varivax III: 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
Varicella immunization: SubQ:
US labeling: Two doses of 0.5 mL 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 vaccine receive a second dose (CDC/ACIP [Marin 2007]).
Canadian labeling: Two single doses 0.5 mL separated by 4 to 8 weeks (Varivax III) or ≥6 weeks (Varilrix); 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 (NACI 2016).
Postexposure prophylaxis (healthy, previously unvaccinated individuals) (off-label use): SubQ: 0.5 mL administered ideally within 72 hours postexposure but may be used up to 120 hours (5 days) postexposure (CDC/ACIP [Marin 2007])
Refer to adult dosing.
Varicella immunization: SubQ:
Children ≥12 months: 0.5 mL; a second dose may be administered ≥3 months later
Note: The ACIP recommends the routine childhood vaccination be 2 doses, with the first dose administered at 12 to 15 months of age. The second dose should be administered at 4 to 6 years of age before school entry, but it may be administered earlier provided ≥3 months have elapsed after the first dose. Children ≥ 7 years and adolescents who received only 1 dose of vaccine should receive a second dose. If the second dose was administered ≥4 weeks after the first dose, it may be considered as valid (ACIP [Marin 2007]).
Adolescents ≥13 years: Refer to adult dosing.
Children ≥12 months:
Varilrix: Two doses of 0.5 mL separated by ≥6 weeks
Varivax III: 0.5 mL as a single dose
Alternative recommendations (NACI 2016): Two 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.
Adolescents ≥13 years: Refer to adult dosing.
Postexposure prophylaxis (healthy, previously unvaccinated individuals) (off-label use): Children ≥12 months and Adolescents: SubQ: 0.5 mL administered ideally within 72 hours postexposure but may be used up to 120 hours (5 days) postexposure (CDC/ACIP [Marin 2007])
Dosing: Renal Impairment
There are no dosage adjustments provided in the manufacturer's labeling
Dosing: Hepatic Impairment
There are no dosage adjustments provided in the manufacturer's labeling
Use the total volume of the provided diluent to reconstitute vaccine. Gently agitate to mix thoroughly. (Total volume of reconstituted vaccine will be ~0.5 mL.) Administer vaccine within 30 minutes of preparation (90 minutes for Varilrix [Canadian product]).
For SubQ injection only; inject in the outer aspect of upper arm or the anterolateral thigh. Do not administer IV or IM. Administer immediately following reconstitution. Varilrix (Canadian product) is to be administered in the deltoid region only. Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection (ACIP [Kroger 2017]). To prevent syncope related injuries, adolescents and adults should be vaccinated while seated or lying down (ACIP [Kroger 2017]). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering person's name, title, and address be entered into the patient's permanent medical record.
Prior to reconstitution and during shipping, store vaccine in freezer at -50°C to -15°C (-58°F to 5°F). Use of dry ice may subject vaccine to temperatures colder than -58°F (-50°C). Vaccine may be stored under refrigeration at 2°C to 8°C (36°F to 46°F) for up to 72 hours. Protect from light. Store diluent at room temperature of 20°C to 25°C (68°F to 77°F) or in refrigerator. Gently agitate to mix thoroughly. (Total volume of reconstituted vaccine will be ~0.5 mL.) Administer immediately following reconstitution, discard reconstituted vaccine if not used within 30 minutes.
Varilrix (Canadian product): Prior to reconstitution, store vaccine under refrigeration at 2°C to 8°C (36°F to 46°F). Vaccine not affected by freezing. Store diluent at 25°C (77°F) or under refrigeration. Following reconstitution, vaccine may be stored for 90 minutes at 25°C (77°F) or up to 8 hours under refrigeration. Discard if not used within recommended times.
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. 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. Avoid combination
Axicabtagene Ciloleucel: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of infection may be increased. Axicabtagene Ciloleucel may diminish the therapeutic effect of Vaccines (Live). Management: Avoid live virus vaccines for at least 6 weeks prior to initiation of lymphodepleting therapy, during axicabtagene ciloleucel infusion, and after treatment until full immune recovery is achieved. Consider therapy modification
AzaTHIOprine: May enhance the adverse/toxic effect of Vaccines (Live). AzaTHIOprine may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose azathioprine (3 mg/kg/day or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns and is not a contraindication for administration of zoster vaccine. Higher doses of azathioprine should be avoided. Consider therapy modification
Belimumab: May enhance the adverse/toxic effect of Vaccines (Live). Avoid combination
Corticosteroids (Systemic): May enhance the adverse/toxic effect of Vaccines (Live). Corticosteroids (Systemic) may diminish the therapeutic effect of Vaccines (Live). Management: Doses equivalent to less than 2 mg/kg or 20 mg per day of prednisone administered for less than 2 weeks are not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses and longer durations should be avoided. Consider therapy modification
Daclizumab: May enhance the adverse/toxic effect of Vaccines (Live). Daclizumab may diminish the therapeutic effect of Vaccines (Live). 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: Canadian labeling for dimethyl fumarate states that live attenuated vaccine administration is not recommended during treatment. U.S. labeling does not mention this. Consider therapy modification
Dupilumab: May enhance the adverse/toxic effect of Vaccines (Live). 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. Avoid combination
Fingolimod: May enhance the adverse/toxic effect of Vaccines (Live). Vaccinal infections may develop. Fingolimod may diminish the therapeutic effect of Vaccines (Live). Avoid combination
Immune Globulins: May diminish the therapeutic effect of Vaccines (Live). Management: Consult full interaction monograph for dose interval recommendations. This interaction does not apply to oral Ty21a typhoid vaccine or others listed as exceptions. Consider therapy modification
Immunosuppressants: May enhance the adverse/toxic effect of Vaccines (Live). Immunosuppressants may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live organism vaccines with immunosuppressants; live-attenuated vaccines should not be given for at least 3 months after immunosuppressants. Exceptions: AzaTHIOprine; Beclomethasone (Oral Inhalation); Betamethasone (Systemic); Budesonide (Systemic); Corticotropin; Cortisone; Cytarabine (Liposomal); Deflazacort; Dexamethasone (Systemic); Fludrocortisone; Fluticasone (Oral Inhalation); Hydrocortisone (Systemic); Leflunomide; Mercaptopurine; Methotrexate; MethylPREDNISolone; PrednisoLONE (Systemic); PredniSONE; Triamcinolone (Systemic). Avoid combination
Leflunomide: May enhance the adverse/toxic effect of Vaccines (Live). Leflunomide may diminish the therapeutic effect of Vaccines (Live). Management: The ACIP guidelines state that live-attenuated vaccines should generally be avoided for at least 3 months after cessation of immunosuppressant therapy. However, the ACR does not recommend avoiding live vaccines in patients being treated with leflunomide. Consider therapy modification
Mercaptopurine: May enhance the adverse/toxic effect of Vaccines (Live). Mercaptopurine may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose 6-mercaptopurine (1.5 mg/kg/day or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns and is not a contraindication for administration of zoster vaccine. Higher doses of mercaptopurine should be avoided. Consider therapy modification
Methotrexate: May enhance the adverse/toxic effect of Vaccines (Live). Methotrexate may diminish the therapeutic effect of Vaccines (Live). Management: Low-dose methotrexate (0.4 mg/kg/week or less) is not considered sufficiently immunosuppressive to create vaccine safety concerns. Higher doses of methotrexate should be avoided. Consider therapy modification
Ocrelizumab: May enhance the adverse/toxic effect of Vaccines (Live). Ocrelizumab may diminish the therapeutic effect of Vaccines (Live). Avoid combination
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. 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. Consider therapy modification
Salicylates: May enhance the adverse/toxic effect of Varicella Virus-Containing Vaccines. Reye's Syndrome may develop. Consider therapy modification
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. Consider therapy modification
Tisagenlecleucel: May enhance the adverse/toxic effect of Vaccines (Live). Specifically, the risk of infection may be increased. Tisagenlecleucel may diminish the therapeutic effect of Vaccines (Live). Management: Avoid live virus vaccines for two weeks prior to initiation of lymphodepleting therapy, during tisagenlecleucel infusion, and after treatment until full immune recovery is achieved. Consider therapy modification
Tuberculin Tests: Vaccines (Live) may diminish the diagnostic effect of Tuberculin Tests. Management: If a parenteral live vaccine has been recently administered, a scheduled PPD skin test should not be administered for at least 4-6 weeks following the administration of the vaccine. 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. Exceptions: Adenovirus (Types 4, 7) Vaccine; Cholera Vaccine; Rotavirus Vaccine. Monitor therapy
Venetoclax: May enhance the adverse/toxic effect of Vaccines (Live). Venetoclax may diminish the therapeutic effect of Vaccines (Live). Management: Avoid use of live, attenuated vaccines before, during, or after (prior to B-cell recovery) venetoclax treatment. Avoid combination
All serious adverse reactions must be reported to the U.S. Department of Health and Human Services (DHHS) Vaccine Adverse Event Reporting System (VAERS) 1-800-822-7967 or online at https://vaers.hhs.gov/esub/index. In Canada, adverse reactions may be reported to local provincial/territorial health agencies or to the Vaccine Safety Section at Public Health Agency of Canada (1-866-844-0018).
Local: Injection site reaction (19% to 33%)
Miscellaneous: Fever (10% to 15%)
1% to 10%:
Central nervous system: Chills, disturbed sleep, fatigue, headache, irritability, malaise, nervousness
Dermatologic: Varicella-like rash (1% to 6%), rash at injection site (varicella-like; 1% to 3%), contact dermatitis, dermatitis, diaper rash, eczema, miliaria, pruritus, urticaria, xeroderma
Gastrointestinal: Abdominal pain, constipation, decreased appetite, diarrhea, nausea, period of tooth development, vomiting
Genitourinary: Herpes labialis
Hematologic & oncologic: Lymphadenopathy
Hypersensitivity: Hypersensitivity reaction
Neuromuscular & skeletal: Arthralgia, myalgia, neck stiffness
Respiratory: Cough, respiratory tract disease (lower/upper)
<1% (Limited to important or life-threatening): Anaphylactic shock, anaphylaxis, aplastic anemia, anterior uvetitis (children; Krall 2014), aseptic meningitis, ataxia, Bell's palsy, cerebrovascular accident, encephalitis, erythema multiforme, febrile seizures, Guillain-Barré syndrome, hemiparesis (acute), hepatitis, herpes zoster, IgA vasculitis, keratitis (children; Krall 2014), necrotizing retinitis (immunocompromised patients), pneumonitis, seizure (nonfebrile), Stevens-Johnson syndrome, thrombocytopenia (including immune thrombocytopenia), transverse myelitis, varicella (disseminated or vaccine strain)
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 2017]).
• 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 2017]).
• 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 2017]).
• 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 2017]). 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 2017]; IDSA [Rubin 2014]).
• HIV: Although the manufacturer contraindicates administration to persons with HIV, guidelines for use are available. Children with HIV infection with age-specific CD4+ T-lymphocyte percentages ≥15% may receive live attenuated varicella vaccine. Vaccination may be considered for children >8 years, adolescents and adults with CD4+ T-lymphocyte counts ≥200 cells/microliter (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 2017]).
• 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 [Kim 2016]).
• 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 inactivated) for which a person is eligible at a single clinic 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 2017]).
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]).
• 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 ACIP Recommended Immunization Schedules (ACIP [Kim 2017]; CDC/ACIP [Robinson 2017]). 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 2017]). 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 2017]).
• Transmission of virus: The manufacturer notes that vaccinated individuals should not have close association with susceptible high-risk individuals for 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 notes that transmission of the virus is rare and 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]).
Rash, fever; monitor for anaphylaxis and syncope for 15 minutes following administration (ACIP [Kroger 2017]). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
Varicella virus vaccine is contraindicated for use in pregnant females and pregnancy should be avoided for 3 months (per manufacturer labeling; 1 month per ACIP) following vaccination.
Information was collected from 1995-2013 using the manufacturer’s pregnancy registry, and included 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.
Varicella disease during the 1st or 2nd 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]).
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.
• Discuss specific use of vaccine and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience irritability or injection site pain, edema, or irritation. Have patient report immediately to prescriber chickenpox-like rash, shingles, wheezing, or shortness of breath (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for health care professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience, and judgment in diagnosing, treating, and advising patients.
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Other brands: Varivax