Age: 14.0
Sex: F
Vaccine: MMR, MMRV, VARCEL
Symptoms: Vaccination failure, Varicella virus test negative
Clinical narrative: Information has been received from the authors of a published article regarding to 14 year old female patient. The patient did not have a history of chicken pox infection and was up to date with her vaccines. The patient was in good health and had no sick contacts or travel history. Immunity to hepatitis B had been previously documented. The patient had no known history of asthma, allergies, atopic dermatitis, or allergic rhinitis; no other infections were noted in the patient's history. Moreover, the patient was not receiving any medications. The patient received the recommended two doses of M-M-R II, 0.5 ml, subcutaneously  (strength, frequency, lot# and expiration date were not provided) for prophylaxis and PROQUAD 0.5 ml dose subcutaneously  (strength, frequency, lot# and expiration date were not provided) for prophylaxis after reconstitution in a sterile diluent for subcutaneous injection). The first dose VARIVAX 0.5 ml, subcutaneously  (strength, frequency, lot# and expiration date were not provided) for prophylaxis, was administered at 14 months of age and a second dose PROQUAD at 4 years of age. The third dose (re-immunization) VARIVAX was given at 14 years of age. It was reported that peripheral blood samples (5 ml) were collected. Data were reported as ratios as follows: ranges for varicella zoster virus (VZV) Ab IgG: negative <0.91, positive >1.09; VZV Ab IgM: negative < 0.901, positive > 1.09. On an unspecified date in May 2017, the ranges of post-re-immunization bloods for VZV IgG Abs changed to negative < 135.00; 135.00164.99 equivocal; >165.00 positive. Prior to re-immunization, VZV IgG Ab levels were negative (< 0.90 Ab index) and VZV IgM VZV Ab levels were also negative (= 0.90 Ab index) indicating either no prior exposure to VZV or lack of a specific immune response to immunization. However, 1 week post-re-immunization VZV IgG Ab levels were positive (690.70 Ab index) and VZV IgM Ab levels were negative (= 0.90 Ab index). For weeks 28, VZV IgG Ab was present, while VZV IgM levels were negative (-), except for week 8, where VZV IgM levels were positive (0.99 Ab index). In contrast, VZV IgE Ab levels were undetectable pre- and post-re-immunization. Measles Ab IgG levels were < 25.00 AU/ml (range <25.00 negative, 25.0029.99 equivocal, >29.99 positive). Mumps Ab IgG levels were 17.90 AU/ml (range < 9.00 negative, 9.0010.99 equivocal, >10.99 positive). Rubella Ab IgG levels were < 0.90 Ab index (range <0.90 negative, 0.900.99 equivocal, = 1.00 positive). Pre-re-immunization, distributions of lymphocyte subpopulations (CD3+CD4+, CD3+CD8+, CD19+, CD4+CD60+, CD8+CD60+) in the peripheral blood of the patient were all within normal ranges. However, post-re-immunization (4 weeks), numbers of T cell subpopulations remained unchanged, while CD19+ B cells increased 48% post-re-immunization (8 weeks), the numbers of T cell subpopulations remained unchanged, while the numbers of CD19+ B cells decreased slightly (6%). It was reported that the patient received two doses of M-M-R II, but had negative responses for measles and rubella (Vaccination failure). It could be speculated that a lack of a robust T cell memory response may indicate the underlying pathology of secondary vaccine failure, which was defined by the authors as a gradual loss of immunity after an initial immune response over a period of years after vaccination (wanning immunity). Upon internal review, the event Vaccination failure was considered to be medically significant. A copy of the published article is attached as further documentation of the patient's experience.