Conditions: Shingles
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 10
Healthy volunteers: yes

Brief summary:
The purpose of this study is to learn more about the immune response to varicella zoster virus (VZV).

Detailed description:
Participants 70 years of age or older will receive the FDA-approved shingles vaccine (Zostavax). Blood samples and optional skin biopsies will be obtained before and after vaccination to study the immune responses to shingles vaccination.

Arms:
arm 1: 10 persons over 70 years of age that received Zostavax (single 0.65-mL dose subcutaneously in the deltoid region of the upper arm)

Interventions: intervention 1: Zoster Vaccine Live
Intervention descriptions: intervention 1: None

Protocol document:
Prot_SAP_000.pdf: 
VRC 401: Immune Response to Shingles  
 
[1] 
 
 
version 4.0, 16-OCT-15 
 
 
 
Immune Response to Shingles Vaccination 
 
 
Principal Investigator:   
David Koelle, MD 
University of Washington, Seattle 
 
Study Site: 
University of Washington  
 
Virology Research Clinic 
 
908 Jefferson St, 11th floor 
 
Seattle, WA 98104 
 
 
 
 
Study Protocol  
 
Version 4.0  
16 October 2015 
 
 
NCT02624375 
 


Immune Response to Shingles  
 
[2] 
 
 
 
version 4.0, 16-OCT-15 
 
 
 
 
 
 
 
 
Table of Contents 
1 
Background ........................................................................................................................................... 3 
2 
Study Purpose ....................................................................................................................................... 3 
3 
Participant Selection ............................................................................................................................. 3 
 
Inclusion Criteria ........................................................................................................................... 3 
 
Exclusion Criteria ........................................................................................................................... 4 
4 
Study Procedures .................................................................................................................................. 5 
 
Screening Visit ............................................................................................................................... 5 
 
Enrollment Visit (Day 0) ................................................................................................................ 5 
 
Follow-up Visits ............................................................................................................................. 5 
 
Skin Biopsy .................................................................................................................................... 5 
 
Additional Visits ............................................................................................................................ 5 
5 
Risks & Benefits ..................................................................................................................................... 6 
 
Potential Risks ............................................................................................................................... 6 
 
Potential Benefits .......................................................................................................................... 6 
6 
Clinical Procedures ................................................................................................................................ 6 
 
Zostavax vaccination ..................................................................................................................... 6 
6.1.1 
Recommended Dose and Schedule ...................................................................................... 7 
6.1.2 
Preparation for Administration ............................................................................................. 7 
6.1.3 
Contraindications .................................................................................................................. 7 
 
Skin Biopsy .................................................................................................................................... 8 
7 
Non-Investigational Study Medications ................................................................................................ 8 
8 
Safety .................................................................................................................................................... 8 
 
Adverse Events .............................................................................................................................. 8 
 
Serious Adverse Events ................................................................................................................. 9 
 
Reporting Procedures ................................................................................................................... 9 
 
Follow-up of Adverse Events ...................................................................................................... 10 
9 
Data Analysis Plan ............................................................................................................................... 11 
10 
Human Subjects Protections ........................................................................................................... 11 
 
IRB Approval ................................................................................................................................ 11 
 
Informed Consent ....................................................................................................................... 11 
Appendix A:  Table of Procedures ............................................................................................................... 12 
 


Immune Response to Shingles  
 
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1
Background 
 
There are two clinical illnesses caused by varicella zoster virus (VZV):  chickenpox which typically 
occurs during childhood, and shingles (also known as zoster, or herpes zoster) which typically occurs 
in older adults.  When an individual has their initial infection with VZV they develop chickenpox.  
Then, VZV becomes latent in the neurons on the dorsal root ganglia (DRG) which are collections of 
nerve cell bodies located near the spinal cord.  Shingles occurs when VZV reactivates in the DRG and 
travels back down nerves to the skin.  This can cause a painful rash on the skin or eye in the area 
supplied by the DRG.    
 
Therapy for shingles is possible with oral antiviral medications sometimes given with corticosteroids; 
these are expensive and can have toxicities.  Even after the shingles rash heals, a prolonged pain 
syndrome called post-herpetic neuralgia (PNH) occurs in a substantial proportion of persons; the risk 
of PNH increases with chronologic age.   
 
The FDA has licensed a live attenuated VZV vaccine to prevent both chickenpox and shingles.  The 
vaccine composition is the same for both indications.  The dose varies: the dose for shingles 
prevention is 14 times higher than the dose for chickenpox prevention.  In 1995, universal 
vaccination with Varivax (the brand name for the pediatric dose) became universally recommended 
in the US.  In 2005, the results of a landmark randomized controlled clinical trial in the US, done in 
the Veteran’s administration system, showed that administration of Zostavax (the brand name for 
the higher adult dose) lead to a moderate reduction in the incidence of both shingles and PHN when 
given to older adults.  Currently, the Zostavax vaccine is FDA approved for immunocompetent adults 
50 or older. ACIP recommends Zostavax at age 60 and most insurance companies follow this 
guideline by paying for Zostavax at age 60. 
 
It is not clear how Zostavax works. It is generally thought that long term immune memory to VZV, set 
into place by childhood chickenpox, gradually wanes over time, and that a delicate equilibrium 
between the latent virus in neurons and the immune system finally tips in favor of the virus and the 
individual gets clinical shingles.  Zostavax, being a live vaccine, is thought to be able to stimulate or 
re-stimulate a specific immune response to VZV, include the components of antibodies, T-cells with 
the CD4 marker, and T-cells with the CD8 marker.  Because Zostavax contains all 70 proteins encoded 
by the VZV genome, it is thought that these immune components are stimulated quite broadly and 
that the vaccine elicits immune responses to many VZV proteins. To date, the research on this topic is 
simplistic and minimal. Our lab has developed systems to use before and after vaccine blood samples 
to measure in quantitative detail the CD4 and CD8 T cell immune response to each individual VZV 
protein.   
 
2
Study Purpose 
 
The overall purpose of this protocol is to study the immune responses to shingles vaccination.  
3
Participant Selection 

Inclusion Criteria 
 


Immune Response to Shingles  
 
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Men and women who meet all of the following criteria are eligible for inclusion in this study: 
x
50 years of age or older 
x
History of chickenpox 
 

Exclusion Criteria 
 
Men and women who meet any of the following criteria are not eligible for this study: 
x
Previous vaccination with Zostavax or with the chickenpox vaccine. 
x
History of ever having had shingles. 
x
Been in close contact with a person who had chickenpox or shingles in the past 5 years. 
x
VZV seronegative 
x
Taking systemic suppressive regular doses of drugs with anti-VZV activity such as acyclovir, 
famciclovir, or valacyclovir.   Episodic use is allowed.  For Cohort 1: medication cannot be 
taken 24 hours prior to or 30 days after receiving Zostavax per CDC recommendations. 
x
HIV seropositive.  
x
Hepatitis C infection or active Hepatitis B infection.   
x
History of a life-threatening allergic reaction (anaphylactic/anaphylactoid reaction) to 
gelatin, neomycin, or any other component of shingles vaccine.  Neomycin allergy 
manifested as contact dermatitis is not an exclusion. 
x
Has immunosuppression as a result of an underlying illness (e.g. leukemia, lymphoma or 
other malignant neoplasms) or treatment with immunosuppressive or cytotoxic drugs, or 
use of anticancer chemotherapy or radiation therapy. 
x
Has long-term use of oral or parenteral steroids (>7 days), or high-dose inhaled steroids 
(>800 mcg/day of beclomethasone dipropionate or equivalent) within the preceding 
6 months (nasal and topical steroids are allowed). 
x
Women of child-bearing potential only: pregnant or planning to become pregnant 3 months 
post vaccination (Cohort 1 only). 
x
Donated blood in the past 8 weeks or planning to donate blood during the study 
x
Weighs less than 110 lbs 
x
Has any condition or medical history that would, in the opinion of the site principal 
investigator place the subject at an unacceptable risk of injury or render the subject unable 
to meet the requirements of the protocol. 
 
Additional exclusions for skin biopsy: 
1. Has an acute or chronic medical condition that, in the opinion of the investigator, would 
render biopsies unsafe 
2. History of coagulopathy or taking medication that may cause bleeding (long term aspirin, 
heparin, coumadin)  
3. History of keloid formation or excessive scarring  
4. History of frequent cellulitis or boils (>3 episodes in past 2 years) requiring antibiotic 
therapy. 
5. Allergy to lidocaine, silver nitrate, or mupirocin. 
 



Immune Response to Shingles  
 
[5] 
 
 
 
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4
Study Procedures 

Screening Visit  
 
Study background and procedures will be explained. Potential participants will have a chance to 
ask questions and informed consent will be obtained.  A separate consent form will be used for 
HSV testing. 
 
Demographic, medical, and sexual history information will be obtained. Study specific 
inclusion/exclusion criteria will be evaluated.   We will gather medical history specific to VZV 
infection, including history of chickenpox or shingles.   
 
Blood will be drawn for HSV serology unless previous documentation is available.  Blood will be 
drawn for laboratory testing of HIV, HepB, HepC, VZV and CMV serology.  If HIV, HepB and HepC 
testing was performed in the last year and the participant was negative and is low risk, the test(s) 
need not be repeated based on medical history and clinical judgment. 
 
If participants have a medical history and/or laboratory confirmation of HIV, Hepatitis C or active 
Hepatitis B infection, they will be referred to an appropriate provider, as needed, and will not be 
eligible for further participation.  Subjects will be eligible regardless of the results of their tests for 
antibodies to HSV-1, HSV-2 and CMV.   
 

Enrollment Visit (Day 0) 
 
Eligible subjects will return for an Enrollment Visit.  A blood sample (up to 110 ml) will be 
obtained for immunological assays and VZV research serology.  Additional blood (up to 10 ml) will 
be obtained for HLA typing.  After the blood sample is obtained, a standard dose of Zostavax will 
be administered.  Participants will be provided with a copy of the CDC Shingles Vaccine 
Information Sheet. 

Follow-up Visits 
Participants will return for follow-up visits at Day 7-14, 28, and 180.  Blood will be drawn for 
immunological assays and VZV research serology.   
 

Skin Biopsy 
 
Two 3-mm skin biopsies will be collected from the upper arm (contralateral to the vaccine 
injection) at Day 0 and again at Day 28.  The biopsy will be performed prior to vaccination on Day 
0.  
 

Additional Visits  
 


Immune Response to Shingles  
 
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All participants may be asked to return for additional visits should the laboratory require extra 
blood samples for analysis.  Up to 110 ml of blood may be collected during a visit for 
immunological assays and VZV research serology.     
 
5
Risks & Benefits 

Potential Risks 
 
Phlebotomy: Blood drawing may cause discomfort and/or bruising.  Rarely an infection may 
develop.  Clinical discretion will be used when drawing blood from elderly (65+) participants.  If 
necessary, blood draw volumes will be adjusted (50 ml minimum). 
 
Zostavax vaccination:  Mild reactions include redness, soreness, swelling, or itching at the site of 
the injection and headache.  Serious adverse reactions include anaphylaxis. There is no 
documentation of a person getting chickenpox from someone who has received the shingles 
vaccine.  Some people who get the shingles vaccine will develop a chickenpox-like rash near the 
place where they were vaccinated. There is a risk of disseminated infection in 
immunocompromised persons; therefore, they will be excluded from the study. There is a risk of 
transmission of the vaccine virus between vaccines and susceptible contacts.  As with any 
vaccination, there may be side effects that are not known at this time.  
 
Biopsy:  The diameter of the biopsy will be equivalent to a very small straw.  Anticipation of the 
procedure may cause anxiety.  The biopsy itself may cause pain, even with the use of an 
anesthetic.  Biopsies may cause a pressure or tugging sensation.  Bleeding may also occur; in the 
case of excessive bleeding, silver nitrate will be applied.  Infection and scarring are rare 
complications of biopsies.  Biopsies will not be performed on face or neck.   
 
Lidocaine (injectable, +/- epinephrine): Lidocaine administration is associated with temporary 
pain and burning.  Skin biopsy may cause discomfort even when the area of the skin is numbed 
using lidocaine.  Allergic reactions to lidocaine may occur, even in subjects with no history of 
allergic reactions.  Examples of allergic reactions include wheezing or difficulty in breathing, 
lightheadedness or fainting, skin rash and itching.  As with any drug there may be unknown side 
effects. 
 

Potential Benefits 
 
Subjects are not expected to benefit from participation. Society may benefit from an increased 
understanding of the cellular immune response and pathogenesis of varicella zoster virus and 
vaccination. 
 
6
Clinical Procedures 

Zostavax vaccination 
 


Immune Response to Shingles  
 
[7] 
 
 
 
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ZOSTAVAX is a live attenuated virus vaccine indicated for prevention of herpes zoster (shingles) in 
individuals 50 years of age and older. 
6.1.1 
Recommended Dose and Schedule 
 
ZOSTAVAX will be administered as a single 0.65-mL dose subcutaneously in the deltoid region of 
the upper arm.  
6.1.2 
Preparation for Administration 
 
Use only sterile syringes free of preservatives, antiseptics, and detergents for each injection 
and/or reconstitution of ZOSTAVAX. Preservatives, antiseptics and detergents may inactivate the 
vaccine virus.  
 
ZOSTAVAX is stored frozen and should be reconstituted immediately upon removal from the 
freezer.  
 
When reconstituted, ZOSTAVAX is a semi-hazy to translucent, off-white to pale yellow liquid.  
 
Reconstitution:  
 
Use only the diluent supplied.  
 
Withdraw the entire contents of the diluent into a syringe.  
 
To avoid excessive foaming, slowly inject all of the diluent in the syringe into the vial of 
lyophilized vaccine and gently agitate to mix thoroughly.  
 
Withdraw the entire contents of reconstituted vaccine into a syringe and inject the total 
volume subcutaneously.  
 
ADMINISTER IMMEDIATELY AFTER RECONSTITUTION to minimize loss of potency. 
Discard reconstituted vaccine if not used within 30 minutes. Do not freeze reconstituted 
vaccine.  
6.1.3 
Contraindications 
 
Do not administer ZOSTAVAX to individuals with a history of anaphylactic/anaphylactoid reaction 
to gelatin, neomycin or any other component of the vaccine. Neomycin allergy manifested as 
contact dermatitis is not a contraindication to receiving this vaccine. 
 
ZOSTAVAX is a live, attenuated varicella-zoster vaccine and administration may result in 
disseminated disease in individuals who are immunosuppressed or immunodeficient. Do not 
administer ZOSTAVAX to immunosuppressed or immunodeficient individuals including those with 
a history of primary or acquired immunodeficiency states, leukemia, lymphoma or other 
malignant neoplasms affecting the bone marrow or lymphatic system, AIDS or other clinical 
manifestations of infection with human immunodeficiency viruses, and those on 
immunosuppressive therapy. 
 
Do not administer ZOSTAVAX to pregnant women. It is not known whether ZOSTAVAX can cause 
fetal harm when administered to a pregnant woman or can affect reproduction capacity. 
However, naturally occurring VZV infection is known to sometimes cause fetal harm. Therefore, 


Immune Response to Shingles  
 
[8] 
 
 
 
version 4.0, 16-OCT-15 
 
 
 
 
 
 
 
 
ZOSTAVAX should not be administered to pregnant women, and pregnancy should be avoided for 
3 months following administration of ZOSTAVAX. 
 

Skin Biopsy 
 
Biopsies will be obtained by trained clinicians.  Biopsies will obtained from areas of the healed 
shingles rash and areas of normal skin. Biopsies will be performed only when participants are willing.  
Participants are free to refuse a biopsy at any visit.  Biopsies will be performed on the trunk, 
buttocks, arms, or legs.  Biopsies will not be performed on the face. Pre and post biopsy 
photographs will be taken for each biopsy.   
3 mm punch biopsies will be performed as per the Biopsy SOP. Briefly, the skin/mucosal surface will 
be prepped with chlorhexidine or betadine. 1-5 cc lidocaine +/- epinephrine (1%) will be used to 
anesthetize the skin. A biopsy will be performed and placed into a 15mm tube with 6 ml of media. A 
supply of 15ml conical vials are kept in the lab refrigerator.  The tube will be shipped with an ice 
pack to the Koelle lab. 
Given the small size of the tissue obtained, sutures are not necessary. Pressure will be applied to the 
site for 5 minutes. If excessive bleeding persists, silver nitrate may be used to stop the bleeding. 
Participants will be advised to take over-the-counter Tylenol or ibuprofen for pain relief. These will 
be provided to the participants through the clinic free of charge as needed.  
7
Non-Investigational Study Medications 
 
Name 
Dose 
How administered 
Zostavax® 
Single 0.65ml dose 
Subcutaneously in the 
deltoid region of the 
upper arm 
Silver nitrate 
One applicator, as needed for bleeding 
Topical 
Double antibiotic ointment 
1-3 times daily, as needed 
Topical 
1% lidocaine  
10mg/ml.  Up to 5 ml per dose. 
By injection 
 
8
Safety 

Adverse Events 
 
An adverse event (AE) is defined as any untoward medical occurrence in a patient or a clinical 
investigation participant administered a pharmaceutical, which does not necessarily have a causal 
relationship with the treatment. Due to the specific setting in which this study is performed 
(outpatient research clinic), this study will focus on hospitalizations and other severe AE. 
Mechanisms of obtaining information on AE will rely primarily on biweekly visits to the clinic with 
a health care provider. The occurrence and severity of all AEs will be listed and graded according 


Immune Response to Shingles  
 
[9] 
 
 
 
version 4.0, 16-OCT-15 
 
 
 
 
 
 
 
 
to the NCI CTC criteria. For a complete listing, see http://ctep.info.nih.gov/CTC3/ctc.htm. The 
following information will be collected on all AEs experienced during this study: 
 
x
Name of the event: If the event is described in the NCI CTC, the Investigator should use that 
terminology. Otherwise, terminology that clearly describes the pathophysiology of the event 
and body system affected should be used. 
x
Onset Date 
x
Date of resolution 
x
Severity 
o If an event is not described on the NCI CTC and therefore not graded, the following 
grading will be used: 
1. Mild, easily tolerated by the patient, causing minimal discomfort and not 
interfering with everyday activities. 
2. Moderate, sufficiently discomforting to interfere with normal everyday 
activities 
3. Severe, prevents normal everyday activities 
4. Life-threatening, places the patient at immediate risk for death 
x
Relationship to study procedures/drug: All AEs will have a causality assessment performed 
at the time of reporting the event to document the Investigator’s perception of causality. 
For the purposes of this study, causality will be assigned using the following criteria: 
o Related: The event cannot be attributed to the patient’s underlying medical 
condition or other concomitant therapy and there is a compelling temporal 
association between the onset of the events and study drug administration that 
leads the Investigator to believe that there is reasonable chance of a causal 
relationship. 
o Remote: A relationship is not obvious but cannot be ruled out. 
o Not related: The patient’s underlying medical condition or concomitant therapy can 
easily be identified as the cause of the event and there is no temporal relationship 
between the event and the study drug. 

Serious Adverse Events 
The Investigator is required to determine if each AE was a SAE. A SAE is any AE occurring at any 
dose of study drug that results in any of the following outcomes: 
x
Death 
x
A life-threatening adverse drug experience 
x
Inpatient hospitalization (hospitalizations for elective medical/surgical procedures, 
scheduled treatments, or routine check-ups are not SAE by these criteria) 
x
A persistent or significant disability / incapacity 
 
Important medical events that may not meet any of the above criteria may be considered a 
serious adverse experience when, based upon appropriate medical judgment, it may jeopardize 
the patient or participant and may require medical or surgical intervention to prevent one of the 
outcomes listed above. 

Reporting Procedures 
 


Immune Response to Shingles  
 
[10] 
 
 
 
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Adverse events including local and systemic reactions not meeting the criteria for SAEs will be 
captured on the appropriate CRF.  Information to be collected includes event description, date of 
onset, investigator assessment of severity, investigator assessment of relationship to study 
product, date of resolution of the event, seriousness, and outcome.  The intensity of nonserious 
AEs can be assessed by a licensed clinician (i.e., physician, nurse, Nurse Practitioner, Physician 
Assistant).  Causality of nonserious AEs can be assessed only by a clinician licensed to make 
medical diagnoses (ie, physician, Nurse Practitioner, Physician Assistant).  All AEs occurring while 
on study will be documented appropriately regardless of relationship.   
 
Any medical condition that is present at screening will be considered as baseline and will not be 
reported as an AE.  If the severity of any pre-existing medical condition increases during the study 
period, then it will be recorded as an AE 
 
All SAEs will be reported immediately to the Investigator.  
 
SAE Alternate: A clinician from the Virology Research Clinic is available at any time by calling the 
operator at the Children’s Hospital at 206-598-0924 and asking for the Virology Research Clinic 
Clinician on-call.  
 
All SAEs will be: 
x
Recorded on the appropriate SAE report form. 
x
Followed through resolution by a study physician. 
 
Timelines for submission of an SAE form are as follows:   
x
All deaths and life-threatening events regardless of relationship, will be recorded on the 
SAE form and the PI will be notified within 24 hr of identification of the SAE. 
 
All SAEs determined to be related to study procedures will be reported to the Human Subjects 
Division of the University of Washington within 10-days of becoming aware of the event. 
 
The SAE report will include the following information (as available) 
x
Patient ID 
x
Description of SAE (onset date, severity, causal relationship) 
x
Basic demographic information 
x
Outcomes attributed to the event 
x
Summary of relevant test results, laboratory data, and other relevant history 
x
The first and last dates of study drug administration 
x
Statement whether study drug was discontinued or schedule modified 
x
Statement whether the event abated after study drug was discontinued or schedule modified  
x
Statement whether the event recurred after reintroduction of the study drug if it had been 
discontinued. 

Follow-up of Adverse Events 
 
All AEs will be followed to adequate resolution or until considered stable. 
 


Immune Response to Shingles  
 
[11] 
 
 
 
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All SAEs reported to the Virology Research Clinic will be relayed to the Human Subjects Division 
(HSD) of the University of Washington as required by HSD policy.   
 
9
Data Analysis Plan 
 
Positive response to VZV proteins in lymphoproliferation assays will be determined on a per-cell-
line basis surpassing this threshold: at least 2.33 × median absolute deviation of all negative-
control antigen samples above the median response of those same samples. This calculation has a 
theoretical false-positive rate of 1.0%. VZV antigen wells will be scored positive only if both 
replicates exceed the threshold. ORFs synthesized as fragments (eg, ORF22) were scored positive 
once if any fragment was deemed positive. 
 
Antibody titers, T-cell frequencies, and T-cell breadth will be compared between the different time 
points using the nonparametric Friedman's test for repeated measures. If significant, subsequent 
analysis of measures using Dunn's test identified which time points were different from 
prevaccine samples. Correlation analyses will be performed using the Spearman's test. 
Nonparametric tests will be used because the data are likely to be highly left skewed, thus did not 
satisfy assumptions of normality. Two-sided P values <.05 will be considered statistically 
significant. Statistical tests and graphs were generated using Prism (v7 or greater, GraphPad 
Software, La Jolla, California). 
 
10 Human Subjects Protections 
 IRB Approval 
 
Prior to the initiation of the study, the principal investigator will obtain written approval to conduct 
the study via the University of Washington Human Subjects Review Committee.  
 Informed Consent 
 
The investigator or study coordinator will explain the purpose and nature of the study, including 
potential benefits and risks to the participant, to each potential participant before enrollment in 
the study. The participant must sign an informed consent form approved by the IRB before entering 
the study. All original informed consent forms must be retained by the principal investigator with 
the participant’s records. The participant will receive a copy of the signed informed consent form. 
 
 
 
 
 
 


VRC 401: Immune Response to Shingles  
 
[12] 
 
 
version 4.0, 16-OCT-15 
 
Appendix A:  Table of Procedures  
 
Study Day 
Screen 
Day 0 
Day 7 - 14 
Day 28 
Day 180 
Additional 
Visits 
Obtain Informed Consent 
X 
 
 
 
 
 
Review Inclusion/Exclusion 
Criteria 
X 
X 
 
 
 
 
Medical History 
X 
X 
 
 
 
 
HIV Serology 
X 
 
 
 
 
 
HSV Serology 
X 
 
 
 
 
 
CMV Serology  
X 
 
 
 
 
 
VZV Serology 
X 
 
 
 
 
 
Hepatitis C Serology 
X 
 
 
 
 
 
Hepatitis B Surface Antigen 
X 
 
 
 
 
 
Blood (DNA) for HLA Typing 
 
X 
 
 
 
 
Blood Draw for Immunological 
Assays 
 
X 
(100) 
X 
(100) 
X 
(100) 
X 
(100) 
X 
(100) 
VZV Research Serology  
 
X 
X 
X 
X 
X 
Vaccination 
 
X1 
 
 
 
 
Skin Biopsy 
 
X2 
 
X 
 
 
1 Blood draw will occur prior to vaccination  
2 Biopsy obtained prior to vaccination