Table 1 Checklist regarding clinical and immunological requirements prior to varicella zoster virus vaccination

Low-intensity immunosuppression (LIIS)

 □ Prednisone ≤ 0,5mg/kg (max. 10mg) daily

 □ Methotrexate ≤ 15mg/m² (max. 15mg) weekly

 □ Azathioprine ≤ 2mg/kg (max. 100mg) daily

High-intensity immunosuppression (HIIS)

Glucocorticoids and synthetic DMARDs

 □ Prednisone > 0,5 to < 2mg/kg (> 10mg to < 20mg) daily

 □ Methotrexate > 15mg/m² or > 15mg to 30mg weekly

 □ Azathioprine > 2 to 3mg/kg daily

 □ Leflunomide ≤ 0,5mg/kg (max. 20mg) daily

 □ Cyclosporine ≤ 3mg/kg daily (trough level ≤ 100μg/l)

 □ mTOR-inhibitors (sirolimus or everolimus) (trough level ≤ 4 μg/l)

 □ Mycophenolate ≤ 1200mg/m2 (max. 2g) daily

Biological DMARDs

 □ Abatacept ≤ 10mg/kg per 4 weeks

 □ Adalimumab ≤ 24mg/m² (max. 40mg) per 2 weeks

 □ Anakinra ≤ 3mg/kg (max. 150mg) daily

 □ Etanercept ≤ 0,8mg/kg (max. 50mg) weekly

 □ Infliximab ≤ 6mg/kg per 4 weeks

 □ Tocilizumab ≤ 12mg/kg biweekly if weight < 30kg

 □ Tocilizumab ≤ 8mg/kg biweekly if weight > 30kg

Special situations:

 • If on canakinumab, consider switching to anakinra temporarily.

I. Medical history and physical exam

 □ No family history or clinical evidence of primary immunodeficiency

 □ No measles-mumps-rubella vaccination at the same time or within < 4 weeks before VV

 □ For 2nd VV: At least 3 months from first dose of VV for patients on HIIS

II. Clinical assessment

 □ Inactive rheumatic disease

 □ Stable antirheumatic therapy for at least 3 months

 □ No active infection

III. Medications

 □ Not more than 2 synthetic DMARDs

 □ Not more than 1 biological agent +/− 1 synthetic DMARD

 □ No IV methylprednisolone pulse therapy or oral prednisone ≥ 2mg/kg or ≥ 20mg daily for > 2 weeks within < 1 month before and after VV

 □ No IV cyclophosphamide in previous 6 months

 □ No rituximab in previous 6 months or lasting B-cell deficiency

 □ No IVIG in previous 6 months (high-dose IVIG [2g/kg] 11 months)

 □ No blood products in previous 3 months

 □ No therapy with aspirin planned in 6 weeks after vaccination

Basic laboratory testing for all patients:

 □ VZV-IgG < 200 mIU/ml (prior to1st VV)

 □ WBC ≥ 3,000/mm³

 □ Lymphocytes ≥ 1,200/mm³

 □ IgG ≥ 500 mg/dl

 □ IgM ≥ 20mg/dl

 □ Tetanus toxoid antibody ≥ 0.1 IU/ml

Additional laboratory testing for patients on HIIS or LIIS with abnormal basic lab result:

 □ CD4 cell count > 200/mm³ if > 5 yrs old OR CD4 cell count > 500/mm³ if 1-5 yrs old

 □ T cell function testing^a positive

Special situations:

• If WBC < 3000/mm³:

 • exclude neutropenia <1500/mm³

• If lymphocytes 700-1.200/mm³:

 • rule out low CD4+ T-cells

• If Lymphocytes < 700/mm³:

 • absolute contraindication

• If IgG < 500mg/dl or IgM < 20mg/dl:

 • rule out humoral and cellular immunodeficiency

• If tetanus antibody-level < 0,10IU/ml:

 • give tetanus vaccination and control serologic response in 4 weeks

 □ All prerequisites are met

 □ Basic laboratory testing normal

 □ Additional lab testing normal (if applicable), or additional testing not applicable

IF ALL THREE ITEMS ABOVE ARE CHECKED, VV IS SUPPORTED WITHOUT SUSPENSION OF THE CURRENT IMMUNOSUPPRESSION.^b,c