Chickenpox(Varicella)

Ana Corona, PHNJuly 2002

What is Chickenpox (Varicella)?

Chickenpox is an acute viral infectious disease

Varicella-zoster virus (VZV)

VZV is a DNA virus A member of Herpes

virus group. Primary infection

results in Varicella. Recurrent infection

results in herpes zoster (shingles).

Pathogenesis of Varicella

Day 0 – 3 •Infection of conjunctivae and/or mucosa of the upper respiratory tract•Viral replication in regional lymph nodes

Day 4 – 6 •Primary Viremia•Viral replication in liver, spleen, and other organs

Days 10 – 12 •Secondary Viremia

Day 14 •Infection of skin and appearance of vesicular rash

Clinical Features

• Mild prodrome (fever, malaise) for 1-2 days

• Successive crops (2-4 days) of pruritic vesicles

• Generally appear first on head; most concentrated on trunk

• Can spread over the entire body causing between 250 to 500 itchy blisters

• Generally mild in healthy children

What is The Chickenpox Illness Like?

• Chickenpox most commonly causes an illness that lasts about 5-10 days.

• Children usually miss 5 or 6 days of school or childcare due to chickenpox.

• 1 child in 10 has a complication from chickenpox serious enough to visit a health care provider

• Including infected skin lesions and other infections.

• Dehydration from vomiting or diarrhea• Exacerbation of asthma• More serious complications such as

pneumonia

The Lesions

• Each lesion progresses through a series of characteristic stages over about a week.

• Papules and vesicles develop into pustules, which then crust over prior to healing.

• A prominent feature of chickenpox is the development of several crops of spots.

• The peak of the illness, 3-4 days after first appearance of the rash, there are lesions at all stages of development, from new vesicles through to crusts.

Transmission: How do you get Chickenpox?

• Acquired by inhaling virus-containing particles, trapped in tiny droplets released into the air from the nose or throat of an infected person.

• The virus (VZV) enters the body by infecting cells in the respiratory tract.

• It spreads to many other parts of the body, including the skin, where it causes the characteristic rash.

• A person with chickenpox is contagious 1-2 days before the rash appears and until all blisters have formed scabs.

• It takes from 10-21 days after contact with an infected person for someone to develop chickenpox

Incubation period and prodromal illness

• The wide range commonly quoted for the incubation period: 7-23 days.

• Time of contact and true source of infection may be difficult to pinpoint.

• General constitutional symptoms sometimes precede the rash. This is called a prodrome.

• Young children generally have either no or a very mild prodrome.

• Older children and adults: the prodrome may be more pronounced.

• Symptoms include fever (which may precede the rash by up to 6 days), headache, backache and sore throat

The Stages of Chickenpox

Incubation Period Usually (14-17 days)

Prodrome (1 – 3 days)

Vesicles

Pustules

Scabs

Recovery typically 7 days after rash appears (ranges 5 - 35 days)

Herpes Zoster (Shingles)

• Reactivation of Varicella Zoster Virus

• Associated with: – Aging– Immunosuppressio

n– Intrauterine

exposure– Varicella at <18

month of age

Can chickenpox be caught from someone with Herpes

Zoster (Shingles)?

• Yes. • The rash of shingles contains VZV particles,

just like the rash of chickenpox. • Shingles carries a small risk of transmitting

chickenpox to someone who has not had chickenpox before.

• An infant might acquire chickenpox by very close contact with a grandparent with shingles

• The risk of transmission is low - because VZV is not excreted from the throat during shingles.

Complications

• Bacterial infection of lesions• CNS manifestations• Pneumonia (rare in children)• Hospitalization: 3 per 1000 cases• Death: 1 per 60,000 cases

Groups at Increased Risk of Complications

• Normal Adults• Immunocompromised persons• Newborns with maternal rash onset

within 5 days before to 48 hours after delivery

Chickenpox during pregnancy may result in:

• Congenital Varicella syndrome• Severe Varicella syndrome• Risk of neonatal death

Congenital Varicella Syndrome

• Results from maternal infection during pregnancy

• Period of risk may extend through first 20 weeks of pregnancy

• Atrophy of extremity with skin scarring, low birth weight, eye and neurologic abnormalities

• Risk appears to be small (<2%)

Laboratory Diagnosis

• Laboratory diagnosis is not routinely required• Useful if confirmation of the diagnosis or

determination of susceptibility is necessary• Most frequent source of isolation is vesicular

fluid• Stained smears from vesicular scrapings

(Tzanck Smear).• Serology Tests for Varicella IgM antibody• ELISA and Latex Agglutination (LA) useful in

screening for varicella immunity

Can you get chickenpox more than once?

• Yes• But it is uncommon to do so.• For most people, one infection is

thought to confer lifelong immunity.

Management

• Interventions designed to minimize fever and discomfort:

• Antipyretic medicines• Cool baths and soothing lotions • Chickenpox is not usually treated with a

specific antiviral compound owing to its short duration and generally mild, uncomplicated nature.

• Antiviral medication may be appropriate for older patients, in whom the disease tends to be more severe.

Acyclovir Therapy

• Healthy nonpregnant persons >13 years of age

• Children >12 months with chronic cutaneous or pulmonary disorders or on salicylate therapy

• Children receiving short intermittent or aerosolized steroids

• IV in Immunocompromised children and adults with viral-mediated complications

• Not recommended for post-exposure prophylaxis

What home treatments are available for chickenpox?

• Fingernails trimmed short• Calamine lotion and Aveeno (oatmeal) baths

may help relieve some of the itching• Aspirin or aspirin-containing products to

relieve your child's fever are not recommended.

• The use of aspirin has been associated with development of Reye syndrome (a severe disease affecting all organs - most seriously affecting the liver and brain, that may cause death).

• The use of non aspirin medications such as acetaminophen is recommended.

Complications

• Certain groups of persons are more likely to have more serious illness with complications.

• These include adults, infants, adolescents and people with weak immune systems from either illnesses or from medications such a long-term steroids.

What Complications Result From Varicella?

• The most common complications are:

• Bacterial infections of the skin and soft tissues in children

• Septicemia• Toxic Shock

Syndrome• Necrotizing Fascitis• Osteomyelitis• Bacterial

pneumonia• Septic arthritis. 

Complications: Continued

• Varicella is a well described risk factor for invasive group A streptococcus infections.

• Other complications:• Cerebellar ataxia• Encephalitis• Hemorrhagic complications leading to

bleeding disorders including disseminated intravascular coagulation (DIC).

Morbidity and mortality

• Since 1999, states have been encouraged to report chickenpox deaths to CDC.

• In 1999 and 2000, CDC received reports that showed that deaths from chickenpox continue to occur in healthy, unvaccinated children and adults.

• Most of the healthy adults who died from chickenpox contracted the disease from their unvaccinated children.

How serious a disease is varicella?

• Prior to the availability of varicella vaccine there were approximately 4 million cases of varicella a year in the U.S.

• Many health care providers are not aware that 11,000 hospitalizations and 100 deaths occurred every year in the United States before varicella vaccine became available.

• The majority of deaths and complications occurred in previously healthy individuals.

When is it necessary to go to the doctor for

treatment?

• If a fever lasts longer than 4 days or rises above 102 ºF.

• Lesions which become very red, warm, tender, or is leaking pus may mean there is a bacterial infection.

• Lethargy• Difficulty walking• Stiff neck• Severe Vomiting• Difficulty breathing• Severe cough.

Can chickenpox be prevented?

Yes, chickenpox can now be prevented by vaccination

Varicella Vaccine

Composition Live Virus (Oka-Merck strain)

Efficacy 95% (range 65%-100%)

Duration of Immunity >7 years

Schedule 1 dose (<13 years of age)

Varicella Vaccine Recommendations

• Routine vaccination at 12 to 18 months of age

• Recommended for all susceptible children by the 13th birthday

• Persons >13 years of age without history of Varicella

• Two doses separated by 4 – 8 weeks

Varicella Vaccine: Post-exposure Prophylaxis

• Varicella vaccine is recommended for use in susceptible person after exposure to Varicella

• 70% - 100% effective if given within 72 hours of exposure

• Not effective if >5 days but will produce immunity if not infected

Varicella Vaccine: Adverse Reactions

• Injection site complaints: 20%• Rash: 3% - 4%• May be maculopapular rather than

vesicular• Average 5 lesions• Systemic reactions uncommon

Zoster Following Vaccination

• Most cases in children• Risk from wild virus 4 to 5 times

higher than from vaccine virus• Mild illness without complications

Varicella Vaccine: Contraindications and

Precautions

• Severe allergy to vaccine component or prior dose of vaccine

• Pregnancy• Immunosuppression• Moderate or severe acute illness• Recent blood product• Immunocompromised persons

should not be vaccinated• Vaccinate persons with humoral

immunodeficiency

Varicella Zoster Immune Globulin (VZIG)

• May modify or prevent disease if given <96 hours after exposure

• Indications:– Immunocompromised persons– Newborn of mothers with onset 5 days

before to 2 days after birth– Premature infants with postnatal

exposure– Susceptible adults and pregnant women

What problems can occur after chickenpox

vaccination?

• Soreness, redness, or swelling at injection site is the most common side effect, occurring about 20% of the time.

• A very mild rash or several small bumps can result in about 1% to 4% of vaccine recipients.

• It may be possible for someone who gets a rash from chickenpox vaccine to give vaccine strain chickenpox to another person.

• The vaccine may cause a mild fever 2 weeks after vaccination.

• Seizures usually caused by fever may occur in less than 1 in 1000 vaccine recipients.

Have serious reactions ever occurred from the chickenpox vaccine?

• After distribution of the first 10 million doses of the vaccine, reports of serious adverse events after vaccination

• Seizures, encephalitis, pneumonia, ataxia and anaphylaxis have been very rare, occurring approximately 1 for every 50,000 doses given

What should I do if there is a serious reaction after

chickenpox vaccination?

• Call health care provider or 911 right away.

• Write down what happened and the date and time it happened.

• Ask your health care provider or health department to file a Vaccine Adverse Event Report Form or you can call (800) 822-7967 (toll-free).

Vaccine Birth Defects

• There is a theoretical risk that when administered one month prior to, or during, pregnancy, the vaccine may cause birth defects similar to those that can occur from natural chickenpox:

• Limb abnormalities• Abnormal brain development• Mental Retardation• Scarring of the skin and eye

abnormalities

Why not allow children to acquire natural infection and offer vaccine only to

susceptible adolescents and adults?

• Approximately 60% of hospitalizations and 40% of deaths due to varicella occur in children less than 10 years of age.

• The majority of this morbidity is preventable by vaccination.

Continued

• Children miss an average of 5-6 days of school when they have varicella

• Caregivers miss 3-4 days of work to care for their sick children.

• The majority of adults who acquire varicella and persons at high risk for severe disease who are not eligible for vaccination, contract the disease from unvaccinated children.

Evaluation of Patient Education Materials

Usefulness Provide useful information Prevention

Readability Easy to read 5th – 6th grade reading level

Availability Easy access from medical office, DHS

Cost FreeNo cost

Evaluation of Community Resources

Services offered Information on preventive measuresImmunizations

Population served Unimmunized population against chickenpox

Accessibility of services

Immunization Clinics Easy access

Payment for services Free Immunizations

Community Resources

• Keepkidshealthy.com: http://visit.referralware.com/2/FreeOffer.jsp• Information on Shingles: CDC:

http://www.cdc.gov/nip/diseases/varicella/faqs-gen-shingles.htm• Varicella Vaccination in Pregnancy Registry: 1 (800) 986-8999• Varicella Vaccine Information: 1 (800) 9VARIVAX• Information on acyclovir therapy

http://www.aap.org/family/chckpox.htm• Prevention of Varicella: Updated Recommendations of the

Advisory Committee on Immunization Practices (ACIP)http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/rr4806a1.htm

• Immunization Action Coalition: www.immunize.org• Merck: www.chickenpoxinfo.com• National Immunization Program website: http://www.cdc.gov/nip• Vaccine Adverse Event Report (800) 822-7967 • Los Angeles County Department of Health Services Clinics: 313

N. Figueroa St. Los Angeles, CA 90012: webmaster@dhs.co.la.ca.us

Question

1. A 6-year-old boy receiving prednisolone 2 mg/kg for asthma comes to the clinic the day he develops varicella rash. Which of the following is the required treatment?

A: Varicella-zoster immune globulin (VZIG)

B: Acyclovir C: Varicella vaccine D: All of the above E: None of the above

Answer

The correct answer is B:• VZIG and vaccine are effective if

given within 3-4 days of exposure but are ineffective once the varicella rash has appeared.

• Children on systemic steroids are at high risk for complications and should receive acyclovir

Quiz: True or False?

2. Varicella spread can be prevented by isolating all children with Varicella rash.

ANSWER• False: The disease is infectious 2 days

before the rash appears. • Children also may acquire the disease

from adults with herpes zoster

References

1. Atkinson, W. Wolfe, C. & Humiston, S. (2000). Epidemiology and prevention of vaccine-preventable diseases (6th ed.). Centers for Disease Control and Prevention.

2. Centers for Disease Control and Prevention: http://www.cdc.gov

3. Immunization Action Coalition: www.immunize.org

4. Merck, (1999). Chickenpox: A disease worth preventing. Merck & Co., Inc.

5. Varicella from Pediatrics: http://author.emedicine.com/PED/topic2385.htm

Any Questions?