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Chickenpox Presentation
 

Chickenpox Presentation

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    Chickenpox Presentation Chickenpox Presentation Presentation Transcript

    • Chickenpox (Varicella)
      • Ana Corona, PHN
      • July 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
      • Infection of skin and appearance of
      • vesicular rash
      • Secondary Viremia
      • Primary Viremia
      • Viral replication in liver, spleen,
      • and other organs
      • Infection of conjunctivae and/or
      • mucosa of the upper respiratory tract
      • Viral replication in regional lymph
      • nodes
      Day 14 Days 10 – 12 Day 4 – 6 Day 0 – 3
    • 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
        • Immunosuppression
        • 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 1 dose (<13 years of age) Schedule >7 years Duration of Immunity 95% (range 65%-100%) Efficacy Live Virus (Oka-Merck strain) Composition
    • Varicella Vaccine Recommendations
      • Routine vaccination at 12 to 18 months of age
      • Recommended for all susceptible children by the 13 th 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 Free No cost Cost Easy access from medical office, DHS Availability Easy to read 5 th – 6 th grade reading level Readability Provide useful information Prevention Usefulness
    • Evaluation of Community Resources Free Immunizations Payment for services Immunization Clinics Easy access Accessibility of services Unimmunized population against chickenpox Population served Information on preventive measures Immunizations Services offered
    • 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: [email_address]
    • Question
      • 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
      • Atkinson, W. Wolfe, C. & Humiston, S. (2000). Epidemiology and prevention of vaccine-preventable diseases (6 th ed.). Centers for Disease Control and Prevention.
      • Centers for Disease Control and Prevention: http://www.cdc.gov
      • Immunization Action Coalition: www.immunize.org
      • Merck, (1999). Chickenpox: A disease worth preventing. Merck & Co., Inc.
      • Varicella from Pediatrics: http://author.emedicine.com/PED/topic2385.htm
    • Any Questions?