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  • 1. Chickenpox (Varicella)
    • Ana Corona, PHN
    • July 2002
  • 2. 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).
  • 3. 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
  • 4. 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
  • 5. 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
  • 6. 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.
  • 7. 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
  • 8. 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
  • 9. 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)
  • 10. Herpes Zoster (Shingles)
    • Reactivation of Varicella Zoster Virus
    • Associated with:
      • Aging
      • Immunosuppression
      • Intrauterine exposure
      • Varicella at <18 month of age
  • 11. 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.
  • 12. Complications
    • Bacterial infection of lesions
    • CNS manifestations
    • Pneumonia (rare in children)
    • Hospitalization: 3 per 1000 cases
    • Death: 1 per 60,000 cases
  • 13. Groups at Increased Risk of Complications
    • Normal Adults
    • Immunocompromised persons
    • Newborns with maternal rash onset within 5 days before to 48 hours after delivery
  • 14. Chickenpox during pregnancy may result in:
    • Congenital Varicella syndrome
    • Severe Varicella syndrome
    • Risk of neonatal death
  • 15. 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%)
  • 16. 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
  • 17. 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.
  • 18. 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.
  • 19. 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
  • 20. 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.
  • 21. 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.
  • 22. 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. 
  • 23. 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).
  • 24. 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.
  • 25. 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.
  • 26. 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.
  • 27. Can chickenpox be prevented ?
    • Yes, chickenpox can
    • now be prevented by vaccination
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. Varicella Vaccine: Adverse Reactions
    • Injection site complaints: 20%
    • Rash: 3% - 4%
    • May be maculopapular rather than vesicular
    • Average 5 lesions
    • Systemic reactions uncommon
  • 32. Zoster Following Vaccination
    • Most cases in children
    • Risk from wild virus 4 to 5 times higher than from vaccine virus
    • Mild illness without complications
  • 33. 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
  • 34. 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
  • 35. 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.
  • 36. 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
  • 37. 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).
  • 38. 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
  • 39. 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.
  • 40. 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.
  • 41. 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
  • 42. 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
  • 43. 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]
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. Any Questions?