Chickenpox Presentation 1209266936137555 9

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Chickenpox

(Varicella)

Ana Corona, PHN

July 2002


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What is Chickenpox (Varicella)?

Chickenpox is an acuteviral infectious disease

Varicella-zoster virus(VZV)

VZV is a DNA virus

A member of Herpes virusgroup.

Primary infection resultsin Varicella.

Recurrent infection resultsin herpes zoster (shingles).


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Pathogenesis of Varicella

Day 0 3 Infection of conjunctivae and/or

mucosa of the upper respiratory tract

Viral replication in regional lymphnodes

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


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Clinical Features

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

Successive crops (2-4 days)of pruritic vesicles

Generally appear first onhead; most concentratedon trunk

Can spread over the entirebody causing between 250to 500 itchy blisters

Generally mild in healthychildren


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What is The Chickenpox Illness

Like?

Chickenpox most commonly causes an illness thatlasts about 5-10 days.

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

1 child in 10 has a complication from chickenpoxserious 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


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The Lesions

Each lesion progresses througha series of characteristic stagesover about a week.

Papules and vesicles developinto pustules, which then crustover prior to healing.

A prominent feature ofchickenpox is the developmentof several crops of spots.

The peak of the illness, 3-4 daysafter first appearance of therash, there are lesions at allstages of development, fromnew vesicles through to crusts.


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Transmission: How do you get

Chickenpox?

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

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

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

A person with chickenpox is contagious 1-2 daysbefore the rash appears and until all blisters haveformed scabs.

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


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Incubation period and prodromal

illness

The wide range commonly quoted for the incubationperiod: 7-23 days.

Time of contact and true source of infection may bedifficult to pinpoint.

General constitutional symptoms sometimesprecede 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 bemore pronounced.

Symptoms include fever (which may precede therash by up to 6 days), headache, backache and sorethroat


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Herpes Zoster (Shingles)

Reactivation of Varicella

Zoster Virus Associated with:

Aging

Immunosuppression

Intrauterineexposure

Varicella at


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Can chickenpox be caught from

someone with Herpes Zoster

(Shingles)?

Yes.

The rash of shingles contains VZV particles, justlike the rash of chickenpox.

Shingles carries a small risk of transmittingchickenpox to someone who has not hadchickenpox before.

An infant might acquire chickenpox by very closecontact with a grandparent with shingles

The risk of transmission is low - because VZV is notexcreted from the throat during shingles.


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Complications

Bacterial infection of lesions

CNS manifestations Pneumonia (rare in children)

Hospitalization: 3 per 1000 cases

Death: 1 per 60,000 cases


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Groups at Increased Risk of

Complications

Normal Adults

Immunocompromised persons Newborns with maternal rash onset within

5 days before to 48 hours after delivery


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Chickenpox during pregnancy may

result in:

Congenital Varicella syndrome

Severe Varicella syndrome Risk of neonatal death


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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 neurologicabnormalities

Risk appears to be small (


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Laboratory Diagnosis

Laboratory diagnosis is not routinely required

Useful if confirmation of the diagnosis ordetermination 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


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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.


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Management

Interventions designed to minimize fever anddiscomfort:

Antipyretic medicines

Cool baths and soothing lotions

Chickenpox is not usually treated with a specificantiviral 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 moresevere.


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Acyclovir Therapy

Healthy nonpregnant persons >13 years of age

Children >12 months with chronic cutaneous orpulmonary 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


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What home treatments are

available for chickenpox?

Fingernails trimmed short

Calamine lotion and Aveeno (oatmeal) baths mayhelp relieve some of the itching

Aspirin or aspirin-containing products to relieveyour child's fever are not recommended.

The use of aspirin has been associated with

development of Reye syndrome (a severe diseaseaffecting all organs - most seriously affecting theliver and brain, that may cause death).

The use of non aspirin medications such asacetaminophen is recommended.


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Complications

Certain groups of persons are more likely

to have more serious illness withcomplications.

These include adults, infants, adolescentsand people with weak immune systems

from either illnesses or from medicationssuch a long-term steroids.


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What Complications Result

From Varicella?

The most commoncomplications are:

Bacterial infections ofthe skin and softtissues in children

Septicemia

Toxic Shock

Syndrome Necrotizing Fascitis

Osteomyelitis

Bacterial pneumonia

Septic arthritis.


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Complications: Continued

Varicella is a well described risk factor for

invasive group A streptococcus infections. Other complications:

Cerebellar ataxia

Encephalitis

Hemorrhagic complications leading tobleeding disorders including disseminatedintravascular coagulation (DIC).


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Morbidity and mortality

Since 1999, states have been encouraged to

report chickenpox deaths to CDC. In 1999 and 2000, CDC received reportsthat showed that deaths from chickenpoxcontinue to occur in healthy, unvaccinatedchildren and adults.

Most of the healthy adults who died fromchickenpox contracted the disease fromtheir unvaccinated children.


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How serious a disease is

varicella?

Prior to the availability of varicella vaccine

there were approximately 4 million cases ofvaricella a year in the U.S.

Many health care providers are not awarethat 11,000 hospitalizations and 100 deathsoccurred every year in the United Statesbefore varicella vaccine became available.

The majority of deaths and complicationsoccurred in previously healthy individuals.


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When is it necessary to go to the

doctor for treatment?

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

Lesions which become very red, warm, tender, oris leaking pus may mean there is a bacterialinfection.

Lethargy Difficulty walking

Stiff neck Severe Vomiting

Difficulty breathing Severe cough.


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Varicella Vaccine

Composition Live Virus (Oka-Merckstrain)

Efficacy 95% (range 65%-100%)

Duration of Immunity >7 years

Schedule 1 dose (


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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


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Varicella Vaccine: Post-exposure

Prophylaxis

Varicella vaccine is recommended for use in

susceptible person after exposure toVaricella

70% - 100% effective if given within 72 hoursof exposure

Not effective if >5 days but will produceimmunity if not infected


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Varicella Vaccine: Adverse Reactions

Injection site complaints: 20%

Rash: 3% - 4% May be maculopapular rather than

vesicular

Average 5 lesions

Systemic reactions uncommon


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Zoster Following Vaccination

Most cases in children

Risk from wild virus 4 to 5 times higherthan from vaccine virus

Mild illness without complications


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Varicella Vaccine: Contraindications

and Precautions

Severe allergy to vaccine component orprior dose of vaccine

Pregnancy

Immunosuppression

Moderate or severe acute illness

Recent blood product Immunocompromised persons should not

be vaccinated

Vaccinate persons with humoral

immunodeficiency


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Varicella Zoster Immune Globulin

(VZIG)

May modify or prevent disease if given


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What problems can occur after

chickenpox vaccination?

Soreness, redness, or swelling at injection site isthe 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 aftervaccination.

Seizures usually caused by fever may occur in lessthan 1 in 1000 vaccine recipients.


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Have serious reactions ever

occurred from the chickenpox

vaccine?

After distribution of the first 10 million

doses of the vaccine, reports of seriousadverse events after vaccination

Seizures, encephalitis, pneumonia, ataxiaand anaphylaxis have been very rare,

occurring approximately 1 for every 50,000doses given


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Vaccine Birth Defects

There is a theoretical risk that when

administered one month prior to, orduring, pregnancy, the vaccine may causebirth defects similar to those that can occurfrom natural chickenpox:

Limb abnormalities

Abnormal brain development

Mental Retardation

Scarring of the skin and eye abnormalities


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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 inchildren less than 10 years of age.

The majority of this morbidity ispreventable by vaccination.


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Evaluation of Patient Education

Materials

Usefulness Provide usefulinformation

Prevention

Readability Easy to read 5th 6th

grade reading level

Availability Easy access from medicaloffice, DHS

Cost Free

No cost


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Evaluation ofCommunity Resources

Services offered Information on preventivemeasures

Immunizations

Population served Unimmunized populationagainst chickenpox

Accessibility of services Immunization ClinicsEasy access

Payment for services Free Immunizations


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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 therapyhttp://www.aap.org/family/chckpox.htm

Prevention of Varicella: Updated Recommendations of the AdvisoryCommittee 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 protected]


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uestion

1. A 6-year-old boy receiving prednisolone 2 mg/kgfor asthma comes to the clinic the day he developsvaricella rash. Which of the following is therequired treatment?

A: Varicella-zoster immune globulin (VZIG)

B: AcyclovirC: Varicella vaccine

D: All of the aboveE: None of the above


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Answer

The correct answer is B:

VZIG and vaccine are effective if givenwithin 3-4 days of exposure but areineffective once the varicella rash hasappeared.

Children on systemic steroids are at highrisk for complications and should receiveacyclovir


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uiz: True or False?

2. Varicella spread can be prevented by

isolating all children with Varicella rash.

ANSWER

False: The disease is infectious 2 daysbefore the rash appears.

Children also may acquire the diseasefrom adults with herpes zoster


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References

1. Atkinson, W. Wolfe, C. & Humiston, S. (2000).Epidemiology and prevention of vaccine-

preventable diseases (6th

ed.). Centers for DiseaseControl and Prevention.

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

3. Immunization Action Coalition:

www.immunize.org4. Merck, (1999). Chickenpox: A disease worthpreventing. Merck & Co., Inc.

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


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Any Questions?

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