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

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
– 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

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 Free
No cost
 Evaluation of Community Resources

Services offered Information on preventive

measures
Immunizations
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?