Presentation on theme: "Chickenpox in Children, Adults and Pregnancy: What to do?"— Presentation transcript:
1 Chickenpox in Children, Adults and Pregnancy: What to do? Dr. Nayyar Raza KazmiCommunity Pediatrics ProjectDepartment of Health, Government of NWFPChicken Pox is a viral illness caused by the Varicella Zoster virus which is a DNA virus causing an eruptive fever in children and adults. Once attacked, the Immunity conferred in Life Long.
2 BACKGROUND > 90% of population infected by 15 yrs attack rates 90% for household contactsmorbiditybacterial skin infectionspneumoniaencephalitis, post varicella cerebritisdays from school/workhospitalizations (<1%)
3 BACKGROUND risk of death: lower for children than infants increases with age for adolescents/adults30% for perinatally exposed infants2/100,000 aged 1-142.7/100,000 aged 15-1925.2/100,000 aged 30-49
4 STRATEGIES Prevent infection? Treat infection? infection control passive vaccination (VZIG)active vaccination (live attenuated)Treat infection?who to treat?what to treat with?
5 VARICELLA IN CHILDREN Prevention Options -vaccination -school omission Treatment Options-symptomatic-antiviral medications
6 VARICELLA VACCINE: Efficacy 96-100% seroconversion within 4-6 weeks post vaccination> 90% with high titers after 20 years< 2% breakthrough of varicella 2 years outattenuated diseaseNot available in Pakistan
7 VARICELLA VACCINE: Side Effects fever (12%)pain at site (2%)rash at injection site (1.5%)generalized rash (1.5%)transmission of vaccine virushigher if vaccinees are immunocompromised
8 WHO SHOULD BE VACCINATED? YES> 1 year of agevaricella susceptibleno history of chicken poxno contraindicationsNO< 1 year of ageimmunedeficient in householdpregnancymild natural chickenpox
9 VARICELLA IN CHILDRENUsually previously well children develop malaise and low grade fever which rises once the rash appears. The rash begins along the hairline on face as macules which progresses to tiny vesicles with surrounding erythema.(Dew drops on rose petal appearance) . Rash then appears in successive crops over the trunk and extremities. They heal in 7-10 days. Sometimes hemorrhage may occur within the vesicles which may be mistaken as Meningococcemia.
10 SCHOOL WITHDRAWALS The Evidence contagious 1-2 days before the rash until all lesions crusteddocumented transmission of infection to classmates prior to rash (AJDC 1989-Brunell)
11 ACYCLOVIR IN CHILDREN The Evidence Balfour et al J Peds 1990 & Dunkle et al NEJM 1991RCT of 102 and 815 childrenacyclovir (20mg/kg/dose) qid vs placebolesions, fever, itchingno change in complications or titers* RCT Randomized Control Trial
12 ACYCLOVIR IN CHILDREN no serious adverse drug reactions noted cost of medications needs to be considered!!!!** acyclovir is not routinely recommended for the treatment of chickenpox in healthy children
13 PROPHYLACTIC ACYCLOVIR IN CHILDREN 40 mg/kg/day after exposure symptomatic cases with acyclovir vs placebo (16% vs 100%) (Asano et al Pediatrics 1993)79-85% still had serologic evidence of infection
14 PROPHYLACTIC ACYCLOVIR IN CHILDREN severity if acyclovir given for two weeks (Suga et al Arch Dis Child 1993, PIDJ 1998)development of resistance is a concern**routine acyclovir prophylaxis not recommended in otherwise healthy children
15 VARICELLA IN HEALTHY ADULTS 38 yo healthy man with no previously documented chicken pox develops fever and vesicular rash 18 days after his son recovers from chickenpox.Has lesions in mouth and urethra and increasing cough.
16 VARICELLA IN HEALTHY ADULTS incidence of pneumoniahospitalization rates (10%)mortality compared to childrentime from work/school
17 VARICELLA IN ADULTS The Evidence RCT’s in adults with acyclovir given within 24 hours of onset800mg qid x 5 days duration, severity of illness(Wallace et al An n Int Med; 1992, Feder Arch Intern Med;1990)No studies to date with valacyclovir or famciclovir
18 VARICELLA IN PREGNANCY pregnancy alters cellular immunity needed to fight viral infections pneumonitismortalitymaternal complications in 2nd and 3rd trimesterpremature labour/delivery, IUGRsmall risk of fetal infection
19 VARICELLA IN PREGNANCY-What To Do? prevent infectionVZIGinfection controldiagnose earlytreat infection
20 VARICELLA IN PREGNANCY-The Evidence no evidence to suggest that maternal acyclovir prevents fetal infectionno evidence of teratogenic effect of acyclovir at therapeutic doseshigh doses have in vitro effects
21 VARICELLA IN PREGNANCY treat based on maternal status800mg qid x 5 daysIV therapy if pneumonia
22 VARICELLA IN FETUS2.2% transmission to fetus (1.2%-4.9%) (Pastuszak et al NEJM 1994)intrauterine infection more common in 1st trimestercongenital infectionscarring, limb deformities, cataracts, CNS involvement, chorioretinitisneonatal or childhood zoster (0.8% -1%)
23 VARICELLA IN NEONATESduring maternal varicella 24% of fetuses get transplacentally infectedcritical timesis 5 days before to 2 days after birthneonates < 28 weeks gestation or <1000gm1st month of life if mother non-immune and in NICU, immunedeficiency etcinfant mortality up to 30%
24 VARICELLA IN NEONATESInfant born at full term following uncomplicated delivery. Mother noticed to have varicella lesions 2 days prior to delivery with low grade fever.Infant is completely well with no skin lesions, no fever etc.
25 VARICELLA IN NEONATES The Evidence VZIG if peripartum maternal infection (Hanngren K et al Scand J Infect Dis 1985)attack rate still 51%incubation period of 11 daysattenuates infection (Miller et al. Lancet 1989 ) mortality rate (1-2%), lesionsno literature regarding the use of acyclovir for prevention of disease in this group
26 VARICELLA IN NEONATES Perinatal Exposure < 4 weeks of age treat with acyclovir due to high mortality< 4 weeks of agetreat if mother is not immune, if infant born < 28 weeks gestation, < 1000gm, sick in NICUno clinical trials to date however good studies with acyclovir in other neonatal infections