1. Chickenpox in Children, Adults and Pregnancy: What to do?
Dr. Nayyar Raza Kazmi
Community Pediatrics Project
Department of Health, Government of NWFP
Chicken 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 contacts
morbidity
bacterial skin infections
pneumonia
encephalitis, post varicella cerebritis
days from school/work
hospitalizations (<1%)

3. BACKGROUND risk of death: lower for children than infants
increases with age for adolescents/adults
30% for perinatally exposed infants
2/100,000 aged 1-14
2.7/100,000 aged 15-19
25.2/100,000 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 out
attenuated disease
Not 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 virus
higher if vaccinees are immunocompromised

8. WHO SHOULD BE VACCINATED?
YES
> 1 year of age
varicella susceptible
no history of chicken pox
no contraindications NO
< 1 year of age
immunedeficient in household
pregnancy
mild natural chickenpox

9. VARICELLA IN CHILDREN
Usually 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 crusted
documented 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 1991
RCT of 102 and 815 children
acyclovir (20mg/kg/dose) qid vs placebo
lesions, fever, itching
no 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 pneumonia
hospitalization rates (10%)
mortality compared to children
time from work/school

17. VARICELLA IN ADULTS The Evidence
RCT’s in adults with acyclovir given within 24 hours of onset
800mg 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
 pneumonitis
mortality
maternal complications in 2nd and 3rd trimester
premature labour/delivery, IUGR
small risk of fetal infection

19. VARICELLA IN PREGNANCY-What To Do?
prevent infection
VZIG
infection control
diagnose early
treat infection

20. VARICELLA IN PREGNANCY-The Evidence
no evidence to suggest that maternal acyclovir prevents fetal infection
no evidence of teratogenic effect of acyclovir at therapeutic doses
high doses have in vitro effects

21. VARICELLA IN PREGNANCY
treat based on maternal status
800mg qid x 5 days
IV therapy if pneumonia

22. VARICELLA IN FETUS
2.2% transmission to fetus (1.2%-4.9%) (Pastuszak et al NEJM 1994)
intrauterine infection more common in 1st trimester
congenital infection
scarring, limb deformities, cataracts, CNS involvement, chorioretinitis
neonatal or childhood zoster (0.8% -1%)

23. VARICELLA IN NEONATES
during maternal varicella 24% of fetuses get transplacentally infected
critical times
is 5 days before to 2 days after birth
neonates < 28 weeks gestation or <1000gm
1st month of life if mother non-immune and in NICU, immunedeficiency etc
infant mortality up to 30%

24. VARICELLA IN NEONATES
Infant 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 days
attenuates infection (Miller et al. Lancet 1989 )
 mortality rate (1-2%),  lesions
no 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 age
treat if mother is not immune, if infant born < 28 weeks gestation, < 1000gm, sick in NICU
no clinical trials to date however good studies with acyclovir in other neonatal infections