Chickenpox Presentation

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 yearsDuration 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 [phone] (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 ImmunizationsPayment 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 [phone]
•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 [phone]
•Los Angeles County Department of Health Services Clinics: 313 N. Figueroa St.
Los Angeles, CA 90012: [email protected]

44. 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

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
1.Atkinson, W. Wolfe, C. & Humiston, S. (2000).
Epidemiology and prevention of vaccine-preventable
diseases (6
th
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

48. Any Questions?