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Varicella-Zoster Virus
Kaveh Haratian,Ph.D.
Medical Virologist
Department of Bacteriology and Virology
School of Medicine
Alborz University of Medical Sciences Oct 26, 2013
Varicella-Zoster Virus
Varicella (chickenpox) acute, highly contagious viral disease with worldwide
distribution majority of annual costs*
80% to 85% of chickenpox : physician visits 85% to 90% of chickenpox : hospitalization most of which are related to productivity losses by
caregivers mainly a childhood disease
5 years of age : infection rate 50%
12 years of age : infection rate 90%
Health Canada. CCDR 1999;25(S5):1-29.
Varicella-Zoster Virus
mostly a mild disorder in childhood
tends to be more severe in adults
It may be fatal
Neonates
Immunocompromised persons 4% to 13% of individuals who had previous varicella
infection : recurrences of varicella-like rash* The risk factors
young age (< 12 months) at first infection
a milder symptoms at first infection
*Hall S, et al. Pediatrics 2002;109:1068-73.
Varicella-Zoster Virus
Fatality rates for varicella*
adults 30 deaths/100,000 cases
infants 7 deaths/100,000 cases
1-19 yr of age 1-1.5 deaths/ 100,000 cases
In the United States
adults account for only 5% of cases but for 55% of the approximately 100 chickenpox deaths each year
In Canada, from 1987 to 1996
70% of the 53 reported chickenpox deaths occurred in those > 15 years of age.
*Meyer PM, et al. J Infect Dis 2000;182:383-90. Preblud SR. Pediatrics 1981;68:14-7.
The pathogen
a double-stranded DNA virus : human herpesvirus-3 subfamily Alphaherpersvirinae
only one serotype is known
humans are the only reservoir VZV enters the host through the nasopharyngeal
mucosa, and almost invariably produces clinical disease in susceptible individuals
Following varicella, the virus persists in sensory nerve ganglia, from where it may later be reactivated to cause herpes zoster (Shingles)
Transmission
The virus is transmitted by
direct contact with the rash
Airborne respiratory droplets
vertical transmission (mother to baby) during pregnancy can transmit the virus for up to 48 hours before rash
appears and remains contagious until all spots crust over little genetic variation
no animal reservoir
visceral dissemination of the virus has occurred in 30% and mortality in 7% to 10% of these patients*
*Feldman S, et al. Pediatrics
1975;56:388.
Signs and symptoms
In healthy children
the disease is generally mild.
The illness usually appear 14–16 days after exposure
Incubation period 10-21 days
Prodromal symptoms : particularly in older children Low-grade fever preceding skin manifestations by 1-2 D 24-48 hr before rash
Mild abdominal pain
Mild cough and runny nose Mild headache
malaise or irritability
Signs and symptoms
red, itchy rash appear first on the scalp, face, trunk quickly turn into clear fluid-filled vesicles
24-48 hr later, clouding and umbilication of lesions
initial lesions are crusting, new crops form on trunk and then the extremities
Characteristics : various stages of evolution
oropharyngeal, vagina involvement : common
cornial involvement and serious ocular disease : rare
the average number of varicella lesion is about 300 lesions
<10 to >1,500 lesions Itching may range from mild to intense
Laboratory studies
unnecessary for diagnosis, obvious clinically
Immunohistochemical staining of skin lesion scrapings can confirm varicella A Tzanck smear : multinucleated giant cells
useful for high-risk patients who require rapid confirmation
not sufficiently sensitive or specific for varicella
more specific immunohistochemical staining of such scrapings, if available
Immunoglobulin M tests : not reliable, positive results indicate current or recent VZV activity
Redbook27th Ed;2006;711-725.
Immune response
Natural infection induces lifelong immunity to clinical varicella in almost all immunocompetent persons
Newborn babies of immune mothers are protected by passively acquired antibodies during their first months of life
Temporary protection of non-immune individuals can be
obtained by injection of varicella-zoster immune globulin
within 3 days of exposure
The immunity acquired in the course of varicella prevents
neither the establishment of a latent VZV infection, nor the possibility of subsequent reactivation as zoster.
Immune response
Antibody assays : indication of previous infection or response to vaccination less reliable as correlates of immunity, particularly to zoster failure to detect antibodies against VZV does not
necessarily imply susceptibility, as the corresponding cell-mediated immunity may still be intact
20% of persons aged 55–65 show no measurable cell-mediated immunity to VZV in spite
of persisting antibodies, and a history of previous varicella Zoster is closely correlated to a fall in the level of VZV-
specific T-cells
an episode of zoster will reactivate the specific T-cell response
High-risk groups
High risks of complications Newborns and infants whose
mothers never had chickenpox or the vaccine
Teenagers Adults Pregnant women
People whose immune systems are impaired by another disease or condition
People who are taking steroid medications for another disease or condition, such as asthma
People with the skin inflammation eczema
Complications of Varicella
herpes zoster (shingles) lifetime risk 15%-20% mainly affecting the
elderly and immunocompromised persons
secondary bacterial skin and soft tissue infections
otitis media bacteremia, pneumonitis osteomyelitis septic arthritis
endocarditis necrotizing fasciitis toxic shock-like syndrome hepatitis thrombocytopenia
hemorrhagic varicella cerebellar ataxia encephalitis severe invasive group A
streptococcal infection increases the risk 40-60 fold*
*Health Canada. CCDR 1999;25(S5):1-29. Davies HD, et al. N Eng J Med 1996;335:547-54.
Complications of Varicella
When compared with children, adults are
3 to 18 fold higher risk : admitted to hospital for varicella
11 to 20 fold higher : higher rates of complications such as pneumonia
1.1- to 2.7-fold higher : encephalitis* The risk factors identified in adults for varicella pneumonia
underlying chronic lung disease
Smoking** varicella pneumonia occurring in 3.4% to 9.3% of pregnant
women (no higher than in nonpregnant adults)*** High mortality *Choo PW, et al. J Infect Dis 1995;172:706-12
**Ellis ME, et al. Br Med J 1987;294:1002. ***Harger JH, et al. Obstet Gynecol 2002;100(2):260-65.
Neonatal varicella
can be a serious illness, depending upon
the timing of maternal varicella and delivery
If the mother develops varicella within 5 days before or 2 days after delivery acquires the virus transplacentally no protective antibodies
Prophylaxis or treatment is required with varicella-zoster immune globulin (VZIG) and acyclovir
Without these drugs, mortality rates 20% - 30%*
The primary causes of death are severe pneumonia and
fulminant hepatitis
*Derrick CW Jr, et al.South Med J 1998 Nov; 91(11): 1064-6.
Neonatal varicella
Onset of maternal varicella more than 5 days antepartum provides the mother sufficient time to manufacture and
pass on antibodies along with the virus. Full-term neonates : usually have mild varicella Treatment with VZIG is not recommended, but
acyclovir may be used, depending on individual circumstances
Derrick CW Jr, et al.South Med J 1998 Nov; 91(11): 1064-6.
Congenital varicella syndrome
gestational varicella : currently no evidence associated increase in spontaneous abortion, stillbirth, or prematurity transplacental or perinatal infection can have other serious
outcomes.
0.4% of live births when maternal infection occurred from conception through the 12th week of gestation
2% when infection occurred between the 13th and 20th week of gestation*
A smaller, prospective study of 347 women who had varicella during pregnancy found an overall congenital varicella syndrome rate of 0.4%**
*Enders G, et al. Lancet 1994;343:1547-50. **Harger JH, et al. Obstet Gynecol 2002;100(2):260-65.
Congenital varicella syndrome
maternal infection with chickenpox (maternal varicella
zoster) early during pregnancy (i.e., up to 20 weeks
gestation)
The range and severity of associated symptoms and
physical findings may vary greatly from case to case
depending upon when maternal varicella zoster infection occurred during fetal development
Stigmata of Varicella-Zoster Virus Fetopathy
Damage to Sensory Nerves
Cicatricial skin lesions
Hypopigmentation
Damage to Optic Stalk and Lens Vesicle
Microphthalmia
Cataracts
Chorioretinitis
Optic atrophy
Damage to Brain/Encephalitis Microcephaly
Hydrocephaly
Calcifications
Aplasia of brain
Damage to Cervical or Lumbosacral Cord Hypoplasia of an extremity
Motor and sensory deficits
Absent deep tendon reflexes
Anisocoria
Horner’s syndrome Anal/urinary sphincter dysfunction
Nelson, Textbook of Pediatrics.17th ed;246:973-977.
Type of exposure
Household
Playmate: face to face, indoor play
Hospital
Varicella : same 2-4 bed room, adjacent beds in a large ward
Zoster : intimate contact with a person deemed contagious
NB : mother had onset of chickenpox within 5 days
before delivery or within 2 days after delivery
VariZIG is indicated for susceptible people
Redbook27th Ed;2006;711-725.
Postexposure Immunization
Varicella vaccine
Susceptible people > 12 mo of age, including adults
As soon as possible within 72 hr and possibly up to
120 hr after varicella exposure
To prevent or modify disease
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Chemoprophylaxis
If VariZIG is not available or > 96 hr after exposure
Oral Acyclovir (some experts recommend)
80 mg/kg/day divided 4 times/day for 7 days
Start on day 7-10 after varicella exposure
if vaccine is contraindicated
Susceptible immunocompromised adults Limited data on acyclovir as postexposure prophylaxis
in healthy children
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Passive immunoprophylaxis
VZIG : cessation of manufacture,2005
VariZIG (Varicella-Zoster Immune Globulin)
125 U/10 kg IM, Maximum dose 625U
lessen the severity of the disease
Likelihood that the exposed person is susceptible to varicella
Probability that a given exposure to varicella or zoster will result in
infection
Likelihood that complications of varicella will develop if person
is infected
If VariZIG is not available, choose IGIV (Immune Globulin
Intravenous)
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Passive immunoprophylaxis
VariZIG should be administered as soon as possible, but no later than 96 hours after exposure
Newborns whose mothers have chicken pox five days prior to two days after delivery
Children with leukemia or lymphoma who have not been vaccinated
Persons with cellular immunodeficiencies or other immune problems
Persons receiving drugs, including steroids, that suppress the immune system
Pregnant women
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Candidates for Acyclovir or VariZIG
Immunocompromised children without Hx.of varicella
or varicella immunization
NB : mother had onset of chickenpox within 5 days
before delivery or within 2 days after delivery
Hospitalized preterm infants (GA 28 wks) whose
mother lack Hx or serology of varicella
Hospitalized preterm infants (GA < 28 wks or BW
< 1000gm) regardless Hx of varicella or zoster serostatus
Redbook27th Ed;2006;711-725.
Treatment
Healthy children
no medical treatment
antihistamine to relieve itching
IV Acyclovir (nucleoside analogues)
< 1 yr 30 mg/kg/day in 3 divided doses for 7-10 days > 1 yr 1500 mg/m2/day divided q 8 h for 7-10 days Immunocompromised patients Patients being treated with chronic corticosteroids
medications to shorten the duration of the infection
help reduce the risk of complications
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Treatment Oral Acyclovir (Category B drug)
80 mg/kg/day divided in 4 doses for 5 days, Max dose 3200 mg/day (* some experts recommend)
Healthy people at increased risk of moderate to severe varicella
> 12 yr of age
Chronic cutaneous or pulmpnary disorders
Receiving long-term salicylate therapy
Receiving short, intermittent, or aerosonized courses of
corticosteroids
*Secondary household cases
(disease usually is more severe than in primary case)
*Pregnancy, especially during the second and third trimesters
*HIV-infected patients with relatively normal CD4+ T-lymphocytes
*Leukemia in whom careful follow-up
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Treatment
Valacyclovir and Famciclovir
approved for use only in adults
Complicated cases
Hospitalization
skin infections and pneumonia : antibiotics encephalitis : antiviral drugs
Don't give Aspirin : Reye's syndrome.
Recommendations of the Advisory Committee on Immunization Practices. MMWR 2006;55:209-210.
Care of Hospital Exposure
Identify those who are susceptible: both personel and patients
immunocompromised patient
immunocompetent patient who:
< 6 month old without maternal history of chickenpox
> 6 month old with unimmunized/unvaccinated
All exposed susceptible patients should be discharged as soon as possible.
All susceptible patients who cannot be discharged should be placed in airborne and contact precaution from day 10-21 after exposure.(28 day who received VariZIG)
Redbook27th Ed;2006;711-725.
Care of Hospital Exposure
All susceptible exposed staff should be furloughed from
day 8-21 post exposure to an infectious patient. (28 day
who received VariZIG)
Serologic testing for immunity is not necessary for
personel who have been immunized
Immunizaed health care personel who develop
breakthough infection should be considered infectious
Varicella immunization is recommended for susceptible personnel if there are no contraindications to vaccine use
Redbook27th Ed;2006;711-725.
A Varicella Zoster outbreak among Thai healthcare workers
45 yrs-old, Thai woman, admitted to Thammasart
Hospital ICU because of CAP
Day 11, she develop chicken pox Healthcare workers IgG + IgG -
Hx of Varicella + 23 0
Hx of Varicella - 30 47
Sensitivity = 23/53 = 43%
Specificity = 17/17 = 100%
PPV = 23/23 = 100% NPV = 47/77 = 61%
Sereprevalence
•>90% adults seropositive (in general)
•History of Varicella 97-99% predictive of antibodies •Negative or uncertain history 79-93% seropositive
Apisarnthanarak A, et al. Infect Control Hosp Epidemio,2007
Isolation of the hospitalized patient
Standard precautions, airborne and contact precaution
Recommended for patients with varicella for a minimum of 5 days
after onset of rash and until all lesions are crusted
For exposed susceptible patients
Airborne and contact precautions from 10-21 days after exposure
to index patient (28 days for those who received VariZIG or IGIV)
For neonates born to mothers with varicella and, if still
hospitalized, should be continued until 21 or 28 days of age if they received VariZIG or IGIV Airborne and contact precautions
Redbook27th Ed;2006;711-725.
Who should get chickenpox vaccine?
all susceptible children and adults
A second dose catch-up varicella vaccination is recommended for
children, adolescents, and adults who previously had received only one dose
exposed to chickenpox may receive varicella vaccine within 3 days (72 hours) to 5 days (120 hours) prevent or diminish the severity of illness
National Foundation for Infectious Diseases.USA. August 2006
Who should get chickenpox vaccine? special consideration in Adults
not received the vaccine not already had chickenpox higher risk for exposure/transmission
College students Household contacts of immunocompromised persons Residents and staff in institutional settings Inmates and staff of correctional institutions International travelers Military personnel Nonpregnant women of childbearing age Teachers and day care workers Non-immune persons
National Foundation for Infectious Diseases.USA. August 2006
Prevention
The attack rate in unvaccinated susceptible children was 88%
The varicella vaccine is the best way to prevention CDC estimate complete protection from the virus for
nearly 90% Unvaccinated older children
7-13 yr receive two catch-up doses of the varicella vaccine
at least 3 mo apart > 13 yr
receive two catch-up doses of the varicella vaccine
at least 4 wks apart
CDC. MMWR 2005 Jul 29; 54(29): 717-21.
Prevention
Unvaccinated adults who've never had chickenpox but are at high risk of exposure
If you don't remember whether you've had chickenpox or the vaccine, a serum antibody test
If you've had chickenpox, you don't need the vaccine
CDC. MMWR 2005 Jul 29; 54(29): 717-21.
Varicella vaccine
Oka strain of VZV since 1974
a single dose of vaccine : seroconversion 95% optimal age for varicella vaccination is 12–24 months In Japan and several other countries
one dose of the vaccine : sufficient, regardless of age In the United States
two doses, four to eight weeks apart
Recommendation for adolescents and adults
after the first dose : seroconversion 78%
after the second dose : seroconversion 99%
Hall S, et al. Pediatrics 2002;109:1068-73
Asano Y, et al. Biken J 1980;23:157-61.
Varicella vaccine
Varicella outbreak in a day-care center
efficacy 100% in preventing severe disease
86% in preventing all disease
From the Japanese experience
immunity to varicella following vaccination lasts for at least 10–20 years
In the United States : routine vaccination Since 1995
70%–90% protection against infection
> 95% protection against severe disease 7–10 years after immunization*
*Clements DA, et al. Pediatr Infect Dis J 1999;18:1047-50. Vasquez M, et al. N Eng J Med 2001;344:955-60. Izurieta H, et al. JAMA 1997;279:1495-99.
Varicella vaccine
In immunocompromised persons, including patients with advanced HIV infection contraindication : fear of disseminated vaccine-induced
disease Vaccine safety
asymptomatic HIV-infected children with CD4 counts of more than 1,000 cell/μL
patients with leukaemia in remission or solid tumours before chemotherapy
uremic patients waiting for transplantation a killed varicella vaccine has been studied in VZV-positive
bone marrow transplant patients where a multiple-dose schedule has been reduce the severity of zoster
A Vaccine to prevent Herpes Zoster and Post-herpetic Neuralgia in older adults
Randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine enrolled 38,546 adults 60 years of age or older burden of illness due to herpes zoster, a measure affected by the
incidence, severity, and duration of the associated pain and discomfort
secondary end point was the incidence of postherpetic neuralgia
Results > 95 % of the subjects continued in the study to its completion a median of 3.12 years of surveillance for herpes zoster. A total of 957 confirmed cases of herpes zoster
(315 among vaccine recipients and 642 among placebo recipients)
NEJM2005;352:2271-2284.
A Vaccine to prevent Herpes Zoster and Post-herpetic Neuralgia in older adults
107 cases of postherpetic neuralgia (27 among vaccine recipients and 80 among placebo recipients) were included in the efficacy analysis.
zoster vaccine reduced the burden of illness due to herpes zoster by 61.1% (P<0.001)
reduced the incidence of postherpetic neuralgia by 66.5% (P<0.001), and reduced the incidence of herpes zoster by 51.3% (P<0.001)
Reactions at the injection site were more frequent among vaccine recipients but were generally mild
Conclusions The zoster vaccine markedly reduced morbidity from
herpes zoster and postherpetic neuralgia among older adults
NEJM2005;352:2271-2284.
Breakthrough Varicella
Varicella in persons who have received the vaccine
less severe than the disease in unvaccinated individuals
3% to 4% per year after varicella vaccination 5% to 20% after household exposure to wild-type virus. The risk that vaccinated individuals with breakthrough
disease will infect others appears to correlate with the number of lesions that develop. > 50 lesions were equally as likely to transmit the
infection to household contacts < 50 lesions were only half as likely to transmit the
infection (J. Seward, Centers for Disease Control and Prevention, Atlanta: personal communication)
NEJM 2001;344:955-60. JAMA 1997;279:1495-99. Pediatrics 1999;104:561-63.
Comparison of severity of varicella
symptoms in naturally infected children and varicella vaccine recipients
Nagai T. Clin Virol 1997;25:271-81.
Vaccine associated adverse events
Varilix® GlaxoSmithKline
In children < 13 years of age In adolescents and adults
Adverse effects
local pain, redness and
swelling 11% - 22%
Varicella-like rash 1%
other rash types 10%
Reactions at the injection
site tended to be mild and transient Fever 11%
the first and second doses
local symptoms
12% and 16%
fever 29% and 20%
varicella-like rash
0.9% and 1.3%
Product monograph. Varilix®. GlaxoSmithKline, September 12, 2002.
Risk of clinical reactions of Oka strain varicella vaccine
Asano Y. J Infect Dis 1996;174Suppl3:S310-3.
Vaccine associated adverse events
In healthy children
27% : local swelling and redness at the site of injection < 5% : a mild varicella-like disease with rash within 4 wks rare occasions of mild zoster following vaccination
Since licensure and distribution of more than 10 million doses of vaccine in the United States, the Vaccine Adverse Event Reporting System (VAERS) reports of
encephalitis, ataxia
pneumonia
thrombocytopenia
arthropathy and erythema multiforme
These events may not be causally related and they occur at much lower rates than following natural disease
A tetravalent vaccine with the combined measles-mumps-rubella vaccine
Immune response
VZV IgG
Varicella vaccine MMRV vaccine
(ProQuad)
6 wks after dose 1 85.7% 91.2%
6 wks after dose 1 and
3 mos between doses
99.6% 99.2%
6 wks after dose 2
at age 4–6 yrs
99.4% 98.9%
1.Kuter B, et al. Pediatr Infect Dis J 2004;23:132–7. 2.Shinefield H, et al. Pediatr Infect Dis J 2005;24:665–9. 3.Reisinger KS, et al. Pediatrics 2006;117:265–72.
Humoral and cellular immune response among children aged 12 months–12 years measured at 6 weeks postvaccination, by vaccine type and vaccination schedule — United States, 1988–2002
Contraindications for Varicella vaccine
a history of anaphylactic reactions to any component of the vaccine including neomycin
pregnancy due to theoretical risk to the fetus
pregnancy should be avoided for 4 wks following vaccination
ongoing severe illness, and advanced immune disorders of any type except for patients with acute lymphatic leukaemia in
stable remission ongoing treatment with systemic steroids
for adults more than 20 mg/day
for children more than 1mg/kg/day
American Hospital Formulary Service (AHFS) Drug Information 1997, p.2653-2655.
Contraindications for Varicella vaccine
A history of congenital immune disorders in close family members is a relative contraindication both varicella-zoster immune globulin (VZIG) and antiviral
drugs are available should persons in the immunocompromised categories receive the vaccine by mistake
Administration of blood, plasma or immunoglobulin
< 5 mo before immunization or
3 wks afterwards
reduce the efficacy of the vaccine use of salicylates is discouraged for 6 wks following
varicella vaccination : risk of Reye syndrome American Hospital Formulary Service (AHFS) Drug Information 1997, p.2653-2655.
Between 1995 and 2004 : Researchers from the Centers for Disease Control and Prevention (CDC) and the Los Angeles Department of Health Services looked at data on 350,000 Californians > 11,000 people who developed chickenpox, almost
1,100 had been vaccinated The study also found that 8- to 12-year-olds who
contracted chickenpox after being vaccinated at least 5 years earlier were twice as likely to have "moderate or severe" cases than those who had gotten the vaccine less than 5 years before.
early on with just one dose may still develop chickenpox at an older age, when the illness may be more severe
Study : Single Dose of Varicella Vaccine Not Enough
Study : Single Dose of Varicella Vaccine Not Enough
Randomized clinical trial : compared the efficacy of 1 dose of vaccine with that of 2 doses
the cumulative rate of breakthrough varicella during a 10-year observation period
was 3.3-fold lower among children who received 2 doses than that among children who received 1 dose (2.2% and 7.3,respectively; p<0.001)
Breakthrough cases occurred occasionally in 0.8% of 2-dose vaccine recipients.
Kuter B, et al. Pediatr Infect Dis J 2004;23:132–7.
Study : Single Dose of Varicella Vaccine Not Enough
The majority of cases of breakthrough disease occurred 2–5 years
after vaccination; no cases were reported 7–10 years after vaccination
Of 16 children with breakthrough cases, three (19%) had >50 lesions.
The proportion of children with >50 lesions did not differ between the 1-dose and 2-dose regimens (p = 0.5).
In 2006, the CDC recommended
First dose at 12 - 15 mo of age a booster dose at 4 - 6 yr old
Kuter B, et al. Pediatr Infect Dis J 2004;23:132–7.
Category 1996 recommendations
1999 recommendations
2007 recommendations
Routine
childhood
schedules
1 dose
recommended at
age 12–18months
No change 2 doses recommended
• 1st dose at age 12–15 months
• 2nd dose at age 4–6 years
Adults and
adolescents
aged >13 years
2 doses, 4–8 weeks apart
2 doses, 4–8 weeks apart
No change
Recommended
2 doses, 4–8 weeks apart
Recommended for all
adolescents and adults
without evidence of immunity
Catch-up
vaccination 1 dose recommended for all susceptible
children aged 19
months–12 years
(i.e., those with no history of varicella or
vaccination)
No change 2nd dose recommended for all
persons who received 1 dose previously
Recommendations of the Advisory Committee on Immunization Practices (ACIP):MMWR,June 22, 2007 / Vol. 56 / No. RR-4
Category 1996 recommendations
1999 recommendations
2007 recommendations
HIV-infected
persons
Contraindicated
2 doses, 3 months
apart
Considered for
asymptomatic
or CDC N1 or A1
or CD4+ >25%
2 doses, 3 months
apart
Considered for
CD4+ >15%
Outbreak
control
vaccination
None Should be
considered
Recommended 2 dose
vaccination policy
Postexposure
vaccination
Vaccination
requirements
None
None
Recommended within 3–5 days
Recommended for
children without
evidence of immunity
attending child
care centers and
entering elementary
school
No change
Recommended for
children attending
child care centers,
students in all grade
levels and persons
attending college
Recommendations of the Advisory Committee on Immunization Practices (ACIP):MMWR,June 22, 2007 / Vol. 56 / No.
RR-4
Herpes Zoster
rash usually resolves within 14-21 days
Postherpetic neuralgia pain persisting at least 1 month after the rash has healed incidence increases dramatically with age
4% in aged 30-50 years 50% in older than 80 years
Immunocompetent host
all ages : same as Varicella in imunocompromised host > 12 yr : Acyclovir 4,000 mg/day in 5 divided doses for 5-7 days
Immunocompromised children < 12 yr : Acyclovir 60 mg/kg/day IV q 8 hr, for 7-10 days > 12 yr : Acyclovir 30 mg/kg/day IV q 8 hr, for 7 days
Redbook27th Ed;2006;711-725.
Herpes Zoster
the boosting of cell-mediated
immunity by exposure to wild-type varicella infection
reduces the risk of zoster in adults*
The adults with the most
contact with children had roughly one-fifth the zoster
risk of those with the least contact with children**
**Levine MJ, Vaccine 2000;18(25):2915-20.
*Solomon BA, et al. J Am Acad Dermatol 1998;38:763-65. Thomas SL, et al. Lancet. URL: 2 July, 2002.
Infantile zoster
Infantile zoster usually manifests within the first yr
The cause is maternal
varicella infection after the 20th week of gestation
commonly involves the thoracic dermatomes
NEJM1994 Mar 31; 330(13): 901-5.
Complications of Herpes Zoster
Postherpetic neuralgia
Ocular involvement with facial zoster
Meningoencephalitis
Cutaneous dissemination
Superinfection of skin lesions
Hepatitis/pneumonitis Peripheral motor weakness/segmental myelitis
Cranial nerve syndromes, particularly ophthalmic and facial (Ramsay Hunt syndrome)
Corneal ulceration
Guillain-Barré syndrome
Ann Neurol 1994; 35 Suppl: S4-8.
Isolation of the hospitalized patient
Immunocompromised patient who have zoster (localized
or disseminated) and immunocompetent patients with
disseminated zoster
Airborne and contact precautions for the duration of
illness
For immunocompetent patients with localized zoster
Contact precautions until all lesions are crusted
Redbook27th Ed;2006;711-725.
National Advisory Committee on Immunization. CCDR 2002;28(ACS-3):1-7.
National Advisory Committee on Immunization. CCDR 2002;28(ACS-3):1-7.
Management of chickenpox in pregnancy
Management of significant exposure* to varicella zoster virus (VZV) during pregnancy
Immunoglobulin Interval (months)
HBIG
RIG
Measles prophylaxis
standard
immunocompromised
VZIG
Blood transfusion
Washed RBCs
RBCs, adenine saline added
Packed RBCs
Whole blood
Plasma and platelet
Replacement of immune deficiency (IVIG)
ITP
400 mg/kg
1,000 mg/kg
1,600-2,000 mg/kg
Kawasaki disease
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