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Chickenpox

Article · June 2013

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HOME CLINICAL A-Z CURRICULUM ESSENTIALS PRESCRIBING NURSE ADVANCED PRACTICE GUIDELINES

JUNE 2013
Dr Mary Lowth
MA MB BChir FRCGP PGCME

Infectious diseases in GP and medical educationalist

children: Chickenpox
As with many infectious diseases associated with childhood,
chickenpox is generally a relatively mild condition in children,
but far more unpleasant in adolescents and poses significant
risks in adults and pregnancy. So if you think it isn’t anything
to worry about, think again

Most practice nurses will have seen varicella – chickenpox – in small

children, who are frequently brought into the surgery for confirmation of
diagnosis. Most practice nurses will be aware of the disease as a mildly
unpleasant but self-limiting illness of children, and most practice nurses will
have had it themselves.

In this article we discuss chickenpox and its possible serious sequelae, in

certain groups of individuals. We look at the chicken pox vaccine and its
currently recommended use. We also examine the use of herpes zoster
immunoglobulin (HZIG) and aciclovir in managing the disease,

WHY CHICKENS?

There are several theories regarding the origin of the term chickenpox. It is
often stated to be a modification of ‘chickpeas’ based on resemblance of the
vesicles to chickpeas, or due to the rash resembling chicken pecks. Other
theories include the designation chicken for a child (i.e., literally ‘child pox’) or
a corruption of itching-pox. Samuel Johnson explained the designation as
‘from its being of no very great danger.’ This was in comparison to the more
deadly smallpox.1

INCIDENCE AND PREVALENCE

Varicella has a seasonal variation in incidence, peaking in the late spring, and
90% of adults raised in the UK are immune.2

RISKS

The complications of chickenpox3 are shown in Box 1. The risk increases up

with age. In adolescents the disease is unpleasant, in adults, smokers and
pregnant women it can pose significant danger.
THE VIRUS

Chickenpox is caused by a herpes virus, HHV3.4 Others in the herpes virus

family include herpes simplex 1 and 2 (cold sores and genital herpes) and
Epstein Barr virus (glandular fever). Typical of all the herpes viruses is that
following primary infection there is a long term persistence of the virus in the
body, with reactivation a possibility later on after certain stimuli such as stress
and reduced immunity.

In the case of chickenpox this reactivation comes in the form of shingles,

which can itself be a very unpleasant condition, and which is most common in
mid to late adulthood.

Spread

The incubation period for chickenpox is around two weeks, although it ranges
from 10 days to about 3 weeks.5

Like many childhood diseases chickenpox is spread via respiratory droplet

infection. It then causes a viraemia and spreads via the blood and lymphatic
systems to the skin, where it causes the characteristic vesicular rash. The
lesions of chickenpox also secrete infectious virus until they crust over.

Notification

Chickenpox is a notifiable disease in Scotland and Northern Ireland,2 but not

in England and Wales.

TYPICAL INFECTION IN A CHILD5

The clinical illness begins with a rising temperature and malaise, usually for
24 hours or so, rapidly followed by the development of papules.

On the first day there may be only a few of these, often on the face and scalp.
However, within 24 hours more papules appear and the first papules turn to
vesicles and spread to the trunk and abdomen and eventually to the limbs. At
that point, with the lesions looking like tiny fried eggs, the diagnosis is usually
clear.

Vesicles can be so few that the infection passes undetected, or so many that
they cover every inch of the body. It’s often the case that siblings of an
affected child, who have a huge ‘loading dose’ because they are closely
exposed to the virus, have a much more dramatic cropping of vesicles than
the index child.

Each vesicle lasts three or four days, after which it crusts with a granular
scab. Picking these off can result in permanent scarring as the lesion extends
to the deeper skin layer.

Vesicles can affect mucus membranes as well as the skin. Lesions can
therefore be in places where other rashes are not common, such as the oral
cavity, eyes, genitalia and external ear canals.

The total course of chickenpox from the initial temperature to the crusting
over of the last vesicles (after which the patient is no longer infectious) is
usually 7-10 days. While chickenpox parties are often fashionable as a
means to make sure other very young children acquire immunity whilst so
young, children are generally not welcome in school or nursery while actively
infectious. This is partly because the illness needs symptomatic
management, and partly because of the risks to non-immune adults,
particularly those who are pregnant.

CHICKENPOX IN ADULTS

Chickenpox is a much worse disease in adults, particularly the over 50s,

those who smoke and in those who are pregnant.6 The illness is more
unpleasant and debilitating, with a higher rate of complications. The risk of
fulminating varicella pneumonia, which can be rapidly fatal, is significant in
these groups.
For this reason, adults (and this includes anyone over 14 years of age) are
usually offered antiviral treatment if their disease presents early, and
monitored or reviewed if it presents later (see below).

TREATMENT OF CHICKENPOX

The current NICE guidance6 is that children with chickenpox under the age of
14 should be treated symptomatically. This means with paracetamol or
ibuprofen for pain and fever, and topical soothing agents such as calamine on
the lesions, and chlopheniramine for itch. A broad spectrum antibiotic can be
added if the lesions develop superadded infection.

Aciclovir is not recommended for otherwise healthy younger children with

chickenpox.

Aciclovir is recommended for those aged 14 or over who present within 24

hours of rash onset. This is particularly important with multiple lesions and
marked symptoms, and those at risk of complications including smokers and
those on steroids.

Parents should bring their children back for review if they develop a high
temperature after initial improvement, with redness and pain around the
lesions, or if there are symptoms suggestive of pneumonia (cough),
encephalitis (altered consciousness, altered balance/ataxia, altered speech)
or dehydration (may be due to pain from intraoral lesions).

Older patients should be reviewed during their illness, at least by phone, as

their risk of complications is significant, particularly if they have presented too
late for effective antiviral therapy.

Bacterial superinfection

This is the most common complication of chickenpox.6 It makes the lesions

more itchy and is more likely to lead to scarring. Oral antibiotics are helpful.
Complications include secondary scarlet fever, scalded skin syndrome, and
sepsis (including toxic shock syndrome).

Why not treat with antivirals?

Aciclovir is fairly innocuous medication. It certainly reduces the number of

vesicles and the length and intensity of the disease. Why not, then, just treat?

In the NICE evidence summary,6 a Cochrane systematic review did not find
sufficient evidence to support the use of aciclovir in young, immunocompetent
children with uncomplicated chickenpox. Aciclovir reduced the maximum
number of lesions and the number of days with fever, but did not reduce the
occurrence of complications of chickenpox.

A review by BMJ Clinical Evidence into the use of aciclovir in otherwise

healthy adults found that aciclovir reduced the time to full crusting of lesions
and reduced the number of lesions but only if given within 24 hours of rash
onset. The reviewers could not identify any trials examining whether aciclovir
reduced complication rates. However, the increased risks in adults led NICE
to conclude that it made sense to treat this group.6

Preventative immunoglobulin: VZIG and its role

VZIG is varicella zoster immunoglobulin, prepared from pooled donor plasma.

It is used as a preventative in individuals exposed to chickenpox who are at
significant risk from infection. This includes pregnant women, neonates and
the immunosuppressed. Its availability is limited by supply and its used is
restricted.7

MANAGING EXPOSURE IN PREGNANT WOMEN

Pregnant women who have had definite chickenpox in the UK are likely to be
immune and no testing is needed (although they should be seen if they get a
rash).

Non-immune pregnant women are at greatest risk late in the second trimester
and early in the third trimester: between 1995 and 1998 there were nine
varicella deaths in pregnant women in England and Wales.7
The degree of risk is probably due to the relative immunosuppression of
pregnancy and is related to the stage of pregnancy at which infection
develops.

Therefore, if non-immune pregnant women are exposed to chickenpox we try

to treat to prevent them developing it. The treatment is expensive and scarce,
so we must be selective in whom we give it.

The Royal College of Obstetricians and Gynaecologists7 recommends that

non-immune women who are exposed to chickenpox while pregnant should
have their immune status ascertained by serology. Non-immune women
should be given VZIG as soon as possible. It is effective up to 10 days post
contact. The aim is to prevent infection – dosing with anti-chickenpox
immunoglobulin aims to mop up all active virus from the body before it can
get into cells and cause disease.

Contact with shingles is unlikely to result in chickenpox in a non-

immune individual unless the shingles is disseminated or exposed (e.g.
ophthalmic shingles).

CHICKEN POX IN PREGNANCY

Risks to the mother

Chickenpox can be harmful in pregnancy both to mother and baby.

Around 10% of pregnant women with chickenpox will develop varicella

pneumonia, slightly more at later gestation. Mortality of this condition was up
to 45% prior to antiviral agents being available, although it is now less than
1% due to the development of antivirals and improved intensive care.

Pregnant women who develop a rash which may be chickenpox should be

seen at once: if they are more than 20 weeks pregnant AND present within
24 hours of rash onset they should be given oral aciclovir (VZIG is purely
preventative and has no benefit once chickenpox has appeared).

Aciclovir can be used earlier in pregnancy as there is no evidence of the drug

causing fetal harm (but usually this would be on the advice of a specialist.)7,8

Risks to the fetus

The baby of a pregnant woman with chickenpox is at risk of fetal varicella

syndrome, in which the vesicles scar the developing fetus causing limb
hypoplasia, microcephaly, cataracts and growth retardation. However, the
incidence is only around 2% of affected pregnancies, primarily in women
between 12 and 20 weeks pregnant. From 20-28 weeks there is still some
risk of scarring but the risk is much lower.

Women who have chickenpox in pregnancy need detailed ultrasound

scanning 5 weeks post infection to look for fetal varicella syndrome.

Neonatal varicella

Babies are also at risk around the time of delivery if mothers develop
chickenpox in the last 7 days of their pregnancy. In such cases the baby is
highly likely to acquire the mother’s chickenpox but has not had chance to
acquire the mother’s immunity. This is because, initially, the infected woman
will make anti-varicella IgM rather than IgG, and IgM is too large to cross the
placenta to the baby. The baby is therefore undefended and is in the same
position as an immunosuppressed adult (highly vulnerable to overwhelming
infection.)

Babies born within 7 days of onset of mother’s rash are therefore given VZIG
at birth to try to prevent infection, and may also be treated with aciclovir.

Maternal shingles around delivery is not a risk to the baby as the

mother has antibodies to varicella fro her original chickenpox infection
and will have passed these to the baby during pregnancy.

VACCINATION

The chickenpox vaccine is not part of the UK childhood vaccination

programme in the UK,9 although it is given routinely in the USA and it is
available here privately. It is a live vaccine using attenuated virus so it cannot
be given to pregnant women nor to immunosuppressed individuals including
those on steroids and those with HIV.

The schedule is two doses four to eight weeks apart, at an age-related dose
providing about 98% protection in children and 75% in those over fourteen.10

In the UK it is used only to protect people who are most at risk of serious
complications from chickenpox infection, usually by vaccinating those non-
immune individuals who might come into contact with them (including their
families, and health care workers).

Box 2 outlines the arguments for and against vaccination in the UK. At
present there is no intention to introduce it on a routine basis.

There is an argument (see Box 2) for offering it to adolescents who have not
had primary varicella infection by the age of fourteen years, but this is not
currently planned.

WHO opinion

Information concerning aspects of varicella vaccination is incomplete. The

duration of protection and the zoster-preventive effect of vaccination need to
be better understood. Furthermore, there is little information from developing
countries on the disease burden of varicella and zoster. It is unlikely that
varicella will be among the priority vaccine-preventable diseases in most
developing regions.

SUMMARY

Chickenpox can be lethal and is certainly an unpleasant disease to acquire

beyond early childhood. It is easy to recognize and simple to treat, although
in view of the benign nature of its course in most young children aciclovir is
not routinely used in under 14s.

Chickenpox is a dangerous condition in pregnancy and in the

immunosuppressed and the over 50s. It poses a risk of harm to the
developing fetus.

Vaccination is not routinely offered in the UK but it is in many countries. To

start a vaccination programme which does more good than harm we would
need to know that we could achieve high sustained vaccine coverage in a
fairly short time, and to feel sure that the protection offered by the vaccine did
not simple wear off in later life.

REFERENCES

1. Johnson, Samuel (1839). Dictionary of the English language. London:

Williamson. p. 195.

2 Health Protection Agency Website : chickenpox http://www.hpa.org.uk/Topic

s/InfectiousDiseases/InfectionsAZ/ChickenpoxVaricellaZoster/ accessed
21/5/13

3. Lissauer T and Clayden G, Third Illustrated Textbok of Paediatrics Mosby

Elsevier 2007

4. Belshe, Robert B. (1984). Textbook of human virology (2nd ed.). Littleton

MA: PSG. p. 829.

5. Graham-Davies E, Elliman D A C, Hart C A et al: Manual of Childhood

Infections British Paediatric Association pub Saunders 1996

6. NICE recommendations on treatment of chickenpox http://cks.nice.org.uk/c

hickenpox#!scenariorecommendation

7. Royal College of Obstetricians and Gynaecologists guidance on

management of chickenpox exposure in pregnancy http://www.rcog.org.uk/wo
mens-health/clinical-guidance/chickenpox-pregnancy-green-top-13 Accessed
21/5/13.

8. Use of acyclovir in pregnancy: UK Teratology Information Service

December 2010 version 1 : www.uktis.org/docs/aciclovir.pdf accessed
21/5/13

9. NHS Choices: Chickenpox Vaccination: http://www.nhs.uk/chq/pages/1032.

aspx?categoryid=62&subcategoryid=63 accessed 21/5/13
10. WHO information on chickenpox vaccination http://archives.who.int/vaccin
es/en/varicella.shtml Accessed 21/5/13

11. Immunisation against infectious disease : the Green Book on line:

Chapter 34: Varicella https://www.gov.uk/government/organisations/public-
health-england/series/immunisation-against-infectious-disease-the-green-
book accessed 21/5/13

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