Journal of Infection (2008)

57,95 e 102

www.elsevierhealth.com/journals/jinf

REVIEW

Chickenpox in adultse Clinical management

c
A.J. Tunbridge a,*, J. Breuer ,b K.J.M. Jeffery , on
behalf
of the British Infection Society
a

Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Glossop Road, Shefeld S10 2JF, UK
Barts and The London School of Medicine and Dentistry, 4 Newark Street, Whitechapel, London E1 2AT, UK
c
Department of Microbiology, Oxford Radcliffe Hospitals NHS Trust, Headington, Oxford OX3 9DU, UK
b

Accepted 9 March 2008

Available online 13 June 2008

KEYWORDS
Varicella;
Chickenpox;
Aciclovir;
Severe infection;
Pregnancy;
Adult

Summary Acute varicella zoster virus (VZV) infection, or chickenpox, is still perceived by
manyas amild infection of childhood. However,chickenpox isincreasingly common inadults
andadolescentswhotogetherwithimmunosuppressedindividualsareatahigherriskofsevere
infection. Antiviral therapy is available which both ameliorates symptoms and decreases the
severityofchickenpox ifadministered earlyinthecourse oftheinfection. Passive immunisationwithvaricellazosterimmunoglobulin(VZIG)maypreventorattenuateinfectionfollowing
exposure to varicella of an immunocompromised or pregnant individual or a neonate. Active
immunisation is available and is universal in many developed countries.
ThisreviewreectscurrentbestpracticeinmanagementofchickenpoxinadultsbyspecialistphysiciansintheUK.Theaccompanyingowcharthasbeenformulatedtoguideemergency
physiciansandgeneralpractitionersthroughthedecision-makingprocessregardingtreatment
and admission for specialist care.
2008Published by Elsevier Ltd on behalf of The British Infection Society.

However, in many tropical countries the epidemiology is

different,withlessthan60%ofadultsbeingimmune.2 Factorscontributingtothismayincludepopulationdensityand
Chickenpox, or varicella, is a well-recognised systemic
climatic effects.3 In temperate climes the incidence of
infectioncausedbyvaricellazostervirus(VZV).Intemper4
chickenpox in adolescents and adults is increasing,
which
ate countries chickenpox is usually a mild, self-limiting
mayinpartbeduetoincreasedworldtravelandeconomic
infection, affecting pre-school children. In the UK 90% of
migration of susceptible individuals. Morbidity and mortal1
adults over the age of 18 years are seropositive for VZV.
4,5
ityisgreaterinadultsthaninchildren.
Specicriskfactors include pre-existing lung disease, smoking, and
immunocompromise, including immunosuppressive drug
* Correspondingauthor.Tel.: 441142713561;fax: 44114226
5
therapy, HIV infection and malignancy.
For every 100,000
8875.
E-mail address:anne.tunbridge@sth.nhs.uk (A.J. Tunbridge). individuals who develop chickenpox, between four and

Introduction

0163-4453
/$34 2008Published by Elsevier Ltd on behalf of The British Infection Society.
doi:10.1016/j.jinf.2008.03.004

96

A.J. Tunbridge et al.

6,7

ninewilldie,ofwhom81 e 85%willbeadults. Chickenpox

isvetimesmorelikelytobefatalinpregnancythaninthe
8
non-pregnant adult.

It may be important to differentiate chickenpox from

other vesicular rashes. Chickenpox rash is centripetally
distributed, particularly involving the face and trunk, with
fewerlesionsonthelimbs.Earlyinthediseaselesionsatall
stages of development may be seen. Variola (smallpox)
Pathogenesis
lesionsclassicallyappearedrstlyonthetongueandpalate
DuringprimaryinfectionVZVcolonisestheupperrespiratory andassmallmaculesonthefacebeforecentrifugalspread.
tract,followedbyseedingofthereticuloendothelialsystem. The vesicles or nodules were rm, well-circumscribed,
Viraemia is followed by spread to the skin and mucosal deeper in the skin, and all at the same stage of desurfaces, with development of the characteristic vesicles.velopment. Although global eradication of smallpox was
Infection is controlled by both humoral and cell mediatedannouncedin1979thevirusremainsonterestbecauseof
immuneresponses.Followingprimarychickenpox,thevirus bioterrorism concerns. Other conditions that may be
establisheslatencyinthedorsalrootganglia.Subsequently confused with chickenpox include impetigo (may begin as
areductionincellmediatedimmunefunctionorsenescence regional vesicles before crusting develops), drug related
eruptions, contact dermatitis, erythema multiforme and
mayallowreactivationofthevirus,resultinginthedermatomalvesicularrashofshingles,alsoknownasherpeszoster. Stevens
e Johnson syndrome, enteroviral infections (hand,
foot and mouth disease; typically a peripheral distribution
of whitish-grey tender at vesicles), disseminated mollusInfectivity
cum contagiosum, plus scabies, poison ivy and pityriasis
rosea, the latter three being intensely itchy conditions.
Chickenpox has a high attack rate, affecting 90% of nonimmune exposed individuals. The incubation period is
9
10e 21 days. Infectivity is at its highest from 2 days prior Assessment of a patient with chickenpox
to onset of the rash, with airborne droplet spread playing
Clinical examination may reveal little apart from the rash.
animportantroleintransmission. Thevirusisalsodirectly
shed from vesicles, and may be transferred by heavily The absence of respiratory signs does not preclude the
14
contaminated clothing or bedding until all the vesicles presence of pneumonitis. Chest radiography and pulse
oximetry should be performed on all patients who are at
have crusted over and dried, usually after
e 65days.
A non-immune individual can develop primary chicken-particular risk of pneumonitis (see below) or who develop
symptoms of cough or breathlessness. Any patient with
poxaftersignicantexposuretoshingles.Itisimportantto
signs of severe disease (see Table 1) should be assessed
reassure contacts that anyone who has had chickenpox or
by a specialist physician in hospital.
shinglesinthepastcanbeconsideredtobeimmune.10 Re11
Thrombocytopenia and moderately raised liver transexposure to VZV protects against herpes zoster.
aminasesareoftenseen,butusuallyresolvewiththeacute
14
illness.
Clinical chickenpox and its differential

diagnosis

Complications of chickenpox

The clinical diagnosis is rarely in doubt, although disseminated herpes zoster or herpes simplex in immunocomproPneumonitismaybelife-threateningandisaparticularrisk
mised individuals may be difcult to differentiate from in pregnant women, the immunocompromised, those with
primaryVZVinfection.Fever,malaiseandlethargyprecede pre-existing lung disease (not including asthma), and
the eruption of the rash by 24h. The rash starts on the smokers. Between 5 and 14% of adults with chickenpox
15
trunk and face, develops in crops, and typically spreads will develop pulmonary involvement.
Patients with more
to involve much of the skin surface. It is initially macular,than one risk factor are more likely to develop severe
16
proceeding to papules and vesicles that are uid lled varicellapneumonitisrequiringrespiratorysupport.Close
and become pustular, often turning yellow. The lesions monitoring of respiratory rate and oxygen saturation is
are intensely itchy, with surrounding erythema. Most
essential as pneumonitis can progress rapidly.
patientshaveamoderateriseintemperature.Themucous
Centralnervoussysteminvolvementmayresultinacute
membranes of the oropharynx and genital tract may
cerebellar ataxia which usually occurs during the recovery
become involved. In immunocompetent individuals the periodandismostlikelytobeimmunologicallymediatede
rash peaks at 48h. The vesicles will then begin to crust itisusuallybenignandself-limitinginchildren.Morerarely
over before drying up; new lesions may appear for up to varicellaencephalitisoccurswhichcarriesamortalityofup
5
days. Scabs usually separate and are shed within 2 weeks
to 20%. Signicant invasive infection, causing multi-system
17
oftheonsetonfection.Fullresolutionoftheskinlesions
failure, may occur in immunocompromised patients.
may take up to a month (Fig. 1).
Secondary bacterial infection with Staphylococcus
A typical presentation may occur, particularly in the aureusor Group A Streptococci is a common complication
immunocompromised, e.g. with the development of ab- of chickenpox and may result in skin and soft tissue infecdominal pain due to visceral disease prior to onset of thetion, osteomyelitis, septicaemia or toxic shock syndrome.
classicskinrash.12 Inbonemarrowtransplantrecipientsthe A signicant rise in temperature 2 or 3 days into the
syndromeofacuterightupperquadrantpainduetohepatic illness may indicate a secondary bacterial infection and
necrosismaybemisinterpreted intheearly stages asgraft treatmentwithappropriateantibiotics,suchasucloxacil13
versus host disease.
lin, co-amoxiclav or a macrolide should be considered.

Chickenpox in adults

97

Chickenpox in Adults: Clinical Management

Box 2

Box 1
Chickenpox is the primary systemic infection with Varicella-Zoster virus (VZV)
Acute systemic VZV has
mortality and morbidity in adolescents and adults
1
1
compared to children . Immunocompromised adults and non-immune pregnant
2
woman are at particular risk.
Prompt treatment with aciclovir

duration and severity of symptoms

There is no evidence of benefit of aciclovir once the rash has been established
3
for >48hrs
Infectivity: 2 days prior to onset rash, until all vesicles crusted. Immunity in contacts
can be assumed if there is a clear history of clinical chickenpox.
In cubation of chickenpox: 10-21 days

Signs of severe infection include:

Respiratory symptoms
(clinical respiratory signs often absent)
Densely cropping vesicles
Haemorrhagic rash
Bleeding (from any site)
Any neurological changes
Persisting fever with new vesicles
>6 days after onset
If signs of severe infection present,
seek specialist advice

Patient with clinical chickenpox?

N
Y

Pregnant ?

Signs of severe
infection? (Box 2)

Gestation >36/40
or risk of premature
2
labour ?

Oral Aciclovir 800mg x5/day

for 7 days (Box 3), monitor
for severe infection (Box 2)

N
Y
Immunocompromised?
(For details see reference 4)
Primary immunodeficiency

Admit to isolation bed in hospital

for regular monitoring

Chemo or radiotherapy within last 6

months (12 months for Bone marrow
transplant)

IV Aciclovir (10mg/kg tds)

Y

Steroids (>40 mg prednisolone/day

for >1 week) within last 3 months

Check LFTs, renal function and

clotting for DIC

On other immunomodulatory drugs

CXR for evidence of pneumonitis,

(consider risk/benefit in pregnancy)

HIV positive

Monitor pO
2
Y
N

If temp fails to settle consider

possible secondary S. aureus or
Streptococcal infection
Switch to oral therapy as soon as
possible

New vesicles and fever

within last 24-48 hrs?

Signs of severe
infection? (Box 2)

Symptomatic treatment
only,monitor for severe
infection (Box 2)

Box 3

Monitor for severe infection (Box 2)

NB: Smokers and those with chronic
lung disease have increased risk of
pneumonitis

Oral Treatment:
Valaciclovir 1g tds
or Famciclovir 500mg tds
or Aciclovir 800mg x5/day

Give oral treatment (Box 3) +

symptomatic relief.

7 days

(NB: bioavailability of oral Aciclovir is poor)

Intravenous treatment:
Aciclovir 10mg/kg tds
Renal impairment: dose reduction
5
required for all forms of Aciclovir
Pregnancy: No adverse data for use
of Aciclovir, data inadequate for
5
Valaciclovir or Famciclovir

Figure 1

References:
1. United Kingdom Advisory Group on Chickenpox.
Consensus guidelines for management of varicella-zoster infection.
J.Infection 1998; 36 Suppl 1:1-83.
2. Scientific Advisory Committee of Royal College of Obstetricians and Gynaecologists.
Guidelines on chickenpox in pregnancy. 2007; Guideline No. 13: 1-8.
3. Wallace MR, Bowler WA, Murray NB, Brodine SK, Oldfield EC3rd
Treatment of adult varicella with oral acyclovir. A randomized, placebo-controlled trial.
Ann Intern Med. 1992 Sep 1;117(5):358-63.
4. Immunisation against Infectious Disease,The Green Book. Chapter 34 Varicella. Department
of Health, London, 2006.
http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254
5. Joint Formulary Committee. British National Formulary. 54 ed. London:
British Medical Association and Royal Pharmaceutical Society of Great Britain; Sept 07

Chickenpox in adults
e clinical management.

98

A.J. Tunbridge et al.

The relatively low frequency of serious complications of

VZV infection in adults means that trials of aciclovir treatmenthavebeeninsufcientlypoweredtodemonstrateareduction in the complication rate, although a retrospective
Respiratory symptoms
analysisof46reportsof272patientswithvaricellapneumo(clinical respiratory signs are often absent).
niashoweda3.6-foldhighermortalityrateinthosewhodid
Densely cropping vesicles.
28
not receive aciclovir.
Qualitative cost analysis does howHaemorrhagic rash.
eversuggest thattreatmentofalladultsandadolescents is
29,30
Bleeding
worthwhile.
A minimum of 1 week of antiviral therapy
(e.g. from gums, haemoptysis, GI bleeding).
isrecommended.Twoweekstherapymaybeappropriatein
Any neurological changes
severe disease or in the immunocompromised, for whom
(cerebellar signs, encephalopathy).
intravenoustherapyisusuallyrecommended,althoughwith
Persisting fever with new vesicles
>6 days after onset.
rapid improvement an early switch to oral therapy may be
considered.IntheUK,theuseofaciclovirisnotrecommen31
dedinimmunocompetentchildrenundertheageof12,
as
Haemorrhagic complications include pulmonary and thecomplicationrateislowandtreatmentconfersminimal
20
benetwhencomparedtoadolescentsandadults.
Aciclovir
gastrointestinal bleeding, intra-cerebral haemorrhage and
disseminatedintravascularcoagulation.Evidenceofbleed- should be used in children if they or their sibling contacts
32
ing,e.g.easybruising,haemorrhagicskinlesions,bleeding haveasignicantmedicalcondition. Aplacebo-controlled
gums,orhaemoptysis,shouldbeurgentlyinvestigatedwith study does recommend aciclovir for adolescents, as they
20
havemoreseverediseasethanyoungerchildren.
prompt admission to hospital.
Aciclovir at a dose of 10mg/kg intravenously every 8h
should
be used for those who have or are at risk of severe
Investigation of chickenpox
disease.31 Intensive supportive therapy may be required
and antibiotic cover is appropriate if secondary bacterial
Althoughthemajorityofdiagnosesaremadeclinically,the
sepsis is suspected. A small retrospective study of the use
virus may be detected by molecular techniques (PCR) or
ofsteroidsinseverevaricellapneumoniashowedsomebenvirus isolation from uid/cells from the base of the
et,33 but there is no data from prospective randomised
vesicular lesion. This may be helpful in the management
controlled trials and steroids are not currently recommenof the immunocompromised patient, in whom a vesicular
ded. There is no evidence that varicella zoster immunorash may have other causes such as disseminated herpes
globulin (VZIG) reduces the severity of infection.
simplex infection or graft versus host disease.
Supportive therapy, such as anti-pruritic drugs can be
helpful for all age groups. Mouthwashes and soothing
Treatment of chickenpox
topical lotions, plus anaesthetic gels for the genital area
if there is mucosal involvement, are also useful for
Aciclovir inhibits VZV replication, reducing severity and symptomatic treatment.
shorteningdurationofsymptomsifgivenwithin24hofthe
Chickenpox in pregnancy
onsetonfection.18e 21 Whileitisrareforpatientstopresentwithinsuchashorttimeframe,apragmaticapproachis
to consider antiviral agents in patients who present within
Pregnant women are at signicant risk of varicella pneu24e 48h of new vesicles, implying that the disease is still monitis and severe disease. The risk is highest after 20
22
evolving.
For immunocompetent individuals presenting weeks gestation as T-cell function starts to decline or in
more than 48h after the development of new lesions
those who smoke, have chronic lung disease, are immuno15,34
symptomatic treatment only is advised, but they should suppressedorhavemorethan100skinlesions.
Therisk
be monitored for signs of severe infection (see Table 1). of miscarriage and premature labour in later pregnancy is
35
Aciclovirhasagoodsafetyproleandiswell-tolerated.
also increased.
Fetal varicella syndrome is a recognised
However, the bioavailability of oral aciclovir is poor,
complication of infection in the rst half of pregnancy,
requiring dosing at 800mg 5 times daily. In addition the affecting approximately 0.4% of infants born to mothers
IC90 of VZV for aciclovir and related compounds is higherinfectedupto12weeks,and2%ofthoseinfectedbetween
36e 39
than for herpes simplex virus and therefore levels may be13 and 20 weeks of gestation.
There have been rare
suboptimal for inhibition of viral replication. The pro-drugcases of fetal varicella syndrome reported in infants
38
valaciclovir,atadoseof1g3timesdaily,greatlyenhances
exposed between 20 and 28 weeks gestation.
Shingles in
23
39
bioavailability, resulting in 3- to 4-fold higher plasma
the mother does not present a risk to the infant.
aciclovir levels that can be achieved with oral aciclovir.
Neonates have a signicant risk of severe varicella
Famciclovir, the pro-drug of penciclovir, dosed at 500mg infection when the onset of maternal infection is within 5
3 times daily,also hasenhanced bioavailability when com-days prior to or 2 days after delivery, due to the lack of
pared with aciclovir. These second generation antiviral transferofprotectivematernalantibodiesandtherelative
drugsarerecommendedrstlineforthetreatmentofshinimmaturity of the neonatal immune system. Mortality is
40
gles (herpes zoster), as they accelerate healing, reduce thought to be up to 30% without active treatment,
and
pain and reduce dosing frequency compared to aciclo- VZIGisrecommendedforallinfantswhosemothersdevelop
vir.24e 26 Theyarebecomingthepreferredoralformulations chickenpox 7 days before to7 days after delivery. Intrave27
for chickenpox in many cases.
nous aciclovir should be given to these infants if they
Table 1 Indicators of severe disease in acute varicella
14
infection

Chickenpox in adults

99

develop chickenpox, whether or not they received VZIG. Chickenpox in the immunocompromised
Shinglesinthersttwoyearsoifeisthoughttobeareac39
tivation of chickenpox acquired in utero.
Patients in the categories shown in Table 2 should be conTherearenodatatosuggestanincreasedriskofadverse sidered as being at risk of severe VZV infection,43 and
events following aciclovir exposure at any stage in preg- should receive antiviral therapy as soon as possible. Early
31,35
nancy.
The Royal College of Obstetrics and Gynaecol- assessment in hospital is recommended, as parenteral
44
ogy guidelines state that any pregnant woman at more treatment is most appropriate to prevent complications.
35
than20weeksgestationshouldbetreatedwithaciclovir,
New lesions may appear over several days in the immunowhichislikelytobeofbenettothemother withminimal
compromised, and antiviral treatment should be adminisrisk to the fetus. However, in each case of chickenpox in tered if new lesions or fever have been observed in the
earlypregnancy(i.e.<20weeks),theriske benetoftreatprevious 24
e 48h, regardless of time since onset.
mentshouldbeconsideredbyanexpertinthemanagement
of infections, so that the patient is able to make an
Primary prevention of chickenpox
informed decision. The International Aciclovir Pregnancy
Register reported on 1129 prospectively followed pregnancies of which 712 involved aciclovir exposure in the rst Thereare2varicellavaccinescurrentlylicensedintheUK:
Varilrix (GSK), and Varivax(SPMSD). Both are live attentrimester with no evidence of adverse outcome. It is usual
uatedvaccinesandareadministeredtonon-immuneadults
practice in many parts of the world to treat pregnant
women with antiviral therapy in all trimesters.
Limited data on the use of valaciclovir in pregnancy,
mainly for conditions other than VZV infection, provide
Table 2
Immunocompromised patients in whom acute
43
some useful pharmacokinetic data and do not reveal any varicella infectionis likelyto develop into severe disease
evidence of toxicity. The Valaciclovir Pregnancy Registry
has reported on 56 valaciclovir exposed pregnancies, 14 1. Patientswithsevereprimaryimmunodeciencysuchas
SevereCombinedImmunodeciency (SCID)orWiskott
e
involving rst trimester exposure, with no evidence of an
Aldrich syndrome.
adverse outcome. A prospective double-blind trial of
aciclovir versus valaciclovir for herpes simplex infection in 2. All patients receiving immunosuppressive chemotherapy or radiotherapy for malignant disease, up to 6
the third trimester showed signicantly higher peak serum
months after completion of treatment.
aciclovir concentrations in the valaciclovir group than in
41
3. All patients on immunosuppressive therapy following
the aciclovir group. No laboratory or clinical evidence of
a solid organ transplant.
toxicity was detected, although patient numbers were
small. High dose valaciclovir has also been used in a trial 4. All patients who have undergone bone marrow transoftreatmentforsymptomaticintrauterinecytomegalovirus
plantation, up to 12 months after completing all
infection; therapeutic concentrations of aciclovir were
immunosuppressive therapy, or longer if graft versus
a
obtained in fetal blood.42 There are no data for the use
host disease has occurred.
of famciclovir in pregnancy.
5. Patients taking high doses of systemic steroids, e.g: in
VZIG is commonly used in pregnant non-immune chickadults 40 mg/day for
>1 week; in children 2mg/kg/
enpox contacts to prevent or attenuate disease. Studies
day for>1 week or 1mg/kg for>1 month. Risk is
havenotbeensufcientlypoweredtoexaminetheeffectof
maintained up to 3 months after treatment has
VZIG administration on the incidence of fetal varicella
stopped.
syndrome;acasehasbeendescribedinthebabyofamother
6.
Patients receiving other immunomodulatory drugs such
38
whodidreceiveVZIG. Ifpassiveimmunityistobeoffered,
as azathioprine, cyclosporine, methotrexate, cycloitshouldbegivenassoonaspossibleupto10daysafterthe
phosphamide and the cytokine inhibitors, and/or
exposure. There is also no evidence that aciclovir reduces
chronic low dose steroid therapy.
the incidence of fetal varicella syndrome, again due to
7.
Patients with HIV infection, particularly if the CD4
a lack of studies with sufcient power to demonstrate
3 b
count is less than 200cells/mm .
achangeinwhatisarareevent.Theobstetricteamshould
8. Neonates, either exposed by maternal infection 7 days
be informed of the cases of chickenpox in pregnancy to
beforeorafterbirth,oranyexposureupto7daysafter
enablemonitoringforthesyndrome.
birth.
For mild disease in pregnancy oral aciclovir is the
c
current recommendation in the UK, administered at
9. Non-immune pregnant women.
30
a dose of 800mg 5 times daily for 1 week. However,
a
Patients who have undergone bone marrow transplantation
second generation antiviral drugs should be considered onshould be offered vaccination once all immunosuppressive
expert advice. If there is any concern about severity of
therapy has been stopped for more than 12 months.
b
the disease (see Table 1), referral to hospital should be
Patients with HIV who have not previously had chickenpox,
3
and have a CD4 count greater than 400cells/mm
should roumade for consideration of parenteral therapy. Women
tinely be offered vaccination; at CD4 counts 200
400cells/
whoareclosetotermshouldbeadmittedtoanisolationfae
mm3 , vaccination should be considered if the patient is stable
cilitywithaccesstospecialistobstetricandpaediatricser51
anti-retroviral therapy.
vices because of the signicant risk of premature labour on
c
Non-immunepregnantwomenshouldbeconsideredforVarand of neonatal infection. Intravenous aciclovir should be
icellavaccineassoonaspossibleafterdelivery,35,47althoughit
administered,andifpossible,deliveryoftheinfantdelayed
is not licensed for use during breastfeeding.
35
until at least 5 days after the onset of infection.

100

A.J. Tunbridge et al.

and children over the age of 12 in a 2 dose schedule. In Conclusion

countries with a universal varicella immunisation programmeamarkedreductionintheincidenceofchickenpox These guidelines reect current best practice for the
hasleadtoadeclinein attributable morbidity andmortal- management of chickenpox in adults by specialist physiity, and to a fall in varicella-related healthcare utilisation cians in the UK. Recommendations include antiviral treat45
and cost of the disease management. Currently there
ment for adults who present withine24
48h of rash onset,
are no plans to vaccinate children routinely against VZV and treatment of women in early pregnancy.
The latter is
9
in the UK but expert groups are recommending its imple-supported in the most recent version of the guidelines
46
mentationacrossEurope. However,vaccinationisadvised published by the UK Royal College of Obstetricians and
35
forseronegativechildrenifamemberoftheirhouseholdis
Gynaecologists. It is unlikely that sufciently powered
atriskofseveredisease,e.g.siblingsofachildwithleukaetreatment studies will be performed to demonstrate a remia,orchildrenwithaparentundergoingchemotherapy,in duction in the complication rate of adult chicken pox, or
43
viewofthehighattackrateinclosecontacts. Itisconsida reduction in fetal varicella syndrome, but the suggested
ered that only a universal immunisation programme would
drug regimens have a good safety record. Furthermore,
adequately reduce morbidity and mortality in pregnancy.the demonstrated reduction in the number of days with
VaricellavaccinationisnowrecommendedintheUKfor
fever and the number of vesicles has potential economic
29
all non-immune healthcare workers in primary care and benets for the workforce.
hospital settings, as the rate of transmission in the health The owchart on management of chickenpox in the
care setting is high and vulnerable patients may be put at
adulthasbeendesignedforpatientspresenting toprimary
9
risk. Allhealthcareworkersshouldbeaskedaboutahistory care or an emergency admissions service. Perceptions of
of chickenpox or shingles, and have antibody testing andchickenpox as a mild disease of childhood lead to an
subsequentvaccinationasappropriate.Womenareadvised underestimation of its potential to cause severe disease
47
not to become pregnant within 1 month of vaccination.
in adolescents and adults. This owchart will facilitate
Varicellavaccinationisalsorecommendedfornon-immune early initiation of treatment, the evidence for which is
healthy close contacts of immunocompromised patients. presented
A
above. A owchart for the management of
clear history of chickenpox or shingles is considered to besusceptible individuals following exposure to chickenpox
adequateevidenceommunityinthosebroughtupintem- is already available in the UK in the Department of Health
10
43
50
perate climes,
although it can be less reliable in adults Green Book
and from the Health Protection Agency.
48
bornandraisedinareasoowseroprevalence.
LackommunityshouldbeconrmedbytestingforVZVIgGinserum
priortoimmunisationasasymptomaticinfectioniscommon.

Prevention of chickenpox following exposure

Acknowledgments

With thanks to Prof MW McKendrick, Shefeld Teaching

Varicella zoster immunoglobulin (VZIG) reduces the risk of
Hospitals; Dr C Conlon, Oxford Radcliffe Hospitals; Dr C
infection following exposure by40% andcanattenuate theMcNulty, Health Protection Agency; and Dr DH Dockrell,
severityofdisease.49 Itshouldbeconsideredforindividuals University of Shefeld Medical School. These guidelines
who full all three of the criteria listed in Table50
3.
have been subject to a consultation process through the
VZIGmaybeofferedupto10daysafterexposure,butis
Clinical Virology Network and the guidelines committee of
ideally administered within 7 days of contact with an
the British Infection Society.
43
infectivecaseofchickenpoxorexposedshingles.
Further
guidance on prophylaxis of at risk individuals, including References
pregnant women, is available in the Department of Health
Green Book available via the internet.43 Patients who
1. VyseAJ,GayNJ,HeskethLM,Morgan-CapnerP,MillerE.Serohave received VZIG should be advised that medical advice
prevalenceofantibodytovaricellazostervirusinEnglandand
shouldstillbesoughtifchickenpoxoccurs,asantiviraltherWalesinchildrenandyoungadults.EpidemiolInfect2004;132:
apy may be required. In those for whom VZIG is not indi1129e 34.
cated the use of aciclovir may be considered for use as 2. Lee BW. Review of varicella zoster seroepidemiology in India
50
prophylaxis.
and Southeast Asia.Trop Med Int Health 1998 Nov;3(11):
886e 90.
3. Lolekha S, Tanthiphabha W, Sornchai P, Kosuwan P, Sutra S,
Table 3 Main criteria for patients requiring VZIG
Warachit B, et al. Effect of climatic factors and population
densityonvaricellazostervirusepidemiologywithinatropical
1. Have a clinical condition which puts them at risk
country.Am J Trop Med Hyg2001Mare Apr;64(3e 4):131e 6.
of severe varicella infection (see Table 2).
4. Fairley CK, Miller E. Varicella-zoster virus epidemiologye
2. Are seronegative for antibodies to VZV.
a changing scene?
J Infect Dis1996;174(Suppl. 3):S314
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