0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
From the Centers for Disease Control and Prevention | Morbidity and Mortality Weekly Report|

Notes from the Field: Severe Varicella in an Immunocompromised Child Exposed to an Unvaccinated Sibling with Varicella—Minnesota, 2011 FREE

JAMA. 2012;308(10):968. doi:.
Text Size: A A A
Published online

MMWR. 2012;28:541.

Varicella usually is a self-limited disease but can result in serious complications (e.g., encephalitis, pneumonia, sepsis, hemorrhagic varicella, and death), especially among immunocompromised persons. Implementation of the varicella vaccination program in the United States, beginning in 1995, has led to declines of >95% in varicella-related hospitalizations and deaths among populations routinely vaccinated.1

On December 13, 2011, the Minnesota Department of Health was notified of varicella in a girl, aged 3 years, admitted to a hospital after a 2-day history of fever of 102.7°F (39.3°C) and an extensive maculopapulovesicular rash (>500 skin lesions) with vesicles in the mouth and throat. The child received weekly immunosuppressive therapy with methotrexate (12.5 mg) for juvenile rheumatoid arthritis diagnosed at age 18 months. Neither she nor her younger sibling, aged 21 months, had received a first dose of varicella vaccine (routinely recommended at age 12–15 months). Their parents refused vaccination because of personal beliefs. The parents reported varicella in the younger sibling 2 weeks before her older sister was admitted. The older sister had not received prophylactic varicella zoster immune globulin (VariZIG); however, her parents monitored her for varicella symptoms.

The patient was treated with intravenous acyclovir for 7 days. Her fever resolved, and no new skin lesions appeared after hospital day 2. Moderate thrombocytopenia (platelet count: 103,000/ μ L; normal: 150,000–450,000/ μ L) resolved by hospital day 6. No other substantial laboratory abnormalities or signs of organ dysfunction were reported. She was discharged in good condition on hospital day 8.

Varicella vaccination is not recommended for children with congenital or acquired T-lymphocyte immunodeficiency (except certain categories of human immunodeficiency virus–infected children), including children receiving long-term immunosuppressive therapy, because of risk for complications from live vaccine virus infection.2 However, these patients are at high risk for severe or fatal varicella and depend on indirect protection through high levels of varicella immunity among the general population, and especially among their close contacts, to prevent exposure. Varicella vaccination of household contacts of immunocompromised patients is recommended if contacts lack evidence of varicella immunity. If exposure to varicella zoster virus occurs, postexposure prophylaxis with VariZIG (available through an Investigational New Drug protocol*) is recommended for immunocompromised patients and other persons at high risk for severe disease who lack evidence of varicella immunity.2 In 2011, the period after exposure during which a contact may receive VariZIG was extended from 96 hours to 10 days; VariZIG should be administered as soon as possible after exposure.3

Clinicians should remain vigilant for opportunities to prevent varicella through vaccination of household members of immunocompromised patients and administration of passive immunoprophylaxis (VariZIG) for up to 10 days after a susceptible, immunocompromised patient is exposed. Resources to help clinicians discuss vaccination with hesitant parents are available at http://www.cdc.gov/vaccines/spec-grps/hcp/conv-materials.htm.

Reported by: Vicki Buttery, MS, Lynn Bahta, Claudia Miller, MS, Minnesota Dept of Health. Mona Marin, MD, Div of Viral Diseases, National Center for Immunization and Respiratory Diseases; Sarah K. Kemble, MD, EIS Officer, CDC. Corresponding contributor: Sarah K. Kemble, skemble@cdc.gov, 312-942-2061.

*Additional information available at http://www.fffenterprises.com/products/varizig.aspx.

REFERENCES

Marin M, Zhang JX, Seward JF. Near elimination of varicella deaths in the US after implementation of the vaccination program.  Pediatrics. 2011;128(2):214-220
PubMed   |  Link to Article
CDC.  Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR. 2007;56(RR-4):
PubMed
Centers for Disease Control and Prevention (CDC).  FDA approval of an extended period for administering VariZIG for postexposure prophylaxis of varicella.  MMWR. 2012;61(12):212
PubMed

Figures

Tables

References

Marin M, Zhang JX, Seward JF. Near elimination of varicella deaths in the US after implementation of the vaccination program.  Pediatrics. 2011;128(2):214-220
PubMed   |  Link to Article
CDC.  Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR. 2007;56(RR-4):
PubMed
Centers for Disease Control and Prevention (CDC).  FDA approval of an extended period for administering VariZIG for postexposure prophylaxis of varicella.  MMWR. 2012;61(12):212
PubMed
CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections