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From the Centers for Disease Control and Prevention
September 12, 2012

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

JAMA. 2012;308(10):968. doi:

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
1.
Marin M, Zhang JX, Seward JF. Near elimination of varicella deaths in the US after implementation of the vaccination program.  Pediatrics. 2011;128(2):214-220PubMedArticle
2.
CDC.  Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP).  MMWR. 2007;56(RR-4):PubMed
3.
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):212PubMed
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