1. Varicella & Pregnancy Dr S. Asadi Infectious diseases specialist
Shahid Beheshti university of medical sciences

2. Epidemiology
children 5 to 9 years of age, who represent 60% of all cases. Children < 15 yrs represent 90% cases
By adulthood, 90%-95% of the U.S. population have antibodies to varicella.
In the tropics, varicella occurs more often in adults; thus, immigrants from these areas are more likely to be susceptible than the remainder of the population at comparable ages.
Between 150,000 to 200,000 cases of varicella are reported annually to the Centers for Disease Control and Prevention (CDC), representing 4%-6% of all cases.

3. Mode of Transmission
Person to Person: Direct contact with vesicular fluid or via aerosolized respiratory droplets
Need airborne and contact precautions

4. Incubation period Typically, 14-16 days with a range of 10-21 days
May be prolonged in Immunocompromised patients and those that have received VZIG
Incubation period may be up to 28 days with VZIG

5. Period of communicability
2 days before the onset of rash through 5-6 days after onset of rash or when lesions crust over
Immunocompromised patients are probably contagious during the time when new lesions are appearing

6. Clinical presentation
Prodrome: Fever and malaise x1-2 days usually only in adults
Rash: generalized, pruritic rapidly progresses from macules to papules to vesicles; usually progresses from head on down.
Zoster: vesicular eruption generally unilaterally in dermatomal distribution. Most often in truncal area or CN V; Pain.paresthesia my precede rash

9. ZOSTER

10. Congential Varicella Syndrome
Occurs with maternal infection with VZV in the first trimester especially 8-12 wks
Cicatricial scarring of skin most common manifestation
Other Manifestations:
Chorioretinitis
Microphthalmia
congenital cataracts
hypoplastic limbs
mental retardation
early death
Cutis Aplasia

11. Disseminated Varicella in the newborn
Newborn at very high risk if mother develops rash of Primary varicella five days before or within 48 hrs after delivery
Severe infection in 17-30% and estimated case fatality rate of 31% in first 5-10 days

12. Diagnostic Tests
ACTIVE DISEASE: Direct Flourescent Antibody for VZV: from vesicle scraping; more rapid and sensitive than culture
IMMUNE STATUS: Latex agglutination for IgG to VZV: Rapid (15 minutes); very sensitive

13. Treatment Acyclovir (PO or IV) VZIG
Should be administered as soon as possible after exposure
Limited window to affect outcome of Varicella infxn due to viral replication
VZIG

14. Acyclovir
Not recommended for routine use in otherwise healthy children with varicella
Oral Acyclovir should be considered in:
Pts older than 12 y/o
Pts with chronic cutaneous or pulm diseases
Pts receiving long term ASA therapy
Pts receiving short,intermittent or aerosolized courses of Corticosteroids
Immunocompromised pts should always be treated with IV Acyclovir

15. Indications for VZIG Household: Residing in the same household
Playmate: Face to face indoor play (5 min to one hour)
Hospital:
Varicella: same 2-4 bed room face to face contact with infectious person or visit by contagious person
Zoster: Intimate contact (touching/hugging) person who is contagious
Newborn infant: Primary varicella in mother 5d or less before delivery or < 48 hrs after delivery

16. Candidates for VZIG when significant exposure has occured
Immunocompromised children with no Hx of Chicken Pox
Susceptible Pregnant women
Newborn infant whose mother had onset of Chicken pox within 5d before delivery or within 48 hrs after delivery
Hospitalized infant >28 wks GA whose mother lacks reliable history of chicken pox or serologic evidence of immunity
Hospitalized infant <28 wks GA regardless of maternal varicella Hx

17. Hospital Isolation
Exposed susceptible patients should be placed in strict isolation from day 8 to day 21 after exposure to the patient
Isolation should include contact and airborne isolation for a minimum of 5 days after the onset of rash or until the lesions crust over
Pts exposed to pts who received VZIG and develop disease should be kept in isolation until day 28

18. Review What’s the incubation period for Varicella??
No VZIG days
VZIG days
What’s the period of communicability?
2 days before onset of rash and at least 5 days after or until lesions crust over
When is the newborn at risk for Disseminated Varicella?
When the mother has onset of primary varicella rash 5 days before birth or within 48 hrs after birth