Case Study Of Varicella

to the editor: Chickenpox incidence rates have decreased substantially across the United States since the introduction of the varicella vaccine and subsequent school immunization requirements in many states.1 This does not mean, however, that the risk of adverse outcomes from varicella infection has disappeared. A recent death from congenital varicella highlights the need for physicians and public health workers to maintain awareness of the threat that varicella poses to pregnant women and their fetuses.

On May 10, 2011, a male infant was born at 34 to 35 weeks' gestation to a 22-year-old mother who reported in April that she had had varicella in the first trimester of the pregnancy. Because of intrauterine growth restriction, the infant's birth weight was 870 g (1 lb, 15 oz). He also had several other conditions consistent with congenital varicella syndrome, including club foot, liver calcifications, dermatome scarring of the face, and microcephaly with ventriculomegaly. Life support was removed, and the infant died on May 13, 2011.

The mother was from Mexico and had not received varicella vaccine, nor had she had the infection prior to her pregnancy. In April 2011, she reported having chickenpox in January along with a child in her household. A varicella immunoglobulin M antibody assay performed in April was positive. Neither the mother nor her child had sought medical care, and their infections were not reported to the health department by a school or employer.

This case highlights several important considerations. First, the risk of congenital varicella remains, although the incidence and case fatality rates continue to decline.2 Usually when a vaccine is introduced, the burden of disease shifts from a younger population to an older population. Second, even though use of varicella vaccine is increasing across the country, adults and adolescents may still be at risk because they are typically not targeted by immunization campaigns. Finally, women from tropical areas such as Central or South America may reach adulthood without having had chickenpox, leaving them vulnerable to infection during pregnancy.3

Health care professionals need to be aware of the risks of congenital varicella and screen women of childbearing age for immunity to varicella, especially those from Latin America. Screening should begin by asking about the patient's history of varicella infection or vaccination. Those who are unsure or not immune should be vaccinated if they are not pregnant; in those who are pregnant, a titer should be obtained, and the patient should be counseled to avoid contact with persons who have chickenpox or shingles, and to inform her obstetrician immediately if exposure or symptoms occur.4 Additionally, susceptible pregnant women need to be informed of the risks of congenital varicella, so that they are aware of the importance of reporting such exposures to their physicians for possible intervention (administration of varicella zoster immune globulin, or watchful waiting and administration of acyclovir [Zovirax] if symptoms develop).3


Harlingen, Tex


Corpus Christi, Tex

Author disclosure: No relevant financial affiliations to disclose.


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1. Guris D, Jumaan AO, Mascola L, et al. Changing varicella epidemiology in active surveillance sites—United States, 1995–2005. J Infect Dis. 2008;197(2 suppl):S71–S75....

2. 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.

3. American Academy of Pediatrics. Varicella-zoster infections. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2009:714–727.

4. Marin M, Guris D, Chaves SS, Schmid S, Seward JF; Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-4):1–40.

  • Hall S, Maupin T, Seward J, Jumaan AO, Peterson C, Goldman G, et al. Second varicella infections: are they more common than previously thought?. Pediatrics. 2002 Jun. 109(6):1068-73. [Medline].

  • Rockley PF, Tyring SK. Pathophysiology and clinical manifestations of varicella zoster virus infections. Int J Dermatol. 1994 Apr. 33(4):227-32. [Medline].

  • Dowell SF, Bresee JS. Severe varicella associated with steroid use. Pediatrics. 1993 Aug. 92(2):223-8. [Medline].

  • Davis MM, Patel MS, Gebremariam A. Decline in varicella-related hospitalizations and expenditures for children and adults after introduction of varicella vaccine in the United States. Pediatrics. 2004 Sep. 114(3):786-92. [Medline].

  • [Guideline] American Academy of Pediatrics Committee on Infectious Diseases. Prevention of varicella: recommendations for use of varicella vaccines in children, including a recommendation for a routine 2-dose varicella immunization schedule. Pediatrics. 2007. 120:221-231. [Medline]. [Full Text].

  • Zhou F, Harpaz R, Jumaan AO, et al. Impact of varicella vaccination on health care utilization. JAMA. 2005 Aug 17. 294(7):797-802. [Medline]. [Full Text].

  • Nguyen HQ, Jumaan AO, Seward JF. Decline in mortality due to varicella after implementation of varicella vaccination in the United States. N Engl J Med. 2005 Feb 3. 352(5):450-8. [Medline].

  • Seward JF, Watson BM, Peterson CL, Mascola L, Pelosi JW, Zhang JX, et al. Varicella disease after introduction of varicella vaccine in the United States, 1995-2000. JAMA. 2002 Feb 6. 287(5):606-11. [Medline].

  • Shah SS, Wood SM, Luan X, Ratner AJ. Decline in varicella-related ambulatory visits and hospitalizations in the United States since routine immunization against varicella. Pediatr Infect Dis J. 2010 Mar. 29(3):199-204. [Medline]. [Full Text].

  • National, state, and local area vaccination coverage among children aged 19-35 months--United States, 2006. MMWR Morb Mortal Wkly Rep. 2007 Aug 31. 56(34):880-5. [Medline].

  • Buchholz U, Moolenaar R, Peterson C, Mascola L. Varicella outbreaks after vaccine licensure: should they make you chicken?. Pediatrics. 1999 Sep. 104(3 Pt 1):561-3. [Medline]. [Full Text].

  • Galil K, Lee B, Strine T, et al. Outbreak of varicella at a day-care center despite vaccination. N Engl J Med. 2002 Dec 12. 347(24):1909-15. [Medline]. [Full Text].

  • Seward JF, Zhang JX, Maupin TJ, Mascola L, Jumaan AO. Contagiousness of varicella in vaccinated cases: a household contact study. JAMA. 2004 Aug 11. 292(6):704-8. [Medline].

  • Ozaki T, Nagai H, Kimura T, Ichikawa T, Suzuki S, Kito H, et al. The age distribution of neutralizing antibodies against varicella-zoster virus in healthy individuals. Biken J. 1980 Mar. 23(1):9-14. [Medline].

  • Kouwabunpat D, Hoffman J, Adler R. Varicella complicated by group A streptococcal sepsis and osteonecrosis. Pediatrics. 1999 Oct. 104(4 Pt 1):967-9. [Medline]. [Full Text].

  • Perella D, Fiks AG, Jumaan A, Robinson D, Gargiullo P, Pletcher J, et al. Validity of reported varicella history as a marker for varicella zoster virus immunity among unvaccinated children, adolescents, and young adults in the post-vaccine licensure era. Pediatrics. 2009 May. 123(5):e820-8. [Medline].

  • Cowan MR, Primm PA, Scott SM, Abramo TJ, Wiebe RA. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med. 1994 Apr. 23(4):818-22. [Medline].

  • Doctor A, Harper MB, Fleisher GR. Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella. Pediatrics. 1995 Sep. 96(3 Pt 1):428-33. [Medline].

  • Lesko SM, O'Brien KL, Schwartz B, Vezina R, Mitchell AA. Invasive group A streptococcal infection and nonsteroidal antiinflammatory drug use among children with primary varicella. Pediatrics. 2001 May. 107(5):1108-15. [Medline].

  • Tappeiner C, Aebi C, Garweg JG. Retinitis and optic neuritis in a child with chickenpox: case report and review of literature. Pediatr Infect Dis J. 2010 Dec. 29(12):1150-2. [Medline].

  • Matsukura H, Murakami M, Sakaki H, Mitani T, Shimura S. Varicella glomerulonephritis preceding the cutaneous lesions. Clin Nephrol. 2009 Aug. 72(2):161-2. [Medline].

  • Chickenpox in Pregnancy. RCOG Green-top Guideline No. 13. Available at Accessed: May 11, 2015.

  • Barclay L. Guidelines Revised on Chicken Pox in Pregnancy. Medscape Medical News. Available at Accessed: May 11, 2015.

  • Pastuszak AL, Levy M, Schick B, et al. Outcome after maternal varicella infection in the first 20 weeks of pregnancy. N Engl J Med. 1994 Mar 31. 330(13):901-5. [Medline]. [Full Text].

  • Derrick CW Jr, Lord L. In utero varicella-zoster infections. South Med J. 1998 Nov. 91(11):1064-6. [Medline].

  • American Academy of Pediatrics Committee on Infectious Diseases: The use of oral acyclovir in otherwise healthy children with varicella. Pediatrics. 1993 Mar. 91(3):674-6. [Medline].

  • Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG – United States, 2013. Available at Accessed: July 23, 2013.

  • [Guideline] Marin M, Meissner HC, Seward JF. Varicella prevention in the United States: a review of successes and challenges. Pediatrics. 2008 Sep. 122(3):e744-51. [Medline]. [Full Text].

  • Pinquier D, Gagneur A, Balu L, et al. Prevalence of anti-varicella-zoster virus antibodies in French infants under 15 months of age. Clin Vaccine Immunol. 2009 Apr. 16(4):484-7. [Medline]. [Full Text].

  • [Guideline] Update: recommendations from the Advisory Committee on Immunization Practices (ACIP) regarding administration of combination MMRV vaccine. MMWR Morb Mortal Wkly Rep. 2008 Mar 14. 57(10):258-60. [Medline].

  • [Guideline] Marin M, Güris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007 Jun 22. 56:1-40. [Medline].

  • Su JR, Leroy Z, Lewis PW, Haber P, Marin M, Leung J, et al. Safety of Second-Dose Single-Antigen Varicella Vaccine. Pediatrics. 2017 Mar. 139 (3):[Medline].

  • Lee LE, Ho H, Lorber E, et al. Vaccine-era varicella epidemiology and vaccine effectiveness in a public elementary school population, 2002-2007. Pediatrics. 2008 Jun. 121(6):e1548-54. [Medline]. [Full Text].

  • Verstraeten T, Jumaan AO, Mullooly JP, et al. A retrospective cohort study of the association of varicella vaccine failure with asthma, steroid use, age at vaccination, and measles-mumps-rubella vaccination. Pediatrics. 2003 Aug. 112(2):e98-103. [Medline]. [Full Text].

  • Chaves SS, Gargiullo P, Zhang JX, et al. Loss of vaccine-induced immunity to varicella over time. N Engl J Med. 2007 Mar 15. 356(11):1121-9. [Medline].

  • Arbeter AM, Granowetter L, Starr SE, et al. Immunization of children with acute lymphoblastic leukemia with live attenuated varicella vaccine without complete suspension of chemotherapy. Pediatrics. 1990 Mar. 85(3):338-44. [Medline].

  • Quian R J, Protasio P A, Dall'orso V P, et al. [Varicella outbreak in a village in Uruguay]. Rev Chilena Infectol. 2010 Feb. 27(1):47-51. [Medline]. [Full Text].

  • Watson B, Seward J, Yang A, Witte P, Lutz J, Chan C. Postexposure effectiveness of varicella vaccine. Pediatrics. 2000 Jan. 105(1 Pt 1):84-8. [Medline].

  • Klein NP, Fireman B, Yih WK, et al. Measles-mumps-rubella-varicella combination vaccine and the risk of febrile seizures. Pediatrics. 2010 Jul. 126(1):e1-8. [Medline].

  • Hviid A. Measles-mumps-rubella-varicella combination vaccine increases risk of febrile seizure. J Pediatr. 2011 Jan. 158(1):170. [Medline].

  • [Guideline] Marin M, Broder KR, Temte JL, Snider DE, Seward JF. Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010 May 7. 59:1-12. [Medline].

  • American Academy of Pediatrics Committee on Infectious Diseases. Policy Statement--Prevention of Varicella: Update of Recommendations for Use of Quadrivalent and Monovalent Varicella Vaccines in Children. Pediatrics. 2011 Aug 28. [Medline].

  • Marin M, Marti M, Kambhampati A, Jeram SM, Seward JF. Global Varicella Vaccine Effectiveness: A Meta-analysis. Pediatrics. 2016 Mar. 137 (3):1-10. [Medline].

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