Comparing active and passive varicella surveillance in Philadelphia, 2005-2010: recommendations for the transition to nationwide passive varicella disease surveillance.

OBJECTIVE: The Philadelphia Department of Public Health (PDPH) conducts active surveillance for varicella in West Philadelphia. For its approximately 300 active surveillance sites, PDPH mandates biweekly reports of varicella (including zero cases) and performs intensive case investigations. Elsewhere in Philadelphia, surveillance sites passively report varicella cases, and abbreviated investigations are conducted. We used active varicella surveillance program data to inform the transition to nationwide passive varicella surveillance. METHODS: We compared classification of reported cases, varicella disease incidence, and reporting completeness for active and passive surveillance areas for 2005-2010. We assessed reporting completeness using capture-recapture analysis of 2- to 18-year-old cases reported by schools/daycare centers and health-care providers. RESULTS: From 2005 to 2010, PDPH received 3,280 passive and 969 active surveillance varicella case reports. Most passive surveillance reports were classified as probable cases (18% confirmed, 56% probable, and 26% excluded), whereas nearly all of the active surveillance reports were either confirmed or excluded (36% confirmed, 11% probable, and 53% excluded). Overall incidence rates calculated using confirmed/probable cases were similar in the active and passive surveillance areas. Detection of laboratory-confirmed, breakthrough, and moderate-to-severe cases was equivalent for both surveillance areas. CONCLUSIONS: Although active surveillance for varicella results in better classified cases, passive surveillance provides comparable data for monitoring disease trends in breakthrough and moderate-to-severe varicella. To further improve passive surveillance in the two-dose-varicella vaccine era, jurisdictions should consider conducting periodic enhanced surveillance, encouraging laboratory testing, and collecting additional varicella-specific variables for passive surveillance.

Varicella in a Paediatric Intensive Care Unit: 10-year review from Starship Children's Hospital, New Zealand.

AIMS: Varicella is now a vaccine-preventable disease but is generally considered benign, making it a low priority for a funded universal immunisation scheme. We aimed to increase the knowledge of the severity, morbidity and mortality caused by varicella, by a review of cases requiring paediatric intensive care in New Zealand where vaccine is available but not funded. METHODS: This is a retrospective chart review of children admitted to the paediatric intensive care unit (PICU) over a 10-year period (July 2001-July 2011) identified from the PICU database with a primary or secondary code for varicella. RESULTS: Thirty-four cases were identified and 26 cases were included. Of the 26 cases, 84.6% were Maori or Pacific Island ethnicity, 54% had no preceding medical condition and 23% were immunocompromised. Main PICU admission reasons were neurologic (38.5%), secondary bacterial sepsis or shock (26.9%), respiratory (15.4%), disseminated varicella (11.5%), or other causes (7.7%). Fifty per cent of children required inotropic support and 81% invasive ventilation. Four children died (15%), three of whom were immunocompromised. A further eight children (31%) had ongoing disability at hospital discharge. CONCLUSION: Varicella, or its secondary complications, requiring paediatric intensive care, carries high mortality, particularly for immunocompromised patients, and long-term morbidities, mostly affecting previously healthy children.

The effect of clinical severity and eyelid rash on ocular involvement in primary varicella infection.

PURPOSE: To describe ocular manifestations in primary varicella infection and their relationship to systemic severity and the associated eyelid rash. METHODS: One hundred consecutive children with primary varicella were examined prospectively. The cases were classified as mild, moderate, and severe according to the severity of clinical presentation. Excluding the presence of eyelid rash, children with ocular findings were assigned to group 1 (G1), and those without ocular findings were assigned to group 2 (G2). Patients in G1 were also evaluated according to the nature of ocular manifestations and the course of uveitis. RESULTS: Twenty-one percent of patients had ocular involvement (G1) and 79% had no ocular involvement (G2). While chickenpox had a mild course in 85.7% of patients in G1 and 88.6% of patients in G2, all others had a moderate course. None of the children had a severe course. A varicella eyelid rash was present in 28.6% of patients in G1 and 13.9% in G2. Among ocular findings, 38.1% of patients had conjunctivitis, 57.1% had anterior uveitis, and 4.8% had disciform keratouveitis. There was no significant association between severity of chickenpox and severity of ocular involvement (p=0.712). There was also no relationship between eyelid rash and ocular involvement (p=0.787). CONCLUSIONS: There is neither an association between the severity of chickenpox and the severity of ocular involvement nor an association between the presence of a varicella eyelid rash and the development of uveitis. As the prognosis regarding sequelae of ocular involvement in varicella infection is good, only those patients with ocular signs and symptoms need be referred by pediatricians for an ophthalmologic examination.

Clinical studies on molar-incisor-hypomineralisation part 2: development of a severity index.

AIM: This was to examine the records of 182 children (aged 6-14 years) with molar-incisor-hypomineralisation (MIH) or molar hypomineralisation (MH) in order to develop and examine a Hypomineralisation Severity Index for first permanent molars (FPMs). STUDY DESIGN: Records of 429 FPMs in these children were examined and scored for eruption status, extent of hypomineralisation, sensitivity, number of restorative treatments; summed scores were converted to an index for each dentition (possible range: 1.25-7.00). Indices were examined regarding medical conditions occurring singly or in combinations in parentally-recalled children's histories to age 3 years; mean indices were compared for dentitions with these conditions/combinations. RESULTS: The proportion of FPMs receiving no/preventive treatment was higher in dentitions with MH than with MIH (56% vs. 41%); restorative treatment for FPMs was more frequent in dentitions with MIH than with MH (45% vs. 29%). Dentitions with MIH had higher severity indices than those with MH (MIH: index range: 3.25-5.25: 43%; MIH: index range: 1.25-2.00: 61%). Mean severity indices clearly had a higher trend in dentitions of children with certain condition combinations than for those without. Ten condition combinations each contained 3 to 5 medical conditions; 11/12 condition combinations included fevers; 9/12 included chicken pox; 9/12 included perinatal conditions, 6/12 included antibiotic use. CONCLUSIONS: A preliminary Hypomineralisation Severity Index developed for dentitions with hypomineralised first permanent molars in children has shown that MIH and MH form part of an MIH spectrum, where MIH is a more severe form of the condition than MH. The index has indicated associations between hypomineralisation of these molars and combinations of medical conditions, particularly implicating fevers, chicken pox, perinatal conditions and antibiotic use. Further clinical studies are indicated to validate the proposed index and confirm its prognostic value in treatment planning.

Varicella outbreak in a residential home.

We report an outbreak of varicella in a residential home for 29 children(aged 4 to 16 years) with severe physical and learning disability. We report our group's incidence, complication and hospitalisation rate of varicella despite anti-viral therapy. As we did not have a control group we use statistics pertaining to the general population for comparison. All 15 non-immune children contracted varicella within 30 days of the index case. The complication rate was 9 in 15, three time higher than in the general population. The hospitalisation rate was 5 in 15. This is remarkably high. The incidence of hospitalisation in the general population is 1 to 5 per 1,000. In conclusion we suggest that the guidelines for varicella vaccination should include all non-immune children and adults with severe to profound physical and learning disability. We recommend that this disease should be notifiable in the severely physically disabled population. We recommend that within 3 days of exposure to varicella children with severe to profound physical and learning disability are vaccinated to prevent infection (post exposure prophylaxis). These findings are important in countries where varicella vaccination is not part of the routine vaccination program and is not part of the routine vaccination program and is only offered to select groups of children.

Oral manifestations of infections of infections due to varicella zoster virus in otherwise healthy children.

Varicella zoster virus (VZV) causes varicella (or chickenpox) and establishes latency in nerve ganglia after the primary infection. The reactivation of virus later in life can cause mono- or polyneuropathy. The cranial nerves most commonly involved are five (herpes zoster or shingles), six, seven eight, nine and ten. In the present study we describe the oral lesions associated with VZV infections in normal children. In a 3 year period we examined 62 children, age 2 to 13 years old with diagnosed varicella and a 4 year old boy with herpes zoster at the 3rd branch of the trigeminal nerve. According to the clinical picture of varicella, the disease was defined as: (1) group A mild cases; (2) group B moderate cases; (3) group C severe. The manifestations of varicella were: mild varicella 19 children, moderate 26 children and severe 17 children. The results of the present study indicate that the prevalence of oral manifestations of varicella is related to the severity of the disease. In 17 severe cases, oral lesions were always present and the number was between 5 to 30. From 26 moderate cases, oral lesions were observed in 23 and the number was between 2 to 10. From 19 mild cases, oral lesions were present only in 6 cases and their number was 1 or 2. Often varicella's oral lesions resemble manifestations of other entities, and this may cause differential diagnostics problems.

The effectiveness of the varicella vaccine in clinical practice.

BACKGROUND: A live attenuated varicella vaccine was approved for use in the United States in March 1995 and is recommended for all susceptible persons 12 months of age or older. METHODS: To assess the effectiveness of the varicella vaccine, we conducted a case-control study with two controls per child with chickenpox, matched according to both age and pediatric practice. Children with potential cases of chickenpox were identified by active surveillance of pediatric practices in the New Haven, Connecticut, area. Research assistants visited the children on day 3, 4, or 5 of the illness, assessed the severity of the illness, and collected samples from lesions to test for varicella-zoster virus by polymerase chain reaction (PCR). RESULTS: From March 1997 through November 2000, data collection was completed for 330 potential cases, of which 243 (74 percent) were in children who had positive PCR tests for varicella-zoster virus. Of the 56 vaccinated children with chickenpox, 86 percent had mild disease, whereas only 48 percent of the 187 unvaccinated children with chickenpox had mild disease (P<0.001). Among the 202 children with PCR-confirmed varicella-zoster virus and their 389 matched controls, 23 percent of the children with chickenpox and 61 percent of the matched controls had received the vaccine (vaccine effectiveness, 85 percent; 95 percent confidence interval, 78 to 90 percent; P<0.001). Against moderately severe and severe disease the vaccine was 97 percent effective (95 percent confidence interval, 93 to 99 percent). The effectiveness of the vaccine was virtually unchanged (87 percent) after adjustment for potential confounders by means of conditional logistic regression. CONCLUSIONS: Varicella vaccine is highly effective as used in clinical practice.

Varicela e herpes zóster / Varicella and herpes zoster

O vírus varicela-zóster (VVZ) é um alfa-herpesvírus do gênero varicellovirus cuja característica mais marcante é a capacidade de estabelecer latência em células dos gânglios da raiz dorsal de nervos sensitivos após infecção primária. Compreende a varicela, infecção primária - doença exógena - que é a resposta do indivíduo sem imunidade, e o herpes zóster, doença endógena neurocutânea, que representa imunidade parcial e é causada pela reativação do vírus latente. A varicela é doença benigna, comum da infância, altamente contagiosa, que cursa com febre e erupção generalizada, vesiculosa, acompanhada de muito prurido. O herpes zóster é caracterizado por erupção vesicobolhosa localizada e dolorosa, envolvendo um ou mais dermátomos adjacentes, e causado pela reativação do VVX. Sua principal complicação é a neuragia pós-herpética. A incidência e a gravidade do herpes zóster aumentam com a idade e com o decréscimo da imunidade mediada por células

Acyclovir in the treatment of chickenpox.

Although chickenpox is a highly contagious disease affecting 90% of susceptible persons exposed, its morbidity and mortality in healthy patients is minimal. Treatment of chickenpox with oral acyclovir appears to decrease the number of pox lesions and shorten the duration of new lesion formation. Most importantly, children treated with acyclovir begin to feel better soon and had fewer systemic signs and symptoms of chickenpox (fever, fatigue, loss of appetite). However, the greatest mortality from chickenpox is seen in the immunocompromised patient, or in elderly patients with zoster (shingles) due to reactivation of latent varicella infection. Therefore, prevention of varicella is necessary to decrease mortality from the varicella-zoster virus. It is hopeful that the varicella vaccine will be licensed in the U.S. for routine immunization of healthy children within the next year. While its general use will not eliminate either chickenpox or zoster, there will be a considerable decrease in the morbidity and mortality caused by this agent as a result of routine immunization.