Early Good Samaritan Hospital Training School for Nurses Graduate Photograph - By Ben Markham, originally uploaded by vernon_dutton.
In the UK chickenpox affects around 90% of children and is most common between the ages of two and eight years (1), predominantly occurring in the preschool and early school years (2). Infection spreads easily, particularly through schools and nurseries. This means that the school nurse is likely to encounter chickenpox and be asked for advice about managing this common childhood infection. This article aims to give an insight into chickenpox, including a practical approach to managing the symptoms as well as advice for answering some commonly asked questions.
Chickenpox is caused by the varicella zoster virus (VZV). It is usually a mild but highly infectious disease--a previously uninfected person has a 90% likelihood of contracting chickenpox after coming into contact with the virus (2). Outbreaks are usually widespread, with peak incidences occurring in winter and early spring (2). Chickenpox is not a notifiable disease in England and Wales, though it is in Scotland and Northern Ireland.
Chickenpox is transmitted via airborne droplets, direct personal contact with fluid from the vesicles, or contact with infected articles such as children's toys, bedding or clothing. The incubation period, i.e. the time from acquisition of the virus to the emergence of symptoms, is 10 to 21 days (1). Individuals are infectious from about 48 hours before until 5-6 days after the first spots appear (1). After recovery from chickenpox, VZV is not eliminated from the body but remains dormant in sensory nerves and can become reactivated in later life as shingles (herpes zoster). A common misconception is that elderly people should be kept away from children with chickenpox in case they catch shingles, but shingles cannot be contracted from contact with a person with chickenpox.
The first symptoms of chickenpox often include mild flu-like symptoms such as: fever, headache, backache, sore throat and general malaise. These symptoms are followed by a rash up to six days later, which typically begins behind the ears and on the face and trunk, and then spreads further (Figure 1 and Figure 2). The skin lesions are vesicles with surrounding erythema, which develop into pustules that crust over before healing. The spots are usually intensely itchy and appear in successive crops over 3-4 days. At the peak of the illness there are lesions at various stages of development from new spots through to spots that have crusted over. The rash can also occur in the mucous membranes of the mouth, producing multiple aphthous-like ulcers. The total healing time for the rash is around 16 days.
The number of spots varies widely. Some children only have one or two and the illness may even go unnoticed, whereas others are covered in large numbers of spots. Sometimes it is not clinically obvious that a child has contracted chickenpox, but if one person in the household has the virus then other previously uninfected family members have a greater than 90% chance of contracting the disease.
Parents should be advised that there is no cure for chickenpox as it is caused by a virus, but the following may help ease the child's symptoms:
* Try to make sure the child drinks plenty of water
* Ask the pharmacist for advice about giving children's paracetamol or ibuprofen if the child has a fever
* Keep the child as cool as possible; cool sponging or bathing may help
* Dress the child in light, loose clothing and keep bedding to a minimum
* Keep the child's fingernails clean and short to help prevent deep scratching.
The pharmacist will recommend the most appropriate analgesic such as paracetamol or ibuprofen. There are concerns that the use of non-steroidal anti-inflammatory drugs (NSAIDs) in children with varicella is associated with an increased risk of necrotizing soft-tissue infections and infections with invasive group A beta-haemolytic streptococci. However, results from two small case-control studies are conflicting. Advice from NHS Clinical Summaries is that although the association cannot be ruled out with certainty, there is insufficient evidence to advise that ibuprofen or other NSAIDs should be avoided in children with chickenpox (3).
Children under 16 should never be given aspirin and this is particularly important if the child has a viral infection like chickenpox. Reye's syndrome has been reported in children treated with aspirin during natural varicella infection (1). Asprin and systemic salicylates should not, therefore, be given to children under 16 years of age, except under medical supervision, because of this risk (1).
Plenty of fluids should be recommended to help prevent dehydration. Sugar-free ice lollies can be soothing, particularly if the mouth is sore.
Relief of itching
Itching is often the most troublesome symptom of chickenpox. If a child scratches the spots this can lead to infection and possible long-term scarring. There are several options to recommend to help relieve itching.
Applications to the skin
* Calamine lotions and creams have traditionally been recommended for use in chickenpox. Although there is no data to support the efficacy of calamine, the evaporation gives a cooling effect and it is inexpensive to purchase. It can be messy to apply, although aqueous calamine lotion is easier to apply as it has a thicker consistency.
* More recently, a gel has been produced to relieve the itching. It works by establishing an osmotic gradient which draws water towards the skin. The skin acts as the semi-permeable membrane and the gel attracts water from the dermis to the surface of the skin, to hydrate and cool the skin through evaporation. The gel (Care Virasoothe, Thornton & Ross) can be used on the face and the body and is suitable for use on children from six months upwards. It is available over the counter from pharmacies and will be available on prescription from early 2010.
* Chlorphenamine (available as Piriton allergy tablets or syrup [GlaxoSmithKline]), a sedating antihistamine, is specifically licensed for itching in chickenpox. It is suitable for children over 12 months and can help reduce discomfort and restlessness, although there is no direct soothing relief for the skin.
Chickenpox is usually a mild and self-limiting disease and complications are rare in children, unless the child has a weakened immune system, e.g. due to chemotherapy, radiotherapy, treatment with systemic corticosteroids or immunosuppressants, HIV or AIDS or leukaemia and other malignancies (4).
Those with a weakened immune system are more at risk of developing severe disseminated chickenpox where other organs in addition to the skin are infected. Complications may include pneumonia, septicaemia and meningitis (4).
In around 5-10% of chickenpox cases a child may develop a bacterial skin infection due to severe scratching which breaks the blisters, causing infection. This sort of infection requires topical or oral antibiotics.
Chickenpox and steroids
Chickenpox can be more severe in children who are taking steroids, because steroids have a tendency to reduce the body's immunity to infection. So, contracting chickenpox while on steroids can result in a severe episode of the illness. If a child being treated with steroids who has not had chickenpox is in direct contact with the virus, the GP should be contacted immediately. A blood test may be arranged to check whether the child has antibodies to VZV and an injection of varicella zoster immune globulin (VZIG) might be recommended.
Chickenpox and pregnancy
Approximately 90% of pregnant women are immune to the chickenpox virus as a result of having it earlier in life (1), but a very small number of women (3 in every 1,000, or 0.3%) contract chickenpox during pregnancy in the UK (4). If a pregnant woman is in contact with chickenpox and has never had the disease or is not sure whether she has nor not, she should be advised to contact her GP as soon as posssible (5). A blood test can be arranged to see whether she is immune.
Chickenpox in pregnancy can cause complications both for the mother and the baby, depending on what stage of pregnancy the mother is at (5).
* Up to 28 weeks of pregnancy
There is no evidence of an increased risk of early miscarriage because of chickenpox. There is a risk to the child of fetal varicella syndrome which can cause scarring of the skin, eye defects, shortened limbs and brain damage, but this is very rare, affecting 1-2%
* Between 28 and 36 weeks of pregnancy
The baby may contract VZV but it is unlikely to cause any symptoms; however, the virus may become active again, causing shingles in the first few years of the child's life
* After 36 weeks and up to birth
The baby may become infected and could be born with chickenpox. There is a slightly increased risk of the baby being born prematurely
* Around the time of birth
If the baby is born within seven days of the mother's chickenpox rash appearing, the baby may develop severe chickenpox.
The Royal College of Obstetricians and Gynaecologists recommends acyclovir for women with chickenpox who are more than 20 weeks pregnant, but it must be started within 24 hours of the rash appearing (5).
Varicella zoster immune globulin (VZIG) is given to those who are seronegative for VZ antibodies, who do not have any clinical signs of chickenpox, but have had significant contact with the virus and fall into one of the following categories:
* Immunocompromised individuals
* Those on high doses of steroid therapy
* Non-immune pregnant women
* Neonates born to women who develop chickenpox seven days before or after delivery
VZIG does not necessarily prevent chickenpox from developing but can lessen the severity of the infection and reduce the risks of complications. The injection can be given for up to 10 days after coming into contact with the virus, so long as VZ symptoms have not appeared (6).
Most people contracting varicella will not need antiviral treatment. However, it is important to recognise groups of patients who are likely to benefit from antiviral treatment with acyclovir.
Intravenous acyclovir may be prescribed for:
* Immunocompromised patients, e.g. with malignancy, HIV, organ transplant, high-dose immunosuppressive treatment
* Those with systemic disease affecting the heart or lungs, e.g. cystic fibrosis
* Patients on high-dose steroids.
Oral acyclovir may be prescribed for:
* Patients with a chronic medical condition
* Patients over 12 years of age, to reduce the complication rate
* Pregnant women.
Acyclovir appears to be effective in reducing the number of days with fever and the number of lesions in those infected with chickenpox.
Vaccination against chickenpox
A varicella zoster vaccine is licensed in the UK for use in healthy individuals who are seronegative for VZ antibodies. Adults and children over 13 are given two subcutaneous injections 4-8 weeks apart. Younger children only need one vaccination. Mild symptoms of the disease may develop during the first month after immunisation, including a generalised vaccine-related rash.
Although the VZ vaccination is part of the childhood immunisation programme in the USA and Germany, it is not given as a routine childhood vaccination in the UK (7). However, the Joint Committee on Vaccination and Immunisation (JCVT) has been examining the evidence on chickenpox and shingles vaccines, and varicella immunisation is now recommended for non-immune health care workers (HCWs) who work in primary care and in hospitals and who have direct patient contact. This is to protect susceptible HCWs and also to protect vulnerable patients from acquiring chickenpox from an infected member of staff (8).
Varicella vaccination may be offered to adults who are seronegative for VZ immunoglobulin because chickenpox is more severe in adults. It may be given to seronegative women planning a pregnancy, but contraception must be used between vaccinations and for three months after the second vaccination.
Salicylates such as aspirin must not be taken during the vaccination period or for six weeks afterwards because of the risk of Reye's syndrome, which is associated with taking salicylates during varicella infection.
Concerns about adding the varicella vaccine to the UK childhood immunisation schedule are that it may increase the incidence of shingles. This is because adults will no longer receive natural boosts to their immune systems from occasional exposure to the virus.
Chickenpox is a very common childhood illness and is usually quite mild. However, school nurses can play a significant role in advising parents, carers and school staff about diagnosis, infection control and management of symptoms.
* Chickenpox is common, particularly in children of primary school age, with peak incidences in winter and early spring
* Transmission is via airborne droplets, direct personal contact with fluid from the vesicles, or contact with infected articles such as children's toys, bedding or clothing
* The incubation is 10-21 days
* A child is infectious until about one week after onset of the rash and should stay at home until all the blisters have crusted over
* Infection is usually mild but special care is needed for immunocompromised children or those taking steroids
* The most troublesome symptom is often itching from the spots which can be eased by a suitable gel or lotion
* Non-immune individuals who are pregnant should contact their GP as soon as possible
COMMONLY ASKED QUESTIONS ABOUT CHICKENPOX
Chickenpox is one of the illnesses people most commonly search for on the NHS Choices website (1). Below are some of the most commonly asked questions:
How long should my child stay away from school?
A child is infectious until about one week after the rash has appeared. The child should therefore stay at home until all the blisters have fully crusted over. This usually happens about a week after the first blister has appeared.
Is it possible to get chickenpox more than once?
After having chickenpox, it is rare to get the condition again. Usually lifelong immunity develops after exposure to the virus.
I'm pregnant and haven't had chickenpox--should I have a vaccination?
The chickenpox vaccination is not given in pregnancy because the effects on the unborn child are unknown (7). If a pregnant woman finds out she is not immune to chickenpox, her doctor may discuss vaccination after the baby's birth.
Should I take my child to the GP?
Referral to a doctor is usually not necessary unless the child is less than one month old or has any of the following symptoms:
* Breathing problems
* Persistent high temperature
* Pains or headaches which become worse
* Being unable to take fluids due to a severe rash in the mouth
* Becoming increasingly unwell
* Has chest pains
* Has skin blisters which become infected and look yellow and pus-filled.
However, parents can be reassured that in general, complications are uncommon in chickenpox.
What if my newborn baby has come into contact with chickenpox?
If a newborn baby comes into contact with chickenpox in the first seven days of life and the mother is immune, the baby will be protected by the mother's immunity and there is no cause for concern. If the mother is not immune, then the baby may be given VZIG.
(1.) NHS Choices. Chickenpox. www.nhs.uk/conditions/ chickenpox (accessed 20/07/09)
(2.) Allen S. Chickenpox and shingles infection. Pharmaceutical Journal 2006; 277:453-456
(3.) NHS Clinical Knowledge Summaries. Chickenpox Management. What are the general issues when prescribing paracetamol or ibuprofen. http://www.cks.nhs.uk/chickenpox /management/prescribing_inform ation/analgesics_antipyretics/para cetamoljbuprofenjssues (accessed 12 Dec 2009)
(4.) Guess HA,Broughton DD, Melton LJ 3rd, Kurland LT. Population-based studies of varicella complications. Pediatrics 1986; 78(4 Pt 2):723-727
(5.) Royal College of Obstetricians and Gynaecologists. Chickenpox in pregnancy: what you need to know. http://www.rcog.org.uk/ womens-health/clinicalguidance/chickenpox-pregnancy-what-you-need to know (accessed 12 Dec 2009)
(6.) Royal College of Obstetricians and Gynaecologists.Infection and Pregnancy--Study Group Statement. Published 01/06/2001. http://www.rcog.org.uk/womenshealth/clinical-guidance/infection- and-pregnancy-study-group-statement (accessed 12 Dec 2009)
(7.) NHS Choices. Why isn't the chickenpox vaccine available in the UK? http://www.nhs.uk/chq/Pages/103 2. aspx (accessed 12 Dec 2009)
(8.) NHS Choices. Who can be vaccinated against chickenpox? http://www.nhs.uk/chq/Pages/103 3. aspx?CategoryID=67&SubCateg oryID=150 (accessed 12 Dec 2009)
Sharon White BSc RGN SCM SCPHN(School Nursing)
School and Public Health Nurses Association (SAPHNA)
White, Sharon. "Managing chickenpox: chickenpox is common in primary schools and school nurses should be ready to advise the school community on infection control, management of symptoms and vaccination, as Sharon White explains." School Health Journal 6.1 (2010): 3+. Academic OneFile. Web. 31 Mar. 2010.
Gale Document Number:A219519291
Disclaimer:This information is not a tool for self-diagnosis or a substitute for professional care.