Varicella Zoster Immunoglobulin VZIG Indications,Limitations

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Infectious Diseases in Children

Varicella Zoster Virus(VZV)

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Dengue and Dengue Hemorrhagic

H1N1 Influenza Epidemic

Varicella Infection in Pregnancy

Chikungunya - Indian Prespective

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Otitis Media In Children

Utility of PCR Tests for Diagnosis of HIV in Infants Exposed to HIV Virus

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VARICELLA ZOSTER VIRUS

Varicella Zoster : Indications and Limitations

Related topics

Varicella Zoster : Clinical Manifestations and Complications

Varicella Zoster : Infection During Pregnancy and Diagnosis

Varicella Zoster : Treatment and Prevention

Varicella Zoster : Side Effects and Serological Testing

Dr. M.R.Lokeshwar Past-President,
Indian Academy of Pediatrics (1998)
President-Pediatric Association of SAARC Countries (PAS) (1999)

Continued...

Can a child suffering from leukemia be
immunized against varicella?

Children with acute leukemia are at an enhanced risk of developing progressive varicella infection and severe complications if they come in contact with a case of varicella. This is due to their immunocompromised state. However, for the same reason, administration of a live, attenuated vaccine like varicella vaccine is contra-indicated in children with acute leukemia. Leukemia children should receive vaccine if they have no history of disease or are found to be seronegative. This can be undertaken only when they are in complete hematological remission, the total lymphocyte count is at least 1200 per mm and when there is no other evidence of lack of cellular immune competence. While vaccinating such children, it is advised that maintenance therapy be withheld one week before and after the immunization. Patients under radiotherapy should normally not be vaccinated during the treatment phase.

What future developments can one expect with regards to varicella vaccine ?

Exciting developments are awaited in case of varicella vaccine. A combination vaccine combining this vaccine with MMR vaccine is likely to be developed. This will decrease the number of injections received by a child. Studies are being undertaken to see if varicella vaccine can boost cellular immunity of older individuals so that herpes zoster can be prevented. Further studies are required to judge the need for booster immunization.

What VZIG ?

VZIG or varicella zoster immunoglobulin is prepared by selection of serum containing high titres of varicella zoster antibodies. It is available for intramuscular injection and provides passive immunity against varicella zoster to the recipients.

What are the indications for using VZIG ?

VZIG provides immediate protection from varicella infection if it is administered to susceptible individuals within 96 hours of exposure. To derive maximum benefit it should be given as soon after exposure as possible. The possible indication for its use include :

Susceptible immunocompromised individuals who have been recently been exposed to a case of varicella
Newborn to a mother who has developed varicella within 5 days before to 48 hours after the delivery
Premature infants of gestational age of less than 28 weeks
Susceptible pregnant women exposed to varicella.

Some believe that it may also be useful in ameliorating the expression of varicella in susceptible adults, who are at increased risk of complications from varicella infection. VZIG may not prevent infection; however, if infection occurs it is usually sub clinical or mild.

What are the limitations of using VZIG?

The limitations of using VZIG are as follows :

VZIG offers passive immunity, which lasts for only about 3 weeks. It does not provide long-lasting immunity. Individual at high risk from developing complications of varicella will require VZIG every 3-4 weeks to have complete protection
For it to be effective, VZIG has to be administered soon after exposure and definitely within 72-96 hours.
It may not be able to provide complete protection. The incidence of disease in immunocompromised children who have received VZIG after household exposure is still 33-50%.
Its administration may prolong the incubation period. Hence, recipients could be infectious for as many as 10-28 days after exposure.
The product is difficult to procure and is extremely expensive.

How is VZIG administered ?

VZIG is administered intramuscularly in the dose of 125 u/10 kg body weight. The minimum dose is 125 u while the maximum dose is 625 u. For it to be effective, it has to be given soon after exposure. It is hardly of any use, if its administration is delayed by more than 96 hours after exposure.

How does one prevent nosocomial spread of VZV infection ?

VZV is highly contagious and VZV infection may be life-threatening in certain patient populations. Nosocomial transmission of VZV infection occurs due to air-borne transmission from an index case of varicella or due to direct contact with lesions from a patient with dermatomal zoster.

The following recommendations have been made to avoid or limit the nosocomial spread of VZV infection :

Avoid admitting a patient with VZV infection
If an immunocompetent patient with dermatomal zoster has to be admitted, he should be put on drainage and secretion precaution and people who haven't had chickenpox should not be allowed to enter the room.
Severely immunocompromised persons who develop dermatomal zoster carry a higher risk of dissemination. Hence, they should be placed under strict isolation precautions. These may be relaxed to drainage and secretion procedure once the primary dermatomal begins to heal.
Patients with varicella or disseminated zoster should be placed on strict isolation precautions.
VZV transmission can also be prevented by using negative pressure ventilation rooms.
If a case is detected to have developed chickenpox after admission to the hospital, patient-related and staff-related epidemiological investigations are begun :
- Obtain an in-hospital 'travel history' from the index case.
- Examine records of appropriate areas to determine patient-population at risk
- Among the population at risk, those who have had VZV infection in past do not require any further work-up.
- Amongst those with negative or uncertain history of previous VZV infection, determine exposure history. No further follow-up is require if there were no exposure. Those with negative or uncertain history of previous VZV infection but with history of exposure to the index case in the hospital should have their blood drawn for serological testing. Immunocompromised individuals amongst them should also receive appropriate doses of VZIG as early as possible. All these patients should be discharged as early as possible. If discharge is not possible, those found susceptible on the basis of serological testing should continue to be isolated for 21 days while no follow-up is require in immune individuals.
- The exposed staff member who has no history of pervious VZV infection should undergo serological testing. Susceptible among them should be re-assigned to low-risk area for at least 21 days after exposure. Immune staff member do not require any reassignment or follow-up.

How does epidemiology of chickenpox vary in different geographical?

The VZV infections are known to occur at much earlier age in temperate climate while they are supposed to occur at a later age in individuals staying in warmer tropical areas. Thus in the United States and European Union as many as 60% of the pre-school children demonstrate antibody to VZV. The proportion of seroprevalence rises to 78% by 11 years of age. In contrast, the mean age of chickenpox sufferer is higher in tropical countries, with many more cases occurring among adolescents and adults. There is paucity of Indian data. One study showed that only 29.7% of student nurses aged 17-20 years had antibodies against varicella while another study showed that less than 5% of under-five children were seropositive. Studies from southeast Asia and Latin America also indicate a much lower age specific seroprevalence rate.

Last created on 23-02-2001
Last updated on 25-05-2007