Chicken pox or measles contact in child on a drug that targets the immune
system.
Patients at risk
Children receiving long term immune modifying therapy including methotrexate,
cyclosporine, azathioprine, cyclophosphamide, mycophenolate and the new biologic
treatments including the anti-TNFagents etanercept, adalimumab, infliximab and golimumab,
and others such as tocilizumab, abatacept, rituximab and anakinra. Patients receiving
prednisolone are at increased risk if they have received >1mg/kg for > 4 weeks or > 2mg/kg
for >7 days.
This advice is for contact with chicken pox and or measles.
Contact with Chicken pox (varicella zoster virus; VZV)
(If circumstances permit, varicella zoster antibody status should be checked prior to starting
immunosuppressive treatment; where appropriate, varicella zoster vaccine should be given
at this time.)
The varicella vaccine is considered for children on a case-by-case basis for patients on
certain low dose immunosuppressant drugs. Please see vaccination section for more
details.
Chicken pox is highly contagious and spreads by infective droplets or fluid from vesicles.
One attack usually confers permanent immunity. Incubation period is 2 to 3 weeks. Varicella
is contagious from about 5 days before the onset of the rash until the crusts begin to
disappear.
Reactivation of the virus may appear later as herpes zoster (shingles).
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Severe complications are more common in immunocompromised patients and include
secondary skin infection, haemorrhagic varicella lesions with evidence of disseminated
intravascular coagulation, pneumonia and encephalitis.
Passive protection against chickenpox (or herpes zoster) with ZIG and/or aciclovir should
be
given in the event of significant contact in non-immune patients.
Significant contact
Significant contact with VZV is defined as play or direct contact for more than 15
minutes, on ward, at school or in household, during the infectious period from 2 days
prior to onset of rash, until crusting of all vesicles.
Significant contact with herpes zoster (shingles) is direct contact with exposed lesions
only.
VZV immune status
Ascertain the clinical history of past infection (including whether the infection was
confirmed by medical personnel and the antibody status if previously measured.
If significant contact and patient on an immune targeted drug then check antibody status.
Prophylactic treatment of varicella antibody negative patients:
Intramuscular zoster immunoglobulin (ZIG) can be given to protect patients for 3 weeks
or more. However, severe chicken pox may still occur. To receive ZIG a patient must
be at risk of severe chicken pox, have had significant exposure and shown not to have
anti-bodies.
If less than 72 hours from contact, give (ZIG) and if <10 days still consider giving ZIG as
may attenuate infection if administered. If clotting disorder or on anti-coagulation give
IVIg. The protection lasts approximately 4 weeks.
ZIG dose:
IVIg dose
Under 6 years
250 mg
6-11 years
500 mg
11-15 years
750 mg
Over 15 years
1000mg
0.2g/kg
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Or give oral aciclovir; widely prescribed as a prophylactic agent in this setting. However,
there is relatively little supportive clinical literature.
Aciclovir dose (from 7 – 21 days following the initial contact.)
Child 1month – 18years - 10mg/kg 4 times daily for 7 days.
Whichever method of prophylaxis is used, the patient and family should be instructed to
contact the specialist unit immediately if any suspicious skin lesions develop so that early
treatment with intravenous aciclovir may be considered.
Treatment of active chicken pox in immunocompromised
Principles
Isolation of the patient.
Symptomatic and supportive treatment.
Prevention or early treatment of complications.
Children treated with low dose methotrexate (<20 mg/m2)
Acyclovir (oral) – 7 days
1 month - 2 years
200 mg 4 times daily
2-6 years
400 mg 4 times daily
6-12 years
800 mg 4 times daily
12-18 years
800 mg 5 times daily
Children treated with methotrexate >20 mg/m2 or any other immunosuppressive drug listed
above may require IV acyclovir:
Acyclovir: 1-5 days IV and complete 10 day course orally
0- 3 months
10-20mg/kg 3 times daily
3 months – 12 years
500 mg/m2 3 times daily
Over 12 years
10mg/kg
3 times daily
Contact with measles
Passive protection against measles with human normal Ig (NIg) should be given in the event
of significant contact, unless patient is shown to be positive for measles antibody. If less
than 14 days (most effective if within 72 hours) from contact, in view of the potential severity
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of measles infection in these patients, give either intramuscular NIg or if thrombocytopenic
IVIg. The protection lasts approximately 4 weeks.
Subcutaneous NIg dose:
0.6mls/kg
IV NIg dose:
0.15g/kg
IVIg dose
0.4g/kg (For patients with coagulation disorders)
For further advice please call:
1. Clinical Nurse Specialists via the Rheumatology adviceline on 01865 737656
2. Dr Wilkinson (Consultant Paediatrician & Rheumatologist) 01865 738049 via
secretary Hannah Trendell
Reference
cBNF 2011
TVCN Chickenpox and measles passive immunisation guidelines (2011)
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