Post-exposure prophylaxis against varicella-zoster virus infection
- Mary A Albrecht, MD
Mary A Albrecht, MD
- Associate Professor of Medicine
- Harvard Medical School
- Section Editors
- Martin S Hirsch, MD
Martin S Hirsch, MD
- Editor-in-Chief — Infectious Diseases
- Section Editor — Viral Infections
- Professor of Medicine
- Harvard Medical School
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
Varicella-zoster virus (VZV) is one of eight herpesviruses known to cause human infection and is found worldwide. Primary infection with VZV causes chickenpox, with fever and a characteristic vesicular rash. Although varicella is usually a mild, self-limited illness, it can be associated with complications, such as pneumonia, hepatitis, encephalitis, and secondary bacterial infection. Complicated infection can lead to morbidity and mortality, particularly among immunocompromised hosts and pregnant women.
This topic will address the use of active immunization (varicella vaccine) and passive immunization (VariZIG) and other interventions for post-exposure prophylaxis in nonimmune individuals. The efficacy and safety of the varicella vaccine for routine immunization in children and adults are discussed elsewhere. (See "Vaccination for the prevention of chickenpox (primary varicella infection)".)
Post-exposure prophylaxis for neonates, pregnant women, bone marrow transplant recipients, and health care workers is discussed elsewhere. (See "Varicella-zoster infection in the newborn" and "Varicella-zoster virus infection in pregnancy" and "Prevention and control of varicella-zoster virus in hospitals" and "Immunizations in hematopoietic cell transplant candidates and recipients".)
The clinical manifestations and management of varicella are discussed separately. (See "Clinical features of varicella-zoster virus infection: Chickenpox" and "Varicella-zoster infection in the newborn" and "Treatment of varicella (chickenpox) infection".)
VZV infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles).
- Marin M, Güris D, Chaves SS, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007; 56:1.
- VariZIG for prophylaxis after exposure to varicella. Med Lett Drugs Ther 2006; 48:69.
- American Academy of Pediatrics. Varicella-zoster infections. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed, Pickering LK (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2012. p.774.
- Marin M, Watson TL, Chaves SS, et al. Varicella among adults: data from an active surveillance project, 1995-2005. J Infect Dis 2008; 197 Suppl 2:S94.
- Struewing JP, Hyams KC, Tueller JE, Gray GC. The risk of measles, mumps, and varicella among young adults: a serosurvey of US Navy and Marine Corps recruits. Am J Public Health 1993; 83:1717.
- Centers for Disease Control and Prevention (CDC). Varicella-related deaths among adults--United States, 1997. MMWR Morb Mortal Wkly Rep 1997; 46:409.
- Perella D, Fiks AG, Jumaan A, 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; 123:e820.
- Breuer J. Herpes zoster: new insights provide an important wake-up call for management of nosocomial transmission. J Infect Dis 2008; 197:635.
- Suzuki K, Yoshikawa T, Tomitaka A, et al. Detection of aerosolized varicella-zoster virus DNA in patients with localized herpes zoster. J Infect Dis 2004; 189:1009.
- Centers for Disease Control and Prevention (CDC). Global Disease Elimination and Eradication as Public Health Strategies. Proceedings of a conference. Atlanta, Georgia, USA. 23-25 February 1998. . MMWR Suppl 1999; 48:1.
- Salzman MB, Garcia C. Postexposure varicella vaccination in siblings of children with active varicella. Pediatr Infect Dis J 1998; 17:256.
- Asano Y, Nakayama H, Yazaki T, et al. Protection against varicella in family contacts by immediate inoculation with live varicella vaccine. Pediatrics 1977; 59:3.
- Macartney K, McIntyre P. Vaccines for post-exposure prophylaxis against varicella (chickenpox) in children and adults. Cochrane Database Syst Rev 2008; :CD001833.
- Masur H, Kaplan JE, Holmes KK, et al. Guidelines for preventing opportunistic infections among HIV-infected persons--2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Ann Intern Med 2002; 137:435.
- Haddad MB, Hill MB, Pavia AT, et al. Vaccine effectiveness during a varicella outbreak among schoolchildren: Utah, 2002-2003. Pediatrics 2005; 115:1488.
- Izurieta HS, Strebel PM, Blake PA. Postlicensure effectiveness of varicella vaccine during an outbreak in a child care center. JAMA 1997; 278:1495.
- American Academy of Pediatrics. Committee on Infectious Diseases. Varicella vaccine update. Pediatrics 2000; 105:136. (Updated May 16, 2006).
- Brunell PA, Ross A, Miller LH, Kuo B. Prevention of varicella by zoster immune globulin. N Engl J Med 1969; 280:1191.
- Levin M, Nelson W, Preblud S, et al. Clinical Trials With Varicella-Zoster Immunoglobulins, Academic Press Inc., Ltd, London 1986. p.255.
- Koren G, Money D, Boucher M, et al. Serum concentrations, efficacy, and safety of a new, intravenously administered varicella zoster immune globulin in pregnant women. J Clin Pharmacol 2002; 42:267.
- Zaia JA, Levin MJ, Preblud SR, et al. Evaluation of varicella-zoster immune globulin: protection of immunosuppressed children after household exposure to varicella. J Infect Dis 1983; 147:737.
- Gershon AA, Steinberg S, Brunell PA. Zoster immune globulin. A further assessment. N Engl J Med 1974; 290:243.
- Orenstein WA, Heymann DL, Ellis RJ, et al. Prophylaxis of varicella in high-risk children: dose-response effect of zoster immune globulin. J Pediatr 1981; 98:368.
- Brunell PA, Gershon AA, Hughes WT, et al. Prevention of varicella in high risk children: a collaborative study. Pediatrics 1972; 50:718.
- ROSS AH. Modification of chicken pox in family contacts by administration of gamma globulin. N Engl J Med 1962; 267:369.
- Centers for Disease Control and Prevention (CDC). A new product (VariZIG) for postexposure prophylaxis of varicella available under an investigational new drug application expanded access protocol. MMWR Morb Mortal Wkly Rep 2006; 55:209.
- VariZIG - Highlights of prescribing information. http://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/FractionatedPlasmaProducts/UCM333220.pdf (Accessed on December 22, 2012).
- Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG--United States, 2013. MMWR Morb Mortal Wkly Rep 2013; 62:574.
- Evans EB, Pollock TM, Cradock-Watson JE, Ridehalgh MK. Human anti-chickenpox immunoglobulin in the prevention of chickenpox. Lancet 1980; 1:354.
- http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm (Accessed on July 08, 2011).
- Asano Y, Yoshikawa T, Suga S, et al. Postexposure prophylaxis of varicella in family contact by oral acyclovir. Pediatrics 1993; 92:219.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on September 21, 2016).
- GENERAL BACKGROUND
- Person to person
- Mother to child
- INCUBATION PERIOD
- ASSESSMENT OF RISK OF INFECTION
- Determining susceptibility
- Types of exposure
- Role of serologic testing
- TYPES OF POSTEXPOSURE PROPHYLAXIS
- Who is eligible for varicella vaccine?
- Which patients require passive immunoprophylaxis?
- EFFICACY OF IMMUNIZATION DURING OUTBREAKS
- VARICELLA VACCINE ADMINISTRATION
- Available formulations
- Adverse events
- Testing for seroconversion
- PASSIVE IMMUNIZATION
- General background
- Historical perspective
- - Zoster immune globulin
- - Varicella-zoster immune globulin
- - Clinical data
- - Indications
- - Time interval from exposure
- - How to administer
- Intravenous immune globulin (IVIG)
- Monitoring for infection
- ACYCLOVIR FOR POSTEXPOSURE PROPHYLAXIS
- Healthy children and adults
- Immunocompromised hosts
- Pregnant females
- WHAT TO DO WHEN PROPHYLAXIS FAILS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS