Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Deaths from chickenpox
- J Claire Bramley (9 November 2001)
-
Data are a persuasive argument against mass vaccination
- Daniel Highkin (10 November 2001)
-
Chickenpox and immunodeficient children
- Torstein Vik (11 November 2001)
-
Chickenpox in England and Wales
- Subhash C Arya (12 November 2001)
-
Normal illness?
- C Gunstone (13 November 2001)
-
Treatment for chickenpox
- Hannah Hutton (14 November 2001)
-
Global Health
- C Gunstone (15 November 2001)
-
Death from Chickenpox-the role of ECMO
- Giles Peek (17 November 2001)
-
Chickenpox associated morbidity
- A H Mohsen (20 November 2001)
-
Prevention of fatal adult chickenpox
- Richard Gunstone (30 November 2001)
-
Varicella in adults - do not forget health care workers
- Philip Rice (11 December 2001)
|
|
|||
|
J Claire Bramley, Epidemiologist (Immunisation) Scottish Centre for Infection and Environmental Health
Send response to journal:
|
EDITOR - Rawson and colleagues laudably highlight the potential severity of chickenpox. The authors rightly state that the age distribution of chickenpox is changeable. However, recent data from Scotland1, England and Wales2 and the United States3 show that the previous shift4 toward increased infection in older age groups has not been sustained. In recent years the trend has been towards decreased age at infection, with the majority of cases now occurring among the one to four age group, rather than among school age children. Varicella vaccine is recommended for routine administration in the United States and Canada, among other countries, but its suitability for inclusion the UK childhood immunisation programme is still being considered. Therefore, further work on the epidemiology of chickenpox in the UK is now particularly important. To this end, we have proposed a one -year period of enhanced active surveillance for severe complications of varicella in hospitalised children throughout the UK and the Republic of Ireland, using the British Paediatric Surveillance Unit ‘orange card’ scheme5. The information gained, together with that of Rawson and colleagues, and others, would help to determine the advisability of a universal programme for the UK, and provide a baseline against which to evaluate its impact, should it be adopted. References 1. Bramley JC, Jones IG. Epidemiology of chickenpox in Scotland: 1981 to 1998. Communicable Disease and Public Health 2000;3(4):282-7. http://www.phls.co.uk/publications/cdph.htm 2. Ross AM, Fleming DM. Chickenpox increasingly affects preschool children. Communicable Disease and Public Health 2000;3(3):213-215. http://www.phls.co.uk/publications/cdph.htm 3. Herrin VE, Gray GC. Decreasing rates of hospitalization for varicella among young adults. Journal of Infectious Diseases 1996;174:835-838. 4. Fairley CK, Miller E. Varicella-zoster virus epidemiology - a changing scene? Journal of Infectious Diseases 1996;174(Suppl 3):S314-319. 5. Royal College of Paediatrics and Child Health. British Paediatric Surveillance Unit 15th Annual Report 2000-2001. London: British Paediatric Surveillance Unit, 2001:58. http://bpsu.inopsu.com/Publicat.htm |
|||
|
|
|||
|
Daniel Highkin The Vancouver Clinic, Vancouver, WA, USA
Send response to journal:
|
The authors conclude that there are not persuasive arguments for mass vaccination. In fact, I think that their data provide persuasive argument against such mass vaccination programs as we have here in the USA. The study demonstrates that 19% of the cases, but 81% of the deaths, are in adults, which is consistent with earlier data. Varicella is much more likely to be lethal among adults than among children. As with other vaccines, one would expect the immunity from V-Z vaccine to wane in 15-20 years. Thus, if we vaccinate children we will have a large cohort of young adults who are not immune to chickenpox, unless they all come in to get boosters. This seems unlikely, given the low likelihood of regular doctor visits for people in their 20's. However, there will still be a large reservoir of potential exposure to the virus in the form of Herpes Zoster. Thus, there is the potential for large-scale exposure of non-immune young adults to the varicella-zoster virus if there is a large vaccination program. It would be far preferable for people to be exposed naturally to chickenpox and perhaps reserve the vaccine for those who reach young adulthood without getting chickenpox. |
|||
|
|
|||
|
Torstein Vik, Professor of Paediatrics (Paediatric and perinatal epidemiology) Dep. of Community Medicine, Norwegian University of Science and Technology, 7489 Trondheim, Norway
Send response to journal:
|
Rawson et al found that chickenpox was a definite or contributory cause of death in 75 cases in England and Wales 1995-7 (BMJ 2001;323:1091- 1093). They found that a high proprtion of elderly (> 65 years) people died from the disease, whereas only one of the children had HIV. However, I would like to know the proportion of children (and adults) who were immune-deficient /-compromised due to cancer treatment, or whether these patients were excluded. |
|||
|
|
|||
|
Subhash C Arya, Research Physician Centre for Logistical Resrearch and innovation
Send response to journal:
|
Editor--Three year mortality attributable to chicken pox in England and Wales during the period 1995-1997, as reviewed by Rawson and colleagues (9 November, p1091)1, points to the maximum deaths among those aged less than 4 years or those above 65 years of age. Though chickenpox vaccine is yet not fully licensed in the United Kingdom, antivirals like acyclovir, famciclovir and valciclovir have been marketed for several years. Antiviral should be used to address the annual chickenpox mortality of at least 25 in England and Wales. Randomized, double blind, placebo-controlled trials with oral acyclovir were encouraging in adolescents and adults with chickenpox. Adolescents were less likely to have residual hypopigmented skin lesions after four weeks. That indicated that acyclovir therapy reduced the spread of virus to deeper layers in dermis2. The usual recipe, to start within 24 hours of appearance of rash, is of acyclovir, 20mg/kg, four times a day for five days3. Furthermore, adults with varicella pneumonia have also been treated effectively with intravenous acyclovir. Acyclovir did not affect host response to virus4. Recently, acyclovir has been formulated in a twice-daily controlled formulation that has an extended time of absorption from small intestine5. Such a formulation that would not require medication four time a day would indeed be an asset and eventually replace the current four times a day schedule3. Postexposure antiviral prophylaxis has been introduced against those exposed to HIV. Likewise, close contacts of those afflicted with varicella might be protected through a prophylaxis recipe with acyclovir. That would emerge as a valuable armory against chickenpox mortality till chickenpox awaiting availability of fully licensed chickenpox vaccine in the England and Wales. Subhash C Arya, MBBS, PhD
References 1. Rawson H, Amelia A, Noah N. Deaths from chickenpox in England and Wales 1995-7: analysis of routine mortality data. BMJ 2001; 323:1091-3 2. Wallace MR, Bowler MA, Murray NB, et al. Treatment of adult varicella with oral acyclovir: a randomized, placebo-controlled trial. Ann Int Med 1992;117:358-363 3. Physicians' Desk reference. 53rd edition. Medical Economics Company. Montvale. 1999. PP 1273 4. Haake DA, Zakowski PC, Haake DL, Bryson YJ. Early treatment with acyclovir for varicella pneumonia in otherwise healthy adults: retrospective controlled study and review. Rev Infect Dis 1990;12:788-798 5. Barnard DL. Genvir (Flanel Technologies). Curr Opin Investig Drugs 2001;2(5):622-3 |
|||
|
|
|||
|
C Gunstone, GP Gordon Street Surgery, Burton upon Trent, Staffs, DE14 2JA
Send response to journal:
|
There are 10 deaths per day on British roads. I think that there needs to be a sense of proportion in disease prevention. Disease is a normal part of life. To prevent disease may alter our perception of life, maybe depriving our children and society of the experience of how to cope with and respond to disease.(All that will be left will be colds and cancer!!) With the current fears over MMR, the interrest arround 'Gulf War Syndrome' I think it would be difficult to get enough parental support for mass vaccination. Maybe the message from this article is that we should have a low threshold to use aciclovir in paople over 45 with chickenpox? How about more on road safety - 10 death per day is an awful death toll - unremarked in the press and yet a bigger killer than menngitis etc etc? | |||
|
|
|||
|
Hannah Hutton, Mother Home
Send response to journal:
|
I'm pleased to see that your results do not on their own provide sufficient evidence for mass vaccination, because this would surely be a very expensive route. How many of these cases received treatment in the form of VZIG or acyclovir? I had chickenpox at the beginning of the year while 27 weeks pregnant and cannot fault the care of my GPs in the rapid response they provided. My four year old son started chickenpox on Christmas Day, I saw the GP on Boxing Day and because I'd requested to be tested for immunity at my initial pregnancy blood test, she knew immediately that I was not immune, so arranged for the VZIG the next day. My two year old son then came down with it about 10 days later and I followed on 6th January. I started the acyclovir within two hours of the spots first appearing and they were completely gone within 36 hours. While I was ill for the next few days, I have no doubt that I had it very mildly due to the medication. But I get the feeling that if I had not been pregnant, nothing would have been done. Why can't adults be treated for chickenpox this way as standard? Surely this would be much cheaper than mass vaccination? I suppose the downside is that while treatment may prevent nearly all deaths, it wouldn't produce a large profit for Pasteur- Merieux. |
|||
|
|
|||
|
C Gunstone, GP Gordon Street Surgery, Burton upon Trent, Staffs
Send response to journal:
|
If one were to cost a chicken pox vaccination programme – say £3 per course for say 500,000 children per year = £9,000,000 for 25 lives saved. (Cost per life = £360,000.) If one were to buy say rehydration sachets at 33p per unit, one could buy 27,000,000. If these were used on children with diarrhoea in the third world, one could save (I’m guessing wildly here) 500 lives. (Cost per life = £18,000) Therefore one would obviously spend the money on saving 500 lives. The problem would be convincing the government to part with its money. Or do we actually agree that in a global situation, it is permissible to be racist? |
|||
|
|
|||
|
Giles Peek, Lecturer in Cardiac Surgery University of Leicester
Send response to journal:
|
Deaths from Chicken Pox- the role of ECMO. EDITOR- We applaud Rawson 1 for highlighting the potentially devastating effects of varicella infection, particularly the fact that adults in the UK are dying from this disease and these deaths are increasing in number. We know the pneumonitits caused by varicella infection can lead to respiratory failure that is often the cause of death in these patients. Antiviral therapy may help in such patients but only if their severely compromised physiology can be adequately supported until they recover. Extra Corporeal Membrane Oxygenation (ECMO) has been reported to be used successfully in cases of adult respiratory failure due to varicella pneumonia 2-5 and we would like to bring the results of such intervention to the attention of Rawson and colleagues. We have treated 15 adults with ECMO for confirmed varicella pneumonitis in Leicester between August 1992 and December 1999. These 15 patients had a mean age of 36 years with range 24-61, and were significantly hypoxic on referral with a ratio arterial oxygen tension to fraction of inspired oxygen (PaO2/FIO2) of 8.09 KPa. The overall survival in these patients was 60%. However of the 11 patients we treated with veno-venous ECMO the survival was 75% (compared to zero for the four patients treated via veno-arterial ECMO). It seems likely, therefore, that ECMO is a treatment that should be considered for fulminant varicella pneumonitis, but the numbers treated so far are too few to be sure of the effectiveness of this invasive treatment . To resolve this uncertainty, currently all such cases in the UK can be referred for entry into the CESAR trial (Conventional ventilation or ECMO for Severe Adult Respiratory failure) Suitable patients will be randomised to receive either ECMO or continued conventional ventilation. Further details about the trial are available from www.cesar-trial.org. Neil Roberts Clinical ECMO fellow. Heartlink ECMO centre, Glenfield Hospital Leicester, LE3 9QQ. Neilrob52@hotmail.com. Giles J Peek Lecturer in Cardiac Surgery, Division of Cardiac Surgery, University of Leicester, Principal Investigator CESAR (Corresponding Author, e mail: ycq57@dial.pipex.com) Nikki Jones Research Fellow in Cardiac Surgery, Division of Cardiac Surgery, University of Leicester, CESAR Trial Research Fellow Richard K Firmin ECMO Director and Consultant Cardiac Surgeon, Glenfield Hospital Leicester LE3 9QQ, Principal Investigator CESAR Diana Elbourne Head of Medical Statistics Unit, LSHTM, Principal Investigator CESAR 1.Rawson H, Crampin A, Noah N. Deaths from chickenpox in England and Wales 1995-7: analysis of routine mortality data. BMJ 2001; 323: 1091-3. 2.Marriage S, Lyall EG, Nadel S, Britto J. Prolonged extracorporeal life support for varicella pneumonia. Crit Care Med.1998 Jun;26(6):1138-9. 3.Lee AW, Kolla S, Schreiner RJ Jr, Hirschl RB, Bartlett RH. Prolonged extracorporeal life support (ECLS) for varicella pneumonia. Crit Care Med. 1997 Jun;25(6):977-82. 4.Claydon AH, Nicholson KG, Wiselka MJ, Firmin RK. Varicella pneumonitis: a role for extra-corporeal membrane oxygenation? J Infect. 1994 Jan;28(1):65-7. 5.Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK. Extracorporeal Membrane Oxygenation for adult respiratory failure.Chest.1997;112:759-64. |
|||
|
|
|||
|
A H Mohsen, Clinical Research Fellow Weston Education Centre, GKT School of Medicine, Cutecombe Road, SE5 9RS
Send response to journal:
|
Chickenpox associated morbidity Editor We read the paper published by Rawson et al1 with interest (1). It has previously been recorded that chickenpox in healthy adults has a 25 fold greater risk of complications than in a childhood (2). The paper by Rawson et al demonstrates a significant mortality of chicken pox in England and Wales but is not able to address the question as to the associated morbidity - certainly a very important issue when addressing the value of immunisation on a population. We recently performed a prospectively study on respiratory function in adult patients with chickenpox hospitalised in a subregional infectious diseases unit in a UK hospital over a period of 29 months (3). Sixty six adult patients with chickenpox were hospitalised during the period, 4 of whom were immunocompromised. Thirty eight patients fulfilled the study protocol and of these, fifty percent had radiological evidence of pneumonia (all immunocompetent)3. Three female patients required admission to intensive care unit, two of whom were pregnant. One patient presented with chickenpox encephalitis and five had superimposed bacterial skin infections. Severe respiratory disease was associated with the presence of new respiratory symptoms, close contact with the index case and a history of current smoking. On follow up at a year post infection, 37% of patients with radiological pneumonia and 10.6% of those without pneumonia continued to have reduced single breath carbon monoxide transfer factor (TLCO). This effect was independent from the effect of smoking and may indicate permanent lung damage. It may therefore be that the morbidity relates not only to the acute infection and admission but also longer term effects on the lung function but the exact clinical relavance of our findings are uncertain at present. However the study does indicate that chicken pox causes significant morbidity in adults which may be seen increasingly in the future. Accurate data on morbidity as well as mortality are required to inform the debate on the value of mass vaccination for chickenpox in the UK. No competing interest. Dr Abdul H Mohsen, MD, MRCP, DTM&H
M W McKendrick FRCP
References 1. RawsonH, Crampin A, and Noah N. Deaths from chickenpox in England and Wales 1995-7: analysis of routine mortality data. BMJ 2001;323: 1091- 1093. 2. Centre for Disease Control. Varicella-zoster immune globulin for the prevention of chickenpox. MMWR 1984;33:84-90. 3. Mohsen AH, Peck R J, Mason Z, Mattock L, McKendrick MW. Lung function tests and risk factors for pneumonia in adults with chicken pox. Thorax 200; 56:796-799. |
|||
|
|
|||
|
Richard Gunstone, Retired consultant physician (infectious disease and general medicine Walsgrave Hospital,Coventry, CV2 2DX
Send response to journal:
|
The following statistics, although more than a decade old, (1) are relevant to the paper(2) by Rawson et al:- Incidence of pneumonia in adult varicella;- 0.3 to 1.8%;42 to 47% in smokers; mortality in varicella pneumonia 11% but 35% in pregnant patients. I therefore suggested (3) that when chickenpox is diagnosed or suspected the attendant medical staff should enquire about contacts, particularly adult contacts who have not had chickenpox, especially those who smoke or who are pregnant. For these contacts (and for other immune supressed patients) prophylaxis with varicella-zoster immunoglobulin or anti-viral drugs shoujld be considered. For patients who can't recall a history of varicella-zoster, microbiology laboratories can readily check their immunity by estimating the serm VZIgG. (1) Haake DA,ZSakowski PC, Haaka DL,Bryson YJ. Rev Infect Dis 1990:12:788-796 (2) Rawson H, Campin A, Noah N BMJ 2001 323: 1091-3 (3 November) (3) Gunstone RF J.Infect 1994 29 235-6 |
|||
|
|
|||
|
Philip Rice, Consultant Virologist St George's Hospital, London
Send response to journal:
|
We agree with the conclusion of Rawson et al that although deaths in adults from chickenpox have increased in number and proportion, this does not justify mass immunisation with varicella vaccine.1 However, one population that would clearly benefit from vaccination is susceptible healthcare workers. At St George's Hospital, prospectively collected data over the past three years has identified a total of 25 cases of chickenpox in staff and students. We were able to determine the country of birth in 22 of these individuals and found that the majority of cases, 13/22 (59%) occurred in people born outside the United Kingdom. This figure was higher than expected since only 39% of the St George's workforce who have patient contact are black or from an ethnic minority. Since Rawson et al found that there was a disproportionately higher mortality among such people compared with those born here, it would be interesting to know if occupations, such as those in healthcare with a higher likelihood of exposure, were over-represented amongst the cases of fatal varicella. Live attenuated varicella vaccine has been in use now for over 2 decades.2 Moreover, it has had a license for use in susceptible individuals in the USA since 1995, and has an excellent safety and efficacy record.3 We believe that the increased mortality from chickenpox in adults of working age of between 1:1000 and 1:5000 demonstrated by Rawson may make it indefensible for NHS Trusts not to offer varicella vaccine to their susceptible staff for two reasons: personal safety at work and nosocomial chickenpox. Indeed, if only medical and nursing staff and students had been vaccinated in the last three years at St George's, 85% of chickenpox cases in hospital staff would have been prevented. Devi R, Muir D, Rice P. Department of Medical Microbiology, St George's Hospital, Blackshaw Road, London SW17 0QT References 1. Rawson H, Crampin A, Noah N. Deaths from chickenpox in England and Wales 1995-7 analysis of routine mortality data. BMJ 2001; 323: 1091-93 2. Asano Y, Suga S, Yoshikawa T, et al. Experience and reason: twenty year follow-up of protective immunity of the Oka strain live varicella vaccine. Paediatrics 1994; 94: 524-6 3. Vazquez M, La Russa P S, Gershon AA, et al. The effectiveness of the varicella vaccine in clinical practice. N Engl J Med 2001; 344: 955-60 |
|||