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Chickenpox: an elusive childhood disease surfacing in adulthood as shingles.

A number of the classic "childhood diseases" -- so called because they inevitably struck each new generation of youngsters -- are now unfamiliar to most Americans. Today, polio, rubella, diphtheria, pertussis (whooping cough), and measles are preventable by timely vaccination.

But there's one major exception: chicken-pox -- or, as it's known medically, varicella (a diminutive of "variola," the technical term for smallpox). Some 3.5 million Americans, mostly children, come down with this viral illness each year.

Fortunately, the disease, while highly contagious, is generally mild and, normally, not life-threatening. Some individuals, however, are at higher risk for serious illness; according to the American Academy of Pediatrics (AAP), there are more than 4,500 hospitalizations for chickenpox annually, with 50 to 100 deaths. Recently, the Food and Drug Administration has approved the use of some products to lessen the impact of the illness.

The Usual Course

Varicella occurs chiefly, though not exclusively, in early spring and often spreads rapidly through families, neighborhoods, and such sites as day-care centers. Three- to 6-year-olds who have started school or preschool and have begun to socialize with other children are most vulnerable, although anyone of any age who has never had the disease is susceptible.

After a 10- to 20-day incubation period (the time between exposure to the virus and the onset of illness), an infected youngster begins to feel draggy and usually runs a low fever; uncommonly, the fever may be high or, occasionally, there's none at all. Within a day or two, a characteristic rash appears, often first on the back, chest, or scalp and gradually spreading to the rest of the body over three or four days, during which the fever abates. The tiny pimple-like eruptions eventually turn into small blisters and form crusts, which fall away. About a week elapses from start to finish.

In this normal course, the disease is not a serious health threat. The rash, however, can be intensely itchy and, since scratching can lead to secondary infection by bacteria on the skin, such as staphylococcus ("staph"), doctors advise parents to cut youngsters' nails very short and do everything possible to relieve the itch. Calamine lotion may be helpful; so may immersing the child in a cornstarch or baking-soda bath. As the crusty scabs form, the itching subsides. At that point, it's wise to keep the child occupied, since idle hands may turn to picking at the scabs, causing scarring.

No other treatment is necessary. If, however, the child complains of headache, fever, or general malaise, a non-aspirin pain reliever and fever reducer can alleviate discomfort.

Chickenpox can be transmitted to others through fluid from broken blisters, as well as by droplet infection -- coughing or sneezing. A child is contagious from the day before the rash appears until the lesions have all crusted over. The AAP advises that a child who has had chickenpox can go back to school six days after the onset of the rash -- or even sooner, if all the lesions are crusted over.

Although it occurs far less often, a child can also catch chickenpox from an adult with a different condition -- by contact with the lesions on the skin of a person with shingles. Shingles, which involves a painful, rather than itchy, localized eruption following nerve pathways, may develop in a person who has had chickenpox when the virus, which has remained latent in the body, is reactivated; usually, this happens in older people whose immune systems operate less efficiently. The virus that causes both chickenpox and shingles is known medically as the varicella-zoster virus (VZV).

Help for High-Risk Kids

Although chickenpox represents nothing more than temporary discomfort for most children, it can pose more serious problems for children who are immunocompromised -- a medical term describing those whose immune systems are not working normally. In such children, varicella can even be life-threatening, since under these circumstances it can progress to pancreatitis, hepatitis, encephalitis (inflammations of the pancreas, liver and brain, respectively), or pneumonia.

Still another group of youngsters who may be at increased risk are those taking long-term or high-dose corticosteriods for such chronic conditions as asthma or arthritis. (This refers to steroids that are either inhaled, taken orally, or injected, not to topical medications applied to the skin.) These drugs include prednisone, prednisolone, methylpredinisolone, dexamethasone, triamcinolene, and others. They suppress the immune system to a certain extent, so that children taking them may be at higher risk for complications if they come down with chickenpox.

FDA warned of this risk but stressed that stopping the drugs without medical consultation could be "very dangerous." Cortico-steroids may themselves be lifesaving. And since they disrupt the body's normal hormone production system, even when stopping therapy is considered advisable, they are not withdrawn abruptly but tapered off under medical supervision.

That message is understood by Herbert Behrens, a scientist with the pilot drug evaluation staff of FDA's Center for Drug Evaluation and Research.

"There is no question," says Behrens, "that the benefits of corticosteroids far outweigh the potential risk of a severe case of chickenpox. We would hope no parent would take a child off corticosteroids because of this. If a child taking corticosteroids is exposed to chickenpox, the parent should immediately call the doctor to seek advice on what protective steps, if any, need to be taken."

He added that the form of the drug, as well as the dosage, duration of therapy, and route of administration may affect the risk, but how these differences may affect the risk has not been clearly established. Also not known is how the underlying condition and treatment history might contribute to the risk. At this writing, revised labeling for the various corticosteroids is being developed.

A Medicine -- for Some

While an array of effective antibiotics are available to treat bacterial and fungal infections, effective therapy for viral infections, including varicella, has been elusive. One drug, however, has been found effective against VZV, and in February 1992, FDA approved the use of oral Zovirax (acyclovir) -- available in tablets, and banana-flavored liquid -- for the treatment of chickenpox in otherwise healthy children. (The drug had been previously approved for genital herpes and shingles.)

But oral Zovirax would not be the treatment of choice, for example, if a child at very high risk for complications fell ill with chickenpox, says Dianne Murphy, M.D., assistant director for medical affairs with the Center for Drug Evaluation and Research's division of antiviral drug products: "If a child is immunocompromised, intravenous acyclovir would be the treatment of choice, since pneumonia could develop fairly rapidly." Administering the drug by intravenous injection speeds its action, and another consideration is that the oral form's bioavailability -- the degree to which it is actually usable by the body -- is lower.

Just what good does oral Zovirax do? And who should receive it? In clinical trials with patients from 2 years old through the teens, the drug has been shown to shorten recovery time by a day or so, as well as to reduce the number of lesions. Side effects have been uncommon; in one series of three trials involving almost 1,000 patients, the main adverse effect was diarrhea, reported by 3.2 percent of the 495 receiving the drug -- and also by 2.2 percent of those who received a placebo.

Should all otherwise healthy kids with chickenpox receive oral Zovirax? Probably not, says Janet Arrowsmith-Lowe, M.D., reviewing medical officer in the division of antiviral drug products: "FDA has approved this use because it's been found to be safe and has met efficacy criteria. You have to realize that effectiveness depends on starting the medication early, preferably within 24 hours. That means the patient must get to the doctor fast, the doctor has to recognize the illness and write the prescription, and the parent must quickly obtain the medicine and start to administer it. Of course, to a parent who must stay home from work with the child, cutting a full day off the length of the illness may be worth it."

Murphy also notes the well-known "all-in-the-family effect," as well as the impact of age: "While most normal children won't need acyclovir for chickenpox, it's available in those cases where the physician feels it's desirable. The child who has caught chickenpox from another family member, someone in the same household, is frequently sicker -- not in a life-threatening sense, but certainly in terms of discomfort -- and the drug can help. An even more important group are adolescents; adolescents who come down with chickenpox might be considered candidates for acyclovir, since they do get sicker with chickenpox, and are also at higher risk of complications such as pneumonia, than younger children.

Aside from those special instances, says Murphy, "This is a medical-care issue, a decision to be made by the physician. Most children get over chickenpox without any complications. Acyclovir appears to be a fairly safe drug. We must remember, though, that all drugs have side effects. The basic rule, as with all drugs, is: Don't take it if you don't need it."

The AAP, which issued a policy statement on the question several months after FDA's approval of the drug, concurs, stating that oral acyclovir is "not recommended routinely for treating uncomplicated varicella-zoster infections in otherwise healthy children."

The AAP recommends that oral acyclovir be considered for:

* Teenagers, since they are at higher risk of more severe illness and complications of the disease.

* Children over 1 year of age who have a chronic skin or lung disorder

* Children receiving chronic aspirin treatment as well as those receiving short, intermittent or aerosolized steroid therapy

What About a Vaccine?

Couldn't we avoid these questions, as well as the potential complications of chickenpox (not to mention the down-the-road agony of shingles), with a simple shot in the arm? Is there any hope of a vaccine?

The promise of a vaccine has been with us for at least 15 years, since the development in the mid-1970s of a Japanese vaccine.

There have been multiple studies -- and a number of clinical trials -- in Japan, in the United States, and in other countries, but none has met FDA criteria for vaccine licensing.

Paul Albrecht, M.D., director of the division of virology in FDA's Center for Bilogies Evaluation and Research, whose division reviews the data when applications for vaccine approval are submitted, reports that the latest submission applying for licensure of a varicella-zoster vaccine was received by FDA from a U.S. manufacturer in November 1992.

Until a vaccine is licensed, parents of children at high risk should seek a medical opinion about the appropriateness of VZIG and Zovirax for their children. And parents of healthy children who get chickenpox can continue to care for them by taking simple steps to prevent skin infection, and by remembering not to give them aspirin.
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Author:Shultz, Dodi
Publication:Nutrition Health Review
Date:Mar 22, 1993
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