Managing People at Risk for Severe Varicella

Varicella Zoster Immune Globulin

Prevention for Susceptible Persons Who Cannot Receive Varicella Vaccine

For people exposed to varicella or herpes zoster who cannot receive varicella vaccine, varicella zoster immune globulin can prevent varicella from developing or lessen the severity of the disease. It is only recommended for people who cannot receive the vaccine and 1) who lack evidence of immunity to varicella, 2) whose exposure is likely to result in infection, and 3) are at high risk for severe varicella.

Persons at risk of severe varicella include—

• immunocompromised patients without evidence of immunity to varicella, such as—
  • children with leukemia or lymphoma who have not been vaccinated
  • people on medications that suppress the immune system, such as high-dose systemic steroids or chemotherapeutic agents
  • people with cellular immune-deficiencies or other immune system problems
• newborns whose mothers have varicella from 5 days before to 2 days after delivery
• premature babies exposed to varicella or herpes zoster, specifically—
  • hospitalized premature infants born at ≥28 weeks of gestation whose mothers do not have evidence of immunity
  • hospitalized premature infants born at <28 weeks of gestation or who weigh ≤1,000 grams at birth regardless of their mothers’ varicella immunity status
• pregnant women without evidence of immunity to varicella

The varicella zoster immune globulin product licensed for use in the United States is VariZIG™. VariZIG should be given as soon as possible after exposure to varicella-zoster virus (VZV) and within 10 days of exposure. For more information, see the Morbidity and Mortality Weekly Report article on Updated Recommendations for Use of VariZIG — United States, 2013. VariZIG is currently available from 2 distributors in the US. See the Morbidity and Mortality Weekly Report announcement on the Expansion of VariZIG distribution in the United States.

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Acyclovir Treatment

American Academy of Pediatrics (AAP) recommends that certain groups at increased risk for moderate to severe varicella be considered for oral acyclovir treatment. These high risk groups include

• healthy, persons older than 12 years of age
• persons with chronic cutaneous or pulmonary disorders
• persons receiving long-term salicylate therapy
• persons receiving short, intermittent, or aerosolized courses of corticosteroids

Some health care providers may elect to use oral acyclovir for secondary cases within a household.

For maximum benefit, oral acyclovir therapy should be given within the first 24 hours after the varicella rash starts.

Oral acyclovir therapy is not recommended by the Advisory Committee on Immunization Practices or AAP for use in otherwise healthy children experiencing typical varicella without complications.

Acyclovir is a category B drug based on US Food and Drug AdminIstration (FDA) Drug Risk Classification in pregnancy. Some experts recommend oral acyclovir or valacyclovir for pregnant women with varicella, especially during the second and third trimesters. Intravenous acyclovir is recommended for the pregnant patient with serious, viral-mediated complications of varicella (e.g., pneumonia).

Intravenous acyclovir therapy is recommended for severe disease (e.g., disseminated VZV such as pneumonia, encephalitis, thrombocytopenia, severe hepatitis) and for varicella in immunocompromised patients (including patients being treated with high-dose corticosteroid therapy for >14 days).

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