Friday, June 19, 2015

Chickenpox/Shingles exposure guide



The Varivax (chickenpox vaccine) came out in 1995. Frankly our office was a little slow to adopt it. We did an about face one season when we had hordes of chickenpox patients who were absolutely miserable, and there didn't seem to be a sensible answer as to why we shouldn't simply give the shot to prevent it. The answer that "we had them and survived" seemed a little weak. While it is true that most chicken pox sufferers simply have a very unhappy week, complications do occur. Even the moderate cases can have painful lesions in the genitals and mouth. Some folks get them in the eyes and need round the clock eye drops. Some of the lesions end up leaving scars. At the very least you have a sleepless, itchy week and will need to take time off of work.

All of that being said, some parents opt out and this is not one of the vaccinations that will elicit a strong armed argument from us. For those still on the fence, keep in mind that children generally have an easier time with this virus than adults. It isn't quite as simple to catch as it used to be because there is so much less of it going around. If your unvaccinated child doesn't come down with it, consider getting them the vaccine before they are all grown up and out of the house.  

There are also some studies that indicate that future occurrence of shingles may be less likely in a patient who had the Varivax than someone who had the actual chicken pox. In all honesty that question probably won't be answered for another 40 years or so, when the first wave of kids who got the vaccine become middle aged. In our office we used to see the occasional young patient with shingles and so far since starting the Varivax program we have seen little or no shingles cases in vaccinated kids. I realize that this small sample is statistically useless but one can hope.

Similar to the MMR, infants have some maternal protection that starts to wane when they are about 7 months. The protection is probably gone by a year. The first dose of the shot is usually given between 12-15 months. Unlike the MMR, Varivax is not recommended before the age of a year even if traveling or your child has been exposed. A booster is given between 4-6 years. For children age 13 years or older who are getting the Varivax for the first time, the minimum interval between doses is 4 weeks.

Because most of our patients get immunized, actual cases of chickenpox are getting more and more unusual, but they still are occurring. At our office, we ask that If someone suspects that their child might have chickenpox they alert us ahead of time. One of the nurses will go out and see if it is okay for them to come in. We do our best to try to avoid exposing our other patients. Most of the time it is a false alert. We go out, take a look at the rash and end up bringing them directly into an exam room.

Therefore last week when I went out to check someone, I was surprised to see what looked like a classic case of chickenpox.  Luckily it was a nice sunny day because that family was not welcomed in. That particular patient was NOT vaccinated. It turns out that there is a small spike in cases out there right now.

We get many calls  about the incubation and contagion period of chickenpox and shingles. Here is the scoop.

Kids are contagious a day or two before they get any lesions. They may have a low grade fever and be cranky. It is very likely that they are out and about in school, daycare or activities during this period spreading this virus to anyone who is not immune. It is what it is. No reasonable person expects you to keep your child home every time they are cranky. They remain contagious until all of the lesions have crusted over. That usually takes about a week.

So there you were in the park, playing with patient X. You get a call on day 2 from patient X's parent that they have come down with chickenpox. If they were having close interaction with each other, it is likely that your child was indeed exposed. The chickenpox virus is very contagious. It is airborne and can live on some surfaces. If your child is vaccinated or already had the illness, you likely don't need to worry too much. The vaccine is about 85% effective. The other 15% of folks tend to get much lighter cases. If your child in not immune you are now on alert.

From the first moment of exposure, the incubation period is usually 2 weeks but can range from 10-21 days. If 3 weeks go by with no sign of anything you are likely in the clear. Just because your child has been exposed is not a reason for you to keep them home from school or daycare and for you to miss work. They may or may not catch it.
Do be on the lookout for any signs that your child might be succumbing. The words "I want to go take a nap now" may be a red flag. If they get a fever you may want to issue a warning to any friends or caregivers as you wait to see if vesicles appear. If your child does come down with it they are now patient X and were likely contagious a day or so before the first sign of a rash.

After you recover from chickenpox, the virus can enter your nervous system and lie dormant for years. Eventually, it may reactivate and travel along nerve pathways to your skin - producing shingles. It is most common in folks when they are older adults. It may be stress related. One easy diagnostic trick is that the blistery rash will usually not cross the midline of the body.

Shingles can be spread only if someone comes into direct contact with the lesion. A healthy person who has immunity to chickenpox is generally not considered to be at risk. Someone with a compromised immune system or someone who has never had the chickenpox needs to be a little more cautious. If infected, they would catch chickenpox, not shingles, from the infected person. Over the years we have had a couple of patients who came down with cases of chickenpox that we traced back to a shingles exposure, but again, that is most unusual. It is NOT airborne. If the shingles patient keeps the lesions covered you can still go visit grandma.


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