Varicella-zoster Immune Globulin Research Articles

Management of a major varicella zoster exposure in a pediatric oncology population

Management of the exposure of pediatric oncology patients to varicella zoster virus (VZV) is controversial. We report the exposure of 56 patients to a single child with chicken pox at a pediatric cancer housing facility and describe our strategic approach for their management. We reviewed the immune and clinical status of 56 children with cancer receiving ongoing treatment at Memorial Sloan Kettering Cancer Center (MSK) who, while living at a pediatric cancer housing facility, were exposed to the index patient. The management of patients exposed included: (1) determination of immune status, (2) availability of vaccination history or VZV disease prophylaxis, (3) exposure status and subsequent isolation during the period of incubation, and (4) VZV disease prophylaxis. In addition to the 56 patients exposed to the index case, eight children with cancer treated at other facilities and 11 healthy siblings living in the facility were exposed. Of the 56 MSK patients, 21 were classified as immunosuppressed and received varicella zoster immune globulin (human), intravenous standard immune globulin, or acyclovir based on serostatus and immune function. The cohort was followed for 4 weeks after the exposure and no secondary infections were diagnosed. We performed a risk assessment and created a management plan to control and prevent further exposure and development of disease. No secondary cases developed. This strategic approach could serve as a model for the management of VZV exposure for other pediatric oncology centers.

Varicella zoster immune globulin (human) (VARIZIG) in immunocompromised patients: a subgroup analysis for safety and outcomes from a large, expanded-access program

BackgroundImmunocompromised children and adults are at increased risk for severe disease and death following varicella zoster virus infection. Varicella zoster immune globulin (human) (VARIZIG) is recommended for post-exposure prophylaxis to prevent or attenuate varicella infection in high-risk individuals.MethodsAn open-label, expanded-access program provided VARIZIG to high-risk individuals exposed to varicella or herpes zoster. Immunocompromised participants were stratified by type of immunocompromising condition (“oncologic immunodeficiency”, “primary immunodeficiency”, “solid organ transplant” [SOT], “hematopoietic cell transplant” [HCT], and “other”). Patient characteristics, type of exposure and varicella outcome, and safety data were assessed.ResultsThis analysis included 40 adults (primary [n = 6] or oncologic [n = 10] immunodeficiencies, history of SOT [n = 5] or HCT [n = 6], and other [n = 13]), and 263 children (primary [n = 13] or oncologic [n = 152] immunodeficiencies, history of SOT [n = 36] or HCT [n = 17], and other [n = 45]). Among adults and children, 48% vs 72% were exposed to varicella, 38% vs 16% were exposed to herpes zoster, and 15% vs 12% had an unspecified exposure. Overall incidence of varicella infection in adults after VARIZIG use was 6%; incidence of varicella infection in children after VARIZIG use was 7%. Similar rates were noted in each subgroup. Most cases of varicella were mild, with two children developing > 100 lesions and no cases of varicella-related pneumonia or encephalitis. Varicella-related hospitalizations occurred primarily in children with oncologic immunodeficiencies. One serious adverse event (serum sickness) was considered related to VARIZIG and occurred in a child with oncologic immunodeficiency. There were no varicella- or VARIZIG-related deaths.ConclusionsThese data indicate that VARIZIG may reduce severity of varicella in immunocompromised children and adults.Trial registrationThis study was retrospectively registered with the public clinical trial identification NCT00338442 at https://www.clinicaltrials.gov on 20 June 2006.

Preventing Transmission of Vaccine-Associated Viral Infections from a Patient With Severe Combined Immune Deficiency

Background: The transmissibility of vaccine-strain viruses from immunocompromised patients, such as those with severe combined immune deficiency (SCID) is unknown. The infection control management of a patient diagnosed with SCID and infected with vaccine-strain varicella zoster virus (VZV) and measles virus is described below. A previously healthy, full-term boy was vaccinated at 14 months with measles mumps rubella varicella (MMR) vaccine. He had received prior vaccinations, including rotavirus, without adverse effects. During the 6 weeks after vaccination, the patient developed signs and symptoms clinically consistent with chicken pox and measles. An immune work-up revealed SCID. Methods: The Alberta Health Services (AHS) SCID protocol was followed to manage the patient upon admission at 17 months of age. Multiple meetings with various stakeholders were held to ensure appropriate precautions were followed to minimize the risk of pathogen transmission. Results: The patient was placed on airborne and contact precautions in a negative-pressure room. The pressure differential of the room to the corridor was continually monitored and displayed at the entry to the room. Staff known to be immune to VZV or measles were not required to wear an N95 respirator. All intrahospital movement of the patient was coordinated with the respective care teams and departments, including infection prevention and control, facilities maintenance and engineering, respiratory therapy, and diagnostic imaging. A mask was placed on the patient when movement outside the room was required. VZV testing was positive for the Oka/vaccine strain on all samples tested (ie, nasopharyngeal, skin, blood, and cerebrospinal fluid). Nasopharyngeal swabs and blood were PCR positive for measles genotype A/vaccine strain virus. Both viruses were persistently positive in spite of treatment with acyclovir, valganciclovir, varicella zoster immune globulin, and intravenous immune globulin. Conclusions: There is currently no documented transmission of measles vaccine-strain virus, and transmission of VZV vaccine-strain virus is rare. According to the AHS SCID protocol, the use of airborne and contact precautions for a patient identified with measles and/or VZV supersedes the use of a positive-pressure room for patients identified with SCID. Newborn screening for SCID was implemented in Alberta in June 2019. As a result, more SCID patients will be diagnosed earlier in their course, and therefore prior to most routine vaccinations. However, newborn screening will not pick up some types of combined immune deficiencies. Some children may still be at risk of vaccine-associated illnesses due to undiagnosed underlying immune deficiencies.Funding: NoneDisclosures: None

Safety and Varicella Outcomes in In Utero-Exposed Newborns and Preterm Infants Treated With Varicella Zoster Immune Globulin (VARIZIG): A Subgroup Analysis of an Expanded-Access Program.

BackgroundInfants exposed to varicella zoster virus (VZV) in utero ≤5 days before or ≤48 hours after delivery and preterm infants are at high risk for varicella complications. An expanded-access program assessed varicella outcomes after administration of varicella zoster immune globulin (human) (VARIZIG) in a real-world setting.MethodsIn this open-label, expanded-access program, high-risk infants received ≤125 IU/10 kg of VARIZIG (NCT00338442). VZV outcomes and safety were assessed.ResultsThere were 43 newborns exposed to VZV in utero and 80 preterm infants exposed to VZV; >80% received VARIZIG within 96 hours of reported exposure. When varicella outcomes were available, varicella occurred in 7 of 38 (18%) in utero–exposed newborns and zero of 65 preterm infants. Varicella-related complications were reported in 3 in utero–exposed newborns (3 with >100 lesions, 1 each with encephalitis and pneumonia). Adverse events were reported for 16% of in utero–exposed newborns and 25% of preterm infants, but few were considered related to VARIZIG. There were no deaths attributable to varicella or VARIZIG.ConclusionsVaricella incidence and morbidity were low in in utero–exposed infants and zero in preterm infants who received prophylactic VARIZIG. There were few VARIZIG-related safety concerns.

A fatal case of severe systemic varicella zoster infection in a patient with chronic use of immunosuppressive agents for cutaneous vasculitis.

Acute varicella zoster virus (VZV) infection is a common condition in children, which is considered a mild, self-limited disease with diffuse skin vesicular rash. However, disseminated VZV infection with multiple organ involvement can occur in immunocompromised patients with impaired T cell immunity including solid or hematopoietic stem cell transplant recipients, receiving immunosuppressive therapy, leukemia, lymphoma, and HIV infection. Prompt antiviral therapy is mandatory in those immunocompromised persons. A 52 year-old man receiving chronic immunosuppressive drugs for his underlying leukocytoclastic vasculitis visited emergency department for diffuse skin vesicular rash that developed 4 days after contact with varicella zoster patients at his office. Despite prompt initiation of oral antiviral agents had been prescribed, rapid progression with septic shock, lactate acidosis, and disseminated intravascular coagulopathy occurred. The patient died within 24 h of intensive care unit admission. Varicella zoster infection commonly causes severe complications in adults receiving chronic immunosuppressive therapy. Post exposure prophylaxis varicella zoster immune globulin and early parenteral antiviral agents use after acute varicella virus infection may be mandatory in immunocompromised patients.

Varicella-zoster virus post-exposure management and prophylaxis: A review.

Varicella-zoster virus causes both varicella (chickenpox) and herpes zoster (shingles). Although varicella incidence has dramatically declined since introduction of the live-attenuated varicella vaccine, vaccination rates are suboptimal, and outbreaks still occur. Additionally, herpes zoster incidence continues to rise. Severe or fatal complications may result from varicella transmission to at-risk individuals who are exposed to either varicella or herpes zoster. An increasing number of children and adults are receiving immunosuppressive therapies and are at high risk for severe varicella and other complications if exposed to the virus. Clinical management of individuals exposed to varicella-zoster virus should take into consideration the type of exposure, evidence of immunity, and host-immune status with regard to ability to receive varicella vaccination safely. Post-exposure varicella vaccination may prevent infection or mitigate disease severity in persons eligible for vaccination. Post-exposure prophylaxis with varicella zoster immune globulin is indicated for populations ineligible for vaccination, including immunocompromised children and adults, pregnant women, newborns of mothers with varicella shortly before or after delivery, and premature infants. Appropriate post-exposure management of individuals exposed to either varicella or herpes zoster-including assessment of immune status and rapid provision of optimal prophylaxis-can help avoid potentially devastating complications of varicella-zoster virus infection.

DISCREPANCIES IN BRONCHIAL WASH AND LAVAGE: THE DUBIOUS CASE OF VARICELLA PNEUMONIA

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Varicella pneumonia is a rare but serious infection caused by Varicella Zoster virus (VZV). Diagnosis is attained by clinical presentation, radiologic findings & is aided by detection of VZV in respiratory secretions by polymerase chain reaction (PCR). We present a diagnostic dilemma when two tests have a discrepancy. CASE PRESENTATION: A 41 year old female presented with left upper quadrant (LUQ) abdominal pain, hypotension, melena & somnolence which prompted intubation. She had medical history of end stage liver disease due to alcoholic cirrhosis, esophageal varices, refractory ascites & encephalopathy. Endoscopy showed varices & small bowel ulcer; & paracentesis ruled out bacterial peritonitis. After treatment with octreotide, nexium & prophylactic ceftriaxone; she was was successfully extubated. 3 days later, she developed a new, vesicular, dermatomal rash of shingles on LUQ. This was followed by new extensive multifocal infiltrates, crazy paving pattern & diffuse ground glass opacities on chest imaging (Figure) along with hypoxic respiratory failure which warranted re-intubation. A bronchoscopy was done which showed thick white secretions on bronchial washing (BW) & cloudy fluid on bronchoalveolar lavage (BAL) of right middle lobe & left upper-lingular segment. VZV PCR resulted positive on BW but negative on BAL. Patient was started on Varicella-Zoster immune globulin (VZIG) and acyclovir based on clinical presentation and radiologic features which led to clinical improvement. DISCUSSION: Varicella pneumonia can manifest 1-6 days after onset of the typical rash & is highly infectious with a secondary attack rate of > 90%. In the presence of clinical features of VZV infection, the diagnosis is mediated by chest imaging showing nodular or interstitial pneumonitis with ground glass opacities. Molecular diagnostic assays using PCR are often employed and have sensitivity as high as 96% for detection of VZV (1). However, it can be limited by false positive rate due to contamination and depends on the methodology (2) as well as specimen source although BAL has high sensitivity (3). Our patient developed respiratory failure with radiologic findings shortly after typical zoster rash. Despite adequate sampling, there was a discrepancy in the result obtained from BAL and BW. A comparison of these two hasn’t been studied yet in respect to VZV as well as other common pathogens. We favored to treat the patient due to detection of VZV on BW & the clinical presentation. VZIG administration within 72 hours of exposure is highly efficacious for disease prevention in immunocompromised along with intravenous acyclovir for 7-10 days and has led to overall decline in mortality. CONCLUSIONS: Although VZV DNA detection by PCR is helpful in diagnosing VZV pneumonia, there is no consensus data on its utility on BW in comparison to BAL. The paucity of VZV pneumonia is a hindrance for more extensive studies. Reference #1: Mirouse A et al. Severe varicella-zoster virus pneumonia: a multicenter cohort study. Critical Care. 2017 Dec;21(1):137 Reference #2: Schmutzhard J, Riedel HM, Wirgart BZ, Grillner L. Detection of herpes simplex virus type 1, herpes simplex virus type 2 and varicella-zoster virus in skin lesions. Comparison of real-time PCR, nested PCR and virus isolation. Journal of clinical virology. 2004 Feb 1;29(2):120-6 Reference #3: Stránská R, Schuurman R, de Vos M, van Loon AM. Routine use of a highly automated and internally controlled real-time PCR assay for the diagnosis of herpes simplex and varicella-zoster virus infections. Journal of Clinical Virology. 2004 May 1;30(1):39-44 DISCLOSURES: No relevant relationships by Enambir Josan, source=Web Response No relevant relationships by Supriya Singh, source=Web Response No relevant relationships by Yasir Tarabichi, source=Web Response

Varicella zoster immune globulin (VARIZIG) administration up to 10 days after varicella exposure in pregnant women, immunocompromised participants, and infants: Varicella outcomes and safety results from a large, open-label, expanded-access program

IntroductionDespite vaccination, there were more than 100,000 annual cases of varicella in the United States in 2013–2014. Individuals at highest risk of developing severe or complicated varicella include immunocompromised people, preterm infants, and pregnant women. Varicella zoster immune globulin (human) (VARIZIG) is recommended by the CDC for postexposure prophylaxis to prevent or attenuate varicella-zoster virus infection in high-risk individuals. Contemporary information on administration of VARIZIG is limited.MethodsThis open-label, expanded-access program provided VARIZIG to physician-identified, high-risk participants exposed to varicella. Participants included immunocompromised children/adults, infants (preterm, newborns whose mothers had varicella onset within 5 days before or 2 days after delivery, and those aged <1 year), and pregnant women. VARIZIG (125 IU/10 kg [up to 625 IU]) was administered intramuscularly, ideally within 96 hours, but up to 10 days, postexposure. Incidence of varicella rash and severity (>100 pox, pneumonia, or encephalitis) were assessed up to 42 days after administration.ResultsThe varicella outcome population (n = 507) included 263 immunocompromised participants (32 adults, 231 children), 137 pregnant women, 105 infants, and 2 healthy adults with no history of varicella. Varicella incidence was 4.5% in immunocompromised participants, 7.3% in pregnant women, and 11.5% in infants. The incidence of varicella was similar when comparing VARIZIG administration ≤ 96 hours vs > 96 hours (up to 10 days) postexposure in the entire population (6.2% vs. 9.4%, respectively), and also in each subgroup. Of 34 participants with varicella, 5 developed > 100 pox and 1 developed pneumonia and encephalitis. There were no product-related deaths and only 1 serious adverse event (serum sickness) considered probably related to VARIZIG.ConclusionPostexposure administration of VARIZIG was associated with low rates of varicella in high-risk participants, regardless of when administered within 10 days postexposure. VARIZIG was well-tolerated and safe in high-risk participants.

Implementation of Hospital Policy for Healthcare Workers and Patients Exposed to Varicella-Zoster Virus.

Varicella-zoster virus (VZV) causes a highly contagious and generally benign, self-limited disease. However, in high-risk populations including immunocompromised patients, pregnant women, and neonates, VZV infection can be associated with significant morbidity and mortality. Healthcare-associated transmission of VZV occurs among healthcare workers (HCWs) and patients by airborne transmission or by direct contact with the index case. To minimize the risk of transmission in healthcare settings, all VZV-susceptible HCWs should be encouraged strongly to be immunized with the varicella vaccine. For post-exposure management, active immunization (varicella vaccine), passive immunization (varicella-zoster immune globulin) and/or antiviral agents, and isolation could be used in specific situations. To prevent the transmission of VZV infection in the hospital settings, the development and implementation of hospital policies for appropriate infection control is also warranted. This article reviews the general information and healthcare-associated transmission of VZV and summarizes the recommendations for the pre- and post-exposure management of HCWs and patients, in hospital settings.

Critical Considerations in Anticancer Drug Development and Dosing Strategies: The Past, Present, and Future.

Critical Considerations in Anticancer Drug Development and Dosing Strategies: The Past, Present, and Future.

Cutaneous manifestations of systemic viral diseases in neonates: an update.

Dermatologic findings may be the first signs of a neonatal viral infection. This review provides an update of the diagnostic features and therapies for selected viral illnesses [herpes simplex virus (HSV), varicella zoster virus, enterovirus, and Zika virus] that present with cutaneous manifestations in the neonate. HSV DNA polymerase chain reaction of plasma and cerebrospinal fluid, routinely used in the diagnosis of neonatal HSV, may have expanded utility in assessing prognosis and acyclovir therapeutic efficacy. Maternal antiviral suppressive therapy may alter the clinical appearance of congenital HSV, resulting in delayed diagnosis and treatment. VariZIG, a varicella zoster immune globulin, is a US Food and Drug Administration approved form of prophylaxis for varicella. The Centers for Disease Control and Prevention has expanded the period of VariZIG eligibility for preterm infants, a group particularly susceptible to severe varicella infection. For severe neonatal enterovirus sepsis, the results of a randomized, double-blind, placebo-controlled trial of pleconaril, a viral capsid inhibitor, suggest that this compound is an effective therapy. Human Parechovirus type 3, a strain within a newly formed viral genus, has a similar, and potentially underestimated, clinical presentation to enterovirus sepsis. However, a distinctive erythematous palmoplantar rash may be specific to human Parechovirus type 3 infection. Perinatal Zika virus infection in the neonate may present with a nonspecific macular and papular rash. As this rash is not specific, obtaining a maternal travel history and, if appropriate, requesting additional diagnostic testing are critical for early diagnosis. Neonatal rashes may be harmless and transient, whereas others may reflect the presence of a severe systemic illness. Recognizing key cutaneous features of viral-associated rashes may aid in the prompt and accurate diagnosis and treatment of neonatal viral illnesses.

Updates to the Canadian Immunization Guide: March 2014 to March 2015.

The National Advisory Committee on Immunization (NACI) develops recommendations for the use of vaccines for Canadians, which are summarized in the Canadian Immunization Guide (the Guide) and which is updated on a regular basis. Between March 2014 and February 2015 recommendations on five vaccines have been issued. Updates to the Guide include recommendations made for the alternative dosing administration of the human papillomavirus (HPV) vaccine in adolescents, timing of varicella zoster immune globulin (VarIg) following exposure to varicella, and the meningococcal and quadrivalent influenza vaccines, recently authorized for use in Canada. A change in recommendations for the use of pneumococcal vaccines in adults and individuals with asthma has also been made. The chapter on tick-borne encephalitis vaccine has now been removed from the Guide as this vaccine is no longer available in Canada.

Effectiveness of Varicella Zoster Immune Globulin Administration within 96 Hours versus more than 96 Hours after Exposure to the Varicella-Zoster Virus

목적: 고위험군 환자에서 수두 바이러스 접촉 후 예방 요법으로 수두 면역 글로불린을 투여한다. 두면역 글로불린으로 국내에서는 VZIG, 미국에서는 VariZIG®을 사용한다. 2013년 7월 미국 질병관리본부에서 수두 바이러스 노출 후 VariZIG®투여를 최대 10일까지로 연장하여도 수두 예방 효과가 있음을발표하였다. 본 연구에서 저자들은 수두 노출 후 96시간 이내에 VZIG 투여 군과 96시간 이후 투여군에서 수두 예방 효과를 비교하고자 하였다.방법: 삼성서울병원에서 2001년 1월부터 2012년 12월 사이에 VZIG이 투여된 환자들을 대상으로 향적차트 분석을 통해 평가하였다. 결과: 전체 91명의 환자에서 57명(62.6%)은 남자였고 연령의 중앙값은 5.91세였다. 39명(42.9%)은 병원 내에서 수두 바이러스에 노출되었다. 기저 질환은 고형 종양 41.8%, 혈액 종양 40.7%이었고 그외 다른 질환이 17.5%이었다. 전체 환자 중에서 45명(49.5%)은 조혈모세포 이식 환자였다. 74명(81.3 %)이 수두 바이러스 노출 후 96시간 이내에 VZIG을 투여 받았다. 수두 바이러스 노출 후 96시간 이내에 VZIG이 투여된 군과 96시간 이후에 투여된 군에서 수두 발생은 뚜렷한 차이가 없었다(2.7% vs. 5.9%, P =0.4664). 효소면역분석법 검사에서 수두 항체가 음성인 환자는 22명이었고, 이 환자들에서수두 바이러스 노출 후 96시간 이내에 VZIG이 투여된 군과 96시간 이후에 투여된 군에서 수두 발생은 뚜렷한 차이가 없었다(6.6% vs. 0%, P=0.667). 결론: 본 연구에 의하면 수두 노출 후 96시간 이전에 VZIG 투여군과 96시간 이후에 VZIG 투여군 사이에 수두 발생을 예방하는데 차이가 없었으나, 향후 더 많은 환자수에서 추가 연구가 필요할 것으로 사료된다.

COMMENTARY

COMMENTARY

PEPtalk: postexposure prophylaxis against varicella in children with cancer

ObjectivesTo describe postexposure prophylaxis (PEP) against varicella zoster virus (VZV) in children being treated for malignancy in the UK and Ireland: the population at risk, frequency of exposure, clinical practice...

Preventing varicella in children with malignancies: what is the evidence?

The prevention of varicella in children with cancer is generally agreed to be an important goal, because of their elevated risk of varicella zoster virus (VZV)-associated morbidity and mortality. However, there is a lack of consensus on the best means of achieving this. Here, we review the existing evidence in relation to postexposure prophylaxis against varicella in this group and summarize data regarding the role of active vaccination. Death from varicella during treatment for cancer is now rare, but VZV disease and its prevention remain significant problems in paediatric oncology practice. Measures to reduce VZV exposure amongst seronegative individuals are often neglected. When exposure is known to have occurred, early administration of varicella zoster immune globulin (VZIG) is generally protective against severe and complicated varicella. However, many centres in the UK and Japan use an oral antiviral agent, aciclovir, in place of VZIG. Published evidence for the efficacy of aciclovir as postexposure prophylaxis (PEP) relates mostly to healthy children, with no controlled studies in the immunocompromised. Good evidence already supports the administration of varicella vaccine to healthy susceptible family contacts of children with malignancy, but not to patients themselves. Further data are urgently needed to inform the choice of PEP against VZV in the immunocompromised.

Issues in Chemotherapy

1. Elizabeth A. Van Dyne, MD 1. Kaiser Permanente Medical Center Los Angeles, CA 1. 1. Pickering LK, 2. Baker CJ, 3. Kimberlin DW, 4. Long SS Immunizations in Special Clinical Circumstances . American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2009:72–86 2. 1. Pickering LK, 2. Baker CJ, 3. Kimberlin DW, 4. Long SS Varicella-Zoster Infections. American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW, Long SS, eds. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed.Elk Grove Village, IL: American Academy of Pediatrics; 2009:714–727 3. 1. Meckler G, 2. Lindemulder S Fever and Neutropenia in Pediatric Patients with Cancer . Meckler G, Lindemulder S. Emerg Med Clin North Am. 2009;27:525–544 [OpenUrl][1][CrossRef][2][PubMed][3] 4. 1. Hughes WT, 2. Armstrong D, 3. Bodey GP, 4. et al 2002 Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer . Hughes WT, Armstrong D, Bodey GP, et al. Clin Infect Dis. 2002;34:730–751 [OpenUrl][4][FREE Full Text][5] Children who have cancer may be severely immunocompromised by the oncologic process and the immunosuppression that results from chemotherapy. Their increased susceptibility to infection directs the scheduling of vaccine administration and the urgent treatment of the febrile child. Live (attenuated) vaccines should not be given to patients undergoing immunosuppressive therapy, specifically chemotherapy and radiation treatment. Live vaccines include those manufactured to protect against Salmonella typhi ; influenza (live intranasal vaccine); measles, mumps, rubella (MMR); varicella; rotavirus; polio (oral vaccine); yellow fever; and smallpox. The recommendation is to wait at least 3 months after completion of the last immunosuppressive treatment before administering live vaccines, and many oncologists wait 6 to 12 months. Because the time to immune reconstitution depends on the type of chemotherapy given, the dosage, and the patient's degree of responsiveness to treatment, the recommendations must be tailored to the individual patient and his or her circumstances. Vaccination with inactivated vaccines can be completed without increased risk of infectious complications, but the timing is important because the immune response may be inadequate in immunocompromised patients. An adequate response is usually achieved from 3 months to 1 year following the … [1]: {openurl}?query=rft.jtitle%253DEmergency%2Bmedicine%2Bclinics%2Bof%2BNorth%2BAmerica%26rft.stitle%253DEmerg%2BMed%2BClin%2BNorth%2BAm%26rft.aulast%253DMeckler%26rft.auinit1%253DG.%26rft.volume%253D27%26rft.issue%253D3%26rft.spage%253D525%26rft.epage%253D544%26rft.atitle%253DFever%2Band%2Bneutropenia%2Bin%2Bpediatric%2Bpatients%2Bwith%2Bcancer.%26rft_id%253Dinfo%253Adoi%252F10.1016%252Fj.emc.2009.04.007%26rft_id%253Dinfo%253Apmid%252F19646652%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/j.emc.2009.04.007&link_type=DOI [3]: /lookup/external-ref?access_num=19646652&link_type=MED&atom=%2Fpedsinreview%2F32%2F2%2F86.atom [4]: {openurl}?query=rft.jtitle%253DClin%2BInfect%2BDis%26rft_id%253Dinfo%253Adoi%252F10.1086%252F339215%26rft_id%253Dinfo%253Apmid%252F11850858%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [5]: /lookup/ijlink?linkType=FULL&journalCode=cid&resid=34/6/730&atom=%2Fpedsinreview%2F32%2F2%2F86.atom

Congenital varicella syndrome: the evidence for secondary prevention with varicella-zoster immune globulin

A 33-year-old woman who was engaged to be married presented for her initial visit with an obstetrician. Her varicella-zoster IgG antibody titer, as measured by latex agglutination, was < 0.91, which signified nonimmunity. The patient did not know if she had previously had varicella. She had not been

VZV infection in pregnancy: A retrospective review over 5 years in Sheffield and discussion on the potential utilisation of varicella vaccine in prevention

To study retrospectively the epidemiology, demography and clinical issues related to varicella in pregnancy in a UK city over a 5-year period and help inform the debate on the potential of varicella immunisation in prevention. The hospital records of pregnant women with varicella receiving care at the Regional Department of Infection and Tropical Medicine in Sheffield between 1997 and 2002 were reviewed. Data on pregnant women with varicella not presenting acutely to medical care were obtained. The use of Varicella Zoster Immune Globulin (VZIG) in prevention of varicella during the same 5-year period was determined. The records from the maternity department of Sheffield Hospitals for women undergoing VZV antibody testing between January and December 2004 were reviewed. Data on annual number of deliveries were recorded and the neonatology database used as a source of information regarding effects of chickenpox on the baby. The incidence of varicella infection in pregnancy was at least 6 per 10,000 deliveries. Nineteen pregnant women with varicella were admitted to hospital. Three had pneumonia. Infection occurred in the first pregnancy in a quarter of cases. The minimum cost for all cases admitted to hospital during this period (basic costs per day) was 20,520 pounds sterling. The cost of VZIG use for chickenpox during the same period adjusted for the population size was 10,881 pounds sterling. This was not a comprehensive health economic study and did not attempt to assess additional GP, midwifery, obstetric or social costs nor costs associated with those who did not attend hospital. Two hundred and thirty-three women underwent VZV antibody test during 2004 usually after contact with chickenpox. Sixty percent of women in contact with chickenpox did not present to their GP or hospital immediately. Varicella in pregnancy may be associated with significant morbidity and health care cost and prevention by immunisation is desirable. Though targeted vaccination is attractive, screening in pregnancy followed by a post-partum varicella immunisation programme would fail to protect 25% and would be associated with logistical challenges not occurring with rubella immunisation. Varicella is now a preventable disease by immunisation. Exposure in pregnancy with or without infection has financial costs related to antibody testing and prophylaxis. Infection in pregnancy may be associated with additional costs and potential morbidity to mother and baby. Potential immunisation strategies are considered.

With Levothyroxine, Be Careful where you Put the Decimal; It Should Go without Saying: Successful Weight-Based Programs Require a Weight; Don't Confuse Varicella Virus Vaccine with Varicella-Zoster Immune Globulin

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute for Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 800–233–7767 (800–23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writers' names will be published if desired. ISMP may be contacted at the address shown below.