Download Reducing Varicella Complications in Women of Childbearing Age

Picture courtesy of
Centers for Disease
Control and Prevention
(2011). Chickenpox
Varicella Photos.
Retrieved on 10/23/13
from http://www.cdc.
gov/chickenpox/about/pho
tos.html.
Reducing Varicella Complications in Women of
Lynn M. Scott, RN, IBCLC
Childbearing Age
SUNYIT, NUR 490
November 12, 2013
Background
• Varicella is predominantly a childhood disease (also known as
chickenpox) that is highly contagious and is caused by the varciella
zoster virus (VZV) .
• With the exception of pregnant women, anyone born in the U.S. prior
to 1980 is assumed to be varicella immune.
Nursing Theory
Thielen (2012) states: “Pregnancy itself is not an illness or disease state;
rather, it should be seen as a state of wellness. To facilitate behavior that
promotes health and wellness, Pender’s (Nola J.) health and wellness
model fosters the use of nursing interventions that empower the client’s
ability to self-care through education …” (p. 211).
Methods
• Most severe cases of chickenpox develop in immunocompromised
individuals, adults, and pregnant women and their fetuses.
• If VZV is contracted during the first and second trimester (between the
5th and 24th weeks) of pregnancy, spontaneous abortion and premature
labor may occur, or the baby may be born with varicella pneumonia,
neonatal varicella herpes zoster, or Congenital Varicella Syndrome
(CVS), which includes abnormalities of the limbs, central nervous
system and cognitive impairment, seizures, and growth deficiency.
The information provided in this presentation was obtained from an
integrative literature review of 12 articles obtained from CINAHL and
Medline via EBSCO host and include the following types of research and
informative literature: Comparative study, cross-sectional study, case
study, supplements (3), research letter, pediatric review, vaccine standing
orders, critical review, vaccine recommendations, and patient information
sheet.
• CVS, documented as 14 cases in 2,000 deliveries, carries a 30%
mortality rate in the first few months of lie.
• While at risk for various complications, varicella pneumonia, a high
risk complication of VZV in pregnant women, is the most common
cause of mortality in this population.
• In 2005, the Advisory Committee on Immunization Practices (ACIP)
recommended routine screening during pregnancy for evidence of
immunity to varicella and postpartum vaccination of women without
such evidence.
EVIDENCE OF VARICELLA IMMUNITY
History of varicella
or herpes zoster
Documentation of 2
doses of varciella vaccine
at least4 weeks apart
Lab confirmation of
varicella immunity with
IgG ELISA lab studies
Objectives
PICO QUESTION:
• Taking into consideration the pros and cons of administering the varicella
vaccine, will vaccinating women in the immediate postpartum period
decrease the reportable incidences of mortality and morbidity from
complications of varicella in childbearing-aged women and, subsequently,
their newborns?
• Population: Women of childbearing age during the immediate postpartum
period;
• Intervention: Vaccination with the varicella vaccine;
• Comparison: Pros and cons of vaccination, and;
• Outcome: A decrease in the reportable incidences of mortality and
morbidity from complications of varicella in childbearing-aged women and,
subsequently, their newborns.
Infant with
hemorrhagic varicella
infection with
cellulitis. Picture
courtesy of American
Academy of Pediatrics
(no date). Press Room
Photos. Retrieved
10/28/13 from
http://www.aap.org/enus/about-the-aap/aappress-room/aap-pressroom-mediacenter/pages/AAPPressroomPhotos.aspx.
•
•
EVALUATION STRATEGY
PROS
CONS
1. Since the start of the varicella vaccine
1. The extent to which vaccinated individuals
program in 1995, there has been an
harbor latent infection with vaccine380.9% reduction in the number of
related VZV and the contribution of this
varicella cases.
towards protective immunity against VZV
2. Varicella vaccine will help protect the
is unknown.
public from the risks and costs of the
2. There are several potential adverse effects
complications of varicella.
of the varicella vaccine:
3. Overall adverse effects of the varicella
• Transmission of varicella from a
vaccine were 2.6 cases per 100,000
recently vaccinated individual (5
distributed doses.
cases in 55 million distributed
4. The components of the varicella
doses);
vaccine have not been found in human
• Development of chickenpox or
breastmilk.
herpes zoster (rare) in vaccinated
5. It has been documented that VZV can
individuals;
occur as IgG levels can wane over time.
• Primary failure of vaccine
6. Reinfection with VZV might occur
(infection) and secondary failure of
even after natural exposure or infection.
vaccine (reinfection);
7. Out of 600 women listed in the
• Discomfort at injection site;
• Anaphylactic reaction, seizures,
VARIVAX® Pregnancy Registry (in
Stephen Johnson Syndrome,
conjunction with the Centers for
encephalopathy, rash, etc.
Disease Control and Prevention) that
3. Women who are vaccinated should avoid
were inadvertently vaccinated against
becoming pregnant for 1 month after each
varicella during or around pregnancy,
vaccine injection.
there were no reported cases of CVS.
8. The risk of an infant developing birth
defects due to their seronegative
mother’s exposure to the varicella
vaccine during the highest risk period is
similar to the reported prevalence rate
in the general population.
9. The varicella vaccine is 70%-100%
effective if administered within 72
hours of exposure to an individual
infected with VZV.
10. Varicella-related morbidity and
mortality have dramatically decreased
in countries where varicella vaccination
has been introduced.
As a result of the information obtained through the research contained herein,
policy, protocol, and standing orders on Varicella Vaccine for Postpartum Women
are being created for this author’s employer under the advisement of the
institution’s Executive Director.
Conclusions
Evidence
•
Prevention of VZV infection in pregnant women through the vaccination of
childbearing-aged women is key to continuing the documented reduction of
varicella-related maternal and neonatal morbidity and mortality.
The decline in the number of cases of VZV has decreased the exposure
but increased the susceptibility of women to this virus in their
childbearing years.
•
Varicella vaccination is a safe and effective intervention to prevent VZV
infections and complications of the disease in women of childbearing age with
99% immunity protection by administering two doses of VARIVAX®, 4 weeks
apart, in postpartum women.
Pregnant women who are exposed to VZV in the low-risk period of
gestation should be evaluated as soon as possible through physical
examination and serology testing. Post-exposure prophylaxis with
Varicella Zoster Immune Globulin (VariZIG®) as soon as possibly close
to exposure should be considered for susceptible candidates in order to
avoid potential complications in the pregnant mother (e.g., bacterial
superinfection of skin lesions, pneumonia, acute cerebellar ataxia,
encephalitis, thrombocytopenia, and Reye Syndrome). It is important that
these women are followed up with varicella vaccine upon completion of
their pregnancy..
•
When pregnant mothers develop VZV between 5 days prior to delivery
and 2 days after delivery, their newborns are at high risk for severe
varicella complications, specifically an untreated mortality rate as high as
31%, usually from varicella pneumonia.
•
The assessment of serological data is essential for the appropriateness
and impact of counseling, screening, and vaccination for varicella
•
Healthcare providers should educate their patients about the benefits of
varicella vaccination.
Indications for the Varicella Vaccine
•
Implementation
All adults who do not show evidence of immunity to varicella unless they
have one of the following contraindications:
Contraindications to the Varicella Vaccine
(In childbearing-aged women specifically)
•
History of allergy or anaphylactic reaction to components of varicella
vaccine;
•
Pregnancy or anticipated pregnancy within 1 month;
•
Any malignant conditions including blood dyscrasias, leukemia,
lymphoma, or any other types of malignant neoplasms of the bone
marrow or lymphatic system;
•
Currently receiving high-dose immunosuppressive therapy (e.g., two
weeks or more of 20 mg or greater Prednisone);
•
CD4 and T-Lymphocyte count <200 cells/uL, and;
•
Family history of congenital/hereditary immunodeficiency in a firstdegree relative.
Precautions to the Varicella Vaccine
•
Receipt of antibody-containing blood products within the past 11 months,
and;
•
Moderate to severe acute illness with or without a fever.
References
Centers for Disease Control and Prevention (2013). MMWR: Updated
recommendations for use of VariZIG® - United States, 2013. Retrieved
on 10/23/13 from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6228a4.htm.
FDA.gov (2010). Patient information about Varivax®. Retrieved on 10/23/13
from http://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/
ApprovedProducts/UCM165651.pdf.
Guido, M., Tinelli, A., DeDonno, A., Quattrochi, M., Malvasi, A.,
Camplilongo, F., & Zizza, A. (2012). Susceptibility to varicella zoster
among pregnant women in the province of Lecce, Italy. Journal of Clinical
Virology, 53, 72-76, doi: 10.1016/j.jcv2011.10.007.
Hackley, B. (2008). Incorporating immunization services into reproductive
healthcare. Journal of Midwifery & Women’s Health, 53(3), 175-187.
doi: 10.1016/j.jmwh.2008.01.002.
Hambleton, S., Steinberg, S. P., LaRussa, P. S., Shapiro, E. D., & Gershon, A.
A. (2008). Risk of herpes zoster in adults immunized with varicella vaccine.
The Journal of Infectious Diseases, 197, S196-S199. doi: 10.1086/522131.
Hendriksz, T. (2011). Vaccines for measles, mumps, rubella, varicella, and
herpes zoster: Immunization guidelines. Journal of the American
Osteopathic Association, 111(10), S10-S12.
Immunization Action Coalition (2013). Standing orders for administering
varicella (chickenpox) vaccine to adults. Retrieved on 10/01/13 from
http://www.immunize.org/catg.d/p3080.pdf.
Kett, J. C. (2013). Perinatal varicella. Pediatrics in Review, 34(1), 49-51. doi:
10.1542/pir.34-1-49.
Picone, O., Vauloup-Fellous, C., Senat, M. V., Frydman, R., & GrangeotKeros, L. (2008). Maternal varicella infection during pregnancy in a
vaccinated patient. Prenatal Diagnosis, 28, 971-972. doi: 10.1002/pd.2083.
PubMed.gov (2005). Chickenpox vaccines: New drugs. A favourable riskbenefit balance in some situations. Prescrire International, 14(77), 85-91.
Thielen, K. (2012). Exploring the group prenatal care model: A critical review
of the literature. The Journal of Perinatal Education, 21(4), 209-218, doi:
http://dx.doi.org/10.1891/1058-1243.21.4.209.
Wilson, E., Goss, M. A., Marin, M., Shields, K. E., Seward, J. F., Rasmussen,
S. A., & Sharrar, R. G. (2008). Varicella vaccine: Exposure during
pregnancy. The Journal of Infectious Diseases, 197, S178-S184. doi:
10.1086/522136.