Varicella (Chickenpox) Kathleen H. Harriman, Gilberto F. Chavez INFECTIOUS AGENT Varicella zoster virus is a member of the herpesvirus family.

Humans are the only reservoir of the virus, and disease occurs only in humans. MODE OF TRANSMISSION Varicella is transmitted from person to person by direct contact, inhalation of aerosols from vesicular fluid of skin lesions of varicella (chickenpox) or herpes zoster (shingles), which is a reactivation of latent varicella, or from infected respiratory tract secretions that might also be aerosolized. The varicella zoster virus enters the host through the upper respiratory tract or the conjunctiva. In utero infection can also occur as a result of transplacental passage of virus during maternal varicella infection. EPIDEMIOLOGY Varicella occurs worldwide. In temperate climates, varicella tends to be a childhood disease, with peak incidence during late winter and early spring. In tropical climates, infection tends to occur at older ages, resulting in higher susceptibility among adults than in temperate climates. Varicella vaccine is routinely used to vaccinate healthy children in only some countries, including the United States, Australia, Canada, Costa Rica, Dominican Republic, Germany, Mexico, Qatar, Spain, South Korea, Switzerland, United Arab Emirates, and Uruguay. Although varicella is still widely circulating in the United States, the risk of exposure to varicella zoster virus is higher in most other parts of the world than it is currently in the United States. Additionally, exposure to herpes zoster poses a risk for varicella infection in susceptible travelers, although localized herpes zoster has been shown to be much less infectious than varicella. Travelers at highest risk for severe varicella disease are immunocompromised people or pregnant women without a history of varicella disease or vaccination (see below for postexposure prophylaxis recommendations). CLINICAL PRESENTATION Varicella is generally a mild disease in children. Infection is often characterized by a short (1 or 2 days) prodromal period (low-grade fever, malaise), although this may be absent, and by pruritic rash consisting of crops of macules, papules, and vesicles (typically 250500 lesions), which appear in 3 or more successive waves and resolve by crusting. Serious complications are the exception, but they can occur, most commonly in infants, adolescents, and adults. Complications include secondary bacterial infections of skin lesions, pneumonia, cerebellar ataxia, and encephalitis. The average incubation period for varicella is 1416 days (range, 1021 days). The period of communicability is estimated to begin 12 days before the onset of rash and end when all

lesions are crusted, typically 47 days after onset of rash in immunocompetent people, but this period may be longer in immunocompromised people. Although varicella vaccine is 70%90% effective in preventing all varicella, modified varicella, also known as breakthrough varicella, can occur in vaccinated people. In breakthrough varicella, which is often mild, the rash is often atypical in appearance with less than 50 vesicles and a predominance of maculopapular lesions; a fever is less common or of shorter duration. Breakthrough varicella is infectious, although less so than varicella in unvaccinated people. People with breakthrough varicella should be isolated for as long as lesions persist. DIAGNOSIS Skin lesions are the preferred specimen for laboratory confirmation of varicella disease. Vesicular swabs or scraping and scabs from crusted lesions can be used to identify varicella zoster virus by polymerase chain reaction or direct fluorescent antibody. In the absence of vesicles or scabs, scrapings of maculopapular lesions can be collected for testing. Serologic tests may also be used to confirm disease:

In the absence of skin lesions, a significant rise in serum varicella IgG from acuteand convalescent-phase samples by any standard serologic assay can confirm a diagnosis retrospectively but may not be reliable in immunocompromised people. Commercially available tests may not be sufficiently sensitive to reliably demonstrate vaccine-induced immunity.