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Deaths from chickenpoxhttp://bmj.com/cgi/content/full/324/7337/609/a
LettersDeaths from chickenpox Deaths from chickenpox in adults are decreasing
EDITOR
The change in age related varicella mortality is the result of a shift in the
age distribution of infection. Over the past two decades there has
been an increase in cases in the youngest age group (possibly due to
greater attendance of day-care).2-4 Over
the same time period there has been a gradual increase in reported
incidence in adults, which peaked in the late 1980s and has been
falling since (figure (b)). This is broadly reflected in the gradual
decrease in deaths in adults during the past decade. The exception to
this trend are 1996 and 1997
We would like to thank the Office for National Statistics, and Douglas Fleming and the Birmingham Research Unit, Royal College of General Practitioners, for data.
Epidemiology of chickenpox in United Kingdom needs further investigation 
EDITOR Varicella vaccine is recommended for routine administration in the United States and Canada, among other countries, but its suitability for inclusion in the United Kingdom's childhood immunisation programme is still being considered. Further work on the epidemiology of chickenpox in the United Kingdom is therefore now particularly important. We have proposed a one year period of enhanced active surveillance for severe
complications of varicella in children admitted to hospital
throughout the United Kingdom and the Republic of Ireland, using the
British Paediatric Surveillance Unit's orange card scheme.5
The information gained, together with that of Rawson et al, and
others, would help to determine the advisability of a universal
programme for the United Kingdom, and provide a baseline against
which to evaluate its impact should it be adopted.
Healthcare workers should not be forgotten
EDITOR At St George's Hospital in London we identified a total of 25 cases of chickenpox in staff and students from data prospectively collected over the past three years. We were able to determine the country of birth in 22 of these and found that most cases (13/22 (59%)) occurred in people born outside the United Kingdom. This figure was higher than expected since only 39% of the St George's workforce who have contact with patients are black or from an ethnic minority. Since Rawson et al found that there was a disproportionately higher mortality among such people compared with those born here, it would be interesting to know if occupations, such as those in health care with a higher likelihood of exposure, were over-represented among the cases of fatal varicella. Live attenuated varicella vaccine has been in use now for over two decades.2
Moreover, it has had a licence for use in susceptible individuals in
the United States since 1995 and has an excellent safety and efficacy
record.3 We believe that the increased
mortality from chickenpox in adults of working age of between 1:1000
and 1: 5000 shown by Rawson et al may make it indefensible for NHS
trusts not to offer varicella vaccine to their susceptible staff for
two reasons: personal safety at work and nosocomial chickenpox. If
only medical and nursing staff and students had been vaccinated in
the last three years at St George's, 85% of chickenpox cases in
hospital staff would have been prevented.
Chickenpox associated morbidity may be long term
EDITOR Sixty six adult patients with chickenpox were admitted to hospital during the period, four of whom were immunocompromised. Thirty eight patients fulfilled the study protocol and of these, 50% had radiological evidence of pneumonia (all immunocompetent).3 Three female patients required admission to intensive care unit, two of whom were pregnant. One patient presented with chickenpox encephalitis, and five had superimposed bacterial skin infections. Severe respiratory disease was associated with the presence of new respiratory symptoms, close contact with the index case, and a history of current smoking. On follow up at a year post-infection, 37% of patients with radiological pneumonia and 10.6% of those without pneumonia continued to have reduced single breath carbon monoxide transfer factor. This effect was independent from the effect of smoking and may indicate
permanent lung damage. It may therefore be that the morbidity relates
not only to the acute infection and admission but also to longer term
effects on the lung function, but the exact clinical relevance of our
findings is uncertain at present. The study does, however, indicate
that chickenpox causes significant morbidity in adults, which may be
seen increasingly in the future. Accurate data on morbidity as well
as mortality are required to inform the debate on the value of mass
vaccination for chickenpox in the United Kingdom.
Extracorporeal membrane oxygenation has important role
EDITOR Extracorporeal membrane oxygenation has been reported to be used successfully in cases of adult respiratory failure resulting from varicella pneumonia and we would like to bring the results of such intervention to the attention of Rawson et al.2-5 We have treated 15 adults with this procedure for confirmed varicella pneumonitis in Leicester between August 1992 and December 1999. These 15 patients had a mean age of 36 years (range 24-61), and were significantly hypoxic on referral with a ratio of arterial oxygen tension to fraction of inspired oxygen (PaO2/FiO2) of 8.09 kPa. The overall survival rate in these patients was 60%. Of the 11 patients, however, we treated with venovenous extracorporeal membrane oxygenation the survival rate was 75% (compared with zero for the four patients treated with venoarterial extracorporeal membrane oxygenation). It seems likely, therefore, that this is a treatment that should be
considered for fulminant varicella pneumonitis, but the numbers
treated so far are too small to be sure of the effectiveness of this
invasive treatment. To resolve this uncertainty, currently all such
cases in the United Kingdom can be referred for entry into the CESAR
(conventional ventilation or extracorporeal membrane oxygenation for
severe adult respiratory failure) trial. Suitable patients will be
randomised to receive either extracorporeal membrane oxygenation or
continued conventional ventilation. Further details about the trial
are available from www.cesar-trial.org.
Other related articles in BMJ:
ALL INFORMATION, DATA, AND
MATERIAL CONTAINED, PRESENTED, OR PROVIDED HERE IS FOR GENERAL INFORMATION
PURPOSES ONLY AND IS NOT TO BE CONSTRUED AS REFLECTING THE KNOWLEDGE OR OPINIONS
OF THE PUBLISHER, AND IS NOT TO BE CONSTRUED OR INTENDED AS PROVIDING MEDICAL OR
LEGAL ADVICE. THE DECISION WHETHER OR NOT TO VACCINATE IS AN IMPORTANT AND
COMPLEX ISSUE AND SHOULD BE MADE BY YOU, AND YOU ALONE, IN CONSULTATION WITH
YOUR HEALTH CARE PROVIDER.
DISCLAIMER: All information, data, and material contained, presented, or provided here is for general information purposes only and is not to be construed as reflecting the knowledge or opinions of the publisher, and is not to be construed or intended as providing medical or legal advice. The decision whether or not to vaccinate is an important and complex issue and should be made by you, and you alone, in consultation with your health care provider.
Copyright 2012 by Vaccination News, A Non-Profit Corporation. All Rights Reserved. This content may not be copied unless permission in writing from Sandy Gottstein has been obtained. 
|
 "A foolish faith in authority is the worst enemy of truth." -- Albert Einstein, letter to a friend, 1901 "I know of no safe depository of the ultimate powers of the society but the people themselves, and if we think them not enlightened enough to exercise control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education." -- Thomas Jefferson, letter to William C. Jarvis, September 28, 1820 "What's the point of vaccination if it doesn't protect you from the unvaccinated?" -- Sandy Gottstein "Who gets to decide what the greater good is and how many will be sacrificed to it?" -- Sandy Gottstein |
Deaths
from chickenpox in adults are decreasing
On
the basis of death certificates from the Office for National Statistics from
1995 to 1997, Rawson et al conclude that deaths as a result of
chickenpox are increasing in adults in England and Wales.
