Expanded spectrum of varicella disease and the need for vaccination in India

Varicella vaccine was first licensed in Japan and South Korea in 1989 for use in healthy children and was introduced in US in 1995. So far, 29 countries have adopted varicella vaccine in their universal immunization program (UIP). No Asian country, India included, has adopted the varicella vaccine as part of their UIP. The extra-cutaneous sites for VZV diseases are central nervous system and gastrointestinal tract, the expanded disease spectrum includes vasculopathy, myelitis, inflammatory bowel disease, perforated ulcers, and gastritis. The actual disease burden of varicella is not known as most of the infected individuals may not visit the physician. The amplifiable VZV DNA will not always be detectable in cerebrospinal fluid (CSF) samples in protracted illnesses such as vasculopathies, but demonstrable anti-VZV IgG in CSF has diagnostic value. The World Health Organization (WHO) position paper 2014 recommends two doses of varicella and zoster vaccines in targeted population. In India, varicella vaccine is not included in the UIP due to the cost and the belief that lifelong immunity occurs following primary infection. The expanded spectrum of VZV disease and the mounting body of evidence, however, suggest the need for both varicella and zoster vaccines in routine immunization schedule.

Mpox and Chickenpox Coinfection: Case Series From Southern Nigeria

BACKGROUND

We describe clinicoepidemiologic characteristics of mpox-chickenpox coinfection in Nigeria.

METHODS

A retrospective cohort analysis was performed of confirmed mpox cases in Nigeria from January 2022 to March 2023. Mpox and chickenpox were confirmed by real-time polymerase chain reaction (RT-PCR).

RESULTS

Of 94 (60.0%) suspected cases, 56 had confirmed mpox, of whom 16 (28.6%) had chickenpox coinfection. The median age of confirmed mpox cases was 29 years (interquartile range, 20-37 years), 24 were men (60.7%), 6 (10.7%) were bisexual, and 5 (8.9%) died. Mpox-chickenpox-coinfected patients had more complications than mpox-monoinfected cases (56.3% vs 22.5%, P = .015).

CONCLUSIONS

The high frequency of mpox-chickenpox coinfection argues for accelerated access to mpox and chickenpox vaccines in Africa.

Assessment of the Level of Knowledge and Attitude Towards Herpes Zoster and Its Vaccination Among Individuals at Risk in Saudi Arabia

Background Herpes zoster (HZ) is a viral infection resulting from the reactivation of the varicella-zoster virus. The vaccination was proven to prevent herpes zoster and its complications for individuals over the age of 50 since they are more susceptible to herpes zoster infection. Therefore, it is essential to understand and acknowledge the herpes zoster infection and vaccine. This study aims to assess the level of knowledge and attitude towards herpes zoster and its vaccination among individuals at risk in Saudi Arabia. Methods A cross-sectional study was conducted between February 2023 and June 2023 among the general population in Saudi Arabia, using a self-administered online questionnaire adapted from a previous study after translating it into Arabic. Results A total of 1883 participants were included in this study, almost equally distributed across the five regions of Saudi Arabia. Females represented 62.4% (n=1175), and 56% (n=1062) of participants reported a positive history of chickenpox, while 3.6% (n=67) reported a history of herpes zoster. Furthermore, 78.9% (n=1486) have heard of herpes zoster, while 68.8% (n=1296) have at least one of the herpes zoster risk factors. Only 7.8% (n=147) had high knowledge about HZ, and only 3.1% (n=58) had adequate knowledge regarding the HZ vaccine. Conclusion Our study findings show that the general population of Saudi Arabia has inadequate knowledge about herpes zoster and its vaccine. For that reason, awareness and education programs targeting individuals at high risk of herpes zoster are required to enhance awareness and knowledge about herpes zoster and to improve their attitudes toward the herpes zoster vaccination.

Burden of chickenpox complications in Poland, 2006 to 2021: A comprehensive registry-based study

BackgroundChickenpox, a vaccine-preventable disease caused by the varicella zoster virus, generally presents with mild symptoms but can cause complications necessitating hospitalisation. In Poland, since 2009, vaccination has been obligatory for children up to 12 years of age who are particularly vulnerable to infection and for children in their vicinity.AimTo examine the burden of chickenpox complications and the trends of hospitalisation arising from these complications over time in the Polish population.MethodsData spanning 2006-21 were sourced from the Polish Infectious Diseases Surveillance System, the Nationwide General Hospital Morbidity Study and the Statistics Poland death registry. Standardised and age-specific incidence rates, hospital discharge rates and number of deaths because of chickenpox were calculated. Moreover, the joinpoint regression model was used to analyse trends of annual hospital discharge rates.ResultsOver the analysed timeframe, 25,804 hospitalisations and 52 deaths attributable to chickenpox complications were documented, and 1.0% of chickenpox cases required hospitalisation because of chickenpox. Age-standardised hospitalisation rates varied between 2.3 and 9.6 per 100,000 population. The analysis revealed no statistically significant trend in overall hospital discharge rates from chickenpox complications. However, a notable increase in hospitalisation rates was observed in children aged 0-4 and among inhabitants of rural areas, with annual percentage changes of 4.9% and 3.4% respectively.ConclusionsOur findings suggest that the implementation of a universal chickenpox immunisation programme, supported by health education, should be considered to reduce the number of hospitalisations and nearly eliminate deaths because of chickenpox.

Case report: Hospital-acquired chickenpox in a healthcare setting

Chickenpox (varicella) is a rare occurrence in healthcare settings in the USA, but can be transmitted to healthcare workers (HCWs) from patients with herpes zoster who, in turn, can potentially transmit it further to unimmunized, immunosuppressed, at-risk, vulnerable patients. It is uncommon due to the inclusion of varicella vaccination in the recommended immunization schedule for children and screening for varicella immunity in HCWs during employment. We present a case report of hospital-acquired chickenpox in a patient who developed the infection during his prolonged hospital stay through a HCW who had contracted chickenpox after exposure to our patient's roommate with herpes zoster. There was no physical contact between the roommates, but both patients had a common HCW as caregiver. The herpes zoster patient was placed in airborne precautions immediately, but the HCW continued to work and have physical contact with our patient. The HCW initially developed chickenpox 18 days after exposure to the patient with herpes zoster, and our patient developed chickenpox 17 days after the HCW. The timeline and two incubation periods, prior to our patient developing chickenpox, indicate transmission of chickenpox in the HCW from exposure to the herpes zoster patient and subsequently to our patient. The case highlights the potential for nosocomial transmission of chickenpox (varicella) to unimmunized HCWs from exposure to patients with herpes zoster and further transmission to unimmunized patients. Verification of the immunization status of HCWs at the time of employment, mandating immunity, furloughing unimmunized staff after exposure to herpes zoster, and postexposure prophylaxis with vaccination or varicella zoster immunoglobulin (Varizig) will minimize the risk of transmission of communicable diseases like chickenpox in healthcare settings. Additionally, establishing patients' immunity, heightened vigilance and early identification of herpes zoster in hospitalized patients, and initiation of appropriate infection control immediately will further prevent such occurrences and improve patient safety.

This is a case report of a varicella-unimmunized 31-year-old patient who developed chickenpox during his 80-day-long hospitalization. He had different roommates during his long hospital stay but had no physical contact with them and neither had visitors. On most days, the same HCW rendered care to him and his roommates. One of the patient’s roommates was found to have herpes zoster and was immediately moved to a different room with appropriate infection prevention measures. The HCW is presumably unimmunized to varicella and sustained significant exposure to the patient with herpes zoster during routine patient care which involved significant physical contact. The HCW was not furloughed, assessed for immunity, or given postexposure prophylaxis (PEP). The HCW had continued contact with our patient as part of routine care. On day 18, after exposure to the patient with herpes zoster, the HCW developed chickenpox. 17 days thereafter, our patient developed chickenpox. The time interval of chickenpox infection in the HCW after one incubation period after exposure to the patient with herpes zoster followed by a similar infection of chickenpox in our patient after another incubation period suggests the spread of varicella zoster virus (VZV) from the herpes zoster patient to the HCW and further from the HCW to our patient. Assessing the immunity of HCWs to varicella at the time of employment, ensuring only HCWs with immunity take care of herpes zoster and varicella patients, furloughing unimmunized exposed HCWs, offering PEP, and documentation of patients’ immunity to varicella at the time of hospital admission could help prevent VZV transmission in hospital settings. This is an attempt to publish this novel case due to its high educational value and relevant learning points.

Reactivation of Herpes Zoster in a Young Patient With Multiple Sclerosis Under Dimethyl Fumarate Treatment and Normal Lymphocyte Subsets Count: A Case Report

Herpes zoster (HZ) infection results from the reactivation of the varicella-zoster virus (VZV), which remains dormant in the dorsal root ganglia after an initial chickenpox infection. Although HZ appears more common in people with multiple sclerosis (MS) than expected in the general population, few studies have investigated this association, particularly with a normal absolute lymphocyte count (ALC). Additionally, no reported cases have discussed the clinical presentation of such patients. This report describes the case of a 26-year-old female with a known history of relapsing-remitting MS on dimethyl fumarate (DMF) treatment. She presented with a history of painful erythematous blisters, diagnosed as acute HZ infection with a normal ALC. This case provides evidence that warrants further research and attention to the management of patients with MS receiving DMF, particularly regarding infectious risks. It highlights the importance of pharmacovigilance and the potential benefits of VZV and HZ immunization in DMF recipients.

Guillain-Barré syndrome following varicella-zoster virus infection: a case report and systematic review

Background

Guillain-Barré syndrome (GBS) is an acute inflammatory disease of the peripheral nervous system, rarely following Varicella-zoster virus (VZV) infection. The authors aimed to review all cases in the English literature of GBS that occurred after primary VZV infection to investigate the clinical features, diagnostic workup, treatment, and outcome of patients with GBS following VZV.

Methods

PubMed, Scopus, and Embase are systematically searched from their inception to 9 May 2022 to collect all cases of GBS following varicella-zoster infection. Patients with GBS following VZV reactivation were excluded.

Results

Among the 29 patients, the age of presentation ranged from 1.5 to 70 years with a median of 37, with a yield for males (81.5%). Most of the patients presented with sensory-motor symptoms (65.4%) and suffered from tetraparesis (81.5%). Cranial nerve palsy was present in (84%) of patients, and the seventh cranial nerve was the most commonly affected nerve (75%). Lumbar puncture showed albuminocytological dissociation in (80%) of patients. The dominant nerve conduction study subtype was acute inflammatory demyelinating polyneuropathy (65.3%). in addition, the magnetic resonance imaging showed pathological findings in only (47.5%) of the patients. Intravenous immunoglobulin is now the drug of choice for all cases of GBS following VZV infection.

Conclusion

GBS is a rare neurological complication of primary infection with VZV. However, the authors should suspect this syndrome when a patient develops ascending weakness, regardless of the absence of areflexia and albuminocytological dissociation. Drug therapy with IIVIg ensures a gradual improvement for the patient over a period of weeks to several months.

The Epidemiology of Chickenpox in England, 2016-2022: An Observational Study Using General Practitioner Consultations

Chickenpox is a common childhood disease caused by varicella-zoster virus (VZV). VZV vaccination is not part of the UK childhood immunisation programme, but its potential inclusion is regularly assessed. It is therefore important to understand the ongoing burden of VZV in the community to inform vaccine policy decisions. General practitioner (GP) chickenpox consultations were studied from 1 September 2016 to 9 December 2022. Over the study period, the mean weekly chickenpox consultation rate per 100,000 population in England was 3.4, with a regular peak occurring between weeks 13 and 15. Overall, rates decreased over time, from a mean weekly rate of 5.5 in 2017 to 4.2 in 2019. The highest mean weekly rates were among children aged 1-4 years. There was no typical epidemic peak during the COVID-19 pandemic, but in 2022, rates were proportionally higher among children aged < 1 year old compared to pre-pandemic years. Chickenpox GP consultation rates decreased in England, continuing a longer-term decline in the community. The COVID-19 pandemic impacted rates, likely caused by the introduction of non-pharmaceutical interventions to prevent SARS-CoV-2 transmission. The lasting impact of the interruption of typical disease transmission remains to be seen, but it is important to monitor the chickenpox burden to inform decisions on vaccine programmes.

Real-World Effectiveness of the Varicella Vaccine among Children and Adolescents in Qatar: A Case-Control Study

BACKGROUND

Despite the availability of a highly efficacious vaccine, varicella outbreaks are still being reported globally. In this study, we evaluated the real-world effectiveness of varicella vaccination among children between the ages of 1 and 18 years old during the period 2017 to 2019 in Qatar.

METHODS

A matched case-control study was conducted that included all reported varicella-infected children who visited the primary healthcare system in Qatar from January 2017 to December 2019. The cases were children under the age of 18 years who were clinically diagnosed with varicella. The controls were of the same age, who visited the Primary Health Care Corporation (PHCC) during 2017-2019 with a skin rash where varicella infection was ruled out. The data on varicella vaccination for each participant were obtained from the electronic database in the PHCC during the study period.

RESULTS

We included 862 cases of varicella and 5454 matched controls, with a median age of 8 years (IQR 3-12); 47.4% were female and almost 50% were of Qatari nationality. The year 2019 had the highest varicella infection count with a total of 416 cases. The cases were less likely to be vaccinated against varicella, with approximately a quarter (25.6%) of cases and 36.7% of the controls having either one or two doses of the vaccine (p < 0.001). Compared to not being vaccinated, a single dose vaccination showed a 56% reduction in the odds of varicella infection [OR 0.44, 95% CI: 0.34-0.55; p < 0.000], and a two-dose vaccination showed an 86% reduction in the odds of varicella infection [OR 0.13, 95% CI: 0.06-0.29; p < 0.000].

CONCLUSION

In this multicultural setting, a two-dose varicella vaccination shows reasonable protection against varicella infection.

Vaccines for preventing herpes zoster in older adults

BACKGROUND

Herpes zoster, commonly known as shingles, is a neurocutaneous disease caused by the reactivation of the virus that causes varicella (chickenpox). After resolution of the varicella episode, the virus can remain latent in the sensitive dorsal ganglia of the spine. Years later, with declining immunity, the varicella zoster virus (VZV) can reactivate and cause herpes zoster, an extremely painful condition that can last many weeks or months and significantly compromise the quality of life of the affected person. The natural process of ageing is associated with a reduction in cellular immunity, and this predisposes older adults to herpes zoster. Vaccination with an attenuated form of the VZV activates specific T-cell production avoiding viral reactivation. Two types of herpes zoster vaccines are currently available. One of them is the single-dose live attenuated zoster vaccine (LZV), which contains the same live attenuated virus used in the chickenpox vaccine, but it has over 14-fold more plaque-forming units of the attenuated virus per dose. The other is the recombinant zoster vaccine (RZV) which does not contain the live attenuated virus, but rather a small fraction of the virus that cannot replicate but can boost immunogenicity. The recommended schedule for the RZV is two doses two months apart. This is an update of a Cochrane Review first published in 2010, and updated in 2012, 2016, and 2019.

OBJECTIVES

To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.

SEARCH METHODS

For this 2022 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2022, Issue 10), MEDLINE (1948 to October 2022), Embase (2010 to October 2022), CINAHL (1981 to October 2022), LILACS (1982 to October 2022), and three trial registries.

SELECTION CRITERIA

We included studies involving healthy older adults (mean age 60 years or older). We included randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine (any dose and potency) versus any other type of intervention (e.g. varicella vaccine, antiviral medication), placebo, or no intervention (no vaccine). Outcomes were cumulative incidence of herpes zoster, adverse events (death, serious adverse events, systemic reactions, or local reaction occurring at any time after vaccination), and dropouts.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two new studies involving 1736 participants in this update. The review now includes a total of 26 studies involving 90,259 healthy older adults with a mean age of 63.7 years. Only three studies assessed the cumulative incidence of herpes zoster in groups that received vaccines versus placebo. Most studies were conducted in high-income countries in Europe and North America and included healthy Caucasians (understood to be white participants) aged 60 years or over with no immunosuppressive comorbidities. Two studies were conducted in Japan and one study was conducted in the Republic of Korea. Sixteen studies used LZV. Ten studies tested an RZV. The overall certainty of the evidence was moderate, which indicates that the intervention probably works. Most data for the primary outcome (cumulative incidence of herpes zoster) and secondary outcomes (adverse events and dropouts) came from studies that had a low risk of bias and included a large number of participants. The cumulative incidence of herpes zoster at up to three years of follow-up was lower in participants who received the LZV (one dose subcutaneously) than in those who received placebo (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.43 to 0.56; risk difference (RD) 2%; number needed to treat for an additional beneficial outcome (NNTB) 50; moderate-certainty evidence) in the largest study, which included 38,546 participants. There were no differences between the vaccinated and placebo groups for serious adverse events (RR 1.08, 95% CI 0.95 to 1.21) or deaths (RR 1.01, 95% CI 0.92 to 1.11; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of one or more adverse events (RR 1.71, 95% CI 1.38 to 2.11; RD 23%; number needed to treat for an additional harmful outcome (NNTH) 4.3) and injection site adverse events (RR 3.73, 95% CI 1.93 to 7.21; RD 28%; NNTH 3.6; moderate-certainty evidence) of mild to moderate intensity. These data came from four studies with 6980 participants aged 60 years or older. Two studies (29,311 participants for safety evaluation and 22,022 participants for efficacy evaluation) compared RZV (two doses intramuscularly, two months apart) versus placebo. Participants who received the new vaccine had a lower cumulative incidence of herpes zoster at 3.2 years follow-up (RR 0.08, 95% CI 0.03 to 0.23; RD 3%; NNTB 33; moderate-certainty evidence), probably indicating a favourable profile of the intervention. There were no differences between the vaccinated and placebo groups in cumulative incidence of serious adverse events (RR 0.97, 95% CI 0.91 to 1.03) or deaths (RR 0.94, 95% CI 0.84 to 1.04; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of adverse events, any systemic symptom (RR 2.23, 95% CI 2.12 to 2.34; RD 33%; NNTH 3.0), and any local symptom (RR 6.89, 95% CI 6.37 to 7.45; RD 67%; NNTH 1.5). Although most participants reported that their symptoms were of mild to moderate intensity, the risk of dropouts (participants not returning for the second dose, two months after the first dose) was higher in the vaccine group than in the placebo group (RR 1.25, 95% CI 1.13 to 1.39; RD 1%; NNTH 100, moderate-certainty evidence). Only one study reported funding from a non-commercial source (a university research foundation). All other included studies received funding from pharmaceutical companies. We did not conduct subgroup and sensitivity analyses AUTHORS' CONCLUSIONS: LZV (single dose) and RZV (two doses) are probably effective in preventing shingles disease for at least three years. To date, there are no data to recommend revaccination after receiving the basic schedule for each type of vaccine. Both vaccines produce systemic and injection site adverse events of mild to moderate intensity. The conclusions did not change in relation to the previous version of the systematic review.

Parallel pathogens: Coexistence of chickenpox and idiopathic thrombocytopenic purpura-A case report

This case report documents the unusual co-occurrence of immune thrombocytopena (ITP) and chickenpox in a 15-year-old girl. Initial symptoms included shortness of breath, chest pain, and heavy menstrual bleeding. Laboratory results revealed significant anemia and thrombocytopenia. Treatment involved blood transfusions, prednisolone, and iron supplementation. The patient's vesicular skin rash emerged 8 weeks later, prompting the combined diagnosis of ITP and chickenpox. Antiviral treatments, blood transfusions, and supportive care were used in the course of treatment, leading to full recovery. This case emphasizes the importance of prompt diagnosis, appropriate management, and regular follow-up for patients with both chickenpox and ITP. The coexistence of chickenpox and ITP poses a clinical challenge due to the complex interaction between the viral infection and the immune system. The exact mechanism linking these two conditions remains unclear, making it a baffling case that warrants investigation and further understanding. As low is the occurrence of hemorrhagic chickenpox, the presentation of simultaneous chicken pox with or following ITP was found to be rarer, and thus is this enigmatic case presented. Healthcare providers should remain vigilant about such co-occurrences to prevent complications. In order to improve treatment for instances with comparable clinical presentations and advance our collective knowledge, further study is required to better understand the mechanisms relating viral infections and ITP.

How to distinguish mpox from its mimickers: An observational retrospective cohort study

During the current global outbreak of mpox (formerly monkeypox), atypical features were frequently described outside endemic areas, raising concerns around differential diagnosis. In this study, we included 372 adult patients who had clinical signs consistent with mpox and who were screened using non-variola orthopoxvirus specific quantitative polymerase chain reaction (PCR) between 15 May and 15 November 2022 at the University Hospital Institute Méditerranée Infection, Marseille, France. At least one clinical sample was positive for 143 (38.4%) of these patients and 229 (61.6%) were negative. Clinically, patients who had mpox presented more frequently with systemic signs (69.9% vs. 31.0%, p < 10-6 ) including fever (51.0% vs. 30.1%, p < 10-3 ), myalgia (33.5% vs. 17.9%, p = 0.002), and lymphadenopathy (38.5% vs. 13.1%, p < 10-6 ). Among the patients who were negative for the non-variola orthopoxvirus, an alternative diagnosis was identified in 58 of them (25.3%), including chickenpox (n = 30, 13.1%), syphilis (n = 9, 4%), bacterial skin infection (n = 8, 3.5%), gonococcus (n = 5, 2.2%), HSV infection (n = 5, 2.2%), and histoplasmosis (n = 1, 0.4%). Overall, in the current outbreak, we show that mpox has a poorly specific clinical presentation. This reinforces the importance of microbiological confirmation. In symptomatic patients who are negative for the monkeypox virus by PCR, a broad differential diagnosis should be maintained.

Delineating the Seasonality of Varicella and Its Association With Climate in the Tropical Country of Colombia

BACKGROUND

Varicella causes a major health burden in many low- to middle-income countries located in tropical regions. Because of the lack of surveillance data, however, the epidemiology of varicella in these regions remains uncharacterized. In this study, based on an extensive dataset of weekly varicella incidence in children ≤10 during 2011-2014 in 25 municipalities, we aimed to delineate the seasonality of varicella across the diverse tropical climates of Colombia.

METHODS

We used generalized additive models to estimate varicella seasonality, and we used clustering and matrix correlation methods to assess its correlation with climate. Furthermore, we developed a mathematical model to examine whether including the effect of climate on varicella transmission could reproduce the observed spatiotemporal patterns.

RESULTS

Varicella seasonality was markedly bimodal, with latitudinal changes in the peaks' timing and amplitude. This spatial gradient strongly correlated with specific humidity (Mantel statistic = 0.412, P = .001) but not temperature (Mantel statistic = 0.077, P = .225). The mathematical model reproduced the observed patterns not only in Colombia but also México, and it predicted a latitudinal gradient in Central America.

CONCLUSIONS

These results demonstrate large variability in varicella seasonality across Colombia and suggest that spatiotemporal humidity fluctuations can explain the calendar of varicella epidemics in Colombia, México, and potentially in Central America.

An Autoregressive Integrated Moving Average Model for Predicting Varicella Outbreaks - China, 2019

Introduction

Varicella, a prevalent respiratory infection among children, has become an escalating public health issue in China. The potential to considerably mitigate and control these outbreaks lies in surveillance-based early warning systems. This research employed an autoregressive integrated moving average (ARIMA) model with the objective of predicting future varicella outbreaks in the country.

Methods

An ARIMA model was developed and fine-tuned using historical data on the monthly instances of varicella outbreaks reported in China from 2005 to 2018. To determine statistically significant models, parameter and Ljung-Box tests were employed. The coefficients of determination (R2) and the normalized Bayesian Information Criterion (BIC) were compared to selecting an optimal model. This chosen model was subsequently utilized to forecast varicella outbreak cases for the year 2019.

Results

Four models passed parameter (all P<0.05) and Ljung-Box tests (all P>0.05). ARIMA (1, 1, 1)×(0, 1, 1)12 was determined to be the optimal model based on its coefficient of determination R2 (0.271) and standardized BIC (14.970). Fitted values made by the ARIMA (1, 1, 1)×(0, 1, 1)12 model closely followed the values observed in 2019, the average relative error between the actual value and the predicted value is 15.2%.

Conclusion

The ARIMA model can be employed to predict impending trends in varicella outbreaks. This serves to offer a scientific benchmark for strategies concerning varicella prevention and control.

Causal association between inflammatory bowel disease and herpes virus infections: a two-sample bidirectional Mendelian randomization study

Background

Previous observational or retrospective studies have suggested an association between inflammatory bowel disease (IBD) and herpes virus infections. Using Mendelian randomization (MR) approach, our objective was to determine whether there was a causal association between IBD and herpes virus infections.

Methods

In genome-wide association study (GWAS) datasets of the International Inflammatory Bowel Disease Genetics Consortium, we obtained genetic instrumental variables for three phenotypes from 34,652 participants (12,882 IBD cases and 21,770 controls), 27,432 participants [6,968 ulcerative colitis (UC) cases and 20,464 controls], and 20,883 participants [5,956 Crohn's disease (CD) cases and 14,927 controls], respectively. Summary statistics for herpes virus infections (chickenpox, herpes zoster, and mononucleosis) were obtained from the FinnGen database. MR results were expressed as odds ratio (OR) with 95% confidence interval (CI).

Results

Our study found no evidence of a causal effect of genetically predicted IBD on herpes virus infections [P value for inverse variance weighting (IVW): 0.063 to 0.652]. For the subtypes of IBD, UC had a suggestive association with mononucleosis (P value for IVW: 0.023). It appeared that CD was also weakly associated with mononucleosis (P value for IVW: 0.058; P value for Weighted median: 0.036). In addition, we found a suggestive causality for CD on chickenpox (P value for IVW: 0.038). Neither UC (P value for IVW: 0.574) nor CD (P value for IVW: 0.168) has a causal effect on herpes zoster. The results of the bidirectional MR analysis did not indicate that herpes virus infections were associated with IBD, UC or CD (P value for IVW: 0.239 to 0.888).

Conclusion

This study showed a suggestive causality for both CD-chickenpox and UC-mononucleosis, despite no associations reaching a statistical significance value after corrections for multiple testing. There was no evidence of a causal association between IBD and its two subtypes on herpes zoster.

Post-viral idiopathic purpura fulminans is associated with inherited thrombophilia and anti-cardiolipin antibodies

Introduction

Idiopathic purpura fulminans (IPF) is a rare and severe coagulation disorder, associated with transient anti-protein S (anti-PS) antibodies in the context of post-viral infection such as varicella. Anti-protein S antibodies are frequently found in the context of varicella, in contrast with the rarity of IPF. Other factors such as anti-phospholipid antibodies (APL) and inherited thrombophilia may be associated with severe vascular complication.

Method

This is an ancillary study of a French multicenter retrospective series and systematic review of literature. We analyzed patients who were tested for inherited thrombophilia, namely antithrombin, protein C, protein S deficiency; prothrombin gene G20210A polymorphism (FII:G20210A),Factor V R506Q polymorphism (FV:R506Q); and/or for APL (lupus anticoagulant (LA), anti-cardiolipin antibodies (ACL), or anti-beta 2-GPI antibodies (Aβ2GP1).

Results

Among the 25 patients tested for inherited thrombophilia, 7 (28%) had positive results. Three had FV R506Q, two FII:G20210A, one compound heterozygote FV:R506Q associated to FII:G20210A, and one protein C deficiency. APL testing was performed in 32 patients. It was positive in 19 patients (59%): 17 ACL (53%), 5 LA (16%), 4 Aβ2GP1 (13%). The risk of severe complications was not associated with presence of inherited thrombophilia or APL presence, with RR: 0.8 [95% CI: 0.37-1.71], p = 1 and RR: 0.7 [95% CI: 0.33-1.51], p = 0.39, respectively. We found a high prevalence of inherited thrombophilia or APL in a population of patients with IPF. However, we do not find an association with the occurrence of severe vascular complications or venous thromboembolism.

Using Baidu Index Data to Improve Chickenpox Surveillance in Yunnan, China: Infodemiology Study

BACKGROUND

Chickenpox is an old but easily neglected infectious disease. Although chickenpox is preventable by vaccines, vaccine breakthroughs often occur, and the chickenpox epidemic is on the rise. Chickenpox is not included in the list of regulated communicable diseases that must be reported and controlled by public and health departments; therefore, it is crucial to rapidly identify and report varicella outbreaks during the early stages. The Baidu index (BDI) can supplement the traditional surveillance system for infectious diseases, such as brucellosis and dengue, in China. The number of reported chickenpox cases and internet search data also showed a similar trend. BDI can be a useful tool to display the outbreak of infectious diseases.

OBJECTIVE

This study aimed to develop an efficient disease surveillance method that uses BDI to assist in traditional surveillance.

METHODS

Chickenpox incidence data (weekly from January 2017 to June 2021) reported by the Yunnan Province Center for Disease Control and Prevention were obtained to evaluate the relationship between the incidence of chickenpox and BDI. We applied a support vector machine regression (SVR) model and a multiple regression prediction model with BDI to predict the incidence of chickenpox. In addition, we used the SVR model to predict the number of chickenpox cases from June 2021 to the first week of April 2022.

RESULTS

The analysis showed that there was a close correlation between the weekly number of newly diagnosed cases and the BDI. In the search terms we collected, the highest Spearman correlation coefficient was 0.747. Most BDI search terms, such as "chickenpox," "chickenpox treatment," "treatment of chickenpox," "chickenpox symptoms," and "chickenpox virus," trend consistently. Some BDI search terms, such as "chickenpox pictures," "symptoms of chickenpox," "chickenpox vaccine," and "is chickenpox vaccine necessary," appeared earlier than the trend of "chickenpox virus." The 2 models were compared, the SVR model performed better in all the applied measurements: fitting effect, R²=0.9108, root mean square error (RMSE)=96.2995, and mean absolute error (MAE)=73.3988; and prediction effect, R²=0.548, RMSE=189.1807, and MAE=147.5412. In addition, we applied the SVR model to predict the number of reported cases weekly in Yunnan from June 2021 to April 2022 using the same period of the BDI. The results showed that the fluctuation of the time series from July 2021 to April 2022 was similar to that of the last year and a half with no change in the level of prevention and control.

CONCLUSIONS

These findings indicated that the BDI in Yunnan Province can predict the incidence of chickenpox in the same period. Thus, the BDI is a useful tool for monitoring the chickenpox epidemic and for complementing traditional monitoring systems.

Varicella-Zoster Virus Myocarditis: Early Clinical Diagnosis and Outcome

Varicella-zoster virus (VZV) is a viral infection that causes chickenpox and shingles. Although it is usually self-limiting, it can lead to severe complications, especially in pediatric and immunocompromised patients. VZV was first discovered as a cause of myocarditis in 1953. In this review article, we aim to investigate the early clinical diagnosis of myocarditis in VZV infections and the efficacy of the VZV vaccine in preventing myocarditis. The literature search was done using PubMed, Google Scholar, and Sci-Hub databases. A high VZV mortality rate was noted among adults, infants, and immunocompromised patients. The early diagnosis and treatment of VZV myocarditis can reduce mortality.

Safety of varicella vaccination strategies: An overview of reviews

The safety of new vaccines under development as well as existing vaccines is a key priority for national and international public health agencies. A number of countries have implemented universal childhood varicella vaccination programmes over the past 30 years. However, strategies differ in terms of the number of doses, type of vaccine(s) recommended, age at vaccination and interval between doses for a two-dose schedule. An overview of reviews was undertaken to assess the existing systematic review evidence of the safety of varicella vaccination strategies. The review was restricted to immunocompetent children aged 9 months to 6 years inclusive. A comprehensive search of databases, registries and grey literature was conducted up to 2 February 2022. Two reviewers independently screened, extracted data and assessed the methodological quality of included reviews. Overlap of included reviews was also assessed. A total of 17 reviews, incorporating both the monovalent varicella only and quadrivalent measles-mumps-rubella-varicella (MMRV) vaccines were included in the overview; six assessed the safety of one-dose strategies, four assessed the safety of two-dose strategies and 14 reviews did not specify the dosing strategy. The evidence suggests that mild local and systemic reactions are relatively common with varicella vaccination. Febrile seizures are also possible adverse effects of both the monovalent and quadrivalent MMRV vaccine, but serious adverse reactions are rare. While most reviews contained methodological flaws, and analysis by vaccine type and dosing strategy was restricted due to lack of detail in reporting of the reviews, there was clear and consistent evidence from a substantial evidence base, comprising 34 randomised controlled trials and 62 other primary studies/reviews, that varicella vaccination is safe.

Varicella in the Neonatal ICU due to the Varicella Vaccine Oka Strain

BACKGROUND

Varicella vaccination of non-immune post-partum women is recommended to reduce the risk of chickenpox in mothers and their infants. Though rare, transmission of the varicella vaccine strain vOka can occur from recent vaccinees to non-immune contacts who usually develop mild chickenpox.

METHODS/RESULTS

Here we describe an infant hospitalized in the neonatal ICU with vaccine-strain varicella due to transmission from their mother who received the varicella vaccine post-partum. We describe the infection prevention and control strategies implemented to prevent further transmission.

CONCLUSION

Vaccine-strain varicella transmission from mother to infant is a rare event and its occurrence in the neonatal ICU setting can be challenging. Anticipatory guidance for mothers vaccinated in the postpartum period and support of parents of an infected infant are recommended.

Computer-Aided Detection and Classification of Monkeypox and Chickenpox Lesion in Human Subjects Using Deep Learning Framework

Monkeypox is a zoonotic viral disease caused by the monkeypox virus. After its recent outbreak, it has become clear that a rapid, accurate, and reliable diagnosis may help reduce the risk of a future outbreak. The presence of skin lesions is one of the most prominent symptoms of the disease. However, this symptom is also peculiar to chickenpox. The resemblance in skin lesions in the human subject may disrupt effective diagnosis and, as a result, lead to misdiagnosis. Such misdiagnosis can lead to the further spread of the disease as it is a communicable disease and can eventually result in an outbreak. As deep learning (DL) algorithms have recently been regarded as a promising technique in medical fields, we have been attempting to integrate a well-trained DL algorithm to assist in the early detection and classification of skin lesions in human subjects. This study used two open-sourced digital skin images for monkeypox and chickenpox. A two-dimensional convolutional neural network (CNN) consisting of four convolutional layers was applied. Afterward, three MaxPooling layers were used after the second, third, and fourth convolutional layers. Finally, we evaluated the performance of our proposed model with state-of-the-art deep-learning models for skin lesions detection. Our proposed CNN model outperformed all DL models with a test accuracy of 99.60%. In addition, a weighted average precision, recall, F1 score of 99.00% was recorded. Subsequently, Alex Net outperformed other pre-trained models with an accuracy of 98.00%. The VGGNet consisting of VGG16 and VGG19 performed least well with an accuracy of 80.00%. Due to the uniqueness of the proposed model and image augmentation techniques applied, the proposed CNN model is generalized and avoids over-fitting. This model would be helpful for the rapid and accurate detection of monkeypox using digital skin images of patients with suspected monkeypox.

Mendelian randomization study on the causal effect of chickenpox on dementia

Some viruses, such as varicella zoster virus, are associated with severe dementia. The present study aims to identify the causal link between chickenpox and dementia. To date, the largest publicly available genome-wide association study (GWAS) for chickenpox (710 cases and 211 856 controls from European individuals) and for dementia (5933 cases and 212 859 controls from European individuals) were used to performed this two-sample Mendelian randomization (MR) study. We found no significant pleiotropy or heterogeneity in all seven selected chickenpox genetic instrumental variants in dementia GWAS. Of seven chickenpox genetic variants, two are located in the intergenic region and five are located in intron. We found that as chickenpox genetically increased, dementia risk increased based on an inverse-variance weighted analysis (β = 0.070, 95% confidence interval [CI] for β: 0.014-0.126; odds ratio [OR] = 1.073, 95% CI for OR: 1.015-1.134; p = 0.014) and weighted median (β = 0.071, 95% CI for β: 0.002-0.141; OR = 1.074, 95% CI for OR: 1.002-1.152; p = 0.045). Reverse MR analysis showed no causal effect of dementia on chickenpox. Our analysis suggests a causal effect of genetically increased chickenpox on dementia risk. Thus, chickenpox may be a potential risk factor for dementia.

Anti-SOX1 Antibodies in a 3-Year-old Girl, Post-Varicella

Anti-SRY-related HMG-box gene 1 (SOX1) antibodies were initially described in adults with paraneoplastic neurological disorders, where they are considered high-risk onconeural autoantibodies. Only two pediatric cases of anti-SOX1 antibodies have been reported: a 17-year-old adolescent presenting with paraneoplastic limbic encephalitis due to Hodgkin lymphoma and a 12-year-old girl presenting with non-paraneoplastic encephalitis. We present a unique case of anti-SOX1 antibodies in a 3-year-old girl, post-varicella infection. Initially, she presented with ataxia and dysmetria, with subsequent reports from parents of urinary incontinence and significant behavior changes. Additionally, reflexes in the lower limbs were absent. Anti-SOX1 antibodies tested positive in both serum and cerebrospinal fluid. Oncological screening at presentation and a seven-month follow-up showed no malignancies. The patient exhibited favorable clinical progress without requiring treatment. At the seven-month follow-up, serum antibodies tested negative. This case report broadens the known clinical spectrum, being the first description of post-varicella anti-SOX1 antibodies.

Clinical efficacy and effectiveness of alternative varicella vaccination strategies: An overview of reviews

A number of countries have implemented universal childhood varicella vaccination programmes over the past 30 years. However, strategies differ in terms of dosing schedule (one- or two-dose), type of vaccine(s) recommended (monovalent, quadrivalent measles-mumps-rubella-varicella, or both), age at vaccination, and dosing interval for a two-dose schedule. An overview of reviews was undertaken to assess the existing systematic review evidence of the clinical efficacy/effectiveness of alternative varicella vaccination strategies. A comprehensive search of databases, registries and grey literature was conducted up to 2 February 2022. Two reviewers independently screened, extracted data and assessed the methodological quality of included reviews. A total of 20 reviews were included in the overview; 17 assessed the efficacy/effectiveness of one-dose strategies and 10 assessed the efficacy/effectiveness of two-dose strategies. Although the quality of most reviews was deemed 'critically low', there was clear and consistent evidence that vaccination is very effective at reducing varicella. While the analysis was restricted due to lack of detail in reporting of the reviews, the evidence suggests that two-dose strategies are more efficacious/effective than one-dose strategies in preventing varicella of any severity, but that both strategies have similar high efficacy/effectiveness in preventing moderate or severe varicella. Based on this evidence in this overview of reviews, a key consideration for policymakers on the possible introduction of a childhood varicella vaccination programme and the choice between a one- or two-dose strategy, will be whether the objective of a programme is to prevent varicella of any severity or to prevent moderate to severe varicella.

Outbreak of Monkeypox Virus Disease: An Update on Epidemiology, Pathophysiology and Available Treatment Options

The monkeypox virus is a zoonotic illness with a tropical distribution in Africa, and around the world. The disease is spread through contact with infected animals or humans, and can also be spread from person to person through close contact with respiratory or bodily fluids. Fever, swollen lymph nodes, blisters, and crusted rashes characterize the disease. The incubation period is five to twenty-one days. It is difficult to distinguish the rash caused by infection from varicella and smallpox. Laboratory investigations are essential aspects of illness diagnosis and surveillance, and novel tests are required for more accurate and faster diagnosis. Antiviral drugs are being used to treat monkeypox. Scarring as well as other comorbidities, are prevalent in survivors, with the case mortality rate varying from 1 to 11%. The virus was found in monkeys at a Danish research facility in 1958, from which the term 'monkeypox' is derived. The primary human case was found in a child in the Democratic Republic of the Congo (DRC) in 1970. The World Health Organisation (WHO) has recently declared monkeypox a public health emergency of international concern. This manuscript attempts to review the various aspects of monkeypox disease and its allopathic as well as alternative treatment options available and serves as a valuable resource for healthcare professionals, researchers, and the general public.

Chickenpox and multiple sclerosis: A Mendelian randomization study

Observational studies have suggested a suspected association between varicella-zoster virus (VZV) infection and multiple sclerosis (MS), but the connection has remained unclear. The aim of the present study is to evaluate the causal relationship between chickenpox which is caused by VZV infection and MS. We performed a two-sample Mendelian randomization analysis to investigate the association of chickenpox with MS using summary statistics from genome-wide association studies (GWAS). The GWAS summary statistics data for chickenpox was from the 23andMe cohort including 107 769 cases and 15 982 controls. A large summary of statistical data from the International Multiple Sclerosis Genetics Consortium (IMSGC) was used as the outcome GWAS data set, including 14 802 MS cases and 26 703 controls. We found evidence of a significant association between genetically predicted chickenpox and risk of MS (odds ratio [OR] = 35.27, 95% confidence interval [CI] = 22.97-54.17, p = 1.46E-59). Our findings provided evidence indicating a causal effect of chickenpox on MS. Further elucidations of this association and underlying mechanisms are needed for identifying feasible interventions to promote MS prevention.

Cost effectiveness and budget impact of universal varicella vaccination in Russia

This economic evaluation assesses the cost-effectiveness and budget impact of introducing a two-dose varicella vaccine in the Russian national immunization program. A static Markov model followed a simulated 2019 Russian cohort over its lifetime and compared outcomes and costs of three varicella vaccination strategies: strategy I (doses given at 12 and 15 months of age), strategy II (doses given at 1 year and 6 years of age), and a no vaccination scenario. Inputs on age-dependent clinical pathways, associated costs, and related health outcomes were collected from national sources and published literature. Results are presented as incremental cost-effectiveness ratio (ICER) from the healthcare payer and societal perspective over the lifetime of the birth cohort and the budget impact over a 10 years' time horizon. Vaccination strategies I and II resulted in an ICER of approximately 1.7 million rubles per quality-adjusted life years gained from the healthcare payer perspective and were cost-saving from the societal perspective. From the healthcare payer perspective, the costs per varicella case averted were 5,989 and 7,140 rubles per case for strategies I and II, respectively. However, from the societal perspective, vaccination is a dominant strategy and the budget impact analysis shows significant healthcare savings over 10 years, with strategy I realizing savings of ~2 billion rubles more than strategy II. From a public health impact perspective, varicella vaccination of children at 12 and 15 months of age through the Russian NIP is expected to be cost-effective with an affordable budget impact compared to no vaccination.

Rapid Detection of the Varicella-Zoster Virus Using a Recombinase-Aided Amplification-Lateral Flow System

Varicella-zoster virus (VZV) is the etiological agent of varicella (chickenpox) and herpes zoster (shingles). VZV infections are ubiquitous and highly contagious, and diagnosis is mostly based on the assessment of signs and symptoms. However, monkeypox, an emerging infectious disease caused by the monkeypox virus (MPXV), has clinical manifestations that are similar to those of VZV infections. With the recent monkeypox outbreak in non-endemic regions, VZV infections are likely to be misdiagnosed in the absence of laboratory testing. Considering the lack of accessible diagnostic tests that discriminate VZV from MPXV or other poxviruses, a handy and affordable detection system for VZV is crucial for rapid differential diagnosis. Here, we developed a new detection method for VZV using recombinase-aided amplification technology, combined with the lateral flow system (RAA-LF). Given the prevalence of VZV worldwide, this method can be applied not only to distinguish VZV from other viruses causing rash, but also to foster early detection, contributing substantially to disease control.

Changing Epidemiology of Varicella Outbreaks in the United States During the Varicella Vaccination Program, 1995-2019

We describe the changing epidemiology of varicella outbreaks informed by past and current active and passive surveillance in the United States by reviewing data published during 1995-2015 and analyzing new data from 2016 to 2019. Varicella outbreaks were defined as ≥5 varicella cases within 1 setting and ≥1 incubation period. During the 1-dose varicella vaccination program (1995‒2006), the number of varicella outbreaks declined by 80% (2003-2006 vs 1995-1998) in 1 active surveillance area where vaccination coverage reached 90.5% in 2006. During the 2-dose program, in 7 states with consistent reporting to the Centers for Disease Control and Prevention, the number of outbreaks declined by 82% (2016-2019 vs 2005-2006). Over the entire program (1995-2019), outbreak size and duration declined from a median of 15 cases/outbreak and 45 days duration to 7 cases and 30 days duration. The proportion of outbreaks with <10 cases increased from 28% to 73%. During 2016‒2019, most (79%) outbreak cases occurred among unvaccinated or partially vaccinated persons eligible for second-dose vaccination, highlighting the potential for further varicella control.

Celebrating 25 Years of Varicella Vaccination Coverage for Children and Adolescents in the United States: A Success Story

Tracking vaccination coverage is a critical component of monitoring a vaccine program. Three different surveillance systems were used to examine trends in varicella vaccination coverage during the United States vaccination program: National Immunization Survey-Child, National Immunization Survey-Teen, and immunization information systems (IISs). The relationship of these trends to school requirements and disease decline was also examined. Among children aged 19-35 months, ≥1 dose of varicella vaccine increased from 16.0% in 1996 to 89.2% by the end of the 1-dose program in 2006, stabilizing around at least 90.0% thereafter. The uptake of the second dose was rapid after the 2007 recommendation. Two-dose coverage among children aged 7 years at 6 high-performing IIS sites increased from 2.6%-5.5% in 2006 to 86.0%-100.0% in 2020. Among adolescents aged 13-17 years, ≥2-dose coverage increased from 4.1% in 2006 to 91.9% in 2020. The proportion of adolescents with history of varicella disease declined from 69.9% in 2006 to 8.4% in 2020. In 2006, 92% of states and the District of Columbia (DC) had 1-dose daycare or school entry requirements; 88% of states and DC had 2-dose school entry requirements in the 2020-2021 school year. The successes in attaining and maintaining high vaccine coverage were paramount in the dramatic reduction of the varicella burden in the United States over the 25 years of the vaccination program, but opportunities remain to further increase coverage and decrease varicella morbidity and mortality.

Clinical Manifestations of Varicella: Disease Is Largely Forgotten, but It's Not Gone

After 25 years of varicella vaccination in the United States, classic varicella and its complications have become an uncommon occurrence. The clinical manifestation of varicella among vaccinated persons is usually modified, with fewer skin lesions, mostly maculopapular, and milder presentation. However, the potential for severe manifestations from varicella still exists among both vaccinated and unvaccinated persons, and thus healthcare providers should keep varicella in the differential diagnosis of a maculopapular or vesicular rash. The prompt recognition and diagnosis of varicella is important because when confirmed, clinical and public health measures need to be taken swiftly.

Association of asthma and herpes zoster, the role of vaccination: A literature review

Herpes Zoster (HZ) is the reactivation of a previous infection with varicella-zoster virus (VZV) which shares the same mode of transmission as HZ. It presents with painful erythematous vesicles in a dermatome which is characterized by a burning sensation before and after the rash. Any conditions with suppressed cellular immunity example diabetes mellitus, chronic obstructive pulmonary disease, asthma, cardiovascular diseases, chronic steroid uses, malignancy, etc. causes reactivation of the virus. Impaired immune responses in asthma patients either in any age group may increase their susceptibility to HZ infection owing to skewed Th1/Th2 immunity, resulting in predominant Th2 conditions and an unwarranted Th2 cell response against respiratory allergens. Similarly, many studies have delineated the association of asthma with HZ. However, the relation between steroid use in asthma and HZ is uncertain, its immunosuppressive effect might be responsible for increased susceptibility to the infection. As HZ increases the economic burden and morbidity, its prevention should use vaccines. There are two types of Food and Drug Administration (FDA)-approved vaccine available against HSV one of which is given as a single dose vaccine called Zostavax, for people 50-59 years but its efficacy falls after 3rd dose and on the subsequent 4th dose and is also contraindicated in human immunodeficiency virus/acquired immunodeficiency syndrome, pregnancy and people taking immunosuppressive drugs. Shingrix is preferred by FDA which is a two doses vaccine that is given 6 months apart for people above 50 years and to immunocompromised people. Hence, proper counseling and education about the risks of herpes should be informed to the patients with timely utilization of the vaccine.

Susceptibility towards Chickenpox, Measles and Rubella among Healthcare Workers at a Teaching Hospital in Rome

Immunization is the best protection against chickenpox, measles and rubella. It is important to identify and immunize susceptible healthcare workers to prevent and control hospital infections. Our aim was to estimate the susceptibility level of healthcare workers at a Teaching Hospital in Rome concerning these diseases and the factors associated to the susceptibility. Methods: a cross sectional study was carried out at the Department of Occupational Medicine of the Umberto I General Hospital of Rome. Participants were recruited during routine occupational health surveillance. As far as inclusion criteria, the following professionals were considered: doctors, nurses, laboratory technicians and other health professionals. Concerning the exclusion criteria, patients with HIV, cancer and diseases of the immune system, and acute illness or fever more than 38.5 °C, were not included in the study. A blood sample was tested for the presence of antibodies against measles, rubella and chicken pox. Results: 1106 healthcare professionals were involved in the study (41.8% nurses, 30.4% doctors, 12.3% laboratory technicians, 15.1% other health professionals): 25 (2.3%), 73 (6.6%) and 35 (3.2%) of these were susceptible to measles, rubella and chicken pox, respectively. The only variable associated with susceptibility of measles was age (p < 0.001). Furthermore, there was evidence of an association between various susceptibilities, particularly between measles and chickenpox (OR: 4.38). Conclusion: this study showed that even if the majority of our healthcare professionals are immunized for MRV, it is necessary not to underestimate the seronegativity of non-immune ones. All health professionals should be vaccinated to ensure safety for patients, especially the weakest.

Monkeypox in pregnancy: virology, clinical presentation, and obstetric management

The 2022 monkeypox outbreak, caused by the zoonotic monkeypox virus, has spread across 6 World Health Organization regions (the Americas, Africa, Europe, Eastern Mediterranean, Western Pacific, and South-East Asia) and was declared a public health emergency of international concern on July 23, 2022. The global situation is especially concerning given the atypically high rate of person-to-person transmission, which suggests viral evolution to an established human pathogen. Pregnant women are at heightened risk of vertical transmission of the monkeypox virus because of immune vulnerability and natural depletion of population immunity to smallpox among reproductive-age women, and because orthopoxviral cell entry mechanisms can overcome the typically viral-resistant syncytiotrophoblast barrier within the placenta. Data on pregnancy outcomes following monkeypox infection are scarce but include reports of miscarriage, intrauterine demise, preterm birth, and congenital infection. This article forecasts the issues that maternity units might face and proposes guidelines to protect the health of pregnant women and fetuses exposed to the monkeypox virus. We review the pathophysiology and clinical features of monkeypox infection and discuss the obstetrical implications of the unusually high prevalence of anogenital lesions. We describe the use of real-time polymerase chain reaction tests from mucocutaneous and oropharyngeal sites to confirm infection, and share an algorithm for the antenatal management of pregnant women with monkeypox virus exposure. On the basis of the best available knowledge from prenatal orthopoxvirus infections, we discuss the sonographic features of congenital monkeypox and the role of invasive testing in establishing fetal infection. We suggest a protocol for cesarean delivery to avoid the horizontal transmission of the monkeypox virus at birth and address the controversy of mother-infant separation in the postpartum period. Obstetrical concerns related to antiviral therapy with tecovirimat and vaccinia immune globulin are highlighted, including the risks of heart rate-corrected QT-interval prolongation, inaccuracies in blood glucose monitoring, and the predisposition to iatrogenic venous thromboembolism. The possibility of monkeypox vaccine hesitancy during pregnancy is discussed, and strategies are offered to mitigate these risks. Finally, we conclude with a research proposal to address knowledge gaps related to the impact of monkeypox infection on maternal, fetal, and neonatal health.

Varicella vaccination in India's universal immunisation program -is it time?

We report two representative cases of complicated varicella in immunocompetent children highlighting the significant vaccine preventable varicella burden in the Indian population. A robust surveillance programme followed by incorporation of varicella vaccine in routine immunization would be the way forward to mitigate this illness.

Post-varicella arterial ischemic stroke in children and neurocognitive performance: a 4-year follow-up study

OBJECTIVE

To analyze data from children who were previously healthy and presented with post-varicella arterial ischemic stroke upon arrival when admitted to the emergency room, with focus on the clinical/laboratory aspects, and neurocognitive performance after four-year follow-up.

METHODS

Seven children presenting with arterial ischemic stroke after varicella were evaluated at pediatric emergency services in the city of São Paulo (SP), Brazil. Ischemic stroke was determined by magnetic resonance imaging/magnetic resonance angiography in a topography compatible with the areas supplied by the middle cerebral or internal carotid arteries. IgG-class antibodies against varicella zoster virus and varicella-zoster virus DNA by polymerase chain reaction in cerebrospinal fluid were tested. Patients with prothrombotic conditions were excluded. The Pediatric Stroke Outcome Measure was applied upon admission and 4-years after the stroke.

RESULTS

All patients (age range: 1.3 to 4 years) included presented chickenpox 5.1 (±3.5) months before. All patients had analysis of anti-varicella-zoster-virus-IgG in cerebrospinal fluid, but only three (43%) had a positive result. Of the patients 43% had no vascular lesions identified in magnetic resonance angiography. All patients showed improvement in their sequela scores. After 4 years, five patients displayed good evolution in the Pediatric Stroke Outcome Measure, and only one patient presented with a score of 2 in the sensorimotor and cognition areas. No recurrence of arterial ischemic stroke was observed.

CONCLUSION

We reinforced the non-progressive course of post-varicella arterial ischemic stroke after 4-year follow-up. The presence of varicella-zoster-virus-DNA detected by polymerase chain reaction, and/or intrathecal IgG antibody against varicella zoster virus, and angiopathy location in magnetic resonance angiography were not determining for the diagnosis. Invasive tests, with low sensitivity, should be well considered in the diagnosis of post-varicella arterial ischemic stroke.

Atypical primary varicella rash: Systematic literature review

Aim

In previously healthy subjects, primary varicella presents with a distinctive vesicular rash that is more intense on the trunk and head than on the extremities. However, an atypical presentation may occasionally develop. We aimed at systematically assessing the characteristics of cases affected by atypical primary varicella rash.

Methods

The United States National Library of Medicine, Excerpta Medica and Web of Science databases were reviewed, without date or language restrictions. Articles were eligible if reporting previously healthy and immunocompetent subjects with a primary varicella rash (i.e., a photo‐localised primary varicella or skin inflammation‐associated primary varicella).

Results

Thirty‐eight reports providing information on 59 cases of atypical primary varicella were identified. Twenty‐four cases (median 8.5 years of age, 19 females) were photo‐localised and 35 (median 4.8 years of age, 15 females) were associated with pre‐existing skin inflammation (including cast occlusion, diaper irritation, operative sites, burns, insect bites, vaccinations or pre‐existing skin disease). The skin rash was monomorphic and without a “starry sky” appearance.

Conclusion

Primary varicella may have a modified presentation in areas of irritation such as sun exposure or pre‐existing inflammation. There is a need for a wider awareness of these modulators of varicella rash.

Mary Shelley's migraines and fatal stroke: some observations on their primary cause

In this article the origins of Mary Shelley's neurological and cerebrovascular problems are described. Through a reanalysis of her biography, her early health issues caused by a dermatological condition, potentially eczema, psoriasis or chickenpox, are related, thanks to current biomedical knowledge, to her migraines and strokes, including the one that killed her.

Chickenpox in Poland in 2020

INTRODUCTION

Chickenpox is an infectious disease caused by the varicella zoster virus. The characteristic feature of this virus is very high visibility of 90-95%. The most common connection is direct contact with the disease or via droplets. The United States was the first country to introduce a universal, population-based childhood varicella vaccination program in 1995. In its 25 years of implementation, this program has significantly reduced the burden of chickenpox. There was a more than 97% reduction in varicella incidence and a 90% reduction in varicella-related hospitalizations and deaths, the highest (99%) in those under the age of 20 (born after starting the vaccination programme). Chickenpox is very common in Poland. In recent years, starting from 2002, there has been an upward trend in the incidence of chickenpox, except for 2020. In 2020, a decrease in the number of cases was recorded.

OBJECTIVES

The aim of the study was to assess the epidemiological situation of chickenpox in Poland in 2020 and to compare it with the situation in previous years.

MATERIAL AND METHODS

Evaluation of the epidemiological situation of chickenpox in Poland in 2020 was based on the results of the analysis of aggregate data published in the annual bulletins: "Infectious diseases and poisonings in Poland in 2020." and "Vaccinations in Poland in 2020". In addition, recommendations from the Protective Vaccination Program for 2020 were used.

RESULTS

In 2020, 71,567 cases of chickenpox were registered in Poland, i.e. 39.6% less than in the previous year. The incidence of chickenpox in 2020 was 186.6 per 100,000 and was lower than in 2019. The lowest incidence was recorded in the Świętokrzyskie Voivodship - 118.5/100,000, while the highest in the Kujawsko-Pomorskie Voivodeship - 263.5/100,000. Most cases concerned children aged 0-4 years (36,661). The incidence of chickenpox in men was higher than in women, and in rural areas higher than in urban dwellers. Hospitalization due to chickenpox in 2020 covered 1,368 people, which accounted for 0.51% of the total number of registered cases.

CONCLUSIONS

In 2020, there was a decrease in the number of cases of chickenpox compared to the previous year. The lower incidence may have been the result of reduced transmission of the varicella virus due to changes in the health behavior of the population during the COVID-19 pandemic (isolation measures and the introduction of a lock down throughout Poland limiting the activity of the population).

Why do they call chickenpox chickenpox?

Have you ever thought about the lay term chickenpox and wondered where it came from? Or what the corresponding terms might be in other languages? Chickenpox has a fascinating etymology that can serve as an entertaining teaching and learning opportunity for busy clinicians and their trainees. Four facts about the term are presented, each of which contributes to an illustration of the history of the disease, but also offers a deeper understanding of the transmission and clinical features of the illness. Etymological and linguistic origins also illustrate how parents and doctors have observed, explained and feared the condition.

Phase 3, open-label, Russian, multicenter, single-arm trial to evaluate the immunogenicity of varicella vaccine (VARIVAX™) in healthy infants, children, and adolescents

Varicella (chickenpox) is a common, highly contagious disease caused by primary infection with varicella zoster virus (VZV), which can result in bacterial superinfection, central nervous system complications, and hospitalization. Stage 2 of this Phase 3 open-label study (ClinicalTrials.gov identifier: NCT03843632) enrolled 100 healthy infants, children, and adolescents (12 months–6 years, n = 37; 7–12 years, n = 33; 13–17 years, n = 30) without a clinical history of varicella. Participants aged 12 months–12 years were administered 1 dose of VARIVAX™ 0.5 mL (Varicella Virus Vaccine Live [Oka/Merck]) and adolescents aged 13–17 years were administered 2 doses 6 weeks apart. For participants seronegative at baseline (VZV antibody titer <1.25 glycoprotein enzyme-linked immunosorbent assay [gpELISA] units/mL), immunogenicity was assessed by seroconversion (VZV antibody titer ≥5 gpELISA units/mL) and VZV antibody geometric mean titers 6 weeks after the final dose. For participants who were VZV seropositive at baseline (VZV antibody titer ≥1.25 gpELISA units/mL), immunogenicity was assessed by antibody titer geometric mean fold rise and percentage of participants with ≥4-fold rise in antibody titer 6 weeks after the final dose. A Vaccine Report Card was used to report solicited and unsolicited adverse events through 42 days post-vaccination. After series completion among seronegative participants across age groups (n = 74), 98.6% demonstrated seroconversion 6 weeks post-vaccination; among seropositive participants (n = 26), 65.4% had ≥4-fold rise in antibody titer 6 weeks post-vaccination. No new safety signals were observed. Administering VARIVAX to infants, children, and adolescents resulted in an acceptable immune response with a safety profile consistent with the licensed product.

Phase 3, open-label, Russian, multicenter, single-arm trial to evaluate the immunogenicity of varicella vaccine (VARIVAX™) in healthy adults

Varicella (chickenpox) is a common, highly contagious disease caused by primary infection with varicella zoster virus (VZV). Adults typically experience more severe symptoms than children and have a higher risk of developing complications. Stage 1 of this Phase 3 open-label study enrolled healthy adults in Russia aged 18-75 years without a clinical history of varicella infection. Eligible participants (n = 50) were administered 2 doses of VARIVAX™ (Varicella Virus Vaccine Live [Oka/Merck]) 0.5 mL 6 weeks apart. For participants seronegative at baseline (VZV antibody titer <1.25 glycoprotein enzyme-linked immuno-sorbent assay [gpELISA] units/mL), immunogenicity was assessed by seroconversion (VZV antibody titer ≥5 gpELISA units/mL) and assessment of geometric mean titers of VZV antibody as measured by gpELISA 6 weeks after Dose 2. For VZV seropositive participants at baseline (VZV antibody titer ≥1.25 gpELISA units/mL), immunogenicity was assessed by geometric mean fold rise in antibody titer and percentage of participants with a ≥ 4-fold rise in antibody titer 6 weeks after Dose 2. A Vaccine Report Card was used to record solicited and unsolicited adverse events through 42 days post-vaccination. All participants who were seronegative (n = 26) at baseline demonstrated seroconversion 6 weeks after Dose 2. Among participants who were seropositive at baseline (n = 23), 60.9% had a ≥4-fold rise in antibody titer 6 weeks after Dose 2. Vaccination was generally well tolerated, with no new safety signals identified. Administration of 2 doses of VARIVAX in adults in Russia results in acceptable immune responses with safety data consistent with the licensed product (Clinicaltrials.gov identifier: NCT03843632).

Rare complications of chicken pox in immunocompetent children: Acute respiratory distress syndrome

Chickenpox is a highly contagious disease caused by varicella zoster virus. Fever and papulovesicular rash are hallmarks of this disease. These manifestations are self-liming and complete recovery is seen in most cases. We report two cases of chickenpox infection where the rare and atypical manifestations of acute respiratory distress syndrome with pleural effusion were seen.

Infectious disease activity during the COVID-19 epidemic in Japan: Lessons learned from prevention and control measures

In Japan, the Law Concerning the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases (the "Infectious Diseases Control Law") classifies infectious diseases as category I-V infectious diseases, pandemic influenza, and designated infectious diseases based on their infectivity, severity, and impact on public health. COVID-19 was designated as a designated infectious disease as of February 1, 2020 and then classified under pandemic influenza as of February 13, 2021. According to national reports from sentinel surveillance, some infectious diseases transmitted by droplets, contact, or orally declined during the COVID-19 epidemic in Japan. As of week 22 (June 6, 2021), there were 704 cumulative cases of seasonal influenza, 8,144 cumulative cases of chickenpox, 356 cumulative cases of mycoplasma pneumonia, and 45 cumulative cases of rotavirus gastroenteritis; these numbers were significantly lower than those last year, with 563,487 cumulative cases of seasonal influenza, 31,785 cumulative cases of chickenpox, 3,518 cumulative cases of mycoplasma pneumonia, and 250 cumulative cases of rotavirus gastroenteritis. Similarly, many infectious diseases transmitted by droplets or contact declined in other countries and areas during the COVID-19 pandemic. One can reasonably assume that various measures adopted to control the transmission of COVID-19 have played a role in reducing the spread of other infectious diseases, and especially those transmitted by droplets or contact. Extensive and thorough implementation of personal protective measures and behavioral changes may serve as a valuable reference when identifying ways to reduce the spread of infectious diseases transmitted by droplets or contact in the future.

Acceptance of varicella vaccination

Varicella is a common vaccine-preventable disease that usually presents in children as a mild infection; however, severe complications also occur. The burden of varicella is significant in the terms of incidence, complication, and hospitalization rate related to varicella and economic disease burden. Despite the evidence of overall positive effects of varicella vaccination, there are great differences in the implementation of varicella vaccination and in the uptake of the vaccine from country to country. Improving acceptance of varicella vaccination on the national and on the individual level would decrease the burden of the disease on the health of children and on health-care resources. In studies determining factors of parental acceptance of varicella vaccination questions specific for varicella vaccination were highlighted. Addressing these issues with open, evidence based communication is important to improve and maintain the trust of the public in varicella vaccination.

Guillain-Barré Syndrome Following Chickenpox With Multiple Cranial Nerve Palsies and Cerebrospinal Fluid Pleocytosis

Guillain-Barré syndrome (GBS) is a rare complication of chickenpox. All cases of post-varicella GBS published in the literature have been associated with the classical albuminocytological dissociation. We report the case of a 48-year-old male with flaccid areflexic quadriparesis and bilateral seventh, ninth, tenth, and twelfth cranial nerve palsies 10 days after chickenpox. Cerebrospinal fluid (CSF) analysis done in the second week showed marked lymphocytic pleocytosis. Electroneurographic studies were suggestive of acute inflammatory demyelinating polyradiculopathy. He had near-total neurological recovery with intravenous immunoglobulin. Our case demonstrates that GBS can occur after primary varicella infection, and marked CSF pleocytosis can be an additional feature.