SDMS ID: P2010/0397-001 WACSClinProc4.

23/09 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Varicella and the Newborn Varicella-Zoster Virus Exposure and Infection in the Newborn Period Varicella exposure and/or infection in the newborn Midwives and medical officers Chicken pox, varicella, neonate, newborn P2010/0317-001 Varicella in Pregnancy

Purpose: Varicella, the primary infection with herpes varicella zoster virus (VZV), in pregnancy may cause maternal mortality or serious morbidity. It may also cause fetal varicella syndrome (FVS). Background: VSV is a DNA virus of the herpes family that is highly contagious and transmitted by respiratory droplets and by direct personal contact with vesicle fluid or indirectly via fomites (non-living material such as linen). The primary infection is characterised by fever, malaise and a pruritic rash that develops into crops of maculopapules which become vesicular and crust over before healing. The incubation period is 1 3 weeks and the disease is infectious 48 hours before the rash appears and continues to be infectious until the vesicles crust over. A history of chickenpox infection is 97-99% predictive of the presence of serum varicella antibodies. Pregnant women should be advised to avoid contact with people who have or those who have been exposed to varicella zoster virus.

Significant Exposure Significant exposure is defined as living in the same household as a person with active varicella or herpes zoster, or direct face to face contact with a person with varicella or herpes zoster for at least 5 minutes, or being in the same room for at least one hour. Zoster Immunoglobulin (ZIG) High-titre zoster immunoglobulin (ZIG) is available for the prevention of varicella in high-risk subjects. ZIG must be given within 96 hours of exposure. ZIG immunoglobulin should only be given by intramuscular injection. Zoster Immunoglobulin (ZIG) dose based on weight Weight of patient (kg) Dose (IU) 0-10 200 11-30 400 >30 600
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*The Australian Immunisation Handbook (NHMRC 2008) recommended dosage of ZIG differs from the product information. The Australian Immunisation Handbook (NHMRC 2008) has revised the dosage to minimise wastage of ZIG. Management of newborns of mothers with perinatal chickenpox Maternal chickenpox in the peri-partum period poses a risk of severe neonatal varicella. The increased peri-partum severity is attributed to a large transplacental inoculum of virus in the absence of protective maternal antibody. The timing of maternal infection in relation to delivery determines the risk to the infant. o Infection with onset more than seven days before delivery ensures adequate transplacental passage of specific anti-VZV antibody to protect the newborn o Infection with onset 7 days or less before delivery puts the infant at risk of severe neonatal varicella o Newborns of seronegative mothers have increased risk of severe illness if exposed to varicella in the first 28 days of life. o Breastfeeding of infected or exposed babies is encouraged. o A mother and/or baby with active vesicles should be isolated from other mother and babies but and infected mother does not need to be isolated from her own baby. ZIG should be given to: o Newborns whose mothers develop varicella from 7 days or fewer before delivery to 2 days after delivery o Newborns exposed to varicella in the first month of life, if the mother has no personal history of infection of VZV and is seronegative Management of newborns exposed to VZV infection on the postnatal ward or at home The risk of the newborn developing severe disease from postnatal exposure is considerable less than from transplacentally acquired varicella. The risk to the newborn is determined primarily by the presence or absence of transplacentally acquired maternal IgG antibody. If the mother has had chickenpox, the risk from siblings is negligible. If not, the newborn should be given ZIG. A newborn does not need to be isolated from its siblings with chickenpox, whether or not the baby was given ZIG. ZIG should be given to: o A newborn up to 28 days old exposed to VZV if the mother is seronegative, her serostatus can not be determine, or if the infant was born at or before 28 weeks gestation. Management of VZV exposure within the neonatal unit VZV poses a particular threat in this setting, because babies born prematurely are relatively deprived of the usual third trimester transfer of transplacental antibodies. o Infant born after 28 weeks gestation should only be given ZIG if they have had significant exposure and serological tests show the mother to be seronegative o All infants born at or before 28 weeks gestation or born weighing less than 1000g with significant exposure should be given ZIG regardless of the of maternal serology. o Quarantine of cases should continue until all lesions have crusted o Quarantine of contacts should be from 7 to 21 days after exposure and from 7 to 28 days after exposure if they received ZIG o Aim to discharge all patients requiring quarantine from hospital as soon as possible.

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Follow-up of Newborns who have received ZIG All newborns who have received ZIG should be monitored for rash and parents should be informed to seek medical attention as varicella may still occur despite passive immunisation. Newborn Varicella Aciclovir should be considered for newborns with varicella that are: o Full term newborns less than 28 days old o Premature newborns to at least 44 weeks gestation o Any newborn with severe or progressive disease. Aciclovir, an antiviral agent, can shorten the duration of illness if administered during the incubation period or within 24 hours of the onset of the rash. Precautions for Healthcare Workers Non-immune healthcare workers who have had significant exposure to chickenpox may be offered vaccination within 3 days of exposure. If a non-immune healthcare worker declines vaccination they should be reallocated to minimise patient contact or placed on sick leave from 8 to 21 days post-contact. Attachments
Attachment 1

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: 06 May 2009

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REFERENCES Heuchan A & Issacs D 2001 The management of varicella-zoster virus exposure and infection in pregnancy and the newborn period. Online: http://www.mja.com.au/public/issues/174_06_190301/heuchan/heuchan.html National Health and Medical Research Council 2008 The Australian Immunisation Handbook 9th Edition Online: http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home Royal College of Obstetricians and Gynaecologists 2007, Chickenpox in pregnancy guideline Online: http://www.rcog.org.uk/index.asp?PageID=514

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