CORRELATION BETWEEN CHICKENPOX (VARICELLA) AND VACCINATIONS

in MALANG, EAST JAVA

Paper

Arranged to Fullfill the Assignment of English for biology guided by Dr. Sueb,
M.Kes.
Will be presented on Wednesday, November 15, 2017

By group 4 class C Of 2017

Asmarita Ningsih NIM: 170341615115

Dwi Agustin Nurul Hidayah NIM: 170341615074

Olivia Nabilla Maharani NIM: 170341615088

UNIVERSITAS NEGERI MALANG

FACULTY OF MATHEMATICS AND NATURAL SCIENCES

DEPARTMENT OF BIOLOGY

Nopember 2017
 Correlation Between Chickenpox (Varicella) and Vaccinations in Malang, East Java

ASMARITA NINGSIH, DWI AGUSTIN, OLIVIA NABILLA & DR. SUEB, M.KES.
dwiaenha6@gmail.com, sueb.fmipa@um.ac.id
Universitas Negeri Malang-FMIPA, Biology, Malang
INDONESIA

Abstract

Chickenpox is considered a universal childhood infection in temperate parts of the

world with >90% seropositivity by adolescence. In Indonesia, it was recorded during January
to November at least 1771 people affected by this disease outbreak (Dinkes RI, 2016). As in
East Java, data from East Java provincial health office there are 671 people affected by
chickenpox disease. The purpose of this research is to know the correlation between varicella
or chicken pox and vaccinations. This research is descriptive quantitative. We administered a
survey questionnaire to people who have had varicella. We used 30-item of questionnaire,
and interview with the poeple who have had varicella. We use Odds Ratio (OR), to count
how much vaccines take effect to varicella. The population are all poeple who have had
varicella in ambarawa street, and its samples are 30 poeple have had varicella. The result is
many of the poeple who have not received the vaccine are more commonly infected with
chickenpox. Vaccine is very influential on the human immune in warding off the virus. So,
knowledge of the vaccine should be more disseminated.

Keywords: Chickenpox, VZV, vaccine.

INTRODUCTION

Chickenpox is considered a universal childhood infection in temperate parts of the

world with >90% seropositivity by adolescence. If missed during childhood the next most
likely time of exposure to VZV is probably when young adults have children of their own. A
case of chickenpox is described in a 94-year-old female who had not had children.
Chickenpox in older people is uncommon but life-threatening and could be prevented by
wider use of varicella vaccine than is currently recommended in the UK. A case for this is
made in light of relatively recent recommendations on the wider use of varicella vaccine in
the US (Justin, 2010).
Chickenpox (varicella) is a highly contagious disease recognized by a characteristic
and often pathognomonic maculopapular vesicular rash. Varicella may lead to serious
complications, including secondary bacterial skin and softtissue infections, cerebellitis,
encephalitis, pneumonia, and coagulopathy (Heininger, 2006). Neonates, adolescents, and
immunocompromised individuals are more susceptible to complications (Boelle, 2002).
Reported rates of complications from varicella range from 40.7% to 83.3% among
hospitalized children (Galil, 2002). Mortality rates of 2 to 4 for every 100,000 infected people
were noted. More than 95% of the non-vaccinated populations were infected with varicella,
and most of them are younger than 20 years (Banz, 2003). Children younger than 10 years of
age, particularly those between 3 and 6 years, exhibit a high incidence of infection when they
do not receive varicella vaccine as part of a universal vaccination program (American
Academy of Pediatrics, 2007). In 1998, the World Health Organization (WHO)
recommended routine childhood varicella vaccination in countries where chickenpox
significantly affects public health (WHO, 1998). Since the introduction of universal
vaccination, a number of countries have witnessed declines in varicella incidence,
hospitalization, and/or mortality, including the United States of America, Australia Italy,
Germany,and Taiwan. Varicella vaccination provides long-term effectiveness in preventing
varicella and may reduce the risk of herpes zoster (Jean-Jasmin, 2004). Furthermore, varicella
vaccination is cost-effective in the Asian regions. In Singapore, the benefit–cost ratio of
vaccination is 2 , which indicates that every US$1.00 invested in vaccination would save
US$2.25.20 Similar findings were reported in 2 studies in Taiwan, which reported a benefit–
cost ratio of 2.06 21 and 0.9,22 respectively (Yawn, 1997).

In Indonesia there is not much data that records cases of chickenpox nationally. The
recorded data is epidemic data of smallpox in certain areas only (Dinkes RI,2006). Based on
data WHO Indonesia, occupying the third in the case of chickenpox. In Indonesia this disease
is considered to be underestimated by most people. Because in Indonesia this disease is
considered a myth as well, because it is a disease that must be experienced and not
preventable. In Indonesia, it was recorded during January to November at least 1771 people
affected by this disease outbreak (Dinkes RI, 2016).

As in East Java, data from East Java provincial health office there are 71 people
affected by chickenpox disease. Of that amount, during the last two months there is a
significant increase to 4. As in the district of Malang, there are 171 people who are divided
from various districts that there are in Malang Regency, such as districts ngantang there are
17 people sufferers, kasembon sub-district there are 9 patients, and other districts (Dinkes
Propinsi Jatim, 2016).

Vaccination represents an essential component of preventive medicine. Despite the

well-established benefits of immunization, missed-opportunities for vaccination remain a
public health concern (Link-Gelles , et al.2012). Previous research shows that physician
attitudes towards vaccines can directly influence patient decisions to accept or reject
vaccination (Johnson, 2008). Inadequate physician knowledge regarding vaccines and patient
eligibility for vaccination can further reduce vaccination coverage rates (Smailbegovic,2003).
Experience with vaccines prior to and during medical school may impact future physician
recommendations about immunizations to patients. A recent study investigating the
immunization requirements of US health professional schools reported that 100% of surveyed
medical schools required students to receive specified vaccines prior to matriculation
(Lindley et al. 2011). During their clinical years, medical students may discuss and
recommend vaccines as part of their pediatric and internal medicine clerkships, which occur
sometime in their third or fourth year. Studies conducted on medical students in Canada and
Germany identified the importance of assessing student knowledge of vaccines to support the
creation of targeted educational interventions to help prepare students for patient interactions
related to immunization (Pelly et al. 2010).
In women who reach childbearing age without natural immunity or vaccination as part
of a childhood immunization programme, chickenpox in pregnancy can be avoided by
vaccination. Although two vaccines are licensed for use in the UK, (Royal College of
Obstetricians and Gynaecologists, 2010). They are not included in the standard childhood
immunization programmes nor routinely recommended for nonimmune adult women apart
from health care workers. VZV vaccine has been shown to be effective in preventing
infection following exposure and is most effective when given within three days of exposure
(Watson et al.2000). The Varivax vaccine is a live attenuated vaccine therefore some advise
avoidance of pregnancy for one month (Australian Technical Advisory Group on
Immunisation, 2008) or three months (Royal College of Obstetricians and Gynaecologists,
2010). Post-vaccination though no birth defects related to inadvertent vaccine exposure have
been reported (Shields et al, 2001). There is one case report of a VZV susceptible pregnant
woman, who following vaccination of her one year old child, developed chickenpox.
Transmission was confirmed using PCR. A therapeutic termination of pregnancy was
performed but no virus was isolated from fetal tissue (Salzman et al, 1997). Vaccinees who
develop chickenpox <42 days after vaccination are likely to represent wild virus infection
(Watson, 2002) but the disease is mild, infectivity is low, and there is little or no risk of
complications (Vazquez et al, 2005). Breast feeding is safe following postnatal vaccination
and post VZV vaccination breast milk samples have failed to detect any VZV DNA (Bohlke
et al,2003).
The purpose of this review is to know the correlation between varicella or chicken
pox and vaccinations.

METHOD
Study design
We administered a survey questionnaire to people who have had varicella. We
selected these study populations to establish a baseline of poeple knowledge, attitudes, and
practices related to varicella and its vaccination.
Survey design
We developed a 30-item of questionnaire, and interview with the poeple who have
had varicella. We obtained permission to use knowledge, attitude, and practice questions
from a previously validated instrument used in a study to investigate varicella. We developed
additional questions based on our review of the literature and current vaccination guidelines.
The survey questionnaire included four sections that addressed student: (1) knowledge of
pediatric and adult vaccination topics and guidelines, (2) attitudes towards vaccination
(including vaccination policies and the utility of vaccines), (3) practices (including personal
uptake of vaccines and immunization resources used to educate themselves and/or patients),
and (4) demographics (to characterize student exposure to preventive medicine practices).
Survey distribution
 We gave students a maximum of 30 minutes to complete the survey and instructed
them not to use web-based resources, books, reference materials, or other supplemental aids.
Data analysis
We performed all statistical analyses using SPSS 21.0™ (IBM; Chicago, IL). We
examined the responses to the open-ended questions using thematic content analysis. We
compute an overall frequency of each variable and then make in percentage. We take the
vaccine as a variable to be calculated its strength in affecting varicella.We used OR to count
the strength of vaccines in affecting varicella.

RESULT & DISCUSSION

Table 1. Distribution sample characteristics in terms of Frequency and percentage (N = 30)

NO CHARACTERISTIC VARIABLE FREQUENCY PERCENTAGE

14-16 5 16,6
1 Age in years 17-19 23 76
20-22 2 6,6
Male 10 33,3
2 Genders
Female 20 66,6
No education - -
Elementary school - -
3 Educational status Junior high school 1 3,3
Senior high school 4 13,3
College 23 76,6
Government employees - -
Policeman/military - -
Entrepreneur - -
4 Employment
House wife - -
Students 30 100
Etc. - -
Yes 16 53,3
5 Given the vaccine No 14 46,6

The below table 1 shows that majority of the sample 76% are in the age group of 17—
19 years , 16,6 % are in the age group of 14-16 years, and 6,6%. Majority of the respondents
(66,6%) are female. Last educational of the respondents (3,3%) are junior high school,
(13,3%) are senior high school,and 76,6% are college. Majority of the respondents (100%)
are students. That result is significant with some article journals.
Much of what is known about VZV transmission dynamics in the community comes
from outbreak investigations at elementary schools or day care centers. In these settings,
varicella attack rates among children who had previously received a single dose of varicella
vaccine ranged from 12%–42% (Miron et al, 2005). A recent report found that prior receipt
of a second dose of vaccine did not appreciably decrease the attack rate during a
schooloutbreak (Gould et al, 2009). In contrast, in an elementary school outbreak during
which the second dose of vaccine was given as an intervention for outbreak control, the
attack rate was reduced from 43% among children who had received only a single
vaccination to 5% among 2-dose recipients (Nguyen et al, 2010). Large-scale, school-based
varicella outbreaks such as these serve as important sentinel events but may not be
representative of the true burden and infectivity of VZV in the community. In the study by
Viner et al,. 80% of epidemiologically linked transmissions involved, <4 secondary cases
and, in the absence of a dedicated varicella surveillance system, would be unrecognized and
unreported.
Despite the continued documentation of outbreaks among immunized school children,
the varicella vaccine epitomizes a public health success story. In the prevaccine era, varicella
was an almost universal disease of childhood. After the widespread implementation of
pediatric vaccination in the United States, incidences of VZV-related infection,
hospitalization, and death have all markedly declined (Marin et al, 2008). In the present
study, 90% of children who developed secondary varicella had received $1 doses of vaccine
before the onset of infection, representing vaccine failures. However, even in these
breakthrough cases, the benefits of vaccination are evident. As has been reported elsewhere
(Chaves et al, 2005), >70% of breakthrough varicella cases had mild disease characterized
by, <50 skin lesions. Vaccinated varicella cases were associated with a significantly lower
proportion of secondary cases compared with unvaccinated cases, presumably related to
lower virus burden and shorter duration of viral shedding. Finally, there was a significant
decline in the incidence of allVZV-related infections in Philadelphia schools beginning in
2007 correlating with the recommendation for a second dose of vaccine for school aged
children. These ecological data are supported by a case control study reporting that the odds
of developing varicella were decreased 95% among children after receipt of a second dose of
varicellavaccine (Shapir, et al. 2011). Based on these results, it is anticipated that with
increasing 2-dose coverage, the rates of varicella among children will continue to decline.
Table 2. OR vaccine calculations.

Given the vaccine N

Yes 16 33
No 13 26
N 29 59
Odds 1,23
OR 1,056

Table 2 shows the results of OR calculations on the vaccine. The value of OR

indicated means that the person who has been given the vaccine is 1,056 times the varicella.
Thus, it can be said that those who do not go through the vaccine will have a greater chance
than those who have been vaccinated. These results are consistent with the pediatric journals
obtained, that the vaccine affects our immune immunity against varicella.

The most common adverse reactions following varicella vaccine are local reactions,
such as pain, soreness, erythema, and swelling. Based on information from the
manufacturer’s clinical trials of varicella vaccine, local reactions are reported by 19% of
children and by 24% of adolescents and adults (33% following the second dose). These local
adverse reactions are generally mild and self-limited. A varicella-like rash at injection site is
reported by 3% of children and by 1% of adolescents and adults following the second dose.
In both circumstances, a median of two lesions have been present. These lesions generally
occur within 2 weeks, and are most commonly maculopapular rather than vesicular. A
generalized varicella-like rash is reported by 4%–6% of recipients of varicella vaccine (1%
after the second dose in adolescents and adults), with an average of five lesions. Most of
these generalized rashes occur within 3 weeks and most are maculopapular.

Systemic reactions are not common. Fever within 42 days of vaccination is reported
by 15% of children and 10% of adolescents and adults. The majority of these episodes of
fever have been attributed to concurrent illness rather than to the vaccine.

Varicella vaccine is a live virus vaccine and may result in a latent infection, similar to
that caused by wild varicella virus. Consequently, zoster caused by the vaccine virus has been
reported, mostly among vaccinated children. Not all these cases have been confirmed as
having been caused by vaccine virus. The risk of zoster following vaccination appears to be
less than that following infection with wild-type virus. The majority of cases of zoster
following vaccine have been mild and have not been associated with complications such as
postherpetic neuralgia. (Davis et al, 2004).
CONCLUSION

There is have the correlation between varicella or chicken pox and vaccinations. The
value of OR indicated means that the person who has been given the vaccine is 1,056 times
the varicella. The risk of zoster following vaccination appears to be less than that following
infection with wild-type. So, knowledge of the vaccine should be more disseminated.

ACKNOWLEDGEMENT
Thank you for our lecturer of English for Biology State University of Malang , Mr. Dr. H.
Sueb, M. Kes for his help in this article.

REFERENCES
American Academy of Pediatrics. 2007. Committee on Infectious Diseases. Prevention of
varicella: recommendations for use of varicella vaccines in children, including a
recommendation for a routine 2- dose varicella immunization schedule.
Pediatrics;120:221.
Australian Technical Advisory Group on Immunisation. 2008. The Australian Immunisation
Handbook. 9. Canberra: Australian Government Department of Health and Ageing,
Office of Health Protection;9-4-2010Ref Type: Report.
Banz K, Wagenpfeil S, & Neiss A. 2003. The cost-effectiveness of routine childhood
varicella vaccination in Germany. Vaccine;21:1256–1267.
Boelle PY and Hanslik T. 2002. Varicella in non-immune persons: incidence, hospitalization
and mortality rates. Epidemiol Infect.;129:599– 606.
Bohlke K, Galil K, Jackson LA, Schmid DS, Starkovich P, & Loparev VN. 2003. Postpartum
varicella vaccination: is the vaccine virus excreted in breast milk? Obstet Gynecol;
102(5 Pt 1):970–977. [PubMed: 14672472].
Chaves SS, Zhang J, & Civen R.2008. Varicella disease among vaccinated persons: clinical
and epidemiological characteristics, 1997– 2005. J Infect Dis; 197:S127–31.
Davis MM, Patel MS, & Gebremariam A. 2004.Decline in varicellarelated hospitalizations
and expenditures for children and adults after introduction of varicella vaccine in the
United States. Pediatrics;114:786–92.
Dinas Kesehatan RI. 2016.
Dinas Kesehatan Propinsi Jawa Timur. 2016.
Galil K, Brown C, & Lin F. 2002. Hospitalizations for varicella in the United States, 1988 to
1999. Pediatr Infect Dis J;21:931–935.
Gould PL, Leung J, & Scott C.2009. An outbreak of varicella in elementary school children
with two-dose varicella vaccine recipients—Arkansas, 2006. Pediatr Infect Dis J ;
28:678–81.
Heininger U and Seward JF. 2006. Varicella. Lancet. 368:1365–1376.
Jean-Jasmin LM, Lynette SP, & Stefan M. 2004.Economic burden of varicella in Singapore–
a cost benefit estimate of implementation of aroutine varicella vaccination. Southeast
Asian J Trop Med PublicHealth;35:693–696.
Johnson DR, Nichol KL, & Lipczynski K.2008.Barriers to adult immunization. Am J Med
121: S28-35.
Justin Bendig and Fiona Sindall.2010. Case Report Chickenpox at Ninety Four: A Case for
Extending the Use of Varicella Vaccine in the UK. UK. Hindawi Publishing
Corporation Case Reports in Medicine Volume 2010, Article ID 561707, 3 pages
doi:10.1155/2010/561707.
Lindley MC, Lorick SA, Spinner JR, Krull AR, & Mootrey GT.2011. Student vaccination
requirements of U.S. health professional schools: a survey. Ann Intern Med 154: 391-
400.
Link-Gelles R, Chamberlain AT, Schulkin J, Ault K, & Whitney E.2012.Missed
opportunities: a national survey of obstetricians about attitudes on maternal and infant
immunization. Matern Child Health J 16: 1743-1747.
Marin M, Meissner HC, & Seward JF. 2008.Varicella prevention in the United States: a
review of successes and challenges. Pediatrics;122:e744–50.
Miron D, Lavi I, Kitov R, & Hendler A. 2005. Vaccine effectiveness and severity of varicella
among previously vaccinated children during outbreaks in day-care centers with low
vaccination coverage. Pediatr Infect Dis J; 24:233–6.
Nguyen MD, Perella D, Watson B, Marin M, Renwick M, & Spain CV.2010. Incremental
effectiveness of second dose varicella vaccination for outbreak control at an elementary
school in Philadelphia, Pennsylvania, 2006. Pediatr Infect Dis J; 29:685–9.
Padmavathi GV, Nagaraju B, Shampalatha SP, Nirmala M, Fareeda Begum, Susan TT, &
Pavani GV. 2013. Knowledge and Factors Influencing on Gastritis among Distant
Mode Learners of Various Universities at Selected Study Centers Around Bangalore
City With a View of Providing a Pamphlet. Sch. J. App. Med. Sci., 2013; 1(2):101-
11010.
Pelly LP, Pierrynowski Macdougall DM, Halperin BA, Strang RA, & Bowles SK.2010.The
Vaxed Project: an assessment of immunization education in Canadian health
professional programs.BMC Med Educ 10: 86.
Royal College of Obstetricians and Gynaecologists. 2010. Green-top Guideline No. 13.
London: Royal College of Obstetricians and Gynaecologists;. Chickenpox in
Pregnancy; p. 1-11.Ref Type:Report
Salzman MB, Sharrar RG, Steinberg S, & LaRussa P.1997.Transmission of varicella-vaccine
virus from a healthy 12-month-old child to his pregnant mother. J Pediatr; 131(1 Pt
1):151–154.[PubMed: 9255208]
ShapiroED,VazquezM, & EspositoD.2011.Effectiveness of 2 doses of varicella vaccine in
children. J Infect Dis; 203:312–15.
Shields KE, Galil K, Seward J, Sharrar RG, Cordero JF, & Slater E. 2001.Varicella vaccine
exposure during pregnancy: data from the first 5 years of the pregnancy registry.
Obstet Gynecol.; 98(1):14–19. [PubMed: 11430950]
Smailbegovic MS, Laing GJ, Bedford H.2003.Why do parents decide against immunization?
The effect of health beliefs and health professionals. Child Care Health Dev 29: 303-
311.
Vazquez M, & Shapiro ED. 2005.Varicella vaccine and infection with varicella-zoster virus.
N Engl J Med.; 352(5):439–440. [PubMed: 15689581]
Watson B. 2002.Varicella: a vaccine preventable disease?. J Infect.; 44(4):220–225.
[PubMed:12099727]
Watson B, Seward J, Yang A, Witte P, Lutz J, & Chan C. 2000.Postexposure effectiveness of
varicella vaccine. Pediatrics; 105(1 Pt 1):84–88. [PubMed: 10617709]
WHO. Varicella vaccines WHO position paper. Wkly Epidemiol Rec.1998;73:241–248.
Yawn BP, Yawn RA, & Lydick E. 1997. Community impact of childhood varicella
infections. J Pediatr;130:759–765.
ATTACHMENT