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Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
CHICKENPOX
1. Agent: Varicella-zoster virus (VZV), a member skin scarring, localized muscular atrophy,
of the herpesvirus family. encephalitis, cortical atrophy, chorioretin-
itis, and microcephaly.
2. Identification:
Perinatal Varicella: Perinatal varicella
a. Symptoms: occurs within first 10 days of life from a
mother infected from 5 days before to 2
Varicella (chickenpox): Varicella, the days after delivery; it has a 30% fatality
primary infection with VZV is an acute, rate. The severity of disease results from
generalized disease that occurs most fetal exposure to the virus without the
commonly in children and is characterized benefit of passive maternal antibody.
by a maculopapular rash (few hours), then Postnatally acquired varicella occurs after
vesicular rash (3-4 days), often 10 days of age and is rarely fatal.
accompanied by fever. Lesions are
typically more abundant on trunk; but b. Differential Diagnosis: Generalized
sometimes present on scalp, mucous herpes simplex, impetigo, drug rash,
membranes of mouth and upper respiratory secondary syphilis, smallpox, and other
tract. Lesions commonly occur in viral exanthems. See EXANTHEMS—
successive crops, with several stages of DIFFERENTIAL DIAGNOSIS in Appendix
maturity present at the same time. Lesions A.
are discrete, scattered and pruritic. Mild,
atypical and inapparent infections also c. Diagnosis: Serum antibody studies, direct
occur. “Breakthrough” chickenpox which smear and culture of lesion fluid.
can be seen in previously vaccinated
persons, is usually a mild illness 3. Incubation: Usually 14-16 days but can be as
characterized by few lesions, most of which short as 10 or as long as 21 days. May be
are papular or papulovesicular. The most prolonged after receipt of varicella zoster
common complications of varicella are immune globulin (VariZIG) and in the
secondary bacterial infection of skin immunodeficient.
lesions, dehydration, pneumonia, and
central nervous system involvement. 4. Reservoir: Human.
Hospitalization occurs in ~3 per 1,000
cases. The overall death rate is ~1 per 5. Source: Mucous membranes and vesicles.
60,000 cases. Complications increase with
age; death rates as high as 25 per 100,000 6. Transmission: Direct contact with patient with
have been reported for persons in the 30- varicella or zoster; droplet or airborne spread
49 age group. of vesicle fluid (chickenpox and zoster) or
secretions of the respiratory tract (chickenpox);
Zoster (herpes zoster, shingles): Zoster indirectly by contaminated fomites. Scabs are
occurs more often in adults or not infectious.
immunocompromised persons and results
from reactivation of latent VZV in sensory 7. Communicability: Communicable 5 days
ganglia. Grouped vesicular lesions appear before eruption (especially 1-2 days before
unilaterally in the distribution of 1 to 3 eruption) and for up to 5 days after onset of
sensory dermatomes. Severe pain and lesions. Communicability may be prolonged in
paresthesia are common. persons with altered immunity.
Congenital Varicella Syndrome: Primary 8. Specific Treatment:
varicella infection in the first 20 weeks of
gestation is occasionally associated with For cases: Acyclovir (IV) in susceptible
abnormalities in the newborn that include immunocompromised persons, when
low birth weight, limb hypoplasia, cicatricial administered within 24 hours of rash onset,
PART IV: Acute Communicable Diseases
CHICKENPOX — page 1Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
has been effective in reducing morbidity and Immunization Program will file: VARICELLA
mortality associated with varicella. The FDA (CHICKENPOX) HOSPITALIZED CASE
has licensed oral acyclovir for varicella in REPORT (CDPH 8299).
otherwise healthy children. The American 5. Epidemiologic Data:
Academy of Pediatrics considers the use of
oral acyclovir appropriate in otherwise healthy a. Exposure to known case.
persons at increased risk of moderate to b. History of either varicella or shingles
severe varicella, such as those older than 12 implies immunity from reinfection.
years, those with chronic skin or pulmonary
disorders, those receiving chronic salicylate c. Lack of varicella history is not proof of
therapy or short, intermittent or aerosolized susceptibility. Obtain serologic tests to
corticosteroids or in secondary case-patients determine immune status if indicated.
that live in the households of infected children.
CONTROL OF CASE, CONTACTS & CARRIERS
9. Immunity: Infection confers long immunity;
second attacks of chickenpox can occur. Routine investigation of individual cases of
chickenpox or shingles is not required.
REPORTING PROCEDURES
CASE:
1. Outbreaks associated with an acute health
care facility: report immediately by telephone 1. Chickenpox (Varicella): Avoid contact with
(Title 17, Section 2500, California Code of immunologically compromised persons.
Regulations). Exclude from school or work until the 6th day
after onset of rash, or sooner if all lesions are
Report Form: CD OUTBREAK dry.
INVESTIGATION ACUTE HEALTH CARE
FACILITY (HOSPITAL) (H-1165AHCF) 2. Zoster (Shingles): Avoid all contact with
immunocompromised persons. Case may work
2. Outbreaks associated with a sub-acute health with immunocompetent persons as long as all
care facility: report immediately by telephone lesions are covered.
(Title 17, Section 2500, California Code of
Regulations). CONTACTS:
Report Form: CD OUTBREAK Note: The following guidelines apply mainly to
INVESTIGATION SUB-ACUTE HEALTH chickenpox contacts—contact to a shingles case
CARE FACILITY INVESTIGATION (H-1164- is defined as direct contact with active lesions.
SubAcute).
1. Passive Immunization with VariZIG: Effective
3. Fatal cases: report immediately by telephone in preventing or modifying disease if given
to Immunization Program. within 10 days of first exposure to the case
during case’s period of communicability.
Immunization Program will file: VARICELLA Immunologically normal adults and
DEATH INVESTIGATION WORKSHEET and adolescents should be evaluated on an
must notify the State Division of individual basis. Serologic determination of
Communicable Disease Control immediately. immune status is advised. Candidates for
See Instructions for the Varicella Death VariZIG include:
Investigation Worksheet.
a. Immunocompromised, susceptible children.
4. Hospitalized cases (not cases of herpes
zoster/shingles): report within 7 calendar days b. Susceptible pregnant women. Serologic
from time of identification by mail, telephone, determination of immune status is advised.
or electronic report.
c. Newborn infant of a mother who had onset
of chickenpox within 5 days before delivery
to 48 hours after delivery.
PART IV: Acute Communicable Diseases
CHICKENPOX — page 2Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
d. Hospitalized premature infant (>28 week a. Interview exposed patients and staff about
gestation) whose mother has no history of prior varicella disease to determine
chickenpox or serologic evidence of susceptibility. See above.
immunity. b. Susceptible exposed patients should be
e. Hospitalized premature infants (Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
varicella vaccine is not contraindicated be
2. Identify persons that have had close contact vaccinated as soon as possible (includes a
with the case or cases during the time period second vaccination for children who did not
of two days before, to five days after case had receive the second dose of varicella vaccine —
rash onset. (Close contact is defined as direct see item 2 in “CONTACTS” section of this
physical or face-to-face contact, or one or document). The letter should also inform all
more hours of room contact with an infectious high-risk persons to consult with their health
person.) care provider about the chickenpox exposure
(pregnant women should inform their prenatal
3. Identify susceptible persons among the close care provider as soon as possible). Based on
contacts. (Persons who have a reliable history patterns of transmission, it may only be
of varicella disease or a documented history of necessary to notify parents and staff of
vaccination or serological evidence of varicella children in the same classroom where the
are all considered immune.) Also, identify exposure occurred; however, in other
susceptible close contacts that are at high risk instances it may also be reasonable to notify
for serious disease or complications if they get persons in groups such as the band or sports
varicella and recommend VariZIG for these team with which the case participates. If there
persons if it can be given within 10 days of first is documented transmission among several
exposure to the varicella case. (For definition grade levels, it may even be necessary to
of high-risk, see OUTBREAK notify the entire school. Templates of
INVESTIGATION section and item 5 under notification letters regarding exposures (for
PREVENTION-EDUCATION section of this schools or other facilities) are available
document.) from the LACIP.
4. For grades where students are of the age to 6. District public health nursing should continue
have been covered by the California school to follow the outbreak and provide weekly
varicella vaccination entry requirement that updates to LACIP surveillance staff until there
was implemented on July 1, 2001 and after have been no new cases for 21 days from the
consultation with Los Angeles County last communicable day of the last case. Notify
Immunization Program (LACIP) surveillance LACIP surveillance staff by phone when the
staff, advise the school to exclude all un- outbreak has been closed.
vaccinated children who refuse or are unable
for medical reasons to be vaccinated against 7. When the outbreak has been closed, complete
varicella. These students should be excluded the outbreak investigation form VARICELLA
from the start of the outbreak for up to 21 days (CHICKENPOX) HOSPITALIZED CASE
after the onset of the last case. (Exclude all REPORT (CDPH 8299), obtain necessary
high-risk susceptible persons, regardless of review and approval by SPA medical director,
varicella school entry requirement applicability and forward to the Morbidity Central Reporting
as soon as a single probable or confirmed Unit.
case of varicella has been identified.)
Previously unvaccinated persons who are 8. District public health nursing should notify the
vaccinated during an outbreak may return to LACIP surveillance staff of any outbreak
school two weeks after receipt of one dose of reports or 1-2 cases among high risk
chickenpox vaccine, as long as they have not populations that may have been directly
become ill with chickenpox as a result of the relayed to the district by the facility, rather than
exposure. Such students would still need to through LACIP.
receive the second dose of vaccine in order to
be in compliance with current varicella vaccine Note: For outbreaks involving Los Angeles Unified
recommendations. School District (LAUSD) schools, work with the
LAUSD nursing services office when initiating the
5. As soon as an outbreak has been identified, investigation and when conducting follow-up
advise the school to send out notification activities.
letters to parents and staff informing them
about the outbreak. The letter should
recommend that susceptible persons for whom
PART IV: Acute Communicable Diseases
CHICKENPOX — page 4Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
PREVENTION-EDUCATION 1. Serology for diagnosis: Paired sera required
(IgG).
1. Children entering kindergarten, as well as
children 18 months and older entering or Note: Testing for IgM antibody is not indicated
already in childcare are required to show proof since commercially available methods lack
of vaccination or physician documentation of sensitivity and specificity.
prior varicella disease, as of July 1, 2001.
Container: VR SEROLOGY—contains a
2. Keep fingernails short and control scratching of serum separator tube (SST, a red-gray top
lesions. vacutainer tube).
3. Alert patient to possible complications: viral Laboratory Form: Test Requisition and
pneumonia, encephalitis, secondary infections, Report Form H-3021
Reye syndrome.
Examination Requested: VZV Serology.
4. Children with varicella should not receive
aspirin or medication containing salicylate, Material: Whole clotted blood.
which is associated with development of Reye
syndrome. Amount: 8-10 ml.
5. Greatest risk for complications is for Storage: Refrigerate.
immunocompromised persons (e.g., those with
leukemia, cancer, HIV/AIDS, etc.), as well as Remarks: Collect first blood specimen as early
those on steroids or other immunosuppressive as possible. Collect the second approximately
drugs. 2 weeks after the first. Send each specimen as
it is collected. Do not store.
6. Disinfect fomites soiled with discharges of
nose, throat, and lesions. 2. Serology to Determine Immunity Status:
Submit single blood specimen as outlined
7. VZV vaccine was licensed in 1995 in the USA above for IgG testing.
for use in healthy children (>12 months) and
most adults. This vaccine should not be used 3. Microscopy (Smear): When doing smear of
to immunize women who are pregnant or who lesion(s), collect swab for culture at the same
intend to become pregnant within one month. If time.
a pregnant woman is inadvertently immunized
call the Varicella Vaccination in Pregnancy Container: Two clean slides in a holder.
registry (1-800-986-8999).
Laboratory Form: Test Requisition and
DIAGNOSTIC PROCEDURES Report Form H-3021
Laboratory diagnosis of varicella is not routinely Examination Requested: VZV DFA.
required. However, with the decreased incidence
of varicella as a result of widespread vaccination, Material: Cellular material from base of
it should be considered in confirming outbreaks, lesions. Use sterile cotton swab (viral
especially if some of the cases have previously culturette) to break open early-stage vesicles
been vaccinated and are experiencing (before crusting state), absorb fluid, and
breakthrough disease. In addition, hospitalized scrape cells from the base of the lesion.
and fatal varicella cases must be confirmed so as Spread material evenly onto clean slides in
to rule out the rare possibility of smallpox; see circular areas about the size of a dime. Make
chapter on SMALLPOX. Serological testing is at least 1 slide with 2 smears—2 slides if
helpful in confirming current or past disease, or possible. Air-dry and submit in closed slide
susceptibility to future disease. Clinical and container, then place swab back into culturette
epidemiological history is required to aid the for culture (see below).
laboratory in test selections.
Storage: Ambient temperature.
PART IV: Acute Communicable Diseases
CHICKENPOX — page 5Acute Communicable Disease Control Manual (B-73)
REVISION—MARCH 2019
Material: Fluid and cellular material from early-
4. Culture: stage lesion. Collect vesicular fluid in capillary
tube and place in holder or collect fluid and
Container: Viral culturette or capillary tube cellular material with culturette swab as above
with holder. for smears and place swab back into the
culturette transport tube.
Laboratory Form: Test Requisition and
Report Form H-3021 Storage: Keep refrigerated at 4oC and deliver
to the Virus Laboratory within 72 hours. Do not
Examination Requested: VZV Culture. freeze any specimen when the clinical
background suggests VZV, CMV, or RSV.
PART IV: Acute Communicable Diseases
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