ae Wellington-Dufferin-Guelph Public Health -_ Public Health Report to: ‘Submitted by: Prepared b BOH Report ~ BH.OL.SEPT0413.R29 September 4,2013, Board of Health Dr. Nicola Mercer, Medical Officer of Health & CEO Janice Walters, Manager of Control of Infectious Diseases Diane Wallace, Supervisor of Control of Infectious Diseases Approved by: Rob Thompson, Director of Health Protection Subject: ‘THE CHANGING DEMOGRAPHIC OF VARICELLA-ZOSTER VIRUS EPIDEMIOLOGY RECOMMENDATION(S) (@) That the Board of Health receive this Report for information. ; MD, MBA, MPH, FRCPC ‘Medical Officer of Health & CEO etEXECUTIVE SUMMARY Varicella (chickenpox) is one of the most common human infections with close 10.95% of the ‘Canadian population demonstrating serologic evidence of infection by adulthood (2-5). The ‘varicella-zoster virus (VZV) isa highly contagious DNA virus, belongs to the herpes family and causes two distinct disease: chickenpox and shingles. Transmission occurs via the airborne route as well as through direct contact wit vesicular fluid. The primary infection is characterized initially by malaise and fever, followed by a prutitic rash that develops into crops of vesicles that crust over before healing. Typically the lesions occur in erops over 5-6 ays and are more abundant on the trunk, although they can sometimes be present on the scalp, mucous membranes of the mouth, respiratory tract, conjunctiva and rectal and vaginal ‘mucosa (I). The incubation period for varicella is 14-21 days, with the period of communicability as long as 5 days before onset of the rash and continues until all vesicles are rusted, usually about $ days aftr the onset of the rash (1). ‘Most infections are mild and self-limited. Prior tothe year 2000, there were over 2000 hospitalizations per year in Canada due tothe disease, with 5 to 10 deaths (2,5). The ‘majority of hospitalizations occured in previously ealthy children. In 2% to 10% of eases, complications occur, usually manifesting as cellulitis resulting from suprainfetion with bacteria (2). One of the most serious sequelae of chickenpox isthe development of invasive Streptococcus pyogenes (Group A Streptococcus, [iGAS)) infection, The financial burden tothe healthcare system is significant; an uncomplicated case of chickenpox is estimated 10 enst hetween $236.50 and $370.00 par ease, with complicated ‘cases having a cost estimate of between $7000.00 to $8398.00 per ease (7,8). In Ontario, from 1998-2004, an average of 18,089 cases of chickenpox was reported annually (1). ‘In 2004, a publicly funded varicella vaccine was introduced for 1 year old children and in 2005 for 5 year old children, throughout Canada, Since the introduction ofthe vaccine, ‘annual hospitalizations for treatment of varicella has dropped from 288 (1999 to 2004) to 114 (2005-2009) (10). Between 2007 and 2012, Wellington Dufferin Guelph Public Health (WDGPH) received the following numbers of Iaboratory-confirmed cases, 2007: 3 cases; 2008: 2 cases; 2009: 9 cases; 2010: 2 cases; 2011: 5 eases, 2012: 5 cases; 2013: 3 cases (as of June 17). Coincding with the drop in disease burden, the impact of the vaczne is also changing the VZV demographic (11). Although varicella is relatively uncommon in pregnant ‘women, in can result in significant fetal and maternal morbidity and morality (9). In ‘pregnant women who contrac varicella, 28% will have complications which carry an increased risk of mortality (9). In the absence of intervention, maternal varicella with onset S days before or 2 days after delivery is associated with severe disease in the newborn in 17% 10 30% of eases and carries an infant morality rate of 31% (9).The WDGPH unit has recently had « numberof challenging cases of varicella disease in clients who fall nto an older ‘demographic, including cases and exposures in pregnant women and newboms, OD BOR Repo SOT PagarBACKGROUND Effect of a Publiely-funded Immunization Program In 2010, Public Health Ontario (PHO) released the Ontario Burden of Infectious Disease ‘Study. In this report, the authors tate their data “provide a stati estimate of varicella zoster burden, but the epidemiology has been changing over time due to approval of varicella, vaccines in Canada in 1998 and the implementation of a publicly funded immunization rogram in Ontario in 2004” (11,12). Further, the PHO report documents that when vaccine ‘uptake by the population is poor, this has the potential to increase the burden of disease in the future in a variety of ways: ‘© the average age at infection may increase with an accompanying increase in disease severity ‘+ the increased age at infection may increase the number of congenital and neonatal ceases of VZV, and ‘+ the reduced incidence may increase the burden of zoster through reduced natural boosting ofthe population (11, 13). ‘The WDGPH Experience WDGPH receives sporadic cases of chickenpox, reported by hospital, clinics, daycares and schools on a routine basis. The entire period of communicabilty is reviewed and investigated to determine whether contact tracing needs tobe initiated. Uncomplicated cases from healthy children usually require minimal follow-up, wit cases investigated for any possible exposure tw highviak individuals, including neonates, progaaut woucu and insnunmpromised persons. In instances involving cases that have sought medical attention, the investigation is ‘often more complicated. Inthe past, exposures of large numbers of persons have oceurred in clinic waiting rooms, group home settings, hospital emergency rooms and other areas where people congregate. In situations where exposures have occurred in clinic or hospital waiting rooms, WDGPH works with the facility to obtain lists of people who may have shared airspace with te affected individual. As chickenpox isa disease spread by the airborne route transmission ean oceur between individuals gathered inthe same area, such as waiting rooms, public transportation or classrooms. High risk individuals who have been exposed to a suspected or confirmed case of chickenpox, may be referred to their family physician or ‘obstetrician for follow-up. In instances where there is risk to a neonate or prenatal cli the peripartum period, referrals may be made to hospital forthe administration of passive «antibodies (immunoglobulins) to prevent or meliorate the disease, ‘The Changing Demographic of Varicella Epidemiology ‘In Canada, surveillance data on varicella is avilable through the Canadian Notifiable Disease Surveillance System (CNDSS), The following table contains recent data on the incidence of varicella in Canada forthe five years before and after the introduction of the publicly funded vaccination programme (the year for which the most recent data is available) (0) iT BOR apoB SEPTATETable I- Incidence overtime (rate per 100,000), both sexes combined, by age in Canada 1999- 2008. Yar [ims [Tied [Sto [Wis [sw | 207 [5D [WwW WH tan _| yeas _|years_| yes | years | year eas | year 1999 | 30819 | Hos of | 10088 | 137.06 [ 2906 [1028 1363_[ am [235 2000 | 36438 | 12146 [ssa.77 [21425 [3165 [Ma [1597 [11.07 [316 2001 21602 [20099 [2833 [486 [76 [40s [267 —[-79) 3002 7332 | sreaa| ne [1875_[ 279 [93 La —[ 309 yo 76th Sone S10 oss [rat rs cs 2008 3072 | 3940 [394 — [221 7 aa 2006 1633 [493 47.6 [1s a 2007 1226 [ ras [4s [138 [9 [96 28 2008 1775 [ass7_69 [ust b7 Tiss 38 ‘Through all age groups, between 1999 and 2003 incidence decreased over time, with disease in younger populations decreasing at an increased rate over older populations (blue boxes). ‘The varicella vaccine was introduced in 2004 and the decrease in the incidence of disease in children from birth to 14 years of age was dramatic (red boxes). Children in the 5 to 9 years ‘of age group had the highest burden of disease (in bold type), however, from 2003 to 2004, the incidence decreased by over 92%, from a rate of 851.33 eases/100,000 to 66.55 ‘ases/100,000. Concerning from a public health perspective, over the same time period, 2004-2008, the decease in incidence for those 15 years of age and over is minimal (green ‘boxes). The largest decrease is seen in the 20 to 24 years of age group, with a 60% decrease, from a rate of 1.75 eases/100,000 to 0.7 eases/100,000. The incidence actualy increased in the 40 to 59 years of age group in the same time pesiod, with the renin wee groups displaying a 3% decrease (15 t019 years of age), 10% decrease (25 to 29 years of age) and 30% decrease (30 to 39 years of age). It is important to note thatthe lowest decline in incidence occurs in the age groups that bracket the child-bearing years for women, from, onset of menses to discontinuation of menses, approximately ages 15 through 50 years. As a secondary contributing factor to the changing demographic of varicella, data suggest ‘that people from the tropies are les likely to acquire immunity in childhood and therefore have higher rates of susceptibility to chickenpox as adults (10). Canada's new immigration rules introduced in 2012 and implemented in 2013, target people inthe 18-35 year age range, ‘which coincides well with a woman’s child-bearing years. The impact ofthe change in {favour of younger immigrants, some percentage of wino will have resided ina topical country, has yet to be discerned ‘Varicella in Pregnancy ‘Mortality rates ae higher in pregnant women than in non-pregnant adults. Most cases occur ‘when mothers are infected between 8 and 20 weeks gestation. The overall risk is small compared to other viruses during pregnancy and is approximately 2% if infected prior to 20 weeks and 196 if prior to 13 weeks. Characteristic findings of congenital varicella syndrome include: intrauterine growth esrition, ocular defets, limb abnormalities, central nervous system (CNS) abnormalities, and cicatricial skin lesion (13).‘Varicella in the Newborn [Newboms bom to mothers who are exposed to VZV or have clinical disease manifestations within two weeks of delivery are at greatest risk. Neonatal varicella i a serious disease with mortality rate of up to 30% (10). [If the mother develops chickenpox less than five days prior ta delivery there is insufficient time for development of matemal immunoglobulins (IgG) and passive t protection tothe fetus. Premature infants ae at increased risk of contract passive antibody transfer to the newborn declines with age and seronegatvity frequently ‘occurs in infants older than two months of age (15). ‘The clinical pictur of neonatal varicella is variable, ranging ftom mild chickenpox-like symptoms to disseminated infection ‘Management of Exposures ‘The specific intervention depends upon the timing of exposure, the mother's serological status and gestational age, VZIG should be offered to newborns that have had a significant ‘exposure within the first two weeks of life whose mothers do not have evidence of immunity ‘VIG, when indicated, should be offered as soon as possible, ideally within 96 hours, although some experts extend the window upto 10 days (14). For immunocompromised infants, physicians should seek paediatric consultation prior fo VZIG administration. ANALYSIS/RATIONALE, ‘Based on the recent case of chickenpox in a pregnant woman, a Physician Advisory was released to all physicians within the WDGHU borders on July 8, 2013. The advisory ‘encouraged primary care providers to document the antenatal varicella immunity status ofall pregnant women and to provide varicella vaccination to all non-immune individuals as part ‘of pre-pregnaney and postpartum care. ‘The Ontario Hospital Association (OHA) and the Ontario Medical Association (OMA) reviewed and revised the VaricellaZoster (Chickenpox/Shingles) Surveillance Protocol for Ontario Hospitals in May, 2012 (Appendix B). The recommendation for replacement of Doealth care workers (HCWS) states: At the time of hiring or placing, occupational health must ascertain the HCW's immune status to varicella, Evidence of immunity includes: ‘documentation of receipt of 2 doses of varicella vaccine 4 laboratory evidence of immunity ‘diagnosis or verification ofa history of typical varicella (chickenpox) by a health eare provider ‘diagnosis or verification ofa history of herpes zoster (shingles) by a health care provider.must be noted that persons witha self-provided history of chickenpox or zoster should no Tonger be assumed to be immune (16). ‘The Provincial Infectious Diseases Advisory Committee (PIDAC) recommends in the Infection Prevention and Control for Clinical Office Practice Best Practice draft document, the following: taf should know their immunization status and have their immunizations upto date Immunizations appropriate for health care providers include: ‘© annual influenza vaccine ‘+ measles, mumps, rubella (MMR) vaccine(¢wo doses) or serologic documentation of immunity varicella vaccine(¢wo doses) or serologic documentation of immunity hepatitis B vaccine (complete series) and serologic confirmation of immunity for stafT ‘who may be exposed to blood, body fluids or contaminated sharps in their work ‘+ tetanus vaccine (every 10 years) ‘+ acellular pertussis vaccine (one dose Tap) Due to the nature ofthe work of HCWs atthe WDGPH unit, and based on the draft PIDAC document, WDGPH will revise the eurent immuni i ‘OMA and PIDAC recommendations. ONTARIO PUBLIC HEALTH STANDARD ‘An operational responsibility listed in the Jstinaional/ Facility Outbreak Prevention ‘and Control Protocol (2008), is that the board of health shall assist institutionsaclitis in the review and revision, as needed, of ther existing infection prevention and control policies and procedures and shall provide public health recommendations for outbreak prevention and management, Asspecific requirement of the Infectious Diseases Program Standard is outined in Requirement #5: ‘The board of health shall participate on committes, advisory bodies, or networks that address infection prevention and control practices of, but not li LTCHs, which shall include consul + Infection prevention and control policies and procedures; + Surveillance systems for infectious diseases of public health importance; and + Response plans to cases/outbreaks of infectious diseases of public health importance. Another specifi requirement ofthe Infectious Diseases Program Standard is ‘outlined in Requirement #8: ‘The board of health shall provide public health management of cases and outbreaks to ‘minimize the public health risk in aveordance with the Infectious Diseases Protocol, 2008 (or as current); the Istiuional/Facitity Outbreak Prevention and Control Protocol, 2008 (or 8s current); and provincial and national protocols on best practice, BOR Repo BHT SEPT PetarWDGPH STRATEGIC COMMITMENT Community and Partner Relationships We will work with our communities and key stakeholders and consider their perspectives in cur decision-making processes. We will idemtify important partnerships and collaborate to improve the health in our communities Evidence-Informed Practices ‘We will use the best available information to guide our decisions regarding which programs and services to provide, the manner in which we provide them, and the allocation of our resources in support of these decisions. APPENDICES NONE. REFERENCES 1, Infectious Diseases Protocol. 2009. Appendix A. Disease-Specific Chapters CChiekenpox (Varicella) 2. Sweet, LP. Gallant, M. Morris and S.A. Halperin. 2003, Canada’s first universal varicella immunization program: Lessons fom Prince Edward Island, Can. J. Infect, Di, 1441-44, 3. Law, B.J. 2000. Towards universal childhood immunization against chickenpox? Pediat. Child Health. 5:262-6 4. Ratnam, S. 2000. Varicella susceptibility in a Canadian population. Can J. Infect. Dis. 11249-33, 5. National Advisory Committee on Immunization. 1999, Statement on recommended use of varicella virus vaccine. Can. Commun. Dis. Rep. 25(ACS-a):1- 16. 6. Laupland, K.B., HD Davies, D.E. Low, et al. 2002, Invasive group A streptococcal disease in children and association with varicella-zoster virus infections. < Version current December 18, 2002. 7. Law, B.C. Fitzsimon, L. Ford-Jones, etal, 1999. Cost of chickenpox in Canada: ar I. Cost of uncomplicated cases. Paediatrics. 104:106 8. Law, B.C. Fitzsimon, L. Ford-Jones, J. MeCormick, M. Riviere, members of ‘the Immunization Monitoring Program-Active (IMPACT). 1999. Cost of chickenpox in Canada: Part Il Cost of complicated eases and total economic impact. 104:7-14 9. Ontatio Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committe. Best Practices for Infection Prevention and Control in Perinatology. Toronto, ON: Queen’s Printer for Ontario; 2012, 10, Public Health Ageney of Canada. htp://www phae-aspe ge. ca/id-milaz-index- phpivaricella, OT DO Rep HT STS Peeve11. Kwong, JC, NS. Croweroft, M.A. Campitelli MA, S. Ratnasingham, N. Daneman, S.L. Deeks, D.G. Manuel. Ontario Burden of Infectious Disease Study ‘Advisory Group; Ontario Burden of Infectious Disease Study (ONBOIDS): An ‘OAHPP/ICES Report. Toronto: Ontario Agency for Health Protection and Promotion, Institute for Clinial Evaluative Sciences; 2010. 12. Kwong J.C., P. Tanuseputro, B. Zagorski, R. Moineddin, K.J. Chan. Impact of varicella vaccination on health cate outcomes in Ontario, Canada: effect ofa publicly funded program? Vaccine 2008; 26(47):6006-12. 13. Brisson M, W. J. Edmunds, N.J. Gay, E. Miller. Varicella vaccine and shingles, JAMA 2002; 257(17;2211-2 14. Shrim, A., G. Koren, M. Yudin, D. Farine, Management of varicella infection (chickenpox) in pregnaney. J. Ostet. Gynnecol. Can, 2012; 34(3):287-292. 15. Speer, ME, Varicellaoster infection in the newborn. ww upiodate.com. 2013, 16. Ontario Hospital Association and the Ontario Medical Association, the Joint Communicable Diseases Surveillance Protocols Commitee in collaboration with the Ministry of Health and Long-Term Care. Varicella/zoster (chickenpox/shingles) surveillance protocol for Ontario hospitals. May, 2012. 17. Ontario Agency for Health Protection and Promotion, Provincial Infectious Diseases Advisory Committe. Infection Prevention and Control for Clinieal Office Practice. ‘Toronto, ON: Queen's Printer for Ontario; December 2012. matte