What Is Chickenpox?

Also known as varicella, chickenpox is a viral infection characterized by it’s eponymous blister-like pustule skin rash.

Like the millions and millions of people born before 1996–when the vaccine was introduced–I had chickenpox. One morning before school I felt a hard little scab on my abdomen, and went and showed my mom. Casually, she said I was staying home. Eventually, I had maybe about 20-40 crusty blisters in all–I really don’t remember the number. But I do remember the itchiness, the Calamine lotion, and the baths, and other than that it was uneventful. No secondary infections, nothing in my eyes, maybe only a few on my face. After all is said and done, I have a little pock mark in the cleavage of one of my breasts–a tiny reminder I had and survived chickenpox.

I know everyone’s experience is different. By that token, we cannot pretend that a disease is more serious than it is simply because it can be dangerous for a small minority, yet uneventful for most. Likewise, a vaccine can be very dangerous for a small minority (whom we should also care about since we are using the idea of protecting a small minority to mandate universal vaccination, right?)

Bottom line, everyone, everyone, EVERYONE deserves to make their own individual health decisions and that shouldn’t be a problem because if vaccines work, then they work! You should have nothing to worry about.

In the early 1990s, nearly every child would get chickenpox. There would be about 4 million cases a year, and around 100 deaths mostly due to secondary complications and exacerbated by administration of incorrect medications which make the prognosis worse, ie. aspirin, benadryl, ibuprofen, etc.

The vaccine has changed the landscape of how we view chickenpox. Now that it’s “vaccine-preventable” it has become a more serious illness. But some places, like the UK, had never adopted universal chickenpox vaccination–until just last year they began talks of adding it to the routine schedule. In other countries with notoriously low infant and child mortality rates, such as Japan, chickenpox vaccination had been part of ‘voluntary’ immunizations, with only about 20-30% of children vaccinated against the virus. Japan only recently added varicella vaccine to its routine schedule in 2014.

Signs and Symptoms

Chickenpox is known for it’s itchy, blister like rash.

The rash often first appears on the chest, back and face, and can spread to the entire body.

The rash appears 10-21 days after exposure to the virus.

Viral rashes are the immune system’s method of clearing the infection or ridding itself of the virus. Chickenpox is a herpesvirus, so similar to other herpesviruses, after a chickenpox infection, varicella lies dormant (inactive) in the body, but can reactivate later in life as shingles.

Other signs and symptoms:

• Fever
• Loss of appetite
• Headace
• Tiredness and a general feeling of being unwell

Once the chickenpox rash appears, it can go through three phases:

• Raised pink or red bumps (papules), which break out over several days
• Small fluid-filled blisters (vesicles), which form in about one day and then break and leak
• Crusts and scabs, which cover the broken blisters and take several more days to heal

Contagiousness

You can spread the virus to other people for up to 48 hours before the rash appears, and until all blisters have broken open and crusted over.

Severity

The disease is generally mild in healthy children. In severe cases, the rash can cover the entire body, and lesions may form in the throat, eyes, and mucous membranes of the urethra, anus and vagina.

Complications of chickenpox include secondary bacterial infections, Reyes Syndrome, complications of use of antipyretics and antihistamines, or immunocompetence of the patient.

Here is a MMWR (the CDC) describing 3 varicella-related deaths among children in 1997: child 1: was given acetaminophen and diphenhydramine (benadryl) and he rapidly deteriorated. (Here is a case report that describes the toxicity of benadryl in children with chickenpox: “Diphenhydramine toxicity in three children with varicella-zoster infection.“) Child 2: was treated with antipyretic and antipruritic medications, developed a strep A infection, which entered his blood and his death was attributed to GAS (group A strep) septicemia, pneumonia, and pleural effusion, complicating varicella infection. Child 3: had chickenpox then developed cellulitis of the left foot, diagnosed with sepsis, possible viral meningoencephalitis, and mild pleural effusion. A cerebrospinal fluid examination revealed lymphocytic pleocytosis, and blood and urine cultures grew penicillin-resistant Staphylococcus aureus, and eventually bacterial endocarditis, etc. 

Dormancy / Latency

Like other herpesviruses, after a chickenpox infection, the varicella zoster virus lies dormant (inactive) in the human ganglia (trigeminal and dorsal root ganglia), but can reactivate later in life as shingles. Because the vaccine used to prevent chickenpox uses a live virus, the vaccine can cause the same latency and later reactivation of shingles.

“After primary infection, the virus remains latent in sensory ganglia, and reactivates upon weakening of the cellular immune system due to various conditions, erupting from sensory neurons and infecting the corresponding skin tissue.

The current varicella vaccine (v-Oka) is highly attenuated in the skin, yet retains its neurovirulence and may reactivate and damage sensory neurons. The reactivation is sometimes associated with postherpetic neuralgia (PHN), a severe pain along the affected sensory nerves that can linger for years, even after the herpetic rash resolves. In addition to the older population that develops a secondary infection resulting in herpes zoster, childhood breakthrough herpes zoster affects a small population of vaccinated children. There is a great need for a neuro-attenuated vaccine that would prevent not only the varicella manifestation, but, more importantly, any establishment of latency, and therefore herpes zoster. “

Interestingly, it appears that even wild-type varicella zoster virus can still become dormant or latent in vaccinated children, despite vaccination. In other words, the vaccine does not prevent the latency of the wild-type virus, though it may suppress the body’s response of rash:

“Despite vaccination, varicella-zoster virus (VZV) remains an important pathogen. We investigated VZV latency in autopsy specimens from vaccinees, in gastrointestinal tissue removed surgically, and in a guinea pig model. We propose that retrograde transport from infected skin and viremia deliver VZV to neurons in which it becomes latent. Wild type (WT) VZV was found to be latent in many ganglia of vaccinated children with no history of varicella, suggesting that subclinical infection with WT-VZV occurs with subsequent viremic dissemination. The 30% to 40% rate of WT-VZV zoster reported in vaccinees and occasional trigeminal zoster due to vaccine type VZV (vOka) are consistent with viremic delivery of VZV to multiple ganglia. “

“The results of our study of autopsied children were surprising, not only in that many ganglia on both sides of the body were found to contain latent VZV, but also because the virus was overwhelmingly WT, despite vaccination and the absence of a history of varicella. These observations suggest that although varicella vaccine may successfully prevent clinical varicella, it does not necessarily prevent subclinical infection or superinfection of individuals with WT VZV or the ability of WT VZV to establish latency.” 

Medical Contraindications

• NSAIDs (non-steroidal anti-inflammatory drugs) should be avoided at all costs. Using ibuprofen with chickenpox can result in life-threatening bacterial skin infections.
• The use of aspirin in children with chickenpox has been associated with Reye’s syndrome, a severe disease that affects the liver and brain and can cause death.
• Tylenol (acetaminophen) use during chickenpox does not alleviate symptoms in children with varicella and may prolong illness.

Treatment

• Calamine lotion contains skin-soothing properties, including zinc oxide. Calamine is a historic name for an ore of zinc. Using a clean finger or cotton swab, dab or spread calamine lotion on itchy skin areas. Note that you shouldn’t use calamine lotion on or around chickenpox on your eyes.
• Alternately, you can make your own calamine lotion: 1 tablespoon sea salt, 1 tablespoon baking soda, 1 tablespoon bentonite clay or zinc oxide, plus enough water or witch hazel to form a paste. Add a few drops of lavender, chamomile, and peppermint essential oils.
• L-Lysine is an antiviral support.
• Draw a cool bath with baking soda, uncooked oatmeal, colloidal oatmeal, or chamomile flowers / tea to help relieve some of the itching. 
• Keep fingernails trimmed or wear mittens to prevent or minimize itching.
• If you do scratch a blister by accident, wash your hands with soap and water for at least 20 seconds.
• Distraction is the secret to so many things. Play games, watch movies, reading, play chess or put a puzzle together. Viral illnesses just take time, the body knows what it’s doing.

It appears that chickenpox may date back to the ancient Greeks. They called the disease ‘zoster’ after the word for girdle or belt, which is often where the rash first appears.

The disease is caused by the varicella zoster virus (VZV) that belongs to the herpes virus family. After the initial infection, the virus can go latent in cranial nerve and dorsal root ganglia and may reactivate years later during times of stress or sickness as herpes zoster, aka Shingles.

Like most of the common childhood diseases, chickenpox was brought by European explorers and settlers to North America in the 15th century, and spread easily among the Native Americans who had not encountered this virus before.

Before the 18th century most blistery skin rash illnesses were grouped together and not differentiated with certainty. Smallpox, chickenpox and syphilis could have been confused for one another.

For many decades, there have been observations that people with a history of febrile illnesses have a reduced risk for certain cancers. In other cases, children with leukemia went into remission during a chickenpox infection. What could be happening in these instances? Could there be an unknown or unidentified benefit to viral infections?

A 2016 case control study, “History of chickenpox in glioma risk: a report from the glioma international case–control study (GICC)” found that:

In our study, a positive history of chickenpox was associated with a 21% lower glioma risk, adjusting for age and sex. The protective effect of chickenpox was stronger for high‐grade glioma, particularly among those under age 40. Our findings, which represent the results of the largest study to date on this topic, confirm the inverse associations previously reported in the literature on VZV and glioma.

Here is a case report that describes a 2.5 year old boy who has a spontaneous partial recovery of leukemia after a chickenpox infection. Spontaneous remissions of cancer during infection have been noted since the 1950s, though the children in this case report (at least for varicella) all went on to die, and only had remission during active infection. I wonder though, if it’s a function of the virus itself, or the immune system being directed toward a different pathogen, that explains the remission. Immune mechanisms are involved in targeting cancer. For example, CD8 cytotoxic T lymphocytes are the immune cells that can kill cancer cells, but also get exhausted in the tumor microenvironment.

Breastfeeding

If a mother has contracted chickenpox naturally, her breastmilk contains antibodies against chickenpox which provides passive immunity to her infants and nursing children.

The passive immunity may avoid or spare breastfed child’s symptoms of chickenpox.

A study examined the course of disease in a 9-year-old boy and his father who consumed frozen breast milk:

The boy presented with a crusted varicella rash. The medical history revealed premature cessation of the typical varicella rash on day 3. It was coincidental with a supply of frozen human milk by his mother. Next, the father (41 years old) of this patient contracted chickenpox: he was on frozen breast milk from day 2, and no new pox emerged thereafter.

Conclusion:

The rash spread and numbered 50 to 150 lesions on day 2. Instead, the typical rash was expected to appear in three successive crops of lesions throughout the first week. The disease usually numbers approximately 250-500 lesions in unvaccinated healthy persons. Frozen breast milk may shorten chickenpox duration.

The nice thing about breastmilk is there are no side effects!

Vaccination

There are several different varicella vaccines:

Varivax is a live varicella virus vaccine given subcutaneously. The first dose is administered at 12-15 months of age, second dose 4-6 years of age.

• Varivax package insert (frozen)
• Varivax package insert (refrigerated)

ProQuad is a 4-in-1 vaccine against measles, mumps, rubella and varicella virus. It is given subcutaneously, at 12-15 months of age, and again at 4 to 6 years.

• ProQuad package insert

Description:

Varivax is a preparation of the Oka/Merck strain of live, attenuated varicella virus. The virus was initially obtained from a child with wild-type varicella, then introduced into human embryonic lung cell cultures, adapted to and propagated in embryonic guinea pig cell cultures and finally propagated in human diploid cell cultures (WI-38). Further passage of the virus for varicella vaccine was performed at Merck Research Laboratories (MRL) in human diploid cell cultures (MRC-5) that were free of adventitious agents. This live, attenuated varicella vaccine is a lyophilized preparation containing sucrose, phosphate, glutamate, processed gelatin, and urea as stabilizers.

Ingredients:

Refrigerator-stable VARIVAX, when reconstituted as directed, is a sterile preparation for subcutaneous injection. Each approximately 0.5-mL dose contains a minimum of 1350 plaque-forming units (PFU) of Oka/Merck varicella virus when reconstituted and stored at room temperature for a maximum of 30 minutes. Each 0.5-mL dose also contains approximately 18 mg of sucrose, 8.9 mg hydrolyzed gelatin, 3.6 mg of urea, 2.3 mg of sodium chloride, 0.36 mg of monosodium L-glutamate, 0.33 mg of sodium phosphate dibasic, 57 mcg of potassium phosphate monobasic, and 57 mcg of potassium chloride. The product also contains residual components of MRC-5 cells including DNA and protein and trace quantities of neomycin and bovine calf serum from MRC-5 culture media. The product contains no preservative.

Frozen: VARIVAX, when reconstituted as directed, is a sterile preparation for subcutaneous injection. Each approximately 0.5-mL dose contains a minimum of 1350 plaque-forming units (PFU) of Oka/Merck varicella virus when reconstituted and stored at room temperature for a maximum of 30 minutes. Each 0.5-mL dose also contains approximately 25 mg of sucrose, 12.5 mg hydrolyzed gelatin, 3.2 mg of sodium chloride, 0.5 mg of monosodium L-glutamate, 0.45 mg of sodium phosphate dibasic, 0.08 mg of potassium phosphate monobasic, and 0.08 mg of potassium chloride. The product also contains residual components of MRC-5 cells including DNA and protein and trace quantities of sodium phosphate monobasic, EDTA, neomycin and fetal bovine serum. The product contains no preservative.

Duration of protection:

The duration of protection of VARIVAX is unknown; however, some long-term efficacy studies [by the manufacturer?] have demonstrated continued protection up to 10 years after vaccination. Many have reported breakthrough chickenpox infections.

Side Effects / Adverse Reactions from the Varivax Clinical Trial:

• Upper respiratory illness
• cough
• irritability / nervousness
• fatigue
• disturbed sleep
• diarrhea
• loss of appetite
• vomiting
• otitis
• diaper rash / contact rash
• headache
• teething
• malaise
• abdominal pain
• other rash
• nausea
• eye complaints
• chills
• lymphadenopathy
• myalgia
• lower respiratory illness
• allergic reactions, including hives, allergic rash
• stiff neck
• heat rash / prickly heat
• arthralgia
• eczema / dermatitis
• constipation
• itching
• pneumonitis
• seizure
• cold/canker sore

Post-Marketing Experience Of Varivax

• Anaphylaxis
• Anaphylactic shock
• Angioneurotic edema, facial edema, peripheral edema
• Necrotizing retinitis (in immunocompromised individuals)
• Aplastic anemia; thrombocytopenia (including idiopathic thrombocytopenic purpura (ITP))
• Varicella (vaccine strain)
• Encephalitis
• cerebrovascular accident
• transverse myelitis
• Guillain-Barré syndrome
• Bell’s palsy
• ataxia
• non-febrile seizures
• aseptic meningitis
• meningitis
• dizziness
• paresthesia
• Cases of encephalitis or meningitis caused by vaccine strain varicella virus have been reported in immunocompetent individuals previously vaccinated with VARIVAX months to years after vaccination. Reported cases were commonly associated with preceding or concurrent herpes zoster rash
• Pharyngitis
• pneumonia/pneumonitis
• Stevens-Johnson syndrome
• erythema multiforme
• Henoch-Schönlein purpura
• secondary bacterial infections of skin and soft tissue
• including impetigo and cellulitis
• herpes zoster

ProQuad Post Marketing Experience

Infections and infestations Subacute sclerosing panencephalitis (see below), encephalitis (see below), aseptic meningitis (see below), meningitis, measles, atypical measles, pneumonia, respiratory infection, infection, varicella (vaccine strain), influenza, herpes zoster, orchitis, epididymitis, cellulitis, skin infection, retinitis, bronchitis, parotitis, sinusitis, impetigo, herpes simplex, candidiasis, rhinitis. Although not reported following vaccination with ProQuad, cases of encephalitis or meningitis caused by vaccine strain varicella virus have been reported in immunocompetent individuals previously vaccinated with VARIVAX (same varicella vaccine strain as in ProQuad) months to years after vaccination. Reported cases were commonly associated with preceding or concurrent herpes zoster rash (see below). Blood and the lymphatic system disorders Aplastic anemia, thrombocytopenia, regional lymphadenopathy, lymphadenitis. Immune system disorders Anaphylaxis and related phenomena such as angioneurotic edema, facial edema, and peripheral edema, anaphylactoid reaction. Psychiatric disorders Agitation, apathy, nervousness. Nervous system disorders Measles inclusion body encephalitis [see Contraindications (4.2)], acute disseminated encephalomyelitis, transverse myelitis, cerebrovascular accident, encephalopathy (see below), Guillain-Barré syndrome, optic neuritis, Bell’s palsy, polyneuropathy, ataxia, hypersomnia, afebrile convulsions or seizures, febrile seizure, headache, syncope, dizziness, tremor, paraesthesia. Eye disorders Necrotizing retinitis (in immunocompromised individuals), retrobulbar neuritis, ocular palsies, edema of the eyelid, irritation eye. Ear and labyrinth disorders Nerve deafness, ear pain. Vascular disorders Extravasation blood. Respiratory, thoracic and mediastinal disorders Pneumonitis [see Contraindications (4.3)], pulmonary congestion, wheezing, bronchial spasm, epistaxis, sore throat. Gastrointestinal disorders Hematochezia, abdominal pain, mouth ulcer. Skin and subcutaneous tissue disorders Stevens-Johnson syndrome, Henoch-Schönlein purpura, erythema multiforme, acute hemorrhagic edema of infancy, purpura, skin induration, panniculitis, pruritus. Musculoskeletal, connective tissue and bone disorders Arthritis and/or arthralgia (usually transient and rarely chronic, see below); pain of the hip, leg, or neck; myalgia; musculoskeletal pain. General disorders and administration site conditions Injection-site complaints (burning and/or stinging of short duration, edema/swelling, hive-like rash, discoloration, hematoma, induration, lump, vesicles, wheal and flare), varicella-like rash, warm to touch, stiffness, warm sensation, inflammation, injection-site hemorrhage, injection-site injury.

Deaths have been reported following vaccination with measles, mumps, and rubella vaccines; however, a causal relationship has not been established in healthy individuals.

When the varicella vaccine was first introduced, it was a one dose series. As time unfolded, we found that outbreaks were happening in fully vaccinated student populations. Vaccine immunity wanes, and this is true for every vaccine. Eventually a second dose was added to the schedule because the one dose was ineffective.

The same playbook happened for measles vaccine (MMR) as well. It originally was a one-dose series, which turned into two doses as children in school were developing measles. We can easily see the same thing happening with both pertussis, and of course, COVID-19.

Chickenpox outbreak in a highly vaccinated school population

“A chickenpox outbreak occurred in a school in which 97% of students without a prior history of chickenpox were vaccinated. Students vaccinated >5 years before the outbreak were at risk for breakthrough disease. Booster vaccination may deserve additional consideration.”

Varicella outbreak in a highly-vaccinated school population in Beijing, China during the voluntary two-dose era

“Moderate two-dose varicella vaccine coverage was insufficient to prevent a varicella outbreak. Two-dose recipients with breakthrough varicella are contagious. High two-dose varicella vaccine coverage and timely isolation of cases may be needed for varicella outbreak prevention in the two-dose era.”

One dose of varicella vaccine does not prevent school outbreaks: is it time for a second dose?

“Although disease was mostly mild, the outbreak lasted for approximately 2 months, suggesting that varicella in vaccinated persons was contagious and that 99% varicella vaccination coverage was not sufficient to prevent the outbreak.”

A Centralized Outbreak of Varicella among Children Attending Preschool in Suzhou, China

“Single-dose varicella vaccine is effective in reducing the varicella attack rate, but not high enough to prevent outbreak.”

1. Management of chickenpox with frozen mother’s milk

Interventions and results: The boy presented with a crusted varicella rash. The medical history revealed premature cessation of the typical varicella rash on day 3. It was coincidental with a supply of frozen human milk by his mother. Next, the father (41 years old) of this patient contracted chickenpox: he was on frozen breast milk from day 2, and no new pox emerged thereafter.

Conclusions: The rash spread and numbered 50 to 150 lesions on day 2. Instead, the typical rash was expected to appear in three successive crops of lesions throughout the first week. The disease usually numbers approximately 250-500 lesions in unvaccinated healthy persons. Frozen breast milk may shorten chickenpox duration.

2. Complications of varicella requiring hospitalization in previously healthy children

Skin or soft tissue infections and pneumonia were the most common complications. Central nervous system complications (15), dehydration (8) and Reye’s syndrome (6) accounted for 75% of the nonsuppurative complications. Cellulitis (7), pneumonia (3) and encephalitis (3) 

3. A Case of Aseptic Meningitis Without Skin Rash Caused by Oka Varicella Vaccine

Here, we present a previously healthy adolescent with aseptic meningitis without skin rash caused by varicella vaccine derived from the Oka/Biken strain; the patient received a single dose of varicella vaccine at 1 year of age. Pediatricians should be aware of the potential for reactivation of varicella vaccine derived from the Oka/Biken strain, which can cause aseptic meningitis in vaccinated children even in the absence of a skin rash.

4. Varicella Vaccine Meningitis as a Complication of Herpes Zoster in Twice-Immunized Immunocompetent Adolescents

Varicella vaccine is a live attenuated virus that retains some of its neurotropic properties. Herpes zoster caused by vaccine virus still occurs in immunized children, although the rate is much lower than in children who had wild-type varicella.

We now report a third case of varicella vaccine meningitis and define risk factors shared by all 3 immunized adolescents. The diagnosis in cerebrospinal fluid in this third case was verified by amplifying and sequencing portions of the viral genome, to document fixed alleles found only in the vaccine strain.

5. Herpes zoster after vaccination with one dose varicella vaccine to a 4-year-old child

We present the case of a four-year-old immunocompetent girl who developed herpes zoster after she had received one dose of varicella-zoster virus live attenuated vaccine at the age of 15 months.

6. Vaccine Oka Varicella Meningitis in Two Adolescents

Like wild-type varicella-zoster virus, however, vaccine Oka (vOka) varicella can establish latency and reactivate as herpes zoster, rarely leading to serious disease, particularly among immunocompromised hosts.

We present 2 adolescents with reactivated vOka meningitis, 1 immunocompetent and 1 immunocompromised, both of whom received 2 doses of varicella vaccine many years before as children. Pediatricians should be aware of the potential of vOka varicella to reactivate and cause clinically significant central nervous system disease in vaccinated children and adolescents.

7. Twelve Children with Varicella Vaccine Meningitis: Neuropathogenesis of Reactivated Live Attenuated Varicella Vaccine Virus

To better understand vOka neuropathogenesis, we reassessed 12 published cases of vOka meningitis that occurred in once-immunized and twice-immunized children, all of whom had bouts of herpes zoster preceding the central nervous system infection. Eight of the 12 meningitis cases occurred in children who had received only one immunization. 

8. Varicella zoster virus vaccines: potential complications and possible improvements

“The current varicella vaccine (v-Oka) is highly attenuated in the skin, yet retains its neurovirulence and may reactivate and damage sensory neurons. The reactivation is sometimes associated with postherpetic neuralgia (PHN), a severe pain along the affected sensory nerves that can linger for years, even after the herpetic rash resolves. In addition to the older population that develops a secondary infection resulting in herpes zoster, childhood breakthrough herpes zoster affects a small population of vaccinated children.” 

9. Latency of Varicella Zoster Virus in Dorsal Root, Cranial, and Enteric Ganglia in Vaccinated Children

“Despite vaccination, varicella-zoster virus (VZV) remains an important pathogen. We investigated VZV latency in autopsy specimens from vaccinees, in gastrointestinal tissue removed surgically, and in a guinea pig model. We propose that retrograde transport from infected skin and viremia deliver VZV to neurons in which it becomes latent. Wild type (WT) VZV was found to be latent in many ganglia of vaccinated children with no history of varicella, suggesting that subclinical infection with WT-VZV occurs with subsequent viremic dissemination. The 30% to 40% rate of WT-VZV zoster reported in vaccinees and occasional trigeminal zoster due to vaccine type VZV (vOka) are consistent with viremic delivery of VZV to multiple ganglia.” 

For more studies, please visit the Vaccine Studies Page.