October 2, 2002
UNPROTECTED PEOPLE: Stories of
people who have suffered or died from vaccine-preventable diseases
INDIANA GIRL DIES OF VARICELLA
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The Immunization Action Coalition (IAC)
publishes articles about people who have suffered or died from
vaccine-preventable diseases and occasionally devotes an IAC EXPRESS issue
to such an article. This is the 50th in our series.
The focus of the article is the distressing and preventable death of an
11-year-old girl from varicella zoster infection complicated by
streptococcal sepsis. The likely cause of the child's exposure was a
chickenpox outbreak at school.
Wayne Staggs, MS, and Donna Allen, BS, of the Immunization Program of the
Indiana State Department of Health, wrote the article. It appeared in the
August 2002 issue of the Department's publication Indiana Epidemiology
Newsletter, under the headline "Varicella Death Reported in Indiana." We are
reprinting the article with the Department's permission and making it
available to you with the exception of a graph and some other details.
On May 23, 2002, a previously healthy 11-year-old white female presented to
the Emergency Room of Hospital A with a history of fever, tachypnea, and
varicella zoster infection that had lasted up to 12 days. The
Emergency Room physician recognized the patient was in shock and she was
immediately transported to the Pediatric Intensive Care Unit of Hospital B.
Upon arrival at the Pediatric Intensive Care Unit, the patient was noted to
be hypotensive and cyanotic. Her blood pressure was 58/33 with a
temperature of 101.2 F and a pulse rate of 180 per minute. At this time the
patient was urgently intubated, but was poorly perfused with no pulses
palpable. Cardiopulmonary resuscitation was initiated, which lasted
approximately 33 minutes. Examination at this time revealed a severely
encephalopathic child with occasional gasping respirations and no other
movements and no response to pain.
Further physical examination revealed a patient covered with severe
vesicular eruptions that extended from her face and covered her entire trunk
to involve the extremities up to below the level of the knees as well
as below the level of the elbows. She had vesicular lesions in the
interdigital areas of both hands and feet and there were a number of
petechial lesions noted all over her body. Her entire trunk was covered with
ulcerated necrotic lesions as well as some hemorrhagic lesions noted on her
The patient had been treated previously with Acyclovir for two days
(beginning May 16), but was switched to Famvir on May 18 following some
facial swelling thought to be from the Acyclovir. The patient completed a
five-day course of Famvir.
A blood culture revealed gram positive cocci, which was later identified as
Streptococcus pyogenes (group A beta hemolytic strep). There was no
laboratory analysis performed to specifically identify varicella virus as
the agent causing the rash.
As the child's condition continued to deteriorate throughout the day, the
fact that this was an irreversible case of septic shock was described to the
parents. The child died early in the morning on May 24, 2002. Due to the
clarity and severity of the septicemia with which this child presented and
the profound septic shock, it was decided that the cause of death was an
obvious case of varicella zoster infection complicated by streptococcal
sepsis. It was therefore concluded an autopsy was not necessary.
This case was not vaccinated, but the mother reported that the child had a
mild case of chickenpox when she was five or six years old. It was also
reported that a number of chickenpox cases were occurring at the child's
school, and therefore the school exposure is considered the likely source of
infection for this case.
Seven deaths due to varicella have been reported in Indiana from 1997 to
2002. During the four-year period from 1997-2000, a mean of 125.5
hospitalizations resulting from varicella infection has been reported
through the Indiana Hospital Discharge Database.
According to the latest National Immunization Survey (Quarter 1, 2001 -
Quarter 4, 2001), 58.9% of infants 24 months of age born in Indiana from
February 1998 to May 2000 were vaccinated with varicella vaccine. In the
United States, 76.3% of infants of the same age group were vaccinated with
varicella vaccine. . . .
Efforts to increase routine and catch-up varicella vaccination among
children should include educating health-care providers that deaths and
severe morbidity from varicella are preventable. Policies that delay
vaccination of susceptible children until adolescence accept the
considerable disease burden that occurs among children 2-11 years of age.
The most effective strategy focuses on vaccinating children routinely at
12-18 months of age and vaccinating all susceptible older children and
adolescents. Children have the highest disease incidence and are the group
that serve as the primary source of transmission of varicella to
groups at higher risk for severe disease, including adults and persons not
eligible for vaccination. Most deaths and severe morbidity from varicella in
children and adults can be prevented by implementing recommended policies
for childhood vaccination.
IAC EXPRESS editor's note: The article reports that Indiana's varicella
vaccine coverage rate for two-year-old children is currently 17% below the
national rate. In addition Indiana has no varicella prevention mandate.
Given these circumstances, this child's death points to the need to expand
school-entry laws for varicella vaccination. Currently, 27 states require
varicella vaccination for children entering elementary school in the 2002
For a camera-ready (PDF) version of the article as it appeared in the
Indiana Epidemiology Newsletter, go to:
To read other IAC Unprotected People stories in either HTML or camera-ready
(PDF) format, go to:
DISCLAIMER: The Immunization Action Coalition (IAC) publishes Unprotected
People stories for the purpose of making them available for our readers'
review. We have not verified this story's content, for which the authors are
DO YOU KNOW OF STORIES OF UNPROTECTED PEOPLE? Please let us know if you have
personal stories of people who have suffered or died from
vaccine-preventable diseases or if you know of stories that have appeared in
the media describing suffering that occurred because someone was not
immunized. Send your stories or case reports to IAC Express by email to
email@example.com or by fax to