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Zoster Immunoglobulin

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Introduction

Zoster Immunoglobulin (ZIG) is a high titre immunoglobulin extracted from donors.  It is used in the passive prevention of varicella infection in high risk individuals.

The decision to whether to give ZIG or not is based on three factors:

  1. The likelihood that the exposed person is susceptible to varicella.
  2. The probability that a given exposure to varicella will result in infection.
  3. The likelihood that complications will develop if the person is infected.

Significant Contact

Varicella (chickenpox) is infectious from 48 hours before rash until crusting of all lesions has occurred (usually 5 days after rash starts). Transmission from a person with localised shingles (zoster) is much less likely than from a person with varicella and not usually a significant contact.

  1. Household contact - Infection is very likely to occur in a susceptible individual living with an infected contact.
  2. Playmate contact - More than one hour of play indoors with infected individual.
  3. Newborn infant contact - Mother of neonate develops chicken pox (not shingles) seven days before to seven days after delivery.
  4. Hospital contact - In same two bed room or face to face contact >5 minutes.

Which Children are at Risk?

Susceptible individuals who are likely to develop serious varicella infection and complications include the following:

Paediatric

  1. Those receiving high dose corticosteroid therapy (>0.5 mg/kg/day of Prednisone or equivalent within the last three months).
  2. Children receiving immunosuppressive therapy or chemotherapy.
  3. Children with malignancy.
  4. Congenital immunodeficiencies.
  5. HIV positive without history of chickenpox.

Neonatal

See the following Newborn Services Clinical Guidelines:
Chickenpox exposure
VZIG information

  1. Neonates whose mothers develop chicken pox <7 days before or up to 7 days after delivery.
  2. Preterm infants <28 weeks or <1000 g, regardless of maternal history.
  3. Preterm infants >28 weeks whose mothers have not had chicken pox. If mother unsure of past history of chickenpox then serological testing should be done.
  4. ZIG given to mother within five days of delivery may not protect the infant and the infant should be given ZIG on delivery.  The child may also need to be treated with acyclovir.
  5. Maternal varicella is not a contraindication to breast feeding.  If a baby's siblings have chickenpox, the baby should be given ZIG if the mother is non-immune, but the baby does not need to be separated from mother or siblings.

Non immune pregnant women and any immunocompromised adults and adolescents are also important risk groups who require prophylaxis when assessing contacts of a varicella case.

Hospital exposures or exposure of immunocompetent non-immune individuals

Varicella vaccine is effective in preventing illness or modifying varicella severity if used within three days, and possibly up to five days of exposure. Varicella vaccine is funded for post-exposure prophylaxis of immune competent hospital in-patients who are suspectible to varicella.

Administration of ZIG 

ZIG should be given within 96 hours of exposure but may have some efficacy if given up to 10 days post exposure in a patient at high risk.

ZIG is available from the New Zealand Blood Service and is manufactured by CSL in Melbourne from New Zealand donors.  It should be given IM, never IV.

Dosing

Weight of patient (kg) Dose (IU) No. of vials
0 - 10 125 1
10.1 - 20 250 2
20.1 - 30 375 2
30.1 - 40 500 3
Over 40 600 3

The duration for which ZIG recipients are protected against varicella is unknown.  If a second exposure occurs more than three weeks after administration of ZIG in a recipient in whom varicella did not develop, another dose of ZIG should be given.

Obtaining ZIG at Starship Child Health

ZIG is available from the Blood Bank but must be discussed with the Haematologist on call.  It can be requested by filling out a yellow request for blood products form. If not available (for supply reasons) intravenous immunoglobulin can be given (dose to be advised by haematologist on call for Blood Bank).

Information for Families

See the Kidshealth factsheet on Chickenpox (http://www.kidshealth.org.nz/chickenpox)

References 

  • RED BOOK 2012  Pickering L (ed). Red Book: Report of the Committee on Infectious disease, 29th ed. Elk Grove Village, IL: American Academy of Pediatrics.
  • Dowell S, Bresee J. Severe varicella associated with steroid use. Pediatrics 1993;92(2):223-228.
  • Burnett I. Immunoglobulin should be given if steroid dose was 0.5mg/kg/day in preceding three months. BMJ 1995;310:327.
  • Issacs D. Neonatal chickenpox. J Paediatr Child Health 2000 36, 76-77.
  • Management of Perinatal Infections Guidelines from the Australasian Society of Infectious Diseases 2002 (rev 2014)
  • Ministry of Health Immunisation Handbook 2014
  • Centers for Disease Control and Prevention (CDC), Marin M, Guris D, et al. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommendations and Reports 2007;56(RR-4):1-40.
  • Wen S et al. Prospective surveillance of hospitalisations associated with varicella in New Zealand children J Paediatr Child Health 2015 51, 1078-1083

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Document Control

  • Date last published: 22 February 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Infectious Diseases
  • Author(s): Lesley Voss, Emma Best
  • Owner: Emma Best
  • Editor: Greg Williams
  • Review frequency: 2 years

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