Infection advice

There are certain infections that are dangerous for cancer patients, in particular chicken pox and measles. Families are advised to contact their treatment centre immediately if their child or adolescent with cancer has been in contact with any of the diseases listed below:

Chicken pox

You may get parents asking your advice with regards to chicken pox contact. If this is the case please advise them to contact their ward.

Risk of infection from chicken pox

A significant contact is classed as five minutes of conversation with an infected person or being in the same room for 15 minutes.
Chicken pox is infectious from 2 days before onset of spots until last crop of spots is crusted over. Incubation period usually 10-21 days.
Chickenpox has a 90% attack rate.
Disseminated chickenpox in an immunocompromised patient can be fatal.
Remember siblings and parents with chickenpox can infect other in-patients so should be advised not to visit the ward.
Hand gel is insufficient to prevent cross infection. Wash hands properly.

Prophylaxis

Prophylaxis should be given if there has been a significant contact (see above) within last 7 days to those listed:

Up to 12 months post Bone Marrow Transplant
During, and for 6 months after, chemotherapy or radiotherapy if IgG negative (see below)
3 months after prolonged steroid course
Solid organ transplant
Neonates

VZV Immunoglobulin (VZIG)

Undertake a risk assessment to determine patients/staff/relatives exposure risk.
Ensure other primary medical/surgical teams are aware of exposure risk.
Check varicella immunity of patient – if not sure, phone patient’s treatment centre
If VZV IgG positive within last 6 months, no VZIG needed.
If VZV IgG negative within last 6 months, VZIG required - patient will require to go to own treatment or shared care centre
If unknown status, check VZV IgG status ASAP or give VZIG after discussion with consultant
VZIG must be given within 10 days of exposure.
VZIG can be given to susceptible pregnant women.
VZIG is 50% effective, can attenuate infection and lasts three weeks.
If patient is given VZIG remember that this may only attenuate infection and that they may be infectious for up to 4 weeks after administration. Important for infection control and ward visits.
Sometimes if a CYP is on Aciclovir or having immunoglobulin the decision will be taken not to give VZIG.

VZV-Vaccine (live: for active immunisation)

Can be given to susceptible, immunocompetent, non-pregnant staff via Occupational Health within 4 days of exposure.
Can be given to non-immune siblings and parents of patients via GP

Chicken Pox Infection – Treatment

Any child / adolescent with cancer presenting with chicken pox should be admitted to hospital and the following treatment commenced immediately

Any vesicle in a haematology or oncology patient must be assumed to be VZV until proven otherwise, even if no contact known.
Swab lesion – ensure liquid from inside vesicle is taken on to swab, then place in viral transport medium (pink liquid) often kept in treatment rooms.
Send swab ASAP to virology..
Treat with high dose IV aciclovir for at least 7 days. (see below for dose)
Give concurrent hydration

Shingles

Shingles is caused by the same virus as chicken pox, the varicella zoster virus. Shingles can only occur if you have had chicken pox and it is caused by reactivation of the virus which has been lying dormant in the body. This can happen when immunity is low. The virus travels along a nerve path and will appear as a rash on the skin supplied by that nerve. There has to be skin to skin contact for Shingles to be infectious as it is not spread by the respiratory route.

Treatment

As for chicken pox, shingles must be treated promptly with intravenous Aciclovir and will require admission to hospital for at least 3 days, usually up to 7 days.

Severity of infection will be assessed by doctor in patient’s treatment centre
Usual practice is admission for first 24-48 hours and high dose IV aciclovir.
If patient well and home circumstances allow, he/she may be discharged to continue on oral aciclovir x 5 per day for total 10 days or oral valaciclovir if > 12 years (only available as capsules).

Cold sores

These are caused by the herpes simplex virus and some CYP get recurrent problems. If they are persistent or troublesome they are usually treated with oral Aciclovir. Cold sores rarely cause major problems but can be uncomfortable and can delay bone marrow recovery after intensive drug treatment.

Pneumocystis (Carinii) jiroveci Pneumonia (PCP)

Children and Young People (CYP) receiving long term therapy may be at risk of an unusual type of pneumonia called pneumocystis. This infection is due to an organism which may be present in most people’s lungs. In patients who are on immunosuppressive drugs long term, the infection may be activated. This infection is characterised by fever, tachypnoea and a dry cough. Many chemotherapy regimens may increase the risk of developing PCP. In these circumstances they will be on a low dose Cotrimoxazole two or three days a week, throughout their treatment, to help prevent it occurring.

Measles

Measles can be a very serious infection in children receiving chemotherapy. Fortunately, most children in Britain have now been immunised with the MMR vaccine. Provided a child has been immunised with MMR he / she is very unlikely to get measles. If a child comes in direct contact with another child with measles, and he / she has not had measles or the MMR vaccine, he / she needs to receive an injection of immune globulin. This is called HIG (human immune globulin) and it has to be given as an intramuscular injection. It should be given within 48 hours of contact with measles but can be given after this period if necessary.

There is no risk to the sick child of transmission of the virus from other children who have recently been immunised.

Vaccinations / Immunisations

Whilst on treatment children and adolescents should not have live vaccinations / immunisations.

The only exception to this is the flu vaccine which should be given in the injection form rather than the nasal vaccine.

When the child / adolescent has finished treatment, the need for repeat vaccinations will be discussed. Children and adolescents should be re-immunised or given boosters 6-12 months after stopping therapy. If a child / adolescent has had a bone marrow transplant, specific advice will be given from the transplant hospital.

Immunisations of brothers and sisters

Full immunisation is recommended for brothers and sisters. Immunisation against measles is especially important. It is recommended that all household members also receive the annual flu vaccine (Flag word) while the CYP is on treatment. Again, ideally this should be administered as an injection or else the ill CYP would need to be isolated from the family member who had had the nasal vaccine for up to two weeks.