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Satellite Manual

4.3 Antiemetics

4.4 Treatment of Varicella-Zoster Infections

The immunocompromised individual with either primary (Varicella) or recurrent (Zoster) infection is at increased risk of severe disease.  Zoster can occur in any dermatome in the immunocompromised host, but can also disseminate into multiple dermatomes and cause organ involvement.

Period of Contagion
Varicella is contagious usually for 1 to 2 days before the rash develops and for as long as it takes for all lesions to crust over.

Incubation Period
The incubation period is usually 14 –16 days, occasionally as early as day 10 and as late as day 21 after contact.  Use of Varicella-Zoster immune globulin (VariZIG) can prolong the incubation period to 28 days.  Immunocompromised patients may experience a shorter incubation period.

Exposure Assessment
Persons with varicella (chickenpox) are contagious from 1 to 2 days before the rash onset and up until the crusting of all lesions.  The skin lesions of zoster (shingles) are considered infectious from their onset until they have crusted and dried.

The following situations are considered significant exposures to varicella zoster virus:

  1. Continuous household contact (living in the same dwelling with a person with varicella.)
  2. Being indoors for > 1 hour with a case of varicella.
  3. Being in the same hospital room for > 1 hour, or > 15 minutes of face-to-face contact, with a patient with varicella.
  4. Touching the lesions of a person with active varicella or zoster (shingles).

Determine Immunity/Susceptibility
Patients are considered immune if they have varicella IgG present at, or before, cancer diagnosis or documented age-appropriate doses of varicella vaccine.  Recent publications have suggested, however, that children on therapy may in fact lose their immunity.  Immune status of on treatment patients should be discussed with the treating tertiary centre.  Stem cell transplant recipients should be considered to be non-immune until age appropriate varicella vaccine has been administered post transplant.  

Dosing
Susceptible cancer patients should be considered immunocompromised and receive VariZIG based on body weight.  The recommended dose is 125 IU for each 10 kg body weight up to a maximum of 625 IU.  The minimum dose is 125 IU.  As with other blood products, informed consent from patients or their parents/guardians must be obtained before administration of VariZIG.

VariZIG is of maximal benefit if administered within 96 hours after first exposure.  However, since the exact timing of transmission is unknown it can be used within 96 hours of the most recent exposure.  Protection is believed to last for approximately 3 weeks.  Subsequent exposures > 3 weeks after a dose of VariZIG would require additional doses if the criteria for VariZIG use outlined in the Post-exposure prevention of varicella section still exist.

Varicella and Zoster Infections in the Immunocompromised Host
The immunocompromised child is particularly vulnerable to varicella.  Varicella can result in pneumonitis, hepatitis, encephalitis and DIC, resulting in rapid deterioration and death.

Acyclovir should be instituted by the intravenous route at the first indication of varicella in the immunocompromised child.

Oral Acyclovir is not used in the initial management of varicella.  Before oral Acyclovir therapy is instituted, discussion should take place with the patient’s tertiary centre oncologist.

Varicella-zoster may remain limited, but it may also disseminate and lead to the same life-threatening complications of a primary varicella infection.  It is recommended that an immunocompromised child diagnosed with zoster at a Satellite Centre receive initial Acyclovir by the intravenous route and the child be admitted to hospital for observation.  Contact should occur with the patient’s tertiary centre oncologist who will assist the satellite physician in determining subsequent therapy.
There is never a role for topical acyclovir or anti-virals.

Dose of Acyclovir for Varicella
Acyclovir 500 mg/m2/dose IV q8h for 7- 10 days
OR
Acyclovir 10 mg/kg/dose IV q8h

NOTE: One should ensure patient is well hydrated with good urine output while on acyclovir

Susceptible Patients who have completed chemotherapy and who have been exposed to chicken pox should be considered for VariZIG.  In general, it takes 3-6 months following completion of chemotherapy for the immune system to recover sufficiently to contain a varicella infection.  Most physicians would provide VariZIG for up to 6 months post-chemotherapy in a patient who had been treated for leukemia.  Thereafter, the patient should be immunized.

Zoster is treated with the following doses of Acyclovir:

<12y 20 mg/kg/dose  IV q8h x 7 days
OR
>12y 10 mg/kg/dose IV q8h x 7 days

Please contact the patient’s tertiary centre at the time of diagnosis.

References

  1. Public Health Agency of Canada, National Advisory Committee on Immunization. Canadian Immunization Guide, 2015. http://www.phac-aspc.gc.ca/publicat/cig-gci/p05-01-eng.php#vacc.  Accessed December 22, 2015.
  2. American Academy of Pediatrics Committee on Infectious Diseases. (2009). Red Book: 2009 Report of the Committee on Infectious Diseases. (28th ed.). Grove Village, IL: American Academy of Pediatrics.

Primary author Dr. Marina Salvadori, Children’s Hospital, London Health Sciences Centre, London with input from Dr. Nisha Thampi, Children’s Hospital, London Health Sciences Centre, London.

4.5 TPN Document
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In this Section

  • 1.1 History & Overview
  • 1.2 Acknowledgements
  • 1.3 Committees and Working Groups
  • 1.4 Satellite Manual Disclaimer
  • 2.1 Principles of Satellite Care
  • 2.2 Eligible Patients
    • 2.2.1 Children Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.2 Children Not Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.3 Children Eligible for the Management of Complications on a Satellite Centre
    • 2.2.4 Eligibility of Children Requiring Supportive Care
  • 2.3 Scope of Satellite Practice
    • 2.3.1 Implementation of Psychosocial Treatment Plan (Process for Communication)
    • 2.3.2 Limitations on Satellite Practice
  • 2.4 Advanced Satellite Practice
  • 3.1 Safe Handling, Administration and Disposal of Chemotherapy Agents
  • 3.2 Accidental Exposure/Spills
  • 3.3 Extravasation Management
    • 3.3.1 Sample Extravasation Documenting Tool
  • 3.4 Injecting SC Medication Via an Insuflon
  • 3.5 Chemotherapy Administration Reference List
  • 3.6 Central Venous Catheter Care
  • 3.7 Chemotherapy Quick Reference
    • 3.7.1 Rapid Hydration Document
    • 3.7.2 Provider Guide: Prevention and Management or Irinotecan induced Diarrhea
    • 3.7.3 Parent Handout: Prevention and Management of Irinotean induced diarrhea
    • 3.7.4 Capizzi Methotrexate
    • 3.7.5 Erwinia L-Asparaginase
  • 4.1 Management of Fever and Neutropenia
    • 4.1.1 Routine Order Sample Sheet
    • 4.1.2 Fever Cards (Sample)
    • 4.1.3 Criteria for low-risk designation. Risk categorization refers to risk of bacteremia and serious complications, including mortality.
  • 4.2 Pentamidine Administration
    • 4.2.1 Inhaled Pentamidine
    • 4.2.2 Intravenous Pentamidine
  • 4.3 Antiemetics
  • 4.4 Treatment of Varicella-Zoster Infections
  • 4.5 TPN Document
  • 4.6 Immunization of Children with Cancer
  • 4.7 Transfusion
  • 4.8 When to consult the Tertiary Centre
  • 5.1 Palliative Care Overview
  • 5.2 Communication
  • 5.3 Settings of Care
  • 5.4 Symptom Management
  • 5.5 End of Life
  • 5.6 When a Child Dies in the Satellite Centre
    • 5.6.1 Reconciling your grief
    • 5.6.2 Funeral arrangement checklist
    • 5.6.3 Helping Children who grieve
    • 5.6.4 Coping with the Holidays
    • 5.6.5 The grieve experience
  • 6.1 Goals and Objectives
  • 6.2 Participant Site Selection
    • 6.2.1 Tertiary Site Selection
    • 6.2.2 Community Site Selection
  • 6.3 POGO’s Roles
    • 6.3.1 PHIPA, Privacy and Research
  • 6.4 Funding
    • 6.4.1 Funding Support for Tertiary Activity
    • 6.4.2 Financial Support for Pediatric Oncology Community Activity
  • 6.5 Infrastructure and Formal Requirements
    • 6.5.1 Tertiary Partners’ Role in Provincial Pediatric Oncology Satellite Program
    • 6.5.2 Satellite Partners’ Role in Provincial Pediatric Oncology Satellite Program
  • 7.1 Preamble
  • 7.2 Investigator responsibilities
  • 7.3 Training Requirements
    • 7.3.1 General Training for Conduct of Research
    • 7.3.2 Protocol Specific Training
  • 7.4 Research Activites that may be completed in satellite centres under supervision of DSI
  • 7.5 Research Activities to be completed in Tertiary Centres Only
  • 7.6 Recognition and Reporting of Adverse Events (AEs)
  • 7.7 Data Transfer
  • 7.8 Pharmacy Drug Accountibility
  • 7.9 Site Inspections and Quality Assurance
  • 8.1 Pediatric Oncology Shared Care Initial Data Transfer Sheet
  • 8.2 Shuttle Sheet
  • 8.3 Psychosocial Communication Tool
  • 9.1 Satellite Readiness/ Preparedness Checklist
  • 9.2 Education Report for Tertiary Centres
  • 9.3 Education Report for Satellite Centres
  • 9.4 Vital Signs Report
  • 9.5 Self- Assessment
  • 9.6 Satellite Contact Form
  • 9.7 Annual Satellite Caseload Report
  • 9.8 POGO Provincial Satellite Program Annual Accounting Report
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