Does chickenpox vaccine protect against necrotizing fasciitis (flesh-eating disease) in children?

A recent study published by the Ontario Group A streptococcal study suggests that the incidence of invasive group A strep infection associated with chickenpox in children is one more reason to have your children vaccinated against chickenpox (1). From 1992 to 1996 there were 1087 case of invasive group A streptococcal infection identified in residents of Ontario, 243 (22.4%) of these occurred in children (incidence 1.1 per 100,000 population per year in 1992 - 2.3 per 100,000 per year in 1996).

Invasive group A strep disease in children was associated with a variety of clinical syndromes which include skin infections (cellulitis-30%) , necrotizing fasciitis (flesh-eating disease - 4%), upper respiratory infection (18%) and pneumonia (6%). Infection of the bones or joints (osteomyelitis or arthritis) was present in 19% of cases and 16 % of cases had infections of the blood without any other site of infection identified.

16% of the children who became infected had some form of chronic underlying illness such as heart disease, asthma or cancer. However, 31 of 205 children (15%) for whom a history was available had had chickenpox within a month before the onset of their group A strep infection. Infection usually occurred 5 days after the onset of the chickenpox rash. Children who had chickenpox were more likely to have a group a strep infection of the skin than infection at any other site.

The majority of children with invasive group A strep infection were admitted to the hospital; 12% were admitted to intensive care units and 4.1% died. Children were more likely to die if they had an existing chronic illness (other than asthma) prior to infection and they were more likely to have necrotizing fasciitis (flesh-eating disease) if they had chickenpox immediately prior to their group A strep infection.

In this study, risk of acquiring invasive group A strep infection after chickenpox was increased 58-fold. The reasons for these increased risks are not entirely clear. This data suggests that the increased risk may result from the breakdown of the skin barrier caused by chickenpox lesions. In addition, chickenpox infection itself may reduce the immune system's ability to fight off bacterial infections such as group A strep infection.

Information from this study, in addition to other previously published studies (2-4) confirms chickenpox as one of the single most important risk factors for acquisition of serious group A streptococcal infection in children. Childhood vaccination could reduce invasive disease in children by at least 10% - One more reason why vaccination of children against chickenpox is a good idea.

Reference List

1. Laupland KB, Davies HD, Low DE, Schwartz B, Green K, Ontario Group A Streptococcal Study Group, McGeer A. Invasive group A streptococcal dsease in children in association with Varicella-Zoster virus Infection. Pediatrics. 105(5), May 2000.

2. Zurawski CA, Bardsley MS, Beall B, et al. Invasive group A streptococcal disease in metropolitan Atlanta : a population-based assessment. Clin Inf Dis. 1998;27:150-157.

3. Brogan TV, Nizet V, Walhausen JHT, Rubens CE, Clarke WR. Group A streptococcal necrotizing fasciitis complicating primary varicella; a series of fourteen patients. Pediatr Infect Dis J. 1995;14:588-594

4. Zerr DM, Alexander ER, Duchin JS, Koutsky LA, Rubens CE. A case-control study of necrotizing fasciitis during primary varicella. Pediatrics. 1999;103:783-790.

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