A pox on your mail

When I was much younger, chickenpox hit my summer camp.  We had an infirmary set aside with plenty of beds, but not enough medical staff to watch over all the people in it.  They didn’t need much attention, just simple things like water, meals, and for the kids, supervision.  Some of the the counselors were struck down but they were far too miserable to supervise anyone.

The camp administration asked for volunteers to sit in shifts and watch the sick kids.  I was a junior counselor, all of seventeen, and therefore “old enough” to sit watch.  But I couldn’t remember if I’d had chickenpox, the other requirement for volunteering.  The need was acute, and I was allowed to use one of the two phone lines that served the camp to call my mother. She confirmed that I’d had chickenpox, and I was deputized.

I remember one kid I sat with for a while.  She was miserable.  Her throat was on fire, her skin a network of bumps, some oozing, some crusted, some just turning red, all terribly itchy.  One of the older counselors was also there.  He was in his twenties, old for chickenpox, and looked like hell.   He couldn’t breath without feeling fire in his throat.  He couldn’t eat.  He couldn’t sleep.  

Since then I’ve seen less than a dozen cases of chickenpox.  Around the same time I started medical school, the chickenpox vaccine became widely available.   Almost like a switch being thrown, chickenpox was gone as a regular part of childhood.

But the virus was not gone from medical practice.  Varicella zoster virus (VZV) is a member of the herpes virus family, and the cause of chickenpox.  It causes the miserable rash and malaise of chickenpox, the rash that says, “you can’t go to school until the last pox is dried and crusted.”  But even though the rash is gone, the virus is not.  Like other herpes viruses, it sits latent in the body, apparently doing nothing at all.

Until, once again, it decides to make an appearance.  It creeps out of a nerve root where it’s been resting for perhaps decades.  If it’s your nerve root, you may begin to feel a little under the weather.  Then you may notice a slight tingle or itch in horizontal strip on one side of your body.  This can quickly develop into severe pain.  You may go to your doctor’s office complaining of back pain or flank pain, and she may take a look at you and see nothing in particular, sending you on your way with some ibuprofen.

Then comes the rash.  It breaks out in a belt along the painful strip, looking remarkably like chickenpox, but localized, and with searing pain.  Sometime the pain is mild, but often it is unrelenting, burning, electric.  After a few weeks, like chickenpox, the lesions will crust over, maybe leaving small scars or pigmented areas, or perhaps nothing at all—except pain.  Up to half the time, the pain of shingles will outlast the outbreak, often for years, unrelenting, minimally responsive to medications.  Post-herpetic neuralgia (PHN) is the most common complication, but not the only one, not even the worst.  Patients can develop meningitis, encephalatis (inflammation of the brain), scarring of the cornea.  And the misery can be shared.

While the rash is there, virus is shedding, and can enter the air.  It’s not easy to share the virus this way—you need just the right host, someone exquisitely susceptible.  If you and your rash are near someone who isn’t immune to the virus—perhaps a newborn, a friend undergoing chemotherapy, or an older person who never had chickenpox—your shingles can spread the virus, causing chickenpox and often more serious disease such as meningitis, encephalitis, pneumonia.

Shingles is a nasty gift to those who’ve had chickenpox.  The vaccinations against chickenpox and against shingles are a major advance in preventative medicine and public health.  But not everyone thinks so.

As others have been documenting, “pox parties” are making a comeback.  Among those whose superstitions keep them from vaccinating their children, there has been a move toward the old practice, where healthy kids are brought to the home of infected kids so that they get chickenpox when they are young and the disease is likely to be less severe.  This primitive form of inoculation is dangerous and idiotic, but before vaccination was available, it made a bit of sense.  True vaccination, rather than disease-causing inoculation is safer, and doesn’t lead to shingles.

I told you I’ve seen less than a dozen cases of chickenpox as a physician.  This is a problem for Pox Partiers. They can’t always find an a “source” for the virus (i.e., a miserable child).  But they’ve found a work-around.  At least one facebook group is helping insane parents find each other, allowing these abusive but isolated parents to share virus.  Among the methods they’ve “discovered” is taking objects like lollipops, having sick kids lick them, then sending them through the mail to other parents.

There are numerous reasons that this is a bad idea, in addition to being a violation of federal laws.  You cannot just send live virus through the mail—that’s a job left for terrorists.  This intentional attempt to inoculate children rather than vaccinate them exposes them to misery and the possible immediate complications of chickenpox, as well as the risk of shingles and PHN later in life.  It’s just nuts.

There’s a reason that we have laws against sending live virus through the mail.  In addition to the threat posed to the recipients, there’s the threat posed to anyone exposed (remember the postal workers who died of anthrax?).

These are basically acts of child abuse and domestic terrorism, even if the parents don’t realize it.  The first time Homeland Security knocks on a door, they may get the hint.  The first time a child dies, laws won’t matter to the parents.

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  1. ncscadsurvivor

     /  November 6, 2011

    I got chicken pox (not shingles) as an adult, back in 1999.

    A blood test a couple of years earlier, after exposure to someone with it, proved that at the time, I had no varicella antibodies and had never even had a sub-clinical case as a baby.

    It was one of the most miserable experiences of my life. I can’t imagine deliberately infecting someone with this. These parents are, as you say, insane.

  2. DLC

     /  November 6, 2011

    I keep posting to these blog stories, because I want to encourage people like you to write more.
    The thing that should be concerning parents here is : You do not know what is on that lollypop or sputum-contaminated rag! Even assuming it wasn’t some nutcase out to cause as much mayhem as possible, you don’t know what other contaminants are on that lollypop or sucker, or what else the “Donor” kid had. He or she may have had all manner of other viruses, bacterial infections or infectious diseases and not have known it. What if they’re a modern-day typhoid Mary, or smallpox carrier ? Doesn’t any of this ever cross your mind ? “hey! I’m giving my precious child chickenpox, and rubella, and measles and whooping cough, all at once! “

  3. Lynda M O

     /  November 6, 2011

    Insanity in its basest form. I am astounded that parents would do this to a child. Wow.

  4. Veneno

     /  November 6, 2011

    Do we actually know how long vaccine-induced immunity lasts for VZV?

    I’m no anti-vaxxer and have had my child vaccinated against everything that the British NHS will pay for. But I’m not convinced that routine VZV vaccination makes sense. If immunity were guaranteed and lifelong, then yes, of course it would make sense. But we know that naturally acquired VZV immunity has a propensity to break down, which is precisely why shingles emerges.

    I haven’t studied the data in depth but it seems to me that for VZV a vaccination strategy has problems at both ends. Firstly, for any vaccination programme, coverage/effectiveness is NEVER 100%. This means that introducing vaccination means that while naturally acquired infection becomes rarer, the average age at which it is acquires increases. We know that primary VZV infection in non-immune individuals (aka chickenpox) is MUCH more severe among adults than children, so an increase in average age at acquisition is a real cause for concern. Secondarily, if vaccine-acquired immunity does not persist sufficiently, it may mitigate the symptoms of primary infection without preventing latency or secondary reactivation (aka shingles).

    So far as I’m aware, paediatric VZV vaccination hasn’t been in use long enough to have generated any valid data that it prevents shingles. As I understand it, US vaccination policy does not assume this will work, but instead advocates re-vaccination of ageing adults to boost (naturally acquired) immunity and prevent reactivation. In populations where VZV circulates naturally, adult immunity may be frequently boosted through contact with infected children, making such re-vaccination less necessary. Considering that adult re-vaccination is (probably) a lot harder to implement than paediatric vaccination, the fact that the latter may necessitate the former should be a cause for concern.

    I am very very glad that my child acquired VZV naturally at the age of 3, even though it did wreck a family holiday. This remains normal in the UK and much of the rest of the world. It may well be the best strategy.

    In short, in general I am very strongly in favour of vaccination programmes, but I think your blog-post goes way beyond the evidence base in the case of VZV.. The population-level benefits seem very unclear, and I note you cite no references.

  5. I showed this story to my mom a couple days ago, and she was livid. Two summers ago, I came home from my summer job for lunch, and since she hadn’t gotten out of bed yet, I went to check on her. Half her face was paralyzed. I freaked out a little bit, made her smile, raise her arms, and talk to check for stroke. Sure enough, her smile was lopsided, she couldn’t raise her right arm, and her speech was slurred. I rushed her to the hospital, where she was diagnosed with a stroke. It wasn’t until the nurse noticed lesions on her tongue that they realized that she had Bell’s palsy caused by a reactivation of the VZV. Her face is still partially paralyzed, and she needs a gold weight in her eyelid to let it close and keep it from drying out. She can’t drink without a straw, and she frequently injures herself by biting her tongue.

    Even though this is an unusual case, I cannot comprehend anyone who would risk their child’s future health just because it’s more “natural” or that they might need a booster to keep their immunity up.

  6. Veneno

     /  November 7, 2011

    Just to add, I’ve now found the UK’s Joint Committee on Vaccination and Immunisation statement on VZV, which concludes (para 10) that a programme combining paediatric varicella and adult zoster vaccination risks INCREASING the incidence of shingles for the next 40 to 60 years, as well as possibly increasing adult varicella with its attendant risks. Such a programme is accordingly NOT recommended.

    However zoster vaccination of older adults only is likely to be cost-effective if the vaccine can be obtained at suitable price.


  7. I’m not old enough for the shingles vaccine, but when I am, I can call my doctor or go down to the city Department of Health and get it free. I’m not prepared to say that we should be asking children to get sick because many adults find it too inconvenient to go to the doctor. Even in terms of unpaid time off, the time it would take me to go get that shot is less than the time someone else would need to take to care for her sick child. If adult re-vaccination is “harder” to implement, it’s a side effect of adults generally not going to the doctor regularly; it could be set up as routinely as flu vaccines at the drugstore.

    By the way, is there an upper age limit for the regular chicken pox vaccine? When I was at the Department of Health for another vaccine, they asked if I was born in the U.S., which I suspect was proxy for “did you have chicken pox,” since the CDC that assumes anyone born in the U.S. before a certain date had chicken pox as a child.

  8. Veneno

     /  November 7, 2011

    Please try to think about this in terms of population health, not individuals. All vaccination programmes are population level strategies, with population as well as individual level effects. It isn’t helpful to say that “adults can just go and get a shingles vaccine”. Frankly, we know that most won’t. And public health policy has to be based on that reality, not on some airy fairy imaginary world where everyone does what they’re supposed to.

  9. Beth

     /  November 7, 2011

    Stupid, yes, and probably still illegal, but what are the chances of the varicella virus surviving on candy in such numbers that would cause illness in someone with an average immune system? Is this something some antivaxers are just trying or something that’s been documented to strike a child ill? Not something I’m wanting to look up, as I find the whole idea revolting, but still.

    Before the vaccine came out, at 2 years old, my cousin was in the hospital with chickenpox. I was too young to visit, though I’d had it already (a mild case at age 6). I remember being told she had pox down her throat and wasn’t eating. She also got some kind of secondary infection. She lost a lot of weight for such a small child and was in the hospital for more than a week. I wouldn’t wish it upon the children, but how smug would an antivaxer parent be if the virus laden candy did that?

    Does the idea of virus-laden candy strike anyone else as reminiscent of the “poison halloween candy” or even “razor blades in apples” scares? It’s like making sure your kid has a razor blade in their apple because you think mouth gashes are beneficial.

    • PalMD

       /  November 7, 2011

      Varicella is primarily transmitted by respiratory means, so the parents doing this are somewhat idiotic as well as dangerous. The danger comes not only in the potential piggybacking of other pathogens, but the unknown sources. If you request chickenpox from a stranger how do you know it isn’t anthrax?

      It this is more than an urban legend, as you seem to suggest. It is typical of the antivaccine movement (therefore plausible) and there are enough of facebook screenshots and discussion forum leaks that this seems to be the real thing.

  10. JustaTech

     /  November 7, 2011

    My father-in-law almost lost an eye to an attack of shingles as a teenager. His vision in that eye is severely limited. He was in so much pain he had to be straight-jacketed before he pulled his eye out. I would not wish that kind of pain on anyone. Why would you want to make your child vulnerable to that?

    Maybe if we called it “herpes” rather than “chicken pox” people would be less excited about giving it to their kids!

  11. PalMD

     /  November 7, 2011

    @Veneno: In the US context, the calculus has been different (see e.g. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6034a2.htm). The “supposeds” and “maybes”, and, for better or worse, the cost, don’t figure as prominently as in your statements.

    As to adult vaccine coverage, the argument is simply invalid. There are many, many vaccines that are recommended for American adults. Compliance is a public health issue, not simply something for which we toss our hands in the air and say, “well, real people won’t do it.” Especially without evidence.

  12. Veneno–

    Part of my point is that there’s nothing inherent in adults that makes an effective vaccination program impracticable. But here and now, I walk past drugstores with large signs promising I can get a flu vaccine on the spot, inexpensively (if I’m not insured). That wasn’t true five years ago. Here and now, my employer provided flu shots free of charge, in the office, last month.

    Again, if I need a tetanus booster, I can count on my doctor’s office having it. I can’t count on them having the shingles or the hepatitis B vaccine. But that’s not inherent in the vaccines themselves. Widespread vaccination for shingles will require a decent publicity campaign to let people know that it exists and is useful, and better distribution. Yes, it’s a population-level public health issue: that’s not a reason to give up on the idea.

  13. You know, I SO thought this was a hoax when I ran into the story about sending things through the mail … Why? Because I’m baffled that anyone would put a lollipop (or rag) from someone ‘unknown’ into their child’s mouth. I mean, really? WTH?! And that’s not even considering the “sending viruses through the mail risking exposure to others”.

    Then again, I guess all of the participants in this “mix and ‘helping'” consider the people not involved in this are fair game since ‘we’ don’t understand that vaccines are dangerous. If it wasn’t for the fact that children can’t decide who their parents are, and that these parents threaten the children, I’d say “let them have the disease and get complications”. obviously it’s not the parents who will suffer though – but their innocent children and their friends….

  14. The thing about the internet is that any old sociopath can pretend to be a nice mom with a kid with chicken pox. FSM only know where these suckers have actually been.

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