Family Practice Vol. 18, No. 3, 249-252
© Oxford University Press 2001
Infectious Diseases |
General practice survey of the management of chickenpox: appropriate targeting of antiviral therapy
Department of General Practice and Primary Care and
a Department of Infectious Diseases, St George's Hospital Medical School, London, UK.
Correspondence to Dr Tess Harris, Lecturer in Department of General Practice and Primary Care, St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 0RE, UK.
Shepherd J, Harris T, Harrison T and Hilton S. General practice survey of the management of chickenpox: appropriate targeting of antiviral therapy. Family Practice 2001; 18: 249–252.
Received 27 June 2000; Revised 3 October 2000; Accepted 8 January 2001.
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Abstract |
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Background. A working party of specialists and GPs recently published their consensus on recommended treatments for chickenpox. These are the closest to recommended guidelines available in the UK. They offer a rational basis for targeting those groups most at risk of complications with antiviral treatment.
Objectives. The aim of the present study was to compare current practice by GPs in the management of chickenpox, particularly in targeting of antiviral therapy, with the working party recommendations.
Method. A questionnaire survey was conducted of all GP principals within a single London Health Authority. Responses to nine chickenpox clinical scenarios were compared with the working party recommendations.
Results. The response rate was (69.2%) 227/328. In five of the nine scenarios, fewer than 70% of GPs selected the correct response according to the recommendations. There was both underuse and overuse of antivirals according to the recommendations, with only 42% (96/227) advising oral antivirals or referral for an asthmatic treated with oral steroids 1 month previously, and 24% (53/221) advising oral antivirals 3 days after the chickenpox rash appeared.
Conclusions. The results suggest some high risk groups may be being undertreated with oral antivirals and there may be considerable use of oral antivirals in situations where they are of no proven benefit.
Keywords. Antivirals, chickenpox, primary care.
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Introduction |
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Between 1991 and 1992, there were 70 consultations for chickenpox in general practice per 10 000 person years at risk.1 In the UK, 90% of chickenpox infections occur in children2 but the risk of complications is 25 times greater3 and mortality is 15 times greater in adults.2 There appears to be a change in the seroprevalence of varicella antibodies in the UK, with increasing susceptibility amongst adults compared with 10–20 years ago.4 The incidence, numbers of hospital admissions and deaths from chickenpox are all increasing in the UK,4 and increasing numbers of adult cases are presenting to GPs.3 In England and Wales, there are approximately 17 deaths a year from chickenpox in adults; immunosuppression is a contributory factor in only a quarter.3 Complications include secondary skin and soft tissue infection, chickenpox pneumonitis, thrombocytopenia, cerebellar ataxia and chickenpox encephalitis.3
In January 1998, a working party of specialists and GPs published their consensus on recommended treatments of chickenpox.3 The main recommendations for patients likely to present to GPs are shown (Table 1
footnotes). While this information was not widely disseminated to GPs, it included specific recommendations for the primary care management of chickenpox and is the closest to recommended guidelines available in the UK. The purpose of this study was to investigate current practice by GPs in the management of this very common infectious disease. This paper will not discuss the management of shingles or the post-exposure prevention of chickenpox.
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Method |
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A questionnaire was sent to all 336 GP principals in Merton, Sutton and Wandsworth Health Authority. This Authority spans parts of inner and outer London and Surrey and has a mixed patient population in terms of socio-economic status and ethnicity; 15% of the population are from black and minority ethnic communities. Doctors were given different management options to select for nine clinical scenarios based on the recommendations of the working party. The questionnaire was piloted first on 25 other GPs, and ambiguous questions were removed or modified. Non-responders were remailed after 3 months.
Details on practice size, qualifications and years since registration were obtained from the Health Authority. Associations between these variables and the number of correct options selected were sought using a chi square test. A large sample approximation was used to calculate 95% confidence intervals (CIs) for proportions.
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Results |
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Eight GPs had retired or were on extended leave. The response rate was 227/328 (69.2%). Management options selected by GPs for the clinical scenarios are shown in Table 1
. There were five scenarios where fewer than 70% of GPs selected the correct response according to the working party recommendations. Of the GPs, 39% (89/226) said they would treat the asymptomatic heavy smoker with antivirals, 62% (139/225) said they would refer the patient on azathioprine, 42% (96/227) said they would give oral antivirals or refer an asthmatic treated with oral steroids 1 month ago, 24% (53/221) said they would give oral antivirals to a heavy smoker 3 days after the appearance of the chickenpox rash and 69% (154/223) said they would refer a patient with chest symptoms and fever to a specialist. There were no statistically significant associations between practice size (test of trend P = 0.07), years since registration (test of trend P = 0.75) or qualifications (MRCGP/ MRCP) (P = 0.91) and the number of options selected in agreement with working party recommendations.
A total of 92.5% (210) of GPs said they would like guidelines on which patients with chickenpox should receive antiviral treatment or specialist referral.
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Discussion |
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The study has some potential limitations. The response rate was fair (69.2%) but doctors with an interest in chickenpox may be more likely to respond. This study looks at reported behaviour not actual behaviour, which may be less favourable.
The results show that the majority of GPs follow the conservative option of symptomatic treatment only for healthy adults and children with no additional risk factors. Even in this group of healthy adults, chickenpox has a 25-fold greater risk of complications than in children.3 The commonest and sometimes fatal complication in adults is varicella pneumonitis. Those at particular risk for this are pregnant women, heavy smokers, those with severe chronic lung disease and patients receiving or having received systemic steroids within the last 3 months regardless of dose.3 The working party recommends these groups should be given oral antivirals if seen within 24 h of the rash.3 (Although aciclovir appears safe in pregnancy, it is not licensed for such use and the manufacturer keeps a register of pregnant users.) In this survey, asymptomatic heavy smokers were not seen as a particularly vulnerable group as only 39% (89/226) of GPs would have treated them with an oral antiviral. Only 69% (154/223) of GPs would have referred a patient with chest symptoms and fever to a specialist, but >90% of such patients will develop pneumonitis.3 Any patient with varicella who becomes breathless should be admitted to hospital for treatment with intravenous aciclovir. Most GPs recognized the risk of long-term immunosuppressants; 62% (139/225) would refer the patient on azathioprine; however, only 42% (96/227) would give oral antivirals or refer an asthmatic given a short course of steroids 1 month ago.
Oral antivirals are expensive; the recommended course for chickenpox is £75.11–£118.08, depending on which antiviral is used,6 and cost is often cited as a reason against routine use in adults. However, this survey showed that almost a quarter of GPs would give an oral antiviral to a heavy smoker 3 days after the appearance of the chickenpox rash despite treatment only being of proven benefit when begun within 24 h of onset of the rash.7
The working party recommendations offer a rational basis for targeting those most at risk, but were published in a source not widely read by GPs. Our study suggests that wider dissemination of the recommendations is needed if this targeting is to be achieved. Hopefully, the publication of this paper in a journal which is read by GPs will accelerate the dissemination process.
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Acknowledgments |
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We would like to thank all the general practitioners in Merton, Sutton and Wandsworth Health Authority who responded to this questionnaire.
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References |
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1 McCormick A, Fleming D, Charlton J. Morbidity Statistics from General Practice. Fourth National Study 1991–1992. London: Office of Population Census and Surveys, HMSO.
2 Brody MB, Moyer D. Varicella-zoster virus infection, the complex prevention–treatment picture. Postgrad Med 1997; 102: 187–194.
3 Wilkins EGL, Leen CLS, McKendrick MW, Carrington D. Management of chickenpox in the adult—a review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. J Infect 1998; 36 (Suppl 1): 49–58.
4 Miller E, Vurdien J, Farrington P. Shift in age in chickenpox. Lancet 1993; 341: 308–309.[Web of Science][Medline]
5 Tarlow MJ, Walters S. Chickenpox in childhood—a review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. J Infect 1998; 36 (Suppl 1): 39–47.
6 British National Formulary March 2000; no. 39.
7 Wallace MP, Bolwer MA, Murray NB, Brodine SK, Oldfield EC III. Treatment of adult varicella: a randomised, placebo-controlled trial of oral aciclovir. Ann Intern Med 1992; 117: 358–363.
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