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. 2019 Jul;24(7):839-848.
doi: 10.1111/tmi.13243. Epub 2019 May 22.

Varicella in Tshuapa Province, Democratic Republic of Congo, 2009-2014

Jessica Leung  1 , Andrea M McCollum  2 , Kay Radford  1 , Christine Hughes  2 , Adriana S Lopez  1 , Sarah Anne J Guagliardo  2   3 , Beatrice Nguete  4 , Toutou Likafi  4 , Joelle Kabamba  5 , Jean Malekani  6 , Robert Shongo Lushima  7 , Elisabeth Pukuta  8 , Stomy Karhemere  8 , Jean Jacques Muyembe Tamfum  8 , Mary G Reynolds  2 , Emile Wemakoy Okitolonda  4 , D Scott Schmid  1 , Mona Marin  1
Affiliations

Varicella in Tshuapa Province, Democratic Republic of Congo, 2009-2014

Jessica Leung et al. Trop Med Int Health. 2019 Jul.

Abstract
in English, French

Objective: To describe varicella cases in Tshuapa Province of the Democratic Republic of the Congo identified during monkeypox surveillance.

Methods: Demographic, clinical and epidemiological data were collected from each suspected monkeypox case 2009-2014. Samples were tested by PCR for both Orthopoxviruses and varicella-zoster virus (VZV); a subset of VZV-positive samples was genotyped. We defined a varicella case as a rash illness with laboratory-confirmed VZV.

Results: There were 366 varicella cases were identified; 66% were ≤19 years old. Most patients had non-typical varicella rash with lesions reported as the same size and stage of evolution (86%), deep and profound (91%), on palms of hands and/or soles of feet (86%) and not itchy (49%). Many had non-typical signs and symptoms, such as lymphadenopathy (70%) and sensitivity to light (23%). A higher proportion of persons aged ≥20 years than persons aged ≤19 years had ≥50 lesions (79% vs. 65%, P = 0.007) and were bedridden (15% vs. 9%, P = 0.056). All VZV isolates genotyped from 79 varicella cases were clade 5. During the surveillance period, one possible VZV-related death occurred in a 7-year-old child.

Conclusions: A large proportion of patients presented with non-typical varicella rash and clinical signs and symptoms, highlighting challenges identifying varicella in an area with endemic monkeypox. Continued surveillance and laboratory diagnosis will help in rapid identification and control of both monkeypox and varicella and improve our understanding of varicella epidemiology in Africa.

Objectif: Décrire les cas de varicelle identifiés dans la province de Tshuapa en République Démocratique du Congo (RDC) au cours de la surveillance de la variole du singe (monkeypox). MÉTHODES: Des données démographiques, cliniques et épidémiologiques ont été recueillies pour chaque cas présumé de monkeypox entre 2009 et 2014. Les échantillons ont été testés par PCR pour les orthopoxvirus et le virus varicelle-zona (VZV); un sous-ensemble d’échantillons positifs au VZV a été génotypé. Nous avons défini un cas de varicelle comme une éruption cutanée avec confirmation du VZV en laboratoire. RÉSULTATS: 366 cas de varicelle ont été identifiés; 66% avaient 19 ans ou moins. La plupart des patients présentaient une éruption non typique de varicelle avec des lésions rapportées de la même taille et le même stade d’évolution (86%), profonds (91%), sur la paume des mains et/ou la plante des pieds (86%), sans démangeaisons (49%). Nombre d'entre eux présentaient des signes et des symptômes inhabituels, tels qu'une adénopathie lymphatique (70%) et une sensibilité à la lumière (23%). Une proportion plus élevée de personnes âgées de 20 ans et plus que de personnes âgées de 19 ans et moins avaient 50 lésions ou plus (79% contre 65%, p = 0,007) et étaient alitées (15% contre 9%; p = 0,056). Tous les isolats de VZV génotypés chez 79 cas de varicelle appartenaient au clade 5. Au cours de la période de surveillance, un décès possible lié au VZV est survenu chez un enfant de 7 ans.

Conclusions: Une forte proportion de patients ont présenté une éruption de varicelle ainsi que des signes et symptômes cliniques non typiques, soulignant les difficultés rencontrées pour identifier la varicelle dans une zone endémique pour le monkeypox. Une surveillance continue et des diagnostics de laboratoire aideront à identifier et à contrôler rapidement le monkeypox et la varicelle et à améliorer notre compréhension sur l’épidémiologie de la varicelle en Afrique.

Keywords: RDC; Africa; Afrique; Democratic Republic of Congo, DRC; République Démocratique du Congo; chickenpox; epidemiology; monkeypox; varicella; varicella-zoster virus; varicelle; variole du singe monkeypox; virus varicelle-zona; Épidémiologie.

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Conflict of interest statement

Conflicts of interest:

None

Figures

Figure 1.
Figure 1.. Epidemiological curve of laboratory-confirmed varicella cases in Tshuapa Province, Democratic Republic of the Congo, September 2009–February 2014 (N = 357)abc
a 357 varicella cases had rash onset date available; 9 cases were missing information on rash onset date. bThe peaks in February 2011 and February 2012 correspond to workshops on monkeypox surveillance that were conducted for public health officials in Tshuapa Province, Democratic Republic of the Congo during those months. cThere were 6 varicella cases reported in 2009, before the start of the enhanced surveillance project.
Figure 2.
Figure 2.. Geographical distribution of laboratory-confirmed varicella cases in Tshuapa Province, Democratic Republic of the Congo by Health Zone, September 2009–February 2014 (n = 366)ab
aThe distribution of varicella cases by health zone are as follows: Busanga (27%), Djolu (20%), Mondombe (13%), Mompono (9%), Wema (6%), Ikela (6%), Boende (4%), Befale (4%), Bokungu (4%), Lingomo (3%), Monkoto (2%), and Yalifafu (2%). bThe higher concentration of varicella cases identified in Busanga and Djolu could be due to involvement of these two areas, as well as Ikela, in a special monkeypox research project during 2013–2015. Busanga is a smaller area in which most people live near the main road, which may make it easier to reach and investigate suspected cases.
Figure 3.
Figure 3.. Photos of two laboratory-confirmed varicella patients identified as part of monkeypox surveillancea
a Image 3A: 38-year-old female patient with desquamation of crusts from an extensive disseminated rash. Image 3B: 61-year-old female patient with active lesions.
Figure 4.
Figure 4.. Flow diagram of varicella-zoster virus (VZV) laboratory results from specimens tested at Institut National de Recherche Biomedicale (INRB) and the Centers for Disease Control and Prevention (CDC)
aA total of 476 specimens from 355 varicella patients were submitted to INRB for testing; 263 specimens (55%) were vesicular fluid, 192 (40%) were crusts, and 21 (4%) were blood specimens. Of these 355 patients, 237 (67%) had 1 specimen tested for VZV and 118 (33%) had ≥3 specimens tested. After testing at INRB, 334 (94%) of the 355 case-patients had ≥1 VZV positive specimen by PCR. bThere were 294 DNA specimens extracted at INRB. An additional 412 skin lesion specimens (59% from vesicles) from 355 patients were sent to the CDC National VZV Laboratory. Among these 355 patients, 106 (30%) had 1 specimen tested and 249 (70%) had ≥3 specimens tested. After testing at CDC, 345 (97%) of the 355 patients with specimens sent to CDC had ≥1 VZV positive specimen by PCR. cAmong the 344 specimens tested at both INRB and CDC, there were 91% (313) with concordant results, and 9% (31) with discordant results. Reasons for the discordant results could be due to differences in assay sensitivity, different specimens tested from the same patient, or potential false positive results if a high number of PCR cycles for amplification were used.
See this image and copyright information in PMC

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