Factors associated with mortality in immunocompromised children with varicella

Combatting vaccine-preventable disease is a core strategy to achieve universal health coverage, including varicella. In immunocompetent children, varicella is generally a benign, self-limiting disease that rarely causes complications and death, whereas in immunocompromised children, morbidity and mortality due to varicella are much higher. The aim of this study is to analyze the factors of varicella-related death in immunocompromised children at one center, Dr. Sardjito General Hospital, Indonesia.

We recorded immunocompromised pediatric patients (1 month-18 years old) diagnosed with varicella retrospectively between January 2017 and December 2022 at Dr. Sardjito General Hospital. Factors associated with mortality were tested using bivariate analysis.

A total of 74 children with varicella were hospitalized during the study period. Of these patients, 63 were immunocompromised (85%). Thirty-six (57%) patients had an underlying haematological malignancy ; 11 (18%) patients had solid organ tumors; and 16 (25%) patients had non-malignant diseases. The mean age was 8.4 (± 4.65) years, with a male-to-female ratio of 1.3 to 1. The median time from the onset of the first skin rash to the administration of an intravenous acyclovir was 2 (0-8) days. None of the patients had received the varicella vaccination. Twenty patients (32%) developed one or more complications, where pneumonia accounted for the highest number of cases (12.7%). We recorded varicella-related deaths in 6 (9.5%) patients. Children who had ≥ 2 varicella complications (RR 23.64 (95%CI 3.06-182.90), p < 0.001), and with neutrophil/lymphocyte (NLR) ratio > 3.3 (RR 6.67 (95% CI 0.83-53.81); p 0.047) were associated with a significantly higher risk of death.

Multiple complications and a neutrophil/lymphocyte (NLR) ratio > 3.3 were associated with a significantly higher risk of death in immunocompromised children with varicella.