Download Shingles • Introduction • Transmission • Signs and Symptoms

Shingles
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Introduction
Transmission
Signs and Symptoms
Complications
Diagnosis
Treatment
Infection Prevention and Control Precautions for
Residents with Shingles
 Additional considerations
–Identify all exposed contacts
–Management of staff contacts
–Management of high risk residents/client contacts
Developed by
In conjunction with
Date developed
Approved by
Reference number
Revision date
Responsibility for
review
Liz Forde, Patricia Coughlan, Niamh McDonnell and Máire Flynn
Mary Thompson CNM3 and Brigid Quaid CNM3 Occupational Health
Department
Dr. Fiona Ryan and Dr. Ann Sheehan, Department of Public Health
Dr. Bartley Cryan, Consultant Microbiologist
August 2012
Cork and Kerry Infection Prevention and Control Committee
Kerry Infection Prevention and Control Committee
IPCG 10.5/ 2012
Revision number
0
2015 or sooner if new evidence becomes available
Infection Prevention and Control Nurses
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 1 of 6
Shingles
Introduction
The varicella-zoster virus (VZV) causes two distinct clinical infectious diseases,
chickenpox (varicella) and shingles (herpes zoster). Following chickenpox
infection, the varicella zoster virus remains dormant or inactive in the nervous
tissue for several years but may reappear following reactivation and cause
shingles. Reactivation of the virus results in an infection of a nerve and the area of
the skin supplied by the nerve causing a cutaneous rash.
Anyone who has had chickenpox in the past may develop shingles as it is a
recurrence or reactivation of the varicella zoster virus.
It is not possible to develop shingles from exposure to a person with chickenpox.
It is possible however, to develop chickenpox as a result of exposure to a person
with shingles.
Transmission
Shingles lesions are infectious until they dry and crust over, however, the risk of
transmission is low if the lesions are covered. Infectiousness may be prolonged in
immunocompromised patients. The virus is confined to the rash and is transmitted
by:
• Direct contact with the vesicles fluid
• Droplet or airborne spread of vesicle fluid from disseminated shingles
cases.
A person with a shingles rash can pass the virus to someone who has never had
chickenpox, but that person will develop chickenpox not shingles. A person with
chickenpox cannot spread shingles to someone else. Shingles comes from the
dormant virus inside the person’s body (from their primary chickenpox infection),
not from an outside source.
Persons in the prodromal phase (before the rash appears) or who have post
herpetic neuralgia (PHN), but no longer have active lesions are not infectious.
Signs and Symptoms
The first sign of shingles is typically pain, itching, or tingling in the affected skin
usually 1 to 4 days before the rash appears. Headache, fever, photo phobia and
myalgia may also occur at this stage (prodromal phase).
The rash begins as an erythematous, maculopapular rash that develops into
clusters of clear vesicles. These vesicles then burst releasing varicella zoster virus.
New vesicles continue to form over 3-5 days and progressively crust over – the
rash is usually persistent for about 7 days but the pain may continue for longer.
The affected area may become intensely painful.
People with a poor immune system have a higher than normal risk of developing a
more severe rash of longer duration or of developing disseminated shingles
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 2 of 6
(defined as appearance of lesions somewhere other than along or near the path of
a nerve).
Complications
Postherpetic neuralgia (PHN) - This is the most common complication. It is
uncommon in people aged under 50 but becomes more common with age and
estimated that it affects one-third of people over 80.
 PHN is when the pain persists where the rash was present after the rash
and any other symptoms of shingles have resolved. PHN can cause severe
nerve pain (neuralgia) that can last for weeks or months or even longer in a
few cases.
Postherpetic neuralgia may be treated with a number of different painkilling
medicines.
Skin infection-The vesicles become infected with bacteria. The surrounding skin
becomes red and tender which may need to be treated with a course of
antibiotics.
Ophthalmic shingles - This is where shingles affects part of the trigeminal nerve
and can cause complications that affect the eye
If not treated, ophthalmic shingles may cause loss of vision.
Diagnosis
Shingles is diagnosed by the GP from the symptoms and the appearance of the
rash. Testing is not usually necessary.
Treatment
Analgesics and anitvirals drugs such as acyclovir can be used to treat shingles.
People at higher risk of developing serious complications from shingles may be
given antiviral drugs such as acyclovir and/or immunoglobulin (a specialised
preparation of antibodies taken from the plasma of blood donors), which may
prevent severe illness developing. See “Shingles - Information Leaflet”
Infection Prevention and Control Precautions for Residents with Shingles
 All staff caring for a resident/client with suspected shingles should have a
previous history of chickenpox or be known to be immune. The
Occupational Health Department holds vaccination and immunity details on
staff who have attended for pre-employment assessment. (Please make
contact with the Occupational Health Department if you have a query in
relation to your immunity).
Only immune staff should care for these residents.
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Inform the Infection Prevention and Control Nurse that you have a
resident/client with a possible/confirmed diagnosis of shingles and seek
advice.
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 3 of 6
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Residents/clients with localized shingles that can be covered with clothing
should be cared for using Standard Precautions and generally do not require
a single room.
All residents/clients with shingles that are either disseminated, are exposed
e.g. face or who, for whatever reason will scratch at the lesions should be
placed in a single room until all lesions have crusted over. Single room and
Contact Precautions are advised because of the risk of varicella in
susceptible immuno-compromised patients.
Please refer to Contact Precautions in Transmission-Based Precautions in
Section 6 for further detail.
Shingles-Additional consideration for infection prevention
Identify all exposed contacts
Contacts
A Shingles ‘Contact’ can be defined as any resident/client or staff member
who is non-immune to the varicella-zoster virus and who has had contact with
a case of disseminated, exposed shingles from the day of the rash until
crusting of the exposed rash
This will include:
• Contact with the wet shingles rash
• Contact with clothing and bedding soiled by discharge from the blisters
Management of Staff Contacts
 Staff contacts that are not immune to chickenpox must be identified
because they may be affected themselves or may transmit the disease to
vulnerable patients while incubating the disease themselves. These staff
must report immediately to Occupational Health.
 The ward/department manager needs to report all cases of disseminated
shingles to the Occupational Health Department so that contact screening
can commence. The Occupational Health Department will establish if there
are any possible staff contacts that may require vaccination or Varicella
Zoster Virus Immunoglobulin (VZVIG).
 Non-immune staff must report immediately to Occupational Health and be
offered vaccination to protect themselves and patients. (Refer to
Immunisation Guidelines for Ireland, 2008)
Potentially High Risk People include:
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Pregnant women
Infants under 1 month old
Immunosuppressed individuals including those with haematological
malignancies, on chemotherapy, high dose steroids or with HIV
infection.
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 4 of 6
Management of high risk resident/client contacts
 If a resident/client is immuno-compromised and contracts VZV then the
decision regarding where the patient should be nursed will be made in
consultation with the clinician responsible for their care.
 The medical officer/clinician should discuss the case with a Medical
Microbiologist or Consultant in Public Health Medicine. If Human VaricellaZoster Immunoglobulin (VZIG) is indicated, the optimum time for
administration of medication is within 96 hours of exposure (Refer to
Immunisation Guidelines for Ireland, 2008).
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 5 of 6
Reference and Bibliography
Centre for Disease Control http://www.cdc.gov/shingles/hcp/clinical-overview.html
Accessed 24th November 2011
Clinical Knowledge Summaries - Chickenpox
http://www.cks.nhs.uk/chickenpox/management/detailed_answers/advice_for_someone_with_c
hickenpox#-321645 Accessed 19th December 2011
Health
Protection
Surveillance
Centre.
Factsheet
Varicella
(Chickenpox)
http://www.hpsc.ie/hpsc/A-Z/VaccinePreventable/VaricellaChickenpox/Factsheet/ Accessed 23rd
November 2011
Immunisation Advisory Committee (2008) Immunisation guidelines for Ireland Royal College of
Physicians
of
Ireland
http://www.immunisation.ie/en/HealthcareProfessionals/ImmunisationGuidelines2008/
Accessed 15th December 2012
Occupational Health Department Cork University Hospital (2010) Policy and Procedure on the
Management of Healthcare Staff who are Non Immune to Varicella Zoster Virus in Cork
University Hospital Group
Royal
United
Hospital
Bath
(2011)
Chickenpox
and
Shingles
Policy
http://www.ruh.nhs.uk/about/policies/documents/clinical_policies/yellow_infection_control/Yello
w_602_Chickenpox_Shingles.pdf Accessed 24th November 2011
Strategy for Antimicrobial Resistance in Ireland (2011) Guidelines for Antimicrobial Prescribing in
Primary
Care
in
Ireland
http://www.hpsc.ie/hpsc/AZ/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,3334,en.pdf
Accessed 18th December 2011
Guidelines on Infection Prevention and Control 2012
HSE South (Cork & Kerry)
Community and Disability Services
Varicella (Chickenpox and Shingles)
Page 6 of 6