Shingles. HSE South (Cork & Kerry) Page 1 of 6 Community and Disability Services

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1 Shingles 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 Liz Forde, Patricia Coughlan, Niamh McDonnell and Máire Flynn In conjunction with 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 Date developed August 2012 Approved by Cork and Kerry Infection Prevention and Control Committee Kerry Infection Prevention and Control Committee Reference number IPCG 10.5/ 2012 Revision number 0 Revision date 2015 or sooner if new evidence becomes available Responsibility for Infection Prevention and Control Nurses review HSE South (Cork & Kerry) Page 1 of 6

2 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 HSE South (Cork & Kerry) Page 2 of 6

3 (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. Inform the Infection Prevention and Control Nurse that you have a resident/client with a possible/confirmed diagnosis of shingles and seek advice. HSE South (Cork & Kerry) Page 3 of 6

4 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:- Pregnant women Infants under 1 month old Immunosuppressed individuals including those with haematological malignancies, on chemotherapy, high dose steroids or with HIV infection. HSE South (Cork & Kerry) Page 4 of 6

5 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 Varicella- Zoster Immunoglobulin (VZIG) is indicated, the optimum time for administration of medication is within 96 hours of exposure (Refer to Immunisation Guidelines for Ireland, 2008). HSE South (Cork & Kerry) Page 5 of 6

6 Reference and Bibliography Centre for Disease Control Accessed 24 th November 2011 Clinical Knowledge Summaries - Chickenpox hickenpox# Accessed 19 th December 2011 Health Protection Surveillance Centre. Factsheet Varicella (Chickenpox) - Accessed 23 rd November 2011 Immunisation Advisory Committee (2008) Immunisation guidelines for Ireland Royal College of Physicians of Ireland Accessed 15 th 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 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 Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,3334,en.pdf Accessed 18 th December 2011 HSE South (Cork & Kerry) Page 6 of 6