Herpes zoster primary prevention: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Herpes zoster}} | {{Herpes zoster}} | ||
{{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}} | {{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{AA}} | ||
==Overview== | ==Overview== | ||
The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated. A vaccine for shingles is licensed for persons aged 60 years and older. | The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated. A vaccine for shingles is licensed for persons aged 60 years and older.<ref name=CDCVZV>https://www.cdc.gov/shingles/vaccination.html Accessed on October 24th, 2016</ref> | ||
==Primary Prevention== | ==Primary Prevention== | ||
[[Zostavax]] vaccine is recommended for individuals aged 60 years and older to prevent Herpes zoster. Other primary prevention strategies include intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruits.<ref name="pmid16330478">{{cite journal |author=Thomas SL, Wheeler JG, Hall AJ |title=Micronutrient intake and the risk of herpes zoster: a case-control study |journal=International Journal of Epidemiology |volume=35 |issue=2 |pages=307-14 |year=2006 |pmid=16330478 |doi=10.1093/ije/dyi270}}</ref><ref>{{cite journal|last=Irwin|first=MR|coauthors=Olmstead, R & Oxman, MN|title=Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi|date=2007|journal=Journal of the American Geriatrics Society|volume=55|issue=4|pages=511-517|url=http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01109.x|doi=10.1111/j.1532-5415.2007.01109.x|accessdate=2007-04-08}}</ref> | |||
===Vaccines=== | ===Vaccines=== | ||
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center | |||
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! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Varicella containing vaccines}} | |||
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Indications}} | |||
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Efficacy and immunogenicity}} | |||
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Recommended dose}} | |||
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Contraindications}} | |||
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| style="padding: 5px 5px; background: #DCDCDC;" |'''Herpes zoster vaccine (Zostavax)'''<ref name=CDC3>http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016</ref><ref>Poland, Gregory. "The Growing Paradigm of Preventing Disease." Annals of Internal Medicine. 2005;143539-541. </ref><ref>Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418</ref><ref name="pmid1658650">{{cite journal| author=Hardy I, Gershon AA, Steinberg SP, LaRussa P| title=The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 22 | pages= 1545-50 | pmid=1658650 | doi=10.1056/NEJM199111283252204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1658650 }} </ref><ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | |||
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*Approved for persons 50 years and older | |||
*Not recommended by ACIP in adults younger than 60 years of age | |||
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*Vaccine recipients 60 to 80 years of age had 51% fewer episodes of zoster | |||
:*Efficacy declines with increasing age | |||
:*Significantly reduces the risk of postherpetic neuralgia | |||
*Reduces the risk of zoster 69.8% in persons 50 through 59 years of age | |||
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*Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster) | |||
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*Severe allergic reaction to vaccine component or following a prior dose | |||
*Immunosuppression | |||
*Pregnancy | |||
*Moderate or severe acute illness | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;" |'''New Herpes zoster vaccine (Shingrix)'''<ref name="pmid25916341">{{cite journal| author=Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ et al.| title=Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 22 | pages= 2087-96 | pmid=25916341 | doi=10.1056/NEJMoa1501184 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25916341 }} </ref> | |||
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*Adults aged 50 years or older (first pivotal phase 3 trial) | |||
*Adults aged 70 years and over (second pivotal phase 4 trial) | |||
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*Efficacy between 91-97% for all age groups | |||
*Efficacy does not decrease with increasing age group | |||
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*Two doses 2 to 6 months apart | |||
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*Immunocompromised individuals | |||
|- | |||
|} | |||
===Infection control preventive measures=== | |||
Infection-control measures after exposure to herpes zoster depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated. In all cases, standard infection-control precautions should be followed.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | |||
'''If the patient is immunocompetent''' | |||
*Localized herpes zoster: then standard precautions should be followed and lesions should be completely covered. | |||
*Disseminated herpes zoster: defined as appearance of lesions outside the primary or adjacent dermatomes, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | |||
'''If the patient is immunocompromised''' | |||
*Localized herpes zoster: then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until lesions are dry and crusted. | |||
*Disseminated herpes zoster: then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | |||
* | |||
====Management of Healthcare Personnel==== | ====Management of Healthcare Personnel==== | ||
The following steps should be taken when healthcare personnel (HCP) are exposed to someone with varicella or herpes zoster: | The following steps should be taken when healthcare personnel (HCP) are exposed to someone with varicella or herpes zoster: | ||
*HCP who have received 2 doses of varicella vaccine should be monitored daily during postexposure days 8–21 for fever, skin lesions, and systemic symptoms suggestive of varicella. HCP can be monitored directly by employee health program or infection control practitioners or instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. If symptoms occur, the HCP should be immediately removed from patient care areas and receive antiviral medication. Healthcare personnel with varicella and disseminated herpes zoster should be excluded from work until all lesions have dried and crusted or, in the absence of vesicular lesions, until no new lesions have appeared for 24 hours. | *HCP who have received 2 doses of varicella vaccine should be monitored daily during postexposure days 8–21 for fever, skin lesions, and systemic symptoms suggestive of varicella. HCP can be monitored directly by employee health program or infection control practitioners or instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. If symptoms occur, the HCP should be immediately removed from patient care areas and receive antiviral medication. Healthcare personnel with varicella and disseminated herpes zoster should be excluded from work until all lesions have dried and crusted or, in the absence of vesicular lesions, until no new lesions have appeared for 24 hours.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | ||
*HCP who have received 1 dose of varicella vaccine should receive the second dose at any interval after exposure to someone with rash (provided 4 weeks have elapsed after the first dose). After vaccination, management is the same as that of HCP who have received 2 doses of varicella vaccine. | *HCP who have received 1 dose of varicella vaccine should receive the second dose at any interval after exposure to someone with rash (provided 4 weeks have elapsed after the first dose). After vaccination, management is the same as that of HCP who have received 2 doses of varicella vaccine.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | ||
*Unvaccinated VZV-susceptible HCP are potentially infective from days 8 to 21 after exposure and should be furloughed or temporarily reassigned to locations remote from patient-care areas during this period. Exposed HCP without evidence of immunity should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash may modify the disease if infection occurred. Vaccination 6 or more days after exposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection). For unvaccinated VZV-susceptible HCP at risk for severe disease and for whom varicella vaccination is contraindicated (e.g., pregnant HCP), varicella-zoster immune globulin after exposure is recommended. | *Unvaccinated VZV-susceptible HCP are potentially infective from days 8 to 21 after exposure and should be furloughed or temporarily reassigned to locations remote from patient-care areas during this period. Exposed HCP without evidence of immunity should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash may modify the disease if infection occurred. Vaccination 6 or more days after exposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection). For unvaccinated VZV-susceptible HCP at risk for severe disease and for whom varicella vaccination is contraindicated (e.g., pregnant HCP), varicella-zoster immune globulin after exposure is recommended.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref> | ||
To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all | ===Preventing Transmission in Healthcare Settings=== | ||
To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.<ref name=CDC3>http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016</ref> | |||
Evidence of immunity to VZV for | Evidence of immunity to VZV for healthcare personnel includes any of the following: | ||
* | *Documentation of vaccination with 2 doses of varicella vaccine; | ||
* | *Laboratory evidence of immunity or laboratory confirmation of disease; | ||
* | *Diagnosis or verification of a history of varicella disease by a healthcare provider; or | ||
* | *Diagnosis or verification of a history of herpes zoster by a healthcare provider. | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WS}} | |||
{{WH}} | |||
[[Category:Infectious skin diseases]] | [[Category:Infectious skin diseases]] | ||
[[Category:Viral diseases]] | [[Category:Viral diseases]] | ||
[[Category:Herpesviruses]] | [[Category:Herpesviruses]] | ||
Latest revision as of 22:10, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aysha Anwar, M.B.B.S[3]
Overview
The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated. A vaccine for shingles is licensed for persons aged 60 years and older.[1]
Primary Prevention
Zostavax vaccine is recommended for individuals aged 60 years and older to prevent Herpes zoster. Other primary prevention strategies include intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruits.[2][3]
Vaccines
| Varicella containing vaccines | Indications | Efficacy and immunogenicity | Recommended dose | Contraindications |
|---|---|---|---|---|
| Herpes zoster vaccine (Zostavax)[4][5][6][7][8] |
|
|
|
|
| New Herpes zoster vaccine (Shingrix)[9] |
|
|
|
|
Infection control preventive measures
Infection-control measures after exposure to herpes zoster depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated. In all cases, standard infection-control precautions should be followed.[8]
If the patient is immunocompetent
- Localized herpes zoster: then standard precautions should be followed and lesions should be completely covered.
- Disseminated herpes zoster: defined as appearance of lesions outside the primary or adjacent dermatomes, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.[8]
If the patient is immunocompromised
- Localized herpes zoster: then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until lesions are dry and crusted.
- Disseminated herpes zoster: then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.[8]
Management of Healthcare Personnel
The following steps should be taken when healthcare personnel (HCP) are exposed to someone with varicella or herpes zoster:
- HCP who have received 2 doses of varicella vaccine should be monitored daily during postexposure days 8–21 for fever, skin lesions, and systemic symptoms suggestive of varicella. HCP can be monitored directly by employee health program or infection control practitioners or instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. If symptoms occur, the HCP should be immediately removed from patient care areas and receive antiviral medication. Healthcare personnel with varicella and disseminated herpes zoster should be excluded from work until all lesions have dried and crusted or, in the absence of vesicular lesions, until no new lesions have appeared for 24 hours.[8]
- HCP who have received 1 dose of varicella vaccine should receive the second dose at any interval after exposure to someone with rash (provided 4 weeks have elapsed after the first dose). After vaccination, management is the same as that of HCP who have received 2 doses of varicella vaccine.[8]
- Unvaccinated VZV-susceptible HCP are potentially infective from days 8 to 21 after exposure and should be furloughed or temporarily reassigned to locations remote from patient-care areas during this period. Exposed HCP without evidence of immunity should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash may modify the disease if infection occurred. Vaccination 6 or more days after exposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection). For unvaccinated VZV-susceptible HCP at risk for severe disease and for whom varicella vaccination is contraindicated (e.g., pregnant HCP), varicella-zoster immune globulin after exposure is recommended.[8]
Preventing Transmission in Healthcare Settings
To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.[4]
Evidence of immunity to VZV for healthcare personnel includes any of the following:
- Documentation of vaccination with 2 doses of varicella vaccine;
- Laboratory evidence of immunity or laboratory confirmation of disease;
- Diagnosis or verification of a history of varicella disease by a healthcare provider; or
- Diagnosis or verification of a history of herpes zoster by a healthcare provider.
References
- ↑ https://www.cdc.gov/shingles/vaccination.html Accessed on October 24th, 2016
- ↑ Thomas SL, Wheeler JG, Hall AJ (2006). "Micronutrient intake and the risk of herpes zoster: a case-control study". International Journal of Epidemiology. 35 (2): 307–14. doi:10.1093/ije/dyi270. PMID 16330478.
- ↑ Irwin, MR (2007). "Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi". Journal of the American Geriatrics Society. 55 (4): 511–517. doi:10.1111/j.1532-5415.2007.01109.x. Retrieved 2007-04-08. Unknown parameter
|coauthors=ignored (help) - ↑ 4.0 4.1 http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016
- ↑ Poland, Gregory. "The Growing Paradigm of Preventing Disease." Annals of Internal Medicine. 2005;143539-541.
- ↑ Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418
- ↑ Hardy I, Gershon AA, Steinberg SP, LaRussa P (1991). "The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group". N Engl J Med. 325 (22): 1545–50. doi:10.1056/NEJM199111283252204. PMID 1658650.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016
- ↑ Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ; et al. (2015). "Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults". N Engl J Med. 372 (22): 2087–96. doi:10.1056/NEJMoa1501184. PMID 25916341.