Herpes zoster primary prevention

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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.

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.

Vaccines

Varicella containing vaccines	Indications	Efficacy and immunogenicity	Recommended dose	Contraindications
Varicella vaccine (Varivax)	Children Routine vaccination at 12-15 months of age Routine second dose at 4-6 years of age Adolescents and Adults All persons 13 years of age and older without evidence of varicella immunity	Detectable antibody 97% of children 12 months through 12 years following 1 dose 99% of persons 13 years and older after 2 doses 70% to 90% effective against any varicella disease 90%-100% effective against severe varicella disease	Children Minimum interval between doses of varicella vaccine is 3 months for children younger than 13 years of age Adolescents and Adults 2 doses separated by at least 4 weeks Do not repeat first dose because of extended interval between doses	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness Recent blood product
Measles-mumps-rubella-varicella vaccine (ProQuad)	Approved for children 12 months through 12 years Do not use for persons 13 years and older	Efficacy of MMRV vaccine was inferred from that of MMR vaccine and varicella vaccine on the basis of noninferior immunogenicity Formal studies to evaluate the clinical efficacy of MMRV vaccine have not been performed	May be used for both first and second doses of MMR and varicella vaccines Minimum interval between doses is 3 months	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness Recent blood product Personal or family (i.e., sibling or parent) history of seizures of any etiology
Herpes zoster vaccine (Zostavax)	Approved for persons 50 years and older Not recommended by ACIP in adults younger than 60 years of age	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	Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster)	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness
New Herpes zoster vaccine (Shingrix)	Adults aged 50 years or older (first pivotal phase 3 trial) Adults aged 70 years and over (second pivotal phase 4 trial)	Efficacy between 91-97% for all age groups Efficacy does not decrease with increasing age group	Two doses 2 to 6 months apart	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.

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.

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.

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.
• 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.
• 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.

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.

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.