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]

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

The intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruit, may reduce the risk of developing shingles. In one study, patients who consumed less than one serving of fruit a day had three times the risk as those who consumed over three servings per day. For those aged 60 or more, micronutrient and vegetable intake had a similar lowering of risk. A recent study evaluated the effects of two types of behavioral intervention, Tai Chi and health education, on healthy adults, who, after 16 weeks of the intervention, were vaccinated with VARIVAX, a live attenuated Oka/Merck Varicella zoster virus vaccine.

Vaccines

Varicella (Chickenpox) Vaccine can prevent this disease. Currently, two doses of vaccine are recommended for children, adolescents, and adults.

A live attenuated VZV Oka/Merck strain vaccine is available and is marketed under the trade name Varivax. It was developed by Merck, Sharp & Dohme in the 1980s from the Oka strain virus isolated and attenuated by Michiaki Takahashi and colleagues in the 1970s. It was submitted to the U.S. Food and Drug Administration for approval in 1990 and was approved in 1995. Since then, it has been added to the recommended vaccination schedules for children in Australia, the United States, and many other countries, causing controversy because it is only expected to be effective for about twenty years, leaving adults vulnerable to the most dangerous forms of infection by this virus. The use of varicella virus vaccine live (Varivax) has been limited by practitioner concerns that adults vaccinated as children could develop severe varicella infection complications if immunity provided by the vaccine is not long-lasting. However, clinical data has proved that the vaccine is effective for over 10 years in preventing varicella infection in healthy individuals and when breakthrough infections do occur, illness is typically mild.

In 2006, the FDA approved Zostavax for the prevention of shingles. Zostavax is a more concentrated formulation of the Varivax vaccine, designed to elicit an immune response in the eldery whose immunity to VZV wanes with advancing age. It was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2006 to reduce the risk of shingles and its associated pain in people age 60 years and older. Zostavax is developed by Merck & Co. and has proven successful in preventing half the cases of herpes zoster in a study of 38,000 people who received the vaccine. The vaccine also reduced by two-thirds the number of cases of postherpetic neuralgia. However, prior to the vaccine, it has long been known that adults received natural immune boosting from contact with children infected with varicella. This helped to suppress the reactivation of herpes zoster. In Massachusetts, herpes zoster incidence increased 90%, from 2.77/1000 to 5.25/1000 in the period of increasing varicella vaccination 1999-2003. The effectiveness of the varicella vaccine itself is dependent on this exogenous (outside) boosting mechanism. Thus, as natural cases of varicella decline, so has the effectiveness of the vaccine.

The risk for developing shingles increases with age. The Shingles Prevention Study involved individuals age 60 years and older and found the shingles vaccine significantly reduced disease in this age group. The vaccine is currently recommended for persons 60 years of age and older. Even people who have had shingles can receive the vaccine to help prevent future occurrences of the disease.

At this time, CDC does not have a recommendation for routine use of shingles vaccine in persons 50 through 59 years old. However, the vaccine is approved by FDA for people in this age group.

Risk of Acquiring Herpes zoster after Vaccination

The attenuated vaccine virus can reactivate and cause herpes zoster. People who get vaccinated against varicella may develop herpes zoster later in life. However, their risk is lower than people who were infected with wild-type VZV.

• In a study of children with leukemia, those who got varicella vaccine had a 67% lower risk of herpes zoster than children who had had varicella.
• Data on healthy children show a similar pattern of reduced risk of herpes zoster in those vaccinated against varicella.
• The number of older adults who got varicella vaccine since it was licensed in 1995 is quite low. So, there is very little information on the risk of herpes zoster in people who got varicella vaccine as adults.

Prevention in Healthcare Settings

Management of Patients with Herpes Zoster

Infection-control measures 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 with:

• 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 with:

• 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.

To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all HCP have evidence of immunity to VZV. This information should be documented and readily available at the work location. HCP 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 HCP and for management of HCP after exposures in the workplace.

Evidence of immunity to VZV for HCP 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.