Managing Herpes Zoster (Shingles) Exposures in Health Care Settings

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Control measures for patients with localized rash

• If the patient is immunocompetent and the rash is localized, follow standard precautions, and cover all lesions until lesions are dry and crusted.
• If a patient is immunocompromised and the rash is localized, follow standard precautions plus airborne and contact precautions until disseminated infection is ruled out. If dissemination is ruled out, follow standard precautions and cover all lesions until lesions are crusted.
• Only health care workers with adequate evidence of immunity to varicella should care for patients with zoster.

Control measures for patients with disseminated or generalized rash

• If the rash is disseminated (lesions outside the primary or adjacent dermatomes), follow standard precautions plus airborne and contact precaution until the lesions are crusted, regardless of if the patient is immunocompromised or immunocompetent.
• Place patient in negative airflow rooms. If this is unavailable, place patients in their own room and keep the door closed. Those without immunity to varicella should not enter the room.
• Only health care workers with adequate immunity to varicella should care for patients with zoster.

Zoster transmission

Zoster is not spread person to person. However, if someone is not immune to varicella and is exposed to zoster, they may develop varicella disease.

• For localized zoster, transmission occurs through contact with the fluid in the blisters of the rash. A person is not infectious before the blisters appear or after the rash has crusted over.
• For disseminated zoster, transmission occurs through airborne and droplet transmission, in addition to contact with fluid in the blisters of the rash. Disseminated zoster is likely as infectious as varicella.

Management of exposed individuals

Evaluate evidence of immunity to varicella in all individuals exposed to zoster.

• For localized zoster, exposures include those with intimate contact (i.e., changing bandages, touching, hugging). These exposures are usually limited.
• For disseminated zoster, exposures include those in the same 2- to 4- person bedroom, adjacent beds in a large area, or face-to-face contact.

Evidence of immunity to varicella includes:

• Documentation of age-appropriate varicella vaccination:
  • Children age 12 months to 4 years: One dose of varicella vaccine.
  • Children age 4 years and older, adolescents, and adults: Two doses of varicella vaccine.
• Laboratory evidence of immunity or laboratory confirmation of disease.
• Born in the United States before 1980.
  • For health care workers, pregnant women, and immunocompromised persons, birth before 1980 should not be considered evidence of immunity.
• Health care provider diagnosis of varicella or zoster or verification of history of varicella or zoster disease. Health care providers should refer to CDC: Clinical Overview of Chickenpox (Varicella) when verifying history of disease in patients.

Exposed individuals without evidence of immunity should be offered post-exposure prophylaxis in the following situations:

• Healthy individuals age 12 months and older should be given varicella vaccine (as long as it is not contraindicated) within 5 days of exposure.
• The following individuals should receive VariZIG within 10 days of exposure:
  • Immunocompromised individuals.
  • Pregnant woman.
  • Hospitalized preterm infants (28 weeks or more) whose mother lacks evidence of immunity against varicella.
  • Hospitalized preterm infants less than 28 weeks of gestation or birthweight of 1000g or less, regardless of maternal immunity.
  • It is not indicated for newborn infants whose mother had onset of zoster around delivery to receive VariZIG. This differs from the varicella recommendations.

Management of exposed health care workers

To prevent transmission of varicella in health care facilities, all health care workers should have evidence of immunity to varicella. This information should be documented and readily available. Visit Ensuring Immunity to Varicella in Health Care Workers for more information. Health care workers exposed to zoster:

• With adequate evidence of immunity to varicella:
  • Should be monitored daily for symptoms of varicella from days 8-21 after exposure.
• With 1 documented dose of varicella vaccine:
  • Should receive a second dose of varicella vaccine. Monitor for symptoms of varicella from days 8-21 after exposure.
• Without any documented varicella vaccine:
  • Should be furloughed from days 8-21 after exposure or removed from patient care settings during this time. These health care workers should be offered varicella vaccine within 3-5 days after exposure if it is not otherwise contraindicated. Health care workers who are at high risk for severe disease and cannot receive varicella vaccine are recommended to receive VariZIG.