Preventing Varicella-Zoster Virus (VZV) Transmission from Zoster 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. Evidence of immunity 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.
- Commercial assays can be used to assess disease-induced immunity, but they lack sensitivity to always detect vaccine-induced immunity (i.e., they might yield false-negative results).
- Verification of history or diagnosis of typical disease can be provided by any health-care provider (e.g., school or occupational clinic nurse, nurse practitioner, physician assistant, or physician). For persons reporting a history of, or reporting with, atypical or mild cases, assessment by a physician or their designee is recommended, and one of the following should be sought: (a) an epidemiologic link to a typical varicella case or to a laboratory-confirmed case or (b) evidence of laboratory confirmation if it was performed at the time of acute disease. When such documentation is lacking, persons should not be considered as having a valid history of disease because other diseases might mimic mild atypical varicella.
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