Management of Shingles in Healthcare Settings

Infection Control Precautions

The Centers for Disease Control and Prevention (CDC) recommends implementing contact precautions, including placing the patient in a single room or maintaining >3 ft spatial separation from others, using appropriate PPE, limiting patient transport and movement, and using dedicated or disposable patient-care equipment for patients with localized shingles 1
The CDC suggests implementing both airborne and contact precautions, including placing the patient in an airborne isolation room with negative pressure, or a private room with door closed, and wearing N95 respirators or masks for patients with disseminated shingles or immunocompromised patients 1
Patients with herpes zoster should be placed under airborne and contact precautions until all lesions are dry and crusted, as recommended by the CDC 2, 3
Immunocompromised patients should maintain strict airborne and contact precautions even with localized herpes zoster until disseminated infection is ruled out, as recommended by the CDC 2
If negative air-flow rooms are unavailable, patients should be isolated in closed rooms and contact with non-immune persons should be restricted, as advised by the CDC 2
Patients with disseminated zoster (lesions in >3 dermatomes) require stricter isolation measures, as recommended by the American Journal of Kidney Diseases 1

Only staff with documented immunity to varicella-zoster virus (VZV) should care for patients with suspected shingles, with evidence of immunity including documented receipt of 2 doses of varicella vaccine, laboratory evidence of immunity, laboratory confirmation of previous disease, or healthcare provider verification of history of varicella or herpes zoster, as recommended by the CDC 2, 3
Healthcare workers' immunity status should be verified before allowing contact with suspected cases, and not relying solely on verbal history of chickenpox without verification, as suggested by the CDC 3
Exposed healthcare workers without immunity should be excluded from duty from the 8th day after first exposure through the 21st day after last exposure, and if varicella develops, they should be excluded until all lesions are dry and crusted, as recommended by the CDC 2
Consider post-exposure vaccination within 3-5 days of exposure for exposed healthcare workers without immunity, as advised by the CDC 2

Patients with herpes zoster should avoid close contact with pregnant women who have never had chickenpox or the varicella vaccine, newborns and infants, immunocompromised individuals, and individuals without history of chickenpox or varicella vaccination, as advised by the CDC 2, 3
Susceptible household contacts should avoid direct contact with lesions, and consider avoiding close contact until lesions are crusted and consulting their healthcare provider about potential prophylaxis if they are high-risk, as recommended by the CDC 4
Patients with herpes zoster should cover all lesions completely with clean, dry bandages or clothing until they are fully crusted and dry, as recommended by the CDC 2
Extra precautions should be taken to protect vulnerable populations, including pregnant women without immunity to varicella, premature infants, and immunocompromised individuals, as recommended by the CDC 2, 3

The Infectious Diseases Society of America recommends starting antiviral treatment as soon as possible, ideally within 72 hours of rash onset, to decrease viral shedding and reduce the duration of lesions, which may reduce transmission risk 5
Antiviral medications decrease viral shedding and reduce the duration of herpes zoster lesions, as reported by the American Journal of Kidney Diseases 1
Starting antiviral treatment as soon as possible, ideally within 72 hours of rash onset, is crucial in managing herpes zoster, although the exact timing may vary depending on individual circumstances, as recommended by the American Journal of Kidney Diseases 1
Patients with localized herpes zoster that can be completely covered may return to work/school once they feel well enough, although those who work with high-risk populations (healthcare, childcare, schools) should consult occupational health guidelines, as advised by the CDC
Patients with disseminated zoster should remain home until all lesions are crusted, as recommended by the CDC 2, 3

The CDC advises maintaining precautions until all lesions are dry and crusted, and for immunocompromised patients, continuing precautions throughout the course of the illness and reassessing regularly 1
Herpes zoster presents a significant transmission risk because VZV can be transmitted through the airborne route from patients with herpes zoster, as reported by the CDC 2, 3
Transmission can occur even without direct contact with the index case, as noted by the CDC 3