Shingles, caused by the varicella zoster virus (VZV), commonly affects the ageing population, with around 50% of people having developed shingles by 85 years. It is a re-emergence of the chicken pox virus, which is also caused by VZV. Once a person is infected with VZV, the virus sits concealed in the cranial nerve and dorsal ganglia root (the nerve roots into the spinal cord that control pain and messages). VZV spontaneously reactivates under certain circumstances, causing the secondary infection known as shingles.  

Shingles is the secondary infection to a primary and historic infection of chicken pox, causing both neurological and dermatological symptoms. Shingles symptoms include pain, tingling or sensitivity in an area of the body, which precedes the development of an itchy, blistering rash. The symptoms are primarily on one side of the body and can be very painful, particularly if around the eye or ear area. The nerve pain occurs as the virus travels down a nerve pathway to the epidermis (the outer layer of skin) where a rash is produced. Unlike chickenpox where blisters are singular, shingles blistering is clustered in an area, often shaped like a band or girdle on one side of the body. Occasionally, more than one nerve path is affected. Non-rash symptoms can be flu-like, and include general malaise, fever and headache.

In some people, the nerve pain or inflammation can outlast the blistering and rash, known as post-herpetic neuralgia (PHN). PHN is a serious complication of shingles where pain and inflammation remain along the nerve path that was affected. PHN occurs in approximately 10%–15% of cases. Additional severe complications can include nerve paralysis, loss of hearing, blindness or encephalitis (inflammation of the brain).

Susceptibility

Shingles does not transmit shingles—it can however cause the primary infection of chicken pox in those who have not yet experienced chicken pox nor been immunised against it.

Immunocompromised individuals are more susceptible to developing shingles. This includes those undergoing chemotherapy, taking steroid medication or experiencing stress. Shingles generally occurs in people over 50 years of age, however it can occur in younger persons.

Treatment for Shingles

See your GP as soon as shingles symptoms appear. There are several antiviral medications available. It is important to have antiviral treatment as soon as possible to reduce the possibility and severity of complications.

Conservative skincare for shingles rash or blistering includes topical lotion (oatmeal and calamine), wet compresses and wound dressings. Treatments are aimed at addressing the itchiness, preventing the development of secondary bacterial (staph type) infections and minimising epidermal damage and scarring.

Oral analgesia (i.e. Panadol) is recommended for pain, and there are specialised treatments available for severe and complex pain. 

Transdermal analgesic patches can be effective for painful sites once they begin to crust over. Capsaicin cream is an over the counter treatment, reported to be effective once blisters begin to crust over, and is very effective in the treatment of PHN.

If the shingles impact the eyes in any way, the person needs to be reviewed immediately by an ophthalmologist. This should be considered an emergency.

Transmission consideration

Standard and contact precautions are advised when caring for residents with shingles. The varicella zoster virus is found in the blisters and is contagious to someone who has not had chicken pox before. Therefore, staff who have not had nor been immunised against chicken pox should not provide care for those with shingles.

Until the shingles rash crusts over, the affected person should avoid contact with pregnant women, infants and people with weak immune systems.

Isolate from young children who may not have been vaccinated against chickenpox and those who are pregnant.

https://www.cdc.gov/shingles/about/transmission.html

Vaccination

Shingles vaccination Zostavax is available in both the AU and NZ national immunisation programme and is highly recommended for people over the age of 50. It provides prevention against the development of shingles with prevention rates around 50%. The vaccine reduces the occurrence of shingles and potential debilitating outcomes such as nerve damage and blindness. Check with your general practitioner to see if a shingles vaccination is appropriate.

Zostavax is no longer available in the USA as of November 2020, instead a vaccine called Shingrix is being utilised with prevention rates reportedly around 90%.

Exclusion from work

Healthcare workers affected with shingles should not provide any care if their blisters cannot be covered. Ideally they should remain off work until the affected areas have crusted over. Alternatively, seek the advice of your local public health unit. Affected healthcare workers must not provide ANY direct patient care if lesions cannot be covered (e.g. ophthalmic zoster).
If active lesions can be covered, affected workers can provide care to all patients except for pregnant women, neonates, severely immunocompromised patients, burns patients and patients with extensive eczema.

Further information

Here is a quick overview of shingles: https://www.youtube.com/watch?v=wAvb-HS_O9U.

Further reading

Management of shingles and other contagious diseases in the aged care setting can be difficult. Bug Control’s infection control policy and procedures manuals, available in print and as a highly interactive digital version, can help keep you and your RACF prepared for just about anything.