Prevention and control of varicella-zoster virus in hospitals
- David J Weber, MD, MPH
David J Weber, MD, MPH
- Professor of Medicine, Pediatrics and Epidemiology
- University of North Carolina Schools of Medicine and Public Health
- William A Rutala, PhD, MPH
William A Rutala, PhD, MPH
- Research Professor of Medicine
- University of North Carolina School of Medicine
Varicella-zoster virus (VZV) infection causes two clinically distinct forms of disease: varicella (chickenpox) and herpes zoster (shingles). Primary VZV infection results in the diffuse vesicular rash of varicella, or chickenpox. Endogenous reactivation of latent VZV typically results in a localized skin infection known as herpes zoster, or shingles. Varicella is generally a mild disease in children, although serious complications can sometimes occur (eg, secondary bacterial skin infections and pneumonia). Complications from VZV infection are more common in neonates, adults, or immunocompromised persons.
Because varicella is highly contagious and may cause serious disease, the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics (AAP), and infectious disease experts have published recommendations regarding the prevention of VZV among health care personnel, isolation of patients with VZV infection, and the management of patients and health care personnel exposed to VZV. Issues specific to infection control and care of exposed health care personnel are discussed below.
The epidemiology and clinical manifestations of VZV have changed significantly since the introduction of the varicella vaccine. These issues, as well as the diagnosis, treatment, and prevention of varicella infection are discussed elsewhere. (See "Epidemiology of varicella-zoster virus infection: Chickenpox" and "Vaccination for the prevention of chickenpox (primary varicella infection)" and "Clinical features of varicella-zoster virus infection: Chickenpox" and "Treatment of varicella (chickenpox) infection" and "Clinical manifestations of varicella-zoster virus infection: Herpes zoster" and "Treatment of herpes zoster in the immunocompetent host".)
IMPORTANCE OF INFECTION CONTROL
Control of VZV is important in health care facilities for the following reasons:
●VZV is highly contagious. This is particularly true of patients who present with varicella, compared to those with zoster, who are generally less infectious.
Subscribers log in hereLiterature review current through: Jul 2017. | This topic last updated: Jul 21, 2016.References
- Weber DJ, Rutala WA, Hamilton H. Prevention and control of varicella-zoster infections in healthcare facilities. Infect Control Hosp Epidemiol 1996; 17:694.
- Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011; 60:1.
- Paul N, Jacob ME. An outbreak of cadaver-acquired chickenpox in a health care setting. Clin Infect Dis 2006; 43:599.
- Adler AL, Casper C, Boeckh M, et al. An outbreak of varicella with likely breakthrough disease in a population of pediatric cancer patients. Infect Control Hosp Epidemiol 2008; 29:866.
- Mahamud A, Wiseman R, Grytdal S, et al. Challenges in confirming a varicella outbreak in the two-dose vaccine era. Vaccine 2012; 30:6935.
- Park CS, Kim DS, Kim KH. Varicella outbreak in the patients during group therapy: seroprevalence in a healthcare system during breakthrough varicella occurrence. Clin Exp Vaccine Res 2013; 2:140.
- Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2007; 56(RR-4):1.
- Chen SY, Suaya JA, Li Q, et al. Incidence of herpes zoster in patients with altered immune function. Infection 2014; 42:325.
- Okamoto A, Abe A, Okamoto M, et al. A varicella outbreak in B-cell lymphoma patients receiving rituximab-containing chemotherapy. J Infect Chemother 2014; 20:774.
- Josephson A, Gombert ME. Airborne transmission of nosocomial varicella from localized zoster. J Infect Dis 1988; 158:238.
- Saidel-Odes L, Borer A, Riesenberg K, et al. An outbreak of varicella in staff nurses exposed to a patient with localized herpes zoster. Scand J Infect Dis 2010; 42:620.
- Breuer J. Herpes zoster: new insights provide an important wake-up call for management of nosocomial transmission. J Infect Dis 2008; 197:635.
- Lopez AS, Burnett-Hartman A, Nambiar R, et al. Transmission of a newly characterized strain of varicella-zoster virus from a patient with herpes zoster in a long-term-care facility, West Virginia, 2004. J Infect Dis 2008; 197:646.
- Johnson JA, Bloch KC, Dang BN. Varicella reinfection in a seropositive physician following occupational exposure to localized zoster. Clin Infect Dis 2011; 52:907.
- Yoshikawa T, Ihira M, Suzuki K, et al. Rapid contamination of the environments with varicella-zoster virus DNA from a patient with herpes zoster. J Med Virol 2001; 63:64.
- Suzuki K, Yoshikawa T, Tomitaka A, et al. Detection of aerosolized varicella-zoster virus DNA in patients with localized herpes zoster. J Infect Dis 2004; 189:1009.
- Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 1998; 19:407.
- Lyznicki JM, Bezman RJ, Genel M. Report of the Council on Scientific Affairs, American Medical Association: immunization of healthcare workers with varicella vaccine. Infect Control Hosp Epidemiol 1998; 19:348.
- http://www.phac-aspc.gc.ca/publicat/cig-gci/p03-work-travail-eng.php#table-1 (Accessed on September 20, 2013).
- Nettleman MD, Schmid M. Controlling varicella in the healthcare setting: the cost effectiveness of using varicella vaccine in healthcare workers. Infect Control Hosp Epidemiol 1997; 18:504.
- O'Neill J, Buttery J. Varicella and paediatric staff: current practice and vaccine cost-effectiveness. J Hosp Infect 2003; 53:117.
- Troiani L, Hill JJ 3rd, Consoli S, Weber DJ. Varicella-Zoster Immunity in US Healthcare Personnel With Self-Reported History of Disease. Infect Control Hosp Epidemiol 2015; 36:1467.
- Macartney K, McIntyre P. Vaccines for post-exposure prophylaxis against varicella (chickenpox) in children and adults. Cochrane Database Syst Rev 2008; :CD001833.
- Kappagoda C, Shaw P, Burgess M, et al. Varicella vaccine in non-immune household contacts of children with cancer or leukaemia. J Paediatr Child Health 1999; 35:341.
- Kamboj M, Sepkowitz KA. Risk of transmission associated with live attenuated vaccines given to healthy persons caring for or residing with an immunocompromised patient. Infect Control Hosp Epidemiol 2007; 28:702.
- Seigel JD, Reinhart E, Jackson M, Chiarella L. The Healthcare Infection Control Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007. http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf (Accessed on February 09, 2012).
- American Academy of Pediatrics. Varicella-zoster infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th ed, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.846.
- http://www.cdc.gov/chickenpox/hcp/healthcare-setting.html (Accessed on February 06, 2014).
- Tang JW, Eames I, Li Y, et al. Door-opening motion can potentially lead to a transient breakdown in negative-pressure isolation conditions: the importance of vorticity and buoyancy airflows. J Hosp Infect 2005; 61:283.
- Breuer J, Schmid DS. Vaccine Oka variants and sequence variability in vaccine-related skin lesions. J Infect Dis 2008; 197 Suppl 2:S54.
- Centers for Disease Control and Prevention (CDC). Updated recommendations for use of VariZIG--United States, 2013. MMWR Morb Mortal Wkly Rep 2013; 62:574.
- Suga S, Yoshikawa T, Ozaki T, Asano Y. Effect of oral acyclovir against primary and secondary viraemia in incubation period of varicella. Arch Dis Child 1993; 69:639.
- Lin TY, Huang YC, Ning HC, Hsueh C. Oral acyclovir prophylaxis of varicella after intimate contact. Pediatr Infect Dis J 1997; 16:1162.
- Ishida Y, Tauchi H, Higaki A, et al. Postexposure prophylaxis of varicella in children with leukemia by oral acyclovir. Pediatrics 1996; 97:150.
- Asano Y, Yoshikawa T, Suga S, et al. Postexposure prophylaxis of varicella in family contact by oral acyclovir. Pediatrics 1993; 92:219.
- Fisher JP, Bate J, Hambleton S. Preventing varicella in children with malignancies: what is the evidence? Curr Opin Infect Dis 2011; 24:203.
- Kumar A, Moulik NR, Verma N. Successful prevention of varicella outbreak in an overcrowded paediatric oncology ward using oral acyclovir prophylaxis. J Trop Pediatr 2015; 61:151.
- IMPORTANCE OF INFECTION CONTROL
- GENERAL PRINCIPLES OF VIRAL TRANSMISSION
- Incubation period of varicella
- Secondary attack rates of VZV
- NOSOCOMIAL TRANSMISSION
- Transmission from persons with varicella
- Transmission from persons with zoster
- PREVENTION OF VARICELLA AMONG HEALTH CARE PERSONNEL
- Rationale for immunizing susceptible health care personnel
- Establishing susceptibility to infection
- Active immunization of susceptible health care personnel
- - Assessment of immunity after immunization
- - Documentation of varicella immunization
- - Adverse events of vaccination
- INFECTION CONTROL MEASURES
- Isolation precautions for patients with varicella
- Isolation precautions for patients with herpes zoster
- EVALUATION OF EXPOSURE AMONG PERSONNEL
- MANAGEMENT OF EXPOSED PREVIOUSLY VACCINATED HEALTH CARE WORKERS
- MANAGEMENT OF EXPOSED SUSCEPTIBLE HEALTH CARE PERSONNEL
- Work furlough
- Post-exposure prophylaxis
- - Varicella vaccine
- Among health care personnel who are unvaccinated
- Among health care personnel who have received one dose of vaccine
- Rash among exposed health care personnel who received post-exposure vaccine
- - Varicella-zoster immune globulin
- - Antiviral Therapy
- MANAGEMENT OF HEALTH CARE PERSONNEL WITH VZV INFECTION
- Diagnosis of VZV in health care workers
- Work restrictions
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS