Section 10.5 Varicella

Transcription

1 Section 10.5 Varicella Chickenpox Introduction Transmission Signs and Symptoms Complications Diagnosis Treatment Infection Prevention and Control Precautions for Residents with Chickenpox Additional considerations Identify all exposed contacts Management of staff contacts Management of high risk residents/client contacts Shingles Introduction Transmission Signs and Symptoms Complications Diagnosis Treatment Infection Prevention and Control Precautions for Residents with Shingles Additional considerations Identify all exposed contacts Management of staff contacts Management of high risk residents/client contacts Developed by Liz Forde, Patricia Coughlan, Niamh McDonnell and Máire Flynn In conjunction with Mary Thompson CNM3 and Brigid Quaid CNM3 Occupational Health Department Dr. Fiona Ryan and Dr. Ann Sheehan, Department of Public Health Dr. Bartley Cryan, Consultant Microbiologist Date developed August 2012 Approved by Cork and Kerry Infection Prevention and Control Committee Kerry Infection Prevention and Control Committee Reference number IPCG 10.5/ 2012 Revision number 0 Revision date 2015 or sooner if new evidence becomes available Responsibility for Infection Prevention and Control Nurses review HSE South (Cork & Kerry) Page 1 of 9

2 Introduction The varicella-zoster virus (VZV) causes two distinct clinical infectious diseases, chickenpox (varicella) and shingles (zoster). Chickenpox is the primary infection caused by the varicella-zoster virus. It is an acute, highly infectious disease most commonly seen in children under 10 years old. Chickenpox is usually a mild, self-limiting illness and most healthy children recover with no complications. Adults tend to suffer more severe disease than children. In Ireland, the incidence of Chickenpox is seasonal reaching a peak from January to April when outbreaks of infection are common. Anyone who has had chickenpox in the past may develop shingles. You can only get shingles if you have previously had chickenpox as it is a recurrence or reactivation of the varicella zoster virus. It is not possible to develop shingles from exposure to a person with chickenpox. It is possible however, to develop chickenpox as a result of exposure to a person with shingles. Second attacks of chickenpox are rare but do occur. Transmission Chickenpox is highly contagious, infecting up to 90% of non-immune people who are exposed to the disease. The incubation period (the time from becoming infected until symptoms appear) ranges from 10 to 21 days although is usually from days. Susceptible individuals who have been in contact with a person with chickenpox should be considered potentially infectious from the 10 th to the 21 st day after exposure. The most infectious period is 1-2 days before the rash appears, but infectivity continues until all the vesicles have crusted over, at least 5 days after onset of the rash. Chickenpox is transmitted by the following routes:- Airborne respiratory droplets. Direct contact with the vesicle fluid. Indirect contact through contact with clothes/linen freshly soiled by vesicle fluid Chickenpox can also be spread from people with shingles. A person with shingles can spread the VZV virus to others who have never had chickenpox. The exposed person would need to come in contact directly or indirectly with the vesicle fluid of the person with shingles but would develop chickenpox and not shingles. Signs and Symptoms Chickenpox may initially begin with cold-like symptoms, as the virus is shed from the naso-pharynx for up to 5 days before the rash appears. This may be accompanied by fever, mild headache and myalgia. HSE South (Cork & Kerry) Page 2 of 9

3 An intensely itchy, vesicular (fluid-filled blister-like) rash appears - these crops of vesicular spots appear, mostly over the trunk and to a lesser extent the limbs. The severity of infection varies and it is possible to be infected but show no symptoms. Infectivity may be prolonged in people with altered immunity. Complications The risk of complications varies with age and is higher in infants under 1 and in persons over 15 years. Nearly all children recover completely and have detectable antibodies for many years. Complications in childhood are uncommon but may occur and include neurological complications (meningitis, encephalitis) and more rare glomerulonephritis and myocarditis. In children under 5, skin bacterial super infection is the most common complication. This manifests as a sudden high grade temperature (often after initial improvement), erythema and tenderness surrounding the original chickenpox lesions. Adults with chickenpox may develop more severe disease with lung involvement of varying severity, with smokers at higher risk of fulminating varicella pneumonia. Maternal infection in pregnancy carries a greater risk of severe varicella pneumonia in the mother, especially late in the second trimester and early in the third trimester. Risks to the foetus and neonate are related to the time of infection in the mother. Varicella infection in the first 20 weeks of pregnancy can cause a variety of abnormalities in the foetus; low birth weight, underdevelopment of a limb(s), skin scarring, poor development of localised muscles or brain abnormality. The mortality rate ranges from 1-2%. Varicella infection around the time of delivery from 5 days before to 2 days after delivery may result in overwhelming infection in the infant and a fatality rate as high as 30%. This severe disease is believed to result from fetal exposure to varicella virus without the benefit of passive maternal antibody. Diagnosis Chickenpox may be diagnosed by clinical signs and symptoms. The diagnostic feature of chickenpox is the vesicular rash which starts as small papules, develop into clear vesicles which become pustules and then dry into crusts. The rash usually appears first on the trunk and successive crops of vesicles appear over several days although hands and feet are relatively spared. Laboratory confirmation is rarely required but if necessary, is available by sending a microscopy slide with vesicle fluid to the National Reference Laboratory. Serology is also available and is used to demonstrate immunity. HSE South (Cork & Kerry) Page 3 of 9

4 Treatment There is no specific treatment for chickenpox. It is a viral infection that will therefore not respond to antibiotics. Treatment should be based on reducing symptoms such as fever and itchiness (See Chickenpox-Information Leaflet ). People at higher risk of developing serious complications from chickenpox may be given antiviral drugs such as acyclovir and/or immunoglobulin (a specialised preparation of antibodies taken from the plasma of blood donors), which may prevent severe illness developing. These people include pregnant women who are not immune, neonates, immunosuppressed people e.g. receiving chemotherapy or radiotherapy, received an organ transplant and are receiving immunosuppressant therapy etc. (Refer to Immunisation Guidelines for Ireland, Chapter 17 Varicella-Zoster updated September 2011 available on the National Immunisation Office website Infection Prevention and Control Precautions for Residents with Chickenpox All staff caring for a resident/client with suspected chickenpox should have a previous history of chickenpox or have evidence of immunity. The Occupational Health Department holds vaccination and immunity details on staff who have attended for pre-employment assessment. (Please make contact with the Occupational health Department if you have a query in relation to your immunity). Only immune staff should care for these residents/clients. Airborne and Contact Precautions should be used for all residents in a healthcare facility during the infectious period until the vesicles have crusted over. Inform the Infection Prevention and Control Nurse that you have a resident/ client with a possible/confirmed diagnosis of chickenpox and seek advice. All residents/clients with a possible/confirmed diagnosis of chickenpox should be placed in a single room or segregated from other non-immune clients until all vesicles are dry and have crusted over. This is advised because of the risk of varicella in susceptible immuno-compromised residents/clients. Masks are not completely effective in preventing transmission, so susceptible persons (staff and visitors) should avoid contact with residents/clients with chickenpox. Please refer to Airborne and Contact Precautions in Transmission-Based Precautions in Section 6 for further detail. HSE South (Cork & Kerry) Page 4 of 9

5 Additional Considerations - Identify all exposed contacts Contacts A Chickenpox Contact is defined as any resident/client or staff member who is non-immune to the varicella-zoster virus and who has had contact with a case of chickenpox at anytime from 48 hours before the onset of the rash until all the vesicles are crusted and there is no further cropping. This will include: Household contacts Contacts in the same room for a significant period usually 1 hour or more (e.g. classroom or a 2-4 bedded hospital room). Direct face to face contacts such as when having a conversation (usually 5 minutes or more) Management of Staff Contacts Staff contacts that are not immune to chickenpox must be identified because they may be affected themselves or may transmit the disease to vulnerable residents/clients while incubating the disease themselves. The ward/department manager needs to report all cases of chickenpox to the Occupational Health Department so that contact screening can commence. The Occupational Health Department will establish if there are any possible staff contacts that may require vaccination or Varicella Zoster Virus Immunoglobulin (VZVIG). Non-immune staff must report immediately to Occupational Health and be offered vaccination to protect themselves and patients. (Refer to Immunisation Guidelines for Ireland, 2008) Potentially High Risk People include:- Those at higher risk for severe disease and complications include: Pregnant women Infants under 1 month old Immunocompromised individuals including those with haematological malignancies, on chemotherapy, high dose steroids or with HIV infection. Management of high risk resident/client contacts If a resident/client is immuno-compromised and has a significant exposure to VZV then the decision regarding where the resident/client should be nursed will be made in consultation with the clinician responsible for their care. The medical officer/team/gp should discuss the case with a Medical Microbiologist or Consultant in Public Health Medicine as appropriate. If Human Varicella-Zoster Immunoglobulin (VZIG) is indicated, the optimum time for administration is within 96 hours of exposure. (Refer to Immunisation Guidelines for Ireland, 2008) HSE South (Cork & Kerry) Page 5 of 9

6 Shingles Introduction The varicella-zoster virus (VZV) causes two distinct clinical infectious diseases, chickenpox (varicella) and shingles (herpes zoster). Following chickenpox infection, the varicella zoster virus remains dormant or inactive in the nervous tissue for several years but may reappear following reactivation and cause shingles. Reactivation of the virus results in an infection of a nerve and the area of the skin supplied by the nerve causing a cutaneous rash. Anyone who has had chickenpox in the past may develop shingles as it is a recurrence or reactivation of the varicella zoster virus. It is not possible to develop shingles from exposure to a person with chickenpox. It is possible however, to develop chickenpox as a result of exposure to a person with shingles. Transmission Shingles lesions are infectious until they dry and crust over, however, the risk of transmission is low if the lesions are covered. Infectiousness may be prolonged in immunocompromised patients. The virus is confined to the rash and is transmitted by: Direct contact with the vesicles fluid Droplet or airborne spread of vesicle fluid from disseminated shingles cases. A person with a shingles rash can pass the virus to someone who has never had chickenpox, but that person will develop chickenpox not shingles. A person with chickenpox cannot spread shingles to someone else. Shingles comes from the dormant virus inside the person s body (from their primary chickenpox infection), not from an outside source. Persons in the prodromal phase (before the rash appears) or who have post herpetic neuralgia (PHN), but no longer have active lesions are not infectious. Signs and Symptoms The first sign of shingles is typically pain, itching, or tingling in the affected skin usually 1 to 4 days before the rash appears. Headache, fever, photo phobia and myalgia may also occur at this stage (prodromal phase). The rash begins as an erythematous, maculopapular rash that develops into clusters of clear vesicles. These vesicles then burst releasing varicella zoster virus. New vesicles continue to form over 3-5 days and progressively crust over the rash is usually persistent for about 7 days but the pain may continue for longer. The affected area may become intensely painful. People with a poor immune system have a higher than normal risk of developing a more severe rash of longer duration or of developing disseminated shingles HSE South (Cork & Kerry) Page 6 of 9

7 (defined as appearance of lesions somewhere other than along or near the path of a nerve). Complications Postherpetic neuralgia (PHN) - This is the most common complication. It is uncommon in people aged under 50 but becomes more common with age and estimated that it affects one-third of people over 80. PHN is when the pain persists where the rash was present after the rash and any other symptoms of shingles have resolved. PHN can cause severe nerve pain (neuralgia) that can last for weeks or months or even longer in a few cases. Postherpetic neuralgia may be treated with a number of different painkilling medicines. Skin infection-the vesicles become infected with bacteria. The surrounding skin becomes red and tender which may need to be treated with a course of antibiotics. Ophthalmic shingles - This is where shingles affects part of the trigeminal nerve and can cause complications that affect the eye If not treated, ophthalmic shingles may cause loss of vision. Diagnosis Shingles is diagnosed by the GP from the symptoms and the appearance of the rash. Testing is not usually necessary. Treatment Analgesics and anitvirals drugs such as acyclovir can be used to treat shingles. People at higher risk of developing serious complications from shingles may be given antiviral drugs such as acyclovir and/or immunoglobulin (a specialised preparation of antibodies taken from the plasma of blood donors), which may prevent severe illness developing. See Shingles - Information Leaflet Infection Prevention and Control Precautions for Residents with Shingles All staff caring for a resident/client with suspected shingles should have a previous history of chickenpox or be known to be immune. The Occupational Health Department holds vaccination and immunity details on staff who have attended for pre-employment assessment. (Please make contact with the Occupational Health Department if you have a query in relation to your immunity). Only immune staff should care for these residents. Inform the Infection Prevention and Control Nurse that you have a resident/client with a possible/confirmed diagnosis of shingles and seek advice. HSE South (Cork & Kerry) Page 7 of 9

8 Residents/clients with localized shingles that can be covered with clothing should be cared for using Standard Precautions and generally do not require a single room. All residents/clients with shingles that are either disseminated, are exposed e.g. face or who, for whatever reason will scratch at the lesions should be placed in a single room until all lesions have crusted over. Single room and Contact Precautions are advised because of the risk of varicella in susceptible immuno-compromised patients. Please refer to Contact Precautions in Transmission-Based Precautions in Section 6 for further detail. Shingles-Additional consideration for infection prevention Identify all exposed contacts Contacts A Shingles Contact can be defined as any resident/client or staff member who is non-immune to the varicella-zoster virus and who has had contact with a case of disseminated, exposed shingles from the day of the rash until crusting of the exposed rash This will include: Contact with the wet shingles rash Contact with clothing and bedding soiled by discharge from the blisters Management of Staff Contacts Staff contacts that are not immune to chickenpox must be identified because they may be affected themselves or may transmit the disease to vulnerable patients while incubating the disease themselves. These staff must report immediately to Occupational Health. The ward/department manager needs to report all cases of disseminated shingles to the Occupational Health Department so that contact screening can commence. The Occupational Health Department will establish if there are any possible staff contacts that may require vaccination or Varicella Zoster Virus Immunoglobulin (VZVIG). Non-immune staff must report immediately to Occupational Health and be offered vaccination to protect themselves and patients. (Refer to Immunisation Guidelines for Ireland, 2008) Potentially High Risk People include:- Pregnant women Infants under 1 month old Immunosuppressed individuals including those with haematological malignancies, on chemotherapy, high dose steroids or with HIV infection. HSE South (Cork & Kerry) Page 8 of 9

9 Management of high risk resident/client contacts If a resident/client is immuno-compromised and contracts VZV then the decision regarding where the patient should be nursed will be made in consultation with the clinician responsible for their care. The medical officer/clinician should discuss the case with a Medical Microbiologist or Consultant in Public Health Medicine. If Human Varicella- Zoster Immunoglobulin (VZIG) is indicated, the optimum time for administration of medication is within 96 hours of exposure (Refer to Immunisation Guidelines for Ireland, 2008). Reference and Bibliography Centre for Disease Control Accessed 24 th November 2011 Clinical Knowledge Summaries - Chickenpox hickenpox# Accessed 19 th December 2011 Health Protection Surveillance Centre. Factsheet Varicella (Chickenpox) - Accessed 23 rd November 2011 Immunisation Advisory Committee (2008) Immunisation guidelines for Ireland Royal College of Physicians of Ireland Accessed 15 th December 2012 Occupational Health Department Cork University Hospital (2010) Policy and Procedure on the Management of Healthcare Staff who are Non Immune to Varicella Zoster Virus in Cork University Hospital Group Royal United Hospital Bath (2011) Chickenpox and Shingles Policy w_602_chickenpox_shingles.pdf Accessed 24th November 2011 Strategy for Antimicrobial Resistance in Ireland (2011) Guidelines for Antimicrobial Prescribing in Primary Care in Ireland Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/Guidelines/File,3334,en.pdf Accessed 18 th December 2011 HSE South (Cork & Kerry) Page 9 of 9