No Assessment Director of Nursing and Operations, DIPC

Shropshire Community Health NHS Trust Document Details Title Management of Chickenpox and Shingles Policy Trust Ref No 759-28158 Local Ref (optional) Main points the document This policy details guidance on the management of covers Chickenpox (Varicella - zoster) and Shingles (Herpes zoster) within Shropshire Community Health Trust Who is the document aimed at? All staff who undertake direct patient care within Shropshire Community Health Trust Author Rachael Allen, Head of Infection Prevention and Control Approval process Approved by (Committee/Director) Infection Prevention and Control notified to Quality and Safety Operational Group Approval Date 25 August 2015 Initial Equality Impact Screening Yes Full Equality Impact No Assessment Lead Director Director of Nursing and Operations, DIPC Category Clinical Sub Category Infection Prevention and Control Review date August 2018 Distribution Who the policy will be distributed to Method Document Links Required by CQC Key Words Amendments History IPC Meeting Members Electronically to IPC Meeting Members and available to all staff via the Trust website Yes No Date Amendment Chicken Pox; Shingles; Varicella zoster; Herpes zoster 1 July 2015 Change of title of policy to Management of Chickenpox and Shingles Policy 2 July 2012 To reflect Shropshire Community Health Trust policy framework Policy title changed to Isolation and Management of Chickenpox and Shingles Policy 3 Review in all areas and addition of Appendices 1-3

Shropshire Community Health NHS Trust Contents 1 Introduction... 1 2 Purpose... 1 3 Definitions... 1 4 Duties... 2 4.1 The Chief Executive... 2 4.2 Director of Infection Prevention and Control... 2 4.3 Infection Prevention and Control Team... 2 4.4 Managers and Service Leads... 2 4.5 Staff... 2 4.6 Committees and Groups... 2 4.6.1 Board... 2 4.6.2 Quality and Safety Committee... 2 4.6.3 Infection Prevention and Control Meeting... 2 5 Clinical Features... 3 5.1 Chickenpox (Varicella-zoster)... 3 5.1.1 Transmission... 3 5.1.2 Infectious Period... 3 5.1.3 Treatment... 3 5.1.4 Risk Groups... 3 5.2 Shingles (Herpes zoster)... 4 5.2.1 Transmission... 4 5.2.2 Infectious Period... 4 5.2.3 Treatment... 4 6 Pregnant Staff... 4 7 Healthcare Workers... 5 8 Prevention via Vaccine... 5 8.1 Pre-Exposure Vaccination (Varicella Vaccine)... 5 8.2 Post Exposure Prophylaxis and Varicella Zoster Immunoglobulin (VZIG)... 6 9 Assessing Immunity to VZV... 6 9.1 Clinical Enquiry... 6 9.2 Antibody Testing... 6 9.3 Recent VZIG... 6 10 Significant VZV Exposure... 6 11 Management of Patients in a Hospital Setting... 7 11.1 Discontinuing Isolation... 7 11.2 Terminal Cleaning... 7 11.3 Personal Protective Equipment (PPE)... 7 11.4 Patients Visitors... 7 12 Procedure for Dealing with Staff Contacts... 7

Shropshire Community Health NHS Trust 12.1 Assessment of Immunity... 7 12.2 Management of Susceptible Staff Contacts... 8 13 Procedure for Dealing with Patient Contacts... 8 13.1 Assessment of Immunity... 8 13.2 Management of Patient Contacts... 8 13.3 Management of at Risk Patient Contacts... 8 14 Management of Infected Healthcare Workers... 8 15 Consultation... 8 15.1 Approval Process... 8 16 Dissemination and Implementation... 9 16.1 Advice... 9 16.2 Training... 9 17 Monitoring Compliance... 9 18 References... 10 19 Associated Documents... 10 20 Appendices... 10 Appendix 1 Management of VZV Exposure during Pregnancy... 11 Appendix 2 Management of VZV Exposure in Immunocompromised Patients... 12 Appendix 3 - Management of VZV Occurring on a Ward... 13

1 Introduction Shropshire Community Health NHS Trust Chickenpox is an acute, infectious disease caused by the varicella-zoster virus (VZV). Sentinel surveillance data for chickenpox shows that by the age of five 65% of children in England will already have had chickenpox; therefore the majority of children susceptible to chickenpox are in the younger age groups, (RCGP 2011). Most chickenpox is mild to moderate and self-limiting but serious complications can occur in adulthood and in pregnant women. This virus can also cause shingles (herpes zoster) which tends to be more common in adults. 2 Purpose This policy details guidance on the management of chickenpox and shingles. All services directly provided by the Shropshire Community Health NHS Trust (SCHT) and all clinical staff should familiarise themselves with the policy. 3 Definitions Term / Abbreviation AIDS CHICKENPOX DH DIPC HCAI HERPES ZOSTER HIV IPC IGAS LESION OHD PAPULAR PHE PHN PIR RCA RCGP SaTH SENTINEL SURVIELLANCE SHINGLES SIP VESICLE VZIG Explanation / Definition Acquired Immunodeficiency Syndrome Chickenpox is an acute, infectious disease caused by the varicella-zoster virus Department of Health Director of Infection Prevention and Control Healthcare Associated Infection Also referred to as Shingles Human Immunodeficiency Virus Infection Prevention and Control Invasive Group A Streptococcus disease A lesion is a break or wound to the skin Occupational Health Department Acute generalised skin eruption Public Health England Post Herpetic Neuralgia Post Infection Review Root Cause Analysis Royal College of General Practitioners Shrewsbury and Telford Hospitals A sentinel surveillance system is used when highquality data are needed about a particular disease Herpes zoster is caused by reactivation of varicella virus Service Improvement Plan Small fluid filled blister Varicella-zoster Immunoglobulin Page 1 of 13

Shropshire Community Health NHS Trust VZV IgG VZV Varicella-zoster Virus Antibodies Varicella-zoster Virus 4 Duties 4.1 The Chief Executive The Chief Executive has overall responsibility for ensuring infection prevention and control is a core part of Trust governance and patient safety programmes. 4.2 Director of Infection Prevention and Control The Director of Infection Prevention and Control (DIPC) is responsible for overseeing the implementation and impact of this policy, make recommendations for change and challenge inappropriate infection prevention and control practice. 4.3 Infection Prevention and Control Team The Infection Prevention and Control (IPC) team is responsible for providing specialist advice in accordance with this policy, for supporting staff in its implementation, and assisting with risk assessment where complex decisions are required. The IPC team will ensure this policy remains consistent with the evidence-base for safe practice, and review in line with the review date or prior to this in light of new developments. 4.4 Managers and Service Leads 4.5 Staff Managers and Service Leads have the responsibility to ensure that their staff including bank and locum staff etc. are aware of this policy, adhere to it at all times and have access to the appropriate resources in order to carry out the necessary procedures. Managers and Service Leads will ensure compliance with this policy is monitored locally and ensure their staff fulfil their IPC mandatory training requirements in accordance with the Mandatory Training Policy and procedure. All staff have a personal and corporate responsibility for ensuring their practice and that of staff they manage or supervise comply with this policy. Need to consider other key staff who may have specific duty under this policy e.g. Medicines Management, Occupational Health Department (OHD). 4.6 Committees and Groups 4.6.1 Board The Board has collective responsibility for ensuring assurance that appropriate and effective policies are in place to minimise the risks of healthcare associated infections. 4.6.2 Quality and Safety Committee Is responsible for: Reviewing individual serious incidents/near misses and trends/patterns of all incidents, claims and complaints and share outcomes and lessons learnt Agreeing and escalating key risks/items of concern to the appropriate Directors and/or the Trust Board 4.6.3 Infection Prevention and Control Meeting Is responsible for: Page 2 of 13

5 Clinical Features Advising and supporting the IPC team Shropshire Community Health NHS Trust Reviewing and monitoring individual serious incidents, claims, complaints, reports, trends and audit programmes Sharing learning and lessons learnt from infection incidents and audit findings Agreeing and escalating key risks/items of concern to the appropriate Directors and/or the Quality and Safety Committee Approval of IPC related policies and guidelines 5.1 Chickenpox (Varicella-zoster) Chickenpox is a highly contagious disease caused by the varicella zoster virus (VZV). It is endemic within the UK, with most infections occurring in children under 5 years old. Chickenpox may initially begin with cold-like symptoms and a high temperature, followed by an intensely itchy, vesicular (fluid-filled blister) rash. Clusters of vesicular spots appear over 3 to 5 days, mostly over the trunk and face, and more sparsely over the limbs. Chickenpox is not a notifiable disease in England and Wales. 5.1.1 Transmission Transmission is through direct person to person contact, airborne droplet infection or through contact with infected articles such as clothing and bedding. The incubation period (the time from acquiring the virus until the symptoms first appear) is from 7 to 21 days. This can be prolonged if the patient is on steroids, is immuno-suppressed or has received varicella zoster immunoglobulin (VZIG), a specialised preparation of antibodies taken from the plasma of blood donors, which may prevent severe illness developing. 5.1.2 Infectious Period The virus is shed from the nasopharynx for up to 5 days before the rash appears and a person is at their most infectious 48 hours before the rash appears. The infectivity continues until all the lesions have crusted over and have dried to form scabs (commonly about 5 to 6 days after onset of illness). The severity of infection varies with each individual and it is possible to be infected and show no symptoms. 5.1.3 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. 5.1.4 Risk Groups Chickenpox is usually a mild illness and most healthy children recover with no complications, Wilkins et al (1998). However, certain groups of people may experience more serious complications such as viral pneumonia, secondary bacterial infections and encephalitis. Groups at risk are: Pregnant women Those who have received oral or parenteral steroids in the past 3 months Immunocompromised patients Patients with leukaemia, lymphoma, or bone marrow transplant recipients Patients who have had solid organ transplants Page 3 of 13

Patients who have had radiotherapy in the last 3 months Patients with severe lung or cardiovascular disease Patients with chronic skin conditions HIV/AIDS patients Adult smokers are at a higher risk of contracting VZV Shropshire Community Health NHS Trust Evidence suggests that chickenpox is the most common risk factor for Group A Streptococcus disease (scarlet fever) in children. Please refer to the SCHT Management of Group A Streptococcus Policy 5.2 Shingles (Herpes zoster) Herpes zoster is caused by reactivation of varicella virus that has remained in the body in a dormant state within nerve cells. It is not known what causes reactivation but, it is usually associated with immune system depression that can occur, for example, in older age, following therapy with immuno-suppressant drugs or from Human Immunodeficiency Virus (HIV) infection. The first sign of herpes zoster is usually pain in the area of the affected nerve, most commonly involving the trunk. A rash of fluid-filled blisters then appears in the affected area, typically only on one side of the body. This rash is usually present for about 7 days but the pain may persist for longer. Persistent pain is more common in elderly people and is termed 'post herpetic neuralgia' (PHN). On average this lasts for 3 to 6 months although it can continue for years in some cases. Ophthalmic zoster develops when the viral infection is localised in or around the eyes. This condition is also often associated with long-term pain. 5.2.1 Transmission Spread may occur from patients who have extensive lesions and those who have never had chickenpox can develop chickenpox. Transmission can occur through direct contact with exudate from wet lesions or airborne via vesicle fluid in disseminated shingles. People with shingles are contagious to those people who have not had chickenpox. However, it is not possible to catch shingles from a person who has chickenpox. 5.2.2 Infectious Period Shingles is potentially infectious from when the vesicles appear to when they dry (usually around a week). Facial shingles is thought to be more infectious than that affecting the rest of the body where clothing may reduce the virus dispersal. 5.2.3 Treatment Treatment with an antiviral decreases viral shedding thus reducing risk of transmission, promotes rapid healing of the skin eruptions and prevents formation of new lesions. It also reduces the severity and pain associated with the acute neuritis. 6 Pregnant Staff Staff who may be pregnant and have previously had chickenpox are considered to be immune. Staff who may be pregnant who have no history of VZV infection or are VZV antibody negative must avoid all contact with staff or patients with VZV disease. Exclusion is not recommended of pregnant women susceptible to chickenpox from settings that may suggest a higher rate of exposure (e.g. hospitals); as exposure to chickenpox is as likely to occur in the wider community. However, should there be a case or an outbreak of chickenpox in that setting then an individual risk assessment should be undertaken. Please refer to Appendix 1. Page 4 of 13

7 Healthcare Workers Shropshire Community Health NHS Trust The SCHT s OHD must assess all staff that have contact with patients on commencing employment in SCHT People with a history of chickenpox or shingles are considered VZV immune. A history of chickenpox is a less reliable predictor of immunity in individuals born and raised overseas and routine testing should be considered. If an individual has no history of chickenpox or shingles antibody testing should be performed. Varicella vaccine is recommended for non-immune healthcare workers who work in primary care and in hospitals and who have direct patient contact. This is to protect vulnerable patients from acquiring chickenpox from an infected member of staff. Staff who are found not to be VZV immune must never care for patients with chickenpox or shingles Pregnant staff of any gestation who have no history of chickenpox or shingles, and who have not received two doses of a varicella-containing vaccine must avoid contact with patients with chickenpox or shingles, (Chin et al 2014). 8 Prevention via Vaccine 8.1 Pre-Exposure Vaccination (Varicella Vaccine) The aim of varicella vaccination is to protect from exposure those who are at the most serious risk of serious illness and is done by immunising specific individuals who are in regular or close contact with those at risk. These include healthcare workers and healthy susceptible contacts of immunocompromised patients where continuing close contact is unavoidable (DH, 2011). Post-vaccination serological testing is not routinely recommended but is advisable for healthcare workers in units dealing with highly vulnerable patients e.g. transplant units (Breuer, 2008). Healthcare workers should be informed at the time of vaccination that they may experience a local rash around the site of injection or a more generalised rash in the month after vaccination. In either case, they should report to the OHD for assessment before commencing work. If the rash is generalised and consistent with a vaccine-associated rash (papular or vesicular), the healthcare worker should avoid patient contact until all the lesions have crusted. Healthcare workers with localised vaccine rashes that can be covered with a bandage and/or clothing should be allowed to continue working unless in contact with immunocompromised or pregnant patients. In the latter situation, an individual risk assessment should be made. NB The vaccine should not be given to: Immunosuppressed patients. For patients who require protection against chickenpox, seek advice from Virologists at Shrewsbury and Telford Hospitals on 01743 261000 Women who are pregnant Pregnancy should be avoided for three months following the last dose of varicella vaccine (see below) Or those who have had a: Confirmed anaphylactic reaction to a previous dose of the vaccine Confirmed anaphylactic reaction to any component of the vaccine, including neomycin or gelatin Page 5 of 13

Shropshire Community Health NHS Trust 8.2 Post Exposure Prophylaxis and Varicella Zoster Immunoglobulin (VZIG) The aim of post-exposure prophylaxis is to protect individuals at high risk of suffering from severe varicella infection. VZIG is recommended for individuals who fulfil ALL of the following three criteria (DH, 2011): 1. significant exposure to chickenpox or herpes zoster 2. a clinical condition that increases the risk of severe varicella (this includes pregnant women, neonates and immunosuppressed individuals) 3. no antibodies to varicella virus Please liaise with Consultant Microbiologist at SaTH on 01743 261000 for advice on the administration of varicella vaccine and varicella-zoster immunoglobulin. 9 Assessing Immunity to VZV 9.1 Clinical Enquiry If a reliable history of past chickenpox or shingles can be obtained from the patient or a close relative, the individual is considered to be VZV immune, with the exception of bone marrow transplant patients. A history of chickenpox is a less reliable predictor of immunity in individuals born and raised overseas. 9.2 Antibody Testing The test for VZV antibody is performed on the serum of a clotted blood sample in the virology laboratory. The level of antibody required for immunity will be indicated by the virology laboratory and will depend on the assay method used. 9.3 Recent VZIG An individual will have circulating antibodies, which may prevent infection or reduce the severity of the illness, for about 4-8 weeks after a dose. 10 Significant VZV Exposure Any potential VZV within the Community Hospitals must be reported to the IPC team. Advice about management of contacts and staff can be obtained during normal working hours from the IPC Team. Outside normal working hours please contact the on-call Consultant Microbiologist via the SaTH switchboard on (01743) 261000 Whenever exposure to VZV is suspected, the diagnosis of chickenpox or shingles must be confirmed either by the GP or a dermatologist. If the index case is within the Community Hospital (either staff or in-patient), the diagnosis of these conditions is clinical; they should be differentiated from other types of rash. An exposure to VZV is significant if: The index case has chickenpox, disseminated shingles or an exposed localised lesion e.g. ophthalmic zoster. If the index case is immunosuppressed then a local lesion anywhere may be significant as the risk of shedding is greater. Exposure occurs between 48 hours before onset of rash to crusting of all lesions (chickenpox) or from day of onset of rash to crusting of all lesions in shingles Contact with index case is deemed to be when in the same room e.g. hospital bay for at least 15 minutes, or direct face to face contact e.g. while having a conversation for more than about 5 minutes during the infectious period of chicken pox or uncovered shingles The susceptibility and immunosuppression of the contact must also be taken into account. Occasionally, a highly immunosuppressed patient has been infected from a case 20-30m away. Page 6 of 13

Shropshire Community Health NHS Trust Side-room isolation is sufficient to prevent significant exposure of others, providing the room has adequate ventilation the door is kept closed and that standard precautions are adhered to. Please refer to the SCHT Standard Precautions and Isolation Policies. 11 Management of Patients in a Hospital Setting All patients clinically suspected to have chickenpox or shingles whilst an in-patient in a Community Hospital must be nursed in source isolation in a single room with the door closed, until they are non-infectious. Staff must adopt standard precautions. Patients: - with shingles should be nursed in a single room during their infectious period. Staff: - contact with patients is kept to a reasonable minimum without compromising patient care. Routine hand hygiene should be carried out at the point of care. In addition hands should be washed with soap and water after removing personal protective equipment (PPE) prior to leaving the isolation room. Once outside the isolation room repeat hand hygiene with alcohol hand gel. 11.1 Discontinuing Isolation Source Isolation precautions for chickenpox can be discontinued when the lesions have crusted over and have dried to form scabs (commonly about 5 to 6 days after onset of illness) and for shingles when the vesicles have dried (usually around a week). 11.2 Terminal Cleaning Isolation rooms or wards should be terminally cleaned following discontinuation of isolation precautions and/or discharge of patients with chickenpox or shingles and include curtain changes. Please refer to the SCHT Cleaning and Disinfection policy for more information. 11.3 Personal Protective Equipment (PPE) Gloves and aprons must be worn for contact with lesions. Gloves, aprons and surgical facemasks must be worn for exposure to respiratory secretions. PPE should be removed, disposed of and hands decontaminated before leaving the isolation room, (Seto 2015) Since the risk of transmission is high, only those known to be immune should care for affected patients. 11.4 Patients Visitors Visitors must be informed of the risks described earlier in the policy and non-immune visitors should be advised and excluded from visiting during the infective period. 12 Procedure for Dealing with Staff Contacts 12.1 Assessment of Immunity If there is a reliable past history of VZV infection, or the staff member knows that they have been tested for VZV antibody and they are antibody positive, no further action need be taken In the absence of a history of VZV infection and a VZV antibody test, the staff member must be tested for VZV antibody If the staff member is pregnant or immunosuppressed, see the procedure for management of susceptible at risk group of patients in section 6 and 8.2 and appendices 1 and 2 below Page 7 of 13

12.2 Management of Susceptible Staff Contacts Shropshire Community Health NHS Trust Non-immune staff who have had significant exposure to VZV must not work with immunosuppressed or obstetric patients for 7-21 days after the contact. Staff can work up until day 7 and not until day 22 allowing for the incubation period to have passed. In all cases, staff must contact the OHD if they become unwell during this time and should be instructed to report sick at the first sign of illness. 13 Procedure for Dealing with Patient Contacts 13.1 Assessment of Immunity If the patient is in one of the risk groups (see Section 5.1.4) and has not been tested for VZV antibody, they must be screened for VZV antibody. Following discussion with the Virologist or Microbiologist at SaTH (see section 10 for contact details), a clotted blood sample (red-topped tube) should be sent to the virology laboratory with a request form asking for a VZV antibody screen and indicating close contact and risk group. The test can usually be performed within 1 working day. Patients not in the risk groups (see Section 5.1.4) must be assessed according to their history of past infection that is a reliable past history of VZV infection, or the patient has been tested for VZV antibody and they are antibody positive. 13.2 Management of Patient Contacts All patients who are not in the risk group and have no immunity should be nursed in a single room in source isolation with door closed from 7-21 days after the contact, or for as long as they remain in hospital. 13.3 Management of at Risk Patient Contacts VZIG may be given up to 10 days after the contact in pregnant women and ideally within 7 days in immunosuppressed patients but maybe given up to 10 after exposure. Whilst not preventing infection in VZV antibody negative susceptible contacts, it may reduce the severity of the infection, please see Section 8.2 and Appendix 2. Patients must be placed in source isolation, please see section 14 below. 14 Management of Infected Healthcare Workers Healthcare workers with chickenpox should not work until the lesions have crusted over and have dried. Healthcare workers with localised shingles on a part of the body that can be covered with a bandage and/or clothing may continue to work if well enough to do so, unless they are in contact with the risk group of patients in which case an individual risk assessment must be carried out. 15 Consultation This policy has been developed by the IPC team in consultation with appropriate Clinical Services Managers, Occupational Health Department, Organisational Development and Workforce Department, Consultant Microbiologist, Medicine Management, Public Health England (PHE) and IPC Meeting members. A total of three weeks consultation period was allowed and comments incorporated as appropriate. 15.1 Approval Process The IPC meeting will approve this policy and its approval will be notified to the Quality and Safety Committee. Page 8 of 13

16 Dissemination and Implementation 16.1 Advice This policy will be disseminated by the following methods: Shropshire Community Health NHS Trust Managers informed via Datix who then confirm they have disseminated to staff as appropriate Staff - via Team Brief and Inform Awareness raising by the IPC team Published to the Staff Zone of the Trust website The web version of this policy is the only version that is maintained. Any printed copies should therefore be viewed as 'uncontrolled' and as such, may not necessarily contain the latest updates and amendments. When superseded by another version, it will be archived for evidence in the electronic document library. Individual Services IPC Link Staff act as a resource, role model and are a link between the IPC team and their own clinical area and should be contacted in the first instance if appropriate. Further advice is readily available from the IPC team or the Consultant Microbiologist at SaTH on 01743 261000. 16.2 Training Managers and service leads must ensure that all staff are familiar with this policy through IPC induction and update undertaken in their area of practice. In accordance with the Trust s mandatory training policy and procedure the IPC team will support/deliver training associated with this policy. IPC training detailed in the core mandatory training programme includes standard precautions and details regarding key IPC policies. Other staff may require additional role specific essential IPC training, as identified between staff, their managers and / or the IPC team as appropriate. The systems for planning, advertising and ensuring staff attend are detailed in the Mandatory Training Policy and procedure. Staff who fail to attend training will be followed up according to the policy. Further training needs may be identified through other management routes, including Root Cause Analysis (RCA) and Post Infection Review (PIR) following an incident/infection outbreak or audit findings. By agreement additional ad hoc targeted training sessions will be provided by the IPC team. 17 Monitoring Compliance Compliance with this policy will be monitored locally by managers and by the IPC team as part of the standing audit programme using adapted Department of Health and Infection Prevention Society audit tools. Attendance at IPC training, which includes Standard Precautions will be monitored by the Organisational Development Department and reported to the IPC meeting and Organisational Development and Workforce Group. As appropriate the IPC team will support Services Leads to undertake IPC RCAs. Managers and Services Leads will monitor subsequent service improvement plans and report to the IPC meeting. Knowledge gained from RCA, PIR and IPC audits will be shared with relevant staff groups using a variety of methods such as reports, posters, group sessions and individual feedback. The IPC team monitor IPC related incidents reported on the Trust incident reporting system and liaising with the Risk Manager advice on appropriate remedial actions to be taken. Page 9 of 13

18 References Shropshire Community Health NHS Trust Bowsher, D. (1999) The lifetime occurrence of Herpes zoster and prevalence of postherpetic neuralgia: A retrospective survey in an elderly population. Eur J Pain 3(4): 335-42 Breuer, J., Scott Schmid, D. and Gershon, A.A. (2008) JID:197 (Suppl 2) pp147-151 Chin, T.L., MacGowan, A.P., S.K. Jacobson, S.K. and Donati, M. (2014) Journal of Hospital Infection 87 11-24 http://cks.nice.org.uk/chickenpox#!scenario accessed 12/05/2015 Department of Health. (2003) Chickenpox (Varicella) Immunisation for health care workers Health Protection Agency. (2011) Guidance on Viral Rash in Pregnancy Investigation, Diagnosis and Management of Viral Rash Illness, or Exposure to Viral Rash Illness in Pregnancy. London, HPA Public Health England. (2014) Chickenpox: public health management and PHE Public Health England. (2013) Immunisation against infectious disease: the green book, Chapter 34 Varicella, PHE. Royal College of General Practitioners, (RCGP). Weekly Returns Service. Annual Report. 2011 Royal College of Obstetricians and Gynaecologists. (2015) Green-top Guideline No. 13. RCOG, London Seto, W.H. (2015) Airborne transmission and precautions: facts and myths. Journal of Hospital Infection 89, 225-228. Vyse, A.J., Gay, N.J., Hesketh, L.M., Morgan-Capner, P., Miller, E. (2004) Seroprevalence of antibody to varicella zoster virus in England and Wales in children and young adults. Epidemiol Infect Dec;132(6):1129-34 Wilkins, E.G., Leen, C.L., McKendrick, M.W. and Carrington, D. (1998) Management of chickenpox in the adult: a review prepared for the UK Advisory Group on Chickenpox on behalf of the British Society for the Study of Infection. Journal of Infection 36(Suppl 1), 49-58. Wilson, J. (2006) Infection Control in Clinical Practice. Bailliere Tindall, London Wilson, J. (2001) Clinical Microbiology: an introduction for healthcare professionals. Bailliere Tindall, London 19 Associated Documents This policy should be read in conjunction with: 20 Appendices Standard Precautions including surgical scrubbing, gowning and gloving Policy Hand Hygiene Policy Isolation Policy Cleaning and Disinfection Policy Management of Group A Streptococcus Policy Linen Handling and Laundry Policy Page 10 of 13

Appendix 1 Management of VZV Exposure during Pregnancy All categories of staff must be immune to chickenpox Varicella-zoster contact - clarify significance of the contact Past history of chickenpox Uncertain or no past history of chickenpox, or woman from a tropical or subtropical country Presents with chickenpox - initial contact should be with the woman's GP Check blood (booking sample if available) for VZV IgG No action needed. Reassure and return to normal antenatal care VZV IgG present VZV IgG not present Give VZIG if less than 10 days since contact or, for continuous exposure, less than 10 days since the appearance of the rash in the index case Advise the woman that she is potentially infectious from 8-28 days after contact Discuss postpartum varicella immunisation Women who develop severe infection and women at high risk of complicated chickenpox should be referred to hospital Intravenous Acilovir should be given Inform women that infection at <28+0 weeks is associated with a small (~1%) risk of FVS Refer to a foetal medicine specialist at 16-20 weeks or 5 weeks after infection Amniocentesis to detect varicella DNA may be considered Woman develops chickenpox despite VZIG Severe Infection Infection at less than 28 weeks of gestation Avoid contact with potentially susceptible individuals (e.g. neonates and other pregnant women) Symptomatic treatment and hygiene should be advised If the woman presents < 24 hours of the appearance of the rash and she is 20 +0 weeks of gestation, prescribe Aciclovir If the woman presents < 24 hours of the appearance of the rash and she is < 20 +0 weeks of gestation, consider Aciclovir Avoid delivery of the baby until at least 7 days since the rash appeared Abbreviations: FVS foetal varicella syndrome; GP general practitioner; IgG Immunoglobulin G; VZIG varicella-zoster immunoglobulin; VZV varicella-zoster virus Page 11 of 13

Appendix 2 Management of VZV Exposure in Immunocompromised Patients All categories of staff must be immune to chickenpox e.g. Is patient immunocompromised? All types of primary immunodeficiency syndromes Currently receiving or have had within 6 months chemotherapy/generalised radiotherapy Bone marrow transplant recipients up to 12 months after immunosuppressive treatment Solid organ transplant recipients who currently receive immunosuppressive treatment Adults who in previous 3 months had 40 mg of prednisolone/day for >1 week Patients on lower dose of steroids in combination with cytotoxic or immunosuppressive drugs Does index case have definite chickenpox/shingles? Was contact during infectious period? NO: VZIG not normally given YES: Is current VZV IgG status positive? YES NO UNKNOWN No further action Give VZIG ideally within 7 days, but up to 10 days after exposure Test VZV IgG urgently Negative Positive No further action Page 12 of 13

Appendix 3 - Management of VZV Occurring on a Ward Confirmed diagnosis in index case Contact the Infection Prevention and Control Team and Occupational Health Service Identify at risk group exposed ** ISOLATE* until crusting of lesions Is current VZV antibody status known? YES: Known +ve IgG test or Chickenpox in the past NO: Test for VZV IgG immediately following exposure No further action VZV IgG result positive * Only staff with a history of chickenpox or serological evidence of immunity should attend the patient ** All members of staff are expected to be immune to chickenpox *** Ideally within 7 days but may attenuate up to 10 days for immuno-compromised patients Patient: in risk group Give VZIG within 10*** days of exposure and nurse in isolation from days 7 21 after exposure VZV IgG result negative ** Staff: Occupational Health to advise Page 13 of 13