Section Page
Number
1 Quick Reference Guide 3-4
Algorithm 1 Management of Patients found to have 3
Chickenpox/Shingles
Algorithm 2 Management of Contacts with significant exposure 4
2 Objectives 5
2.1 Staff Groups 5-6
3 Rationale 6
3.1 Chickenpox 6-7
3.2 Shingles 7
3.3 Patient at Risk Groups 8
5 Broad Recommendations 9
5.1 Management of Patients with Varicella Zoster Infection 9-11
5.2 Management of a VZV Incident 11-12
5.2.1 Patient Related Investigation (Contact Tracing) 12-13
5.2.2 Staff Related Investigation (Contact Tracing) 13
5.3 The Use of Varicella-Zoster Immunoglobulin 13-14
9 References 15-16
11 Appendices 16-20
Appendix 1 Patient VZV Contact List for chickenpox/shingles 17
Appendix 2 Chickenpox Patient Information Leaflet 18
Appendix 3 Shingles Patient Information Leaflet 19
Appendix 4 Monitoring Compliance/Effectiveness Table 20
2 Objective/s
The purpose of this policy/guideline is to guide Infection Prevention and Control (IP&C)
activities in order to prevent nosocomial transmission to patients, staff and visitors.
Chief Executive has overall responsibility for ensuring there are effective procedures
and resources in place to enable the implementation of this policy.
DIPC is responsible for the development and implementation of strategies and policies
on IP&C.
Virology to alert the IP&CT and clinical teams of patient result that may have infection
control implications; and provide help and advice for clinical staff.
Estates are responsible for ongoing maintenance of ventilation systems and general
environment of the isolation room.
Service Provider for cleaning to ensure all areas are cleaned accordingly to the
agreed standard.
Workplace health and wellbeing to Alert IP&CT to any infection issue amongst trust
employees that may have an impact on patients. They will record the VZV status of
staff. To liaise with areas on staff contact tracing as required.
3 Rationale
3.1 Chickenpox
Infectivity - usually 48 hours before onset of the rash until crusting over of lesions.
Use of high dose acyclovir should be considered early in infection for adults and
immunocompromised patients.
Surveillance Chickenpox is not a notifiable disease in England and Wales; therefore
no requirement to inform Public Health. However the IP&CT must be notified of any
clinically suspected or confirmed cases.
3.2 Shingles
Shingles is due to the reactivation of latent VZV (secondary infection). It can occur at
any age. The disease often begins with paraesthesia in the involved segment for 2-3
days.
Erythematous maculopapular lesions develop which rapidly evolve into vesicles and
may coalesce to form bullae.
Those who have had chickenpox who come into contact with a person with shingles are not at
risk of acquiring the disease as they will be immune.
Isolation person to person transmission is via direct contact with vesicles to non-
immune persons. Contact isolation procedures are required i.e. single room with use of
gloves and apron and attention to hand hygiene to prevent infection of non-immune staff
and transfer of virus to susceptible patients.
VZV is highly contagious and over 90% of the general population have serological
evidence of past infection. Most adults are immune and the risk of transmission is
Every effort must be made to prevent transmission to these individuals and the staff who
care for them. It may be difficult to follow the procedure below in full in other areas but it
is important to remember that chickenpox in adults can be a serious infection,
sometimes fatal. Non-immune individuals should be protected by isolation of the index
case who should be cared for by staff who are known to be immune.
The VZV status of all staff that work with immunocompromised patients or in paediatrics,
obstetrics or in the Neonatal Intensive Care Unit should be established. Non-immune
staff should be subsequently immunised, where necessary, and will be given priority by
Workplace Health and Wellbeing. Temporary restriction from patient contact may be
necessary in certain cases and ward managers will be informed of the VZV status of
staff as required. VZV status of immunocompromised patients should be recorded
prospectively. All antenatal patients must have their chickenpox history documented on
Trust held records during booking ANC visit. This is to facilitate contact tracing should
exposure occur.
Author/s: Dr Samir Dervisevic Virology Consultant Date of issue: June 2014
Valid until: June 2017 Guideline Ref No: CA5168V1
Document: Guidelines for the Management pf VZV infections
Copy of complete document available form Trust Intranet
Page 8 of 20
Guidelines for the Management of Varicella-Zoster (VZV) Infections
Timing Chickenpox- 48 hours before onset of rash until it has crusted over
Shingles On day of onset of rash until lesions have crusted over
5 Broad recommendations
In the event of an infection with VZV occurring in hospital the following actions must be
taken: -
Patients with VZV infection must be isolated immediately in single rooms with
closed doors and with no contact with persons without evidence of immunity, this
must include visitors and healthcare workers
Suspicion of VZV infection should be confirmed clinically by a member of the
medical staff and documented in the patients care records
Vesicle/lesion swabs should be taken and sent to Virology in viral transport
medium
Droplet precautions (chickenpox) and contact precautions (shingles) must be
adhered to until all lesions are dry and crusted
Patients with VZV infection should be cared for by staff with evidence of
immunity. This can be by verbal confirmation by staff member or Workplace
Health and Wellbeing records
A member of the IP&CT must be informed by the medical or nursing staff
involved. IP&C Nurses are contactable on ext 5847 or via Bleep 0600. After
17.00, on weekends and bank holidays, duty IP&C person is contactable via the
The patient must be nursed in a side room with designated toilet facilities
Droplet [chickenpox] and contact [shingles] precautions posters applied
Patients do not need to be nursed in negative pressure rooms
The patient should be isolated until all the skin lesions are crusted which is
usually about four to seven days after the appearance of the rash
Offer patient chickenpox/shingles information leaflet (See appendix )
Non immune patients who have been exposed to the patient with Varicella Zoster
infection should be isolated from 7 days following their first exposure until 21
days after there last exposure. This is because administration of VZIG can
prolong the period of VZV excretion
During the period of isolation, disposable aprons and gloves must be worn for
direct patient contact
All waste from the room should be disposed of as clinical waste for the duration
that the patient is in isolation. Waste Management Policy
Cutlery/Crockery
Normal ward issue can be used but must be cleaned by washing in a dishwasher
Linen
All linen must be disposed of as infected linen and be placed into a red alginate
(water soluble) bag before being placed into a white plastic bag. See Bagging
procedure for linen and laundry in the IP&C Manual
Cleaning
The patient environment must be cleaned as per the Cleaning & Disinfection of
Hospitals policy
Theatre Cases
Inform theatre
Place patient at end of theatre list
All staff in contact with the patient should be known to have immunity to VZV
In cases of shingles, area affected must be covered by clothing or if lesions
weeping covered with a dressing
Patient should be taken straight into theatre
Recovered in theatre
Kept to a minimum
Need for isolation should never jeopardise clinical need
No waiting in communal areas
Visitors
When a VZV infection is suspected/confirmed in a patient, ward staff must inform IP&C
immediately.
Chickenpox
The IP&CT will obtain an in-hospital travel history during the 48 hours before onset if
immunocompromised patients, pregnant women or neonates are involved. Ward staff
are responsible for providing a list of patients with significant contact with the index
case. (See Patient VZV contact list in Appendix 3) Including all areas the index case
Shingles
The IP&CT will obtain an in-hospital travel history from the date of onset of rash if
immunocompromised patient, pregnant woman or neonates are involved. Include all
areas the index case may have visited. All patients and staff known to have had
significant contact with the index case are included in the contact list.
(For patients who are in a location where they may become a source of infection to
immuno-suppressed/at risk individuals).
Patients with significant contact are classified on whether they are immunocompromised
or immunocompetent and on whether they have a past history of VZV infection
(chickenpox or shingles) or not.
Take clotted blood for VZV serology. Include on request form whether patient
has been given VZIG or blood transfusion recently. Booking bloods from
pregnant women may be stored in the microbiology laboratory thus negating
the need for venepuncture.
Discuss neonates with duty virologist who will advise if blood test required.
Seek
advice from the Duty Virologist in the Microbiology Department about the use
of VZIG.
Isolate the patient immediately until 21 days after last exposure. If the patient
is shown serologically to be immune, discontinue isolation.
If the patient is susceptible take a second serum 2-3 weeks after exposure.
On the request form indicate if VZIG was given.
Take clotted blood for VZV serology. Include on request form whether patient
has been given blood transfusion recently.
No further action.
A history of VZV infection or serological status must be sought from all exposed staff if
not already available and referred to Workplace Health and Wellbeing.
a) General Advice
Dosage
Issued in vials of 250 mg by virology laboratory (telephone ext 4531 or 01603 288587
and ask to speak to a duty Virologist. Out of hours please contact the on-call Consultant
Virologist via the NNUH switchboard).
b) Immunocompromised Patients
Notes
i) VZIG is
not recommended for asymptomatic HIV positive individuals as
there is no evidence of increased risk of serious illness.
ii) VZIG
should be offered to HIV positive contacts with symptoms of AIDS
who do not have a history of chickenpox or serological evidence of
immunity.
c) Neonates
Notes
To ensure that practice is compliant with the above standards, the following monitoring
processes will be undertaken:
The audit results will be sent to the DIPC and Clinical lead virology consultant who will
ensure that these are discussed at the relevant governance meetings to review the
results and make recommendations for further action.
The authors listed above drafted this document on behalf of the IP&C Department who
has agreed the final content.
HICC
Matrons and Senior Nurses
Consultant Virologists
Ward Sisters and Charge Nurses
Health and Safety Department Operations Centre Manager
The Trust Communications department will disseminate an alert within the Trust wide
communication circular, in order to advise all staff of this Guideline.
This guideline will be available Trust wide via Trust Docs and the IP&C Manual.
9 References
Department of Health- Varicella: the green book, chapter 34, 2006 Varicella-green book
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th
edition. 2009
This policy has been screened to determine equality relevance for the following equality
groups: race, gender, age, sexual orientation and religious groups. This policy is
considered to have little or no equality relevance.
11 Appendices
Infectivity:
Please email form to IP&Cadministrator@nnuh.nhs.uk or ring ext 5847 when complete Chickenpox; 48 hours before onset of rash
until crusting over of lesions
Author/s: Dr Samir Dervisevic Virology Consultant Date of issue: June 2014 Shingles; From onset of rash until crusting
Valid until: June 2017 Guideline Ref No: CA5168V1 over of lesion
Document: Guidelines for the Management pf VZV infections
Copy of complete document available form Trust Intranet
Page 17 of 20
Guidelines for the Management of Varicella-Zoster (VZV) Infections
Appendix 2
CHICKENPOX INFORMATION SHEET
What is Chickenpox?
Chickenpox illness is caused by a virus called Varicella-zoster.
What is shingles?
The clinical name is herpes zoster, which is a caused by the chickenpox virus
(Varicella).
Is shingles infectious?
Yes: because shingles is caused by the chickenpox virus. Anyone who has not had
chickenpox may get chickenpox from someone who has shingles.
When is it infectious?
Until the blisters have crusted over, usually 5-7 days.