SHINGLES

Varicella Zoster Virus

IDENTIFICATION AND DEFINITION

Shingles or (Varicella Zoster Virus) is a painful skin rash caused by the varicella zoster virus, the same virus that causes chickenpox. The most common complication of shingles is severe pain where the shingles rash was. This pain can be debilitating. There is no treatment or cure from this pain. Shingles may also lead to serious complications involving the eye. Very rarely, shingles can also lead to pneumonia, hearing problems, blindness, brain inflammation (encephalitis), or death. It is most common in people who are older or have a dampened immune system, but someone who is healthy can get it as well. The incidences for this disease in 2014 for the U.S. is about 1 in 3 people getting the disease.

(CDC http://www.cdc.gov/vaccines/hcp/adults/downloads/fs-shingles.pdf).


HISTORY OF SHINGLES

Shingles has been known since ancient times and was well documented in ancient medical texts. It was not known to be associated with the chickenpox virus until 1888 by Von Bokay. In 1954 the fluid of the lesions and from chicken pox was acquired and this is how they found out that the Varicella virus was what was causing both diseases, this study was done by Weller. In the 1970’s a live strain of the vaccine was made in Japan.


SIGNS AND SYMPTOMS OF SHINGLES

Shingles is a painful rash that develops on one side of the face or body. The rash forms blisters that typically scab over in 7 to 10 days and clears up within 2 to 4 weeks.

Before the rash develops, people often have pain, itching, or tingling in the area where the rash will develop. This may happen anywhere from 1 to 5 days before the rash appears. Most commonly, the rash occurs in a single stripe around either the left or the right side of the body. In other cases, the rash occurs on one side of the face. In rare cases (usually among people with weakened immune systems), the rash may be more widespread and look similar to a chickenpox rash. Shingles can affect the eye and cause loss of vision.

Other symptoms of shingles can include

  • Fever

  • Headache

  • Chills

  • Upset stomach

(CDC, http://www.cdc.gov/shingles/about/symptoms.html )


TRANSMISSION OF SHINGLES

This virus can be transmitted through direct contact with the vesicular fluids, the spray droplets in the air from someone sneezing or touching a surface that the fluid or droplets are on. The virus incubation period lasts up to 14 to 16 days from exposure, with a range of 10 to 21 days. This means that the people who have the virus can spread it to people up to 3 weeks before they start to feel ill or see any signs of illness.


COMPLICATIONS OF SHINGLES

Varicella in Normal Children

  • Low risk of complications.

  • Accounts for >90% of cases, 75% of all varicella hospitalizations, 70% of cases of encephalitis, 40% to 60% of all deaths, and virtually 100% of Reye Syndrome cases.

  • Most common complication is secondary bacterial infection of cutaneous lesions.

  • CNS Complications:

  • Encephalitis (estimated rate = 1.7/100,000): Cerebellar ataxia is most common, and is associated with a good outcome; diffuse cerebral involvement is less common in children.

  • Reye Syndrome: Recent dramatic decrease in the incidence has occurred, presumably related to decreased use of aspirin in children.

  • Rare: Aseptic meningitis, transverse myelitis, and Guillain-Barre syndrome.

  • Pneumonia: Viral or bacterial, more frequent in adults.

  • Infrequent complications: Thrombocytopenia, hemorrhagic varicella, purpura fulminans, glomerulonephritis, myocarditis, arthritis, orchitis, uveitis, iritis, and clinical hepatitis.

Normal Adults

  • Have a higher risk of complications than normal children.

  • Less than 2% of reported cases are in persons > or equal to 20 years of age, but account for approximately 25% of mortality.

  • Pneumonia: Case fatality rates of up to 30%.

  • Diffuse cerebral encephalitis is more likely to affect adults than children, and has a case fatality rate of up to 37%.

  • Hospitalization rate approximately 14-18/1,000 cases compared with 1-2/1,000 cases in normal children.

Immunocompromised persons (i.e., persons with congenital or acquired immune deficiencies, malignancies, or on immunosuppressive therapy).

  • Immunocompromised persons have a high risk of serious varicella infection.

  • Immunocompromised persons have a high risk of disseminated disease (up to 36% in one report), resulting in multiple organ system involvement, often becoming fulminant and hemorrhagic.

  • Most frequent complications include pneumonia and encephalitis.

  • Increased risk of death; 7% in one report, however, this preceded the widespread use of VZIG and acyclovir and may not reflect current experience.

Congenital Infection

  • Primary varicella infection in the first 16 weeks of gestation is rarely associated with a recognized constellation of abnormalities: low birth weight, hypoplasia of an extremity, cicatricial skin scarring, localized muscular atrophy, encephalitis, cortical atrophy, chorioretinitis, and microcephaly.

  • Risk of congenital birth defects from primary maternal varicella infection during the first trimester is felt to be very low (1%-2%).

  • Rare reports of congenital birth defects following maternal zoster exist; however, virologic confirmation of maternal lesions was lacking.

  • Infection in utero with varicella, particularly after 20 weeks gestation, is associated with zoster in those infants at an earlier age; the exact risk is unknown.

Neonatal Infection Due to Maternal Chickenpox Close to Time of Delivery

  • The onset of maternal varicella from 5 days before to 2 days after delivery may result in severe infection of the neonate (in an estimated 17% to 30%) and an estimated case fatality rate of 31% in the first 5 to 10 days of life.

  • Fetal exposure to varicella virus without protection from sufficient maternal antibody results in severe disease.

  • Infants born to mothers with onset of maternal varicella 5 days or more prior to delivery usually have a benign course, presumably due to passive transfer of sufficient maternal antibody.

Infants After Postnatal Exposure

  • Normal full-term infants with normal birthweight are unlikely to develop serious complications.

  • Premature infants may have medical conditions that put them at increased risk for serious varicella illness and those born before 28 weeks of gestation may not have received adequate maternal antibody.

Pregnancy - There is growing evidence that infection during pregnancy carries increased risk for serious varicella. Further study is needed.

Death

  • Risk in normal children: approximately 1/100,000; in normal infants: approximately 6/100,000.

  • Risk in normal adults: approximately 12/100,000.

  • Risk in leukemics is higher than in normal children and has been reported at 7%.

  • Risk for newborns (who do not receive VZIG) from maternal chickenpox close to time of delivery is estimated at 31%.

  • Majority of deaths occur in normal individuals.

(CDC, http://wonder.cdc.gov/wonder/prevguid/p0000108/p0000108.asp ).

RECOMMENDED CONTROL MEASURES FOR SHINGLES

In order to prevent and control Shingles we should:

  • Get the vaccination

  • Stay away from people who have shingles or if you have to come into contact with them use protective measures such as masking and cloves as well as a cleaning solution whenever the person touches something.

  • If a newborn gets shingles they need to be hospitalized and isolated for at least 21 days.

  • If an elderly individual gets the virus they can start antiviral therapy.

This disease is very contagious and can cause a lot of harm in the community, it is capable of causing outbreaks especially among the very young and the very old in the population.


(CDC, http://wonder.cdc.gov/wonder/prevguid/p0000108/p0000108.asp ).