Shingles Guide

About Shingles

Shingles (Herpes Zoster) occurs most commonly in older age groups, and can cause severe pain. It is a reactivation of the virus which causes chickenpox (varicella-zoster virus VZV). After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles.

This guide provides useful information about clinical features of the disease, as well as information on transmission, complications, and vaccination recommendations.

As a healthcare professional you play an active role in protecting thousands of older Australians who are at a higher risk of shingles and its complications, as well as providing treatment during a zoster infection.

As a healthcare professional you also advise patients about the importance and safety of vaccination, obtain medical history prior to vaccination with zoster vaccine, and check contraindications of live zoster vaccine in immunocompromised individuals.

‘Always be on the lookout for shingles in adults over 50 years, and upon diagnosis provide early pain management and antiviral treatment as indicated.

A PDF version is available for download here.

Cause Of Shingles

Reactivation of the virus which causes chickenpox (varicella-zoster virus VZV) in a person who has previously had varicella (chickenpox).

After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles.^[1][2]

Features Of Shingles

Generally, shingles presents as an acute, self-limiting vesicular rash which is often painful and lasts around 10–15 days.

The rash is usually unilateral, most commonly affecting the lumbar or thoracic dermatomes. The virus works down the nerves that branch out from the spinal cord.

In 80% of cases, early phase occurs 2–3 days before the rash.^[3] Early symptoms may be severe pain (e.g. ‘burning’, ‘stabbing’), itching and numbness around the affected areas. This may be accompanied by headache, photophobia and malaise.

Shingles Complications

Severe pain (where the rash was) known as post-herpetic neuralgia (PHN):

• Persistent chronic neuropathic pain which persists for more than 90 days from the onset of the rash.
• Can interfere with carrying out everyday activities and can be difficult to treat.
• Increased risk of PHN with age: affects around 30% of people with shingles over 80 years of age.^[4]

Serious complications involving the eye called herpes zoster ophthalmicus (in about 10–20% of shingles patients).^[5]

Very rarely, shingles can lead to pneumonia, hearing problems, blindness, encephalitis or death.

Transmission Of Shingles

Shingles cannot be passed from one person to another. However, a person with shingles can pass the varicella zoster virus to a person who has never had chickenpox or who has not had the chickenpox vaccine. In such cases, the person exposed to the virus may develop chickenpox but not shingles.^[6]

The virus is spread by direct contact with the fluid contained in the blisters, which can transfer to sheets and clothing.

Until the blisters scab over, the person is infectious. It is important to counsel contagious patients to avoid contact with people who have a weakened immune system, are pregnant, or newborns.

Shingles is less contagious than chickenpox and the risk of a person with shingles spreading the virus is low if the rash is covered.

Who Is At Risk

In a national serosurvey conducted in 2007, more than 95% of the adult population in Australia had antibodies to VZV by the age 30, indicating that they had been previously infected with the virus.^[7] Therefore almost the entire adult population is at risk of shingles.

Overall, 20–30% of people will develop shingles in their lifetime, most after the age of 50 years. People who are immunocompromised are also at risk.^[8]

Increasing trend

A study published in 2015 looking at general practice data from October 2006 to March 2013, estimated an incidence of herpes zoster in the Australian population of 5.6 per 1,000 persons compared to 4.7 per 1,000 persons based on data recorded from April 2000 to September 2006. As seen for the earlier period, the updated analysis demonstrated that zoster incidence increased with age, from 1.8 per 1,000 persons aged 0–24 years, to 19.9 per 1,000 for those aged 80 years and over.^[9] The factors underpinning the increase of herpes zoster burden remain unclear.

Higher risk of shingles from acute COVID-19

In 2022 a study, published in Open Forum Infectious Diseases, measuring the risk of developing shingles in adults 50 years and over with COVID-19, found that where was a 15% higher herpes zoster risk than those without COVID-19. For those hospitalised following SARS-CoV-2 infection there was a 21% increased risk of developing shingles.^[10]

Treatment

Antiviral treatment (Famciclovir, Valaciclovir or Aciclovir^[*]) may help to reduce pain and shorten the duration of shingles. The treatment is best taken within 72 hours of the onset of the rash but may still be helpful if taken after this time. These antiviral treatments are all considered safe with limited side effects (nausea, headache).

^[*]There is evidence that Famciclovir and Valaciclovir are more effective than Aciclovir in reducing acute pain^[13] and may be associated with greater patient compliance due to their more convenient dosing.

Prevention And Vaccination

Preventing herpes zoster is the best way to avoid post-herpetic neuralgia and other complications.

Shingrix

The Shingrix® vaccine is available for eligible people most at risk of complications from shingles.

A 2-dose course of Shingrix® will be available for free for:

• people aged 65 years and older
• First Nations people aged 50 years and older
• immunocompromised people aged 18 years and older with medical conditions in the table below:

Shingrix® does not contain any live virus so it can be given to people aged 18 years and over who are immunocompromised.^[11]

Who Should Not Receive Shingrix?

Previous anaphylaxis to the vaccine.

There is currently no data on the use of Shingrix during pregnancy (Category B2).

Vaccine Safety

Shingrix causes moderately high rates of local and systemic infections. Common reactions include: injection-site pain (up to 79%), redness (up to 39%), and swelling (up to 26%) and systemic symptoms such as fatigue and myalgia (up to 46%), headache (up to 39%), shivering (up to 28%), fever (up to 22%), and gastrointestinal symptoms (up to 18%).

Can I give zoster vaccine on the same day as other vaccines?

Shingrix can be given with most inactivated or live vaccines (including any of the available pneumococcal vaccines) using separate injections and injection sites. Refer to the AIH for the most recent information.

Shingrix

People can receive Shingrix with other inactivated vaccines (such as tetanus-containing vaccines, pneumococcal vaccines, influenza vaccines and COVID-19 vaccines), either at the same time or any time thereafter.^[14-16]

Note: There is the potential for an increase in mild to moderate adverse events when more than one vaccine is given at the same time (quote AIH reference).

It is acceptable to co-administer Shingrix and FluadQuad (an adjuvanted influenza vaccine) on the same day if necessary.^[17] However, given the lack of co-administration data for these two adjuvanted vaccines, it is preferred to separate their administration by a few days, and ensure that any adverse events following immunisation with the first vaccine have resolved before administration of the other vaccine.^[2][8]