What are the recommendations for preconception screening and management of herpes zoster (shingles)?

Preconception Herpes Zoster Screening and Management

Routine preconception screening for herpes zoster (shingles) is not recommended as it is not part of standard preconception care guidelines. 1

Evidence of Immunity Assessment

When evaluating a woman's immune status to varicella-zoster virus (VZV) before pregnancy, the following criteria can be used to determine immunity:

1. Documentation of 2 appropriately timed doses of varicella vaccine
2. Laboratory evidence of immunity or laboratory confirmation of disease
3. History of varicella (chickenpox) diagnosed by a healthcare professional
4. History of herpes zoster (shingles) diagnosed by a healthcare professional 1

Serologic Testing Considerations

• Serologic screening for VZV immunity is generally neither necessary nor recommended if a person has other acceptable evidence of immunity 1
• For women planning pregnancy who lack evidence of immunity, immunization with varicella vaccine should be completed at least 1 month before conception 1

Management Algorithm for Preconception VZV Assessment

Step 1: Assess VZV Immunity Status

• Review medical records for documented varicella vaccination or disease
• Evaluate for reliable history of chickenpox or shingles
• If immunity status is uncertain, consider serologic testing

Step 2: For Non-Immune Women

• Administer 2 doses of varicella vaccine at least 28 days apart
• Advise to avoid pregnancy for 1 month after each dose 1
• Complete vaccination at least 1 month before attempting conception

Step 3: For Women with History of Herpes Zoster

• No additional screening or vaccination is needed as prior herpes zoster confirms immunity 1
• Document history of zoster in medical record as evidence of immunity

Special Considerations

Immunocompromised Patients

• Live varicella vaccine is contraindicated in women with T-lymphocyte immunodeficiency 1
• For HIV-infected women, vaccination recommendations depend on immune status:
  • Asymptomatic and not immunosuppressed HIV-infected individuals may receive varicella vaccine 1
  • Vaccination is contraindicated in other HIV-infected individuals due to risk of disseminated viral infection 1

Post-Exposure Prophylaxis

If a non-immune pregnant woman is exposed to VZV:

• Varicella zoster immune globulin (VZIG) should be administered within 96 hours of exposure 1
• If oral acyclovir is used, VZV serology should be performed to determine if the patient is seropositive 1

Common Pitfalls to Avoid

1. Misinterpreting mild or atypical varicella history: For individuals reporting mild or atypical cases, assessment by a physician is recommended with either:

   • An epidemiologic link to a typical varicella case or laboratory-confirmed case, or
   • Evidence of laboratory confirmation performed during acute disease 1

2. Unnecessary serologic testing: Testing is not needed for individuals with clear documentation of immunity 1

3. Inadequate timing of vaccination: Failing to allow sufficient time (1 month) between vaccination and conception 1

4. Overlooking herpes zoster history: A history of shingles is sufficient evidence of immunity and does not require additional testing or vaccination 1

Recent Developments

Recent research indicates that herpes zoster vaccination may restore cell-mediated immune response in older adults 2. While current herpes zoster vaccines (recombinant adjuvanted vaccine and live-attenuated vaccine) significantly reduce the incidence of herpes zoster in older adults 3, these vaccines are not indicated for preconception care in young women who have already had varicella or have been vaccinated against it.