Does a patient with shingles require airborne precautions?

Airborne Precautions for Shingles

Yes, shingles requires airborne precautions, but only in specific clinical scenarios: disseminated herpes zoster in any patient, or localized herpes zoster in immunocompromised patients until dissemination is ruled out. 1

Clinical Decision Algorithm

For Immunocompetent Patients with Localized Shingles

• Standard and contact precautions only - airborne precautions are NOT required 1
• Lesions must be completely covered with dressings 1
• Maintain at least 6 feet physical separation from other patients 1
• Patient should wear a surgical mask to prevent droplet transmission 1
• Continue precautions until all lesions are dried and crusted (typically 4-7 days after rash onset) 1

For Disseminated Herpes Zoster (Any Patient)

• Airborne AND contact precautions are mandatory 1
• Requires negative air-flow room (airborne isolation room) 1
• Healthcare personnel must use N95 respirators or equivalent 2
• Continue precautions until all lesions are dry and crusted 1

For Immunocompromised Patients with Any Herpes Zoster

• Airborne AND contact precautions required until disseminated infection is ruled out 1
• Negative air-flow room required 1
• These patients experience prolonged viral shedding and slower healing (7-14 days or longer) 1
• Higher risk for disseminated infection 1

Rationale for Airborne Precautions

Varicella-zoster virus (the causative agent of shingles) is classified as requiring airborne precautions because it can remain infectious over long distances when suspended in the air 2. The virus is grouped with other airborne pathogens including measles (rubeola), tuberculosis, and SARS 2.

Evidence for Airborne Transmission

• Airborne transmission has been documented in healthcare settings, particularly in hospitals 1
• Nosocomial transmission has occurred from patients, hospital staff, and visitors with herpes zoster 1
• Susceptible persons with no direct contact with the index patient have acquired infection in healthcare environments 1

Important Clinical Distinctions

Shingles vs. Chickenpox Transmission

• Shingles is approximately 20% as contagious as chickenpox 1
• Primary transmission route is direct contact with fluid from active lesions 1
• Airborne transmission is possible but primarily documented in healthcare settings 1
• Household transmission risk is significantly lower than chickenpox 1

When Airborne Isolation Rooms Are Unavailable

If an airborne isolation room is not available in outpatient settings:

• Place patient in a private room with door closed 2
• Mask the patient immediately 2
• Transfer to a facility with appropriate isolation capabilities (e.g., hospital) 2

Healthcare Worker Restrictions

For Localized Herpes Zoster in Immunocompetent HCW

• Cover all lesions completely 1
• Restrict from caring for high-risk patients (immunocompromised, pregnant women, neonates) until all lesions are dried and crusted 1

For Disseminated Zoster or Immunocompromised HCW

• Exclude from duty until all lesions are dried and crusted 1
• May require longer periods of isolation due to prolonged viral shedding 1

Common Pitfalls to Avoid

• Assuming antiviral therapy immediately makes the patient non-contagious - viral shedding continues until lesions are fully crusted 1
• Allowing healthcare workers with shingles to care for high-risk patients before complete crusting 1
• Inadequate covering of lesions, which can lead to transmission even with localized disease 1
• Failing to recognize that immunocompromised patients may have prolonged viral shedding 1
• Underestimating airborne transmission risk in healthcare settings 1

High-Risk Populations Requiring Protection

Patients with shingles should avoid contact with:

• Pregnant women 1
• Premature infants and neonates 1
• Immunocompromised persons 1
• Anyone without history of chickenpox or varicella vaccination 1