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Transcript of Herpes Zoster
SHINGLES!!! Goal What is Herpes Zoster? Definition:
VZV infection that manifests years after primary contraction and causes painful herpetic lesions. The lesions follow a zosteriform linear pattern along the dermatones of the sensory nerves where VZV existed latent in the body (CDC, 2012). Zosteriform lesions are clear vesicles that develop in clusters along dermatones on the trunk, but rarely crosses the midline of the body.
If the lesions cross two or more dermatones, it is called disseminated zoster (CDC, 2012).
The vesicles develop over several days and change in appearance in phases from pustular to ulcer and then to crust. The zosteriform rash lasts a week to 10 days and then heals completely in 2 weeks to a month (Harpaz, Ortega-Sanchez & Seward, 2008). Class Disussion Prevent shingles and promote quality of life. Herpes Zoster by
Erin Keim, RN & Terry Lewis, RN
USF FNP students Primary infection with VSV causes varicella or chickenpox, but once the illness resolves, the virus remains dormant in the dorsal root ganglia. Later in life, this virus causes Herpes zoster (CDC, 2012). Objective signs: Josie is 63 years old and in for a routine check-up with her nurse practitioner. Josie is diabetic and aware that she is at risk for some vaccine preventable illnesses such as shingles and influenza. She already had shingles 1 year ago and, thankfully, did not experience residual complications such as PHN. She asks you, the nurse practitioner, what you recommend for her because she does not want to suffer through another painful episode of shingles. It is agreed that prevention of herpes zoster is key. However, when gathering data and searching for appropriate clinical guidelines, it is found there is a great need for further research and evidence to support this claim. Also, while comparing the available clinical guidelines on the prevention of herpes zoster, the guideline chosen was the most up-to-date and, interestingly, was the ONLY guideline available. It is believed, since the guideline was last updated in 2008, it is due for an update or review. Cause:
Varicella-zoster virus (VZV)
*The same virus that causes
varicella or chickenpox in children. *It is difficult to assess population rates of incidence because herpes zoster is not a reportable disease. According to the clinical guideline, certain analysis of studies show an estimated 1 million new cases yearly with increased incidence occurring in people over the age of 60 (Harpaz, Ortega-Sanchez & Seward, 2008).
99.5% of population who are over 40 contracted varicella as a child. This portion of the population is at the
greatest risk for developing Herpes Zoster (CDC, 2012).
Prodromal symptoms are reported as painful, itchy, tingling, even "shock-like" sensations that precede the actual presentation of lesions from days to weeks beforehand.
Other associated symptoms during prodrome include: headache, photophobia, and malaise (CDC, 2012). Subjective Symptoms: Complications The most common is postherpetic neuralgia (PHN). Elderly with zoster are more at risk to develop PHN (CDC, 2012). PHN is residual pain where the zoster lesions were, lasting from weeks to months (CDC, 2012). Herpes zoster can affect the eyes by following the optic nerve in a condition called herpes zoster ophthalmicus.
Lesions can become infected with staph as well as strep.
Palsies can also result.
Herpes zoster can also manifest infection in the viseral organs such as the brain stem, lungs, and liver (CDC, 2012). Clinical
Guideline According to the National
Guideline Clearinghouse guideline
summary of herpes zoster,
all individuals over the
age of 60 should receive
the zoster vaccine. This
significantly reduces the chances
of contracting herpes zoster
(AHRQ, 2008). Recommendations Cost Analysis Five studies that used the Markov cohort model were completed to determine cost effectiveness of getting the immunization vs. no immunization. It determined that cost savings range from "$27,000 to $112,000 per quality-adjusted life-year (QALY) gained" (AHRQ, 2008; Harpaz, Ortega-Sanchez & Seward, 2008). Application to practice After reviewing the cost of treating complications and quality of life considerations, the impact on practice of advance practice nurses is apparent in cost reduction and promotion of quality of life for the patient. However, clinical judgement is important to use in considering who meets criteria and will benefit most from receiving the zoster vaccine. Rational for Guideline Scope and purpose What is the recommended coarse of action to prevent herpes zoster in the population?
Who is the zoster vaccine recommended to?
Who is it not recommended to?
Is it appropriate for the vaccine to be given with others?
When is it contraindicated?
What are the potiential benefits vs risks?
What are the issues regarding implementation of the guideline? Objective: to recommend the use of a vaccine to prevent herpes zoster. Target population: Adults in the US 60 years or older. Clinical questions addressed include: Stakeholders The Advisory Committee on Immunization Practices (ACIP) shingles workgroup (estblished in 2005) developed the guideline.
The guideline does not state commercial interests, however, it was developed shortly after the zoster vaccine was licensed in May 2006 (AHRQ, 2008).
The ACIP shingles workgroup is multidisciplinary including 14 experts in various medical, public health, and scientific fields as well as one group member who represents the public and community interests as consumers (CDC, 2012).
External review of guideline was done in 2006 by the CDC and "external partners." Alterations where made for clarity and to update information in the recommendation (AHRQ, 2008). (AHRQ, 2008). Intended users of the guideline includes:
Advanced Practice Nurses, Physicians, Physicians Assistants, Hospitals, Nurses, public health departments and allied health personnel (AHRQ, 2008). Evidence-based
methodology Unfortunately, a systematic strategy was not used in the development of the guideline. Certain studies were referenced throughout the guideline and various tables were available. The method used to collect evidence was "searches of electronic databases." No description of this method was available. The total number of references use was 224 (AHRQ, 2008). "When scientific evidence was lacking, recommendations incorporated expert opinions of the workgroup members."
(AHRQ, 2008). Epidemiology Recommendations were made and disagreements resolved via a series of conference calls in which discussion on relevant topics on zoster prevention were reviewed. Though various studies are referenced, recommendations were created by "expert consensus." It is possible recommendations may not be appropriately matched to the evidence presented (AHRQ, 2008). Observed in the Shingles Prevention study population where the vaccine and placebo adverse events and rates of hospitalization were similar. Though, those who received the vaccine where shown to be more at risk to develop adverse effects (AHRQ, 2008). *Zoster occurs when the dormant VZV is reactivated. Therefore, susceptible people are those who naturally contracted VZV as a child and possibly those who received a varicella vaccine that used the Oka/Merek strain VZV. Other at risk populations include people who have a history of herpes zoster rash, are immunosuppressed, and those who are taking antiviral medications (Harpaz, Ortega-Sanchez & Seward, 2008). *Age has the greatest influence on development of herpes zoster, also known as shingles. According to the full clinical guideline on prevention of herpes zoster, most studies showed direct correlation with increasing incidence of zoster infection with increase in age.
Increase in age also creates a greater risk for developing complications, namely post-herpetic neuralgia (PHN). Age is associated with decrease in the immune system also placing older people at risk (Harpaz, Ortega-Sanchez & Seward, 2008). Adverse effects and quality of life considerations: Discussed treatment included FDA approved medications for currently existing zoster rash including: acyclovir, famciclovir, and valacyclovir. However, prevention of herpes zoster was the focus of the guideline. Discussion focused on the zoster vaccine, ZOSTAVAX, a live attenuated vaccine that uses the Oka/Merck strain of VZV and is 14 times stronger than the varicella vaccine (Harpaz, Ortega-Sanchez & Seward, 2008). Treatment The clinical guideline used for this presentation is the only guideline and it is considered up-do-date. According AHRQ (2008), the AICP will review and update recommendations as research findings reveal more information "on the epidemiolody and prevention of shingles." Ease of
Use and clarity With use of the AHRQ guideline summary,
key recommendations are easily identified. The clinical guideline is easy to read
and understand. It presents specific recommendations for the target population (adults 60 years and older who are immuncompetent). However, ambiguous recommendations are presented for other at-risk or precautionary populations (AHRQ, 2008). Implementation According to the guideline, the zoster vaccine should be offered to patients 60 years or older along with other vaccinces (such as influenza) to promote preventative healthcare (AHRQ, 2008). The guideline claims cost-effectiveness of the zoster vaccine for society, stating savings of "$27,000-$112,000 per quality-adjusted life-year gained (Harpaz, Ortega-Sanchez & Seward, 2008). *Implementation tools are not provided
with this guideline.
*Performance measures translate into effectiveness of zoster vaccine without
adverse reaction. Adverse effects of the
zoster vaccine that are "clinically significant" should be reported to the Vaccine Adverse Event Reporting System (VAERS) (AHRQ, 2008). Editorial Independence *There is no indication that the guideline process is independent from project funding. Funding comes from the government since the AICP and the CDC are government supported agencies. *There are possible conflicts of interest since the guideline is an internal peer review and based off "expert consensus (AHRQ, 2008)."
*Potential conflicts of interest are not clearly stated. References:
AHRQ. (2008). Prevention of herpes zoster.
Recommendations of the advisory committee on immunization practices: guideline summary. National Guideline Clearinghouse. CDC. (2012). Clinical overview: herpes zoster.
Retrieved from http://www.cdc.gov/shingels/hcp/clinical-overview.html Harpaz, R., Ortega-Sanchez, I., & Seward, J. (2008).
Prevention of herpes zoster. Recommendations of the advisory committee on immunization practices. CDC:MMWR. Atlanta, Ga. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm 1. Does this patient meet appropriate criteria to receive the zoster vaccincation? If so, how? 2. Is it safe for her to receive more than just the zoster vaccine in one setting to promote her preventative health? Recommendations cont. According to the guideline, it is safe to administer the zoster vaccine with other vaccines such as the influenza, tetanus, Td, Tdap, and pneumococcal vaccines (AHRQ, 2008). 3. How would you recognize herpes zoster?
What are symptoms that precede outbreak?
What signs indicate a herpes zoster rash? Much of the societal expenditure arises from complications due to shingles as well as treatment costs. Research Effect of a zoster vaccine on Herpes zoster-related
interference with functional status and health-related quality-of-life measures in older adults (Schmader et al, 2010). Research continued Objective To find out if the zoster vaccine helps reduce problems with activities of daily living (ADL) and health-related quality of life issues with Herpes zoster (Schmader et al, 2010). Research continued Method Randomized double-blind placebo controlled study including 38,546 individuals over the age of 60. 19,270 received the intramuscular vaccine and 19,276 received a placebo injection. Follow-up was completed via monthly automated phone calls. Researchers evaluated 1,308 suspected cases of shingles, determining there were 957 cases of true shingles that could be evaluated. The researchers determined efficacy of the zoster vaccine on reducing herpes zoster related problems through utilization of the Zoster Brief Pain Inventory (ZBPI), Zoster Impact Questionnaire (ZIQ), The EuroQol Visual Analog Scale, and The Medical Outcomes Study 12-Item Short Form Survey (SF-12) (Schmader et al, 2010). Research continued Results "The zoster vaccine reduced the ZBPI ADL burden of interference score 66%,"and "reduced the effects on physical health related quality of life 55%" (Schmader et al, 2010). Research continued Summary In this study, the zoster vaccine was able to reduce health related problems with ADL's by two thirds and HRQL issues by about half. This confirms that in addition to preventing herpes zoster, the vaccine also has the ability to reduce the complications associated with herpes zoster in those who acquire the condition
(Schmader et al, 2010). Schmader, K. E., Johnson,G. R., Saddier, P., Wang,
W. W. B., Zhang, J. H., Chan, I. S. F... et al,
(2010). Effect of a zoster vaccine on herpes zoster-related interference with functional status and health-related quality-of-life measures in older adults. Journal of the American Geriatrics Society, 58(9), 1634-1641.