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Traveler Summary

Key Points

  • Herpes zoster (shingles) is a viral infection caused by the reactivation of the varicella (chickenpox) virus (which becomes dormant following a chickenpox infection). Shingles is not transmitted person to person, although contact with shingles blisters can cause chickenpox in someone who has never had chickenpox.
  • Risk of shingles exists for anyone who has had chickenpox in the past but is highest among older adults and persons with a weakened immune system. Travel poses no additional risk.
  • Symptoms include a localized, extremely painful rash on one side of the body that progresses to blisters then to dry, crusted lesions. Other symptoms include headache, sensitivity to light, and malaise.
  • Consequences of infection most commonly include chronic nerve pain at the site of the healed rash and, less commonly, bacterial infection of the lesions and involvement of the eyes or other organ systems.
  • Prevention includes minimizing the use of medications that suppress the immune system when possible.
  • Shingrix (preferred vaccine) is routinely given as 2 doses (spaced about 2-6 months apart) to all persons 50 years and older, regardless of travel plans or previous vaccination with the older vaccine Zostavax.
  • Vaccine side effects are most commonly headache and injection-site reactions (more severe with Shingrix).
  • Duration of vaccine protection following a completed series is expected to be long term. A booster dose is currently not recommended.

Introduction

In adults with a normal immune system, herpes zoster (shingles) is a localized, extremely painful skin eruption caused by the reactivation of the varicella (chickenpox) virus, which after a primary chickenpox infection, becomes dormant in nerve tissue and remains suppressed by a competent immune system. The virus may become active due to factors such as aging of the immune system, stress, or taking certain medications that suppress the immune system. Shingles generally affects only a single nerve distribution on one side of the body or face, but it may spread to other areas in persons with highly weakened immunity.

Risk Areas

Risk is not related to geography or travel destination but almost 1 of every 3 persons in the U.S. will develop shingles at some time. Approximately 1 million cases occur each year in the U.S., with almost half of all cases occurring among persons 60 years and older.

Transmission

Shingles is not transmitted person to person; however, transmission of the virus via contact with shingles blister fluids or inhalation of aerosolized blister fluids can cause chickenpox in persons who are not immune to chickenpox (e.g., individuals with no history of disease or previous chickenpox vaccination).

Risk Factors

Risk of shingles exists for anyone who has had chickenpox but is highest among older adults and persons with a weakened immune system. Travel poses no additional risk.

Symptoms

Symptoms include a painful, itchy rash localized to one side of the body that (over 3-5 days) develops into clusters of clear blisters, which then become dry and crusted. The blisters usually heal in 2 to 4 weeks and may result in permanent skin scarring. In persons with compromised immunity, the rash may spread (affecting more areas of the body) and may resemble chickenpox. Other symptoms include headache, sensitivity to light, and malaise.

Consequences of Infection

Chronic, persistent pain (postherpetic neuralgia [PHN]), located in the area where the rash appeared, is a common complication of shingles occurring after the rash has resolved. PHN can last for weeks, months, or years and usually occurs in about 13% of persons 60 years and older (but is rare in persons younger than 40 years). Other complications include eye involvement, bacterial infection of the lesions, central nervous system involvement, and other organ involvement, such as the lungs and liver. Most people have only 1 episode of shingles in their lifetime, but second and third episodes are possible.

Need for Medical Assistance

Persons who suspect they might have shingles should seek medical attention. Antiviral drugs, if given within 3 days of symptom onset, have been shown to reduce the duration and severity of illness and may reduce the risk of developing PHN.

Prevention

Nonvaccine

Minimize the use of medications that suppress the immune system when possible. No studies have demonstrated a beneficial effect of general stress reduction or an increased susceptibility due to travel.

Vaccine

Shingrix is routinely recommended for persons 50 years and older (regardless of history of previous episodes of shingles or previous vaccination with Zostavax), especially for adults with chronic medical conditions. Vaccination reduces the risk of shingles and PHN by more than 91% and about 90%, respectively. The older vaccine, Zostavax, should no longer be used, except in cases where Shingrix is unavailable, contraindicated, or based on individual preference.

Side Effects

The most common side effects of herpes zoster vaccines are headache and injection-site reactions (redness, pain, swelling, itching, and warmth). Severe injection-site pain, swelling, and redness (spanning several inches) and extreme tiredness, fever, and gastrointestinal symptoms are common following Shingrix administration. Vaccine-related rash and hypersensitivity have been reported with Zostavax.

Persons with underlying medical conditions or those who have concerns about the vaccine should speak to their health care provider before vaccine administration.

Timing

The primary routine series for Shingrix vaccine consists of 2 doses given 2 to 6 months apart to persons 50 years and older.

A booster dose is not currently recommended, although persons previously vaccinated with Zostavax should be revaccinated with Shingrix.