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November 15, 2023

Herpes Zoster Outbreaks are Still a Problem in the U.S.

Written by the AIHC Blogger    

1 of Every 3 People in U.S. Will Get Herpes Zoster (Shingles).  This topic has been requested by AIHC members for educational purposes.  Due to the high stress levels experienced not only for healthcare workers, but in our society in general, shingles left untreated increases the risk of other complications related to the virus. 

Is there a correlation between stress and outbreaks of shingles?

Stress is at an all-time high.  Inflation, war in foreign countries, our population suffering from social determinants of health issues, lack of adequate staffing in all health care setting are just a few contributing factors which can weaken our immune system, which triggers a herpes zoster reactivation.

A 2018 study published in the American Journal of Epidemiology found that perceived mental stress, negative life events, and a low sense of purpose may contribute to the development of shingles and postherpetic neuralgia, a complication of shingles discussed further below. Moreover, men with high mental stress were twice as likely to be at risk of incident herpes zoster.

In a 2022 review published by Canadian Science, researchers also argued that the reemergence of shingles among people with COVID-19 might be related to the interplay between psychological and immunological stress in the body.

Incidence of Shingles

More than 99% of Americans born before 1980 had chickenpox, even if they don’t remember having it. According to the National Foundation for Infectious Diseases, in the United States (US), approximately 1 million individuals get shingles every year and half of the population who lives to age 85 years will experience shingles during their lifetime.

The incidence of herpes zoster ranges from 1.2 to 3.4 per 1000 persons per year among younger healthy individuals while incidence is 3.9 to 11.8 per 1000 persons per year among patients older than 65 years. There is no seasonal variation seen with herpes zoster.  Recurrences are most common in patients who are immunosuppressed, according to an April 3, 2023 article published by the National Library of Medicine on Herpes Zoster.

Did you know that if you’ve ever had chickenpox, you can get shingles. Even children can get shingles, although it is not common; and the risk of shingles increases as you age.

  • Also, you can get chickenpox from someone who has shingles if you never had chickenpox or never got chickenpox vaccine.

Shingles is caused by the same virus causing chickenpox, the varicella-zoster virus of “VZV.”  Once a person has chickenpox, the virus stays in their body, dormant in the sensory ganglia of the cranial nerve of the dorsal root ganglia. The virus can reactivate later in life and cause shingles.

Although shingles and chickenpox are caused by the same virus, they are not the same illness.

  • Chickenpox is usually a milder illness that affects children.
  • Shingles results from a re-activation of the virus long after the chickenpox illness has disappeared.
    • While it typically resolves in about a month for most people, it can also cause severe and long-lasting pain that is very difficult to treat.

Shingles has no incubation period because it is caused by reactivation of latent infection from primary chickenpox disease.  The infectious period for shingles is until all lesions have crusted over.

You Say It’s Not a Big Deal?  It Can Be!

It is extremely painful, just ask anyone who has suffered through an episode.  The severe pain caused by zoster is due to inflammation of affected nerves with the virus.  Most develop shingles only once, but you can have singles more than once in your lifetime because the virus is still within you.

According to the Centers for Disease Control (CDC), approximately 10% to 18% of people who have shingles develop nerve pain that lasts for months or years after the rash goes away.

  • This nerve pain is called postherpetic neuralgia, or PHN. PHN is the most common complication of shingles.
    • Pain has been described as burning, stabbing, throbbing, and/or shooting pain.
  • Other symptoms can include:
    • Serious complications involving the eye, including vision loss;
    • Long-term nerve pain;
    • Fever, headache, chills;
    • Upset stomach;
    • Muscle weakness;
    • Skin infection, scarring; and
    • Decrease or loss of hearing.

Very rarely, shingles can also lead to:

  • Infection of the lung (pneumonia)
  • Brain inflammation (encephalitis)
  • Death

Triggers for herpes zoster include emotional stress; use of certain medications such as immunosuppressants; acute or chronic illness; exposure to the virus; and presence of a malignancy.

Hospitalizations and Deaths

Approximately 1% to 4% of people with shingles go to the hospital for complications. Older adults and people with weakened or suppressed immune systems are more likely to need to go to the hospital. About 30% of people in the hospital for shingles have a weakened or suppressed immune system, according to the CDC.  Fewer than 100 people die from shingles each year. Almost all shingles deaths are in older adults or people with compromised immune systems.

Controlling the Chickenpox Spread from Shingles

  • There are no isolation or quarantine requirements for shingles. However, recommendations from the American Academy of Pediatrics are as follows:
  • The virus that causes chickenpox is present in the shingles lesions. Therefore, persons with shingles must be very careful about personal hygiene and wash their hands if they touch their lesions.
  • The lesions should be completely covered until the rash is crusted over and dry.
  • If the shingles rash cannot be completely covered, it is advisable that adults and children with shingles stay home.
  • Those with disseminated shingles and immunocompromised people with either localized or disseminated shingles can transmit chickenpox virus via the airborne route and should stay home.
  • If hospitalized, patients should remain on standard, airborne, and contact precautions until lesions are dry and crusted.

ICD-10-CM Coding is Category B02

B02.9 is reported when the patient is without complications.  As mentioned above, this condition can cause complications.  Additional FY 2024 ICD-10-CM codes available are listed below.

Code                     Description       

B02.0                    Zoster encephalitis

B02.1                    Zoster meningitis

B02.21                  Postherpetic geniculate ganglionitis

B02.22                  Postherpetic trigeminal neuralgia

B02.23                  Postherpetic polyneuropathy

B02.24                  Postherpetic myelitis

B02.29                  Other postherpetic nervous system involvement

B02.30                  Zoster ocular disease, unspecified

B02.31                  Zoster conjunctivitis

B02.32                  Zoster iridocyclitis

B02.33                  Zoster keratitis

B02.34                  Zoster scleritis

B02.39                  Other herpes zoster eye disease

B02.7                    Disseminated zoster

B02.8                    Zoster with other complications

B02.9                    Zoster without complications

In Conclusion

Healthcare professionals, coders, billers, auditors and workforce members can learn more about the diagnosis, testing and preventing VZV transmission in health care settings as well as access to related information regarding the Herpes Zoster Vaccine Guidance by accessing this CDC webpage: https://www.cdc.gov/shingles/hcp/index.html

As always, ensure documentation in the patient’s medical record supports medical necessity, coding and billing.   Consider enrolling in the online Clinical Documentation Improvement course w/option to certify online to earn your Certified Medical Documentation Professional (CMDP) credential.

Review other articles related to various conditions posted to the AIHC blog, from topics on compliance, AI, HIPAA, leadership to coding and billing.  Skim through the general listing or click on a topic under “Categories”.

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