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Zoster (shingles)

Ask the Experts: Diseases & Vaccines

Zoster (shingles)

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Zoster (shingles)
 
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Zoster (shingles)
Disease Issues Contraindications and Precautions
Vaccine Recommendations Administering Vaccines
Vaccine Safety Storage and Handling
Disease Issues
How common is shingles (herpes zoster)?
During their lifetime 30% of Americans will develop herpes zoster, which translates into an estimated 1 million cases each year in this country. The risk of zoster increases with increasing age; about half of all cases occur among people age 60 years or older. People who are immunosuppressed, as occurs with leukemia, lymphoma, and human immunodeficiency virus (HIV) infection, and people who receive immunosuppressive drugs, such as steroids and cancer chemotherapy are also at greater risk of zoster. People who develop zoster typically have only one episode in their lifetime. In rare cases a person can have a second or even a third episode.
Can you catch zoster from a person with active zoster infection?
Zoster is caused by reactivation of a latent varicella virus infection (from having chickenpox in the past). Zoster is not passed from one person to another through exposure to another person with zoster. If a person who has never had chickenpox or been vaccinated against chickenpox comes in direct contact with a zoster rash, the virus could be transmitted to the susceptible person. The exposed person would develop chickenpox, not zoster.
Vaccine Recommendations Back to top
How effective is zoster vaccine in preventing shingles?
In the key pre-licensure clinical trial (N Eng J Med 2005;352:2271-84), vaccine recipients had a 51% reduction in shingles and less severe illness when shingles did occur compared with placebo recipients. No significant safety issues were identified during this trial.
Will administering zoster vaccine prevent postherpetic neuralgia (PHN)?
In the pre-licensure trial, zoster vaccine was 66.5% effective in preventing PHN. It is also believed to lessen the severity of both shingles and PHN if a person should develop zoster after vaccination.
To whom should zoster vaccine be given?
ACIP recommends a single dose of zoster vaccine for all adults age 60 years and older whether or not they report a prior episode of herpes zoster. Persons with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition. For a copy of the ACIP recommendations on zoster vaccine, go to www.cdc.gov/mmwr/PDF/rr/rr5705.pdf.
Zoster vaccine is approved by the FDA for people age 50 years and older. Does ACIP recommend that clinicians vaccinate people in their 50s?
At its October 2013 meeting, the ACIP reviewed the current status of zoster vaccine licensure and the burden of herpes zoster (HZ) disease. ACIP declined to vote to expand the recommendations for the use of zoster vaccine to include people age 50 through 59 years for the following reasons: (1) though the burden of HZ disease increases after age 50, disease rates are lower in this age group than they are in persons age 60 years and older; (2) there is insufficient evidence for long term protection provided by the vaccine; and (3) persons vaccinated at younger than age 60 years may not be protected when the incidence of zoster and its complications are highest. However, zoster vaccine is approved by the FDA for persons age 50 through 59 years and clinicians may vaccinate persons in this age group without an ACIP recommendation.
Is there an upper age limit for receipt of the zoster vaccine? Local providers are reluctant to give zoster vaccine to persons age 80-plus years.
There is no upper age limit for zoster vaccine. The incidence of herpes zoster increases with increasing age; about 50% of persons living until age 85 years will develop zoster. ACIP recommends the vaccine for everyone age 60 and older, even though the vaccine's efficacy decreases with an increase in the recipient's age. The clinical trials found an approximately 18% efficacy in people age 80 and older as compared with 64% efficacy in people age 60 through 69 years. In general, with increasing age at vaccination, the vaccine is more effective in reducing the severity of zoster and post-herpetic neuralgia than in reducing the occurrence of zoster.
I understand that varicella vaccine, MMRV (ProQuad), and zoster vaccine each have different concentrations of virus. Would you tell me how they are different?
A dose of varicella vaccine has 1,350 plaque forming units (PFUs) of varicella vaccine virus, MMRV contains 9,800 PFUs (7 times higher than varicella vaccine), and zoster vaccine contains 19,400 PFUs (14 times higher than varicella vaccine).
Before administering zoster vaccine is it necessary to ask if the person has ever had chickenpox or shingles?
No. All persons age 60 years or older-whether they have a history of chickenpox or shingles or not-should be given zoster vaccine unless they have a medical contraindication to vaccination (described below). It is also not necessary to test for varicella antibody prior to giving the vaccine.
Should people who haven't had chickenpox be vaccinated with zoster vaccine?
Serologic studies indicate that almost everyone born in the United States before 1980 has had chickenpox. As a result, there is no need to ask people age 60 years and older for their varicella disease history or to conduct lab tests for serologic evidence of prior varicella disease. A person age 60 years or older who has no medical contraindications, is eligible for zoster vaccine regardless of their memory of having had chickenpox. The same principal applies if a clinician decides to vaccinate a person 50 through 59 years of age.
For patients age 60 or older who don't remember having chickenpox in the past, should we test them for varicella immunity before giving zoster vaccine?
No. Simply vaccinate them with zoster vaccine according to the ACIP recommendations.
We weren't familiar with the recommendations and tested a 60-year-old for varicella antibody because she said she never had chickenpox. Her result was negative. Should this patient receive zoster vaccine or varicella vaccine?
In this situation, since you've tested the patient and the results were negative, the patient should receive varicella vaccine. A person age 60 years or older who has no medical contraindications is eligible for zoster vaccine regardless of their memory of having had chickenpox. However, if an adult age 60 years or older is tested for varicella immunity for whatever reason, and the test is negative, he/she should be given 2 doses of varicella vaccine at least 4 weeks apart, not zoster vaccine. See www.cdc.gov/vaccines/vpd-vac/shingles/hcp-vaccination.htm for more information.
Can someone who has experienced an episode of shingles be vaccinated with the zoster vaccine?
Yes. Zoster vaccine is routinely recommended for all persons age 60 years and older who do not have a contraindication.
How soon after a case of shingles can a person receive zoster vaccine?
The general guideline for any vaccine is to wait until the acute stage of the illness is over and symptoms abate. However, a recent case of shingles is expected to boost the person's immunity to varicella. Zoster vaccine is also intended to boost immunity to varicella. Administering zoster vaccine to a person whose immunity was recently boosted by a case of shingles might reduce the effectiveness of the vaccine. ACIP does not have a specific recommendation on this issue. But it may be prudent to defer zoster vaccination for 6 to 12 months after the shingles has resolved so that the vaccine can produce a more effective boost to immunity.
If a person was exposed to shingles by a spouse within the last few days, is there a recommended waiting period before the exposed person can receive zoster vaccine?
There is no waiting period in such a situation. Zoster vaccine can be given right away or at any time to any person for whom the vaccine is recommended. Shingles is not caused by exposure to another person with shingles. People with shingles can only possibly cause a susceptible person to develop varicella (chickenpox), not zoster.
A 33-year-old patient in my practice has already suffered from three episodes of shingles. He would like to receive the zoster vaccine. Is this a good idea?
Although zoster vaccine is approved by the FDA for people age 50 and older, ACIP recommends it routinely only for people age 60 and older. ACIP does not have a recommendation to administer the vaccine to younger people with recurrent zoster episodes. However, clinicians may choose to administer a vaccine off-label, if in their clinical judgment, they think the vaccine is indicated. The patient should be informed that the use is off-label, and that the safety and efficacy of the vaccine has not been tested in people younger than 50.
Can zoster vaccine be administered to people in long-term care facilities?
Zoster vaccine can be administered to anyone age 60 years and older regardless of where they reside, unless they have a contraindication to vaccination.
Can I give our long-term care residents zoster, injectable influenza, and pneumococcal vaccines on the same day?
Yes. Here are the general rules: (1) all vaccines used for routine vaccination in the United States can be given on the same day; (2) an inactivated vaccine can be administered either on the same day as or at any time before or after another inactivated or a live vaccine; and (3) any 2 LIVE vaccines that are not given on the same day must be spaced at least 4 weeks apart. Zoster vaccine is a live, attenuated vaccine; injectable influenza vaccine and pneumococcal polysaccharide vaccine are inactivated vaccines. So these 3 vaccines can be given on the same day or at any time before or after each other. They should be given as separate injections, not combined in the same syringe.
Should healthcare personnel in long-term care facilities be tested to see if they have had chickenpox before taking care of someone who has received zoster vaccine?
All healthcare personnel should ensure they are immune to varicella regardless of the setting in which they work and regardless of their patients' receipt of zoster vaccine.
The Zostavax package insert says that clinicians should consider administering zoster vaccine and pneumococcal polysaccharide vaccine (PPSV) at least 4 weeks apart. What does ACIP say about this?
This wording was added to the package insert because a Merck study showed that the varicella antibody titer in people who received zoster and PPSV vaccines at the same visit were lower than when people received the vaccines a month apart. However, there is no known serologic correlate for protection against shingles so the importance of this observation is not known. ACIP has not changed its recommendation on the simultaneous administration of these two vaccines. Zoster vaccine and PPSV can be given at the same time or any time before or after each other.
If we inadvertently give a child zoster vaccine rather than varicella vaccine, what should we do?
This is a serious vaccine administration error. The event should be documented and procedures put in place to prevent this from happening again. Zoster vaccine contains about 14 times as much varicella vaccine virus as varicella vaccine. However, no specific action needs to be taken in response to this vaccine administration error. If this was the child's first dose of varicella-containing vaccine he/she will still need the second dose of varicella-containing vaccine on schedule.
A 60-year-old patient was inadvertently given varicella vaccine instead of zoster vaccine. Should the patient still be given the zoster vaccine? If so, how long an interval should occur between the 2 doses?
ACIP recommends that if a provider mistakenly administers varicella vaccine to a person for whom zoster vaccine is indicated, no specific safety concerns exist, but the dose should not be considered valid and the patient should be administered a dose of zoster vaccine during that same visit. If the error is not immediately detected, a dose of zoster vaccine should be administered 4 weeks after the varicella vaccine dose to prevent potential interference of 2 doses of live attenuated virus. Avoid such errors by checking the vial label 3 times to make sure you're administering the product you intended.
We inadvertently gave a 47-year-old healthcare worker zoster vaccine rather than varicella vaccine for work. Does this dose count?
Yes, but this is a serious vaccine administration error because zoster vaccine contains about 14 times as much varicella vaccine virus as varicella vaccine. You should document the event and establish procedures to prevent this from happening again. The dose of zoster vaccine can be counted as the first of two doses of varicella vaccine for an adult who is not immune to varicella. The second dose of varicella vaccine should be given 4 to 8 weeks after the first dose.
If a patient who received zoster vaccine a week ago comes in for a tuberculin skin test (TST), do we need to wait 4 weeks from the time the patient received the vaccine before applying the skin test? This is what we currently do with patients who need a TST after receiving MMR vaccine.
Yes. If you've recently vaccinated the patient with zoster vaccine, you should delay the TST for 4 weeks from the date of the vaccine dose. Ideally, when TST screening and zoster vaccination are both needed, TST screening should be scheduled prior to or on the same day as the zoster vaccination. ACIP's recommendations for use of zoster vaccine do not address the interval between vaccination and TST screening. However, ACIP's General Recommendations on Immunization state that in the absence of specific recommendations, when scheduling TST screening and administering other live-attenuated virus vaccines, clinicians should follow guidelines for measles-containing vaccine (please refer to the General Recommendations on Immunization, page 30).
A long-term care resident age 80 years who received zoster vaccine (Zostavax; Merck) several years ago recently had a mild case of shingles. Is there any recommendation for administering a second dose of vaccine in such a circumstance? Are booster doses ever recommended?
The answer to both questions is no. Zoster vaccine is not 100% effective. In the key clinical trial, overall effectiveness among people age 60 years and older was 51% and decreased with increasing age. However, the vaccine was 67% effective in preventing post-herpetic neuralgia; this effectiveness did not decrease with increasing age. The duration of protection from shingles after a dose of zoster vaccine is not known at this time. However, ACIP has not recommended a second dose for anyone. ACIP recommendations for the use of zoster vaccine are available at www.cdc.gov/mmwr/PDF/rr/rr5705.pdf.
Vaccine Safety Back to top
How safe is zoster vaccine?
In the pre-licensure clinical trial involving more than 38,000 adults, zoster vaccine was administered to about half of the study participants. The other half received a placebo. The occurrence of possible side effects was similar in the vaccine and placebo groups (1.9% and 1.3%, respectively). The incidence of serious medical events, hospitalization and death was the same among people who received zoster vaccine and those who received a placebo vaccination. As with all vaccines, the manufacturer, CDC, and the FDA will continue to monitor the vaccine to provide additional safety information.
What adverse reactions have been reported with this vaccine?
The most commonly reported adverse reactions are redness (36%), pain or tenderness (35%), swelling (26%), and itchiness (7%) at the injection site. No serious adverse reactions have been associated with zoster vaccine.
Contraindications and Precautions Back to top
What are the contraindications and precautions to zoster vaccine?
Contraindications to zoster vaccine:
Severe allergic reaction to a vaccine component or following a prior dose
  Immunosuppression from any cause (disease or treatment of a disease)
  Pregnancy
The only precaution to zoster vaccine is the presence of a moderate or severe acute illness. Vaccination should be deferred until the illness improves.
Pregnancy in a woman age 60 years or older? Really?
It happens. You still need to ask.
If an adult has had zoster with herpetic neuralgia ophthalmic complications, when can they receive the zoster vaccine?
Once they are no longer acutely ill, they can be vaccinated with zoster vaccine (see the question in the previous section regarding vaccination after shingles). There is no evidence that the vaccine will have therapeutic effect for a person with existing postherpetic neuralgia.
How long should we wait before giving zoster vaccine to a patient who has had a blood transfusion?
There is no waiting period for administering zoster vaccine following transfusion. The amount of antigen in zoster vaccine is so substantial that it overpowers any antibody to herpes zoster that may be in the blood product. This is not the case for varicella and MMR vaccines, however. Wait 3 or more months before administering these vaccines to a patient who has received an antibody-containing blood product.
I have a patient who is eligible for zoster vaccination who is going to be receiving chemotherapy soon. What are the guidelines in such a situation?
The risk for zoster and its severe morbidity and mortality is much greater for immunosuppressed people. In this situation, the first step is to review the patient's vaccine history for zoster and other vaccines. Immunocompetent patients 60 years and older who have never received zoster vaccine and who anticipate starting immunosuppressive treatments or who have diseases that might lead to immunodeficiency should receive 1 dose of the vaccine as soon as possible, while their immunity is intact. Administer zoster vaccine at least 14 days before immunosuppressive therapy begins. Some experts advise delaying the start of immunosuppressive therapy until 1 month after zoster is administered, if delay is possible.
When can a patient previously on immunosuppressive chemotherapy receive zoster vaccine?
If the patient was receiving cancer chemotherapy, wait 3 months after therapy is discontinued before administering zoster vaccine. If they were receiving high-dose steroids, isoantibodies, immune-mediators, or immunomodulators, wait 1 month after therapy is discontinued. Lastly, if the person was receiving low doses of methotrexate, azathioprine, or 6-mercaptopurine, waiting is not necessary as these therapies are not considered immunosuppressive. More information on this issue can be found in the zoster ACIP recommendations at www.cdc.gov/mmwr/pdf/rr/rr5705.pdf.
Should a healthy person age 60 years or older receive zoster vaccine if they are going to be in contact with an unvaccinated infant or an immunocompromised person?
Neither situation is a contraindication to zoster vaccination. A person who receives zoster vaccine who has close household or occupational contact with people who are at risk for developing severe varicella or zoster infection need not take any special precautions after receiving zoster vaccine. The only exception is in the rare instance when a person develops a varicella-like rash after receiving zoster vaccine. A vaccine rash is expected to occur less frequently after zoster vaccine than after varicella vaccine. If a rash develops, the vaccinated person should restrict avoid contact with an immunocompromised person if the immunocompromised person is susceptible to varicella.
The Zostavax package insert says that the vaccine is contraindicated in a person with a history of primary or acquired immunodeficiency states, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system. Does this mean that a person who was treated for lymphoma many years ago and is now healthy should not receive zoster vaccine?
No. A person who was treated for leukemia, lymphoma, or other malignant cancers in the past and is now healthy and not receiving immunosuppressive treatment may receive zoster vaccine. However, a person who is immunosuppressed for any reason (disease or treatment) should not receive the vaccine.
Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?
Yes, with one qualification. A diagnosis of an autoimmune condition such as lupus or rheumatoid arthritis is not a contraindication to zoster vaccination. However, the treatment of these conditions may involve the use of an immunosuppressive drug, which could be a contraindication.
A 65-year-old patient is having major back surgery next week. He is requesting zoster vaccine today. Can I give him the vaccine?
Yes, with one qualification. There is no contraindication to vaccinating against zoster before surgery, unless the patient is immunocompromised for some reason.
Administering Vaccines Back to top
How is zoster vaccine administered?
Reconstitute zoster vaccine using only the diluent provided. Administer zoster vaccine by the subcutaneous route immediately after reconstitution to minimize loss of potency. If the vaccine is not administered within 30 minutes of reconstitution, it must be discarded.
The Zostavax package insert says to inject the vaccine into the deltoid region of the upper arm. We always give subcutaneous vaccines in the triceps area of the arm. Is this wrong?
No. The subcutaneous tissue overlying the triceps muscle of the upper arm is the usual location for subcutaneous vaccine injection for an adult.
When reconstituted, the volume of zoster vaccine is 0.65 mL. Should 0.65 mL or 0.5 mL be administered to the patient?
The recommended dose for zoster vaccine is the fully reconstituted amount, 0.65 mL.
Can pharmacists in all states administer zoster vaccine?
According to the American Pharmacist Association, all states allow pharmacists to administer zoster vaccine. Not all pharmacists providse vaccination services, and of those who do, not all administer zoster vaccine. It is best to call the pharmacy ahead of time to find out if they have zoster vaccine to administer to your patients. The vaccine must be administered in the pharmacy. Do NOT instruct the patient to transport the vaccine from the pharmacy back to your office. This could damage or destroy the potency of the vaccine. See below for more information on this issue.
Storage and Handling Back to top
How should zoster vaccine be stored?
All varicella-containing vaccines, including zoster vaccine, must be stored frozen at a temperature of between -58°F and +5°F (-50°C and -15°C) until it is reconstituted. Although the manufacturer states that any freezer that has a separate sealed freezer door and reliably maintains a temperature between -58°F and +5°F is acceptable for storage of varicella-containing vaccines, CDC recommends the use of a separate stand-alone freezer to store frozen vaccines. A storage unit that is frost-free or has an automatic defrost cycle is preferred. The diluent should be stored separately at room temperature or in the refrigerator.
Zoster vaccine may be stored at refrigerator temperature between 36°F and 46°F (2°C and 8°C) for up to 72 continuous hours prior to reconstitution. Vaccine stored between 36°F and 46°F (2°C and 8°C) that is not used within 72 hours of removal from a freezer should be discarded. Zoster vaccine should be reconstituted immediately upon removal from the freezer. Administer zoster vaccine immediately after reconstitution to minimize loss of potency. Discard reconstituted vaccine if not used within 30 minutes. Do not freeze reconstituted vaccine.
How should zoster vaccine be transported to an off-site clinic location?
Neither CDC nor the vaccine manufacturer recommends transporting varicella-containing vaccines. If these vaccines must be transported (for example during an emergency), CDC recommends transport in a portable freezer unit that maintains the temperature between -58°F and +5°F (-50°C and -15°C). Portable freezers may be available for rent in some places. If varicella-containing vaccines must be transported and a portable freezer unit is not available, do NOT use dry ice. Dry ice may subject varicella-containing vaccines to temperatures colder than -58°F (-50°C).
Varicella-containing vaccines may be transported at refrigerator temperature between 36°F and 46°F (2°C and 8°C) for up to 72 continuous hours prior to reconstitution. Vaccine stored between 36°F and 46°F (2°C and 8°C) that is not used within 72 hours of removal from a freezer should be discarded. Detailed instructions for the transport of varicella-containing vaccines at refrigerator temperature are available in the CDC Storage and Handling Toolkit at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf.
People are picking up zoster vaccine at local pharmacies and transporting it to the physician's office to be given. Should this vaccine be given?
This practice is not acceptable. If the vaccine has been exposed to temperature conditions outside of those specified in the package insert the provider must contact Merck for guidance prior to administering the vaccine. Merck's contact information is included in the package insert.
If zoster vaccine that has been damaged by a temperature excursion has been inadvertently administered to a patient, when should the dose be repeated?
According to ACIP's General Recommendations on Immunization, an invalid dose of a live attenuated vaccine (such as zoster vaccine) should be repeated no less than 4 weeks after the invalid dose. This information is located at www.cdc.gov/mmwr/pdf/rr/rr6002.pdf, pages 18–19.
 
This page was reviewed on December 1, 2013
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