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| Vaccine-related
information and recommendations |
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| To whom
should shingles vaccine be given? |
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| A single dose of zoster vaccine is
recommended for 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/rr57e0515.pdf |
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| What do you think about giving zoster
vaccine to nursing home patients? Should healthcare personnel in nursing
homes be tested to see if they have had chickenpox before taking care of
someone who has received zoster vaccine? |
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| Zoster vaccine can be administered to
anyone age 60 years and older regardless of where they reside, unless
they have a contraindication to vaccination. 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. |
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| The new Zostavax vaccine (Merck)
package insert says that Zostavax should not be given simultaneously
with pneumococcal polysaccharide vaccine (PPSV). What does ACIP say
about this? |
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| ACIP has not changed its
recommendation on the simultaneous administration of these two
vaccines (i.e., they can be given at the same time or any time before
or after each other). |
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| Can I give our long-term care
residents zoster, injectable influenza, and pneumococcal vaccines on the
same day? |
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| 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. Zostavax is a live,
attenuated vaccine; injectable trivalent influenza vaccine (TIV) and
pneumococcal polysaccharide vaccine (PPSV) are inactivated vaccines.
Therefore, these 3 vaccines can be given on the same day or at any time
before or after each other. They cannot, however, be given in the same
syringe. |
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| 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. |
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| There is no upper age limit for zoster
vaccine. The incidence of herpes zoster increases with age. It is known
that about 50% of persons living until age 85 years will develop zoster. |
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| I understand that in March 2011,
FDA expanded the age indication for Zostavax (shingles vaccine; ZOS;
Merck) to include the vaccine's use in people age 50 through 59 years
(while retaining the age indication for use in people age 60 years and
older). Can you tell me what ACIP recommends about this? |
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| At its June 2011 meeting, the ACIP
reviewed the current status of ZOS licensure and the burden of herpes
zoster (HZ) disease. ACIP declined to vote to expand the
recommendations for the use of ZOS to include people age 50 through 59
years for the following reasons: (1) vaccines that contain varicella
virus (i.e., varicella, ZOS, and MMRV vaccines) are in recurrent short
supply in the U.S., (2) though the burden of HZ disease increases
after age 50, disease rates are lower in this age group than they are
in the 60-years-and-older age group, (3) currently, ZOS vaccination
rates are less than 10 percent, and (4) a recommendation to vaccinate
people age 50–59 years could result in more zoster disease if the
limited supply of vaccine were to be given to people whose risk of
disease is lower than that of older, more vulnerable adults. |
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| If we inadvertently give a
12-year-old child Zostavax instead of Varivax, what should we do? |
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| This is a serious vaccine administration
error. The event should be documented and procedures put in place to
prevent this from happening again. Zostavax vaccine contains about 14
times as much varicella vaccine virus as Varivax. |
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| We accidentally gave a 47-year-old
healthcare worker Zostavax instead of Varivax for work. Does this count? |
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| Yes, but this is a serious vaccine
administration error because Zostavax vaccine contains about 14 times as
much varicella vaccine virus as Varivax. 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. |
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| I understand that Varivax, ProQuad,
and Zostavax each have different concentrations of antigen. Would you
tell me how they are different? |
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| A dose of Varivax has 1,350 plaque
forming units (PFUs), ProQuad contains 9,800 PFUs (7 times higher than
Varivax), and Zostavax contains 19,400 PFUs (14 times higher than
Varivax). |
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| A 60-year-old patient was 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? |
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| ACIP states the following: "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 as soon as possible but not within 28 days of 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! To download
the ACIP recommendations titled "Prevention of Herpes Zoster," go to: www.cdc.gov/mmwr/PDF/rr/rr5705.pdf |
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| How effective is the new Zostavax
vaccine in preventing shingles? |
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| In clinical trials, vaccine recipients
had a 51% reduction in shingles, less severe illness when shingles did
occur, and 66.5% less postherpetic neuralgia, compared with placebo
recipients. During these trials, no significant safety issues were
identified. |
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| Will administering Zostavax prevent
postherpetic neuralgia (PHN)? |
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| In pre-licensure trials, Zostavax was
66.5% effective in preventing PHN. It is also believed to lessen the
severity of both shingles and PHN if a person should happened to acquire
the disease after vaccination. |
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If a patient who received
Zostavax shingles vaccine (Merck) a week ago comes in for a TST
(tuberculin skin test), 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 show up for a TST after
receiving MMR vaccine. |
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| 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). |
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| Can you catch shingles from a person
with active shingles infection? |
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| Shingles cannot be passed from one
person to another through sneezing, coughing, or casual contact. If a
person who has never had chickenpox or been vaccinated against
chickenpox comes in direct contact with a shingles rash, the virus could
be transmitted to the susceptible person. The exposed person would
develop chickenpox, not shingles. |
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| When administering zoster vaccine, is
it necessary to ask patients if they have ever had chickenpox or
shingles? |
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| 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. Medical contraindications are described in detail in
the recently released CDC recommendations "Prevention of Herpes Zoster."
To obtain a copy, go to www.cdc.gov/mmwr/pdf/rr/rr5705.pdf |
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| Should people who haven't had
chickenpox be vaccinated with zoster vaccine? |
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| Serologic surveys indicate that almost
everyone born in the United States before 1980 has had chickenpox. As a
result, there is no need to ask patients 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. |
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| Can someone who has experienced an
episode of shingles be vaccinated with the zoster vaccine? |
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| Yes. Shingles vaccine is routinely
recommended for all persons age 60 years and older who do not have
contraindications. |
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| How soon after experiencing a case of
shingles can a person age 60 years or older receive zoster vaccine? |
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| The general guideline for any vaccine is
to wait until the acute stage of the illness is over and symptoms abate. |
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| Can we give zoster vaccine to elderly
patients who have cancer or an immunosuppressed condition? |
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| No. Zoster vaccine is contraindicated in
persons with primary or acquired immunodeficiency. |
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| If an adult has had zoster
with herpetic neuralgia ophthalmic complications, when can they receive
the zoster vaccine? |
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| Once they are no longer acutely ill,
they can be vaccinated with zoster vaccine. There is no evidence that
the vaccine will have therapeutic effect for a person with existing
postherpetic neuralgia. |
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| How long should we wait before giving
zoster vaccine to a patient who has had a blood transfusion? |
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| There is no waiting period for
administering zoster vaccine following transfusion. Studies have shown
the efficacy of zoster vaccine in patients receiving blood products. 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. |
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| When can a patient previously on
immunosuppressive chemotherapy receive zoster vaccine? |
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| If the patient was on anticancer
therapy, wait 3 months. If they were on high-dose steroids,
isoantibodies, immune-mediators, immunomodulators, wait 1 month. Lastly,
if they were on low doses of methotrexate, azathioprine, or
6-mercaptopurine, waiting is not indicated as these are not considered
immunosuppressive. See the ACIP recommendations for zoster at www.cdc.gov/mmwr/pdf/rr/rr5705.pdf for details. |
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| 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? |
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| Neither situation is a contraindication
to zoster vaccination. A person who gets vaccinated with 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 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 is given than after varicella vaccine is
given. If a rash develops, the vaccinated person should restrict contact
with an immunocompromised person if the immunocompromised person is
susceptible to varicella. |
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| How is Zostavax administered? |
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| The vaccine is administered
subcutaneously. Reconstitute using the diluent provided and administer
it immediately after reconstitution to minimize loss of potency. If the
vaccine is not administered within 30 minutes, it must be discarded. |
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| When reconstituted, the volume of
zoster vaccine is 0.65 mL. Should 0.65 mL or 0.5 mL be administered to
the patient? |
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| The recommended dose for zoster
vaccine is the fully reconstituted amount, 0.65 mL. |
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| Can pharmacists in all states
administer Zostavax (ZOS)? |
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| According to the American Pharmacist
Association, 45 states currently allow pharmacists to administer ZOS,
including many who administer it on a walk-in basis, using a protocol
or standing orders. Not all pharmacists in the 45 states provide
vaccination services, and of those who do, not all administer ZOS. It
is best to call pharmacies ahead of time to find out if they have ZOS
to administer to your patients. |
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| How should Zostavax be stored? |
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Zostavax must be stored like varicella
vaccine, frozen at a temperature of -58°F to +5°F (-50°C to -15°C)
until it is reconstituted. Any freezer that has a separate sealed
freezer door and reliably maintains a temperature of -58°F to +5°F is
acceptable for storage. The diluent should be stored separately at room
temperature or in the refrigerator.
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| 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? |
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| Zoster vaccine must be stored at freezer
temperature at all times. If the vaccine has been out of the freezer for
more than 30 minutes, it should not be used unless a state health
department or Merck has authorized its use. |
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| Reviewed on 9/11 |
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