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Zoster (shingles)

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Zoster (shingles)

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Zoster (shingles)
 
Zoster (shingles)
Disease Issues Contraindications and Precautions
Vaccine Recommendations Administering Vaccines
Vaccine Safety Storage and Handling
Disease Issues
How common is herpes zoster (shingles)?
During their lifetime about 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 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.
For our "Mother's Day Out" program, one of the teachers has shingles. The program serves moms of 2-month-olds to 4-year-olds. All children are up to date with their vaccinations, but some are too young to have received varicella vaccine. Is it safe for the teacher to work?
In a school setting, an immunocompetent person with zoster (staff or students) can remain at school as long as the lesions can be completely covered. People with zoster should be careful about personal hygiene, wash their hands after touching their lesions, and avoid close contact with others. If the lesions cannot be completely covered and close contact avoided, the person should be excluded from the school setting until the zoster lesions have crusted over. See www.cdc.gov/chickenpox/outbreaks/manual.html for more information. If your program is licensed by a state or county, you should check their regulations as well.
Vaccine Recommendations Back to top
What zoster vaccines are available in the United States?
Two zoster vaccines are available in the United States. Zoster vaccine live (ZVL, Zostavax, Merck) is a live attenuated vaccine that was licensed in 2006. It is approved by the Food and Drug Administration (FDA) for persons 50 years and older and recommended by the Advisory Committee on Immunization Practices (ACIP) for persons 60 year of age and older. It is administered as a single dose by the subcutaneous route.
Recombinant zoster vaccine (RZV, Shingrix, GlaxoSmithKline) was licensed by the FDA in October 2017. It is a subunit vaccine that contains recombinant varicella zoster virus (VZV) glycoprotein E in combination with a novel adjuvant (AS01B). RZV does not contain live VZV. It is approved for persons 50 years and older. RZV is administered as a 2-dose series by the intramuscular route. The second dose should be given 2 to 6 months after the first dose.
How effective are zoster vaccines?
In clinical trials ZVL recipients had a 51% overall reduction in shingles and less severe illness when shingles did occur compared with placebo recipients. ZVL efficacy was inversely related to age; efficacy was 70% among persons 50-59 years of age, 64% among persons 60-69 years of age and 38% among persons 70 years and older. Protection against shingles declined over time after vaccination. By 6 years after vaccination protection declined to less than 35%.
RZV was studied in 2 pre-licensure clinical trials. Efficacy against shingles was 97% for persons 50-59 years of age, 97% for persons 60-69 years of age, and 91% for persons 70 years and older. Among persons 70 years and older vaccine efficacy was 85% 4 years after vaccination.
Will administering zoster vaccine prevent postherpetic neuralgia (PHN)?
Both zoster vaccines reduce the risk of PHN. In the pre-licensure trial ZVL was 67% effective in preventing PHN. RZV reduced the risk of PHN by 91%.
To whom should zoster vaccine be given?
The Advisory Committee on Immunization Practices (ACIP) published revised zoster vaccination recommendations in January 2018 (available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6703a5-H.pdf).
  • Recombinant zoster vaccine (RZV) is recommended for the prevention of herpes zoster and related complications for immunocompetent adults 50 years of age and older
  • RZV is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received zoster vaccine live (ZVL)
  • ZVL remains a recommended vaccine for prevention of herpes zoster and its complications in immunocompetent adults 60 years of age and older. However, RZV is preferred over ZVL in this age group.
These recommendations are a supplement to the 2008 recommendations for the use of ZVL in immunocompetent adults 60 years of age and older, available at www.cdc.gov/mmwr/PDF/rr/rr5705.pdf.
The 2018 zoster vaccine recommendations say that ZVL remains a ďrecommended vaccine for prevention of herpes zosterĒ in immunocompetent adults age 60 years and older. How should providers interpret this language?
While RZV is the preferred zoster vaccine, ZVL may still be given to immunocompetent adults aged 60 years and older in certain cases, such as when RZV is not available, or when a person prefers ZVL or is allergic to RZV.
I am having trouble getting RZV (Shingrix) for my patients. What should I do during the shortage?
Due to high levels of demand for RZV, the manufacturer (GlaxoSmithKline [GSK]) has implemented order limits and providers have experienced shipping delays. It is anticipated these order limits and shipping delays will continue throughout 2018. In response, GSK has increased the U.S. supply available for 2018 and plans to release doses to all customer types on a consistent and predictable schedule for the rest of 2018.
CDC recommends RZV preferentially over ZVL (Zostavax). Clinicians and patients should make every effort to ensure that two doses are administered within the recommended interval of 2 to 6 months. If more than 6 months have elapsed since the first dose of RZV, administer the second dose when possible. Do not restart the vaccine series, and do not substitute ZVL for the second dose of RZV. If you are out of RZV and a patient needs a second dose, the Vaccine Finder may be helpful for patients to locate other providers that have RZV in stock. The Vaccine Finder can be accessed on the CDC website at www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
CDC still recommends ZVL (Zostavax) for healthy adults 60 years and older to prevent shingles. This shingles vaccine may be used in certain cases, such as when a person prefers ZVL or requests vaccination and RZV is unavailable. Patients who have received ZVL are recommended to subsequently receive RZV. Age and time since receipt of ZVL may be considered to determine when to vaccinate with RZV. The minimum interval between ZVL and RZV is 8 weeks.
Additional information for clinicians about RZV is available on the CDC website at www.cdc.gov/vaccines/vpd/shingles/hcp/index.html.
I have ZVL in my freezer but I do not have recombinant zoster vaccine. The manufacturer told us to anticipate ordering limits and intermittent shipping delays for RZV during 2018 so I donít know when I will get RZV doses. In this situation, what is the appropriate approach to patients who come to my practice for shingles vaccine?
ACIP has stated a preference for RZV for people age 50 years and older. However, ACIP also states that ZVL may be used at the clinician's discretion for people age 60 years and older. So, if a person age 60 years and older wants zoster vaccine and RZV is not available, then use of ZVL is appropriate. ZVL provides the best protection in the first year after vaccination. ACIP recommends that people who receive ZVL should be revaccinated with a 2-dose series of RZV. The minimum interval between ZVL and RZV is 8 weeks.
Should RZV be given to people who have already received ZVL? If so what interval should separate them?
ACIP recommends that people who previously received ZVL receive 2 doses of RZV. The first dose of RZV should be given at least 2 months after ZVL.
What is the minimum interval between doses of RZV?
The recommended interval between RZV doses is 2 to 6 months. The minimum interval between doses of RZV is 4 weeks. If the second dose is given less than 4 weeks after the first dose the second dose should be repeated at least 8 weeks after the invalid dose.
What is the minimum age for administering RZV?
The recommended and minimum age for RZV is 50 years. However, if a dose is inadvertently administered to an adult 18 through 49 years of age CDC does not recommend repeating the dose. The second RZV dose should not be administered until the 50th birthday. This guidance does not appear in the most recent zoster ACIP statement but is in the General Best Practices Guidance (Table 3-1 in the Timing and Spacing of Immunobiologics section at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html) and is based on guidance from CDCís zoster subject matter experts.
If the second dose of RZV is delayed more than 6 months after the first dose do I need to restart the series?
No. The vaccine series need not be restarted if more than 6 months have elapsed since the first dose.
Live zoster vaccine (ZVL) is approved by the FDA for people age 50 years and older. Does ACIP recommend that clinicians vaccinate people in their 50s with ZVL?
ACIP does not recommend routine ZVL vaccination of people 50 through 59 years of age. However, ZVL 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. Notwithstanding FDAís licensure, ACIP prefers RZV over ZVL.
If I choose to vaccinate patients age 50–59 years with ZVL, are there any criteria as to which patients in this age group might benefit most from this vaccine?
ACIP recommends routine vaccination of people 50 years and older with recombinant zoster vaccine (RZV). For vaccination providers who choose to use ZVL for persons 50 through 59 years of age despite the absence of an ACIP recommendation, factors that might be considered include particularly poor anticipated tolerance of herpes zoster or postherpetic neuralgia symptoms (for example, attributable to preexisting chronic pain, severe depression, or other comorbid conditions; or inability to tolerate treatment medications because of hypersensitivity or interactions with other chronic medications). More information on this issue is available at www.cdc.gov/mmwr/pdf/wk/mm6044.pdf, page 1528.
Is there an upper age limit for receipt of zoster vaccine?
There is no upper age limit for either zoster vaccine.
If a patient received dose #1 of varicella vaccine (Varivax, Merck) at age 60 years, should we administer zoster vaccine as dose #2?
The action taken depends on why varicella vaccine was given in the first place. If it was given because the person tested negative for varicella antibody, then the next dose should be varicella vaccine. If the varicella vaccine was given in error (i.e., without serologic testing), then RZV or ZVL should be given.
Should a person who received 2 doses of varicella vaccine be vaccinated with zoster vaccine when they turn 50?
In its 2018 zoster vaccine recommendations, the Advisory Committee on Immunization Practices states that recombinant zoster vaccine (RZV; Shingrix, GlaxoSmithKline) may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine (ZVL; Zostavax, Merck).
I understand that varicella vaccine, MMRV (ProQuad, Merck), and live 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 live zoster vaccine contains 19,400 PFUs (14 times higher than varicella vaccine) at the date of expiration. RZV does not contain live varicella zoster virus.
Before administering zoster vaccine is it necessary to ask if the person has ever had chickenpox or shingles?
No. All persons age 50 years or older-whether they have a history of chickenpox or shingles or not-should be given RZV unless they have a medical contraindication to vaccination (described below). It is also not necessary to test for varicella antibody prior to or after 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 50 years and older for their varicella disease history or to perform a laboratory test for serologic evidence of prior varicella disease. A person age 50 years or older who has no medical contraindications, is eligible for recombinant zoster vaccine regardless of their memory of having had chickenpox.
We weren't familiar with the recommendations and tested a 50-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 50 years or older who has no medical contraindication is eligible for recombinant zoster vaccine regardless of their memory of having had chickenpox. However, if an adult age 50 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.
Can someone who has experienced an episode of shingles be vaccinated with zoster vaccine?
Yes. Adults with a history of herpes zoster should receive RZV. If a person is experiencing an episode of zoster, vaccination should be delayed until the acute phase of the illness is over and symptoms abate.
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?
ACIP does not have a recommendation to administer either zoster vaccine to people younger than 50 years 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.
We have an 18-year-old male who had a history of chickenpox disease. He now has shingles. We are unsure what we are to advise for future treatment. Should we administer zoster vaccine?
The Advisory Committee on Immunization Practice does not recommend zoster vaccination for people younger than age 50 years regardless of their history of shingles.
Can zoster vaccine be administered to people in long-term care facilities?
Yes. RZV can be administered to anyone age 50 years and older regardless of where they reside, unless they have a contraindication to vaccination.
Can I give our long-term care residents RZV, injectable influenza, and pneumococcal vaccines on the same day?
Yes. CDCís General Best Practice Guidelines for Immunization advise that non-live vaccines, such as RZV, can be administered concomitantly, at different anatomic sites, with any other live or non-live vaccine. 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 ZVL?
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 live zoster vaccine.
The Zostavax package insert says that clinicians should consider administering live 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 ZVL 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. ZVL and PPSV can be given at the same time or any time before or after each other.
If we inadvertently give a child live zoster vaccine rather than varicella vaccine, what should we do?
This is a serious vaccine administration error. The event should be documented and reported to either the Vaccine Adverse Event Reporting System (VAERS) or the manufacturer. Procedures should put in place to prevent this from happening again. ZVL contains about 14 times as much varicella vaccine virus as varicella vaccine. However, no specific medical 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?
CDC 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. RZV should be administered at least 8 weeks after receipt of the varicella vaccine. However, if RZV is administered less than 8 weeks after the varicella vaccine, it does not need to be repeated. A second dose of RZV should be given 2-6 months after the first dose of RZV. If the clinician prefers to use ZVL a dose can be administered at the same visit. If not given at the same visit ZVL should be administered at least 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.
If varicella vaccine is inadvertently given to an adult to prevent shingles, the previous recommendation was to give ZVL at same visit or at least 28 days later. Now, with the preference for RZV, should the recommendation be to give RZV at least 2 months later?
Yes. If varicella vaccine is inadvertently given to an adult to prevent shingles, CDC suggests that RZV be given at least 2 months later.
If RZV is erroneously given to a child for prevention of varicella, the dose is invalid, but is there a waiting period before a valid dose of varicella vaccine can be given? Is it OK to give a dose of varicella vaccine as soon as the error is discovered?
There is no waiting period. The varicella vaccine dose can be given at any time after the RZV dose.
We inadvertently gave Zostavax rather than Shingrix. Can the dose of Zostevax be counted as the first dose of the Shingrix series?
No. Doses of ZVL cannot be counted towards completing the RZV series. The repeat dose of RZV should be given at least 8 weeks after the dose of ZVL.
We inadvertently gave a 47-year-old healthcare worker live zoster vaccine rather than varicella vaccine for work. Does this dose count?
Yes, but this is a serious vaccine administration error because ZVL contains about 14 times as much varicella vaccine virus as varicella vaccine. You should document the event and report it to either the Vaccine Adverse Event Reporting System (VAERS) or the manufacturer. You should establish procedures to prevent this from happening again. The dose of ZVL 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.
We know that documented receipt of ZVL in the absence of other criteria is not proof of immunity to varicella. Is this true for RZV as well?
Yes. Documented receipt of RZV cannot be used as proof of immunity to varicella. Additionally, a dose of RZV cannot be counted as a dose of varicella vaccine. Please note this is different than ZVL.
If a patient who received live 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 have recently vaccinated the patient with ZVL, you should delay the TST for 4 weeks from the date of the vaccine dose. A TST can be applied at any time before or after receiving RZV. When TST screening is needed and ZVL vaccination is preferred, TST screening should be scheduled prior to or on the same day as the ZVL. ACIP's recommendations for use of ZVL do not address the interval between vaccination and TST screening. However, ACIP's General Best Practice Guidelines for 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 Best Practice Guidelines for Immunization at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/special-situations.html).
Vaccine Safety Back to top
What adverse reactions have been reported with zoster vaccines?
In the pre-licensure clinical trials of ZVL local adverse reactions such as pain, redness and swelling were more common in the vaccinated group (25%-36%) than in the placebo group (5%-8%).
In pre-licensure clinical trials of RZV the most common adverse reactions were pain at the injection site (78%), myalgia (45%), and fatigue (45%). Any grade 3 adverse event (reactions related to vaccination which were severe enough to prevent normal activities) was reported in 17% of vaccine recipients compared with 3% of placebo recipients. Grade 3 injection-site reactions (pain, redness, and swelling) were reported by 9% of vaccine recipients, compared with 0.3% of placebo recipients. Grade 3 solicited systemic events (myalgia, fatigue, headache, shivering, fever, and gastrointestinal symptoms) were reported by 11% of vaccine recipients and 2.4% of placebo recipients. The occurrence of local grade 3 reactions did not differ by vaccine dose. However systemic grade 3 reactions were reported more frequently after dose 2.
For both RZV and ZVL rates of serious adverse events (an undesirable experience associated with the vaccine that results in death, hospitalization, disability or requires medical or surgical intervention to prevent a serious outcome) were similar in vaccine and placebo groups.
What should I advise my patients about adverse reactions after RZV?
Before vaccination, providers should counsel RZV recipients about expected systemic and local adverse reactions (described above). Reactions to the first dose do not strongly predict reactions to the second dose. RZV recipients should be encouraged to complete the series even if they experienced a grade 3 reaction to the first dose.
Contraindications and Precautions Back to top
What are the contraindications and precautions to zoster vaccine?
Contraindications to live 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
Precautions to live zoster vaccine:
  • The presence of a moderate or severe acute illness. Vaccination should be deferred until the illness improves
Contraindication to recombinant zoster vaccine:
  • Severe allergic reaction to a vaccine component or following a prior dose
Precaution to recombinant zoster vaccine:
  • The presence of a moderate or severe acute illness, including herpes zoster. Vaccination should be deferred until the illness improves.
  • There are no available data to establish whether RZV is safe in pregnant or lactating women and there is currently no ACIP recommendation for RZV use in this population. Consider delaying vaccination with RZV in such circumstances.
If an adult has had zoster with postherpetic neuralgia or ophthalmic complications, when can they receive zoster vaccine?
Once they are no longer acutely ill, they can be vaccinated with RZV or ZVL. There is no evidence that either vaccine will have therapeutic effect for a person with existing zoster or 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 either zoster vaccine following transfusion. The amount of antigen in ZVL is high enough to offset any effect of antibody to varicella virus that may be in the blood product. RZV does not contain live virus so can be given at any time after receipt of a blood product.
Can zoster vaccine be given to a person who is currently receiving immunosuppressive treatment?
ACIP recommends the use of RZV or ZVL in persons taking low-dose immunosuppressive therapy (less than 20 mg/day of prednisone or equivalent or using inhaled or topical steroids), or low doses of methotrexate, azathioprine, or 6-mercaptopurine.
As with all live vaccines ZVL is contraindicated in persons receiving high-dose steroid therapy, cancer chemotherapy or treatment with immune modulators (see www.cdc.gov/vaccines/hcp/acip-recs/general-recs/contraindications.html).
RZV is currently licensed for all persons 50 years of age and older. Immunosuppression is not included as a contraindication in the manufacturersí package insert. However, immunocompromised persons and those on moderate to high doses of immunosuppressive therapy were excluded from the clinical efficacy studies so data are lacking on efficacy and safety in this group. ACIP has not made a recommendation regarding the use of RZV in these patients. This topic is anticipated to be discussed at upcoming ACIP meetings as additional data become available.
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. A 2-dose series of RZV should be administered as soon as possible while the personís immune system is intact. If ZVL is preferred the patient should receive 1 dose as soon as possible, while their immunity is intact. Administer ZVL at least 14 days before immunosuppressive therapy begins. Some experts advise delaying the start of immunosuppressive therapy until 1 month after ZVL is administered, if delay is possible. Anticipated immunosuppression is a comorbid condition for which ZVL vaccination at age 50 years or older could be considered (see www.cdc.gov/mmwr/pdf/wk/mm6044.pdf, page 1528).
When can a patient previously on immunosuppressive chemotherapy receive zoster vaccine?
ACIP has not specifically addressed the use of RZV in this situation but it is prudent to defer RZV until the patientís immune system has recovered from the treatment. If the patient was receiving cancer chemotherapy, wait 3 months after therapy is discontinued before administering ZVL. If they were receiving high-dose steroids, isoantibodies, immune-mediators, or immunomodulators, wait 1 month after therapy is discontinued to administer ZVL.
A dose of zoster vaccine was inadvertently given to a patient receiving chemotherapy for colon cancer. We realize this was an error, so please advise us on what to do now.
Zoster vaccines are given to people who presumably had chickenpox earlier in life and so have immunity to varicella virus. The cancer chemotherapy will not change the person's immunity to varicella virus. If the person received RZV no action is necessary. However, if ZVL was given the patient should be monitored for the next two weeks for symptoms that might indicate an adverse reaction, such as fever and rash. If symptoms suggestive of varicella develop, the patient can be started on antiviral therapy, such as acyclovir.
Can someone with hepatitis C receive zoster vaccine?
Hepatitis C infection is not a contraindication for either zoster vaccine. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination with ZVL or RZV until they have completed treatment.
Should a healthy person age 60 years or older receive live zoster vaccine if they are going to be in contact with an unvaccinated infant or an immunocompromised person?
Neither situation is a contraindication to ZVL vaccination. A person who receives ZVL 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 ZVL vaccine. The only exception is in the rare instance when a person develops a varicella-like rash after receiving ZVL. A vaccine rash is expected to occur less frequently after ZVL than after varicella vaccine. If a rash develops, the vaccinated person should 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 ZVL. However, a person who is immunosuppressed for any reason (disease or treatment) should not receive ZVL.
Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?
RZV can be administered in this situation. ZVL can also be administered, with one qualification. A diagnosis of an autoimmune condition such as lupus or rheumatoid arthritis is not a contraindication to ZVL. 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?
RZV can be administered in this situation. ZVL can also be administered with one qualification. There is no contraindication to vaccinating against zoster before surgery, unless the patient is immunocompromised for some reason.
We have a patient with a severe allergy to vancomycin who wants to receive zoster vaccine. According to the Zostavax prescribing information, an allergy to neomycin would be a contraindication to vaccination but we are not sure about allergy to vancomycin.
Vancomycin and neomycin belong to different classes of antibiotics. An allergy to vancomycin is not a contraindication to zoster vaccine. RZV does not contain either neomycin or vancomycin.
We have a 61-year-old patient who is taking 500 mg of valacyclovir (Valtrex) daily. Can she receive zoster vaccine?
Acyclovir, famciclovir, and valacyclovir are antiviral drugs that are active against herpesviruses. These drugs' agents might interfere with replication of live zoster vaccine but will have no effect on RZV (which does not contain live varicella virus). All three drugs have relatively short serum half-lives and are quickly eliminated from the body. Persons taking acyclovir, famciclovir, or valacyclovir should discontinue the drug at least 24 hours before administration of ZVL, if possible. The drug should not be taken again for at least 14 days after ZVL vaccination, by which time the immunologic effect of the vaccine should be established.
If my patient is taking Tamiflu (oseltamivir), can she receive zoster vaccine?
Yes. Although oseltamivir is an antiviral drug, it is only effective against influenza A and B viruses. Live zoster vaccine contains varicella zoster virus which is not affected by oseltamivir. RZV does not contain live virus and also will not be affected by oseltamivir.
Zoster vaccine was inadvertently given to a patient taking Humira (adalimumab) 40 mg per week for rheumatoid arthritis. Because of the high dose, should the patient be started on antivirals as prophylaxis or should the patient just be monitored?
RZV does not contain live varicella virus although response to the vaccine could be reduced in persons who are immunosuppressed. Although ZVL is contraindicated for patients taking biologic agents including tumor necrosis factor (TNF) antagonists (adalimumab is a TNF antagonist), vaccinating patients that are immunocompromised is unlikely to result in serious adverse events.
It is prudent to monitor your patient who received ZVL with a low threshold for any signs of adverse events (such as rash or fever), within one month after vaccination, but prophylactic antivirals are not indicated. Acyclovir, valacyclovir, and famciclovir are active against the vaccine virus and can be used in the unlikely situation in which illness develops.
Administering Vaccines Back to top
How are zoster vaccines administered?
Reconstitute RZV using only the adjuvant solution provided. After reconstitution, administer RZV immediately by the intramuscular route or store the reconstituted vaccine refrigerated between 2° and 8°C (between 36° and 46°F) and use within 6 hours. Discard reconstituted vaccine if not used within 6 hours or if frozen. If vaccine reconstituted with other than the supplied adjuvant solution is administered it should be repeated. The dose can be repeated immediately. There is no interval that must be met between these doses.
Reconstitute ZVL using only the diluent provided. Administer ZVL 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.
A patient was inadvertently given RZV by the subcutaneous rather than the intramuscular route. Does the dose need to be repeated?
RZV has been shown to be immunogenic when given by the subcutaneous route. A dose erroneously given by this route does not need to be repeated.
When reconstituted, the volume of ZVL is 0.65 mL. Should 0.65 mL or 0.5 mL be administered to the patient?
The recommended dose for ZVL is the fully reconstituted amount, 0.65 mL.
When reconstituted, the volume of RZV is more than 0.5 mL. Should the entire volume of reconstituted vaccine be administered or just 0.5 mL as indicated in the package insert?
The RZV adjuvant solution may contain up to 0.75 mL of liquid. The entire volume of the adjuvant solution should be withdrawn and used to reconstitute the lyophilized vaccine. After mixing, withdraw the recommended dose of 0.5 mL. Any reconstituted vaccine left in the vial should be discarded.
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 provide 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?
RZV (Shingrix)
Both lyophilized RZV and the adjuvant solution diluent must be stored at refrigerator temperature, between 2° and 8°C (between 36° and 46°F). Protect the vials from light. Do not freeze. Vaccine or adjuvant solution that has been frozen must be discarded. If vaccine that was frozen was administered, the dose does not count and should be repeated. The repeat dose should be administered 4 weeks after the frozen dose.
After reconstitution, administer RZV immediately or store refrigerated between 2° and 8°C (between 36° and 46°F) and use within 6 hours. Discard reconstituted vaccine if not used within 6 hours.
ZVL (Zostavax)
All vaccines that contain live varicella virus, including ZVL, must be stored frozen at a temperature of between -50°C and -15°C (between -58°F and +5°F) until they are reconstituted. Although the manufacturer states that any freezer that has a separate sealed freezer door and reliably maintains a temperature between -50°C and -15°C 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.
ZVL 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.
If necessary, ZVL may be stored at refrigerator temperature between 2°C and 8°C (between 36°F and 46°F) for up to 72 continuous hours prior to reconstitution. ZVL stored between 2°C and 8°C that is not used within 72 hours of removal from a freezer should be discarded.
How should zoster vaccine be transported to an off-site clinic location?
RZV is stored at refrigerator temperature. Transport of refrigerated vaccines is described in detail in the CDC Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 35–36.
Neither CDC nor the vaccine manufacturer recommends transporting live 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 -50°C and -15°C (-58°F and +5°F). Portable freezers may be available for rent in some places. If live 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 -50°C (-58°F).
Live varicella-containing vaccines may be transported at refrigerator temperature between 2°C and 8°C (between 36°F and 46°F) for up to 72 continuous hours prior to reconstitution. ZVL stored between 2°C and 8°C (between 36°F and 46°F) 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/hcp/admin/storage/toolkit/storage-handling-toolkit.pdf, pages 45–46.
 
This page was updated on August 7, 2018.
This page was reviewed on February 3, 2018.
 
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