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Issue 1117
IAC Express: Weekly immunization news and information
Issue 1117: April 23, 2014

Ask the Experts: CDC Experts Answer Your Questions


The first eight questions and answers (Q&As) in this edition of IAC Express also appeared in the March 2014 issue of Needle Tips; the final two Q&As are newly published.

IAC extends thanks to our experts, medical officer Andrew T. Kroger, MD, MPH, and nurse educator Donna L. Weaver, RN, MN, from the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).

Zoster Vaccine

Zoster Vaccine
Q: 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?

A: 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.

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Q: 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. Are we wrong?

A: No. The subcutaneous tissue overlying the triceps muscle of the upper arm is the usual location for subcutaneous vaccine injection for an adult.

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Q: 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?

A: 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.

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Q: Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?

A: 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.

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Q: A 65-year-old patient is having major back surgery next week. He is requesting zoster vaccine today. Can I give him the vaccine?

A: Yes, with one qualification. There is no contraindication to vaccinating against zoster before surgery, unless the patient is immunocompromised for some reason.

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Q: 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?

A: No. Simply vaccinate them with zoster vaccine according to the ACIP recommendations.

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Q: 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?

A: 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.

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Q: How should zoster vaccine be transported to an off-site clinic location?

A: 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 "Vaccine Storage & Handling Toolkit" at www.cdc.gov/vaccines/recs/storage/toolkit/storage-handling-toolkit.pdf.

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Q: 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?

A: 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.

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Q: If zoster vaccine that has been damaged by a temperature excursion has been inadvertently administered to a patient, when should the dose be repeated?

A: According to the 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.

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How to submit a question to Ask the Experts

IAC works with CDC to compile new Ask the Experts Q&As for our publications based on commonly asked questions. We also consider the need to provide information about new vaccines and recommendations. Most of the questions are thus a composite of several inquiries.

You can email your question about vaccines or immunization to IAC at admin@immunize.org.

As we receive hundreds of emails each month, we cannot guarantee that we will print your specific question in our Ask the Experts feature. However, you will get an answer.

You can also email CDC's immunization experts directly at nipinfo@cdc.gov. There is no charge for this service.

If you have a question about IAC materials or services, email admininfo@immunize.org.

Please forward these Ask the Experts Q&As to your colleagues and ask them to subscribe to IAC Express.

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About IAC Express 
We encourage you to reprint any of these Q&As in your own newsletters. Please credit the Immunization Action Coalition and the Centers for Disease Control and Prevention. Please refer to IAC's preferred citation style.
If you have trouble receiving or displaying IAC Express messages, visit our online help section.
IAC Express is supported in part by Grant No. U38IP000589 from the National Center for Immunization and Respiratory Diseases, CDC. Its contents are solely the responsibility of IAC and do not necessarily represent the official views of CDC. IAC Express is also supported by educational grants from the following companies: bioCSL Inc.; MedImmune, Inc.; Merck Sharp & Dohme Corp.; Novartis Vaccines; Ortho Clinical Diagnostics, Inc.; Pfizer, Inc.; and sanofi pasteur.
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 6NH23IP22550) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.