Shingles Vaccine: CDC/ACIP Recommendations
SUMMARY:
In October 2017, the FDA approved and ACIP recommended a Shingrix (RZV) vaccine for adults ≥50 years of age. Zostavax (ZVL) is no longer available for use in the United States, as of November 18, 2020.
- Herpes Zoster and Postherpetic Neuralgia
- Zoster Vaccine Recommendations
- Clinical Guidance
- Counseling and Adverse Events
- Special Populations
Herpes Zoster and Postherpetic Neuralgia
- Herpes zoster is a localized, painful, cutaneous eruption resulting from reactivation of latent varicella zoster virus (VZV)
- Approximately one million cases occur each year in the United States
- Incidence increases with age
- 50 to 59 years of age: 5 cases per 1,000
- ≥80 years: 11 cases per 1,000
- Postherpetic Neuralgia is the most common complication
- Defined as persistent pain for at least 90 days following the resolution of the herpes zoster rash
- Occurs in 10 to 13% of herpes zoster cases in persons aged >50 years and risk increases with age
Herpes Zoster Vaccine Recommendations
Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults aged ≥50 years
- Two doses of Shingrix provides strong protection against shingles and postherpetic neuralgia (PHN), the most common complication of shingles
- Shingles Prevention: In adults 50 to 69 years old who got two doses, Shingrix was 97% effective; among adults 70 years and older, Shingrix was 91% effective
- Postherpetic Neuralgia: In adults 50 to 69 years old who got two doses, Shingrix was 91% effective; among adults 70 years and older, Shingrix was 89% effective
- Shingrix protection remained high (more than 85%) in people 70 years and older throughout the four years following vaccination
- Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received Zostavax or have already had herpes zoster
- There is no maximum age for Shingrix
Clinical Guidance
- Administer 2 doses (0.5 mL each) administered intramuscularly 2 to 6 months apart
- Shingrix may be used in adults aged ≥50 years, irrespective of prior receipt of varicella vaccine or Zostavax
- If patient previously received Zostavax
- Consider the patient’s age and when he or she received Zostavax to determine when to vaccinate with Shingrix | Differences in efficacy between Shingrix and Zostavax are most pronounced among older patients
- Studies examined the safety of Shingrix vaccination five or more years after Zostavax vaccination | Shorter intervals were not studied, but there are no theoretical or data concerns to indicate that Shingrix would be less safe or effective if administered less than five years after a patient received Zostavax
- Screening for a history of chickenpox (varicella) not required
- Recombinant and adjuvanted vaccines, such as Shingrix, can be administered concomitantly at the same visit, at different anatomic sites, with other adult vaccines (e.g., influenza and pneumococcal vaccines)
- Shingrix is not a treatment for herpes zoster or postherpetic neuralgia
- Pregnancy and breastfeeding
- There are no available data to establish whether Shingrix is safe in pregnant or lactating women
- Consider delaying vaccination with Shingrix in such circumstance
- No current recommendation for booster doses
KEY POINTS:
Counseling and Adverse Events
- Reactions to the first dose of Shingrix did not strongly predict reactions to the second dose
- Vaccine recipients should be encouraged to complete the series even if they experienced a grade 1 to 3 reaction to the first dose of Shingrix
- In studies, Grade 3 solicited symptoms were defined as “preventing normal everyday activity” (pain, headache, fatigue, gastrointestinal symptoms, myalgia, shivering) | surface diameter >100 mm (redness/swelling) | tympanic/oral/axillary temperature >39.0 °C (fever)
- Grade 3 unsolicited adverse events were also defined as “preventing normal, everyday activities”
Adverse Events
- The impact of prophylactic analgesics in conjunction with Shingrix has not been studied
- Adverse local events are relatively common and include
- Pain
- Redness
- Swelling
- General adverse reactions include
- Myalgia
- Fatigue
- Headache
- Shivering
- Fever
- Gastrointestinal symptoms
- Severe (rare) events include
- Difficulty breathing
- Wheezing
- Hives
- Pale skin
- Fast heartbeat
- Dizziness
- Contraindications
- History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine OR after previous dose
- Acute episode of herpes zoster | Wait until acute episode has abated
Special Populations
- Persons with a history of herpes zoster
- Adults with a history of herpes zoster should receive Shingrix as herpes zoster can recur
- Persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease)
- Shingrix should be used
- Immunocompromised persons
- Shingrix may be used in persons taking low-dose immunosuppressive therapy (e.g., <20 mg/day of prednisone or equivalent or using inhaled or topical steroids), persons anticipating immunosuppression or who have recovered from an immunocompromising illness
- Advisory Committee on Immunization Practices recommended 2 RZV doses for prevention of herpes zoster and related complications in immunodeficient or immunosuppressed adults aged ≥19 years
- Second RZV dose should be given 2 to 6 months after the first | For persons who are or will be immunodeficient or immunosuppressed and who would benefit from a shorter vaccination schedule, the second dose can be administered 1 to 2 months after the first
- Persons known to be VZV negative
- Screening for a history of varicella (either verbally or via laboratory serology) is not recommended
- However, in persons known to be VZV negative via serologic testing, ACIP guidelines for varicella vaccination should be followed
- All healthy adults should be assessed for varicella immunity, and those who do not have evidence of immunity should receive 2 doses of single-antigen varicella vaccine 4-8 weeks apart
- Shingrix has not been evaluated in persons who are VZV seronegative and the vaccine is not indicated for the prevention of chickenpox (varicella)
Learn More – Primary Sources:
CDC: Shingles (Herpes Zoster) Vaccination Information for Healthcare Providers
FDA: SHINGRIX (Zoster Vaccine Recombinant, Adjuvanted)
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