The Challenge Of Vaccinating Against Herpes Zoster
Most vaccines, including varicella vaccine, are administered to susceptible persons before infection by the pathogen. These vaccines induce immunity that prevents primary infection and/or disease. In contrast, vaccination against HZ is directed at persons who have previously been infected with VZV and have solid immunity against varicella, but harbor latent VZV that can reactivate and cause HZ . To be effective, zoster vaccine must function as a therapeutic vaccine and induce a more potent immune response to prevent reactivation of latent VZV in a person already infected who has pre-existing immunity to VZV.
Shingles Disease And How To Protect Against It
Shingles, or herpes zoster, is a painful skin rash that develops on one side of the face or body. It is caused by the varicella-zoster virus , the same virus that causes chickenpox. Anyone who has had chickenpox in the past can get shingles because VZV remains in the body after a person recovers from chickenpox. VZV can reactivate many years later, causing shingles.
Shingles is more common in older adults, people who have medical conditions that weaken the immune system, and people who take medications that suppress their immune systems. Getting vaccinated is the best way to prevent shingles.
Vaccination Of Persons With Immune
For patients with IMDs, the general recommendation is to vaccinate before initiating immunosuppressive therapy. The rationale is 2-fold. Compared with the general population, patients with autoimmune diseases such as rheumatoid arthritis , inflammatory bowel disease , and systemic lupus erythematosus are at increased risk for HZ and would benefit from prophylactic immunization. There is concern that the immunosuppressive medications used in these patients place them at even greater risk of HZ . For example, tofacitinib, an immunomodulatory drug that inhibits Janus kinases, doubles the risk of HZ in RA patients receiving anti-TNF and other biologics .
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Table 5 Quality Rating Of Evidence
Liaison Representatives: Dr. J. Blake , Dr. A. Corriveau , Dr. S. Deeks , Dr. A. Mawle , Dr. D. Moore , Dr. A. Pham-Huy .
Ex-Officio Representatives: Dr. M. Carew , Lt.-Col. P. Eagan , Dr. A. Klein , Dr. B. Law , Dr. B. Raymond , Dr. E. Taylor , Ms. M. St-Laurent .
This statement was prepared by: Dr. O. Baclic, Dr. D. Kumar, and Dr. A. Mah, and approved by NACI.
NACI also gratefully acknowledges the contribution of: Dr. M. Landry, Dr. J. Laroche, Dr. C. Légaré, Dr. S. McNeil, Dr. H. Morrison, Dr. A. Opavsky and Dr. S. Rechner.
V Herpes Zoster Vaccine In Persons With A History Of Herpes Zoster Ophthalmicus
In a large cohort study, Tseng et al. showed that HZO naïve HZ vaccine recipients had a reduced risk of HZO compared to unvaccinated persons.Footnote 6 There are now published reports of exacerbations of HZO in persons immunized with herpes zoster vaccine, in individuals with a prior history of herpes zoster ophthalmicus. NACI is aware of 7 cases of exacerbation of herpes zoster ophthalmicus which were temporally associated with the administration of herpes zoster vaccine. Three of these cases are available for review in the literature and four additional cases are reviewed in abstract form.Footnote 11-13
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Is The Shingles Vaccine Worth It
Yes. Although many people are able to recover from shingles without any lasting problems, up to 30% of people go on to have postherpetic neuralgia. Approximately 18% of people have other long-term issues, including:
The vaccine is highly effective at preventing both shingles and its complications.
Routine Vaccination Of People 60 Years Old And Older
CDC recommends a single dose of Zostavax® for people 60 years old or older, whether or not the person reported a prior episode of herpes zoster . People with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition. Zostavax is a live virus vaccine. It can be administered concurrently with all other live and inactivated vaccines, including those routinely recommended for people 60 years old and older, such as influenza and pneumococcal vaccines.
When vaccinating people 60 years old or older, there is no need to screen for a history of varicella infection or to conduct laboratory testing for serologic evidence of prior varicella infection. Even if a person reports that they have not had varicella, they can still receive the herpes zoster vaccine. The Zostavax®zoster vaccine package insert pdf iconexternal icon makes no reference to varicella history, and almost all people 60 years old or older are immune to varicella. The Advisory Committee on Immunization Practices states that people born in the United States prior to 1980 are considered immune to varicella. If serologic evidence of varicella susceptibility becomes available to the healthcare provider, the patient should be offered varicella vaccine not herpes zoster vaccine.
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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Australian Experience With Live Vaccine
The implementation, coverage and safety of the Australian live vaccine program has been evaluated in older adults.29 Disappointingly, in the first 17 months of the program, vaccine uptake was only 34% in 70 year olds and 26% in 7179 year olds according to the Australian Immunisation Register. Uptake was higher among indigenous Australians but varied across jurisdictions. These low estimates of coverage are likely, in part, due to under-reporting by GPs as the number of Zostavax doses distributed under the National Immunisation Program was almost double the number recorded in the Immunisation Register. This highlights the critical need for immunisation providers to ensure vaccination is documented and the data are transmitted to the Register for all vaccines.
Adverse events following immunisation should be reported to the Therapeutic Goods Administration Adverse Events Management System. Events are also captured by AusVaxSafety, which is an active participant-based system that has surveyed around 15,000 patients about their experiences after vaccination.29,32 The vaccine safety profile is consistent with what was expected, when used as recommended. The majority of notifications to both systems were injection-site reactions and rash, which were mild and resolved spontaneously.
The impact of the zoster vaccination program on disease incidence in Australian has not yet been assessed.
Who’s Most At Risk Of Shingles
People tend to get shingles more often as they get older, especially over the age of 70. And the older you are, the worse it can be. The shingles rash can be extremely painful, such that sufferers cannot even bear the feeling of their clothes touching the affected skin.
The pain of shingles can also linger long after the rash has disappeared, even for many years. This lingering pain is called post-herpetic neuralgia .
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Zoster Vaccines In Immunocompromised Populations
Although antiviral treatments are available for HZ, prevention of HZ by vaccination is of importance to immunocompromised patients because they are at increased risk for HZ and severe complications , and even early antiviral therapy does not prevent the development of PHN. The ACIP recommends administration of ZVL or RZV to persons taking low-dose immunosuppressive therapy , persons anticipating immunosuppression, and patients who have recovered from an immunocompromising illness . Immunocompromised persons and those on moderate to high doses of immunosuppressive therapy were excluded from the SPS and ZOE-50/70 efficacy trials . On July 23, 2021 the FDA approved SHINGRIX for the prevention of HZ in adults 18 yoa who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy .
Contraindications And Precautions For Shingles Vaccination
Zostavax should not be administered to:
- A person who has ever had a life-threatening or severe allergic reaction to gelatin, the antibiotic neomycin, or any other component of herpes zoster vaccine.
- A person who has a weakened immune system because of:
- HIV/AIDS or another disease that affects the immune system,
- treatment with drugs that affect the immune system, such as steroids,
- cancer treatment such as radiation or chemotherapy, or
- cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma.
Someone with a minor acute illness, such as a cold, may be vaccinated. But anyone with a moderate or severe acute illness should usually wait until they recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher.
This information was taken from the Shingles Vaccine Information Statement dated 10/06/2009.
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A Closer Look At The Safety Data
Both Shingrix and Zostavax shingles vaccines have been shown to be safe and well tolerated. Common side effects, such as soreness and redness at the injection site, are usually mild to moderate in intensity and resolve quickly on their own.
In 8 clinical trials of more than 10,000 participants:
- Grade 3 reactions were common after patients received Shingrix.
- About 1 out of 10 adults who received Shingrix reported grade 3 injection-site symptoms such as pain, redness, and swelling.
- About 1 out of 10 reported grade 3 systemic reactions such as myalgia , fatigue , headache, shivering, fever, and gastrointestinal illness.
- Most people who got Shingrix reported at least some pain at the injection site.
- A 2013 study showed that patients with a history of a previous shingles rash had the same side effects after Zostavax as those with no history of shingles. See Safety of zoster vaccine in elderly adults following documented herpes zosterexternal icon.
How Is Shingles Spread
You do not “catch” shingles it comes on when there’s a reawakening of chickenpox virus that’s already in your body. The virus can be reactivated because of a range of issues, including advancing age, medicine, illness or stress.
Anyone who has had chickenpox can get shingles. It’s estimated that around 1 in 5 people who have had chickenpox go on to develop shingles.
Read more about the causes of shingles.
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What Is Shingles
Shingles, also known as herpes zoster, is a painful skin rash caused by the reactivation of the chickenpox virus in people who have previously had chickenpox.
It begins with a burning sensation in the skin, followed by a rash of very painful fluid-filled blisters that can then burst and turn into sores before healing. Often an area on just one side of the body is affected, usually the chest but sometimes the head, face and eye.
Read more about the symptoms of shingles.
Why It Is Used
Herpes zoster vaccine can prevent shingles or reduce pain and other symptoms in people who get shingles. Zostavax II is recommended for adults age 60 and over who have not received the chickenpox vaccine.footnote 1 It is available to adults age 50 and older. They can get one dose, whether or not they’ve had shingles before. Shingrix is approved for use in adults 50 years of age and older. It is a two dose series given 2 to 6 months apart.
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What Are The Symptoms Of Shingles
People with shingles often experience pain, tingling or itching and then a painful rash. The rash can occur anywhere on the body, although it is usually in one strip on the right or left side of the body. The rash consists of groups of small, fluid-filled blisters that dry, scab over, and heal in a few weeks. Healing is usually complete, but some people may be left with scars.
Side Effects Of Herpes Zoster Vaccine
The most common side effects of the recombinant vaccine are pain, soreness, redness, and swelling at the injection site and headache, fatigue, muscle pain, shivering, fever, and digestive upset.
The most common side effects of the live-attenuated vaccine are soreness, redness, swelling, and itching at the injection site and headache.
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How Cdc Monitors Vaccine Safety
CDC and FDA monitor the safety of vaccines after they are approved or authorized. If a problem is found with a vaccine, CDC and FDA will inform health officials, health care providers, and the public.
CDC uses 3 systems to monitor vaccine safety:
- The Vaccine Adverse Event Reporting System : an early warning system, co-managed by CDC and FDA, to monitor for potential vaccine safety problems. Anyone can report possible vaccine side effects to VAERS.
- The Vaccine Safety Datalink : a collaboration between CDC and 9 health care organizations that conducts vaccine safety monitoring and research.
- The Clinical Immunization Safety Assessment Project: a partnership between CDC and several medical research centers that provides expert consultation and conducts clinical research on vaccine-associated health risks.
What Is The Shingles Vaccine
The shingles vaccine prevents herpes zoster, otherwise known as shingles. Shingles is a condition that causes a painful, blistering rash on one side of the face or body. This rash usually appears in a limited area on the skin, sometimes in the form of a stripe or patch. In many cases, the rash shows up after strange sensations, such as tingling or itching, have occurred in the same area. The rash turns into blisters and can be intensely painful. Shingles can also cause:
The most common complication of shingles is postherpetic neuralgia, the lingering nerve pain after the rash goes away . It can be long-lasting and debilitating. Other complications can occur, depending on which part of your body shingles affects. Complications can include:
Vision changes or blindness
The vaccine is not intended to treat shingles or its complications, only to prevent them. It is given as an injection into the upper arm muscle in two doses that are spaced 2 to 6 months apart.
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Herpes Zoster In People Who Are Immunocompromised
People who are immunocompromised have an increased risk of herpes zoster compared with non-immunocompromised people. Rates of herpes zoster are up to 15 times higher in people who are immunocompromised due to HIV. In the 1st year after haematopoietic stem cell transplantation, up to 30% of patients may develop herpes zoster.25,36
Uncommon Rare And Very Rare Adverse Events
Uncommon adverse events occur in 0.1% to less than 1% of vaccinees. Rare and very rare adverse events occur, respectively, in 0.01% to less than 0.1% and less than 0.01% of vaccinees.
Both HZ vaccines are safe with serious adverse events reported very rarely in immunocompetent individuals.
Recurrence or exacerbation of herpes zoster ophthalmicus following LZV vaccination has been reported very rarely, involving several cases world-wide following LZV immunization. Following a causality assessment of seven cases of HZO which were temporally associated with the administration of LZV, NACI concluded that there was insufficient evidence to recommend for or against the administration of LZV in individuals with a history of HZO. More evidence is required for further assessment of risk related to HZO recurrence in LZV recipients. At this time, there is insufficient evidence to assess the risk related to HZO recurrence following RZV recipients.
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Available Vaccines And Vaccination Campaigns
Since 2008, the U.S. Advisory Committee on Immunization Practices has recommended that most Americans aged 60 and older get the shingles vaccine. A newer recommendation was issued in 2018 with the licensure of a new vaccine: now most Americans age 50 and older are recommended to get Zoster Vaccine Recombinant, Adjuvanted .
In adults 50-69 years old, Shingrix reduces risk of shingles by more than 96%. For those 70 and older, the vaccine is 91.3% effective at preventing shingles. It very similarly reduces the risk of post-herpetic neuralgia. Modeling studies project that protection will wane to 0 by 19 years after immunization. Study of the expected duration of protection is ongoing.
The antigen in Shingrix is a surface protein of the varicella zoster virus produced by culturing genetically engineered Chinese hamster ovary cells. Vaccination consists of two doses of vaccine, given at months 0 and 2-6.
The older shingles vaccine is a live, attenuated vaccine. It was licensed in 2006. The generic name of the vaccine is Zoster Vaccine, Live . It is still available, although Shingrix is recommended over Zostavax because of its superior effectiveness and duration of protection.
People who have previously been vaccinated with Zostavax are recommended to vaccinate with Shingrix.
Where Can I Get Vaccinated
The best place to go for vaccinations is your family medical clinic. They have your medical records and can check to see if youve already had a particular vaccination. Either your doctor or a nurse can give the vaccination.If you dont have a family doctor, you can go to one of the after-hour medical clinics. Phone them first to make sure they can help you with the vaccination you need.You can find a clinic near you on the Healthpoint website. Put in your address and region, and under Select a service, click on GPs/Accident & Urgent Medical Care.Vaccines on the National Immunisation Schedule are free. Other vaccines are funded only for people at particular risk of disease. You can choose to pay for vaccines that you are not eligible to receive for free.
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Phn And Other Complications
) is the most frequent debilitating complication of herpes zoster. PHN is a neuropathic pain syndrome that persists or develops after the dermatomal rash has healed.
PHN is most commonly defined as the persistence of pain for longer than 3 months after the onset of the rash. But definitions can vary by the period of persistent pain.37,38
Other complications depend on the site of reactivation, and may include:39
- ophthalmic disease, such as keratitis and chorioretinitis
- neurological complications, such as meningoencephalitis and myelitis
- secondary bacterial skin infection
Rarely, some people may develop disseminated herpes zoster. This is characterised by widespread vesicular rash, and visceral, central nervous system and pulmonary involvement. Disseminated disease is more common in people who are immunocompromised, and may be fatal.35
Some people may also experience dermatomal pain without a rash. This is known as zoster siné herpéte.