Prevention of herpes zoster
Zostavax® (Zoster Vaccine Live) is the only vaccine available for herpes zoster. It is given subcutaneously as one dose and is recommended for adults aged 60 years and older. According to the Shingles Prevention Study,38 Zostavax decreases the incidence of herpes zoster by 70% in persons aged between 50 and 59 years, by 64% in those aged between 60 and 69 years, and by 38% among those aged 70 years or older. The vaccine also reduces the incidence of PHN by 66% among persons aged between 60 and 69 years and by 67% among those aged 70 years or older. The only frequent side effects have been injection-site reactions.38-41
Zostavax is not recommended for persons who have received varicella vaccine. However, because varicella vaccine was first introduced in 1995, few adults aged 40 years or older have received it. Contraindications to the administration of herpes zoster vaccine are listed in Table 5.
Persons who have already had herpes zoster can be vaccinated safely with Zostavax.42 According to Hales et al,43 the protection offered by the herpes zoster vaccine wanes within the first 5 years after vaccination. The vaccine’s efficacy for the prevention of PHN also wanes.
Currently, the need for revaccination with a booster for continued protection against zoster is unclear. According to Keating,44 in the future, a booster dose may be needed for adults aged 70 years or older who received their first dose of zoster vaccine 10 or more years previously.
Administration of adult vaccines at the same visit. According to the Advisory Committee on Immunization Practices,10 zoster vaccine can be administered safely and concurrently with any inactivated vaccine, including influenza vaccine; pneumococcal polysaccharide vaccine (PPSV23); tetanus and diphtheria (Td) vaccine; and tetanus, diphtheria, and acellular pertussis (Tdap) vaccine. The vaccines can be administered at the same visit in separate syringes at separate anatomical sites.10,45 Zoster vaccine should be administered at least 4 weeks before or after the administration of a live, attenuated vaccine.
According to the Food and Drug Administration,46 the immunogenicity of zoster vaccine may be diminished if Pneumovax is administered simultaneously. However, the Advisory Committee on Immunization Practices asserts that because compliance can be an issue and the patient may not return in 4 weeks, it is best to administer Pneumovax and Zostavax at the same visit.10
A new vaccine for herpes zoster, not yet available for clinical use, is being tested. This vaccine contains substances that can boost the immune response to herpes zoster. A study including 8122 participants showed that those administered the new vaccine had fewer episodes of herpes zoster.47
Adverse events. Vaccination can cause temporary localized redness and swelling, which subside. Adverse events after vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) at http://www.vaers.hhs.gov or 800-822-7967. Clinicians should be careful to administer the appropriate vaccine: Varivax to children and Zostavax to adults. If a dose of herpes zoster vaccine (Zostavax) is given accidentally in place of varicella vaccine (Varivax), then the dose of herpes zoster vaccine should be considered a single valid dose of varicella vaccine. If varicella vaccine is accidentally administered instead of herpes zoster vaccine to an adult aged 60 years or older, no specific safety concerns exist, but the dose should not be considered valid, and a dose of herpes zoster vaccine should be administered during the same visit.10
Theresa Capriotti, DO, MSN, CRNP, is an associate professor and Meghan Scanlon is an honors BSN student at Villanova University in Pennsylvania.
- Epidemiology and prevention of vaccine-preventable diseases. Varicella-zoster virus. Clinical features. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html#zostervirus. Updated August 11, 2015. Accessed January 4, 2017.
- Shingles (herpes zoster). Epidemiology. Risk factors. Centers for Disease Control and Prevention website. http://www.cdc.gov/shingles/hcp/clinical-overview.html#risk-factors. Updated August 19, 2016. Accessed January 4, 2017.
- Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, Sy LS. A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clin Proc. 2007;82:1341-1349. Erratum in Mayo Clin Proc. 2008;83:255.
- Insinga RP, Itzler RF, Pellissier JM, Saddier P, Nikas AA. The incidence of herpes zoster in a United States administrative database. J Gen Intern Med. 2005;20:748-753.
- Shingles (herpes zoster). Overview. Centers for Disease Control and Prevention website. http://www.cdc.gov/shingles/about/overview.html. Updated March 15, 2016. Accessed January 4, 2017.
- Marin M, Harpaz R, Zhang J, Wollan PC, Bialek SR, Yawn BP. Risk factors for herpes zoster among adults. Open Forum Infect Dis. 2016;3:ofw119. doi: 10.1093/ofid/ofw119. eCollection 2016.
- Cohen JI. Clinical practice: herpes zoster. N Engl J Med. 2013;369:255-263.
- Fashner J, Bell AL. Herpes zoster and post-herpetic neuralgia: prevention and management. Am Fam Physician. 2011;83:1432-1437.
- Zerboni L, Sen N, Oliver SL, Arvin AM. Molecular mechanisms of varicella zoster virus pathogenesis. Nat Rev Microbiol. 2014;12:197-210.
- Harpaz R, Ortega-Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP), Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008;57(RR-5):1-30.
- Kumar VJ, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease. 9th ed. Philadelphia, PA: Elsevier Health Sciences; 2014[BG1] .
- Weinmann S, Chun C, Schmid DS, et al. Incidence and clinical characteristics of herpes zoster among children in the varicella vaccine era, 2005-2009. J Infect Dis. 2013;208:1859-1868.
- Schmader K. Herpes zoster. Clin Geriatr Med. 2016;32:539-553.
- Levin MJ. Varicella-zoster virus and virus DNA in the blood and oropharynx of people with latent or active varicella-zoster virus infections. J Clin Virol. 2014;61:487-495.
- Gershon AA, Chen J, Gershon MD. Use of saliva to identify varicella-zoster virus infection of the gut. Clin Infect Dis. 2015;61:536-544.
- Bader MS. Herpes zoster: diagnostic, therapeutic, and preventive approaches. Postgrad Med. 2013;125:78-91.
- Calianno C, O’Shea S. Herpes zoster in older adults. Nurse Pract. 2013;38:10-14.
- Wilson D. Herpes zoster: a rash demanding careful examination. Nurse Pract. 2014;39:30-36.
- Liesegang TJ. Herpes zoster ophthalmicus natural history, risk factors, clinical presentation, and morbidity. Ophthalmology. 2008;115(2 suppl):S3-S12.
- Vrcek I, Choudhury E, Durairaj V. Herpes zoster ophthalmicus: a review for the internist. Am J Med. 2017;130:21-26.
- Cohen EJ. Management and prevention of herpes zoster ocular disease. Cornea. 2015;34 (suppl 10):S3-S8.
- Roat MI. Herpes zoster ophthalmicus. Merck Manual Professional Version. https://www.merckmanuals.com/professional/eye-disorders/corneal-disorders/herpes-zoster-ophthalmicus. Reviewed September 2014. Accessed January 4, 2017.
- Catron T, Hern HG. Herpes zoster ophthalmicus. West J Emerg Med. 2008;9:174-176.
- Yawn BP, Gilden D. The global epidemiology of herpes zoster. Neurology. 2013;81:928-930.
- Klompas M, Kulldorff M, Vilk Y, Bialek SR, Harpaz R. Herpes zoster and postherpetic neuralgia surveillance using structured electronic data. Mayo Clin Proc. 2011;86:1146-1153.
- Drolet M, Brisson M, Schmader KE, et al. The impact of herpes zoster and postherpetic neuralgia on health-related quality of life: a prospective study. CMAJ. 2010;182:1731-1736.
- Mallick-Searle T, Snodgrass B, Brant JM. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. J Multidiscip Healthc. 2016;9:447-454.
- Johnson RW, Rice AS. Clinical practice. Postherpetic neuralgia. N Engl J Med. 2014;371:1526-1533.
- Prymula R, Bergsaker MR, Esposito S, et al. Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial. Lancet. 2014;383(9925):1313-1324.
- Marin M, Broder KR, Temte JL, Snider DE, Seward JF; Centers for Disease Control and Prevention (CDC). Use of combination measles, mumps, rubella, and varicella vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2010;59(RR-3):1-12.
- Vaccine safety. Measles, mumps, rubella, and varicella vaccine. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccinesafety/vaccines/mmrv-vaccine.html. Updated October 27, 2015. Accessed January 4, 2017.
- Civen R, Marin M, Zhang J, et al. Update on incidence of herpes zoster among children and adolescents after implementation of varicella vaccination, Antelope Valley, CA, 2000 to 2010. Pediatr Infect Dis J. 2016;35:1132-1136.
- Chaves SS, Santibanez TA, Gargiullo P, Guris D. Chickenpox exposure and herpes zoster disease incidence in older adults in the U.S. Public Health Rep. 2007;122:155-159.
- Fu J, Wang J, Jiang C, Shi R, Ma T. Outbreak of varicella in a highly vaccinated preschool population. Int J Infect Dis. 2015;37:14-18.
- Tafuri S, Guerra R, Cappelli MG, Martinelli D, Prato R, Germinario C. Determinants of varicella breakthrough: results of a 2012 case control study. Hum Vaccin Immunother. 2014;10:667-670.
- Epidemiology and prevention of vaccine-preventable diseases. Varicella-zoster virus. Epidemiology. Centers for Disease Control and Prevention website. http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html#epi. Updated August 11, 2015. Accessed January 4, 2017.
- Wang L, Zhu L, Zhu H. Efficacy of varicella (VZV) vaccination: an update for the clinician. Ther Adv Vaccines. 2016;4:20-31.
- Oxman, MN, Levin MJ, Johnson GR, et al; Shingles Prevention Study Group. A vaccine to prevent herpes zoster and post-herpetic neuralgia in older adults. N Engl J Med. 2005;352:2271-2284.
- Schmader KE, Levin MJ, Gnann Jr JW, et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis. 2012;54:922-928.
- Cohen JI. A new vaccine to prevent herpes zoster. N Engl J Med. 2015;372:2149-2150.
- Oxman MN. Zoster vaccine: current status and future prospects. Clin Infect Dis. 2010;51:197-213.
- Morrison VA, Oxman MN, Levin MJ, et al; Shingles Prevention Study Group. Safety of zoster vaccine in elderly adults following documented herpes zoster. J Infect Dis. 2013;208:559-563.
- Hales CM, Harpaz R, Ortega-Sanchez I, Bialek SR; Centers for Disease Control and Prevention (CDC). Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014;63:729-731.
- Keating GM. Shingles (herpes zoster) vaccine (Zostavax®): a review in the prevention of herpes zoster and postherpetic neuralgia. BioDrugs. 2016;30:243-254.
- 45.[BG4] Marin M, Guris D, Chaves SS, Schmid S, Seward JF; Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recommen Rep. 2007;56(RR-4):1-40.
- Safety information. Zostavax (zoster vaccine live) suspension for subcutaneous injection. U.S. Food and Drug Administration website. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ucm200862.htm. Updated March 14, 2016. Accessed January 4, 2017.
- Cunningham AL, Lal H, Kovac M, et al; ZOE-70 Study Group. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016;375:1019-1032.
- Galil K, Brown C, Lin F, Seward J. Hospitalizations for varicella in the United States, 1988 to 1999. Pediatr Infect Dis J. 2002;21:931-935.
- Leung J, Harpaz R, Molinari NA, Jumaan A, Zhou F. Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination. Clin Infect Dis. 2011;52:332-340.
- Kawai K, Yawn BP, Wollan P, Harpaz R. Increasing incidence of herpes zoster over a 60-year period from a population-based study. Clin Infect Dis. 2016;63:221-226.
- Marin M, Meissner HC, Seward JF. Varicella prevention in the United States: a review of successes and challenges. Pediatrics. 2008;122:e744-e751.
- Goldman GS, King PG. Review of the United States universal varicella vaccination program: herpes zoster incidence rates, cost-effectiveness, and vaccine efficacy based primarily on the Antelope Valley Varicella Active Surveillance Project data. Vaccine. 2013;31:1680-1694.
- Joon Lee T, Hayes S, Cummings DM, et al. Herpes zoster knowledge, prevalence, and vaccination rate by race. J Am Board Fam Med. 2013;26:45-51.
- Williams WW, Lu PJ, O’Halloran A, et al; Centers for Disease Control and Prevention (CDC). Vaccination coverage among adults, excluding influenza vaccination—United States, 2013. MMWR Morb Mortal Wkly Rep. 2015;64:95-102.
- Shingles (herpes zoster). Complications. Centers for Disease Control and Prevention website. http://www.cdc.gov/shingles/hcp/clinical-overview.html#complications. Updated August 19, 2016. Accessed January 4, 2017.
- Neuzil KM, Griffin MR. Preventing shingles and its complications in older persons. N Engl J Med. 2016;375;1079-1080.
- Gelb LD. Reducing the incidence and severity of herpes zoster and PHN with zoster vaccination. J Am Osteopath Assoc. 2009;109(6 suppl 2):S18-S21.