II. Indications

  1. Prevention of Shingles in age 50 years or older (previously only approved for age 60 and older)
    1. However due to Vaccine shortages, focus use on those over age 60 years
  2. Indicated even in those who had prior Shingles infection
    1. Rash must have resolved to administer
    2. Delay Vaccine for 12 months following Shingles episode based on expert opinion in 2012
  3. Shingrix is indicated in patients previously treated with Zostavax
    1. Wait at least 8 weeks after Zostavax, before starting Shingrix 2 dose series
  4. Shingrix (inactivated Vaccine) in Immunocompromised adults, age 19 years and older
    1. Added in CDC recommendation for 2022
    2. Confirm prior history of Chicken Pox or Shingles (see below)
  5. Upcoming immunosuppresive therapy (give at least 4 weeks before Vaccine dose)
    1. Chemotherapy
    2. TNF Inhibitors (e.g. Enbrel)
    3. Rituximab
    4. Prednisone >20 mg/day for >14 days

III. Contraindications: Immunocompromised Conditions and Zostavax (does not apply to Shingrix)

  1. AIDS
  2. Human Immunodeficiency Virus with clinical manifestations or CD4 Count <200
  3. Methotrexate >0.4 mg/kg/week
  4. Recent Systemic Corticosteroid use over 20 mg for at least 2 weeks
    1. Delay Immunization for 1 month after steroid course completed
  5. Low level immunosuppressive conditions or medications are NOT a contraindication to Zostavax
    1. Prednisone <20 mg/day or oral Corticosteroid use <14 days
    2. Methotrexate <0.4 mg/kg/week
    3. Inhaled Corticosteroids
    4. Topical Corticosteroids

IV. Contraindications: Other

  1. Concurrent acute febrile illness (Fever >101.3 F)
  2. History of Anaphylaxis to gelatin or neomycin
  3. Unsure of prior Chicken Pox or Shingles history and no prior Varicella Vaccine
    1. Obtain varicella titer in uncertain cases before Vaccine (esp. Immunocompromised patients)
    2. Born in U.S. before 1980 are considered immune and do not need titer before Zostavax
    3. Foreign born
      1. Check titer if no known history of Chicken Pox
      2. Titer positive can recieve Zostavax, and those with negative titer get the Varivax

V. Cost

  1. Approximately: $280 for Shingrix and $212 for Zostavax
  2. Injection and drug are now covered under Medicare Part D

VI. Background

  1. Zostavax varicella titer is 14 times higher than Varivax

VII. Preparations

  1. Zostavax (original Live Vaccine)
    1. Zostavax 0.65 ml SQ for one dose
  2. Shingrix (recombinant, inactivated Vaccine released 2018, preferred)
    1. Inactivated Varicella Vaccine that may be more effective in preventing Shingles than Zostavax
    2. Shingrix for 2 doses IM at 2-6 months apart (minimum 4 weeks between doses)
    3. If prior Zostavax, wait at least 2 months to start Shingrix series

VIII. Precautions

  1. Live, attenuated Varicella-Zoster VirusVaccine
  2. Virus load injected is 14 times greater than Varivax
  3. Pneumovax and VZV Vaccine may be given on same day according to CDC and despite product label
  4. Household contacts of Immunocompromised patients can typically receive VZV Vaccine
    1. If rash develops following Vaccine, cover the rash and avoid contact with Immunocompromised patient

IX. Adverse Effects

  1. Local inflammation at injection site (33% with Zostavax)
  2. Chicken Pox or Shingles-type rash is uncommon

X. Efficacy: Shingrix

  1. Shingles prevention: 97% (compared with 51% for Zostavax)
  2. Number Needed to Treat to prevent 1 Shingles case: 37 (compared with 59 for Zostavax)

XI. Efficacy: Zostavax

  1. Immunity appears to last at least 4 years
    1. In age >60, Vaccine is 69% in first year after Vaccine, but decreases to 4% by 8 years after Vaccine
    2. Tseng (2016) J Infect Dis 213(12): 1872-5 [PubMed]
  2. Decreases Herpes ZosterIncidence by 50%
    1. Decreases cases by 64% in age 60-70, and 38% in age >70 years
    2. Occurs in 3.3% of unvaccinated patients
    3. Occurs in 1.6% of vaccinated patients
    4. Number Needed to Treat to prevent 1 case: 59
  3. Reduces Postherpetic Neuralgia by 66%
    1. Occurs in 0.4% of unvaccinated patients
    2. Occurs in 0.14% of vaccinated patients
    3. Number Needed to Treat to prevent 1 case: 360

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