Herpes zoster primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]Aysha Anwar, M.B.B.S[3]

Overview

The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated. A vaccine for shingles is licensed for persons aged 60 years and older.

Primary Prevention

Zostavax vaccine is recommended for individuals aged 60 years and older to prevent Herpes zoster. Other primary prevention strategies include intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruits.

Vaccines

Varicella containing vaccines	Indications	Efficacy and immunogenicity	Recommended dose	Contraindications
Varicella vaccine (Varivax)	Children Routine vaccination at 12-15 months of age Routine second dose at 4-6 years of age Adolescents and Adults All persons 13 years of age and older without evidence of varicella immunity	Detectable antibody 97% of children 12 months through 12 years following 1 dose 99% of persons 13 years and older after 2 doses 70% to 90% effective against any varicella disease 90%-100% effective against severe varicella disease	Children Minimum interval between doses of varicella vaccine is 3 months for children younger than 13 years of age Adolescents and Adults 2 doses separated by at least 4 weeks Do not repeat first dose because of extended interval between doses	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness Recent blood product
Measles-mumps-rubella-varicella vaccine (ProQuad)	Approved for children 12 months through 12 years Do not use for persons 13 years and older	Efficacy of MMRV vaccine was inferred from that of MMR vaccine and varicella vaccine on the basis of noninferior immunogenicity Formal studies to evaluate the clinical efficacy of MMRV vaccine have not been performed	May be used for both first and second doses of MMR and varicella vaccines Minimum interval between doses is 3 months	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness Recent blood product Personal or family (i.e., sibling or parent) history of seizures of any etiology (MMRV only)
Herpes zoster vaccine (Zostavax)	Approved for persons 50 years and older Not recommended by ACIP in adults younger than 60 years of age	Vaccine recipients 60 to 80 years of age had 51% fewer episodes of zoster Efficacy declines with increasing age Significantly reduces the risk of postherpetic neuralgia Reduces the risk of zoster 69.8% in persons 50 through 59 years of age	Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster)	Severe allergic reaction to vaccine component or following a prior dose Immunosuppression Pregnancy Moderate or severe acute illness
New Herpes zoster vaccine (Shingrix)	Adults aged 50 years or older (first pivotal phase 3 trial) Adults aged 70 years and over (second pivotal phase 4 trial)	Efficacy between 91-97% for all age groups Efficacy does not decrease with increasing age group	Two doses 2 to 6 months apart	Immunocompromised individuals

A live attenuated VZV Oka/Merck strain vaccine is available and is marketed under the trade name Varivax. It was developed by Merck, Sharp & Dohme in the 1980s from the Oka strain virus isolated and attenuated by Michiaki Takahashi and colleagues in the 1970s. It was submitted to the U.S. Food and Drug Administration for approval in 1990 and was approved in 1995. Since then, it has been added to the recommended vaccination schedules for children in Australia, the United States, and many other countries, causing controversy because it is only expected to be effective for about twenty years, leaving adults vulnerable to the most dangerous forms of infection by this virus. The use of varicella virus vaccine live (Varivax) has been limited by practitioner concerns that adults vaccinated as children could develop severe varicella infection complications if immunity provided by the vaccine is not long-lasting. However, clinical data has proved that the vaccine is effective for over 10 years in preventing varicella infection in healthy individuals and when breakthrough infections do occur, illness is typically mild.

In 2006, the FDA approved Zostavax for the prevention of shingles. Zostavax is a more concentrated formulation of the Varivax vaccine, designed to elicit an immune response in the eldery whose immunity to VZV wanes with advancing age. It was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2006 to reduce the risk of shingles and its associated pain in people age 60 years and older. Zostavax is developed by Merck & Co. and has proven successful in preventing half the cases of herpes zoster in a study of 38,000 people who received the vaccine. The vaccine also reduced by two-thirds the number of cases of postherpetic neuralgia. However, prior to the vaccine, it has long been known that adults received natural immune boosting from contact with children infected with varicella. This helped to suppress the reactivation of herpes zoster. In Massachusetts, herpes zoster incidence increased 90%, from 2.77/1000 to 5.25/1000 in the period of increasing varicella vaccination 1999-2003. The effectiveness of the varicella vaccine itself is dependent on this exogenous (outside) boosting mechanism. Thus, as natural cases of varicella decline, so has the effectiveness of the vaccine.

The risk for developing shingles increases with age. The Shingles Prevention Study involved individuals age 60 years and older and found the shingles vaccine significantly reduced disease in this age group. The vaccine is currently recommended for persons 60 years of age and older. Even people who have had shingles can receive the vaccine to help prevent future occurrences of the disease.

At this time, CDC does not have a recommendation for routine use of shingles vaccine in persons 50 through 59 years old. However, the vaccine is approved by FDA for people in this age group.

Risk of Acquiring Herpes zoster after Vaccination

The attenuated vaccine virus can reactivate and cause herpes zoster. People who get vaccinated against varicella may develop herpes zoster later in life. However, their risk is lower than people who were infected with wild-type VZV.

• In a study of children with leukemia, those who got varicella vaccine had a 67% lower risk of herpes zoster than children who had had varicella.
• Data on healthy children show a similar pattern of reduced risk of herpes zoster in those vaccinated against varicella.
• The number of older adults who got varicella vaccine since it was licensed in 1995 is quite low. So, there is very little information on the risk of herpes zoster in people who got varicella vaccine as adults.

Preventing Transmission in Healthcare Settings

To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.

Evidence of immunity to VZV for healthcare personnel includes any of the following:

• Documentation of vaccination with 2 doses of varicella vaccine;
• Laboratory evidence of immunity or laboratory confirmation of disease;
• Diagnosis or verification of a history of varicella disease by a healthcare provider; or
• Diagnosis or verification of a history of herpes zoster by a healthcare provider.