CE/CME

Herpes Zoster Infection

Clinician Reviews. 2013 August;23(8):42-49

References

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16. Wilson JF. Herpes zoster. Ann Intern Med. 2011;154:ITC31-ITC15.

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23. Tyring S, Barbarash RA, Nahlik JE, et al; Collaborative Famciclovir Herpes Zoster Study Group. Famciclovir for the treatment of acute herpes zoster: effects on acute disease and postherpetic neuralgia: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1995;123:89-96.

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27. Shafran SD, Tyring SK, Ashton R, et al. Once, twice, or three times daily famciclovir compared with aciclovir for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind clinical trial. J Clin Virol. 2004;29:248-253.

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PREVENTION
The varicella vaccine was licensed for use in children by the FDA in 1995. In June 2006, the Advisory Committee on Immunization Practices (ACIP) recommended a second dose to boost waning immunity.⁴¹

In 2006, the HZ vaccine (Zostavax), a more concentrated formulation of the varicella vaccine, was approved by the FDA for use in adults age 60 or older; in 2011, approval of the vaccine was extended to adults 50 or older.⁴² As of November 2011, ACIP has continued to recommend routine administration of the HZ vaccine for immunocompetent adults 60 and older, citing lack of evidence for long-term protection in patients vaccinated before age 60, as well as concerns about maintaining sufficient vaccine supplies.

Although ACIP does not recommend routine vaccination against HZ in patients age 50 to 59, health care providers may wish to consider it for patients in this age-group, based on the potential for poor tolerance of HZ or PHN symptoms, anticipated difficulty tolerating the required medications used to treat them, and employment-related considerations.⁴³

Use of the HZ Vaccine
Zostavax is a live attenuated vaccine that increases varicella-specific, cell-mediated immunity in immunocompetent persons.^17,42 It should be administered as a single 0.65-mL dose subcutaneously in the deltoid region of the upper arm⁴²; a booster dose is not licensed for the vaccine.¹⁷ Adverse effects of the HZ vaccine generally include mild injection-site reactions: pain (54%), erythema (48%), swelling (40%), and pruritus (11%).⁴² According to researchers for the Shingles Prevention Study^38,44 (SPS), these reactions were more common in treated patients than in controls and increasingly common in study participants of advancing age. Less than 2% of patients receiving either the HZ vaccine or placebo experienced serious adverse effects.⁴⁴

The evidence to support vaccination against HZ comes mainly from the original SPS,³⁸ a randomized, double-blind, placebo-controlled trial in which more than 38,500 adults 60 and older were enrolled. The SPS researchers showed that the vaccine reduced the incidence of HZ by 51.3%, reduced the incidence of PHN by 67%, and reduced the HZ-associated burden of illness (ie, its incidence, severity, and duration of associated pain and discomfort) by 61%^2,38,45; they also found vaccination against HZ effective for at least three years.

An ongoing substudy involving 14,270 of the original SPS participants produced data showing that from year 4 to year 5 postvaccination, vaccine efficacy in terms of HZ incidence declined from 51% to 40%, respectively, and its efficacy regarding incidence of PHN, from 67% to 60%.⁴⁶ Since there is no strong evidence that any treatment intervention started after shingles presents can reduce the risk for PHN, perhaps the vaccine’s most valuable attribute is its potential for preventing this debilitating and common complication of shingles.

Who Should or Should Not Be Vaccinated?
According to the ACIP, there is no upper age limit on vaccination against shingles. This judgment is supported by the fact that the incidence of zoster and PHN both continue to increase among patients of advancing age.¹⁷

While vaccination is appropriate for most individuals 60 or older, some contraindications exist (see Table 3^17,22,47,48). In cases of anticipated immunosuppression (as in patients scheduled to undergo chemotherapy), vaccination is recommended one month before the start of therapy. Additionally, the safety and efficacy of vaccination is unknown in patients receiving immune modulators and recombinant human immune mediators (eg, adalimumab, etanercept, infliximab); thus, these patients too should be vaccinated one month before starting these treatments or one month after their completion.⁴⁷

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