Prevention of Herpes Zoster

Infection with varicella zoster virus (VZV) causes two distinct clinical conditions. Primary VZV infection causes varicella (i.e., chickenpox), a contagious rash illness that typically occurs among children. A vaccine for preventing initial VZV infection has been available in the United States since 1995, and the Advisory Committee on Immunization Practices (ACIP) recommends routine varicella vaccination for all persons aged >12 months who lack evidence of immunity (1–3). Varicella vaccination has dramatically reduced chickenpox cases among children (3).

VZV can reactivate clinically decades after initial infection to cause herpes zoster (zoster) (i.e., shingles), a localized and generally painful cutaneous eruption that occurs most frequently among older adults. Approximately 1 million new cases of zoster occur in the United States annually. Approximately one in three persons in the general population will develop zoster during their lifetime. A common complication of zoster is postherpetic neuralgia (PHN), a chronic pain condition that can last months or even years. In May 2006, a live, attenuated vaccine for prevention of zoster (ZOSTAVAX®, manufactured by Merck & Co., Inc.) was licensed in the United States for use in persons aged >60 years. This report provides recommendations for use of zoster vaccine for prevention of zoster and its sequelae.

Course Outline

These recommendations represent the first statement by the Advisory Committee on Immunization Practices (ACIP) on the use of a live attenuated vaccine for the prevention of herpes zoster (zoster) (i.e., shingles) and its sequelae, which was licensed by the U.S. Food and Drug Administration (FDA) on May 25, 2006. This report summarizes the epidemiology of zoster and its sequelae, describes the zoster vaccine, and provides recommendations for its use among adults aged >60 years in the United States.

Zoster is a localized, generally painful cutaneous eruption that occurs most frequently among older adults and immunocompromised persons. It is caused by reactivation of latent varicella zoster virus (VZV) decades after initial VZV infection is established. Approximately one in three persons will develop zoster during their lifetime, resulting in an estimated 1 million episodes in the United States annually. A common complication of zoster is postherpetic neuralgia (PHN), a chronic, often debilitating pain condition that can last months or even years. The risk for PHN in patients with zoster is 10%–18%. Another complication of zoster is eye involvement, which occurs in 10%–25% of zoster episodes and can result in prolonged or permanent pain, facial scarring, and loss of vision. Approximately 3% of patients with zoster are hospitalized; many of these episodes involved persons with one or more immunocompromising conditions. Deaths attributable to zoster are uncommon among persons who are not immunocompromised.

Prompt treatment with the oral antiviral agents acyclovir, valacyclovir, and famciclovir decreases the severity and duration of acute pain from zoster. Additional pain control can be achieved in certain patients by supplementing antiviral agents with corticosteroids and with analgesics. Established PHN can be managed in certain patients with analgesics, tricyclic antidepressants, and other agents.

Licensed zoster vaccine is a lyophilized preparation of a live, attenuated strain of VZV, the same strain used in the varicella vaccines. However, its minimum potency is at least 14-times the potency of single-antigen varicella vaccine. In a large clinical trial, zoster vaccine was partially efficacious at preventing zoster. It also was partially efficacious at reducing the severity and duration of pain and at preventing PHN among those developing zoster.

Zoster vaccine is recommended for all persons aged >60 years who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions. The vaccine should be offered at the patient’s first clinical encounter with his or her health-care provider. It is administered as a single 0.65 mL dose subcutaneously in the deltoid region of the arm. A booster dose is not licensed for the vaccine. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing PHN, or to treat ongoing PHN. Before administration of zoster vaccine, patients do not need to be asked about their history of varicella (chickenpox) or to have serologic testing conducted to determine varicella immunity.

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Learning Objectives

After completing this course you’ll be able to:

  1.  Describe the clinical features of zoster and PHN.
  2.  Provide a diagnosis of zoster.
  3.  Describe the epidemiology of zoster and its complications.
  4.  Discuss the treatment and nonspecific management of zoster and PHN.
  5.  Discuss the economic burden of zoster and cost-effectiveness of vaccination.

Table of Contents

Prevention of Herpes Foster

  • Methods
  • Background
    • Biology of VZV
    • Clinical Features of Zoster and PHN
    • Diagnosis
    • Zoster Transmission
    • Epidemiology of Zoster and Complications
    • Treatment and Nonspecific Management of Zoster and PHN
    • Prevention of Transmission from Zoster
  • Zoster Vaccine
    • Vaccine Composition, Dosage, and Administration
    • Storage and Handling
    • Efficacy
    • Immunogenicity
    • Duration of Efficacy and of Immunity
    • Safety and Adverse Events
  • The Economic Burden of Zoster and Cost-Effectiveness of Vaccination
  • Summary of Rationale for Zoster Vaccine Recommendations
  • Recommendations for Use of Zoster Vaccine
    • Routine Vaccination of Persons Aged >60 Years
    • Simultaneous Administration with Other Adult Vaccines
    • Groups for Which Vaccine is Not Licensed
    • Special Groups and Circumstances
    • Contraindications
    • Precautions
    • Program Implementation Issues
  • Future Research and Directions
  • Additional Information About Zoster and Zoster Vaccine
  • Acknowledgments
  • References

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