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Herpes zoster (shingles) vaccine (Zostavax, Shingrix)

Tradenames: - Zostavax (available 2006) [2] - Shingrix FDA approved Oct 2017 [29] - Shingrix more effective than Zostavax [35] Indications: 1) prevention of shingles in the elderly - recombinant adjuvanted Herpes zoster vaccine (Shingrix) recommended for all adults >= 50 years [32] 2) may lower risk of postherpetic neuralgia in elderly] 3) vaccine likely effective & safe in patients taking biologic response modifiers for autoimmune disease (Zostavax) [18] 4) effective (41%) in patients vaccinated prior to chemotherapy (Zostavax) [22] 5) Zostavax may reduce new diagnosis of dementia within 7 years (RR=0.8) [43] * above Contraindications: 1) Zostavax - immunocompromised patients - lymphoma [21] - HIV1 [21] - chemotherapy for cancer - treatment with immunosuppressive agents - >= 20 mg of prednisone/day (ACIP) - safe for patients with immune-related diagnoses such as rheumatoid arthritis or inflammatory bowel disease [15] - safe for patients treated with biologic immunosuppressive agents, including TNF-alpha inhibitors [17] - tuberculosis [13] - see live virus vaccine - symptomatic shingles or active postherpetic neuralgia [12,13] - no need to ask about varicella exposure or check a varicella titer [13] - allergy to neomycin or gelatin [13] - secondary prevention of shingles ? - no difference in recurrence of shingles in vaccinated vs unvaccinated persons [16] 2) Shingrix - Shingrix may be safe for immunocompromised patients [34] - Shingrix effective after autologous stem cell transplantation [38] Benefit/risk: - Zostavax - number needed to treat (NNT) to prevent one episode of shingles = 71 [10], 17 [13], 11 [23]; 40 when vaccinated at age 50 [25];] 13 when vaccinated at age 50 [29]; - NNT to prevent one case of post-herpetic neuralgia = 43 [11], 31 [13] - NNT to prevent one case of post-herpetic neuralgia when vaccinated at age 50 = 1000 [25] - NNT to prevent one Herpes zoster-related death = 3762 [11] - no difference in recurrence of shingles in vaccinated vs unvaccinated individuals [16] - risk to benefit ratio uncertain - vaccination equally common among cases & controls [26] - Zostavax may reduce >= 3 year incidence of dementia [41] - Zostavax may reduce of Alzheimer's Disease, Parkinson's Disease & 0ther neurodegenerative disorders [42] - Shingrix superior to Zostavax - number needed to treat (NNT) to prevent one episode of shingles - 11 when vaccinated at age 60 (Shingrix) [29] Dosage: - 0.5 mL IM, 2 doses 2-6 months apart (Shingrix*) [29,32,33] * Shingrix also recommended (1 dose) after Zostvax [29,32] - immunogenicity & safety profile of Shingrix similar in those previously vaccinated with Zostavax & vaccine-naive patients [30] - Shigrex more effective than Zostavax [35] - Shigrex more cost effective than Zostavax even when only 1 of 2 doses given [37] - GRS11 [17] recommends two doses IM 2-6 months apart regardless of prior immunization with Zostvax, failing to recognize refs [29,32] Keep frozen (< -15 degrees C), reconstitute & use immediately. 19,400 plaque forming units per dose Pharmacokinetics: - after 10 years, Zostavax largely ineffective [24] - overall estimates of Zostavax efficacy between 5-12 years after vaccination are 21% against incidence of shingles, 35% against postherpetic neuralgia [24] - Shingrix reportedly 84% effective after 5-7 years [39] Adverse effects: - adverse effects with Shingrix not greater than Zostavax - 3% of adverse effects with Shingrix serious (hospitalization, life-threatening illness) - rate of 4.0 serious events per 100,000 doses (Shingrix) - rate of 4.4 serious events per 100,000 doses (Zostavax) - most commonly reported adverse events with Shingrix were fever (24%), injection site pain, & chills [36] - risk of Guillain-Barre syndrome is low (10 excess cases per 1 million vaccinations in one analysis) [40] Drug interactions: - labeling suggests spacing Zostavax & pneumococcal vaccines 4 weeks apart, but CDC does NOT advocate waiting [12] Mechanism of action: 1) live virus vaccine (Zostavax) - made from same nonvirulent virus used in varicella virus vaccine (Varivax), but about 20 times more concentrated - efficacy appears to wane with time (& with aging) [20] - no more effective than placebo [35] 2) Shingrix is a recombinant herpes zoster glycoprotein combined with adjuvant, not a live virus vaccine [34] - more effective than Zostavax [35] - reportedly almost 90% effective in elderly > 70 years after 4 years [39] - reportedly 84% effective after 5-7 years [39] Notes: - Zostavax cost is about $150 (2006) - covered under part D of Medicare [13] - may not be cost-effective [4] - vaccine efficacy may wane with time [19] - two-dose, adjuvanted herpes zoster subunit vaccine (Shingrix) is cost effective [31]

Interactions

drug interactions

Related

Herpes zoster (shingles)

Specific

Herpes zoster subunit vaccine recombinant Herpes zoster vaccine (Shingrix)

General

varicella virus vaccine (Varivax)

References

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