For complete information on Zoster : CDC’s recommendations for the use of zoster vaccine, go IAC Answers Your Questions to www.immunize.org/acip

Experts from the Action zoster increases with increasing age; about herpetic neuralgia, compared with placebo Coalition (IAC) answer your questions 50% of persons living until age 85 years recipients. about zoster vaccine. You’ll find addi- will develop zoster. ACIP recommends the In the key pre-licensure of tional Q&As about zoster vaccine on vaccine for everyone age 50 and older. Shingrix recipients 50 years of age and The efficacy of Zostavax declines with the “Ask the Experts” section of older had a 98% reduction in increasing age at time of . The compared to placebo recipients. In a sepa- immunize.org at www.immunize.org/ efficacy of Shingrix declines slightly with askexperts/experts_zos.asp. rate trial among persons 70 years of age increasing age but much less than that of and older Shingrix recipients had an 89% Zostavax. Please describe the zoster reduction in shingles compared to pla- available in the United States. cebo recipients. In both trials postherpetic Before administering zoster vaccine neuralgia was reduced by 86% to 100%. Two different zoster vaccines have been is it necessary to ask (or test) if the person available in the United States. Live zoster has ever had or shingles? What adverse reactions have been vaccine (ZVL; Zostavax, Merck) was avail- No. All persons age 50 years or older – reported with Shingrix? able from 2006 through 2020. A recombi- whether they have a history of chickenpox In pre-licensure clinical trials of Shingrix nant adjuvanted zoster vaccine (RZV; or shingles or not – should be given Shin- the most common adverse reactions were Shingrix, GlaxoSmithKline) was approved grix unless they have a medical contrain- pain at the site (78%), myalgia in 2017. They differed in their schedule (1 dication to vaccination (described below). (45%), and fatigue (45%). Any grade 3 dose for Zostavax, 2 doses for Shingrix), It is also not necessary to test for varicella adverse event (reactions related to vacci- efficacy (Shingrix is more effective than antibody prior to giving the vaccine. nation which were severe enough to Zostavax), contraindications, and storage prevent normal activities) was reported in requirements. Refer to the 2018 Advisory What are the contraindications 17% of vaccine recipients compared with Committee on Immunization recommen- and precautions to zoster vaccine? 3% of placebo recipients. Grade 3 injection- dations (available at www.cdc.gov/mmwr/ The only contraindication for Shingrix is a site reactions (pain, redness, and swell- volumes/67/wr/pdfs/mm6703a5-H.pdf) severe allergic reaction to a vaccine com- ing) were reported by 9% of vaccine recip- for more details on these issues. ponent. The presence of a moderate or ients, compared with 0.3% of placebo severe acute illness is a precaution. Vacci- To whom should zoster vaccine be given? recipients. Grade 3 solicited systemic nation should be deferred until the illness events (myalgia, fatigue, headache, shiver- The Advisory Committee on Immunization improves. There are no available data to ing, fever, and gastrointestinal symptoms) Practices (ACIP) recommends a 2-dose establish whether Shingrix is safe in preg- were reported by 11% of vaccine recipients series of Shingrix for all persons age 50 nant or lactating women. There is currently and 2.4% of placebo recipients. The occur- years and older. Persons of the appropri- no ACIP recommendation for Shingrix use rence of local grade 3 reactions did not ate age should be vaccinated whether or in this population. Consider delaying vac- differ by vaccine dose. However systemic not they report a prior episode of herpes cination with Shingrix in such grade 3 reactions were reported more zoster or chickenpox. Persons who have circumstances. frequently after dose 2. previously received Zostavax should receive a 2-dose series of Shingrix begin- Rates of serious adverse events (an unde- By what route should zoster vaccine be sirable experience associated with the vac- ning at least 2 months after any dose of administered? Zostavax that may have been given. Per- cine that results in death, hospitalization, Shingrix should be administered by the sons with chronic medical conditions may disability or requires medical or surgical intramuscular route in the deltoid. be vaccinated unless a contraindication or intervention to prevent a serious out- precaution exists for their condition. come) were similar in vaccine and pla- How effective is zoster vaccine in prevent- cebo groups. ing shingles? Is there an upper age limit for receipt of the zoster vaccine? In the key pre-licensure Zostavax clinical What should I advise my patients about trial, vaccine recipients had a 51% reduc- adverse reactions after Shingrix? There is no upper age limit for receiving tion in shingles, less severe illness when zoster vaccine. The of herpes Before vaccination, providers should shingles did occur, and 66.5% less post- counsel Shingrix recipients about

continued on the next page �

Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2025.pdf • Item #P2025 (12/20) Zoster Vaccine: IAC Answers Your Questions (continued) page 2 of 2 expected systemic and local adverse reac- receive both doses to get the maximum reference tions (described above). Reactions to the benefit from the vaccine. Recommendations of the Advisory Committee on first dose do not strongly predict reac- Immunization Practices (ACIP) for Use of Herpes tions to the second dose. Shingrix recipi- How should Shingrix be stored? Zoster Vaccines. MMWR, January 26, 2018;67 (No.3): 103-8. Available at www.cdc.gov/mmwr/ ents should be encouraged to complete Both the Shingrix adjuvant suspension volumes/67/wr/pdfs/mm6703a5-H.pdf. the series even if they experienced a grade (diluent) and the lyophilized antigen com- 3 reaction to the first dose. ponent must be stored refrigerated between 2°C and 8°C (36°F and 46°F). How can I assure that my patients receive Protect the vials from light. Neither the both doses of Shingrix on time? diluent nor antigen should be frozen. Dis- Many clinics have implemented reminder card if either vial has been frozen. systems in their practice to help assure After reconstitution, administer Shingrix their patients complete the 2-dose sched- immediately or store refrigerated between ule. This can be enabled by software at the 2°C and 8°C (36°F and 46°F) and use within clinic, pharmacy, or immunization infor- 6 hours. Discard reconstituted vaccine mation system. The system can generate if not used within 6 hours. Do not freeze. a list of patients that might be coming Discard if the vaccine has been frozen. due (or past due) for second doses or can appear on the clinic’s electronic health How should zoster vaccine be transported record as an alert for the provider. to an off-site clinic location? With this information, clinic or pharmacy Shingrix is stored at refrigerator tempera- personnel can send electronic, telephone, ture. Transport of refrigerated vaccines is or written reminders to recipients of the described in detail in the CDC Storage and first dose, to encourage adherence with Handling Toolkit, available at www.cdc. the second dose. Regardless of the man- gov/vaccines/hcp/admin/storage/toolkit/ ner chosen, it’s important that patients storage-handling-toolkit.pdf.

Immunization Action Coalition • Saint Paul, Minnesota • 651-647-9009 • www.immunize.org • www.vaccineinformation.org www.immunize.org/catg.d/p2025.pdf • Item #P2025 (12/20)