Should a Patient Exposed to Shingles Receive the Zoster Vaccine?

Laura R. Lehman, PharmD, BCPS, CACP

Disclosures

November 26, 2008

Question
A 65-year-old male requests a zoster immunization because his spouse has come down with shingles. He does not have symptoms of varicella or zoster and is unsure if he had chickenpox as a child or adult. Should I obtain a varicella titer prior to immunizing him or take a "wait and see" approach to be certain he is not already infected?

Response from Laura R. Lehman, PharmD, BCPS, CACP
Clinical Coordinator, Department of Pharmacy, Carroll Hospital Center, Westminster, Maryland

Shingles, also known as herpes zoster, is a painful rash caused by reactivation of varicella zoster virus (VZV) in an individual with a history of chickenpox or chickenpox immunization. A person who has never had chickenpox can contract VZV from a patient with shingles lesions in the blister-phase, but this is very rare, especially if the lesions are covered. A frequent complication of shingles is postherpetic neuralgia (PHN), a potentially chronic and debilitating inflammation of the affected nerves. The elderly are at high risk of developing shingles. About half of those living to age 85 have experienced at least one episode, and many will go on to suffer from PHN.[1,2]

Zoster vaccine (Zostavax®) is indicated for prevention of shingles in individuals 60 years of age or older.[3] It is a more potent form of the live, attenuated VZV contained in chickenpox vaccines. Overall, in the elderly population, Zostavax® can reduce the incidence of shingles by 50%.[4] In May 2008, the Advisory Committee on Immunization Practices, a group that makes recommendations about vaccine-preventable diseases to the Centers for Disease Control and Prevention, issued the following recommendations for prevention of shingles[1]:

 

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.

 

Contraindications to zoster vaccine include[2,4]:

  • History of anaphylactic/anaphylactoid reaction to gelatin, neomycin, or any other component of the vaccine;

  • Immunocompromised state (eg, hematologic or lymphatic malignancy, AIDS);

  • Immunosuppressive therapy, including high-dose corticosteroids;

  • Active, untreated tuberculosis; and

  • Pregnancy.

Patients who received the chickenpox vaccine should not receive the zoster vaccine. However, few adults over the age of 60 have received the chickenpox vaccine. Zoster immunization should be deferred in the presence of moderate to severe acute illness. Medications active against herpes virus (acyclovir, famciclovir, and valacyclovir) can prevent replication of live attenuated vaccine virus; therefore, these agents should be withheld 24 hours prior to administering the zoster vaccine and again for at least 14 days after vaccination.[1,2,4]

According to product labeling, common adverse effects of Zostavax® (reported within the first 42 days after administration) include injection site erythema, pain, swelling, pruritis, and headache. Noninjection-site zoster-like rashes were reported more with placebo than with vaccine.[3]

Unless the patient described above is immunosuppressed or allergic to the vaccine components, he should discuss zoster vaccine as a routine immunization with his physician, regardless of the outbreak of shingles in his spouse. Because he is older than age 60, he is likely to have been exposed to VZV and to have developed immunity to the virus; therefore, it is not necessary to ask about history of chickenpox or to test for varicella titer. Vaccination should be deferred if illness is present.

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