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Zostavax

Common name:

Herpes zoster, shingles

Protects against herpes zoster (shingles).

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Overview

Almost everyone is at risk of shingles because they are likely to have been exposed to chickenpox, even if they have no history of clinical chickenpox or chickenpox vaccination. Following chickenpox infection, the virus lies dormant in the nerves near the spine and may re-emerge many years later as shingles. Shingles most commonly affects older adults or people of any age with a weakened immune system.

One dose of Zostavax® is indicated for the prevention of shingles. It can be given to patients who have previously had shingles. 

Since 1 April 2018, one dose of Zostavax is funded for adults aged 65 years.

  • A 'catch-up' programme for people who were 66–80 years of age on 1 April 2018 and who are still aged under 81 years has been extended to 31 December 2020.
  • Adults who were 65 years of age on or after 1 April 2018 do not have an age or time limit to 'catch-up' a missed 65 year old dose.
  • Funded vaccine doses are only available through general practice. 

Zostavax is also available for individuals aged 50–64 years or 81 years or older to purchase through general practice and some pharmacies.

This vaccine contains a weakened form of the varicella-zoster virus, and as a live viral vaccine, is not suitable for some people with medical conditions or who are receiving treatments that affect their immune system. It is important to seek medical advice before receiving this vaccine.

Responses to vaccine

Zostavax
Common Responses
  • Mild pain, redness and swelling around injection site
  • Itching or rash around injection site.
  • Headache
Rare Responses  

As with any medicine, very rarely a severe allergic reaction (anaphylaxis) can occur following immunisation.

References

  • Amirthalingam G, Andrews N, Keel P, Mullett D, Correa A, de Lusignan S, et al. Evaluation of the effect of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study. Lancet Public Health. 2018;3(2):e82-e90.
  • Baxter R, Tran TN, Hansen J, Emery M, Fireman B, Bartlett J, et al. Safety of Zostavax™ - A cohort study in a managed care organization. Vaccine. 2012;30(47):6636-41.
  • Baxter R, Bartlett J, Fireman B, Marks M, Hansen J, Lewis E, et al. Long-term effectiveness of the live zoster vaccine in preventing shingles: A cohort study. Am J Epidemiol. 2018;187(1):161-9.
  • Doan HQ, Ung B, Ramirez-Fort MK, Khan F, Tyring SK. Zostavax: a subcutaneous vaccine for the prevention of herpes zoster. Expert Opin Biol Ther. 2013;13(10):1467-77.
  • Keating GM. Shingles (herpes zoster) vaccine (Zostavax®): A review in the prevention of herpes zoster and postherpetic neuralgia. BioDrugs. 2016;30(3):243-54.
  • Gnann Jr JW. Vaccination to prevent herpes zoster in older adults. J Pain. 2008;9(Suppl 1):31-6.
  • Izurieta HS, Wernecke M, Kelman J, Wong S, Forshee R, Pratt D, et al. Effectiveness and duration of protection provided by the live-attenuated herpes zoster vaccine in the medicare population ages 65 years and older. Clin Infect Dis. 2017;64(6):785-93.
  • Ministry of Health. Immunisation handbook 2017 2nd Edition [Internet]. Wellington: Ministry of Health; 2018 [cited 2020 July 20]. Available from: http://www.health.govt.nz/publication/immunisation-handbook-2017
  • Morrison VA, Oxman MN, Levin MJ, Schmader KE, Guatelli JC, Betts RF, et al. Safety of zoster vaccine in elderly adults following documented herpes zoster. J Infect Dis 2013 208 (4): 559-563.
  • Pharmaceutical Management Agency (PHARMAC). New Zealand Pharmaceutical Schedule [Internet]. Wellington: Pharmaceutical Management Agency; [updated 2020 July 20; cited 2020 July 20]. Available from: https://www.pharmac.govt.nz/tools-resources/pharmaceutical-schedule/community/
  • Schmader KE, Oxman MN, Levin MJ, Johnson G, Zhang JH, Betts R et al. Persistence of the efficacy of zoster vaccine in the Shingles Prevention Study and the Short-Term Persistence Substudy. Clin Infect Dis. 2012;55(10):1320-8.
  • Tseng HF, Smith N, Sy LS, Jacobsen SJ. Evaluation of the incidence of herpes zoster after concomitant administration of zoster vaccine and polysaccharide pneumococcal vaccine. Vaccine. 2011;29(20):3628-32.
  • Tseng HF, Liu A, Sy L, Marcy SM, Fireman B, Weintraub E, et al. Safety of zoster vaccine in adults from a large managed-care cohort: A Vaccine Safety Datalink study. J Intern Med. 2012;271(5):510-20.
  • Tseng HF, Harpaz R, Luo Y, Hales CM, Sy LS, Tartof SY, et al. Declining effectiveness of herpes zoster vaccine in adults aged ≥60 Years. J Infect Dis. 2016;213(12):1872-5.
  • Walker JL, Andrews NJ, Amirthalingam G, Forbes H, Langan SM, Thomas SL. Effectiveness of herpes zoster vaccination in an older United Kingdom population. Vaccine. 2018;36(17):2371-7.
  • Willis ED, Woodward M, Brown E, Popmihajlov Z, Saddier P, Annunziato PW, et al. Herpes zoster vaccine live: A 10year review of post-marketing safety experience. Vaccine. 2017;35(52):7231-9.
In Depth

Other brands: None

Vaccine type: Live attenuated

Schedule and administration

One dose of Zostavax® is indicated for the prevention of herpes zoster and the painful complications of herpes zoster (shingles). Prevention of shingles prevents acute shingles-related pain and the risk of chronic pain, known as post-herpetic neuralgia. It is not used as treatment during an episode of shingles or to treat post-herpetic neuralgia. Receipt of Zostavax within the 5 years before an episode of shingles may help to reduce the disease severity, i.e. immunisation may make a subsequent episode of shingles less painful or reduce the risk of post-herpetic neuralgia.

A single dose of Zostavax is recommended for adults aged 50 years and older. There is no upper age limit for administration of Zostavax.

There are no recommendations for booster doses of Zostavax at this time.

Eligibility

From 1 April 2018:

There are two distinct Zostavax eligibility groups.

Standard programme

Adults aged 65 years on/after 1 April 2018

  • No age limit for the standard programme
  • No time limit for the standard programme

Catch-up programme

Adults aged 66–80 years inclusively on 1 April 2018

  • Age limit for the catch-up programme
  • Time limit for the catch-up programme
  • Eligible until 31 December 2020* or they turn 81 years of age, whichever occurs first
  • *PHARMAC extended the duration of the catch-up programme in late 2019

Funded vaccine doses will only be available through general practice.

Zostavax is available for purchase by ineligible adults through general practice and some pharmacies.

Storage and preparation

Store the vaccine and diluent as per cold chain between 2°C to 8°C. Protect from light. 

Administration

Zostavax can be administered to adults:

  • At the same visit as other vaccines, including influenza, pneumococcal, tetanus/diphtheria and other Schedule vaccines. Separate syringes and different injection sites should be used.
  • Whether or not they recall a history of chickenpox disease. Do not do serology to check varicella immunity.
  • If they have had herpes zoster in the past.
  • If they are living with someone who is immunocompromised.

Unlike other live injected vaccines, Zostavax can be administered at any time before or after blood/blood products.

Antiviral medications should be stopped for 24 hours prior to vaccination and for 14 days after vaccination to prevent interference with replication of the live-attenuated vaccine virus.

If Zostavax is not given at the same visit as another live vaccine a 4 week interval between the two live virus vaccines should be observed. However, there are no live viral vaccines indicated for this age group in New Zealand at this time.

Vaccine safety

Zostavax has an excellent safety record since it was introduced in the U.S. in 2006. The vaccine is generally well tolerated. The most common vaccine side effects occur around the injection site, including redness, swelling and/or pain, and headache. Occasionally itching or a rash around the injection site may occur.

Data from ten years of post-marketing adverse events reports submitted to the Merck Sharpe and Dohme global safety database found that more than 9 out of 10 reports were non-serious and local injection site reactions were the most common. Herpes zoster (HZ) cases occurring within two weeks of vaccination were caused by wild-type, not vaccine-type virus. Disseminated HZ was very rare (18 cases reported, <0.1%), and all the cases found to be due to the vaccine-type virus were in immunocompromised patients.

Administration of Zostavax vaccine should be postponed in individuals suffering from a fever over 38°C. The presence of a minor infection is not a reason to delay immunisation.

Zostavax should not be given to:

  • Individuals with current leukaemia, lymphoma, or other bone/marrow/lymphatic neoplasms.
  • Individuals with acquired immune deficiency syndrome (AIDS) or other medical condition causing cellular immunodeficiency.
  • Individuals with tuberculosis (TB).
  • Anyone with severe allergy (anaphylaxis) to a previous dose of herpes zoster virus vaccine or a component of the vaccine.

Specialist advice should be sought for the following groups:

  • Individuals taking immunosuppressive medication or who are recovering from immunosuppressive treatment.
  • Individuals who are HIV-positive.

If there is any doubt about the safety of administering a live attenuated zoster vaccine – DEFER VACCINATION until you obtain more information.

Vaccine effectiveness

In clinical trials, the zoster vaccine is most effective at preventing shingles in people aged 50–59 years (around 7 in 10 immunised protected) and becomes less effective with advancing age. Around 5 in 10 people aged 65–69 years and around 4 in 10 people aged 80 years or older. The real-life effectiveness of Zostavax, particularly against severe disease and post herpetic neuralgia (PHN), appears to be better than was shown during clinical trials and especially for those aged 70–79 years. Protection for those aged 80 years when they were vaccinated aged 80 years or older has also been shown to be similar to vaccine effectiveness in those aged 60–69 years when vaccinated.

Three years after introducing a zoster immunisation programme in the UK for adults aged 70–79 years, the vaccine effectiveness was calculated to be 64% against shingles and 61–91% against PHN in the targeted age group who did not have a history of shingles. Vaccine effectiveness in preventing an episode of shingles decreased to 47% in the 70–79 years age group who had a history of shingles.

In adults who get shingles even though they have been immunised, Zostavax may reduce the pain associated with shingles, the effect of shingles pain on daily activities and the risk of post-herpetic neuralgia. 

Duration of protection

Vaccine effectiveness against an episode of shingles was shown to decrease quickly over the first year after vaccination from around 69% to 50%, and then decreases gradually until effectiveness decreases from around 33% to 17% by the seventh year after vaccination and then decreases to around 4% during the eighth year after vaccination. Although the duration of protection against getting shingles declines, vaccine effectiveness against the severe outcomes of shingles, such as PHN and herpes zoster-associated hospitalisation, remained around at least 50% regardless of age and chronic illness.

    Last updated: Jul 2020