Herpes Zoster Vaccination

Recommendations and Vaccine Specifics for Healthcare Professionals

Vaccination Recommendations

For the recommendations of the Advisory Committee for Immunization Practices (ACIP), see Zoster (Shingles) ACIP Vaccine Recommendations.

Routine Vaccination of People 60 Years of Age or Older

CDC recommends a single dose of herpes zoster vaccine for people 60 years of age or older, whether or not the person reported a prior episode of zoster. People with chronic medical conditions may be vaccinated unless a contraindication or precaution exists for their condition. Zoster vaccine, a live virus vaccine, can be administered concurrently with all other live and inactivated vaccines, including those routinely recommended for people 60 years of age or older, such as influenza and pneumococcal vaccines.

When administering zoster vaccine to people 60 years of age or older, there is no need to ask for a history of varicella or to conduct laboratory testing for serologic evidence of prior varicella-zoster virus infection. Almost all people 60 years of age or older who were born in the United States have had previous infection with varicella-zoster virus. Persons who report that they have not had varicella can still receive the zoster vaccine. Laboratory testing to determine if there is evidence of past infection with varicella zoster virus is not necessary. If serologic testing is conducted and there is evidence of varicella susceptibility, the patient should be offered varicella vaccine not zoster vaccine.

Persons with a reported history of zoster can be vaccinated. Repeated zoster has been confirmed in immunocompetent persons, including soon after a previous episode. Although the precise risk for and severity of zoster as a function of time following an earlier episode are unknown, some studies suggest it may be comparable to the risk in persons without a history of zoster. Furthermore, no laboratory evaluations exist to test for the previous occurrence of zoster, and any reported diagnosis or history might be erroneous. Although the safety and efficacy of zoster vaccine have not been assessed in persons with a history of zoster, different safety concerns are not expected in this group. There are no data to guide the timing of the administration of zoster vaccine after a prior episode of zoster. The general guideline for any vaccine is to wait until the acute stage of the illness is over and symptoms subside.

Vaccination of People 50 through 59 Years Old

In 2011, the Food and Drug Administration expanded the age indication for Zostavax® to include people 50 through 59 years old for preventing herpes zoster. This decision was based on a large study showing that the vaccine reduced the risk of zoster by approximately 70%. For people 50 through 59 years old, the risk of getting zoster and having prolonged pain from post-herpetic neuralgia caused by zoster is much lower than for people 60 years old and older.

The Advisory Committee on Immunization Practices (ACIP) continues to recommend zoster vaccine (Zostavax®) for people age 60 years or older. Healthcare providers considering zoster vaccine for certain people 50 through 59 years old should discuss the risks and benefits of vaccination with their patients. Although the vaccine has short-term efficacy, there have been no long-term studies of vaccine protection in this age group. In people vaccinated at 60 years old or older, vaccine efficacy wanes within the first 5 years after vaccination, and protection beyond 5 years is uncertain. Therefore, people who receive the vaccine before 60 years old might not be protected when their risks for zoster and its complications are highest.

Also, healthcare providers may want to first consider whether the patients 50 through 59 years old would have poor tolerance to zoster or post-herpetic neuralgia symptoms. For example, if the patient has

• preexisting chronic pain, severe depression, or other co-morbidities,
• intolerance to treatment medications due to hypersensitivity or interactions with other medications, or
• extenuating employment-related factors.

No data are available about the effectiveness of zoster vaccine in adults who become immunosuppressed after their vaccination.

Contraindications and Precautions for Zoster Vaccination

Zoster vaccine should not be administered to:

• A person who has ever had a life-threatening or severe allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine. Tell your doctor if you have any severe allergies.
• A person who has a weakened immune system because of:
  • HIV/AIDS or another disease that affects the immune system,
  • treatment with drugs that affect the immune system, such as steroids,
  • cancer treatment such as radiation or chemotherapy, or
  • cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma.
• Women who are or might be pregnant. Women should not become pregnant until at least 4 weeks after getting zoster vaccine.

Someone with a minor acute illness, such as a cold, may be vaccinated. But anyone with a moderate or severe acute illness should usually wait until they recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher.

This information was taken directly from the Shingles Vaccine Information Statement (VIS) dated 10/06/2009.

To learn more about vaccine contraindications and precautions, visit:

• Contraindications and Precautions for Adults Only
• Conditions Commonly Misperceived as Contraindications to Vaccination

For more information on herpes zoster and immunization, visit:

• Prevention of Herpes Zoster Recommendations of the Advisory Committee on Immunization Practices
• Pink Book's Chapter on General Recommendations on Immunization

Administration with Other Vaccines

Zoster vaccine, a live virus vaccine, can be administered concurrently with all other live and inactivated vaccines, including those routinely recommended for people 60 years of age or older, such as influenza and pneumococcal vaccines.

To avoid introducing barriers to vaccination, CDC continues to recommend that zoster vaccine and pneumococcal polysaccharide vaccine (PPSV) be administered at the same visit if the person is eligible for both vaccines.

Vaccine Administration Errors

Zoster vaccine should not be used in children and should not be used in place of varicella vaccine. Also, varicella vaccine should not be used in place of zoster vaccine. Administration of zoster vaccine to a child who was supposed to be vaccinated with varicella vaccine is a serious vaccine administration error. The event should be documented and procedures put in place to prevent this from happening again. This event should be reported to the Vaccine Adverse Event Reporting System (VAERS) by phone 800-822-7967 or through the website.

If a dose of zoster vaccine was given accidentally in place of varicella vaccine (Varivax) for a child or an adult, then that dose of zoster vaccine should be counted the same as a single valid dose of varicella vaccine. That’s because the level of protection against varicella would probably be at least the same from zoster vaccine as for the conventional dose of varicella vaccine. If the erroneous dose was administered in lieu of the first dose of varicella vaccine, a second dose of varicella vaccine is required at the normal time a second dose would be given.

In the event that varicella vaccine was accidentally administered to an adult 60 years of age or older instead of zoster vaccine, Advisory Committee on Immunization Practices states: "If a provider mistakenly administers varicella vaccine to a person for whom zoster vaccine is indicated, no specific safety concerns exist, but the dose should not be considered valid and the patient should be administered a dose of zoster vaccine during that same visit. If the error is not immediately detected, a dose of zoster vaccine should be administered as soon as possible but not within 28 days of the varicella vaccine dose to prevent potential interference of 2 doses of live attenuated virus." The event should be documented and procedures put in place to prevent this from happening again.

Vaccine Specifics

Vaccine Composition, Dosage, and Administration

Zoster vaccine, when reconstituted as directed on the package insert using the supplied diluent, contains a minimum of 19,400 PFU of Oka/Merck strain of varicella zoster virus. The minimum potency of zoster vaccine is at least 14 times the potency of varicella vaccine (Varivax®), which contains a minimum of 1,350 PFU, and is similar in potency to the varicella zoster virus content of measles-mumps-rubella-varicella vaccine (ProQuad®).

Zoster vaccine is administered subcutaneously as a single dose. The vaccine should not be injected intramuscularly. However, it is not necessary to repeat vaccination if it is administered intramuscularly.

The vaccine should be administered immediately after reconstitution to minimize loss of potency. Any unused vaccine should be discarded if not used within 30 minutes.

Vaccine Effectiveness and Duration of Protection

In a large clinical trial involving more than 38,000 people 60 years of age or older, zoster vaccine reduced the overall incidence of zoster by 51% and the incidence of post-herpetic neuralgia by 67%. The efficacy of the vaccine in preventing zoster was higher in people 60 through 69 years of age than in people older than 70 years (64% versus 38%). Zoster vaccine efficacy wanes within the first 5 years after vaccination, and protection beyond 5 years is uncertain.

Studies are ongoing to assess the duration of protection from one dose of zoster vaccine and the need, if any, for booster doses.

There are no comprehensive data on the effectiveness of zoster vaccine in treating shingles once it occurs, and the vaccine is not licensed for this use.

Also see

• Vaccine Safety and Monitoring
• Vaccine Storage and Handling
• Shingles Vaccine Information Statement (VIS)
• Package insert for Zostavax

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