About this disease

Herpes zoster commonly known as shingles is caused by the same virus (varicella-zoster virus) responsible for chicken pox. After you have developed chickenpox, the virus lays dormant (inactive) in the body and can become reactivated later in life to cause shingles.

Shingles occurs mostly in people over 50 years of age. In most cases, it presents as a painful rash of small blisters which usually appears on one side of the face or body.

 

Symptoms

In 80% of cases, there is an early phase which occurs 2 to 3 days before the rash occurs.1 These early symptoms may be severe pain, itching and numbness around the affected areas. The pain may be similar to the pain experienced from kidney stones, blocked blood vessels or inflammation of the gall bladder. This may be accompanied by headache, sensitivity to bright light or a general feeling of being unwell.

A blistery rash may follow which is often painful and lasts approximately 10-15 days.

Shingles can affect any part of the body but the rash typically appears as a band of blisters that wraps around the left or right side of the trunk of the body.

 

  • 1. Dworkin RH,Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clinical Infectious Diseases 2007; 44 Suppl 1: S1-26

How it is spread

Shingles cannot be passed from one person to another. However, a person with shingles can pass the varicella zoster virus to a person who has never had chicken pox or who has not had the chickenpox vaccine. In such cases, the person exposed to the virus may develop chickenpox but not shingles.2,3

The virus is spread by direct contact with the fluid contained in the blisters. Until the blisters scab over, the person is infectious. Avoid contact with people who have a weakened immune system, newborns and pregnant women while you are contagious.

In a national serosurvey conducted in 2007, more than 95% of the adult population in Australia had antibodies to Varicella-zoster virus by age 30, indicating that they had been previously infected with the virus.4 Therefore almost the entire adult population is a risk of shingles.

Shingles is less contagious than chickenpox and the risk of a person with shingles spreading the virus is low if the rash is covered.

  • 2. Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/shingles/about/overview.html

    3. Zoster vaccine for Australian adults/NCIRS Fact sheet: October 2016

    4. Ward K, Dey A, Hull B, et al. Evaluation of Australia’s varicella vaccination program for children and adolescents. Vaccine 2013; 31:1413-9.

     

Complications

The most common complication is severe pain where the shingles rash was. The pain can interfere with you going about your everyday activities. This complication is known as post-herpetic neuralgia (PHN) which is defined as persistent chronic neuropathic pain (nerve pain) which persists for more than 90 days from the onset of the rash. PHN may be difficult to treat. As people get older, they are more likely to develop long term pain as a complication of shingles and the pain is likely to be more severe. In fact, PHN, affects 30% of people with shingles over 80 years of age.

Shingles may also lead to serious complications involving the eye called herpes zoster ophthalmicus (in about 10-20% of shingles patients.5  Very rarely, shingles can lead to pneumonia, hearing problems, blindness, brain inflammation (encephalitis), or death.

  • 5. Cunningham AL, Breuer J, Dwyer DE, et al. The prevention and management of herpes zoster, Medical Journal of Australia 2008; 188:171-6

Prevention

Preventing herpes zoster is the best way to avoid post-herpetic neuralgia and other complications. The zoster vaccine (Zostavax) for use in Australia is a live attenuated (weakened) vaccine, for use in people aged 50 years and older. It is free for all adults aged 70 years through the National Immunisation Program (NIP). A single catch up dose will be funded under the NIP for adults between 71-79 years of age until October 2021. People in this age group have a high likelihood of developing shingles and PHN. The vaccine efficacy against PHN in this age group is 66%.6

Vaccination of other age groups (e.g. those aged 50-69 or 80 years and over) is available on prescription and can be purchased by patients.

The vaccine generally causes no serious side effects. Some people may experience a headache, fatigue or soreness around the site where the shot was given for a few days.

Another vaccine, Shingrix is registered in Australia since December 2018. However, due to high demand worldwide, it is not yet available in Australia. It is an adjuvanted recombinant vaccine which required 2 doses to be administered intramuscularly 2 to 6 months apart. Shingrix demonstrated a high efficacy against herpes zoster of about 97% in adults 50 years and older and importantly a high efficacy against herpes zoster of about 91% in those aged 70 years and older.7 To note the vaccine has high reactogenicity with local injection site reactions and general symptoms such fatigue, headache and myalgia.

Vaccine Safety

Clinical trials have shown the currently available shingles vaccine registered in Australia (Zostavax) is safe and well tolerated among immunocompetent individuals aged 50 years and over. Around 50% of recipients will experience mild reaction such as headache, fatigue and pain at the injection site which will resolve within a few days.

  • 6. Zoster vaccine: Frequently asked questions/ NCIRS Fact sheet: August 2017

    7. Recombinant Varicella Zoster Virus (VZV) glycoprotein E (gE) antigen, TGA, Australian Public Assissment Report, December 2018

Treatment

Antiviral treatment may help to reduce pain and shorten the duration of shingles. The treatment is best taken within 72 hours of the onset of the rash but may still be helpful if taken after this time.

Info for Clinicians

  • Although 2 vaccines are registered in Australia – Zostavax, Merck Sharp & Dohme-Seqirus and Shingrix, GlaxoSmithKline, only Zostavax is currently available.

    It is unclear when Shingrix will be available.

     

    Zostavax is a live attenuated vaccine developed from the same strain as the chicken pox (varicella zoster virus) vaccine but it is around fourteen times stronger.8 Whereas Shingrix is a non-live vaccine consisting of the recombinant varicella zoster virus glycoprotein E antigen and the new AS01B  adjuvant system.

    The registered varicella vaccines are not indicated for preventing Herpes Zoster in older people and Zostavax is not indicated for use in younger people who have not been previously immunised or infected with the varicella zoster virus.

    Zostavax is not indicated during an acute shingles episode nor for the treatment of PHN (post-herpetic neuralgia).

    Protection from vaccination declines with age and time since last vaccination however a booster is not recommended at this stage.9

  • The Shingles Prevention Study (SPS), a single, large, randomised, double-blind placebo controlled trial was conducted among 38 546 adults aged ≥ 60 years. SPS showed that Zostavax reduced:

    • Herpes Zoster by 51.3%

    • PHN by 66.5% and the

    • Burden of illness by 61.1% over a median of more than 3 years follow up.10

  • Zostavax: A single 0.65ml dose is required to be given by subcutaneous injection only.

    (Shingrix will require 2 doses of 0.50mL to be given by intramuscular injection 2 to 6 months apart)

    Zoster vaccines are only registered for use in adults ≥ 50 years of age.

  • Vaccines are registered for use in people aged 50 years and over.

    The live zoster vaccine is recommended for:

      • Adults aged 60 years and over who are not immunocompromised
      • Household contacts (≥50 years of age) of a person who is, or who is expected to become immunocompromised
      • Persons with chronic conditions, such as splenectomy, diabetes, rheumatoid arthritis, inflammatory bowel disease, dermatologic conditions (e.g. psoriasis), cardiorespiratory disease or renal disease (e.g. glomerulonephritis or reduced renal function), if they are not immunocompromised since they may have a higher risk of morbidity and mortality due to shingles.11

    Zostavax is FREE for all adults aged 70 years through the National Immunisation Program (NIP).
    A single catch up dose will be funded under the NIP for adults between 71-79 years of age until October 2021.

    Vaccination of other age groups (e.g. those aged 50-69 or 80 years and over) is available on prescription and can be purchased by patients.

  • Immunisation is most cost effective in this age group because:

    • The likelihood of people developing shingles and PHN is considerably higher than in younger people

    • Although vaccine efficacy is lower against shingles compared to younger people, the efficacy against PHN is 67%

    From SPS, vaccine efficacy in people aged over 80 years was lower and not statistically significant however the number of participants aged over 80 years was low.

  • 1. People who are severely immunocompromised through:

    • Primary or acquired immunodeficiency:
      -Haematologic neoplasms: leukaemias, lymphomas myelodysplastic syndromes
      -Post-transplant: solid organ (on immunosuppressive therapy), haematopoietic stem cell transplant (within 24 months)
      -Immunocompromised due to primary or acquired (HIV/AIDS) immunodeficiency
      -Other significantly immunocompromising conditions
    • Immunosuppressive therapy (current or recent)
      -Chemotherapy or radiotherapy
      -High-dose corticosteroids (≥20 mg of prednisone per day, or equivalent) for ≥14 days
      -All biologics and most disease-modifying anti-rheumatic drugs (DMARDs). Patients taking low doses of specific DMARDs can be safely vaccinated. Refer to the Australian Immunisation Handbook for more details

    2. Pregnant women

    3. Previous anaphylaxis to the vaccine (either Zostavax or varicella vaccine) or its components

  • Obtain medical history prior to vaccination with zoster vaccine, check contraindications of zoster vaccine in immunocompromised individuals

    In persons who are or have recently been immunocompromised, the safety of administering zoster vaccine should always be considered on a case-by-case basis. If there is uncertainty around the level of immunocompromise and when vaccine administration may be safe, vaccination should be withheld and expert advice sought from the treating physician and/or an immunisation specialist.

  • Can I give zoster vaccine on the same day as other vaccines?

    Yes, all inactivated or live vaccines (including any of the available pneumococcal vaccines) may be co-administered with zoster vaccine (using separate syringes and injection sites). If zoster vaccine is not given on the same day as other live viral vaccines (e.g. MMR, yellow fever) separate administration by 4 weeks.  (refer to the Australian Immunisation Handbook).

  • If a rash has been present for less than 72 hours, antiviral treatment may reduce acute pain, duration of the rash, viral shedding and ophthalmic complications. Whether antiviral therapy reduces the incidence of post-herpetic neuralgia is contentious.

    Antiviral treatment is indicated for immunocompetent patients who present within 72 hours of the onset of the rash, and for all immunocompromised patients regardless of the duration of the rash.

    Use famciclovir or valaciclovir or aciclovir.

    There is evidence that famciclovir and valaciclovir are more effective than aciclovir in reducing pain in patients with herpes zoster.12

  • 8. Australian Technical Advisory Group on Immunisation (ATAGI). The Australian Immunisation Handbook 10th ed (2017 update). Canberra: Australian Government Department of Health, 2017

    9. Zoster vaccine for Australian adults/NCIRS Fact sheet: August 2017

    10. Oxman MN, Levin MJ, Johnson GR, et al, A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. New England Journal of Medicine 2005;352:2271-84

    11. Zoster vaccine: Frequently asked questions/NCIRS Fact sheet: April 2018

    12. Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014

Page published:  8 March 2017

Last updated:      2 October 2019

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