Shingles Guide

Shingles Vaccination Information

Shingles (Herpes Zoster) occurs most commonly in older age groups, and can cause severe pain. It is a reactivation of the virus which causes chickenpox (varicella-zoster virus VZV). After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles.

The Shingles – A Guide for Health Professionals provides useful information about clinical features of the disease, as well as information on transmission, complications, and vaccination recommendations.

As a health professional you play an active role in protecting thousands of older Australians who are at a higher risk of shingles and its complications as well as providing treatment during a zoster infection.

Cause of Shingles

Reactivation of the virus which causes chickenpox (varicella-zoster virus VZV) in a person who has previously had varicella (chickenpox).

After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles. ^[1][2]

Features of Shingles

Generally, shingles presents as an acute, self-limiting vesicular rash which is often painful and lasts around 10–15 days.

The rash is usually unilateral, most commonly affecting the lumbar or thoracic dermatomes. The virus works down the nerves that branch out from the spinal cord.

In 80% of cases, early phase occurs 2–3 days before the rash.^[3] Early symptoms may be severe pain (e.g. ‘burning’, ‘stabbing’), itching and numbness around the affected areas. This may be accompanied by headache, photophobia and malaise.

Shingles Complications

Severe pain (where the rash was) known as post-herpetic neuralgia (PHN):

• Persistent chronic neuropathic pain which persists for more than 90 days from the onset of the rash.
• Can interfere with carrying out everyday activities and can be difficult to treat.
• Increased risk of PHN with age: affects around 30% of people with shingles over 80 years of age.^[4]

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, encephalitis or death.

Transmission of Shingles

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 chickenpox or who has not had the chickenpox vaccine. In such cases, the person exposed to the virus may develop chickenpox but not shingles.^[6]

The virus is spread by direct contact with the fluid contained in the blisters, which can transfer to sheets and clothing.

Until the blisters scab over, the person is infectious. Counsel patients to avoid contact with people who have a weakened immune system, newborns and pregnant women while contagious.

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

Who is at Risk

In a national serosurvey conducted in 2007, more than 95% of the adult population in Australia had antibodies to VZV by the age 30, indicating that they had been previously infected with the virus.^[7] Therefore almost the entire adult population is at risk of shingles.

Overall, 20–30% of people will develop shingles in their lifetime, most after the age of 50 years. People who are immunocompromised are also at risk.^[8]

Increasing trend

A study published in 2015 looking at general practice data from October 2006 to March 2013, estimated an incidence of herpes zoster in the Australian population of 5.6 per 1,000 persons compared to 4.7 per 1,000 persons based on data recorded from April 2000 to September 2006. As seen for the earlier period, the updated analysis demonstrated that zoster incidence increased with age, from 1.8 per 1,000 persons aged 0–24 years, to 19.9 per 1,000 for those aged 80 years and over.^[9] The factors underpinning the increase of herpes zoster burden remain unclear.

Prevention & Vaccination

Preventing herpes zoster is the best way to avoid post-herpetic neuralgia and other complications.

Vaccination

There are two vaccines available for people aged 50 years and older, to prevent herpes zoster:

1. Zostavax (Merck): is a live-attenuated varicella zoster virus vaccine given subcutaneously as a single dose.
2. Shingrix (GlaxoSmithKline): is an adjuvant recombinant varicella zoster virus glycoprotein E (gE) subunit (non-live) vaccine given intramuscularly in two divided doses 2-6 months apart.^[10]

Which vaccine should be used?

Shingrix is preferred over Zostavax for people aged 50 years and over, for the prevention of herpes zoster and its complications due to its higher efficacy. Shingrix is now available in Australia under private prescription only. The manufacturer has not submitted it for supply on the NIP at this stage.

Zostavax remains an alternative to Shingrix for people who are immunocompetent. It is available on the NIP for all people at 70 years of age.

People who are immunocompromised

Zostavax (as with other live vaccines) is generally contraindicated in people who are immunocompromised. Shingrix is recommended in this population.

Zoster Vaccine Efficacy

Shingrix demonstrated a high efficacy against herpes zoster of about 97% in adults 50 years and older and about 91% in those aged 70 years and older.

In clinical trials, Zostavax efficacy was lower and decreased with increasing age (70% in people aged 50-59 years, 64% in those aged 60-69 years, 41% in 70-79 years, and 18% in 80-89 years (no longer statistically significant in this age group).

Who should be vaccinated with the zoster vaccine?

• Zoster vaccines are registered for use in people aged 50 years and over. They are recommended for adults aged 60 years and over. Zostavax is recommended for people who are not immunocompromised.^[1]
• Household contacts (50 years of age and older) of a person who is, or who is expected to become immunocompromised.^[1]
• Persons with chronic conditions, such as splenectomy, diabetes, rheumatoid arthritis, inflammatory bowel disease, dermatologic conditions (e.g. psoriasis), cardio-respiratory disease or renal disease (e.g. glomerulo-nephritis or reduced renal function), since they may have a higher risk of morbidity and mortality due to shingles.^[2] Zostavax is not generally recommended for people who are immunocompromised.

The Shingles Prevention Study (SPS) was conducted among 38,546 adults aged ≥ 60 years and showed that compared to placebo, vaccination with Zostavax reduced:

• Herpes zoster (HZ) by 51.3%
• Post herpetic neuralgia by 66.5%]
• Burden of illness associated with HZ by 61.1% over a median of more than three years follow-up.^[12]

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 71–79 years of age until 31 October 2023. People in this age group have a high likelihood of developing shingles and will develop PHN after shingles in 25% of the cases.

Vaccination with Zostavax 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.

Who should not receive the live zoster vaccine?

1. Pregnant women
2. Previous anaphylaxis to the vaccine (either Zostavax or varicella vaccine) or its components.^[7]
3. People who are severely immunocompromised:

• 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, radiotherapy
  • High-dose corticosteroids >= 20mg prednisolone per day, or equivalent for 14 days
  • All biologics and most disease- modifying anti-rheumatic drugs DMARDs.

Before vaccinating people with Zostavax

Obtain medical history prior to vaccination with Zostavax, check contraindications of Zostavax in immunocompromised individuals.

In persons who are or have recently been immunocompromised, the safety of administering Zostavax 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.

UPDATE: Denosumab has been removed from the list of immunosuppressive medications contraindicated with Zostavax as there is currently not enough evidence to suggest it is a contraindication to Zostavax. ^[2][8]

Who should not receive Shingrix?

1. Previous anaphylaxis to the vaccine.

Shingrix and Pregnancy

There is currently no data on the use of Shingrix in pregnant women (Category B2).

Treatment

Antiviral treatment (famciclovir, valaciclovir or aciclovir#) 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. These antiviral treatments are all considered safe with limited side effects (nausea, headache).

#There is evidence that famciclovir and valaciclovir are more effective than aciclovir in reducing acute pain and may be associated with greater patient compliance due to their more convenient dosing.

Vaccine safety

Shingrix causes moderately high rates of local and systemic infections. Common reactions include: injection-site pain (up to 79%), redness (up to 39%), and swelling (up to 26%) and systemic symptoms such as fatigue and myalgia (up to 46%), headache (up to 39%), shivering (up to 28%), fever (up to 22%), and gastrointestinal symptoms (up to 18%).

Zostavax contains live attenuated varicella-zoster virus. It is safe and well tolerated. Some people may experience a headache, fatigue or soreness around the site where the shot was given. The reaction is typically mild and resolves within a few days.

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

Both Shingrix and Zostavax can be given with most inactivated or live vaccines (including any of the available pneumococcal vaccines) using separate injections and injection sites.

Co-administration of COVID-19 vaccines and zoster vaccines has not been evaluated. ATAGI generally recommends a minimum 7-day interval between COVID-19 vaccines and other vaccines.

Zostavax

If Zostavax is not given on the same day as other live viral vaccines (e.g. MMR, yellow fever) separate administration by 4 weeks.^[7]

Shingrix

It is acceptable to co-administer Shingrix and Fluad Quad on the same day if necessary. However, given the lack of co-administration data for these two adjuvanted vaccines, it is preferred to separate their administration by a few days, and ensure that any adverse events following immunisation with the first vaccine have resolved before administration of the other vaccine.^[2]