g logo nhs blue

Summary of shingles (herpes zoster) immunisation policy

Recommendations for the use of the vaccines

  • The aim of the national shingles immunisation programme is to lower the incidence and severity of shingles in older people. It is recommended that it be routinely offered to people aged 70 years
  • A catch-up programme is also being rolled out in those aged 70–79 years, based on evidence of cost effectiveness and as this age group is likely to have the greatest benefit from vaccination. The reasons for this include:
    • the burden of shingles disease within this age group (which increases with age)
    • the estimated effectiveness of the vaccine within this age group (which decreases with age)
    • the duration of protection of the vaccine
    • the lack of knowledge about the effectiveness of a second dose of vaccine
  • The course consists of a single dose of Zostavax®
  • As Zostavax® can be administered concomitantly with inactivated influenza vaccine, the appointment for administration of the seasonal influenza vaccine is an appropriate opportunity to also provide Zostavax®, although any opportunity to provide the vaccine should be used
  • Whilst the vaccine is authorised for use from age 50 years and is effective in this age group, the burden of shingles disease is generally not as severe in those aged 50–69 years when compared with older ages. Furthermore, given that the duration of protection is not known to last for more than 10 years and the need for a second dose is not known, the vaccine is not recommended to be offered routinely below 70 years of age. Administration after 80 years of age is less cost-effective due to the limited effectiveness of the vaccine in older individuals
  • Zostavax is not indicated for prevention of primary varicella zoster virus (VZV) infection (chickenpox) and should not be used in children and adolescents

The shingles vaccination

  • Zostavax® is the only market-authorised shingles vaccine available in the UK. It contains live, attenuated virus derived from the Oka/Merck strain of the VZV, at a significantly higher dose than the Varivax® varicella vaccine

Storage

  • The unreconstituted vaccine and its diluent should be stored in the original packaging at +2°C to +8°C and protected from light

Presentation

  • Zostavax® is available as a lyophilised preparation (an off-white compact crystalline plug) for reconstitution with a diluent (a clear colourless fluid)
  • After reconstitution of the lyophilised suspension, the vaccine should be used immediately, but may be used up to 30 minutes following reconstitution

Dosage and schedule

  • Adults should receive a single 0.65 ml dose of Zostavax®

Administration

  • Zostavax® may be administered by intramuscular or subcutaneous injection, preferably in the deltoid region of the upper arm. Intramuscular injection is the preferred route of administration
  • For individuals with a bleeding disorder, Zostavax® should be given by deep subcutaneous injection to reduce the risk of bleeding
  • The vaccine must not be given intravascularly
  • Zostavax® can be given at the same time as inactivated influenza vaccination. If given at the same time as influenza vaccination, care should be taken to ensure that the appropriate route of injection is used for all the vaccinations
  • Whether administered at the same time as other vaccines or separately, as the eligible population are likely to have a high prevalence of co-morbidity, it is important to check that the recipient has no contraindications to administering a live vaccine
  • Zostavax® can be given at the same time as 23-valent pneumococcal polysaccharide vaccine for those who are eligible for both vaccines
  • The vaccines should be given at separate sites, preferably in different limbs. If given in the same limb, they should be given at least 2.5 cm apart. The site at which each vaccine was given should be noted in the individual's records
  • Based on evidence that MMR vaccine can lead to an attenuation of the varicella vaccine response, it is recommended that a 4-week interval is observed between administration of MMR and Zostavax® vaccines to ensure adequate protection
  • Travel vaccines containing live attenuated virus, e.g. yellow fever, may be given to the age group recommended for shingles vaccination

Contraindications

  • The decision to administer Zostavax® to immunosuppressed individuals should be based on a clinical risk assessment. If the individual is under highly specialist care, and it is not possible to obtain full information on that individual's treatment history, then vaccination should not proceed until the advice of the specialist or a local immunologist has been sought
  • Specialists with responsibility for patients in the vaccine eligible cohorts should include a statement of their opinion on the patient's suitability for Zostavax® in their correspondence with primary care. If primary healthcare professionals administering the vaccine have concerns about the nature of therapies (including biologicals) or the degree of immunosuppression they should contact the relevant specialist for advice
  • The vaccine should not be given to a person who:
    • has primary or acquired immunodeficiency states
    • is on immunosuppressive or immunomodulating therapy
    • has had a confirmed anaphylactic reaction
    • is pregnant

Patients anticipating immunosuppressive therapy

  • The risk and severity of shingles is considerably higher amongst immunosuppressed individuals and therefore eligible individuals anticipating immunosuppressive therapy should ideally be assessed for vaccine eligibility before starting treatment that may contra-indicate future vaccination
  • Eligible individuals who have not received Zostavax® should receive a single dose of vaccine at the earliest opportunity and at least 14 days before starting immunosuppressive therapy, although leaving 1 month would be preferable if a delay is possible

Precautions

  • Immunisation of individuals who are acutely unwell should be postponed until they have recovered fully
  • Immunisation should be delayed in individuals who are being treated with either oral or intravenous antivirals (such as aciclovir) until 48 hours after cessation of treatment
  • Zostavax® is not recommended for the treatment of shingles or post-herpetic neuralgia (PHN). Individuals who have shingles or PHN should wait until symptoms have ceased before being considered for shingles immunisation
  • In immunocompetent individuals who develop shingles, vaccination should be delayed for 1 year. Patients who have two or more episodes of shingles in 1 year should have immunological investigation prior to vaccination. Clinicians may wish to discuss such cases with local specialist teams

Adverse reactions

  • The most commonly reported side-effects for Zostavax®, occurring in at least 1 in 10 people, were injection site reactions including erythema (redness), pain, swelling, and pruritis (itching). Other common reactions reported in at least 1 in 100 people were haematoma, induration and warmth at the injection site, pain in arm or leg, and headache. Very rarely a varicella (chickenpox) like-illness was reported (in fewer than 1 in 10,000 people)
  • A full list of side-effects can be found in the Zostavax® summary of product characteristics. (www.medicines.org.uk/emc/medicine/25927)
  • Serious suspected adverse reactions to Zostavax® should be reported to the Medical and Healthcare products Regulatory Agency (MHRA) using the Yellow Card reporting scheme (www.mhra.gov.uk/yellowcard)
View related immunisation content

full guideline available from…
www.gov.uk/government/uploads/system/uploads/attachment_data/file/503773/2905109_Green_Book_Chapter_28a_v3_0W.PDF

Public Health England. Shingles (herpes zoster): the green book, chapter 28a. (updated February 2016).