Primary prevention

Vaccination can help prevent HZ and HZ-related postherpetic neuralgia.[31][32][33]​​​ Shingrix® is a recombinant zoster vaccine that contains varicella-zoster virus (VZV) glycoprotein E and the AS01B adjuvant system. Zostavax® is a lyophilized or freeze-dried preparation of the Oka/Merck strain of live, attenuated VZV. ​

Zostavax® was the first vaccine approved for use in adults ages ≥50 years for the prevention of HZ and HZ-related postherpetic neuralgia.[34][35][36]​​[37] 

In 2017 Shingrix® was approved by the Food and Drug Administration (FDA), also for adults ages ≥50 years. Following the FDA approval, the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommend using Shingrix® in place of Zostavax® for preventing HZ and postherpetic neuralgia in people ages ≥50 years.[38] This represents a lowering of the recommended vaccination age from ≥60 years. The ACIP also recommended that all patients previously vaccinated with Zostavax® receive Shingrix® at least 2 months after their initial vaccination. Shingrix® requires 2 intramuscular doses to be administered 2 to 6 months apart, and has a substantially higher efficacy than Zostavax®, reducing HZ cases by 97%.[39][40][41]​ An analysis combining two large phase 3 trials of Shingrix® demonstrated that its efficacy against HZ-related complications was similar in adults aged ≥50 years and ≥70 years, and most of the reduction in HZ-related complications was driven by the reduction of HZ cases.[42] More importantly, the efficacy of Shingrix® declines only slightly after 7 years, remaining at >84%.[43] However, efficacy data for the 2-dose series up to 10 years of follow-up are still under investigation. The efficacy of a single dose is also unknown, but studies suggest a single dose does not produce a robust immune response.[33][44][45]​​​​​ Therefore, physicians should try to ensure that patients receive both doses. Furthermore, it is important to complete the series within 2 to 6 months as indicated, because a series with doses 12 months apart has a lower immunogenicity.[46] There is currently no recommendation for Shingrix® in pregnancy; delaying vaccination until after pregnancy may be considered.[41] 

Shingrix® prevents more cases of HZ but also causes more injection-site reactions than Zostavax®.[47] Grade 3 systemic vaccine reactions, defined as symptoms that prevent normal everyday activities, occur in up to 17% of vaccine recipients, and are more frequent after the second dose than the first.[39] A post-licensure safety surveillance 1 year after Shingrix® was introduced in the US found that safety data were consistent with the clinical trials.[48] Shingrix® has been shown to be safe and immunogenic in patients previously vaccinated with Zostavax®.[49] In addition, it can be safely coadministered with the influenza vaccine without interference with the immune response.[50] Shingrix® has been shown to reduce the burden of illness of HZ and the severity of HZ-related pain and improve the patient's overall quality of life.[51] An analysis of Medicare claims data has found an increased risk of Guillain-Barre syndrome (GBS) among people ages ≥65 years who received Shingrix®. Compared to Zostavax® recipients, older adults vaccinated with Shingrix® had a more than twofold higher risk of GBS, equivalent to an attributable risk of 6.47 cases per million doses. However, the risk-benefit balance for Shingrix® still supports its use.[52]

It is important to note that Zostavax® is administered as a single dose subcutaneously; and Shingrix® is administered as 2 doses (2 to 6 months apart in the general population, or 1 to 2 months apart in immunodeficient or immunosuppressed patients) intramuscularly. The need to mix two vaccine components combined with different storage requirements and a different route of administration from Zostavax® leads to a higher risk of errors when administering Shingrix® which has led to the CDC issuing a reminder to physicians.[53]

Immunocompromised patients are at higher risk of HZ infection and vaccination is important.[54] One randomized clinical trial of Shingrix® in adults who had undergone autologous hematopoietic stem cell transplantation found that a 2-dose course of the vaccine significantly reduced the incidence of HZ compared with placebo over a median follow-up of 21 months, with a vaccine efficacy of 68%.[55] A post-hoc analysis of a phase 3 trial of Shingrix® in patients with hematologic malignancies showed an efficacy of 87% within 11 months of follow-up.[56] Other studies have shown that Shingrix® stimulates an immune response in kidney transplant recipients and patients with solid tumors.[57][58] In patients with HIV infection, two doses of Zostavax® were shown to be safe and immunogenic in persons with CD4 counts ≥200 cells/mm³.[59] In a phase-1/2 randomized controlled trial, Shingrix® was shown to increase humoral and cell-mediated immunity among patients with CD4 counts <200 cells/mm³ and caused no vaccine-related severe adverse events.[60] However, there are currently no phase 3 data for either Zostavax® or Shingrix® in patients with HIV. The US guideline for the prevention and treatment of opportunistic infections in adults with HIV recommends vaccination with Shingrix® for adults with HIV age ≥18 years, regardless of CD4 count.[10] The vaccine should not be given during an acute episode of HZ and some experts would delay vaccination until the patient is virologically suppressed on antiretroviral therapy or until CD4 count recovery to maximize response to vaccine.[10]

The ACIP recommends Shingrix® in immunodeficient or immunosuppressed adults ages 19 and over.[61][62] Ideally, Shingrix® should be given before the patients become immunosuppressed or, otherwise, during the period when the immune response is strong (i.e., during periods of lower immunosuppression and stable disease).[63]

In the US, Zostavax® is no longer commercially available; Shingrix® is the only vaccine available for the prevention of HZ.[63]​ In Europe, Shingrix® was granted marketing authorization for preventing HZ and post-herpetic neuralgia in persons ages ≥50 years in January 2018. In July 2020, the authorization was extended to include adults ages ≥18 years at increased risk of HZ. In the UK, from September 2023, Shingrix® will be offered to immunocompetent individuals from ages 60 years (in a phased implementation over a 10-year period starting with those turning 65 and 70 years of age) and to severely immunosuppressed individuals from ages 50 years, replacing Zostavax®.[64]​​​

Secondary prevention

Patients can transmit the virus through fluids from the lesions to people without a history of chicken pox infection; therefore, direct body contact should be avoided. Covering lesions that are not usually covered by clothing may also decrease transmission. Immunocompromised people may shed virus from lesions and from the respiratory tract.

In the US, post-exposure prophylaxis with the varicella vaccine or varicella-zoster immune globulin should be considered if an individual who is susceptible has close exposure to someone with varicella-zoster virus infection.[121] Varicella-zoster immune globulin, is recommended for patients without evidence of immunity to varicella who are at high risk for severe varicella and complications, who have been exposed to varicella or herpes zoster, and for whom varicella vaccine is contraindicated.[112]

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