Shingles Vaccination: Why Wait?

July 14, 2017
Terry Brenneman, MD
Terry Brenneman, MD

ACIP recommends the zoster vaccine be given at age 60 years. That could be too late for some. And, what about this 60-year-old?

[[{"type":"media","view_mode":"media_crop","fid":"61686","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_5685088631707","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"7801","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 311px; width: 435px; float: right;","title":" ","typeof":"foaf:Image"}}]]Current ACIP (CDC) recommendations are to vaccinate against herpes zoster in individuals aged ≥ 60 years. The FDA has approved the vaccine for use in individuals aged ≥ 50 years. One can get shingles at any age, even in childhood. So, why wait until age 60 to offer vaccination?  

Unfortunately, the current vaccine, Zostervax, only provides protection for about 5 years. Since the risk of post herpetic neuralgia (PHN) increases with age, the ACIP decided it best to wait until age 60 before giving the vaccine. The CDC did offer some suggestions as to why a provider might elect to administer Zostervax to someone younger than age 60.

 ♦ Occupation is one consideration. A 55-year-old physician working with immunocompromised children and planning to retire at age 60 might elect to get vaccinated at age 55 to avoid missing work if he should he develop shingles.

 ♦ Someone who might not tolerate PHN well due to another condition (severe depression, another chronic pain syndrome) could also be considered a candidate for earlier vaccination.  

 ♦ Limited life expectancy is another reason a person might benefit from vaccination before age 60. Work is being done on a new vaccine that is expected to work much longer than 5 years.

Try these 2 questions about zoster vaccination raised by a 60-year-old patient in your office.

The otherwise healthy 60-year-old is in for his annual physical and happens to have a nasty cold. He had a moderate case of shingles 3 months earlier and has recovered fully. He asks if he can get vaccinated today because he had heard that one can get shingles more than once.

1. You tell him:A. He is very unlikely to ever get shingles again, so doesn’t need the vaccine.

B. Yes, he can get the vaccine but it is recommended that he wait 6-12 months after his bout with shingles.

C. Yes, he can get the vaccine but should wait until he is feeling well to avoid possible interference with his immune response to the live vaccine since he is presumably producing interferon now.                                                                        

D. Yes, he can get the vaccine today.

Please click here for answer, discussion, and next question>

The best answer is: B. Yes, he can be vaccinated today, but it is recommended that he wait 6-12 months after his bout with shingles.

The ACIP does not have an official recommendation on this, but some experts recommend deferring vaccination for at least 6 months following a case of shingles out of concern that the reactivation of the varicella zoster virus will result in antibody production that might interfere with the vaccine efficacy. Live vaccines need to replicate in the body to mount an immune response and too much specific antibody can interfere with this. Mild illnesses are not a reason to delay any vaccine.  

The patient next mentions to you that his 4-year-old grandson just got vaccinated against varicella (Varivax). He asks you what the difference is between the varicella vaccine and the zoster vaccine.

2. You tell him:

A. They are exactly the same but with different names since Merck had to submit a new indication and do new trials to prove efficacy in shingles prevention..mmune response in the older population. 

B. Zostervax has an adjuvant added to the Varivax component to boost the immune response in the older population.

C. Zostervax has twice the amount of attenuated varicella virus as Varivax has.

D. Zostervax has 14 times the amount of attenuated varicella virus as Varivax has.

Please click here for answer and discussion.

The correct answer is D. Zostervax has 14 times the amount of attenuated varicella virus as Varivax has.

Sanofi makes a flu vaccine for persons over age 65 that has 4 times the antigen of a standard flu vaccine to boost the response of the aging immune system.

Getting old is not for the faint of heart.  
 

CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink Book. Varicella.

Harpaz R, Hales CM, Bialek SR. Update on herpes zoster vaccine: licensure for persons aged 50 through 59 years. MMWR Morbidty and Mortality Weekly Report. 2011;60:1528. 

Immunization Action Coalition. Ask the Experts: Diseases & Vaccines. Zoster (Shingles)