This is the current release of the guideline.

Routine Vaccination of Persons Aged >60 Years

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of all persons aged >60 years with 1 dose of zoster vaccine. Persons who report a previous episode of zoster and persons with chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, and chronic pulmonary disease) can be vaccinated unless those conditions are contraindications or precautions. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing postherpetic neuralgia (PHN), or to treat ongoing PHN. Before routine administration of zoster vaccine, it is not necessary to ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity.

Simultaneous Administration with Other Adult Vaccines

Immunogenicity of zoster vaccine and trivalent inactivated influenza vaccine is not compromised when the two vaccines are administered simultaneously. However, no data exist on administration of zoster vaccine with other vaccines routinely recommended for persons aged >60 years, which are all inactivated. In general, the simultaneous administration of most widely used live, attenuated and inactivated vaccines has not resulted in impaired immune response or an increased rate of adverse events. Therefore, zoster vaccine can be administered with other indicated vaccines during the same visit (e.g., tetanus and reduced diphtheria toxoids [Td], tetanus, reduced diphtheria, and acellular pertussis [Tdap], and pneumococcal polysaccharide vaccines). Each vaccine must be administered using a separate syringe at a different anatomic site. If simultaneous administration is not possible, zoster vaccine can be administered at any time before or after an inactivated vaccine, but at least 4 weeks before or after another live, attenuated vaccine.

Groups for Which Vaccine is Not Licensed

Vaccination of Persons Aged <60 Years

The vaccine is not licensed for persons aged <60 years, and no recommendation exists for routine vaccination of persons aged <60 years. In the clinical trial, the zoster vaccine was evaluated among persons aged >60 years. The vaccine was most effective and well tolerated in the youngest persons (see Table 1 in the original guideline document). Although the vaccine would probably be safe and effective in persons aged <60 years, data are insufficient to recommend vaccination of these persons at this time.

Vaccination of Persons Who Have Received Varicella Vaccine

Zoster vaccination is not recommended for persons of any age who have received varicella vaccine. However, health-care providers do not need to inquire about varicella vaccination history before administering zoster vaccine because virtually all persons currently or soon to be in the recommended age group have not received varicella vaccine. In the United States, varicella vaccination began in 1995. Since that time, few adults aged >40 years would have been susceptible to varicella and thus eligible to receive varicella vaccine. The number of persons eligible for zoster vaccination who have received varicella vaccine is extremely small and will remain so for at least a decade.

Special Groups and Circumstances

Persons with a Reported History of Zoster

Persons with a reported history of zoster can be vaccinated. Repeated zoster has been confirmed in immunocompetent persons soon after a previous episode. Although the precise risk for and severity of zoster as a function of time following an earlier episode are unknown, some studies suggest it may be comparable to the risk in persons without a history of zoster. Furthermore, no laboratory evaluations exist to test for the previous occurrence of zoster, and any reported diagnosis or history might be erroneous. Although the safety and efficacy of zoster vaccine have not been assessed in persons with a history of zoster, different safety concerns are not expected in this group.

Persons Anticipating Immunosuppression

The risk for zoster and its severe morbidity and mortality is much greater among persons who are immunosuppressed. Review of vaccination status for zoster and other vaccines should be a key component of the medical assessment for immunocompetent patients aged >60 years who might be anticipating initiation of immunosuppressive treatments or who have diseases that might lead to immunodeficiency. Such patients without a history of zoster vaccination should receive 1 dose of zoster vaccine at the first possible clinical encounter while their immunity is intact. Zoster vaccine should be administered at least 14 days before initiation of immunosuppressive therapy, although some experts advise waiting 1 month after zoster vaccination to begin immunosuppressive therapy if delay is possible.

Persons Receiving Antiviral Medications

Licensed antiviral medications active against members of the herpesvirus family include acyclovir, famciclovir, and valacyclovir. These agents might interfere with replication of the live, varicella zoster virus (VZV)-based zoster vaccine. All three agents have relatively short serum half-lives and are quickly cleared from the body. Persons taking chronic acyclovir, famciclovir, or valacyclovir should discontinue these medications at least 24 hours before administration of zoster vaccine, if possible. These medications should not be used for at least 14 days after vaccination, by which time the immunologic effect should be established.

Persons Receiving Blood Products

Zoster vaccine can be administered to persons at any time before, concurrent with, or after receiving blood or other antibody-containing blood product because persons with a history of varicella indefinitely maintain high levels of antibody to VZV, and the levels are comparable to those found in donated blood and antibody-containing blood products (e.g., whole blood, packed red blood cells, and plasma immune globulin, hyperimmune globulin, and intravenous immune globulin).

Nursing Mothers

Most live vaccines, including varicella vaccine, are not secreted in breast milk. Therefore, breast feeding is not a contraindication for zoster vaccination. However, this situation will be extremely rare in the target age group for this vaccine.

Contraindications

Allergy to Vaccine Components

Zoster vaccine is contraindicated for persons who have a history of anaphylactic reaction to any component of the vaccine, including gelatin and neomycin. Neomycin allergy is usually manifested as a contact dermatitis, which represents a delayed-type immune response. A history of contact dermatitis to neomycin is not a contraindication for receiving zoster vaccine.

Immunocompromised Persons

Zoster vaccine should not be administered to persons with primary or acquired immunodeficiency including:

• Persons with leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic system. However, patients whose leukemia is in remission and who have not received chemotherapy (e.g., alkylating drugs or antimetabolites) or radiation for at least 3 months can receive zoster vaccine.
• Persons with acquired immune deficiency syndrome (AIDS) or other clinical manifestations of human immunodeficiency virus (HIV), including persons with CD4+ T-lymphocyte values <200 per mm³ or <15% of total lymphocytes.
• Persons on immunosuppressive therapy, including high-dose corticosteroids (>20 mg/day of prednisone or equivalent) lasting two or more weeks. Zoster vaccination should be deferred for at least 1 month after discontinuation of such therapy. Short-term corticosteroid therapy (<14 days); low-to-moderate dose (<20 mg/day of prednisone or equivalent); topical (e.g., nasal, skin, inhaled); intra-articular, bursal, or tendon injections; or long-term alternate-day treatment with low to moderate doses of short-acting systemic corticosteroids are not considered to be sufficiently immunosuppressive to cause concerns for vaccine safety. Persons receiving this dose or schedule can receive zoster vaccine. Therapy with low-doses of methotrexate (<0.4 mg/Kg/week), azathioprine (<3.0 mg/Kg/day), or 6 mercaptopurine (<1.5 mg/Kg/day) for treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease, and other conditions are also not considered sufficiently immunosuppressive to create vaccine safety concerns and are not contraindications for administration of zoster vaccine.
• Persons with clinical or laboratory evidence of other unspecified cellular immunodeficiency. However, persons with impaired humoral immunity (e.g., hypogammaglobulinemia or dysgammaglobulinemia) can receive zoster vaccine.
• Persons undergoing hematopoietic stem cell transplantation (HSCT). The experience of HSCT recipients with VZV-containing vaccines (e.g., zoster vaccine) is limited. Physicians should assess the immune status of the recipient on a case-by-case basis to determine the relevant risks. If a decision is made to vaccinate with zoster vaccine, the vaccine should be administered at least 24 months after transplantation.
• Persons receiving recombinant human immune mediators and immune modulators, especially the antitumor necrosis factor agents adalimumab, infliximab, and etanercept. The safety and efficacy of zoster vaccine administered concurrently with these agents is unknown. If it is not possible to administer zoster vaccine to patients before initiation of therapy, physicians should assess the immune status of the recipient on a case-by-case basis to determine the relevant risks and benefits. Otherwise, vaccination with zoster vaccine should be deferred for at least 1 month after discontinuation of such therapy.

Pregnancy

Zoster vaccine is not recommended for use in pregnant women, although these women are unlikely to be in the vaccine target age group. The effects of the live, attenuated VZV-based zoster vaccine on the fetus are unknown. Women should avoid becoming pregnant for 4 weeks following zoster vaccination. Having a pregnant household member is not a contraindication to zoster vaccination. If a pregnant woman is vaccinated or becomes pregnant within 1 month of vaccination, she should be counseled about potential effects on the fetus. Wild-type VZV poses a small risk to the fetus, and the fetal risk from the attenuated zoster vaccine is probably even lower. Furthermore, virtually all persons receiving the vaccine will have preexisting VZV immunity, which is expected to limit viral replication and presumably further reduce fetal risk. In most circumstances, the decision to terminate a pregnancy should not be based on whether zoster vaccine was administered during pregnancy. Merck & Co., Inc., in collaboration with Centers for Disease Control and Prevention (CDC), has established a pregnancy registry to monitor the maternal-fetal outcomes of pregnant women who are inadvertently administered live-attenuated VZV-based vaccines within 1 month of pregnancy (telephone: 800-986-8999). Patients and health-care providers should report any exposure to zoster vaccine during pregnancy to this registry.

Precautions

Moderate to Severe Illness

Zoster vaccination of persons who have severe acute illness should be postponed until recovery. The decision to delay vaccination depends on the severity of symptoms and the etiology of the disease. Zoster vaccine can be administered to persons who have mild acute illnesses with or without fever.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Not applicable: The guideline was not adapted from another source.

2008 Jun 6

Centers for Disease Control and Prevention - Federal Government Agency [U.S.]

United States Government

Advisory Committee on Immunization Practices Shingles Work Group

Advisory Committee on Immunization Practices

Advisory Committee on Immunization Practices Shingles Work Group

Chair: John Treanor, MD, Rochester, New York

Members: William L. Atkinson, MD, MPH, Atlanta, Georgia; Jeffrey I. Cohen, MD, Bethesda, Maryland; Robert H. Dworkin, PhD, Rochester, New York; Sandra Gambescia, Atlanta, Georgia; Paul M. Gargiullo, PhD, Atlanta, Georgia; Anne A. Gershon, MD, New York, New York; John W. Glasser, PhD, MPH, Atlanta, Georgia; Dalya Güris, MD, MPH, Atlanta, Georgia; Penina Haber, MPH, Atlanta, Georgia; Rafael Harpaz, MD, MPH, Atlanta, Georgia; Beth F. Hibbs, MPH, Atlanta, Georgia; John K. Iskander, MD, MPH, Atlanta, Georgia; Samuel L. Katz, MD, Durham, North Carolina; Philip R. Krause, MD, Bethesda Maryland; Phillip S. LaRussa, MD, New York, New York; Myron J. Levin, MD, Denver, Colorado; Tracy A. Lieu, MD, MPH, Boston, Massachusetts; Mona E. Marin, MD, MPH, Atlanta, Georgia; Kathleen M. Neuzil, MD, MPH, Seattle Washington; Kristin Nichol, MD, MPH, MBA, Minneapolis, Minnesota; Ismael R. Ortega-Sánchez, PhD, Atlanta, Georgia; Gregory A. Poland, MD, Rochester, Minnesota; Sara Rosenbaum, JD, Washington, DC; Tammy A. Santibanez, PhD; William Schaffner, MD, Nashville, Tennessee; Kenneth E. Schmader, MD, Durham, North Carolina; D. Scott Schmid, PhD, Atlanta, Georgia; Jane Seward, MBBS, MPH, Atlanta, Georgia; Heather Stafford, Philadelphia, Pennsylvania; Ray Strikas, MD, Washington, DC; Gregory S. Wallace, MD, Atlanta, Georgia; Barbara Watson, MB ChB, Philadelphia, Pennsylvania

Advisory Committee on Immunization Practices Membership List, June 2007

Chairman: Jon S. Abramson, MD, Wake Forest University School of Medicine, Winston-Salem, North Carolina

Executive Secretary: Larry K. Pickering, MD, CDC, Atlanta, Georgia

Members: Ban Mishu Allos, MD, Vanderbilt University School of Medicine, Nashville, Tennessee; Carol Baker, MD, Baylor College of Medicine, Houston, Texas; Robert L. Beck, JD, Palmyra, Virginia; Janet R. Gilsdorf, MD, University of Michigan, Ann Arbor, Michigan; Harry Hull, MD, Minnesota Department of Health, Minneapolis, Minnesota; Susan Lett, MD, MPH, Massachusetts Department of Public Health, Jamaica Plain, Massachusetts; Tracy Lieu, MD, MPH, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts; Dale L. Morse, MD, New York State Department of Health, Albany, New York; Julia Morita, MD, Chicago Department of Public Health, Chicago, Illinois; Kathleen Neuzil, MD, MPH, University of Washington, Seattle, Washington; Patricia Stinchfield, Children's Hospitals and Clinics, St. Paul, Minnesota; Ciro Valent Sumaya, MD, MPH, Texas A&M University System Health Science Center, College Station, Texas; John J. Treanor, MD, University of Rochester, Rochester, New York; and Robin J. Womeodu, MD, University of Tennessee Health Science Center, Memphis, Memphis, Tennessee

Ex-Officio Members: James Cheek, MD, Indian Health Service, Albuquerque, New Mexico; Wayne Hachey, DO, Department of Defense, Falls Church, Virginia; Geoffrey S. Evans, MD, Health Resources and Services Administration, Rockville, Maryland; Bruce Gellin, MD, National Vaccine Program Office, Washington, DC; Linda Murphy, Centers for Medicare and Medicaid Services, Baltimore, Maryland; George T. Curlin, MD, National Institutes of Health, Bethesda, Maryland; Norman Baylor, PhD, U.S. Food and Drug Administration, Rockville, Maryland; and Kristin Lee Nichol, MD, Department of Veterans Affairs, Minneapolis, Minnesota

Liaison Representatives: American Academy of Family Physicians, Jonathan Temte, MD, Madison, Wisconsin, and Doug Campos-Outcalt, MD, Phoenix, Arizona; American Academy of Pediatrics, Keith Powell, MD, Akron, Ohio, and Carol Baker, MD, Houston, Texas; America's Health Insurance Plans, Andrea Gelzer, MD, Hartford, Connecticut; American College Health Association, James C. Turner, MD, Charlottesville, Virginia; American College of Obstetricians and Gynecologists, Stanley Gall, MD, Louisville, Kentucky; American College of Physicians, Kathleen M. Neuzil, MD, Seattle, Washington; American Medical Association, Litjen Tan, PhD, Chicago, Illinois; American Pharmacists Association, Stephan L. Foster, PharmD, Memphis, Tennessee; Association of Teachers of Preventive Medicine, W. Paul McKinney, MD, Louisville, Kentucky; Biotechnology Industry Organization, Clement Lewin, PhD, Cambridge, Massachusetts; Canadian National Advisory Committee on Immunization, Monica Naus, MD, Vancouver, British Columbia; Healthcare Infection Control Practices Advisory Committee, Steve Gordon, MD, Cleveland, Ohio; Infectious Diseases Society of America, Samuel L. Katz, MD, Durham, North Carolina; London Department of Health, David Salisbury, MD, London, United Kingdom; National Association of County and City Health Officials, Nancy Bennett, MD, Rochester, New York, and Jeffrey S. Duchin, MD, Seattle, Washington; National Coalition for Adult Immunization, David A. Neumann, PhD, Alexandria, Virginia; National Foundation for Infectious Diseases, William Schaffner, MD, Nashville, Tennessee; National Immunization Council and Child Health Program, Romeo S. Rodriquez, Mexico City, Mexico; National Medical Association, Patricia Whitley-Williams, MD, New Brunswick, New Jersey; National Vaccine Advisory Committee, Gary Freed, MD, Swiftwater, Pennsylvania, and Peter Paradiso, PhD, Collegeville, Pennsylvania; Society for Adolescent Medicine, Amy B. Middleman, MD, Houston, Texas; Pharmaceutical Research and Manufacturers of America, Damian A. Araga, Swiftwater, Pennsylvania

Centers for Disease Control and Prevention (CDC), its planners, and its content experts wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on June 16, 2008.

No copyright restrictions apply.