An update for 2017-18 Vaccine Preventable Disease Programme (VPDP) Shingles An update for 2017-18 Vaccine Preventable Disease Programme (VPDP) Background The Joint Committee on Vaccination and Immunisation reviewed all the available medical, epidemiological and economic evidence as well as vaccine safety and efficacy relevant to offering a universal vaccination programme for shingles. As part of the review, age-specific incidence of shingles and associated disease burden were taken into account. Disease burden was measured in terms of those that developed secondary complications as a result of shingles infection, those that required hospitalisation and those that eventually resulted in or contributed to an individual’s death. The JCVI concluded that the incidence of shingles is closely associated with older age groups, with the severity and disease burden increasing as the individual gets older. As a result, the JCVI recommended a universal herpes zoster (shingles) vaccination programme for adults aged 70 to 79 years (up to the 80th Birthday) to commence in September 2013, for the prevention of shingles infection and shingles related post herpetic neuralgia. Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/g roups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_133599.pdf VPDP shingles information page may be found at: http://nww.immunisation.wales.nhs.uk/shingles-vaccination-programme The The WHC (2015) 019 Changes to the Shingles vaccination programme outline details round eligibility

What is shingles? Shingles is a viral infection of the nerve cells and surrounding skin. The virus that causes shingles (Varicella Zoster Virus) also causes chickenpox After a person recovers from chickenpox infection, the virus stays dormant in the nerve cells and can reactivate at a later stage, often decades later Shingles can develop at any time, and is most likely in older age groups It is estimated that around 50,000 cases of shingles occur each year in people aged 70 and over (England and Wales) Around 10-20% of cases of shingles result in ophthalmic shingles Around 4% of cases result in long tern sequelae (including pain) The severity of shingles increases with age 1 in 1,000 cases of shingles are estimated to result in death It is estimated that around 50,000 cases of shingles occur in people aged 70 and over annually (England and Wales) This data is referring to data from GP based studies (The Green Book chapter 28a) Reactivation of the varicella zoster virus (VZV) can be associated with older age, immunosuppressant therapy or HIV infection Infection with varicella zoster (chickenpox) is a pre-requisite for the development of shingles Increasing incidence of shingles infection amongst older age groups is thought to be associated with a decline in cell mediated immunity to varicella zoster virus shingles cannot be transmitted from one person to another, although it can cause chickenpox in individuals who have not previously had the disease and who have direct contact with the fluid from the shingles vesicles   Although uncommon, it is possible to have shingles more than once Shingles is not caused by the same virus that causes genital herpes Opstelten W, Mauritz JW, de Wit NJ et al. (2002) Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract 19(5): 471-5. Bowsher D (1999) The lifetime occurrence of Herpes zoster and prevalence of post-herpetic neuralgia: A retrospective survey in an elderly population. Eur J Pain 3(4):335-42. The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf VPDP shingles information page may be found at: http://nww.immunisation.wales.nhs.uk/shingles-vaccination-programme Shingles – an update for 2017-18

Shingles in older people Shingles is most common in older people The severity of shingles and its complications increases with age An estimated 50 shingles cases result in death annually (mostly in people aged 70 or over) Shingles – an update for 2017-18

From The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf From The Green Book chapter 28a Shingles – an update for 2017-18

Clinical presentation of shingles Initial stage abnormal skin sensations headache, feeling generally unwell, photophobia, and less commonly high temperature 2. Acute stage rash: will begin usually within the distribution of a dermatome may be painful, itch or tingle initially develops into fluid filled blisters after a few days commonly occurs either on one side of the face or body 3. Followed by... the blisters scab over in 7-10 days and clear within 2-4 weeks often continues to cause pain, itching or tingling in the area of the affected nerve Shingles can affect any part of the body, although most commonly affected areas include face (including eyes) chest and abdomen. Individuals may also experience pain in the arms and legs and may feel exhausted. A dermatome can be defined as an area of skin that is supplied by a single nerve. Shingles can affect one or more isolated dermatomes. In individuals with weakened immune systems, a more disseminated rash covering multiple dermatomes may occur and this may appear similar to the chickenpox rash Shingles – an update for 2017-18

A dermatome is an area of skin that is mainly supplied by a single nerve Shingles – an update for 2017-18

Possible complications of shingles Complications are more likely in adults over 50 years of age, with severity of illness increasing with age The most common complications are Post herpetic neuralgia (PHN) Secondary bacterial skin infections Other less common complications include Peripheral motor neuropathy/paresis Facial palsy Ophthalmic Zoster Peripheral motor neuropathy Shingles can lead to hospitalisation and death Shingles can cause a number of secondary complications and the severity of these can be dependent on how weak the individual’s immune system is. Most commonly reported complications in the older age groups include secondary bacterial infections at the site of the rash (that may require antibiotic therapy) and post herpetic neuralgia. Other less common complications can include ophthalmic shingles and peripheral motor neuropathy. Ophthalmic shingles affects the facial nerve (trigeminal) and can cause ulceration, conjunctivitis, retinitis, optic neuritis, and/or glaucoma. Estimates show between 10-20% of shingles cases result in ophthalmic zoster with approximately 4% of these cases resulting in long term sequelae. Peripheral motor neuropathy is more common in the elderly population and results in temporary nerve damage (peripheral motor nerve) that controls movement (peripheral motor nerve) of limbs such as the arm or leg, causing paralysis in the associated limb. This affect is temporary and individuals can make a good recovery. Opstelten W, Mauritz JW, de Wit NJ et al. (2002) Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract 19(5): 471-5. Bowsher D (1999) The lifetime occurrence of Herpes zoster and prevalence of post-herpetic neuralgia: A retrospective survey in an elderly population. Eur J Pain 3(4):335-42. The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf   Shingles – an update for 2017-18

Post herpetic neuralgia (PHN) Pain that persists/appears more than 90 days after the onset of the shingles rash May be a constant burning, itching, stabbing or aching pain which is extremely sensitive to touch Specifically focused in the area affected by shingles More likely to develop and be more severe in people over the age of 50, with one third of suffers over the age of 80 experiencing intense pain In 50% of those affected it can persist for 3 to 6 months, (sometimes longer) Not routinely relieved by common pain killers PHN can last longer than 90 days, for some people its lasts months, or even years. As the pain can be intense and is not generally relieved by common pain killers, PHN can have a negative impact on the individuals quality of life. PHN can contribute to fatigue, insomnia, depression, anxiety and can impair the basic activities of daily living for the individual . Oxman MN, Levin MJ, Johnson GR et al. (2005) A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 352(22): 2271-84. Schamder, K.E. (2002) Epidemiology and impact on quality of life of post herpetic neuralgia and painful diabetic neuropathy. Journal of Clinical Pain. Nov-Dec;18(6):350-4. Shingles – an update for 2017-18

The incidence of PHN increases with age The epidemiology of the disease shows that individuals over 70 years of age are not only at an increased risk of developing the disease, but they also suffer a more severe form of the illness resulting in complications such as PHN and an increase in hospital admissions. The burden of disease is closely related to age with those in the older age groups experiencing severe forms of the illness. The severity of the disease burden is markedly increased in those individuals aged 75-85+ years. Individuals aged 85 years and over account for 4.4% of hospital admissions after the first diagnosis and 8.1% of hospital admissions within the first three diagnoses. They account for 52% of individuals developing PHN after 90 days and as a result of the disease, require a minimum of 22 days in hospital. This highlights the severity and impact of the disease in this age group and outlines the importance of offering vaccination to older individuals.   van Hoek AJ, Gay N, Melegaro A et al. (2009) Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine 27(9): 1454-67.Cited in Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013. Table from The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf From The Green Book chapter 28a Shingles – an update for 2017-18

English: www.publichealthwales.org/shingles Welsh:  www.iechydcyhoedduscymru.org/yr-eryr This is a short personal story; Why shingles vaccine is important to help protect older people from shingles and the pain it can cause Available online at English: www.publichealthwales.org/shingles Welsh:  www.iechydcyhoedduscymru.org/yr-eryr Or order from hplibrary@wales.nhs.uk

Infectious period of shingles Shingles cannot be transmitted from one person to another A person who has not had chickenpox previously may develop chickenpox as a result of exposure to the shingles virus through direct contact with the fluid filled blisters A person with shingles is only infectious (i.e. can cause chickenpox in a susceptible contact) when the fluid filled blister rash is present Shingles is less infectious than chickenpox and covering the rash will greatly reduce the risk of exposure to those non-immune to chickenpox A person is NOT infectious before the rash appears A person is NOT infectious when the rash has crusted over Shingles – an update for 2017-18

The shingles vaccine and the UK immunisation programme Zostavax® is the only licensed shingles vaccine in the UK It is centrally supplied to general practices for use in the programme Since September 2013 shingles vaccine has been offered to individuals aged 70 Catch up elements of the phased programme also offers vaccination to anyone who has reached 70 since the programme began and also 77, 78 and 79 year olds Once an individual reaches 80 they are no longer eligible as part of the programme 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 with a catch up for individuals up to 79 years. The vaccine can be given to individuals until the 80th birthday as part of the routine schedule Details of eligible cohorts can be found in Welsh Government WHC (2017)17 Changes to the Shingles Vaccination Programme http://nww2.nphs.wales.nhs.uk:8080/VaccinationsImmunisationProgsDocs.nsf/3dc04669c9e1eaa880257062003b246b/c6bf676d2e5fef2d802580fb004bae39/$FILE/Welsh%20Health%20Circular%20(2017)%2017%20-%20Changes%20to%20the%20Shingles%20Vaccination%20Programme_English_pdf.pdf Image is of the draft shingles leaflet 2017 (final one is currently awaited). The leaflet will be available from http://www.nhsdirect.wales.nhs.uk/pdfs/shingEng.pdf © Leah Millinship Vaccination against shingles – an update for 2017-18

Birth date range Cohort Cohort definition From To Routine Must have reached 70 years of age since the programme started in 2013 02/09/1942 01/09/1947 Catch up Must have reached 77, 78 or 79 years of age since the programme started in 2013 but must also be under 80 years of age on the day of vaccination 02/09/1937 01/09/1940 The vaccine may be given to individuals in these cohorts from April 2017 in Wales as part of the national vaccination programme WHC (2015) 019 Changes to the Shingles vaccination programme http://nww2.nphs.wales.nhs.uk:8080/VaccinationsImmunisationProgsDocs.nsf/3dc04669c9e1eaa880257062003b246b/c6bf676d2e5fef2d802580fb004bae39/$FILE/Welsh%20Health%20Circular%20(2017)%2017%20-%20Changes%20to%20the%20Shingles%20Vaccination%20Programme_English_pdf.pdf Another way to think about helping identify those eligible is as set out in the previous slide: Routine cohort: Anyone who is 70 on 1st September of the vaccination year is eligible up until their 80th birthday (so this is all those aged 70/71/72/73/74 on 1st September 2017) Catch up element of campaign: offers immunisation to those reaching 77/78/79 on 1st September 2017 but not yet 80 An age eligibility online tool is available at NHS Direst Wales and is currently being updated http://www.nhsdirect.wales.nhs.uk/encyclopaedia/s/article/shingles The WHC (2015) 019 Changes to the Shingles vaccination programme states WHC (2017)17 Changes to the Shingles Vaccination Programme Published 7 April 2017 Birth cohorts for shingles vaccine as part of routine immunisation programme from April 2017

Insert name of presentation on Master Slide This shingles vaccine age eligibility online tool is available at NHS Direst Wales and is currently being updated http://www.nhsdirect.wales.nhs.uk/encyclopaedia/s/article/shingles Insert name of presentation on Master Slide

For those outside the eligible cohorts age range Zostavax® is licensed for use from the age of 50 A prescriber may make a judgment following individual clinical assessment that vaccination against shingles is indicated and beneficial for an individual patient, then it may be prescribed This is outside arrangements for the national programme There may be local HB advice on prescribing guidance and restrictions Shingles – an update for 2017-18

Shingles vaccine - Zostavax® A live attenuated vaccine that contains a high antigen content of varicella zoster virus (VZV) (i.e. a weakened live virus) Licensed for use in persons age 50 years or older The course consists of a single dose It is important to familiarise yourself with the vaccine and the Summary of Product Characteristics (SPC) to avoid administration errors https://www.medicines.org.uk/emc/ Recommended by JCVI for adults aged 70 (with a catch up programme up to 79 years). This is supported by Welsh Government for those aged 70-79 years of age, and being implemented in a phased roll out Marketed by Sanofi Pasteur MSD Zostavax® is recommended for the prevention of shingles infection and shingles related PHN only. Zostavax® should not be used for the treatment of PHN. Zostavax® contains a significantly higher antigen level of varicella zoster virus (VZV) than the routine varicella (chickenpox) vaccine and is not recommended for the prevention of chickenpox infection The vaccine may be administered to individuals outside the routine cohorts if considered clinically appropriate by the prescribing clinician. Whilst the vaccine is authorised for use from the age of 50 years and is effective in this age group, the burden of shingles disease is generally not as severe in the 50-69 age group when compared with older adults. Given that duration of protection is unknown, offering vaccination routinely below the age of 70 years of age may not confer protection during the period when the burden of disease is highest. Healthcare professionals are reminded that in some circumstances the recommendations regarding vaccines given in the Green Book chapters may differ from those in the Summary of Product Characteristics (SPC) for a particular vaccine. When this occurs, the recommendations in the Green Book are based on current expert advice received from the JCVI and this advice should be followed. The Green Book recommendations and/or further advice from the Department of Health should be reflected in PGDs. SPC may be accessed at https://www.medicines.org.uk/emc/ The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf Shingles – an update for 2017-18

Contraindications*. When the vaccine should not be given: History of hypersensitivity to any part of the vaccine (e.g. Neomycin) Primary and acquired immunodeficiency states due to conditions such as: acute and chronic leukaemias; lymphoma*; other conditions affecting the bone marrow or lymphatic system; immunosuppression due to HIV/AIDS; cellular immune deficiencies. Immunosuppressive therapy; Non biological immune modulating drugs eg methotrexate >25mg per week, azathioprine >3mg/kg/day or 6-mercaptopurine >1.5mg/kg/day Had biological therapies (eg anti-TNF) in the last 12 months Active untreated tuberculosis. Pregnancy Zostavax® is contraindicated in individuals receiving high dose corticosteroids (The Green Book, chapters 6 and 28a). People receiving 40mg prednisolone a day for more than one week should not receive the vaccine until at least 3 months after cessation of therapy. A longer delay of up to 6 months may be appropriate for the age cohorts included in the national vaccination programme. Individuals on low doses of corticosteroids should be considered for the vaccine and this should be discussed with their clinical specialist. Zostavax® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or low-dose systemic corticosteroids or in patients who are receiving corticosteroids as replacement therapy, e.g. for adrenal insufficiency. There is the potential for antiviral medicines to lower the effectiveness of Zostavax®, so the vaccine should not be administered to patients currently receiving oral or IV antiviral agents, or within 48 hours after cessation of treatment. Antiviral agents should also not be commenced within 2 weeks after receiving Zostavax®, however topical antiviral agents are not a contraindication. Eligible individuals who have not received Zostavax® and are due to receive immunosuppressive therapy should receive the vaccine at least 14 days before starting immunosuppressive treatment, although a month would be preferable. Zostavax® is not indicated in women of childbearing age. Women who are pregnant should not receive Zostavax® and pregnancy should be avoided for three months following the last dose. It is not known whether VZV is secreted in human milk. Caution should be exercised in administration to a breast-feeding woman. Please refer to The Green Book shingles chapter (28a) and SPC for more detailed information on contraindications and precautions. The Green Book chapter 3 https://www.gov.uk/government/publications/storage-distribution-and-disposal-of-vaccines-the-green-book-chapter-3 SPC available at https://www.medicines.org.uk/emc/ The Green Book chapter 6 https://www.gov.uk/government/publications/contraindications-and-special-considerations-the-green-book-chapter-6 The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf *SPC contains more detail around precautions and contraindications https://www.medicines.org.uk/emc/

When to delay the vaccine*: Acute illness- defer immunisation until recovered Individuals with shingles or PHN should wait until symptoms have ceased before being considered for the immunisation On high dose steroids (delay for at least three months) On long term lower dose corticosteroids (delay for at least three months) Had immunosuppressive chemotherapy or radiotherapy (delay until 6 months after the end of treatment and they are in remission) Antiviral medicines can potentially lower the effectiveness of Zostavax® (delay by at least 48 hours after cessation of treatment) *SPC contains more detail around precautions and contraindications https://www.medicines.org.uk/emc/

When Zostavax® is NOT contraindicated* In those receiving topical/inhaled corticosteroids, low-dose systemic corticosteroids or receiving corticosteroids as replacement therapy e.g. for adrenal insufficiency On low-doses of methotrexate (<25mg per week), azathioprine (<3.0 mg/Kg/day), or mercaptopurine (<1.5 mg/Kg/day) for treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease* Using topical acyclovir Please refer to The Green Book shingles chapter (28a) and SPC for more detailed information on contraindications and precautions *In these individuals, the degree of immunosuppression should be assessed on a case by case basis. Specialists with responsibility for patients in the vaccine eligible age cohorts should include a statement of their opinion on the patient’s suitability for Zostavax® in their correspondence with primary care. Asplenia/splenectomy is not of itself a contraindication, though the underlying cause may be (such as leukaemia or lymphoma infiltration). Humoral deficiencies affecting IgG or IgA antibodies are not of themselves a contraindication unless associated with T cell deficiencies. There are more details around specific conditions and the shingles vaccine in https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/503099/PHE_Shingles_advice_for_health_professionals_2015-16__February2016_V4.pdf If there is any doubt (e.g. common variable immune deficiency), immunological advice should be sought. SPC available at https://www.medicines.org.uk/emc/ The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf Specialist advice should be sought for other treatment regimes *SPC contains more detail around precautions and contraindications https://www.medicines.org.uk/emc/

Precautions* Immunosuppressed patients (including those infected with HIV) who require protection against shingles should seek advice from a specialist In clinical trials of Zostavax® transmission of the vaccine virus has not been reported. There is however a theoretical risk. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact*. Immunisation of individuals who are acutely unwell should be postponed until they have recovered fully. This is to avoid confusing the diagnosis of any acute illness by wrongly attributing any sign or symptoms to the adverse effects of the vaccine. Zostavax® is not recommended for the treatment of shingles or post herpetic neuralgia (PHN) Post-marketing experience with varicella vaccines suggests that transmission of vaccine virus may occur rarely between those vaccinated who develop a varicella-like rash and susceptible contacts. Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported (Zostavax® SPC) The Green Book chapter 28a contains more detailed information on special considerations for individuals on immunosuppressive therapy. *As a precautionary measure, any person who develops a vesicular rash after receiving Zostavax® should ensure the rash area is kept covered when in contact with a susceptible (chickenpox naïve) person until the rash is dry and crusted. If an immunosuppressed person inadvertently receives vaccine, they should avoid contact with susceptible people until the rash is dry and crusted, due to the higher risk of virus shedding. Regarding potential for transmission, the US CDC / ACIP don’t recommend any precautions: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm?s_cid=rr5705a1_e http://www.cdc.gov/vaccines/pubs/acip-list-sup/acip-sup-zoster.htm Chief Pharmaceutical Officer and Chief Medical Officer letter Zostavax and biological therapies offers more advice on vaccinating this group of patients The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf Chief Pharmaceutical Officer and CMO letter Zostavax and biological therapies http://nww.immunisation.wales.nhs.uk/shingles-vaccination-programme#Updates SPC available at https://www.medicines.org.uk/emc/ *SPC contains more detail around precautions and contraindications https://www.medicines.org.uk/emc/

Zostavax® appearance and reconstitution* The pack contains: A single dose vial containing a white/off white compact, crystalline powder plug A pre-filled syringe of clear, colourless liquid solvent When mixed together, Zostavax® should appear as a semi-hazy to translucent, off white/pale yellow liquid To reconstitute the vaccine, inject all of the solvent in the pre-filled syringe into the vial, gently agitate to mix thoroughly and then withdraw the entire contents into the syringe (0.65ml) Separate needles should be used for reconstitution and administration The needle should be pushed into the extremity of the syringe and rotated a quarter of a turn (90o) to secure the connection The vaccine should then be administered immediately If you notice any particulate matter or if the appearance of the solvent or the reconstituted vaccine differs from that described do not use the reconstituted vaccine Discard reconstituted vaccine if it is not used within 30 minutes View SPC at https://www.medicines.org.uk/emc/ *See the SPC for more detail at https://www.medicines.org.uk/emc/

Administration of Zostavax® May be given by intramuscular (IM) or subcutaneous (SC) injection into the upper arm (deltoid region) The preferred route is IM Zostavax® is licensed to be administered subcutaneously or intramuscularly. IM is preferred in view of increased local injection site adverse reactions if given SC Images are from The Green Book Immunisation procedures chapter 4 at https://www.gov.uk/government/publications/immunisation-procedures-the-green-book-chapter-4 Shingles – an update for 2017-18

Giving Zostavax® at the same time as other vaccines Zostavax® may be administered concomitantly with other vaccines including 23-valent pneumococcal polysaccharide (PPV), influenza and live vaccines Zostavax® should ideally be given at the same time as other live vaccines. A four week interval is recommended between MMR and Zostavax® Zostavax® can be given at the same time as PPV for those who are eligible for both vaccines. General Practice are encouraged to offer the shingles vaccination to those eligible when they are called for the annual influenza vaccine. However, scheduling of the appointment should not delay administration of the vaccines and the shingles vaccine can be administered outside of the influenza vaccine season where the two vaccines have not been given together. Given that individuals eligible for seasonal influenza vaccination may also be eligible for shingles vaccine the vaccines may be offered at the same time, it is important to check that the recipient has no contraindications to administering a live vaccine. Ideally, live vaccines should be administered at the same time as each other. If this is not possible, a four week interval is recommended between the two. Note: The Green Book chapter 28a- Shingles states: ‘Given the lack of data it would be appropriate to leave a four week interval between administration of yellow fever vaccine and Zostavax®’  This is pending review, advice on vaccine intervals should be based on  the Revised recommendations for the administration of more than one live vaccine produced by Public Health England in  February 2016 which state that Zostavax® and yellow fever vaccine can be given at the same time or at any time before or after each other. [correct at 20/04/2017] If more than one vaccine is administered the vaccines should be given at a separate site, preferably in a different limb. If more than one vaccine is given in the same limb, they should be given at least 2.5cm apart. The sites at which each vaccine was given should be noted in the individual’s health records. Shingles – an update for 2017-18

Administration of Zostavax® and other live vaccines Vaccine combinations Recommendations Varicella (and zoster) vaccine and MMR If these vaccines are not administered on the same day then a four week minimum interval period should be observed between vaccines Varicella (and zoster) vaccine and other live vaccines Apart from the above combination, Zostavax® may be administered at any time before or after each other In the case of co-administration with MMR vaccine these two vaccines [Zostavax® and MMR] should be given either on the same day or at least four weeks apart. Source: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/503099/PHE_Shingles_advice_for_health_professionals_2015-16__February2016_V4.pdf Source: Revised recommendations for administering more than one live vaccine Public Health England. Shingles – an update for 2017-18

Possible adverse reactions to Zostavax®* Most commonly reported side effects are at the injection site and can include redness, pain, swelling and pruritis Less common injection site reactions include haematoma, induration and warmth Other common side effects include headache, and pain in arm or leg Less common side effects include nausea, joint/muscle pain, fever swollen glands, shingles, rash. Chicken pox is a very rare side effect If a rash occurs around the injection site it should be covered with a dry dressing - As a precautionary measure, any person who develops a vesicular rash after receiving Zostavax® should ensure the rash area is kept covered when in contact with a susceptible (chickenpox naïve) person until the rash is dry and crusted. If the person who received the vaccine is themselves immunosuppressed, they should avoid contact with susceptible people until the rash is dry and crusted, due to the higher risk of virus shedding. *SPC contains more detail about potential adverse reactions at https://www.medicines.org.uk/emc/

Vaccine efficacy and length of protection Zostavax® reduces the incidence of shingles by around 51% in the over 60s, and 38% in the over 70s For those vaccinated but who later developed shingles, the vaccine reduced the incidence of PHN by 66% The need for a second dose is currently unknown It is likely the vaccine confers protection for at least 5 years A one dose schedule of Zostavax® was assessed in clinical trials using 38,547 adults aged 60 and over, and 17,775 adults of whom were 70 and over The efficacy of the vaccine in this age group is estimated to be 38% and boosted immunity for at least 5-7 years but it may not fully prevent the development of shingles infection. However, vaccinating adults aged 70 years and over can help to significantly reduce the severity of the illness (by 55%) and associated PHN by 66.8% Currently, the vaccine manufacturers do not know whether a second dose is required or what the timing of a second dose should be. Current recommendations are based on a one dose schedule of the vaccine with no plans for a second/booster dose. The vaccine is expected to provide protection against shingles for a minimum period of 5 years and at this time, a one dose schedule of the vaccine is recommended with no requirement for a second/booster vaccine. The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/357155/Green_Book_Chapter_28a_v0_5.pdf Oxman MN and Levin MJ (2008) Vaccination against Herpes Zoster and Postherpetic Neuralgia. J Infect Dis 197 Suppl 2 S228-36. van Hoek AJ, Gay N, Melegaro A et al. (2009) Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales. Vaccine 27(9): 1454-67.Cited in Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013. Shingles – an update for 2017-18

Resources Shingles – an update for 2017-18 Welsh Health Circular WHC (2017)17. Changes to the Shingles immunisation programme [link] Green Book, chapter 28a [link] Public Health Wales Vaccine Preventable Disease Programme NHS Wales Shingles intranet pages [link] (NHS Wales intranet only) Public Health Wales Vaccine Preventable Disease Programme NHS Wales Shingles vaccination programme (2017-18) intranet pages [link] (NHS Wales intranet only) Vaccination against shingles:2015/16 Information for healthcare professionals 2015/16 (Published February 2016 Public Health England) [link] Frequently Asked Questions: Varicella (chickenpox and shingles) (Public Health Wales) [link] (NHS Wales intranet only) Health of Wales Information Service (HOWIS) Immunisation and vaccine clinical forum [link] (NHS Wales intranet only) NHS Direct Wales Shingles information and eligibility checker [link] Shingles Support Society [link] Shingles Aware (Sanofi Pasteur MSD) [link] References and key papers are given in the notes pages throughout this presentation, they include: Bowsher D (1999) The lifetime occurrence of Herpes zoster and prevalence of post-herpetic neuralgia: A retrospective survey in an elderly population. Eur J Pain 3(4):335-42. Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013. http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@ab/documents/digitalasset/dh_133599.pdf [accessed 03 July 2013] Opstelten W, Mauritz JW, de Wit NJ et al. (2002) Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract 19(5): 471-5. Oxman MN, Levin MJ, Johnson GR et al. (2005) A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 352(22): 2271- 84. Oxman MN and Levin MJ (2008) Vaccination against Herpes Zoster and Postherpetic Neuralgia. J Infect Dis 197 Suppl 2 S228-36. Public Health England Revised recommendations for the administration of more than one live vaccine https://www.gov.uk/government/uploads/system/uploads/attachment_data/f ile/422798/PHE_recommendations_for_administering_more_than_one_live_ vaccine_April_2015FINAL_.pdf van Hoek AJ, Gay N, Melegaro A et al. (2009) Estimating the cost- effectiveness of vaccination against herpes zoster in England and Wales. Vaccine 27(9): 1454-67.Cited in Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013. Welsh Government WHC (2015) 19 Changes to the Shingles Vaccination Programme http://gov.wales/docs/dhss/publications/150501whc019en.pdf The Green Book chapter 28a https://www.gov.uk/government/uploads/system/uploads/attachment_data/f ile/357155/Green_Book_Chapter_28a_v0_5.pdf SPC at https://www.medicines.org.uk/emc/ The Green Book chapter 4: https://www.gov.uk/government/uploads/system/uploads/attachment_data/f ile/147915/Green-Book-Chapter-4.pdf The Green Book chapter 5: https://www.gov.uk/government/publications/immunisation-by-nurses-and- other-health-professionals-the-green-book-chapter-5 The Green Book chapter 35: https://www.gov.uk/government/publications/yellow-fever-the-green-book- chapter-35   Shingles – an update for 2017-18

Acknowledgment This resource was prepared by the Vaccine Preventable Disease Programme, Public Health Wales as a national training template to support the shingles vaccination programme. Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to Public Health Wales NHS Trust to be stated. © 2017 Public Health Wales NHS Trust. VPDP shingles information page may be found at: http://nww.immunisation.wales.nhs.uk/shingles-vaccination-programme http://nww.immunisation.wales.nhs.uk/shingles-vaccination-programme