1. Shingles An update for 2018-19
Vaccine Preventable Disease programme: promoting immunisation in wales
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
VPDP shingles information page may be found at:
The WHC (2015) 019 Changes to the Shingles Vaccination Programme outline details round eligibility

2. 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 term 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 post herpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract 19(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):
The Green Book chapter 28a
VPDP shingles information page may be found at:
Shingles update slides 2018/19

3. Shingles 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 rash on the neck
Image courtesy of CDC (Centre for Disease Control, US)
Shingles update slides 2018/19

4. Clinical presentation of shingles
Prodromal stage
Abnormal skin sensations, feeling generally unwell, headache, photophobia, and less commonly a high temperature
2. Acute stage
Distribution of a dermatome (area supplied by a single nerve) may be painful, itch or tingle initially, which then develops into fluid filled blisters after a few days, commonly occurs 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 update slides 2018/19

5. 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 update slides 2018/19

6. Possible complications of shingles
Shingles can lead to hospitalisation and death
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
Encephalitis is a very rare complication
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):
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):
The Green Book chapter 28a
Shingles update slides 2018/19

7. 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 post herpetic neuralgia in older adults. N Engl J Med 352(22):
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.
The Green Book chapter 28a
Shingles update slides 2018/19

8. The incidence of PHN increases with age
Green Book chapter 28a.1
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 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): 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
Shingles update slides 2018/19

9. The shingles vaccine and the UK immunisation programme
Routine programme was introduced on 1 September 2013, for 70 year olds
The aim was for the programme to role out for all those aged 70 to 79 over a number of years
A phased “catch up” was introduced and in 2013 people aged 79 years were offered vaccination
Since then more groups within the 70 to 79 year cohort have been offered the vaccine each year
Details of the disease and vaccines are available on the varicella (chickenpox and shingles) disease page:
Shingles update slides 2018/19

10. The shingles vaccine and the UK immunisation programme
There is no requirement for practices to operate active call and recall systems but it would be good practice to do so.
Template letters of invitation can be found at:
programme
Version 1 (advising the patient to contact the surgery to make an appointment) Eng/Cym
Version 2 (containing advice regarding an appointment that has been made) Eng/Cym
Shingles update slides 2018/19

11. Shingles Immunisation programme 2018-19
From April 2018 the following groups are eligible for a free shingles vaccination in Wales:
Date of birth range
Cohort
From To
Routine
02/09/1942
01/09/1948
Catch up
02/09/1938*
01/09/1941
*And under 80 on the day of
vaccination
The vaccine may be given to individuals in these cohorts from April 2018 in Wales as part of the national vaccination programme
Those who are born between 02/09/41 and 01/09/42 will become eligible in April 2019, when it is anticipated that all those between the ages of 70 and 79 will be eligible
Note - Those who are born between 02/09/41 and 01/09/42 will become eligible on 1st April 2019
Shingles update slides 2018/19

12. Shingles Immunisation programme 2018-19
Shingles vaccine eligibility -
Eligibility is defined by an individual’s age on 1st September of each year, and they may receive the vaccine from 1st April that year
Once an individual reaches their 80th birthday they are no longer eligible for a shingles vaccination as part of the national programme
Shingles update slides 2018/19

13. For those outside the eligible cohorts age range
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 Health Board advice on prescribing guidance and restrictions
Shingles update slides 2018/19

14. Shingles vaccine - Zostavax®
Recommended by JCVI for adults aged 70 (with a catch up programme up to 79 years). Supported by Welsh Government for those aged years of age, and being implemented in a phased roll out
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
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 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
The Green Book chapter 28a
Shingles update slides 2018/19

15. Study evaluated the effect of the first 3 years of the vaccination programme on incidence of herpes zoster and post herpetic neuralgia in this population
Findings for first three routine cohorts:
Incidence of herpes zoster fell by 35%
Post herpetic neuralgia fell by 50%
Equivalent reduction for four catch up cohorts:
33% for herpes zoster and 38% for post herpetic neuralgia
Vaccine effectiveness of 62% against herpes zoster and 70-88% against post herpetic neuralgia
Findings
Analysis included 3·36 million person-years of data, corresponding to an average of 310 001 patients aged 60–89 years who were registered at an RCGP practice each year. By Aug 31, 2016, uptake of the vaccine varied between 58% for the recently targeted cohorts and 72% for the first routine cohort. Across the first 3 years of vaccination for the three routine cohorts, incidence of herpes zoster fell by 35% (incidence rate ratio 0·65 [95% 0·60–0·72]) and of post herpetic neuralgia fell by 50% (0·50 [0·38–0·67]). The equivalent reduction for the four catch-up cohorts was 33% for herpes zoster (incidence rate ratio 0·67 [0·61–0·74]) and 38% for post herpetic neuralgia (0·62 [0·50–0·79]). These reductions are consistent with a vaccine effectiveness of about 62% against herpes zoster and 70–88% against post herpetic neuralgia.
Amirthalingam et al., 2017
Shingles update slides 2018/19

16. When Zostavax® should not be given:
Contraindications*
When Zostavax® 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 leukaemia; 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 e.g. methotrexate >25mg per week, azathioprine >3mg/kg/day or 6-mercaptopurine >1.5mg/kg/day
Had biological therapies (e.g. 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
SPC available at
The Green Book chapter 6
The Green Book chapter 28a
*SPC contains more detail around precautions and
contraindications
Shingles update slides 2018/19

17. When to delay Zostavax® *
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
Shingles update slides 2018/19

18. Zostavax® is NOT contraindicated* in individuals
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
If there is any doubt (e.g. common variable immune deficiency), immunological advice should be sought.
SPC available at
The Green Book chapter 28a
Specialist advice should be sought for other treatment regimes
*SPC contains more detail around precautions and
contraindications
Shingles update slides 2018/19

19. Precautions* with Zostavax®
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:
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
Chief Pharmaceutical Officer and CMO letter Zostavax® and biological therapies
SPC available at
*SPC contains more detail around precautions and
contraindications
Shingles update slides 2018/19

20. A tool to help clinicians screen individuals for contraindications to the live attenuated shingles vaccine has been produced by Health Protection Scotland
The screening tool is designed to help identify patients who may be contra-indicated for shingles vaccine
Link to screening tool for contraindications for shingles vaccine
Scotland have given permission for the use of this screening tool in Wales, however it must be used in conjunction with the eligibility cohorts for shingles vaccine in Wales WHC(2015)19.  It does not replace the need for the clinical judgement of the healthcare professional
Link to screening tool:
Shingles update slides 2018/19

21. Zostavax® appearance and reconstitution*
The pack contains a single dose vial containing a white/off white compact, crystalline powder plug, a prefilled 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
*SPC contains more detail around precautions and
contraindications
Shingles update slides 2018/19

22. 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:
Shingles update slides 2018/19

23. 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.
Shingles update slides 2018/19

24. 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: Revised recommendations for administering more than one live vaccine Public Health England.
Shingles update slides 2018/19

25. Possible adverse reactions to Zostavax®*
Most commonly reported side effects are at the injection site and can include redness, pain, swelling and pruritus
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, < than 1 in 10,000 people
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.
More information can be viewed in the Shingles Green Book chapter:
*SPC contains more detail around precautions and
contraindications
Shingles update slides 2018/19

26. Vaccine efficacy and length of protection
For those vaccinated but who later developed shingles, the vaccine reduced the incidence of PHN by 66%
(Oxman et al., 2005; Oxman et al., 2008)
The need for a second dose is currently unknown
The latest data suggests the vaccine confers protection for at least 5 years (Schmader et al., 2010)
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
Oxman MN and Levin MJ (2008) Vaccination against Herpes Zoster and Post herpetic Neuralgia. J Infect Dis 197 Suppl 2 S
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): Cited in Joint Committee on Vaccination and Immunisation (2010) Statement on varicella and herpes zoster vaccines 29 March 2013.
Schmader KE, Oxman MN, Levin MJ, Johnson G, Zhang JH, Betts R, Morrison VA, Gelb L, Guatelli JC, Harbecke R, Pachucki C, Keay S, Menzies B, Griffin MR, Kauffman C, Marques A, Toney J, Keller PM, Li X, Chan IS, Annunziato P; Shingles Prevention Study Group.(2012) Persistence of the efficacy of zoster vaccine in the shingles prevention study and the short-term persistence sub study Clin Infect Dis. Nov 15;55(10): doi: /cid/cis638. Epub 2012 Jul 24.
Shingles update slides 2018/19

27. New shingles vaccine licenced
Shingrix® – herpes zoster vaccine (inactivated, recombinant adjuvanted vaccine)
Shingrix® was licenced in March 2018 by the European Medicines Agency
JCVI are currently considering information that will inform the potential for the use of Shingrix® in the wider UK programme
It is anticipated that Shingrix® could be recommended for individuals contraindicated to live Zostavax® vaccine due to immunocompromising conditions or treatment
More information is available in the JCVI minutes - March 2018
Shingrix® was licenced in March 2018 by the European Medicines Agency:  see JCVI  minutes from Feb 2018
A course of Shingrix® (0, 2-6m) is recommended by Advisory Committee on Immunisation Practices (ACIP) for all adults 50yrs and over including those who’ve previously had Zostavax®. Currently not available to order in the UK with no date set for availability.  
ACIP is a group of medical and public health experts that develop recommendations on use of vaccines in the US.
Shingles update slides 2018/19

28. Shingles programme
Posters and leaflets developed to support the shingles programme in are no longer accurate.
All shingles resources are being reviewed and updated as appropriate
As new resources become available they will be uploaded to the new Shingles vaccination programme ( ) intranet page and public facing resources will be shared with NHS Direct Wales for their shingles webpages
Shingles update slides 2018/19

29. English: www.publichealthwales.org/shingles
Welsh: 
This is a short personal story;
Why shingles vaccine is important to help protect older people from shingles and the pain it can cause. This video has been updated for 2018/19.
Available online at:
English:
Welsh: 
Shingles update slides 2018/19

30. Resources
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 ( ) intranet pages [link] (NHS Wales intranet only)
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 update slides 2018/19

31. 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.
© 2018 Public Health Wales NHS Trust.
VPDP shingles information page may be found at:
Shingles update slides 2018/19