1. Herpes Zoster Vaccination Anupama Raghuram, MD Assistant Professor Department of Internal Medicine Division of Infectious Diseases August 7 th, 2013

2. Herpes Zoster Vaccination Principles of disease: Virus- Herpes varicella zoster Varicella Zoster (VZV) : 1ry infection Chicken-pox Herpes Zoster( HZV): Reactivation of infection Shingles

3. Herpes Zoster Vaccination- Pathophysiology of Disease

5. Transmission: -Direct contact with lesions -Aerosolization of virus from skin lesions -Pt not infectious prior to 1 st lesions appearing/ after re- epithelization of lesions -Person w/o h/o 1ry VZV  exposed to HZV  risk of 1ry VZV

6. Herpes Zoster Vaccination Clinical manifestations:

7. Herpes Zoster Vaccination- Pathophysiology of Disease Precautions with active lesions: -Keep rash covered -Hand washing -Avoid contact with: a) pregnant women w/o h/o VZV b) premature low birth weight infants c) immunocompromised individuals -Isolation: a) localized zoster- not needed b) disseminated zoster- strict isolation ( airborne)

8. Herpes Zoster Vaccination- Pathophysiology of Disease Complications: -Post- herpetic neuralgia (PHN)- 10-15% of pts -Superimposed bacterial skin infections -Ocular complications- acute retinal necrosis -Neurologic complications: motor neuropathy meningitis, encephalitis myelitis GBS stroke syndrome -Herpes zoster oticus- Ramsay Hunt

9. Herpes Zoster Vaccination- Pathophysiology of Disease Diagnosis: -Clinical -Viral cx -Direct immunofluorescence -PCR

10. Herpes Zoster Vaccination Why vaccinate? -1 million cases/ year in the US -$ 1 billion/ year spent on treating HZV -Pain and suffering (rx not always effective/ available, 72 h window) -Prevention of complications

11. Herpes Zoster Vaccination Data on vaccination: A) Shingles Prevention Study (SPS) - 38,546 adults -  incidence of HZV by 51% -  incidence of PHN by 66.5% B) Zostavax Efficacy and Safety Trial (ZEST) - 22,439 adults 50-59 yo - 2/1,000 person-yrs vs 6.6/ 1,000 person- yrs in placebo group (30 vs 99) - vaccine efficacy for prevention 70%

12. Herpes Zoster Vaccination Mechanism of action: boosts VZV- specific immunity Indications: -ACIP- > 60 yo -FDA- approved for > 50 yo ●Vaccine: -Live attenuated -One time SQ injection- 0.65 ml; -Keep frozen and use within 30 min -14 x larger dose compared to VZV -Verification of prior zoster history or serology not necessary -Adverse effects: HA, local injection site reaction

13. Herpes Zoster Vaccination Special situations: A) Episode of prior zoster: - if not acute- OK to give vaccine - if recent acute HZV, benefit of vaccine unclear B) Planned immunosuppression: - give HZV vaccination at least 14 d prior

14. Herpes Zoster Vaccination Special situations: C) Pt due for VZV, given HZV vax mistakenly: - count as 1 dose of VZV, proceed with schedule - AVOID- the 2 vaccines are NOT interchangeable D) Pt due for HZV, given VZV instead - dose much lower in VZV, do not count as a valid dose - if mistake picked up during the visit, give HZV then - mistake picked up later, give HZV after 28 days

15. Herpes Zoster Vaccination ●Contraindications: -Pregnant women -Anaphylactic reaction to gelatin or neomycin -1ry or acquired immunodeficiency (BM malignancy, AIDS, steroids) -Avoid co-administration with PPSV23 ( Pneumovax):  immunogenicity of zoster vaccine

16. References 1.A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. Oxman et al. Shingles Prevention Study Group.N Engl J Med. 2005;352(22):227 2.http://www.cdc.gov/shingles/about/transmission.html 3.http://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi.pdfhttp://www.merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pi.pdf 4.Recommended adult immunization schedule: United States, 2010. Advisory Committee on Immunization Practices. Ann Intern Med. 2010;152(1):36. 5.Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Schmader KE et al. JClin Infect Dis. 2012 Apr;54(7):922-8. 6.Airborne transmission of nosocomial varicella from localized zoster. Josephson A, Gombert ME. J Infect Dis. 1988;158(1):238 7.Rapid contamination of the environments with varicella-zoster virus DNA from a patient with herpes zoster. Yoshikawa T et al. J Med Virol. 2001;63(1):64. 8.Transmission of varicella zoster virus from individuals with herpes zoster or varicella in school and day care settings.Viner K et al. J Infect Dis. 2012 May;205(9):1336-41. Epub 2012 Mar 28.