I have been presenting on vaccines for the last few weeks. I had a few questions on Shingrix. The updated NACI statement on herpes zoster was published earlier this year, and has been integrated into the Canadian Immunization Guide. I thought I would review some of the questions I am commonly asked about Shingrix.
Should Shingrix be used at 50 years or 60 years?
Age is a major risk factor for the development of shingles. This is mostly due to a decrease in antibodies and a decrease in immune system function as we age (immunosenescence).
In the past, Zostavax was recommended for all people 60 years of age and older, but could be considered in people starting at age 50 years. The reason for this recommendation is that the shingles risk increases starting at age 50 years but significantly increases after the age of 60 years. The antibodies to the live vaccine decreases with time, so if given too early it would not protect when the patient was at the highest risk.
With Shingrix, the recommendation is to offer it to everyone 50 years of age and older. The reason is we know that the immunogenicity last up to 9 years. You should comfortably offer Shingrix to all your patients 50 years of age or older.
What if the patient has never had chicken pox (varicella)?
Shingles is a reactivation of the chicken pox virus. A question that comes up is if the person hasn’t had chicken pox, do they really need the shingles vaccine?
Shingrix should be offered to everyone 50 years of age or older regardless of whether the person has a history of varicella infection. Nearly all Canadians 50 years of age or older have had prior varicella exposure, even if a diagnosis of varicella cannot be recalled.
What about the side effects with Shingrix, I heard they are severe?
Shingrix is a adjuvanted IM vaccine injection. Local injection site reactions are more common with Shingrix compared to Zostavax. Approximately 4 out of 5 people report injection site pain and 1 in 3 develop redness at the site of injection. Systemic reactions such as fatigue and mylagia occur in up to 50% of people receiving Shingrix. Up to 40% of people developed headache. Most of these events (>95%) were rated mild or moderate in intensity and lasting less than 2 days.
I think it is crucial that clinicians discuss the risk of side effects with the patient. I would fully expect any vaccine with an adjuvant to cause more local reactions. Letting patients know that this is common, temporary and in most cases, mild, can put them at ease if they occur. If you have a patient that is worried, consider administering on a Friday, so that if they have systemic effects, they are home.
Can I give Shingrix with other vaccines?
Shingrix can be administered with any inactivated or live vaccines protecting against a different disease.
If you have not administered multiple vaccines to a patient at the same visit, consider reviewing Concurrent Administration of Vaccines Section in the Canadian Immunization Guide.
Can I administer Shingrix to an immunocompromised patient?
Zostavax is a live-attenuated vaccine. Since it is live, it is normally contraindicated in immunocompromised patients. Shingrix is a non-live vaccine.
The two key Shingrix trials, ZOE 50 (Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults) and ZOE 70 (Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older) did not include patients who were immunocompromised.
Immunocompromised patients are a high risk group of developing shingles and could benefit from herpes zoster protection. NACI states that Shingrix could be used in people 50 years of age and older.
Bottom line: we know Shingrix is safe to use in immunocompromised patients but we are not sure of how effective it is.
Herpes zoster vaccines are not covered under the public program, do I really have to offer them?
A common concern from healthcare professionals is that they are unsure of their responsibility to recommend vaccines not covered under the public routine program of their province or territory. The Canadian Medical Protective Association (CMPA) published a review of a physician’s responsibilities with new vaccines in 2009.
Bottom-line is these new vaccines are designed to protect your patients against a number of vaccine-preventable diseases. My belief is that all healthcare professionals have an obligation to offer vaccines to candidates based on NACI recommendations regardless if they are free or the patient must purchase. Fundamentally, it is the patient’s right to choose what treatments they would like to receive, and by offering the choice, the patient can choose if he/she would like to receive this treatment.
What is the administration schedule for Shingrix?
Shingrix requires two doses at days 0 and then days 60-180 (2-6 months). NACI states that clinicians could consider administering the second dose 1 year later at the time of the influenza vaccine to improve adherence.
Are boosters required for either shingles vaccine?
At this time, there is no recommendations for booster. This may change as more research is done.