Who should receive the shingles vaccine?
VACCINATE EVEN IF THE PATIENT HAS HAD SHINGLES
The ACIP says that people with a history of zoster can be vaccinated. Recurrent zoster has been confirmed in immunocompetent patients soon after a previous episode. There is no test to confirm prior zoster episodes, and if the patient is immunocompetent, no different safety concerns are anticipated with vaccination in this group.16
ADVERSE EFFECTS ARE MILD
No significant safety concerns have been noted with zoster vaccine. Mild local reactions (erythema, swelling, pain, pruritus) and headache are the most common adverse events. There have been no differences in the numbers and types of serious adverse events during the 42 days after receipt of vaccine or placebo.
CONTRAINDICATIONS
Contraindications to zoster vaccine are:
- A history of anaphylactic or anaphylactoid reactions to gelatin, neomycin, or other components of the vaccine
- Acquired or primary immune deficiency states, including AIDS
- Cancer chemotherapy or radiotherapy
- Leukemia
- Lymphoma
- Organ transplantation
- Active untreated tuberculosis
- Pregnancy or breast-feeding.
However, patients with leukemia in remission who have not received chemotherapy (eg, alkylating drugs or antimetabolites) or radiation for at least 3 months can receive zoster vaccine.
Although zoster vaccine is contraindicated in conditions of cellular immune deficiency, patients with humoral immunodeficiency (eg, hypogammaglobulinemia or dysgammaglobulinemia) can receive it.
Diabetes, hypertension, chronic renal failure, coronary artery disease, chronic lung disease, rheumatoid arthritis, and other medical conditions are not considered contraindications to the vaccine.
The ACIP does not recommend any upper age limit for the vaccine, and preventing zoster is particularly important in the oldest elderly because they have the highest incidence of zoster and postherpetic neuralgia.16
Do not vaccinate during immunosuppressive treatment
If immunosuppressive treatment is planned (eg, with corticosteroids or anti-tumor necrosis factor agents), the vaccine should be given at least 14 days (preferably 1 month) before immunosuppression begins.
The safety and efficacy of zoster vaccine is unknown in patients receiving recombinant human immune mediators and immune modulators, especially anti-tumor necrosis factor agents such as adalimumab (Humira), infliximab (Remicade), or etanercept (Enbrel). These patients should be vaccinated 1 month before starting the treatment or 1 month after stopping it.16
Patients on corticosteroids in doses equivalent to prednisone 20 mg/day or more for 2 or more weeks should not be vaccinated against zoster unless the steroids have been stopped for at least 1 month.11
Low doses of methotrexate (< 0.4 mg/kg/week), azathioprine (Azasan) (< 3.0 mg/kg/day), or 6-mercaptopurine (Purinethol, 6-MP) (< 1.5 mg/kg/day) for the treatment of rheumatoid arthritis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease, and other conditions are not contraindications to zoster vaccination.
Medications against herpes, such as acyclovir (Zovirax), famciclovir (Famvir), or valacyclovir (Valtrex) should be discontinued at least 24 hours before zoster vaccination and should not be started until 14 days afterward.
COSTLY AND EFFECTIVE? OR COST-EFFECTIVE?
The average cost associated with an acute episode of zoster ranges from $112 to $287 if treated on an outpatient basis and $3,221 to $7,206 if the patient is hospitalized (costs in 2006).19
Although pharmacists are licensed to administer influenza and pneumococcal vaccines, several states do not specifically allow them to administer zoster vaccine. Moreover, one usually cannot provide the vaccine out of the office stock and get reimbursed for it (except by some private insurance companies). Instead, the patient needs to take a prescription to a local pharmacy, where the vaccine is placed on ice and then brought back to the physician’s office for administration.
