Transcript Herpes Zoster Vaccination

Herpes Zoster Vaccination
Anupama Raghuram, MD
Assistant Professor
Department of Internal Medicine
Division of Infectious Diseases
August 7th, 2013
Herpes Zoster Vaccination
 Principles of disease: Virus- Herpes varicella zoster
Varicella Zoster
(VZV) :
1ry infection
Chicken-pox
Herpes Zoster( HZV):
Reactivation of
infection
Shingles
Herpes Zoster VaccinationPathophysiology of Disease
Herpes Zoster VaccinationPathophysiology of Disease
Herpes Zoster VaccinationPathophysiology of Disease
 Transmission:
- Direct contact with lesions
- Aerosolization of virus from skin lesions
- Pt not infectious prior to 1st lesions appearing/ after reepithelization of lesions
- Person w/o h/o 1ry VZV  exposed to HZV  risk of 1ry
VZV
Herpes Zoster Vaccination
 Clinical manifestations:
Herpes Zoster VaccinationPathophysiology 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)
Herpes Zoster VaccinationPathophysiology of Disease

Complications:
-
Post- herpetic neuralgia (PHN)- 10-15% of pts
-
Superimposed bacterial skin infections
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Ocular complications- acute retinal necrosis
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Neurologic complications:
motor neuropathy
meningitis, encephalitis
myelitis
GBS
stroke syndrome
-
Herpes zoster oticus- Ramsay Hunt
Herpes Zoster VaccinationPathophysiology of Disease
 Diagnosis:
- Clinical
- Viral cx
- Direct immunofluorescence
- PCR
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
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%
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
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
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
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
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.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.