Varicella Zoster Virus Vaccine

1. Indications
   1. Prevention of Shingles in age 50 years or older (previously only approved for age 60 and older)
      1. However due to vaccine shortages, focus use on those over age 60 years
   2. Indicated even in those who had prior Shingles infection
      1. Rash must have resolved to administer
      2. Delay vaccine for 12 months following Shingles episode based on expert opinion in 2012
   3. Upcoming immunosuppresive therapy (give at least 2-4 weeks before vaccine dose)
2. Contraindications
   1. AIDS
   2. Human Immunodeficiency Virus with clinical manifestations or CD4 Count <200
   3. Immunocompromised Conditions
   4. Recent Systemic Corticosteroid use over 20 mg for at least 2 weeks
      1. Delay Immunization for 1 month after steroid course completed
   5. Concurrent acute febrile illness (Fever >101.3 F)
   6. History of Anaphylaxis to gelatin or neomycin
   7. Unsure of prior Chicken Pox history
      1. Born in U.S. before 1980 are considered immune and do not need titer before Zostavax
      2. Foreign born
         1. Check titer if no known history of Chicken Pox
         2. Titer positive can recieve Zostavax, and those with negative titer get the Varivax
3. Cost
   1. Approximate: $194
   2. Injection and drug are now covered under Medicare Part D
4. Background
   1. Zostavax varicella titer is 14 times higher than Varivax
5. Dose
   1. Zostavax 0.65 ml SQ for one dose
6. Precautions
   1. Live, attenuated varicella-zoster virus vaccine
   2. Virus load injected is 14 times greater than Varivax
   3. Pneumovax and Zostavax may be given on same day according to CDC and despite product label
7. Adverse Effects
   1. Local inflammation at injection site (33%)
   2. Chicken Pox or Shingles-type rash is uncommon
8. Efficacy
   1. Immunity appears to last at least 4 years
   2. Decreases Herpes ZosterIncidence by 50%
      1. Decreases cases by 64% in age 60-70, and 38% in age >70 years
      2. Occurs in 3.3% of unvaccinated patients
      3. Occurs in 1.6% of vaccinated patients
      4. Number Needed to Treat to prevent 1 case: 60
   3. Reduces Postherpetic Neuralgia by 66%
      1. Occurs in 0.4% of unvaccinated patients
      2. Occurs in 0.14% of vaccinated patients
      3. Number Needed to Treat to prevent 1 case: 360
9. References
   1. DeYoung (2007) Am Fam Physician 75:1843-4
   2. Hornberger (2006) Ann Intern Med 145:317-25
   3. Oxman (2005) N Engl J Med 352:2271-84
   4. Fashner (2011) m Fam Physician 83(12): 1432-7