Beth Longware Duff

 its clinical considerations for the use of Shingrix (recombinant zoster vaccine; RZV) to help prevent shingles and related complications in immunocompromised adults aged 19 and older. The move follows the recent unanimous recommendation of the vaccine by the agency’s Advisory Committee on Immunization Practices (ACIP) for adults who are or who will be immunodeficient or immunosuppressed due to disease or therapy.

Shingles (herpes zoster; HZ) is caused by the varicella zoster virus (VZV), which initially causes chickenpox. The virus then remains inactive in the body until it reactivates decades later as shingles. It is estimated that virtually all Americans born before 1980 have had chickenpox and are consequently at risk for shingles.

 there are approximately 7 million immunocompromised adults in the United States, including 3 million stem cell transplant recipients, patients with hematologic or solid tumor malignancies, solid organ transplant recipients, and people living with HIV. Another 22 million Americans are living with autoimmune and/or inflammatory conditions like rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease (IBD). All are at increased risk for developing shingles.

“Risk of herpes zoster (HZ), severe disease, and complications [is] generally higher in immunocompromised (IC) populations,” ACIP noted. “RZV can potentially address an unmet need for HZ prevention in IC populations.”

The CDC’s new clinical considerations for Shingrix and immunocompromised adults include:

Persons who are or will be immunodeficient or immunosuppressed and would benefit from completing the Shingrix 2-shot series in less than the recommended 2- to-6-month period may receive the second dose 1 to 2 months after the first. “A shorter interval between doses may facilitate avoiding vaccination during periods of more intense immunosuppression,” the CDC noted.

Patients should be vaccinated before becoming immunosuppressed. If this is not possible, vaccination should be timed for when the immune response is likely to be most robust. The general level of immune competence in a patient can be judged by a number of factors including disease severity and duration, clinical stability, complications and comorbidities, and any potentially immunosuppressing treatment.

Shingrix, like other recombinant and adjuvanted vaccines, can be administered at the same time as other vaccines, including the flu vaccine.

Evidence of immunity to varicella, which confirms the need for RZV, can be determined 3 ways: through documentation of 2 doses of chickenpox vaccine, or laboratory evidence of immunity or laboratory confirmation of the disease, or diagnosis/verification of a history of varicella or HZ by a healthcare provider.

Providers should counsel immunocompromised patients about expected local and system side effects of the vaccine prior to vaccination so they know what to expect.

The ACIP currently does not recommend RZV for use during pregnancy, so providers are advised to delay the vaccine until post pregnancy. “Recombinant vaccines such as RZV pose no known risk for mothers who are breastfeeding or their infants,” the CDC states. “Clinicians may consider vaccination without regard to breastfeeding status if RZV is otherwise indicated.”

History of severe allergic reaction to any component of the vaccine is a contraindication for vaccination. Moderate or severe acute illness with or without fever should delay vaccination until symptoms conclude. This includes a current episode of HZ.

Clinical considerations for use of recombinant zoster vaccine (RZV, Shingrix) in immunocompromised adults aged ≥19 years. CDC. Reviewed January 20, 2022. Accessed April 15, 2022.

Anderson T. Zoster vaccines session: Burden of herpes zoster in immunocompromised adults. National Center for Immunization & Respiratory Diseases. Division of Viral Diseases, Viral Vaccine Preventable Diseases Branch. June 25, 2021. Accessed April 15, 2022.

Articles

The CDC has updated recommendations for shingles vaccination.

Shingrix Guidelines for the Immunocompromised	

Physical activity has many proven benefits: it helps prevent or manage health issues, improves mood, boosts energy, enhances the body’s immune response, and promotes better sleep. But what about exercising during an illness like shingles; can it help? The answer is “yes,”—with some caveats.

Shingles, also known as herpes zoster (HZ), is an infection caused by the varicella zoster virus (VZV), which first causes chickenpox. The virus then lies dormant in the nervous system, usually for decades, before reactivating as shingles.

The primary symptom of the illness is a painful red blistering rash that can erupt just about anywhere on the body. Accompanying symptoms are fever, headache, tingling sensations on the skin, general fatigue, and sensitivity to light.

It can take up to 5 weeks for the rash to crust over and heal. Until it does, patients are advised to distance themselves from immunocompromised individuals, pregnant women, young children, and others who have not been vaccinated against or have had chickenpox so they do not become infected.

The physical symptoms and social isolation can add considerably to a shingles patient’s distress. Patients and their caregivers can take a number of simple steps to minimize discomfort and raise spirits. Light physical activity—including everyday pursuits and low-impact exercise—is one of them.

For patients who feel up to it, stress-reducing exercise is recommended. It’s important for them to assess their pain level on a scale of 0 to 10 before starting an activity, and to re-evaluate afterwards and back off if the pain level has increased. This is a time for gentle healing, not strenuous exercise.

 suggests simple activities such as stretching and walking. Bike riding is another good option. Tai chi, a traditional Chinese form of exercise involving controlled movement, reportedly not only increases immunity to VZV but is low-impact enough to be practiced during an outbreak.

 Yoga practitioners can continue their routine with modifications like avoiding poses that involve lying on areas of the body affected by the rash.

Those accustomed to intense cardiovascular workouts like long distance cycling or running that can irritate the rash and raise their body temperature should substitute less intense activities until the rash has scabbed over.

Wearing loose-fitting clothes made of natural fibers like cotton will allow for ventilation around the rash. Avoid physical activity that irritates the rash or results in a lot of sweating that could make it worse. Swimming, contact sports, and group exercise situations that could spread the virus should also be put on hold until after the rash heals.

As with all exercise, patients with shingles should listen to their body. If they feel worse after being active, it’s best to pull back and do something less taxing. Break up activity into manageable pieces. Three 10-minute sessions can be more beneficial than one 30-minute workout. And if those sessions can be done outside in fresh air, even better.

Balancing physical activity with adequate rest, healthy balanced meals, stress avoidance, and prescribed antibiotics will help the healing process go smoothly. To avoid a recurrence of shingles, get vaccinated. Shingrix (recombinant zoster vaccine) is the only HZ vaccine available. It is over 90% effective in preventing shingles in adults 50 years and older.

Shingles. National Institute on Aging. Reviewed October 12, 2021. Accessed April 15, 2022. 

https://www.nia.nih.gov/health/shingles#coping

Tai chi boosts immunity to shingles virus in older adults, NIH-sponsored study reports. News release. National Institutes of Health. April 6, 2007. Accessed April 15, 2022. 

https://www.nih.gov/news-events/news-releases/tai-chi-boosts-immunity-shingles-virus-older-adults-nih-sponsored-study-reports

What everyone should know about the shingles vaccine (Shingrix). CDC. Reviewed January 24, 2022. Accessed April 15, 2022. 

https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

Light exercise has both physical and emotional benefits

Staying Active During Shingles

 is now receiving more attention from medical researchers and health care providers alike. At least 2 studies have concluded that reactivation of the varicella zoster virus (

 based in Minnesota, involved more than 1600 adults 22 years and older with medically documented episodes of HZ. Of these patients, 95 had 105 recurrences of the infection, with a recurrence rate at 8 years of 6.2%.

Researchers found that recurrences were significantly more likely in persons with zoster-associated 

 lasting 30 days or more at the initial episode, in 

, and in those aged 50 or older. In some cases, recurrence occurred in as little as 3 months after the first outbreak. People with compromised immune systems were found to be about 2.4 times more likely to have a recurrence than immunocompetent individuals.

“Rates of HZ recurrence appear to be comparable to rates of first HZ occurrence in immunocompetent individuals, suggesting that recurrence is sufficiently common to warrant investigation of vaccine prevention in this group,” the researchers concluded.1 “Zoster vaccine is recommended for prevention of incident cases of HZ. Our high HZ recurrence rates suggest that zoster vaccination should be offered in people who have had an HZ episode to prevent potential recurrences.”

 conducted in Korea, concluded that HZ recurrence is much more common than generally expected, and that associated risk factors—including age and gender—can play an important role in predicting recurrence. The recurrence rate in patients over 50 years was 5.8%, compared with 4.5% in younger participants. Women had more frequent recurrence than men.

Vaccination is the first line of defense against shingles and its recurrence. In 2017, Shingrix was approved by the 

 to prevent shingles and related complications in adults aged 50 and older. More recently, the FDA 

 to include immunocompromised adults 18 and older. The CDC’s 

Advisory Committee on Immunization Practices

 followed suit, recommending Shingrix for adults 19 years and older who are or will be immunodeficient or immunosuppressed due to disease or therapy.

 was proven in clinical trials to be over 90% effective in preventing shingles and its complications. It is given as a 2-dose series administered over 2 to 6 months.

Virtually every person over the age of 50 in the United States carries the 

 that causes shingles, infected before there was an effective vaccine against it. As they age, their immune systems decline and become less resistant to the virus, increasing their risk of developing shingles. Shingrix works by boosting protection against the virus. It can be given before or after a shingles episode.

Yawn BP, Wollan PC, Kurland MJ, St Sauver JL, Saddier P. 

Herpes zoster recurrences more frequent than previously reported.

2011;86(2):88-93. Doi:10.4065/mcp.2010.0618

Recurrence rate of herpes zoster and its risk factors: A population-based cohort study.

2018;34(2):e1. Doi:10.3346/jkms.2019.34.e1

Learn who’s at risk and how vaccination can help.

Recurrent Shingles: More Common Than Once Thought

 (herpes zoster; HZ) by primary healthcare providers do very well when 

 with antivirals and analgesics for the blistering rash and accompanying pain. However, a consultation with a medical specialist may be necessary to help ensure the best outcome for some patients. This includes cases where 

 develop, or when the patient is compromised by 

“The main issue with shingles is in patients that are elderly and have more severe cases,” Lindsay C. Strowd, MD, FAAD, associate professor in the Department of Dermatology at Wake Forest School of Medicine told 

Other high-risk individuals include those receiving chemotherapy or other types of immunosuppressive medications that impair their ability to fight off infections. “They can get a more widespread rash that may not be confined to a local part of the skin,” explains Strowd. “They can get shingles that actually go into their bloodstream or into their cerebral spinal fluid and cause meningitis or other types of more serious infections. It’s one of the reasons that we want to diagnose it quickly and treat it quickly.”

 is 1 category of shingles that is more prone to complications. This includes herpes zoster ophthalmicus (

, which occurs when the varicella zoster virus that causes shingles reactivates in a facial nerve near the ear; and 

, which erupts in the mouth. All can cause serious permanent damage, including blindness, hearing loss, and facial paralysis. Patients are often referred to specialists for treatment, including ophthalmologists and oral facial pain specialists.

), a chronic pain syndrome that lasts weeks to months after an acute outbreak of shingles, is a serious complication that affects up to 20% of patients. Age and immunocompetence appear to be factors for developing PHN.

“In immunosuppressed individuals—for example, people who are on immunosuppressant drugs, people with HIV, people who have an underlying malignancy—shingles can be more severe, and the incidence of postherpetic neuralgia can have a higher frequency,” explains Justin C. McArthur, MBBS, MPH, professor and director of the Department of Neurology, the Johns Hopkins University School of Medicine and past-president of the American Neurological Association.

According to McArthur, prompt treatment of shingles seems to reduce the incidence of PHN and the risk of 

 the varicella zoster virus to susceptible individuals. Treatments include modifying anticonvulsants and narcotics, as well as interventional treatments like transcutaneous electrical nerve stimulation, onabotulinumtoxinA injections (Botox), acupuncture, and injections into the intercostal nerve.

“A primary healthcare provider would typically refer the patient to a pain treatment specialist, who might be a neurologist or anesthesiologist. Because these are interventional procedures, they’re usually done in a specialized pain treatment center,” McArthur said.

Both McArthur and Strowd recommend vaccination against shingles with 

, which is administered as a 2-dose series to adults 50 years and older. It can be given to individuals whether they’ve already had shingles or not.

“Even if you do happen to get it again, if you’ve been vaccinated it usually makes the disease course a lot milder and helps mitigate against some of the long-term complications,” Strowd concluded.

Some patients may benefit from specialized treatment.

Specialist Care for Shingles Complications

A recent global survey of adults 50 and older revealed that just 7% believe they are at high risk of developing shingles, despite the fact that most of them are already infected with the varicella zoster virus (

) that causes the painful condition. In the United States, virtually all adults over the age of 50 carry VZV, which caused a childhood case of 

, then went dormant in the nervous system. In 1 of 3 of these adults, the virus will 

 as shingles at some point in their lives.

To raise awareness of the serious nature of shingles, GlaxoSmithKline (GSK) and the International Federation on Ageing (IFA) have collaborated to launch the inaugural Shingles Awareness Week (February 28-March 6, 2022). This year’s theme, “Shingles is Here,” underscores that VZV is most likely already inside individuals age 50 and older.

“Shingles can occur at any time in adulthood, so it is important to understand the risk factors and how shingles can significantly impact the quality of someone’s life,” explained Sabine Luik, Chief Medical Officer, and SVP, Global Medical Regulatory & Quality at GSK. “The more people are aware of the links between chickenpox and shingles, the sooner people can take action and discuss their concerns with their healthcare provider.”

 is most commonly associated with a blistering red rash that usually erupts across one side of the chest, abdomen, or 

 that accompanies it can be debilitating. Once the rash dries up and heals over, up to 20% of patients develop a complication known as 

, or neuropathic pain that can persist for months or years. Other 

 individuals are particularly susceptible to developing shingles, as are 

“By kickstarting the first-ever Shingles Awareness Week, our aim is to provide evidence-based information to empower individuals to understand their risk and talk to their healthcare professional if they have questions and concerns. We need to ensure we do our part to educate the global community on this preventable, painful condition,” said Roger Connor, President of Vaccines and Global Health, GSK.

The first line of defense against shingles is 

. The only shingles vaccine available in the U.S. is 

, approved by the FDA and CDC in 2017. It is included on the current vaccination schedule for adults issued by the CDC’s Advisory Committee on Immunization Practices (ACIP).

Currently recommended for immunocompetent adults age 

, Shingrix is delivered in 2 doses administered 2 to 6 months apart. GSK, which manufactures the vaccine, states that dosing can be changed to 1 to 2 months for immunocompromised adults who would benefit from a shorter vaccination schedule.

Shingrix has been proven to be over 90% effective in clinical trials and 

 recommended Shingrix for use in immunocompromised individuals 18 and older. The ACIP recommendation is awaiting review and approval by the director of the CDC and the U.S. Department of Health and Human Services.

First-ever Shingles Awareness Week highlights misconceptions about the risks of developing shingles among older adults, and the need for education. News release.February 28, 2022. Accessed March 3, 2022. 

https://finance.yahoo.com/news/first-ever-shingles-awareness-week-020000827.html

GSK and the International Federation on Aging are working to confront risks and misconceptions about the disease.

Raising Shingles Awareness With First-Ever Shingles Awareness Week

Immunizations aren’t just a requirement of childhood—at least not for those who want to stay healthy as an adult.

As the CDC states on its website, protection from some childhood vaccines doesn’t last forever.

 “You may also be at risk for vaccine-preventable disease due to your age, job, lifestyle, travel, or health conditions,” they points out.

In fact, the CDC maintains an Adult Immunization Schedule2 that includes the 

 (Shingrix), a highly effective 2-dose vaccine recommended for immunocompetent adults age 50 and older for the prevention of shingles (herpes zoster virus; HZV) and its complications. 

Statistically, 1 in 3 Americans will develop shingles in their lifetime,

 so the case for getting vaccinated is strong. 

Virtually all adults aged 50+ already have the varicella zoster virus (VZV) in their body, resulting from an earlier bout of 

—after which the virus lay dormant in the nervous system for decades. As an individual’s immune system declines with age, VZV 

 as shingles. In effect, shingles is an illness that’s just waiting to happen.

 there is. The itchy red rash and debilitating pain that are the hallmarks of the infection emerge first. Once they subside, serious 

 can persist for months or even years, most notably postherpetic neuralgia (

). Shingles has also been identified as a risk factor for 

 for individuals with no history of cardiac issues.

HZV can strike more than once. Immunocompromised people are at greatest risk for 

, high stress levels, some immunosuppressive therapies, and certain diseases including 

, hypertension, and chronic obstructive pulmonary disease.

Shingrix is the only shingles vaccine available in the United States. It has been proven to be highly effective in both clinical trials and in the 

 setting. It uses the body’s own immune system to help prevent shingles.

Since its FDA approval in late 2017, reports of serious adverse effects have been 

 include tenderness, redness and swelling at the injection site; fatigue; muscle pain; headache; fever; and nausea. They typically subside within 48 hours and are considered minor compared with symptoms experienced by those who develop shingles.

 not only the recipient, but others as well. Although shingles cannot be passed to another person, VZV is readily transmissible. Any person without immunity to the virus who is exposed to it—including young, unvaccinated children—can develop chickenpox. Once the virus is in their body, they are also at risk of developing shingles at a later date. 

Shingrix is administered in 2 doses, 2 to 6 months apart. Eligible individuals can be vaccinated regardless of previous history of shingles or prior vaccination with Zostavax—which has been withdrawn from the market in the United States by the manufacturer.4 Shingrix is covered by many private health insurance plans, the Affordable Care Act, and Medicare Part D.

In late 2021, the CDC’s Advisory Committee on Immunization Practices unanimously 

 Shingrix for immunocompromised adults 19 years and older.

The recommendation is currently being reviewed for approval by the director of the CDC and the Department of Health and Human Services.

1. Recommended vaccines for adults. CDC. Reviewed November 21, 2019. Accessed January 24, 2022. 

https://www.cdc.gov/vaccines/adults/rec-vac/

2. Adult immunization schedule. CDC. Reviewed February 12, 2021. Accessed January 24, 2022. 

https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

3. Shingles (herpes zoster). CDC. Reviewed October 5, 2020. Accessed January 24, 2022. 

4. For healthcare professionals. CDC. Reviewed October 5, 2020. Accessed January 24, 2022. 

https://www.cdc.gov/vaccines/vpd/shingles/hcp/index.html

5. US Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices votes unanimously to recommend Shingrix for immunocompromised adults aged 19 and up. News release. GSK. October 20, 2021. Accessed January 24, 2022. 

https://www.gsk.com/en-gb/media/press-releases/votes-unanimously-to-recommend-shingrix-for-immunocompromised-adults-aged-19-and-up/#

Five reasons why Shingrix is recommended for adults aged 50-plus. 