Beth Longware Duff

 reports that 2 doses of recombinant herpes zoster (HZ) vaccine, or RZV, (Shingrix) induce “strong and persistent” immune responses in older adults whether they previously received live-attenuated HZ vaccine, or ZVL, (Zostavax) or not.

“Our results further support the US Advisory Committee on Immunization Practices (ACIP) recommendation of Shingrix for immunocompetent adults who previously received Zostavax,” GlaxoSmithKline Vaccines’ Senior Clinical Research and Development Lead Alemnew Dagnew, MD, MSc, told 

. Agnew added that there were no apparent differences between previous ZVL recipients and ZVL-naive participants in the study.

Four hundred thirty individuals 65 years or older participated in the study. Eligibility requirements included having no immunocompromising conditions or a previous history of shingles.  Participants were divided evenly into 2 groups. Members of 1 group had been vaccinated with ZVL at least 5 years earlier; the other participants had not. Both groups were vaccinated with RVZ which is given in 2 doses 2 to 6 months apart. One year after the second dose of RVZ was administered, anti-gE antibody concentrations, gE-specific CD4 T-cell frequencies, and activation marker profiles were similar between the 2 groups. Safety outcomes were also similar, and no shingles episodes were confirmed.

Dagnew said it is encouraging to be able to show that prior vaccination with ZVL does not interfere with the immune responses to RVZ in older adults.

“RZV induced strong humoral and polyfunctional CMI responses that persisted above prevaccination levels up to 1 year after RZV dose 2 in adults aged ≥65  years, irrespective of previous ZVL vaccination, without clinically significant differences in the RZV safety profile between study groups,” the study concluded.

“Therefore, both ZVL-naive individuals and previous ZVL recipients are likely to similarly benefit from RZV vaccination.”

RVZ was approved in 2017 for use in the United States in adults 50 years and older, and is recommended over ZVL by ACIP for the prevention of shingles and related complications like 

, differences in efficacy between RVZ and ZVL are most pronounced among older patients. RVZ was proven in clinical trials to be more than 90% effective in adults 50 years and older. Research has shown that ZVL’s effectiveness is lower and wanes substantially over time, leaving recipients with reduced protection against herpes zoster.

The CDC advises that there is no specific amount of time a provider needs to wait before administering RVZ to patients who have had shingles, but the vaccine should not be given to patients experiencing an acute episode of the infection.

The safety of administering RVZ 5 or more years after ZVL has been studied. “Shorter intervals were not studied, but there are no theoretical or data concerns to indicate that RVZ would be less safe or effective if administered less than 5 years after a patient received ZVL,” noted the CDC.

For patients who previously received ZVL, the CDC recommends that providers consider the patient’s age and when he or she received ZVL to determine when to vaccinate with RVZ.

1.Dagnew AF, Klein NP, HervÃ©. The adjuvanted recombinant zoster vaccine in adults aged ≥65 years previously vaccinated with a live-attenuated herpes zoster vaccine. The Journal of Infectious Diseases. 2020. 

2. Dreisbach EN. Shingrix induces persistent immune responses in older adults, regardless of Zostavax dose. 

April 26, 2020.  https://www.healio.com/news/infectious-disease/20200424/shingrix-induces-persistent-immune-responses-in-older-adults-regardless-of-zostavax-dose

3. CDC. Shingrix Recommendations. CDC; Page last reviewed January 25, 2018. Accessed June 4, 2020. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html.

Articles

Recombinant herpes zoster (HZ) vaccine (Shingrix) induced a strong and persistent immune response in older adults, regardless of previous receipt of live-attenuated HZ vaccine.

Shingrix Delivers Persistent Immune Responses in Seniors	

The medical community has focused in recent months on the virus at the core of the 

coronavirus disease 2019 (COVID-19) pandemic

, but now its broader impact is beginning to come under scrutiny. 

One area of concern is the effect of coronavirus-related stress on the human body. Common stressors include fear of contracting the virus or losing loved ones to it, sheltering at home, sudden job loss, caring for children who would normally be in daycare or school, and overall uncertainty about the future. Will this stress contribute to a spike in other health issues, including herpes zoster (HZ)?

 acknowledges that the COVID-19 outbreak may be stressful for individuals, and that “fear and anxiety about a disease can be overwhelming and cause strong emotions in adults and children.”

While noting that people react differently to stressful situations based on their personalities, backgrounds, and communities, the CDC identifies populations that are most vulnerable. “People at higher risk for severe illness, such as older adults, and people with underlying health conditions are also at increased risk of stress due to COVID-19,” it states.

, individuals with chronic health conditions like 

 have long been known to be at greater risk for developing 

. Psychological distress, sleep disturbance, and depression-all states associated with COVID-19- are among acknowledged triggers that cause the varicella zoster virus to reactivate into shingles. 

 into the psychological antecedents of HZ published in the journal 

concluded that stress, stressful life events, and depression may partially contribute to outbreaks of shingles.

“When psychological influences are present, they are likely to exert their deleterious impact through effects on immunity,” report coauthors Randy A. Sansone, MD, and Lori A. Sansone, MD.

 “For example, studies have found that age, nutrition, and depressive symptoms can lower an individual’s immunity.”

 recently reported that dermatologists it contacted said that they have received an increasing number of telehealth calls on several stress-related skin conditions, including shingles, since the pandemic was announced. Stress can also prolong a patient’s discomfort, lead to lingering complications like 

, weaken the immune system, and delay full recovery.

Besides suggesting stress management techniques, health care providers can counsel patients on ways to lessen their chances of developing shingles beyond the pandemic. The best option they can recommend is vaccination. Although there is no effective COVID-19 vaccine yet, there is effective vaccination against shingles. 

1. CDC. Coronavirus Disease 2019 (COVID-19). Coping with Stress. Page last reviewed: April 30, 2020. 

https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html

2. Sansone RA, Sansone LA. Herpes zoster and postherpetic neuralgia: an examination of psychological antecedents. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4140624/pdf/icns_11_5-6_31.pdf

3. LaMotte S. From migraines to asthma to shingles: The physical toll coronavirus-related stress takes on your body and how to combat it. CNN; May 14, 2020. 

https://www.cnn.com/2020/05/14/health/stress-coronavirus-physical-impact-wellness/index.html

Can coronavirus-related stress cause shingles?

COVID-19 and Herpes Zoster	

Herpes zoster (shingles) is not only painful and can significantly alter daily life for sufferers, but it can also leave them with devastating, long-lasting 

 and nerve damage. Anti-viral drugs administered within 72 hours of the first signs of the telltale rash can treat shingles in its earliest stages to help reduce symptoms and avoid serious complications.

The typical shingles outbreak often starts with a general feeling of unwellness or fatigue. Other early signs and symptoms include mild skin irritation; a burning, tingling, itching, or numbness concentrated in 1 small area on 1 side of the body; aching muscles, fever, headache, chills, and gastrointestinal distress like nausea, vomiting, and diarrhea. Pain can be intense and stabbing, and it usually worsens over the course of the illness.

Within 5 days of the first symptoms, an itchy and burning rash comprised of blisters filled with clear fluid typically forms. This is the infectious period, lasts 7 to 10 days until the blisters scab over, dry up, and grow smaller.

Individuals who experience these symptoms and have a history of chickenpox should consider the likelihood of shingles and seek a medical diagnosis. This is particularly true if blisters develop on the face.

“Blisters near or in the eye can cause lasting eye damage or blindness,” noted the 

 “Hearing loss, a brief paralysis of the face, or, very rarely, swelling of the brain can also occur.”

The risk of developing shingles increases for people over the age of 60; cancer, HIV and organ transplant patients; diabetics and anyone who is under a lot of stress.

Antiviral medicines-including acyclovir, famciclovir, and valacyclovir-can shorten the length and severity of the illness. According to the 

, “These medicines are most effective if you start taking them as soon as possible after the rash appears.”

OTC and prescription pain medications can be used as needed. Itchiness can be alleviated by using wet compresses, calamine lotion, and colloidal oatmeal baths.  

) is the most common complication of shingles, afflicting up to 20% of patients. This long-term, debilitating nerve pain occurs in the same areas that were covered by the rash. Steroids, analgesics, antidepressants, anticonvulsants, and the application of 

 in transdermal patch form can help deliver pain relief.

The risk of developing PHN, its duration, and severity increases with age. Additionally, its incidence is greater among immunocompromised individuals, those who have pain during the early stages of shingles, and those who experienced a severe rash that covered a large portion of skin. Patients over the age of 60 who do not seek treatment for the illness are more likely to develop PHN than those who are treated.

Other complications of shingles may be rare, but serious, including 

, brain inflammation, hearing or vision problems, pneumonia, bacterial skin infections, facial paralysis, loss of taste, and vertigo.

Although there is no cure for shingles, an effective vaccination against it is available as the first line of defense. 

 was licensed by the FDA for adults 50 and older in 2017. It has proven to be over 90% effective at preventing shingles in clinical trials, and is recommended by the FDA’s Advisory Committee on Immunization Practices as the preferred shingles vaccine.

1. Shingles. National Institute on Aging. Last reviewed October 29, 2018. Accessed April 21, 2020. 

2. Treating Shingles. CDC. Last reviewed July 1, 2019. Accessed April 21, 2020. https://www.cdc.gov/shingles/about/treatment.html

Early treatment of shingles reduces symptoms and risk of serious complications.

The Importance of Early Treatment for Shingles	

Recombinant zoster vaccine (RVZ, Shingrix, GlaxoSmithKline), the FDA-approved 2-dose series RVZ for adults 50 years and older, has proven to be highly effective in the prevention of shingles (herpes zoster). According to the 

, 2 doses of RVZ provides more than 90% protection against shingles and its most common complication, 

To ensure maximum protection, it is critical that both doses be administered within a 6-month period, even if the patient experiences 

 after the first dose. New research from Blue Cross Blue Shield (BCBS) of Michigan indicates that a simple phone call to remind patients to come in for their second dose can be helpful.

The study, which was presented at the Academy of Managed Care Pharmacy Nexus annual meeting in late 2019, involved pharmacy interns calling more than 1000 BCBS members who had received their initial dose of RVZ with a reminder that the second dose was coming due. Ninety-two percent of the patients who spoke directly with the intern received the second dose, compared with 87% of those who had no contact

After reviewing the timing of the dose, the researchers concluded that patients who completed the call were significantly more likely to get the second shot within the recommended 60 to 180 days.

Community pharmacist Stephen Giroux, RPh of Middleport, New York told 

 that he has a system in place to encourage patients to get their second dose.

“As part of our expanded pharmacy services, we always call our patients or send a reminder of their choice- text or email-for the second Shingrix dose,” explained the NCPA past president. “We are committed to patient adherence and compliance, so we have a reminder system that everyone gets placed in to assure that they don’t miss the second dose.”

Giroux continued that the reminder calls have been shown to dramatically increase the second dose compliance. “We further ask them, with a flag prompt, when they come in for any other prescription to remember their second dose. We have so many more touch points to accomplish this as accessible health care providers.”

GlaxoSmithKline, the manufacturer of Shingrix, offers individuals a 

 option on its website for voice, email, and text reminders so they don’t miss their second dose

1. New Shingles Vaccine Fact Sheet for Healthcare Providers. CDC; Last reviewed July 1, 2019. 

https://www.cdc.gov/shingles/multimedia/shingles-factsheet-hcp.html

2. Alzouby H, Vandecar S, Stievater T, Kaddis A, Tungol Lin A. Impact of Shingrix (recombinant zoster vaccine) second dose reminder member calls by a commercial health plan [Abstract Z1]. Blue Cross Blue Shield of Michigan. Presented at Academy of Managed Care Pharmacy Nexus Annual Meeting. October 28-November 1, 2019. National Harbor, Maryland.

Pharmacist reminders boost shingles vaccination compliance.

Author | Beth Longware Duff

Articles

Shingrix Delivers Persistent Immune Responses in Seniors

COVID-19 and Herpes Zoster

The Importance of Early Treatment for Shingles

Making the Shingrix Call