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Division of Infectious Diseases
Department of Medicine
Los Alamitos Medical Center, Fountain Valley Regional Hospital
New Brunswick, California
Tracy Zivin-Tutela, MD, has no relevant conflicts of interest to disclose.
Herpes zoster is caused by a reactivation of latent varicella zoster virus (VZV) acquired earlier in life. Those with previous VZV (ie, chickenpox) are at risk of developing shingles. It is manifested by a painful rash that occurs along 1 or more dermatomes, and approximately 1 million cases occur each year in the United States with a 30% lifetime risk of developing shingles. The risk increases with age and one half of the cases occur are among older than 60 years of age. Patients with immunosuppression, including those receiving chemotherapy, steroids, and immunosuppressive medications and patients with HIV, are at a greater risk of developing shingles.
Many believe that shingles is simply a self-limited skin rash, but in fact, reactivation of this viral infection can lead to many serious sequelae carrying a great deal of morbidity in our aging population. Complications of shingles include pneumonia, hearing problems, encephalitis, blindness, postherpetic neuralgia, and death. One of its most common complications is postherpetic neuralgia, which can affect quality of life by requiring prolonged pain management and limiting mobility.
Having a high index of suspicion for diagnosis is important for early treatment and management, but perhaps our biggest intervention as healthcare professionals lies in prevention. The currently available recombinant zoster vaccine (RZV) is safe and highly efficacious.
Zoster Vaccine Live
For several years, we had a live-attenuated vaccine, known as zoster vaccine live (ZVL), which had the limitations of a live vaccine that made it difficult to immunize the immunocompromised, which is precisely the population that would benefit the most from immunity. In addition, there was the downside of a waning immunity over time, which significantly lowered protection within the first 3 years after vaccination. In those aged 70-79 years, efficacy decreased to 41%, and in those 80 years of age or older, efficacy decreased to 18%. As of November 18, 2020, the ZVL is no longer available in the United States and has been removed from the ACIP Adult Immunization recommendation.
Recombinant Zoster Vaccine
We have a new RZV with high efficacy rates and good durability. RZV is the recommended vaccine for the prevention of herpes zoster (shingles) and related complications. RZV efficacy has been evaluated in 2 clinical trials prior to FDA approval. These studies showed greater than 90% efficacy against shingles regardless of age. In patients aged 50-59 years, it showed 97% efficacy, aged 60-69 years, 97% efficacy, and in those aged 70 years or older, it showed 91% efficacy.
RZV is recommended for those aged 50 years or older, with or without previous history of varicella (no screening), regardless of previous receipt of live attenuated vaccine, and it is compatible with other routine vaccinations, meaning, it can be given concomitantly with the influenza, pneumococcal, and—of most importance—the COVID-19 vaccine.
RZV should be offered to those at high risk of developing shingles and complications from shingles, such as those with chronic medical conditions (diabetes mellitus, renal failure, rheumatoid arthritis, chronic obstructive pulmonary disease), patients receiving low-dose steroids, those anticipating immunosuppression (chemotherapy, transplant), or those recovered from an immunocompromising illness. An ounce of prevention with the RZV is worth a pound of cure.
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