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Adjunct Associate Clinical Professor
Division of Geriatric Medicine
Department of Family and Community Medicine
University of Cincinnati College of Medicine
UCHealth Physician/VA Physician
Clinical Professor of Geriatric Medicine
Susan Schrimpf Davis, DO, has no relevant conflicts of interest to report.
This ClinicalThought features key follow-up questions from our Webinar series on vaccinations and healthy aging. Slides are also available for self-study or to use in your noncommercial presentations.
What screening questions should be asked before the RZV 2-series immunization?
Patients should be asked whether they have experienced anaphylaxis or a severe reaction to the first dose of RZV as these responses are a contraindication to a second dose.
RZV is not a live virus but comprises particulate components of the zoster virus. Patients currently experiencing an acute herpes zoster infection should not receive RZV.
Since data are lacking on the safety of RZV in pregnant and lactating women, as a precaution, women should be asked if they are pregnant or lactating even though RZV immunization is intended for persons 50 years of age or older.
Suppose my older adult patients already have shingles. When can they get the RZV series?
There is no specific length of time that needs to pass before receiving RZV, but generally the shingles rash should be dry and resolved with no active shedding of virus before immunization can be given.
My patient has already received the zoster vaccine live (ZVL). Does she need to get the RZV series?
Yes. Studies show that ZVL efficacy is very time limited: In persons older than 70 years of age, it is only effective in 38% after 3 years, whereas RZV efficacy in the same age group at the same time point is 84.7% (95% CI: 69.0-93.4). The efficacy of RZV is so great that clinicians are obligated to remind their patients 50 years of age or older to get one.
Incidentally, the ZVL is no longer commercially available as of July 1, 2020.
Is a history of immunosuppression, such as HIV infection or from organ transplantation, a contraindication for the RZV series?
No. On the contrary, immunocompromised patients and those with chronic disease are at higher risk for impaired suppression of the varicella virus and for getting shingles. They represent an important patient group who should talk with their care team about getting the RZV vaccine. In this high-risk group, the RZV vaccine helps to reduce the risk of developing shingles and the tragedy of suffering from subsequent postherpetic neuralgia.
Younger adults get shingles sometimes. Why isn’t the RZV approved by the FDA for people younger than 50 years of age?
Although younger adults can get shingles, the risk of getting shingles increases substantially in older adults. The generally accepted scientific theory for this is immune senescence or aging of the immune system.
The CDC has reported that the incidence of herpes zoster is approximately 4 cases/1000 US population annually, but its incidence among people 60 years of age or older is much higher: 1 case/100 US population annually. Older people are more vulnerable to getting shingles.
What are the most common adverse events of the RZV injection?
In clinical trials, the most common reported adverse events included pain, redness, and swelling at the injection site; muscle pain; tiredness; headache; shivering; fever; and upset stomach.
Since pain, myalgia, and fatigue are the most common, advising your patients to hydrate well and take acetaminophen at the time of the immunization may help relieve these potential adverse events and be good anticipatory guidance.
RZV was approved for use in the general population in 2017. How do we really know how long the RZV is effective?
Initial studies reported by the CDC showed that the levels of protection from shingles were high at 4 years post vaccination, ranging from 91.2% (95% CI: 75.9% to 97.7%) in persons older than 50 years of age to 88.8% (95% CI: 68.7% to 97.1%) in persons older than 70 years of age.
Ongoing studies show that RZV induced immune responses persist for 9 years after vaccination in older adults, and prediction models estimate responses to continue up to 15 years after vaccination.
Why does the RZV vaccine work, whereas simply being exposed to the varicella zoster virus (VZV) or getting the varicella immunization does not?
The VZV lies dormant in dorsal root and cranial nerve ganglia. When reactivated, a shingles infection occurs. Exposure to the virus leaves the patient vulnerable to shingles and potentially postherpetic neuralgia.
The RZV vaccine is an adjuvanted subunit vaccine consisting of a single recombinant VZV antigen, glycoprotein E(gE), and the AS01B adjuvant system. RZV depends on gE alone to elicit anti-VZV immunity and on AS01B to both shape and enhance the immune response at the lymph nodes proximal to the injection site of the immunization. The enhanced immune response, stimulated by the RZV, helps to keep the ever-present dormant varicella from reactivating.
Does a delay in the second dose of RZV decrease its efficacy?
Currently, there are no studies on the safety or immunogenicity of RZV administered later than 6 months after the first dose. Nevertheless, if your patient is delayed in getting the second RZV immunization beyond 6 months, he or she does not need to “start over.”
However, if for some reason your patient receives the second dose of RZV sooner than 4 weeks after the first dose, it is advised that the second dose be repeated in 2-6 months.
What is your biggest challenge when recommending vaccination against herpes zoster to your older patients? Answer the polling question and leave a comment in the discussion section.