GP Connect feature by Dr. Andrew McLean-Tooke*, Clinical Immunologist, Sir Charles Gairdner Hospital; Dr. Timothy Ford, General Paediatrician and Paediatric Infectious Diseases Physician, Medical Lead for WA Vaccine Safety Surveillance System (WAVSS)
From 1 Novembr 2023, Shingrix will replace Zostavax on the National Immunisation Program (NIP) schedule. In this article, Dr. McLean-Tooke and Dr. Ford discuss the change, Shingrix effectiveness and safety, and ongoing recommendations for vaccination.
Key points:
- Herpes zoster is a painful condition with potentially severe complications.
- Shingrix is a recombinant vaccine which is safe to use in immunocompromised adults.
- Shingrix is a two-dose vaccine schedule given by intramuscular injection.
- Shingrix is highly effective and provides long-lasting protection.
- From 1 November 2023, two doses of Shingrix will be funded on the NIP for specific patient groups.
- Allow 12 months between herpes zoster episode or Zostavax dose and giving Shingrix.
Herpes Zoster
Herpes Zoster (HZ), also known as shingles, results from reactivation of latent varicella zoster virus from sensory nerve roots. It is estimated that one in three people will develop HZ during their lifetime. HZ can occur at any age, with rates rising sharply from the age of 50, but may be seen in younger patients, especially if immunocompromised.
HZ is characterised by a unilateral rash, evolving from a maculopapular rash to one of vesicles that ulcerate and crust over the course of seven to ten days. Prodromal symptoms may include itching, burning and pain along the distribution of the involved dermatome.
The most common complication of HZ is postherpetic neuralgia, defined as pain persisting longer than three months after rash onset. Risk of postherpetic neuralgia increases with age, affecting up to 30 per cent of patients over 80 years with HZ. The pain associated with postherpetic neuralgia can be severe and is almost invariably associated with significant quality of life impairment. Herpes zoster ophthalmicus, due to involvement of ophthalmic branch of the trigeminal nerve, results in direct ocular involvement in 50 per cent of cases, and is sight-threatening in 50 per cent of these cases.
Zoster vaccines
Zostavax, the live attenuated zoster vaccine, which has been on the NIP since 2016, has contributed to a decrease in HZ cases in Australia. The major drawback for this vaccine is that it is contraindicated in patients with moderate to severe immunocompromise, and therefore is not suitable for a large proportion of patients at increased risk of HZ. Inadvertent administration to immunocompromised patients has caused disseminated disease, including fatalities.
An adjuvanted recombinant zoster vaccine, Shingrix, has been registered for use in Australia since 2018, but not previously funded through the NIP. Since this is a recombinant protein vaccine rather than live vaccine, it can be safely given to immunocompromised patients.
Vaccine effectiveness and safety
Studies have shown the two-dose Shingrix schedule is highly effective, with patients over 50 years having greater than 90 per cent protection from HZ and postherpetic neuralgia. This benefit appears to be maintained long term with protection remaining over 70 per cent at 10 years following vaccination. High levels of protection (greater than 61per cent) against HZ and post herpetic neuralgia are still seen in severely immunocompromised adults.
Shingrix causes moderately high rates of local and systemic reactions with the commonest being local reaction site injections including pain, redness and swelling. Systemic reactions include fatigue, myalgia, headache, and gastrointestinal symptoms. Both local and systemic reactions typically resolve in one to three days.
Vaccine recommendations
Shingrix is approved for immunocompetent patients aged over 50 years, and in immunocompromised patients over 18. As of 1 November 2023, Shingrix will replace Zostavax on the NIP. Two doses will be funded on the NIP for non-Indigenous individuals aged over 65 years, Aboriginal and Torres Strait Islander individuals aged over 50 years, and immunocompromised individuals aged over 18 years with conditions at ‘high risk’ of HZ infection, such as stem cell transplant, organ transplant, haematological malignancy and advanced or untreated HIV.
Shingrix is given intramuscularly in two doses, two to six months apart. The optimal time for administration of Shingrix following a previous episode of HZ or recent Zostavax vaccine administration is unclear, and it is suggested patients should wait 12 months before receiving Shingrix.
Additional resources
- NCIRS fact sheets – Zoster vaccines
- National Immunisation Program – Shingles program advice for vaccination providers
- The Australian Immunisation Handbook – Zoster (herpes zoster)
*Acknowledgement: Dr McLean-Tooke as received speaker fees from GSK for educational talks related to the Shingrix vaccine.