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  • Recommendations for Use of Herpes Zoster Vaccines

    Due in large part to its more than 90% protection against shingles, even in the elderly, the recombinant zoster vaccine (RZV) has been deemed the preferred shingles vaccine for immunocompetent adults aged 50 and older. Shingles, or herpes zoster, is a common ailment. Its effects are usually painful, localized cutaneous eruptions. The eruptions result from reactivation of latent varicella zoster virus. After the rash and pain subside (usually in two to four weeks), it is possible for patients to still experience postherpetic neuralgia for several years.

    RZV combines recombinant glycoprotein E with an adjuvant system (AS01B) that boosts the T-cell response to the vaccine. It is a two-dose, subunit vaccine approved by the FDA for the prevention of herpes zoster in adults and immunocompromised adults aged ≥50 years. The predecessor of RZV, zoster vaccine live (ZVL), continues to be used in immunocompetent adults aged ≥60 years, especially if the patient is allergic to RZV, prefers ZVL, or if RZV is unavailable. Even if a patient has previously received ZVL, which only requires one dose, the CDC recommends that they receive two doses of RZV, due to its effectiveness.

    Patients should receive two doses of RZV, with the second dose given two to six months after the first. RZV should be administered intramuscularly in the deltoid region of the upper arm. Whereas ZVL is administered as a single subcutaneous dose, incorrect subcutaneous administration of RZV is more likely to cause a reaction. RZV is supplied as two components: the lyophilized antigen and the adjuvant solution. Both components of RZV, the lyophilized antigen and the adjuvant solution, should be refrigerated between 2° and 8°C. Prior to use, the vaccine needs to be reconstituted. RZV should not be frozen. It would no longer be viable if freezing were to occur.

    Patients should be advised to avoid strenuous activities for several days after the vaccine has been administered. Over-the-counter NSAIDs can be taken if reactions occur. It is important to note that in clinical trials, a reaction to the first dose did not predict a reaction to the second dose, so advise patients to complete the two-dose series of RZV even if a reaction is experienced with the first dose.


    Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67:103-108. https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a5.htm

    GlaxoSmithKline website. Press releases. Shingrix approved in the US for prevention of shingles in adults aged 50 and over. https://www.gsk.com/en-gb/media/press-releases/shingrix-approved-in-the-us-for-prevention-of-shingles-in-adults-aged-50-and-over/. Updated October 23, 2017. Accessed August 17, 2018.

    GlaxoSmithKline website. Shingrix prescribing information. https://gsksource.com/pharma/content/dam/GlaxoSmithKline/US/en/Prescribing_Information/Shingrix/pdf/SHINGRIX.PDF. Accessed August 17, 2018.