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Zoster Vaccine Live

Class: Vaccines
VA Class: IM100
Brands: Zostavax

Medically reviewed on Nov 26, 2018

Introduction

Live, attenuated virus vaccine.1 2 6 15 Zoster vaccine live contains attenuated varicella zoster virus (VZV) of the Oka/Merck strain and is used to boost active immunity to VZV.1 2 6 15

Uses for Zoster Vaccine Live

Prevention of Herpes Zoster

Prevention of herpes zoster (zoster, shingles) in immunocompetent adults ≥50 years of age.1 2 6

Zoster is caused by reactivation of latent VZV infection in individuals who previously had varicella (chickenpox) infection.1 2 6 An estimated 500,000 to 1 million cases of zoster occur each year in the US;166 many patients develop postherpetic neuralgia (PHN) and require long-term management for refractory PHN.2 7 13 166 Risk of developing zoster increases with age and declining cell-mediated immunity to VZV.1 2 3 5 7 13 15 16 166 Zoster occurs principally in individuals >45 years of age;2 3 5 7 13 15 16 estimated lifetime risk of zoster is ≥32%, and 50% of individuals living until 85 years of age will develop zoster.166

Zoster vaccine live is used to boost active immunity to VZV, thereby reducing risk of VZV reactivation.1 2 3 5 15 The vaccine may also reduce frequency, severity, and/or duration of PHN in those who develop zoster despite vaccination.1 2 6

Not indicated for treatment of zoster or PHN.1 6 Do not administer during an acute episode of zoster.6 Has no role in postexposure management of zoster.166

Not indicated for prevention of primary varicella infection (chickenpox);1 do not use in children or adults <50 years of age.1 6 Has no role in postexposure management of chickenpox.166

There are 2 different types of zoster vaccine commercially available in the US for immunization against zoster in adults ≥50 years of age: zoster vaccine recombinant (RZV; Shingrix) and zoster vaccine live (ZVL; Zostavax).1 4 26

For prevention of zoster in immunocompetent adults ≥50 years of age, the US Public Health Service Advisory Committee on Immunization Practices (ACIP) states that zoster vaccine recombinant (not zoster vaccine live) is preferred and can be used in such individuals regardless of history of zoster or prior vaccination with varicella virus vaccine live or zoster vaccine live.4 The recombinant zoster vaccine also preferred in adults ≥50 years of age with certain chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease).4

Although zoster vaccine live is labeled by FDA for use in adults ≥50 years of age,1 ACIP states that data to date indicate that the duration of protection is uncertain 5 years after vaccination with the live, attenuated vaccine and that adults who receive this vaccine at 50–59 years of age may not be protected when their risks for zoster and its complications are highest.20 (See Duration of Immunity under Cautions.)

For prevention of zoster in immunocompetent adults ≥60 years of age, ACIP states that either zoster vaccine recombinant or zoster vaccine live can be used.4

Zoster Vaccine Live Dosage and Administration

Administration

Administer only by sub-Q injection.1 6 Do not administer IM or intravascularly.1 6

Be aware that 2 different types of zoster vaccine are commercially available in the US (zoster vaccine recombinant [RZV; Shingrix] and zoster vaccine live [ZVL; Zostavax]).1 4 8 26 These vaccines have different recommendations for dosage and administration (e.g., different routes of administration, different number of required doses) and different storage requirements.1 4 8 26

FDA alerted healthcare professionals about multiple reports of medication errors related to confusion about the 2 different zoster vaccines (e.g., incorrect reconstitution, incorrect route of administration, incorrect interval or number of vaccine doses, inappropriate age of vaccinee, administration after incorrect storage).8 Follow dosage and administration recommendations for the specific zoster vaccine used.1 4 8 26

Sub-Q Administration

Administer by sub-Q injection into deltoid region of upper arm.1 6

To ensure appropriate delivery, administer sub-Q injections at a 45° angle using a 5/8-inch, 23- to 25-gauge needle.134

Reconstitute and administer using sterile syringes and needles free of preservatives, antiseptics, and detergents to avoid inactivating the live, attenuated virus vaccine.1 134

Reconstitution

To maintain potency during storage, lyophilized zoster vaccine must be kept frozen at −50 to −15°C.1 To minimize loss of potency, reconstitute immediately following removal from the freezer and administer immediately following reconstitution.1 (See Storage under Stability.)

To reconstitute, add entire contents of the vial containing diluent provided by the manufacturer to the vial of lyophilized vaccine.1 To avoid excessive foaming, slowly inject diluent into vial of lyophilized vaccine and agitate gently.1 Use only the diluent supplied by the manufacturer.1

Gently agitate reconstituted vaccine to mix thoroughly.1 Reconstituted vaccine is a semi-hazy to translucent off-white to pale yellow suspension.1

Dosage

Adults

Prevention of Herpes Zoster
Adults ≥50 Years of Age
Sub-Q

Give zoster vaccine live as a single dose consisting of entire contents (0.65 mL) of a reconstituted single-dose vial.1

Duration of protection beyond 4–5 years following the recommended single dose unclear and need for additional (booster) doses of the vaccine not determined.1 3 5 6 20 (See Duration of Immunity under Cautions.)

Special Populations

Hepatic Impairment

No specific dosage recommendations.1

Renal Impairment

No specific dosage recommendations.1

Cautions for Zoster Vaccine Live

Contraindications

  • History of anaphylactic/anaphylactoid reactions to gelatin, neomycin, or any other vaccine component.1 6 (See Sensitivity Reactions under Cautions.)

  • Immunodeficiency or immunosuppression due to disease or therapy (including, but not limited to, history of primary or acquired immunodeficiency states, acquired immunodeficiency syndrome [AIDS] or other clinical manifestations of HIV infection, leukemia, lymphoma, or other malignant neoplasms affecting the bone marrow or lymphatic system [see Individuals with Altered Immunocompetence under Cautions] and immunosuppressive therapy [see Immunosuppressive Agents under Interactions]).1 6

  • Pregnancy.1 6 (See Pregnancy under Cautions.)

Warnings/Precautions

Sensitivity Reactions

Serious adverse reactions, including anaphylaxis, reported.1

Have appropriate medical treatment (e.g., epinephrine) readily available in case an anaphylactic/anaphylactoid reaction occurs.1

Gelatin Allergy

Contains hydrolyzed porcine gelatin (15.58 mg per dose) as a stabilizer.1 6

Contraindicated in individuals with history of anaphylactic/anaphylactoid reaction to gelatin.1 134

ACIP states that individuals with a history of anaphylactic reaction to gelatin or gelatin-containing products should be evaluated by an allergist prior to receiving a gelatin-containing vaccine.134

Neomycin Allergy

Contains trace amounts of neomycin.1

Neomycin hypersensitivity usually manifests as a delayed-type (cell-mediated) contact dermatitis.6 134

Manufacturer states zoster vaccine live is contraindicated in individuals with a history of anaphylactic/anaphylactoid reaction to neomycin.1 ACIP states that individuals with a history of anaphylactic reaction to neomycin should be evaluated by an allergist before receiving a neomycin-containing vaccine.134

Manufacturer and ACIP state that a history of delayed-type allergic reaction to neomycin is not a contraindication to use of the vaccine.1 134

Individuals with Altered Immunocompetence

Because zoster vaccine live contains live, attenuated virus, it is contraindicated in individuals immunocompromised as the result of disease (e.g., primary or acquired immunodeficiencies, HIV infection, leukemia, lymphoma, other malignancies involving the bone marrow or lymphatic system) or immunosuppressive therapy.1 6

Immune response to the vaccine and efficacy may be reduced in individuals with altered immunocompetence.134 In addition, use of zoster vaccine live in individuals with altered immunocompetence may result in serious or fatal disseminated VZV disease caused by the vaccine strain.1 4 Administration of the vaccine to an immunocompromised patient with chronic lymphocytic leukemia was associated with a fatal disseminated VZV infection complicated by meningoencephalitis.21

Although HIV-infected adults (especially those with CD4+ T-cell counts ≤200/mm3) are at increased risk for zoster,155 zoster vaccine live is contraindicated in such individuals.1 6 155 200

When initiation of immunosuppressive therapy anticipated, ACIP and other experts state that administration of a single dose of zoster vaccine live can be considered if the vaccine is administered ≥2–4 weeks prior to initiation of such therapy.134 135 (See Immunosuppressive Agents under Interactions.)

ACIP and other experts state that zoster vaccine live can be administered to healthy, immunocompetent adults who reside in households with immunocompromised individuals.134 135 However, if vaccinee develops zoster-associated rash, avoid close contact with immunocompromised individuals until lesions resolve.134 135

Transmission of Vaccine Virus

Zoster vaccine live contains live, attenuated VZV.1 Transmission of vaccine virus may occur between vaccinees and susceptible contacts.1 6

Transmission of zoster vaccine virus has not been documented to date; however, transmission of Oka/Merck strain of VZV has been reported rarely following administration of varicella virus vaccine live, usually only when vaccine recipient developed a varicella-like rash.6

Weigh risk of possible vaccine virus transmission against risk of developing natural zoster infection that could be transmitted to susceptible contacts.1 6

Concomitant Illness

Base decision to administer or delay vaccination in an individual with a current or recent acute illness on severity of symptoms and etiology of the illness.1 6 134

Do not administer zoster vaccine live during an acute episode of herpes zoster (zoster, shingles);4 defer vaccination until acute stage of the illness is over and symptoms have abated.4

Manufacturer states defer zoster vaccine live in patients with active untreated tuberculosis.1

Manufacturer suggests that zoster vaccine live be deferred in individuals with acute illness (e.g., in the presence of fever).1

ACIP states that mild acute illness generally does not preclude vaccination.134

ACIP states that moderate or severe acute illness (with or without fever) is a precaution for vaccination;134 defer vaccine administration until individual has recovered from the acute phase of the illness.134 This avoids superimposing vaccine adverse effects on the underlying illness or mistakenly concluding that a manifestation of the underlying illness resulted from vaccine administration.134

Limitations of Vaccine Effectiveness

Does not prevent zoster in all vaccine recipients.1 2 In vaccinated individuals who develop zoster, duration of pain and discomfort may be reduced.1 2

May be less effective in those ≥70 years of age than in those 60–69 years of age.1 2

Duration of Immunity

Duration of protection against zoster following a single dose of zoster vaccine live and need for revaccination or additional (booster) doses not fully determined.1 20

Data to date indicate the duration of protection is at least 4–5 years,1 20 but duration of protection beyond 5 years is uncertain.20

Substantial decrease in effectiveness occurs following the first year after vaccination with zoster vaccine live and there is some evidence that efficacy against zoster in vaccinees is <35% by 6 years postvaccination.4

Although zoster vaccine live is labeled by FDA for use in adults ≥50 years of age,1 ACIP states that adults who receive the vaccine at 50–59 years of age may not be protected when their risk for zoster and its complications is highest.20

Improper Storage and Handling

Improper storage or handling of vaccines may reduce vaccine potency resulting in reduced or inadequate immune responses in vaccinees.134

Inspect all vaccines upon delivery and monitor during storage to ensure that the appropriate temperature is maintained.134 To maintain potency, lyophilized zoster vaccine live should be stored frozen at −50 to −15°C and used within 30 minutes following reconstitution.1 (See Storage under Stability.)

Do not administer zoster vaccine that has been mishandled or has not been stored at the recommended temperature.1 134

If there are concerns about mishandling, contact the manufacturer or state or local immunization or health departments for guidance on whether the vaccine is usable.134

Specific Populations

Pregnancy

Contraindicated during pregnancy; avoid pregnancy for 3 months following administration of the vaccine.1

Available data insufficient to assess risks of zoster vaccine live in pregnant women.1 23 134

Naturally occurring VZV infection during pregnancy can cause fetal harm (i.e., congenital varicella syndrome).1 6 7 23

Because theoretical risk for congenital varicella syndrome cannot be ruled out,23 134 do not administer to pregnant women.1 134

Inform vaccinees of theoretical risk of transmitting the live, attenuated vaccine virus to varicella-susceptible individuals, including pregnant women who have not had chickenpox.1 (See Transmission of Vaccine Virus under Cautions.)

Lactation

Manufacturer states it is not know whether live, attenuated VZV contained in zoster vaccine live is distributed into human milk.1

Consider benefits of breast-feeding and importance of zoster vaccine live to the woman along with potential adverse effects on the breast-fed child from the vaccine or from the underlying maternal condition (i.e., susceptibility to reactivation of VZV infection).1

ACIP states that live, attenuated virus vaccines generally do not pose any unusual risks for women who are breast-feeding or their breast-fed infants.134 Although live vaccine viruses can replicate in the mother, most live vaccine viruses (including varicella vaccine virus) do not appear to be distributed into milk.6 134 Therefore, ACIP states that breast-feeding is not a contraindication for zoster vaccine live.6

Pediatric Use

Not indicated in children and adolescents.1

Geriatric Use

Safety and efficacy established only in adults ≥50 years of age, including geriatric adults.1 6 Median age of individuals enrolled in the largest clinical study was 69 years.1

Common Adverse Effects

Injection site reactions (erythema, pain/tenderness, swelling, pruritus, warmth, hematoma, induration), headache, extremity pain.1 6

Interactions for Zoster Vaccine Live

Immunosuppressive Agents

Immune responses to vaccines may be reduced in individuals receiving immunosuppressive therapy.134 135 In addition, use of zoster vaccine live in individuals receiving immunosuppressive therapy may result in serious and potentially fatal disseminated VZV disease caused by the vaccine strain.1 4 Zoster vaccine live contraindicated in individuals receiving immunosuppressive therapy.1 (See Individuals with Altered Immunocompetence under Cautions.)

Generally give live, attenuated virus vaccines ≥2–4 weeks prior to initiation of immunosuppressive therapy and do not give during or for certain periods of time after immunosuppressive therapy discontinued.6 134 135 (See Specific Drugs under Interactions.)

Vaccines

Concurrent administration with age-appropriate inactivated vaccines or toxoids during the same health-care visit (using separate syringes and different injection sites) generally not expected to affect immunologic responses or adverse reactions to any of the vaccines.6

If another parenteral live vaccine is indicated in a patient receiving zoster vaccine live, ACIP states that the vaccines should either be administered on the same day or ≥4 weeks (28 days) apart.6

Specific Drugs

Drug

Interaction

Comments

Antiviral agents active against VZV (e.g., acyclovir, famciclovir, valacyclovir)

Data not available to date regarding use of zoster vaccine live in patients receiving antiviral agents active against VZV1 7 13 16

Possibility of interference with replication of live, attenuated VZV contained in zoster vaccine live6 134

Discontinue antiviral agents active against VZV ≥24 hours before administration of zoster vaccine live, if possible, and do not give such antivirals until ≥14 days after the vaccine6 134

Blood products (e.g., whole blood, packed RBCs, plasma, platelet products)

May be given concurrently with or at any interval before or after blood or other antibody-containing blood products6 134

Immune globulin (immune globulin IM [IGIM], immune globulin IV [IGIV], immune globulin sub-Q) or specific hyperimmune globulin (hepatitis B immune globulin [HBIG], rabies immune globulin [RIG], tetanus immune globulin [TIG], varicella zoster immune globulin [VZIG])

May be given concurrently with or at any interval before or after immune globulin or specific hyperimmune globulin 6 134

Immunosuppressive agents (e.g., chemotherapy, certain biologic response modifiers, corticosteroids, radiation)

Possible decreased immune responses to vaccines;134 increased risk of serious and potentially fatal disseminated VZV disease caused by the vaccine virus1 4

Anti-B-cell antibodies (e.g., rituximab): Optimal time to administer vaccines after such treatment unclear135

Corticosteroids: High-dose systemic corticosteroid therapy (prednisone or equivalent in a dosage ≥2 mg/kg daily or ≥20 mg daily given for ≥2 weeks) considered immunosuppressive;6 134 corticosteroid therapy involving short-term (<2 weeks) or low- to moderate-dose systemic therapy (<20 mg prednisone or equivalent daily); long-term, alternate-day systemic therapy using short-acting drugs; maintenance physiologic doses (replacement therapy); topical therapy (e.g., cutaneous, ophthalmic); oral inhalation; or intra-articular, bursal, or tendon injections should not be immunosuppressive6 134

Chemotherapy or radiation: Generally give live, attenuated virus vaccines ≥2–4 weeks before or defer until ≥3 months after such therapy discontinued134 135

Immunosuppressive anti-rejection therapies in solid organ transplant recipients: Defer zoster vaccine live until ≥1 month after such therapies discontinued134

Anti-B-cell antibodies (e.g., rituximab): ACIP states give zoster vaccine live ≥2 weeks before or defer until ≥1 month after such therapy;134 some experts state generally give live, attenuated virus vaccines ≥2–4 weeks before or defer until ≥6 months after such therapy discontinued134 135

Certain biologic response modifiers (e.g., colony-stimulating factors, interleukins, tumor necrosis factor [TNF] blocking agents): Generally give live, attenuated virus vaccines ≥2 weeks before or defer until ≥3 months after such therapy134

Corticosteroids: Give zoster vaccine live ≥2 weeks before or defer until ≥1 month after high-dose systemic corticosteroid therapy discontinued;6 134 135 may be given concurrently with or any time before or after lower-dose corticosteroid therapy6 134 135

Influenza vaccine

Parenteral trivalent inactivated influenza vaccine: Has been given concurrently with zoster vaccine live in adults ≥60 years of age without a decrease in antibody responses1 6 22

Parenteral quadrivalent inactivated influenza vaccine: Has been given currently with zoster vaccine live in adults ≥50 years of age without a decrease in antibody responses1

Parenteral inactivated influenza vaccine: May be given concurrently with zoster vaccine live (using separate syringes and different injection sites)6 22

Pneumococcal vaccine

Pneumococcal 23-valent vaccine (PPSV23; Pneumovax 23): Concurrent administration with zoster vaccine live in adults ≥60 years of age resulted in significantly reduced antibody response to the zoster vaccine compared to administration 4 weeks apart1 25

Manufacturer of zoster vaccine live states consider giving PPSV23 and zoster vaccine live ≥4 weeks apart1

Stability

Storage

Parenteral

For Injection, for Sub-Q Use

To maintain potency during shipment and storage, keep lyophilized zoster vaccine frozen at −50 to −15°C and protect from light.1

Any freezer (e.g., frost-free) that reliably maintains an average temperature of −50 to −15°C and has a separate sealed freezer door is acceptable;1 use of dry ice may expose the vaccine to temperatures colder than −50°C.1

When optimal handling conditions are not feasible (e.g., during transportation), the lyophilized vaccine may be stored for ≤72 hours at 2–8°C;1 discard the refrigerated vaccine if it has not been used within 72 hours after removal from storage at −50 to −15°C.1

Store vial containing the diluent supplied by the manufacturer separately either at room temperature (20–25°C) or in a refrigerator (2–8°C).1

Contact the manufacturer at 800-637-2590 for information regarding vaccine stability under conditions other than those recommended.1

Use immediately following reconstitution;1 discard reconstituted vaccine if not used within 30 minutes.1 Do not freeze.1

Zoster vaccine does not contain thimerosal or any other preservatives.1 6

Actions

  • Zoster vaccine is a lyophilized preparation containing live, attenuated VZV of the Oka/Merck strain.1 2 3 5 6 15

  • Contains same antigen as varicella virus vaccine live (Varivax); however, zoster vaccine live is about 14 times more potent than varicella virus vaccine live.1 6 10 The higher potency of varicella antigen contained in zoster vaccine live is required to elicit a clinically important increase in cell-mediated immunity to VZV in older adults.2 3

  • Vaccination with a single dose of zoster vaccine live boosts active immunity to VZV, thereby reducing reactivation of VZV and development of zoster and complications of the disease.1 2 3 5 6 15

  • Herpes zoster (zoster, shingles) and varicella (chickenpox) are distinct clinical entities caused by the same virus, VZV.3 6 7 13 16 During primary infection, VZV causes chickenpox; the virus invades sensory neurons and becomes latent in sensory nerve ganglia, establishing a source of potential secondary infection.1 2 3 6 7 13 15 16

  • Zoster is characterized by unilateral, painful, vesicular cutaneous eruption with a dermatomal distribution.1 2 6 13 15 16 Pain may occur during the prodrome, the acute eruptive phase, and the postherpetic phase of the infection (PHN).1 2 6 13 16 Serious complications of the disease (e.g., scarring, bacterial superinfection, allodynia, cranial and motor neuron palsies, pneumonia, encephalitis, visual impairment, hearing loss, death) may occur.1 6 13 15 16

  • A single dose of zoster vaccine live boosts VZV antibody levels 2.3-fold in adults 50–59 years of age or 1.7-fold in adults ≥60 years of age.1

  • Minimum antibody titer that correlates with protection against zoster not established.1 6 15

Advice to Patients

  • Provide copy of manufacturer’s patient information.1 Also provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient’s legal representative (VISs are available at [Web]).24

  • Advise patient of the risks and benefits of vaccination with zoster vaccine live.1

  • Advise patient that zoster vaccine live is used to prevent zoster (shingles) and cannot be used to treat shingles once the condition develops.1 Also advise patient that the vaccine is not used to prevent primary varicella infection (chickenpox).1

  • Advise patient that zoster vaccine may not provide protection against zoster (shingles) in all vaccinees.1

  • Advise patient that they should not receive zoster vaccine live if they have a history of anaphylactic/anaphylactoid reactions to any of its ingredients (e.g., gelatin, neomycin).1

  • Advise patient that they should not receive zoster vaccine live if they have a disease that weakens the immune system (e.g., HIV/AIDS, leukemia, lymphoma) or are receiving treatment that may weaken the immune system (e.g., high-dose corticosteroids).1

  • Advise patient of the theoretical risk of transmitting the vaccine virus to varicella-susceptible individuals, including immunosuppressed or immunodeficient individuals or pregnant women who have not had chickenpox.1 Importance of informing clinician if they expect to be in close contact with individuals with weakened immune systems, neonates, or pregnant women who have not had chickenpox or have not been vaccinated against chickenpox.1

  • Importance of contacting clinicians if an adverse reaction or hypersensitivity reaction (e.g., difficulty breathing or swallowing) occurs following the vaccine dose.1 Clinicians or individuals can report any adverse reactions that occur following vaccination to the Vaccine Adverse Event Reporting System (VAERS) at 800-822-7967 or [Web].1 6

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, and any concomitant illnesses.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information.1 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Zoster Vaccine Live

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

For injectable suspension, for subcutaneous use

≥19,400 plaque-forming units (PFU) of Oka/Merck strain of varicella zoster virus per 0.65 mL

Zostavax

Merck

AHFS DI Essentials™. © Copyright 2018, Selected Revisions November 26, 2018. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

References

1. Merck, Sharp & Dohme Corp. Zostavax (zoster vaccine live) suspension for subcutaneous injection prescribing information. Whitehouse Station, NJ; 2018 Jul.

2. Oxman MN, Levin MJ, Johnson GR et al; Shingles Prevention Study Group. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005; 352:2271-84. http://www.ncbi.nlm.nih.gov/pubmed/15930418?dopt=AbstractPlus

3. Arvin A. Aging, immunity, and the varicella-zoster virus. N Engl J Med. 2005; 352:2266-7. http://www.ncbi.nlm.nih.gov/pubmed/15930416?dopt=AbstractPlus

4. 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. http://www.ncbi.nlm.nih.gov/pubmed/29370152?dopt=AbstractPlus

5. Gilden DH. Varicella-zoster virus vaccine--grown-ups need it, too. N Engl J Med. 2005; 352:2344-6. http://www.ncbi.nlm.nih.gov/pubmed/15930426?dopt=AbstractPlus

6. Centers for Disease Control and Prevention. Prevention of herpes zoster. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008; 57(RR-5):1-30. http://www.cdc.gov/mmwr/PDF/rr/rr5705.pdf

7. Whitley RJ. Varicella-Zoster Virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett’s principles and practice of infectious diseases. 6th ed. New York: Churchill Livingstone; 2005:1780-6.

8. Shimabukuro TT, Miller ER, Strikas RA et al. Notes from the Field: Vaccine Administration Errors Involving Recombinant Zoster Vaccine - United States, 2017-2018. MMWR Morb Mortal Wkly Rep. 2018; 67:585-586. http://www.ncbi.nlm.nih.gov/pubmed/29795075?dopt=AbstractPlus

9. Supplementary Appendix to Oxman MN, Levin MJ, Johnson GR et al; Shingles Prevention Study Group. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005; 352:2271-84. http://www.ncbi.nlm.nih.gov/pubmed/15930418?dopt=AbstractPlus

10. Merck & Co. Varivax (varicella virus vaccine live) prescribing information. Whitehouse Station, NJ; 2009 Jun.

12. Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007; 56(RR-4):1-40. http://www.cdc.gov/mmwr/PDF/rr/rr5604.pdf

13. Gnann JW, Whitley RJ. Clinical practice. Herpes zoster. N Engl J Med. 2002; 347:340-5. http://www.ncbi.nlm.nih.gov/pubmed/12151472?dopt=AbstractPlus

15. Hambleton S, Gershon AA. Preventing varicella-zoster disease. Clin Microbiol Rev. 2005; 18:70-80. http://www.ncbi.nlm.nih.gov/pubmed/15653819?dopt=AbstractPlus http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=544176&blobtype=pdf

16. Dworkin RH, Johnson RW, Breuer J et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007; 44:S1-S26. http://www.ncbi.nlm.nih.gov/pubmed/17143845?dopt=AbstractPlus

17. Merck & Co. North Wales, PA: Personal communication.

18. A phase III clinical trial to study the safety, tolerability and immunogenicity of zoster vaccine live (Oka/Merck) in subjects with a history of herpes zoster. From ClinicalTrials.gov web site. (http://www.clinicaltrials.gov/ct/show/NCT00322231?order=1). Accessed 2007 Jan 8.

20. Hales CM, Harpaz R, Ortega-Sanchez I et al. Update on recommendations for use of herpes zoster vaccine. MMWR Morb Mortal Wkly Rep. 2014; 63:729-31. http://www.ncbi.nlm.nih.gov/pubmed/25144544?dopt=AbstractPlus

21. Alexander KE, Tong PL, Macartney K et al. Live zoster vaccination in an immunocompromised patient leading to death secondary to disseminated varicella zoster virus infection. Vaccine. 2018; 36:3890-3893. http://www.ncbi.nlm.nih.gov/pubmed/29807711?dopt=AbstractPlus

22. Kerzner B, Murray AV, Cheng E et al. Safety and immunogenicity profile of the concomitant administration of zostavax and inactivated influenza vaccine in adults aged 50 and older. J Am Geriatr Soc. 2007; 55:1499-507. http://www.ncbi.nlm.nih.gov/pubmed/17908055?dopt=AbstractPlus

23. Marin M, Willis ED, Marko A et al. Closure of varicella-zoster virus-containing vaccines pregnancy registry - United States, 2013. MMWR Morb Mortal Wkly Rep. 2014; 63:732-3. http://www.ncbi.nlm.nih.gov/pubmed/25144545?dopt=AbstractPlus

24. Centers for Disease Control and Prevention. Live zoster (shingles) vaccine, ZVL, vaccine information statement. 2018 Feb 12. From CDC website. https://www.cdc.gov/vaccines/hcp/vis/index.html

25. Macintyre CR, Egerton T, McCaughey M et al. Concomitant administration of zoster and pneumococcal vaccines in adults ≥60 years old. Hum Vaccin. 2010; 6:894-902. http://www.ncbi.nlm.nih.gov/pubmed/20980796?dopt=AbstractPlus

26. GlaxoSmithKline. Shingrix (zoster vaccine recombinant, adjuvanted suspension for intramuscular injection) prescribing information. Research Triangle Park, NC; 2017 Oct.

134. Kroger AT, Duchin J, Vazquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). From CDC website. Accessed 2018 Aug 15. Updates may be available at CDC website. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf

135. Rubin LG, Levin MJ, Ljungman P et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014; 58:309-18. http://www.ncbi.nlm.nih.gov/pubmed/24421306?dopt=AbstractPlus

155. Panel on Opportunistic Infection in HIV-infected Adults and Adolescents, US Department of Health and Human Services (HHS). Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Accessed August 1, 2018. Updates may be available at HHS AIDS Information (AIDSinfo) website. http://www.aidsinfo.nih.gov

166. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 13th ed. Washington DC: Public Health Foundation; 2015. Available at CDC website. http://www.cdc.gov/vaccines/pubs/pinkbook/index.html

200. Centers for Disease Control and Prevention. Recommended immunization schedule for adults 19 years or older, United States, 2018. Updates may be available at CDC website. http://www.cdc.gov/vaccines/schedules/index.html

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