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Zoster Vaccine Recombinant

Class: Vaccines
VA Class: IM100
Brands: Shingrix

Medically reviewed on Nov 26, 2018

Introduction

Inactivated (recombinant) vaccine.1 Zoster vaccine recombinant contains recombinant varicella zoster virus (VZV) surface glycoprotein E (gE) and an adjuvant (i.e., AS01B) and is used to boost active immunity to VZV.1 2 3 5

Uses for Zoster Vaccine Recombinant

Prevention of Herpes Zoster

Prevention of herpes zoster (zoster, shingles) in adults ≥50 years of age.1 2 3

Zoster is caused by reactivation of latent VZV infection in individuals who previously had varicella (chickenpox) infection.2 3 4 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.4 7 13 166 Risk of developing zoster increases with age and declining cell-mediated immunity to VZV.1 2 3 4 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 recombinant is used to boost active immunity to VZV, thereby reducing risk of VZV reactivation.1 2 3 4 May also reduce frequency and/or duration of PHN in those who develop zoster despite vaccination.1 2 3 4

Not indicated for treatment of zoster or PHN.4 Do not administer during an acute episode of zoster.4 Has no role in postexposure management of zoster.166

Not indicated for prevention of primary varicella infection (chickenpox);1 4 do not use in children or adults <50 years of age.1 4 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 17

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

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 Recombinant Dosage and Administration

Administration

Administer only by IM injection.1 Do not administer sub-Q, IV, or intradermally.1

May be given concurrently with other age-appropriate vaccines.4 When multiple vaccines are administered during a single health-care visit, give each parenteral vaccine using separate syringes and different injection sites.4 134 Injection sites should be separated by ≥1 inch (if anatomically feasible) to allow appropriate attribution of any local adverse effects that may occur.134

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 17 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 17

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 17

IM Administration

Administer reconstituted zoster vaccine recombinant by IM injection, preferably into deltoid region of upper arm.1

To ensure delivery into muscle, make IM injections at a 90° angle to the skin using a needle length appropriate for the individual’s age and body mass, thickness of adipose tissue and muscle at injection site, and injection technique.134 Consider anatomic variability, especially in deltoid, and use clinical judgment to avoid inadvertent underpenetration or overpenetration of muscle.134

Reconstitution

Commercially available as a kit containing single-dose vials of lyophilized VZV gE antigen and single-dose vials of AS01B adjuvant suspension.1

Prior to administration, reconstitute a single-dose vial of lyophilized VZV gE antigen from the kit by adding entire contents of a single-dose vial of adjuvant suspension from the kit according to the manufacturer's directions.1 After adding the adjuvant suspension component to the VZV gE antigen component, gently agitate to ensure the powder is completely dissolved.1 Reconstituted vaccine is an opalescent, colorless to pale brown liquid;1 discard if it contains particulates or appears discolored.1 Consult manufacturer’s labeling for additional information regarding preparation of zoster vaccine recombinant.1

Administer immediately after reconstitution or store at 2–8° for up to 6 hours.1 Discard if not used within 6 hours.1 (See Storage under Stability.)

Dosage

Adults

Prevention of Herpes Zoster
Adults ≥50 Years of Age
IM

Give zoster vaccine recombinant in a series of 2 doses.1 4 200 Each dose is 0.5 mL.1 4

Give second dose 2–6 months after first dose.1 4 200

Minimum interval between the 2 doses is 4 weeks.134 ACIP states repeat second dose if it was inadvertently given <4 weeks after first dose.4

If interruptions or delays result in an interval >6 months between the 2 doses, ACIP states vaccine series does not need to be restarted; however, efficacy of dosing interval >6 months not evaluated to date.4

A 2-dose regimen recommended regardless of history of zoster or prior vaccination with varicella virus vaccine live or zoster vaccine live.4 200

If used in those who previously received zoster vaccine live, give zoster vaccine recombinant ≥2 months after zoster vaccine live.4 200

Special Populations

Hepatic Impairment

No specific dosage recommendations.1

Renal Impairment

No specific dosage recommendations.1

Cautions for Zoster Vaccine Recombinant

Contraindications

  • History of severe allergic reaction (e.g., anaphylaxis) to any component of the vaccine or to a previous dose of the vaccine.1 (See Sensitivity Reactions under Cautions.)

Warnings/Precautions

Sensitivity Reactions

Take all known precautions to prevent adverse reactions, including a review of the patient’s history with respect to possible hypersensitivity to the vaccine or previous vaccine-associated adverse reactions.1

Have appropriate medical treatment readily available in case an anaphylactic reaction occurs.1

Individuals with Altered Immunocompetence

Individuals with altered immunocompetence were excluded from initial clinical trials evaluating safety and efficacy of zoster vaccine recombinant.1 2 3 4 5

ACIP states that recombinant vaccines generally can be administered safely to individuals with altered immunocompetence.134

Recommendations for use of recombinant vaccines in HIV-infected individuals usually are the same as those for individuals without HIV infection.155

Immune response and efficacy may be reduced in individuals receiving immunosuppressive therapy.1 (See Specific Drugs under Interactions.)

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.134

Do not administer zoster vaccine recombinant during an acute episode of zoster;4 defer vaccination until acute stage of the illness is over and symptoms have abated.4

May be administered to age-appropriate adults with certain chronic medical conditions (e.g., chronic renal failure, diabetes mellitus, rheumatoid arthritis, chronic pulmonary disease).4

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

ACIP states 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 In vaccinated individuals who develop zoster, duration of pain and discomfort may be reduced.1 2 3

Duration of Immunity

Duration of protection against zoster following a 2-dose series of zoster vaccine recombinant not fully determined.1 4

Data to date indicate duration of protection following a 2-dose series is at least 4 years;4 ACIP states that substantial protection against zoster is likely for >4 years.4

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 (See Storage under Stability.)

Do not administer 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

Data not available regarding use of zoster vaccine recombinant in pregnant women.1 In animal studies, no evidence that the vaccine or the AS01B adjuvant component of the vaccine affects fetal development or causes fetal harm.1

ACIP states consider deferring administration of zoster vaccine recombinant in pregnant women.4

Lactation

Not known whether zoster vaccine recombinant vaccine is distributed into milk, affects milk production, or affects the breast-fed infant.1

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

ACIP states that recombinant vaccines generally do not pose any unusual risks for women who are breast-feeding or their breast-fed infants.134 However, these experts state consider deferring administration of zoster vaccine recombinant in women who are breast-feeding.4

Pediatric Use

Safety and efficacy not established in pediatric patients.1 Not indicated for prevention of primary varicella infection (chickenpox).1

Geriatric Use

Safety and efficacy established only in adults ≥50 years of age, including geriatric adults.1

No clinically meaningful differences in efficacy among various age groups of adults ≥60 years of age or between those ≥60 years of age and those 50–59 years of age;1 adverse effects reported less frequently in vaccine recipients ≥70 years of age compared with those 50–69 years of age.1

Common Adverse Effects

Injection site reactions (pain,1 2 3 4 erythema,1 2 4 swelling),1 2 4 myalgia,1 2 4 fatigue,1 2 3 4 headache,1 2 4 shivering,1 2 4 fever,1 2 4 GI symptoms (nausea, vomiting, diarrhea, abdominal pain).1 2 4

Interactions for Zoster Vaccine Recombinant

Vaccines

Concurrent administration with other age-appropriate vaccines or toxoids during the same health-care visit (using separate syringes and different injection sites) not expected to affect immunologic responses or adverse reactions to any of the vaccines.4

Specific Drugs

Drug

Interaction

Comments

Immunosuppressive agents (e.g., corticosteroids)

Potential for decreased immune responses to zoster vaccine recombinant1

Corticosteroids: Zoster vaccine recombinant may be used in those receiving low-dose systemic corticosteroid therapy (prednisone or equivalent in a dosage <20 mg daily) or inhaled or topical corticosteroid therapy;4 not evaluated in those receiving high-dose corticosteroid therapy4

Influenza vaccine

Parenteral non-adjuvant-containing influenza virus vaccine inactivated: Concurrent administration of inactivated influenza vaccine (Fluarix Quadrivalent) and zoster vaccine recombinant in adults ≥50 years of age did not interfere with immune responses to either vaccine and was not associated with any safety concerns1 4

Adjuvant-containing influenza virus vaccine inactivated (Fluad): Safety and efficacy of concurrent or sequential administration with zoster vaccine recombinant not evaluated4

Parenteral non-adjuvant-containing influenza virus vaccine inactivated: May be given concurrently with zoster vaccine recombinant (using separate syringes and different injection sites)1 4

Pneumococcal vaccine

Pneumococcal 23-valent vaccine (PPSV23; Pneumovax 23): Concurrent administration with zoster vaccine recombinant in adults ≥50 years of age did not interfere with immune responses to either vaccine and did not affect safety profile of the vaccines10

Zoster vaccine live

Zoster vaccine recombinant has been administered to adults who received zoster vaccine live ≥5 years earlier;4 no data and no theoretical concerns indicating that zoster vaccine recombinant would be less effective or less safe if administered in adults who received zoster vaccine live <5 years earlier4

If used in adults who previously received zoster vaccine live, ACIP recommends that zoster vaccine recombinant be given ≥2 months after zoster vaccine live4 200

Stability

Storage

Parenteral

For Injectable Suspension, for IM Use

Vials containing lyophilized gE antigen: 2–8°; protect from light.1 Do not freeze; if freezing occurs, discard.1

Vials containing AS01B adjuvant suspension: 2–8°; protect from light.1 Do not freeze; if freezing occurs, discard.1

Use immediately following reconstitution.1 Alternatively, reconstituted vaccine may be stored at 2–8°C for ≤6 hours;1 discard if not used within 6 hours.1 Do not freeze: if freezing occurs, discard reconstituted vaccine.1

Actions

  • Zoster vaccine recombinant is an inactivated (recombinant) vaccine used to boost immunity to VZV, thereby reducing the risk of reactivation of VZV and development of zoster and complications of the disease.1

  • Commercially available as a kit containing single-dose vials of lyophilized VZV gE antigen and single-dose vials of AS01B adjuvant suspension.1 The VZV gE antigen component and the adjuvant component must be combined prior to administration (see Reconstitution under Dosage and Administration).1

  • The recombinant VZV gE antigen component is prepared using recombinant DNA technology and Chinese hamster ovary (CHO) cells.1 The adjuvant component is a liposomal formulation of AS01B that enhances the immune response to the recombinant VZV gE antigen.9

  • Administration of a 2-dose vaccination series of zoster vaccine recombinant in adults ≥50 years of age boosts VZV-specific cell-mediated immune responses and VZV-specific humoral immunity resulting in a reduced risk of zoster and PHN in vaccinees.1 2 3 4 9 19 The immunologic response to a 2-dose regimen of the vaccine has been evaluated in adults ≥50 years of age with and without a history of zoster.2 3 5 9

  • Herpes zoster (zoster, shingles) and varicella (chickenpox) are distinct clinical entities caused by the same virus, VZV.4 6 7 13 16 166 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.2 3 6 7 13 15 16 166

  • Zoster is characterized by unilateral, painful, vesicular cutaneous eruption with a dermatomal distribution.2 6 13 15 16 Pain may occur during the prodrome, the acute eruptive phase, and the postherpetic phase of the infection (PHN).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.6 13 15 16

  • Minimum immune response that correlates with protection against zoster not established.1

Advice to Patients

  • Prior to administration, provide a copy of the appropriate CDC Vaccine Information Statement (VIS) to the patient or patient’s legal representative (VISs are available at [Web]).18

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

  • Advise patient of the importance of receiving 2 doses of zoster vaccine recombinant given 2–6 months apart.1

  • Advise patient that zoster vaccine recombinant may not provide protection in all vaccinees.1

  • Inform patients about the potential for adverse reactions temporally associated with the vaccine.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

  • 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 Recombinant, Adjuvanted

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Kit, for IM use only

For injectable suspension, for IM use, 50 mcg of recombinant varicella zoster virus glycoprotein E antigen per 0.5 mL

Injectable suspension, for IM use, AS01B adjuvant containing 50 mcg of 3-O-desacyl-4′-monophosphoryl lipid A (MPL) and 50 mcg of Quillaja saponaria Molina (QS21) per 0.5 mL

Shingrix

GlaxoSmithKline

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

2. Lal, H, Cunningham, AL, Godeaux O et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. NEJM. 2015; 372:2087-96.

3. Cunningham, AL, Lal, H, Kovac M et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. NEJM. 2016; 375:1019-32.

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. Godeaux O, Kovac M, Shu D et al. Immunogenicity and safety of an adjuvanted herpes zoster subunit candidate vaccine in adults ≥50 years of age with a prior history of herpes zoster: A phase III, non-randomized, open-label clinical trial. Hum Vaccin Immunother. 2017; 13:1051-1058. http://www.ncbi.nlm.nih.gov/pubmed/28068212?dopt=AbstractPlus

6. Harpaz R, Ortega-Sanchez IR, Seward JF et al. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2008; 57(RR-5):1-30; quiz CE2-4. http://www.ncbi.nlm.nih.gov/pubmed/18528318?dopt=AbstractPlus

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. Cunningham AL, Heineman TC, Lal H et al. Immune Responses to a Recombinant Glycoprotein E Herpes Zoster Vaccine in Adults Aged 50 Years or Older. J Infect Dis. 2018; 217:1750-1760. http://www.ncbi.nlm.nih.gov/pubmed/29529222?dopt=AbstractPlus

10. Maréchal C, Lal H, Poder A et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine co-administered with the 23-valent pneumococcal polysaccharide vaccine in adults ≥50 years of age: A randomized trial. Vaccine. 2018; 36:4278-4286. http://www.ncbi.nlm.nih.gov/pubmed/29903674?dopt=AbstractPlus

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

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

19. US Food and Drug Administration. Center for Drug Evaluation and Research. Application number 125614: Summary Basis for Regulatory Action. From FDA website https://www.fda.gov/downloads/BiologicsBloodVaccines/Vaccines/ApprovedProducts/UCM584456.pdf

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

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

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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