23. Zoster (herpes zoster/shingles)

Key information

Mode of transmission

Zoster is a reactivation of the varicella-zoster virus in someone who has previously had varicella disease (most often as chickenpox).

Direct contact with zoster vesicles has a low risk of causing varicella in non-immune individuals – can be prevented by covering rash.

There is potential for aerosol transmission from some immunocompromised cases with viraemia.

Period of communicability

Until lesions have crusted.

Incidence and burden of disease

Increasing incidence with age; lifetime risk about 1 in 3. For those aged over 85 years, the risk is 1 in 2. Complications include post-herpetic neuralgia and herpes zoster ophthalmicus.

Funded vaccine

Zoster vaccine (Zostavax), a higher titre formulation of the live attenuated varicella vaccine.

Zoster vaccine is approved for use from age 50 years.

Do not give to children.

Do not give to severely immunocompromised adults.

Dose, presentation, route

ZV:

  • 0.65 mL per reconstituted dose.
  • Vial of vaccine, plus diluent in a pre-filled syringe. The vaccine must be reconstituted prior to injection.
  • Intramuscular or subcutaneous injection.

rZV:

  • 0.5 ml per reconstituted dose
  • vial of vaccine powder and vial of suspension for one dose. The vaccine must be reconstituted prior to injection.
  • Intramuscular injection only

Funded vaccine indications and recommended schedule

One dose of ZV is funded for individuals at age 65 years.

ZV may be given to individuals with a prior history of zoster. After the zoster episode has resolved the vaccination benefit is unclear – wait at least 1 year before administering the vaccine.

Recommended, not funded

Recombinant ZV (rZV, Shingrix)

  • Approved for use from age 50 years
  • recommended for individuals with increased risk of zoster due to age and comorbidities, and individuals who are contraindicated live ZV.

Vaccine efficacy/ effectiveness

ZV: Reduces the burden of zoster illness by 61 percent in all adults aged over 60 years, by 66 percent in those aged 60–69 years and by 55 percent in those aged 70 years and older.

rZV: Showed efficacy against both zoster and post herpetic neuralgia of over 90 percent in participants aged over 50 years and over 70 years, including those with comorbidities, maintained at 84 percent for at least 7 years.

Contraindications

See section 23.6.1, for ZV:

  • risk of disseminated vaccine-derived disease including certain primary and secondary immune deficiencies and immunosuppressive therapy, including high-dose steroids
  • known systemic hypersensitivity to neomycin
  • active untreated TB
  • pregnancy.

23.1. Virology

Varicella-zoster virus (VZV) is a DNA virus from the herpesvirus family. The virus is usually acquired in childhood and primary infection with VZV causes varicella disease (chickenpox). Herpes zoster (zoster), or ‘shingles’, is a clinical syndrome caused reactivation of latent VZV, which resides in the dorsal root or trigeminal nerve ganglia after primary infection. VZV is usually acquired in childhood, but it is often many decades before the virus reactivates, at times when cellular immunity is compromised and is unable to maintain suppression of the virus.

23.2. Clinical features

Herpes zoster (shingles) occurs when the cell-mediated immune response is impaired and unable to maintain suppression of latent varicella-zoster virus reactivation (see chapter 22). Zoster occurs only by loss of suppression and reactivation of the patient’s own virus – which is often acquired in childhood; it is not acquired from other patients with zoster or varicella.[1] But the zoster rash vesicles contain low levels of VZV that are able, through direct contact, to potentially cause varicella in VZV-naïve individuals.

Zoster presents clinically as a unilateral vesicular rash in a dermatomal distribution in most cases. The dermatomal distribution of the rash is the key diagnostic feature. In 70–80 percent of zoster cases in older adults, prodromal pain and/or itching occurs three to four days before the appearance of the rash.[2] In the majority of patients, zoster is an acute and self-limiting disease, with the rash lasting 10–15 days. However, complications can occur, especially with increasing age.

Although most zoster cases occur in adults aged 40 years or older, it may be seen less commonly in infants and children. In those aged under 2 years may reflect in utero chickenpox, with the greatest risk arising following exposure between 25 and 36 weeks’ gestation, and reactivation in early life. Infants who get varicella at a young age have a higher change of having zoster before the age 20 years.

A common complication of zoster is post-herpetic neuralgia (PHN), a chronic, often debilitating pain condition that can last several months or even years. A systematic review of the incidence and complications of zoster found that the risk of developing post-herpetic neuralgia ranges between 5 and about 30 percent (depending on the type of study design, age distribution of the study populations and definition).[3] The risk rises with age, and it is uncommon in healthy children and young people.

Herpes zoster ophthalmicus (HZO) is another complication of zoster, which occurs when VZV reactivation affects the ophthalmic branch of the trigeminal nerve. HZO can occur with or without eye involvement, and can result in prolonged or permanent pain, facial scarring and loss of vision. About 10 percent of zoster patients develop HZO, if that dermatome is affected, and the risk is similar across all age groups.[3]

Zoster occurs more commonly in immunocompromised individuals, such as due to immunosuppression (eg, organ transplant patients, treatments for cancer and immune-mediated inflammatory diseases) and those with HIV. Up to 10 percent of children treated for a malignant neoplasm may develop zoster. In immunocompromised patients, extensive viraemia in the absence of a vigorous immune response can result in a disseminated form of zoster that includes severe multi-organ disease.[24] There is an increased risk of airborne transmission of VZV for immunocompromised individuals with viraemia. Other risk factors for developing zoster include rheumatoid arthritis,[5] sleep disorders[6] and type 2 diabetes.[7]

23.3. Epidemiology

23.3.1. Global burden of disease

Zoster is a sporadic disease occurring as a reactivation of the VZV in individuals who have previously had chickenpox. Approximately one in three people will develop zoster during their lifetime with the incidence rising as cell-mediated immunity to VZV declines with age;[8] 50 percent of those aged 85 years or over will suffer zoster.[910] A systematic review documented an incidence rate between 3 and 5 per 1,000 person-years in North America, Europe and Asia-Pacific.[3] The incidence rate was about 6–8 per 1,000 person-years at age 60 years and 8–12 per 1,000 person-years at age 80 years.

Recurrence is greater in females than males (about 7 percent after eight years compared with 4 percent for males). Third episodes are rare.

VZV is present in lesions of zoster and is transmissible via direct contact with the vesicles to other susceptible individuals (causing chickenpox). Airborne transmission can occur from immunocompromised individuals with disseminated zoster. Episodes of zoster in older individuals provide a constant mechanism for reintroducing the virus, causing varicella in non-immune individuals who are in close contact, who then spread the virus to other susceptible individuals.

Following the introduction of VV onto the childhood schedule, exposure to wild-type virus decreases. It has been theorised that a lack of boosting may lead to an increase in zoster in older adults. However, several studies that have investigated this issue, observed an increase in zoster prior to VV programme introductions and have been unable to attribute any increase in incidence of zoster to childhood VV programmes.[11121314] Such increases have been observed in countries both with and without childhood varicella immunisation.

23.3.2. New Zealand epidemiology

Zoster hospitalisations by age group during 2018/2019 are shown in Figure 23.1, with around 60 percent occurring in adults aged 60 years and older. Hospitalisations are predicted to account for only a very small proportion of the overall zoster cases as most are managed in primary care. Interrogation of general practice electronic records found the incidence of zoster in New Zealand to be similar (approximately 5 per 100,000 patient-years rising to 12.8 per 100,000 in those aged 80–90 years) to the global incidence estimates described in section 23.3.1.[11] In 2018/2019, there were 483 hospitalisations associated with herpes zoster.

Figure 23.1: Hospitalisations with herpes zoster as primary diagnosis by age group, 2018/2019

This bar graph shows the number of hospitalisations for herpes zoster by age group, increasing with age. There were 20 or less in each age group under 30, and climbs from there to around 90 for 60-69 year olds and 70-79 year olds, and close to 120 in those over 80 years.

Source: Ministry of Health.

23.4. Vaccine

23.4.1. Available vaccines

Funded vaccine

ZV (Zostavax, MSD) is a live attenuated varicella-zoster virus vaccine. It is a higher titre formulation of the varicella vaccine and is designed to protect against zoster in those already immune to varicella.[12] By mimicking the immune response seen following a case of zoster and boosting cell-mediated immunity in older adults, the incidence and severity of zoster is reduced by the high-titre vaccine.

Each 0.65 mL dose of ZV (Zostavax, MSD) contains a minimum of 19,400 PFU of the Oka/Merck strain of VZV. Other components include sucrose, hydrolysed porcine gelatin, urea, sodium chloride, monosodium L‑glutamate, sodium phosphate dibasic, potassium phosphate monobasic, potassium chloride, residual components of MRC-5 cells (including DNA and protein), and trace quantities of neomycin and bovine calf serum. The vaccine contains no preservative.

Other vaccine

Also available but unfunded is an adjuvanted recombinant subunit zoster vaccine (rZV; Shingrix, GSK). Containing recombinant VZV glycoprotein E and a proprietary AS01B adjuvant system, it is designed to specifically boost T-cell immunity against VZV.[13] The liposome-based adjuvant contains two immunostimulants: a Quillaja saponaria (soapbark tree) saponin fraction with a detoxified lipopolysaccharide fraction, 3-O-desacyl-4’-monophosphoryl lipid A (MPL), from Salmonella minnesota. It also contains dioleoylphosphatidylcholine, cholesterol, sodium chloride, dibasic sodium phosphate, monobasic potassium phosphate and water.

In two phase III clinical trials (ZOE-50 and ZOE-70), vaccine efficacy of over 90 percent was shown in older adult age groups from 50 years, including those aged over 70 years and those with medical conditions that increase their risk of zoster.[14, 15, 16, 17] Pooled data gave vaccine efficacy of 91 percent (95% CI 87-95 percent) against the incidence of zoster, overall, and 91 percent (86-98 percent) against post-herpetic neuralgia across all age groups. No decline was observed in increased age with efficacy of 91 percent (80-97 percent) against zoster in those aged over 80 years. Long term follow-up of these trial participants found efficacy against zoster plateaued after four to six years and was sustained overall at 84 percent for at least seven years post-vaccination.[18] Although not licenced in New Zealand under age 50 years, clinical trial data has shown good efficacy in immunocompromised participants aged from 18 years with.[19, 20]

23.4.2. Efficacy and effectiveness

Live attenuated zoster vaccine (Zostavax)

The pivotal clinical trial for the live zoster vaccine (Zostavax), the Shingles Prevention Study (SPS), showed that the zoster vaccine reduced the burden of illness of zoster by 61 percent (95% CI: 51–69) in all age groups, by 66 percent (95% CI: 52–76) in the 60–69 years age group, and by 55 percent (95% CI: 40–67) in those aged 70 years and older. There was also a 67 percent reduction (95% CI: 48–79) in post-herpetic neuralgia in all age groups. The study recruited 38,546 adults aged from 60 years, with either a history of chickenpox or of having lived in the US for more than 30 years. Participants received either the live zoster vaccine or a placebo.[12] A cohort study of individuals in the US aged 65 years and over found zoster vaccine was associated with a 48 percent reduction (95% CI: 39–56) incident zoster and 62 percent (95% CI: 32-77) reduction in PHN.[21]

A review of the efficacy of ZV in preventing zoster and PHN concluded that zoster vaccine is safe, effective and highly recommended for the immunisation of immune-competent individuals over the age of 60 years.[1]

Following the introduction of zoster vaccination programme to adults aged 70 years (with catch up for those aged 71–79 years) in the UK, vaccine effectiveness was estimated to be 64 percent (95% CI: 60–80) against zoster and 81 percent (95% CI: 61–91) against PHN. Vaccine effectiveness was lower in those who had a previous history of zoster (47 percent; 95% CI: 31–58).[22]

Duration of protection

The persistence of ZV efficacy was measured for 11 years using a subgroup of individuals from the Shingles Prevention Study discussed above. Vaccine efficacy was statistically significant for the incidence of zoster until eight years post-vaccination.[23] Clinical efficacy of ZV was shown to be increasingly limited with time beyond five years post-vaccination.

In older adults in the UK, effectiveness of ZV against zoster waned with time by the third year post-vaccination to an estimated 45 percent (95% CI: 29–57).[22] In adults aged 60 years or older in the US, the effectiveness of ZV against zoster was shown to decrease from 69 percent in the first year to 4 percent eight years after vaccination; however, after an initial decline in the first year, effectiveness remained at around 30–40 percent up to five years after vaccination.[24] Duration of protection is therefore variable. A compromise is required around the timing of the vaccination – vaccine effectiveness against zoster is highest when a person is vaccinated at a younger age but protection from a single dose may not last to an age where the risk of incidence of PHN is greatest.

Studies have shown that booster doses in adults are immunogenic, but there are no reports on efficacy of giving further doses. The immune response to a second dose declines with advancing age but is similar to the response seen following first doses of individuals of the same age: a prior dose neither enhances nor impairs the response to a booster dose.[25] There do not appear to be any safety concerns with administering a second dose of ZV.[26] Although it is not currently recommended, individuals who previously received an unfunded ZV dose may choose to receive a funded ZV dose, if eligible. At the time of writing, there were no current international guidelines on giving further doses of ZV.

23.4.3. Transport, storage and handling

Transport according to the National Standards for Vaccine Storage and Transportation for Immunisation Providers 2017 (2nd edition).

The live attenuated ZV vaccine must be reconstituted with the supplied diluent. Once reconstituted, ZV must be used within 30 minutes.

The recombinant rZV (Shingrix) must be reconstituted before use with supplied diluent. Once reconstituted, if not used promptly, can be store in a refrigerator (2°C – 8°C) for up to 6 hours. Do not freeze. Protect from light.

23.4.4. Dosage and administration

ZV is registered for adults aged 50 years and older. Do not give to children. Do not give to adults who are severely immunocompromised. 

The dose of reconstituted ZV is 0.65 mL, to be administered intramuscularly or subcutaneously if indicated, in the deltoid area (see section 2.2.3). 

See section 23.6.2 for precautions around ZV administration in individuals receiving antiviral treatments such as acyclovir.

Also available but unfunded for adults aged from 50 years is an adjuvanted recombinant subunit zoster vaccine, rZV (Shingrix). Two doses of 0.5 ml are administered intramuscularly two to six months apart. This vaccine can be given safely to individuals who are immunocompromised and/or receiving immunosuppressive agents. It is recommended to discuss the optimal timing for vaccination with a specialist before the vaccine appointments for those who are severely immunocompromised. Ideally, vaccination should be conducted prior to any planned immunosuppression (see section ‎4.3.7).

Co-administration with other vaccines

Live attenuated ZV can be concurrently administered with influenza vaccine using separate syringes and sites. A spacing of seven days is recommended before or after COVID-19 vaccines (mRNA-CV, ChAd-CV or rCV).

Historically, there were concerns that VZV antibody titres were lower in individuals who received ZV and 23PPV at the same visit, compared with those given the vaccines four weeks apart. However, VZV antibodies are not considered a measure of protection against zoster, and all recent evidence suggests that ZV can be given concurrently with 23PPV.[27]

Recombinant ZV (rZV) can be co-administered with most vaccines, including quadrivalent influenza vaccine, COVID-19 vaccines (mRNA-CV, ChAd-CV), 23PPV and Tdap. Due to limited experience at this time, it is recommended to allow three days spacing between rZV and the COVID-19 vaccine, rCV (Nuvaxovid) or the adjuvanted influenza vaccine (Fluad Quad).

23.5. Recommended immunisation schedule

Table 23.1: Herpes zoster vaccine (ZV) recommendations
Note: Neither history of previous varicella infection nor evidence of prior immunity to VZV is required prior to the routine administration of ZV (except for certain immunocompromised persons, refer below). Funded individuals are shown in the shaded row.

Recommended and funded

1 dose of live ZV at age 65 years

For consideration, but not funded

Two doses of recombinant ZV are recommended but not funded for individuals aged from 50 years:

  • who are at increased risk of zoster[28, 29, 30, 31] and those who have contraindications to live ZV:
    • prior to planned, receivinga or post immunosuppressive therapy
    • with HIV infection
    • with end-stage kidney disease (CKD stages 4–5)
    • prior to or post solid organ transplantation
    • prior to or post HSCT
    • with immune-mediated inflammatory disease (eg, rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease, Crohn’s disease, ulcerative colitis)
    • a first-degree relative with a history of zoster
    • with depression
    • with diabetes
    • with psychiatric disorders
    • with chronic obstructive pulmonary disease
  • personal preference for those aged from 65 years.
  1. Ideally, vaccinate prior to planned immunosuppression. If rZV is given during treatment regimen, take timing of treatment and level of immunosuppression into consideration when timing vaccinations.

23.5.1. Other considerations

Recommended not funded

Adjuvanted recombinant zoster vaccine (rZV; Shingrix) is approved for use in New Zealand for individuals aged 50 years or older. It is recommended but not funded, for from age 50 years particularly those who are at increased risk of zoster due to comorbidities[28, 29, 30, 31] (see Table ‎23.1). Individuals aged from 65 years may prefer unfunded rZ over ZV funded at 65 years. Post hoc analysis from clinical trials of rZV showed good efficacy (over 80 percent against zoster) for at least 7 years, including in individuals aged 70 years and over and people with pre-existing health conditions.[15, 18]

Individuals with a history of zoster (shingles)

Individuals with a history of zoster episodes can be given ZV (funded at age 65 years) or rZV (unfunded from age 50 years). It is possible that a history of previous zoster may be inaccurate or a mistaken diagnosis.[28] In addition, the risk of a repeat episode of zoster has been estimated at approximately 5 percent in immunocompetent individuals.[28]

There are no recognised safety concerns in giving zoster vaccines to people with prior history of zoster.[32, 33] The length of time following an episode of zoster after which it may be beneficial to vaccinate has not been established.[28] It is suggested that ZV or rZV could be given at least 12 months after the episode of zoster has resolved.[28]

Individuals with a history of zoster vaccination

The optimal time for administration of zoster vaccine following live ZV vaccination is not yet established. Individuals who previously received ZV can receive two doses of rZV (unfunded), given at least 12 months after ZV.

Immunocompromised individuals

Recombinant rZV (unfunded) is the preferred vaccine for individuals aged from 50 years with immunocompromise due to an existing illness and/or its treatment or prior to planned immunosuppression. This includes individuals due to receive or following solid organ transplant, chemotherapy or systemic radiotherapy, and individuals with IMIDs (autoimmune disease) or living with HIV infection. There are no safety concerns regarding giving a non-live vaccine to these groups. 

Household contacts of immunocompromised individuals

Live ZV is contraindicated in individuals with current or recent severe immunocompromise due to primary and secondary immune-deficiency states, or due to immunosuppressive therapy (see section 23.6). There are no safety concerns giving live ZV to household contacts of immunocompromised individuals.

If a household contact develops a varicella- or zoster-like rash after vaccination, they should cover the rash and avoid contact with persons who are immunocompromised for the duration of the rash, at least until it crusts.[28] This type of rash can occur uncommonly after vaccination with live ZV; it is not a safety issue after the non-live subunit rZV as this vaccine does not contain any live virus.

See also ‘Household contacts’ in section 4.3.1 for general recommendations for vaccination of household contacts of immunocompromised individuals.

23.6. Contraindications and precautions

See section 2.1.3 for pre-vaccination screening guidelines and section 2.1.4 for general contraindications for all vaccines. Seek specialist advice for primary and secondary immunodeficiency conditions prior to giving ZV (see section 23.6.2).

23.6.1. Contraindications

Live attenuated zoster vaccine (Zostavax)

ZV is a live vaccine containing attenuated varicella-zoster virus and administration to individuals who are immunosuppressed or immunodeficient may result in disseminated varicella-zoster virus infection, including fatal outcomes. If ZV is inadvertently administered to these individuals, seek specialist advice immediately and notify CARM.

Do not give to children.

Contraindications to ZV include:

  • a history of anaphylaxis to neomycin and gelatin (refer to chapter 2)
  • primary and secondary immune-deficiency states due to conditions, such as acute and chronic leukaemias; lymphoma; other conditions affecting the bone marrow or lymphatic system; immunosuppression due to HIV/AIDS (see section 23.6.2 for asymptomatic HIV infection); and cellular immune deficiencies – see sections 4.3.2 and 4.3.3
  • during immunosuppressive therapy (including high-dose corticosteroids and biologics)
  • active untreated TB
  • pregnancy.

ZV is not contraindicated for use in individuals who are receiving low-level immunosuppressive therapy, for example: topical/inhaled corticosteroids or low-dose systemic corticosteroids; who are receiving corticosteroids as replacement therapy (eg, for adrenal insufficiency); low-dose weekly methotrexate or azathioprine (see section 4.3.3, Table 4.1 and Table 4.2).

Recombinant zoster vaccine (Shingrix)

Recombinant rZV (Shingrix) is contraindicated to individuals with a history of hypersensitivity to a previous dose or to any component of the vaccine.

23.6.2. Precautions

Live attenuated zoster vaccine (Zostavax)

Antiviral medications with anti-VZV activity, such as acyclovir, valaciclovir and famciclovir, can interfere with the replication of the VZV strain in the live ZV. It is recommended that antiviral medication be stopped at least 24 hours before vaccination with ZV and restarted at least 14 days after vaccination.

HIV

Asymptomatic HIV-positive individuals with a CD4+ lymphocyte count ≥200 cells/mm3 may be vaccinated upon specialist advice. Results of a phase II trial in HIV-infected adults indicated that ZV was generally safe and immunogenic in those with CD4+ lymphocyte count ≥200 cells/mm3, with no cases of vaccine strain infection.[34, 35]

Serological confirmation of previous VZV infection is recommended for this group prior to vaccination with live ZV.[27]

Individuals with symptomatic HIV infection or AIDS should not be vaccinated with ZV.

Immunocompromised individuals

Live attenuated ZV is contraindicated for individuals with current or recent severe immunocompromise due to primary and secondary immune-deficiency states, or due to immunosuppressive therapy. Individuals receiving low-level immunosuppressive therapy may be considered for vaccination upon specialist advice.

Individuals whose treatment with high-dose systemic immunosuppressive therapy has ceased may be vaccinated with live ZV at age 65 years upon specialist advice, if an appropriate time-interval has passed.[27] For those aged 50 years and over, rZV is recommended but unfunded.

Individuals who are only receiving localised radiotherapy to treat a tumour or lesion can be vaccinated with live vaccines, such as ZV, at any time prior to, during or after radiotherapy.[36]

See Table 4.1 and Table 4.2 in sections 4.3.5 and 4.3.6 for recommendations for the use of ZV in individuals on immunosuppressive therapy.

Serological testing

Generally, neither a history of previous varicella infection nor evidence of prior immunity to VZV is required prior to the routine administration of zoster vaccines.[28] Most older people in New Zealand are seropositive to VZV due to previous primary varicella infection.

Serological confirmation of previous VZV infection is recommended prior to vaccination with ZV in immunocompromised individuals, including those living with HIV infection, and in those who are anticipating significant future immunosuppression or who have ceased immunosuppressive therapy.[28] Individuals in these categories who have negative VZV IgG should not generally be given ZV. Upon specialist advice, VV may be given instead of ZV to seronegative individuals. If a person is seronegative, give VV (funded if an eligible condition); if seropositive give ZV (one dose is funded at age 65 years). Serological testing is not required for non-live rZV.

Laboratory testing to check for an immune response after ZV is not recommended.[28]

Recombinant zoster vaccine (Shingrix)

Serological testing for previous VZV infection is not necessary prior to administration of this vaccine to individuals with immunocompromise. 

There is no data on the use of rZV in human pregnancy (licensed from age 50 years), however, since it is a non-live vaccine, no theoretical safety concerns should it be inadvertently administered to a pregnant woman.

23.7. Potential responses and AEFIs

23.7.1. Potential responses

Live attenuated zoster vaccine (Zostavax)

ZV is generally well tolerated. In clinical trials, injection-site reactions occurred more commonly in ZV recipients than in placebo recipients. PCR testing of VZV from zoster-like rashes occurring in the 42-day period following vaccination are much more likely to be due to wild VZV than to the vaccine virus.[2]

Recombinant zoster vaccine (Shingrix)

During clinical trials, recombinant zoster vaccine (rZV) was generally well tolerated. The most commonly responses were injection-site pain, myalgia and fatigue; other responses included headache, shivering, fever and gastrointestinal symptoms. These were mild to moderate and lasting for one to three days post vaccination, with higher incidence in those aged under 70 years than in the older age groups.[17 ]

23.7.2. AEFIs

Live attenuated zoster vaccine (Zostavax)

A large safety review of ZV in 193,083 individuals aged 50 years and older supports the pre-licensure clinical trial data.[37] The ZV was found to be safe and well tolerated with no increased risk for the adverse event groupings of cerebrovascular events, cardiovascular events, meningitis, encephalitis, encephalopathy, Ramsay Hunt syndrome or Bell’s palsy. A small increased risk of allergic reactions one to seven days after vaccination was reported.

A post-marketing observational study of 29,000 individuals aged 60 years and older did not identify any safety concerns within 42 days of receiving ZV vaccine.[38]

Recombinant zoster vaccine (Shingrix)

Injection-site reactions (eg redness or swelling) were more common after vaccination with rZV than live ZV according to a meta-analysis of clinical trial data (risk difference of 30 percent; 95% CI 2 to 51 percent). There was no statistical difference between serious adverse events or study withdrawal due to adverse events.[39 ]

23.8. Variations from the vaccine data sheet

The ZV (Zostavax) data sheet states that the ZV vaccine and 23PPV (Pneumovax 23) should not be given concurrently. The Ministry of Health recommends that ZV vaccine and 23PPV may be given concurrently[27, 40] (see section 23.4.4).

The ZV data sheet states that ZV should not be given to individuals with HIV/AIDS. The Ministry of Health recommends that asymptomatic HIV-positive individuals with a CD4+ lymphocyte count ≥200 cells/mm3 may be vaccinated upon specialist advice (see section 23.6.2).[27, 40]

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