ACIP: Administer Shingrix to prevent shingles
The Advisory Committee on Immunization Practices recently released its 2018 adult immunization schedule, which included new recommendations advocating for the use of Shingrix for the prevention of shingles and the use of an additional dose of the measles, mumps and rubella vaccine during an outbreak.
“There are roughly a million cases of shingles each year. Disease risk and severity increase with age — starting at age 50,” Sandra A. Fryhofer MD, MACP, FRCP, internal medicine physician in Atlanta and ACP liaison to ACIP, told Healio Internal Medicine. “The major change for zoster vaccination is reflected on the graphics and in the footnotes.”
In the new guideline, the ACIP recommended that two doses of the recombinant zoster vaccine (Shingrix, GlaxoSmithKline) be administered 2 to 6 months apart to immunocompetent adults aged 50 years or older for the prevention of herpes zoster and related complications regardless of whether they had herpes zoster in the past or have previously received the zoster vaccine live (Zostavax, Merck and Co.).
“Shingrix should not be administered during an acute shingles episode,” Fryhofer noted.
“Vaccination does not require prior screening for chickenpox by history or by serology,” she added.
Adults with previously vaccinated with Zostavax should receive two doses of Shingrix 2 to 6 months apart at least 2 months after Zostavax, according to the ACIP. Shingrix or Zostava — although Shingrix is preferred — should be given to adults aged 60 years or older.
Shingrix is more than 90% effective for shingles and postherpetic neuralgia in patients aged 50 years or older which “outshines” Zostavax’s efficacy of 51% for shingles and 66.5% for postherpetic neuralgia in those 60 years and older, according to Fryhofer.
“While protection from [Zostavax] seems to significantly wane with time, [Shingrix’s] efficacy seems to be well maintained,” she said. “[However,] there is a down side. The recombinant vaccine is very reactogenic, which could be a barrier to completing the two-dose series. Although most common side effects of Shingrix include myalgias, fatigue and injection site pain lasting just a few days, 17% had grade 3 reactions with reactions so severe they interfered with normal activities.”
“[Shingrix] contains a brand new adjuvant ASO1-B, never before used in a vaccine in the United States,” Fryhofer added. “The ‘newness’ of the adjuvant is also concerning, and it is hoped that no unforeseen adverse effects will be observed once introduced in to the general population.”
The ACIP did not include a recommendation of the use of Shingrix in pregnant women or adults with immunocompromising conditions, such as HIV.
“The [Shingrix] administration will require patient information and education about risk of shingles,” Fryhofer said. “Providers must also explain the need for two doses of [Shingrix] for maximum protection and stress the ‘reactogenicity’ of this new recombinant vaccine.”
Additionally, the ACIP recommended that adults who have received two or more doses of a mumps-containing vaccine should be given an additional dose of MMR if they are identified by a public health authority as having an increased risk for acquiring mumps due to an outbreak.
Details in the footnotes are important to review because they clarify who needs what vaccine, when and at what dose, according to the ACIP.
“Adult immunization has become more complicated and complex,” Fryhofer said. “As the number of vaccines in our toolbox of protection has expanded, so has the challenge of determining which vaccines patients have had and what they need. Our society is more mobile. Many vaccines are now administered outside the doctor’s office. Vaccination records for adults are often scattered. Although use of immunization registries can help alleviate problems, they are not being well utilized.”
“In 2016, only about 44% of vaccines for adults were documented in registries as compared with 94% of vaccines for children,” she continued. “Consolidating vaccination administration documentation could save time for clinicians and save money for patients and employers and our nation. Vaccines are lifesaving, but they are also expensive. Adult immunization rates are tragically low. We must raise the rates.” – by Alaina Tedesco
Disclosure: Kim reports no relevant financial disclosures. Please see study for all other authors’ relevant financial disclosures. Fryhofer reports no relevant financial disclosures.