Immunization update: NACI recommends RZV (Shingrix®) vaccine in persons aged 50 years and older

Posted Tuesday July 03, 2018

Posted By: Jeffery Satchwill

Category: General

To: Ottawa Immunizers
From: Dr. Geneviève Cadieux, Associate Medical Officer of Health
Date: July 3, 2018

In June 2018, the National Advisory Committee on Immunization (NACI) issued a new recommendation on herpes zoster (shingles) vaccines.

Herpes zoster vaccines authorized for use in Canada

  • Two herpes zoster vaccines are currently authorized for use in Canada in immunocompetent individuals aged 50 years or older:
    • A live attenuated vaccine, Zostavax®II (Live Zoster Vaccine, LZV), has been authorized since 2008. This vaccine is administered subcutaneously as a single dose.
    • A recombinant subunit vaccine, Shingrix®, (Recombinant Zoster Vaccine, RZV) has been authorized in October 2017. This vaccine is administered intramuscularly as a two-dose schedule, 2 to 6 months apart. The second dose may alternatively be given 12 months after the first.

NACI recommendations

  • RZV (Shingrix®) should be offered to all persons aged 50 years of age or older who do not have contraindications, including:
    • Individuals previously vaccinated with LZV (Zostavax®II). Consider re-immunizing with 2 doses of RZV (Shingrix®) at least one year after LZV (Zostavax®II).
    • Individuals with a previous episode of herpes zoster disease. Provide two doses of RZV (Shingrix®) at least one year after the most recent herpes zoster episode.
    • Immunocompromised individuals may be considered for immunization with RZV (Shingrix®), based on a case-by-case assessment of the benefits vs risks. LZV (Zostavax®II) is contraindicated in immunocompromised individuals.
  • LZV (Zostavax®II) may be considered for immunocompetent individuals >50 years of age who do not have contraindications when RZV is contraindicated, unavailable or inaccessible.

Rationale for NACI recommendations

  • Herpes zoster is painful and can have severe complications, including long lasting post-herpetic neuralgia. The incidence and severity of herpes zoster and its complications increase with age. Nearly one in three Canadians develops herpes zoster during their lifetime.
  • Both vaccines are safe, immunogenic, effective and cost-effective in preventing herpes zoster and post-herpetic neuralgia.
    • LZV (Zostavax®II) efficacy decreases with age and over time.
    • RZV (Shingrix®) is twice as effective as LZV (Zostavax®II) against incident herpes zoster and post-herpetic neuralgia in the three years post-immunization.
    • RZV (Shingrix®) efficacy remains higher and appears to decline more slowly than the efficacy of LZV (Zostavax®II) across all age groups.

Publicly-funded herpes zoster vaccine in Ontario:

  • Only the Live Zoster Vaccine (LZV) (Zostavax®II) is publicly funded in Ontario, and only for adults aged 65 to 70 years.
  • At this time, it is not known if/when RZV (Shingrix®) will be publicly funded in Ontario.
  • As per the CMPA, physicians are obligated to inform patients about NACI-recommended vaccines even if those vaccines are not publicly funded.

Co-administration with other vaccines:

  • In general, live and inactivated vaccines may be administered at the same time as other parenteral vaccines. However, two live parenteral vaccines, if they cannot be given at the same time, must be given at least 4 weeks apart.
  • RZV (Shingrix®) may be given at the same time as unadjuvanted seasonal influenza vaccine (concomitant use of RZV with adjuvanted seasonal influenza vaccine has not yet been studied). LZV (Zostavax®II) may be given at the same time as inactivated influenza vaccine.

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