ACIP recommends herpes zoster vaccine for adults aged 60 and older

November 2006

ATLANTA – The Advisory Committee on Immunization Practices has made a unanimous recommendation that individuals aged 60 and older should receive the herpes zoster vaccine to prevent painful shingles.

“Vaccines aren’t just for kids anymore and this vaccine represents an important medical breakthrough aimed at improving health in older people,” Anne Schuchat, MD, director of the CDC’s National Center for Immunizations and Respiratory Diseases, said in a CDC press release. “These vaccine recommendations address a health problem for people aged 60 and older. It has been tested and has been found to be safe and effective in providing protection against shingles and associated chronic pain.”

The recommendation was based on the new herpes zoster vaccine (Zostavax, Merck), which is indicated for people aged 60 and older, particularly those who have had a previous episode of shingles. The live-attenuated vaccine was licensed by the FDA in May 2006 based on study results of more than 38,000 people. In the study, patients who received the vaccine developed shingles at half the rate of those who received a placebo.

At this time, the ACIP committee does not recommend the herpes zoster vaccine for individuals younger than 60 years and immunocompromised individuals. The committee said there was a lack of significant data for these groups.

60 and older recommendation

Information presented to the ACIP committee demonstrated that the herpes zoster vaccine was safe and effective in its prevention. Herpes zoster is common in people aged 60 and older. In the United States, approximately 500,000 to one million people in this age group are affected by shingles annually, according to information presented by Kenneth Schmader, MD, associate professor of medicine at Duke University. The incidence rate is 7.2 cases to 11.8 cases per 1,000 person-years in adults aged 60 and older; half of the people who live until the age of 85 will develop herpes zoster.

The main problem associated with herpes zoster is pain. Herpes zoster can result in postherpetic neuralgia (PHN) or severe pain intensity 90 days to 120 days after rash onset. According to a study of 110 patients with herpes zoster by Jennifer Katz, PhD, with the department of anesthesiology at the University of Rochester School of Medicine and Dentistry and department of psychology at State University of New York College at Geneseo, and colleagues, this pain interfered with physical (14.6%), role (21.8%) and social (26.3%) functioning. A large percentage (42%) of the 110 patients described their pain as “horrible” or “excruciating.”

Increasing age is the most powerful risk factor for herpes zoster and PHN. There is a higher risk of both physical and mental effects, such as scarring, chronic fatigue, physical inactivity, depression and even suicide. At a pain clinic in Liverpool, England, 59% of patients with PHN were prevented from pursuing their usual activities for an average at 1.4 years, according to Schmader.

Shingles prevention study

Michael Oxman, MD, professor of medicine at the University of California at San Diego and staff physician at the VA Medical Center at San Diego, conducted a shingles prevention study of 38,546 patients aged 60 and older, which demonstrated that the herpes zoster vaccine reduced the burden of illness by 61.1%, PHN by 66.5% and herpes zoster by 51.3%. The vaccine reduced morbidity from herpes zoster and PHN in older adults. The researchers found a total of 957 cases of herpes zoster, with 315 among vaccine recipients and 642 among placebo recipients, and 107 cases of PHN, with 27 among vaccine recipients and 80 among placebo recipients. The vaccine reduced the occurrence of shingles by about 50% and PHN by 67%. The researchers found that the vaccine’s ability to prevent shingles declined with increasing age, but the risk of chronic pain in older individuals who still developed shingles was lowered. Only mild adverse events were reported, such as headache and pain at the injection site.

Mark Messonnier, PhD, MS, lead economist of the CDC’s National Center for Immunization and Respiratory Diseases, concluded that the herpes zoster vaccine would likely have a cost-effectiveness of about $100,000 per quality-adjusted life-year gained, based on a summary of recent economic studies.

Zostavax comes as a single-dose injection and costs about $160 and will be covered by part D Medicare.

Herpes zoster is characterized by chronic pain and blistering rash that is most common among the elderly and is much less contagious than chickenpox.

Recommendations of the ACIP become CDC policy when they are accepted by the director of the CDC and are published in the CDC’s Morbidity and Mortality Weekly Report. These recommendations are usually accepted by federal health officials and influenza insurance coverage for vaccinations is recommended.

For more information:

• Katz J, Cooper E, Walther R, et al. Acute pain in herpes zoster and its impact on health-related quality of life. Clin Infect Dis. 2004;39:342-248.
• Schmader K. Epidemiology and impact of herpes zoster and postherpetic neuralgia in older adults. Presented at: ACIP meeting; Oct. 25-26, 2006; Atlanta.
• Oxman M. Shingles prevention study. Presented at: ACIP meeting; Oct. 25-26, 2006; Atlanta.
• Messonnier M and Zhou F. Review of economic studies of varicella zoster vaccine. Presented at: ACIP meeting; Oct. 25-26, 2006; Atlanta.