What is the primary precaution against herpes zoster?

Vaccination is the Primary Precaution Against Herpes Zoster

The most effective strategy to prevent herpes zoster (shingles) and its complications is vaccination with the recombinant zoster vaccine (RZV, Shingrix), which is strongly recommended for adults aged 50 years and older. 1

Recommended Vaccines for Herpes Zoster Prevention

There are currently two types of herpes zoster vaccines available:

1. Recombinant Zoster Vaccine (RZV, Shingrix):

   • Preferred vaccine due to higher efficacy (96% vs 70% for ZVL) 1
   • Recommended for adults aged 50 years and older 1
   • Also recommended for adults aged 18 years and older who are or will be at increased risk due to immunodeficiency or immunosuppression 1
   • Two-dose series
   • Can be used in immunocompromised individuals as it is not a live vaccine

2. Zoster Vaccine Live (ZVL, Zostavax):

   • Less effective than RZV (70% efficacy) 1
   • Contraindicated in immunocompromised individuals due to risk from the live attenuated virus 1
   • Single dose
   • Approved for adults aged 50-79 years 1

Vaccine Efficacy and Recommendations

The CDC Advisory Committee on Immunization Practices has made the following recommendations 1:

• RZV is recommended for prevention of herpes zoster and related complications for immunocompetent adults aged 50 years or older
• RZV is recommended for adults who previously received ZVL
• RZV is preferred over ZVL for prevention of herpes zoster and related complications

Efficacy Considerations:

• RZV maintains protection above 83.3% for up to 8 years, decreasing to 73% at 10 years 1
• ZVL efficacy decreases with age (70% for ages 50-59,64% for 60-69,41% for 70-79, and only 18% for those 80+ years) 1
• ZVL efficacy wanes over time, decreasing from 51.3% to 21.2% for herpes zoster prevention during follow-up from 7 through 11 years post-vaccination 1

Risk Factors for Herpes Zoster

Understanding who is at highest risk helps prioritize vaccination efforts:

• Advanced age (risk increases significantly after 50 years) 1
• Immunocompromised status 1
• Comorbidities such as diabetes mellitus, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease 1
• History of COVID-19 infection 1

Clinical Considerations for Vaccination

• Patients should be educated about the importance of completing the full vaccine series for RZV
• Patients should be informed that vaccination is the most effective way to prevent both herpes zoster and its complications, particularly postherpetic neuralgia
• For patients who previously received ZVL, RZV is still recommended as it provides superior protection 1
• While RZV causes more injection site reactions and systemic symptoms than ZVL, there is no difference in serious adverse events between the vaccines 1

Common Pitfalls in Herpes Zoster Prevention

1. Delaying vaccination - Early vaccination starting at age 50 provides the best protection before risk increases substantially with age
2. Not recognizing the need for vaccination in previously infected individuals - Prior herpes zoster infection does not provide reliable immunity against recurrence
3. Failing to revaccinate with RZV after previous ZVL - Patients who received ZVL should still receive RZV for optimal protection 1
4. Not identifying high-risk patients - Physicians should proactively identify patients with risk factors for herpes zoster and recommend vaccination
5. Underestimating the importance of herpes zoster prevention - Herpes zoster can lead to serious complications including postherpetic neuralgia, herpes zoster ophthalmicus, and other neurological complications

By implementing strong vaccination recommendations and addressing barriers to vaccination, healthcare providers can significantly reduce the burden of herpes zoster and its complications in the adult population.