The Role of the Pharmacist in Herpes Zoster Vaccination

Herpes zoster, sometimes known as shingles, is characterized by a unilateral vesicular eruption with a dermatomal distribution that lasts for 2 to 4 weeks.¹ Shingles is caused by the varicella-zoster virus (VZV), which first infects the trigeminal nerve as chickenpox in childhood and then lays dormant in the dorsal root ganglia.¹

After chickenpox, VZV remains dormant in the body for years, and it might reactivate as shingles later in life. In simple terms, shingles is caused by the reactivation of VZV. In the United States, an estimated 1 million people get shingles each year.² The risk of getting shingles or other serious complications increases as people get older so adults may be more susceptible to shingles.²

Shingles is a painful rash that appears on one side of the body or face.³ Days before the rash show, most people experience discomfort, itching, or tingling in the area.

The rash appears in many places of the body and spreads more widely in individuals with a weaker immune system; however, shingles on the face has the tendency to cause vision loss.² Some individuals may develop post-herpetic neuralgia (PHN) after the rash has faded, which can last for months or years.²

Shingles vaccination is the only way to protect against shingles and PHN.³ The Centers for Disease Control and Prevention (CDC) recommends 2 doses of the recombinant zoster vaccine to prevent shingles and related complications in adults 50 years of age and older.⁴

There was an older shingles vaccine that was a live attenuated version with the trade name Zostavax, which was approved in 2006,⁵ but is no longer available for use in the United States as of November 2020.^2,5 This vaccine contained a weakened version of VZV to produce an immune response.

As a result, it was not recommended for those who are immunocompromised because the vaccination may cause an infection. Usually, vaccination with this vaccine was done after a single-dose injection administered subcutaneously.

However, a newer version of shingles vaccine, Shingrix, is a recombinant, adjuvanted zoster vaccine approved for shingles prevention by the FDA in 2017.⁵ This vaccine has been found to be a step ahead of the earlier developed version because it can be utilized in immunocompromised people or those with a weaker immune system because it is an inactivated vaccine.

Shingrix is not used to prevent primary varicella infection; however, because it can prevent shingles, it can also prevent PHN and other painful complications from shingles.

The most common adverse effects (AEs) of the vaccine involve reactions at the site of injection, which usually lasts 2 to 3 days.⁴ The AEs are temporary and may include pain, redness, or swelling around the injection site.

Shingrix can also cause hypersensitivity or allergic reactions in those with allergies to vaccine ingredients. Symptoms of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness.⁵

It is administered as an intramuscular injection administered in 2 doses separated by 2 to 6 months.⁴ The second dose is necessary to ensure long-term efficacy.

Clinical trials have shown that the recombinant, adjuvanted zoster vaccine is 97% effective at preventing shingles in adults with healthy immune systems aged 50 to 69 years and 68%-91% effective at preventing shingles in adults with weakened immune systems.⁴ It is also 91% effective at preventing shingles in adults over 70 years of age.⁴ This vaccine also provides immunity that stays strong for at least the first 7 years after vaccination.⁴

The CDC does not recommend the recombinant, adjuvanted zoster vaccine for women who are pregnant. People with moderate or severe illness, whether or not they have a fever, should also wait to recover before getting the vaccine.⁴

The efficacy of the live attenuated zoster vaccine may decrease over time, hence the CDC also recommends the recombinant, adjuvanted zoster vaccine to people who have already received the live attenuated zoster vaccine in the past.⁴

Pharmacists play important roles in vaccination campaigns, as they are responsible for, among others, knowing the immunization schedule, recommending specific vaccines for individual patients, and advising them. In light of this, pharmacists' contributions are also critical to the success of the zoster immunization campaign.

Pharmacists as immunizers are vaccine distributors, educators, facilitators, and administrators⁶ with these roles essential in the administration and delivery of the zoster vaccines. In summary, the entire pharmacy community has significant roles to play in order to end herpes zoster.

During the vaccination process, the Advisory Committee on Immunization Practices (ACIP) guidelines for varicella vaccination should also be followed. Vaccinators should also follow the contraindications and precautions for herpes zoster immunization.

It's also necessary to emphasize the need to ensure vaccine equity as health care providers to boost vaccine confidence among minority groups.

References

1. Weaver BA. Herpes zoster overview: natural history and incidence. Journal of Osteopathic Medicine. 2009;109(s62):2-6. Published 2009 Jun 01. doi.org/10.7556/jaoa.2009.20007.
2. Centers for Disease Control and Prevention (CDC). Shingles (Herpes Zoster). Available at: https://www.cdc.gov/shingles/index.html. Accessed May 21, 2022.
3. Gould D. Varicella zoster virus: chickenpox and shingles. Nursing Standard (2014+). 2014;28(33):52-58. Published 2014 Apr 16. doi.org/10.7748/ns2014.04.28.33.52.e8249
4. Centers for Disease Control and Prevention (CDC). Shingles (Herpes Zoster) Vaccination Available at: https://www.cdc.gov/vaccines/vpd/shingles/index.html. Accessed May 21, 2022.
5. Centers for Disease Control and Prevention (CDC). Safety Information for Shingles (Herpes Zoster) Vaccines. Available at: https://www.cdc.gov/vaccinesafety/vaccines/shingles-herpes-vaccine.html. Accessed: May 23, 2022.
6. Bragazzi NL. Pharmacists as Immunizers: The Role of Pharmacies in Promoting Immunization Campaigns and Counteracting Vaccine Hesitancy. Pharmacy (Basel). 2019;7(4):166. Published 2019 Dec 5. doi:10.3390/pharmacy7040166