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#77 Zoster vaccine: Zoster Loster or Imposter Coster?


CLINICAL QUESTION
QUESTION CLINIQUE
What are the benefits of the zoster vaccine to our patients?


BOTTOM LINE
RÉSULTAT FINAL
Over 3 years, zoster vaccine will prevent one case of shingles for every 60-70 patients vaccinated, and one case of post-herpetic neuralgia in 350. Long-term benefits, and effectiveness in specific patient populations (immunocompromised, previous shingles) are unclear.



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EVIDENCE
DONNÉES PROBANTES
Two (RCTs) in immunocompetent patients of zoster vaccine (Zostavax) versus placebo vaccine: 
  • 38,546 age >60 (median age 69). Outcomes at 3 years:1 
    • Herpes zoster (Shingles) 
      • Vaccine 1.67%, placebo 3.42%, number needed to treat (NNT)=58 
    • Post-herpetic neuralgia (PHN): 
      • Vaccine 0.14%, placebo 0.42%, NNT=358 
    • 7-year outcomes of a subgroup2 of patients not helpful as all placebo patients offered vaccine, thus numbers difficult to interpret. 
  • 22,439 age 50-59 (mean age 55) followed 1.3 years:3 
    • Shingles: Vaccine 0.27%, placebo 0.88%, NNT=164 
    • Limitations: Short follow-up, PHN rates not reported. 
  • Adverse events: ~1% more patients had systemic adverse events1,3,4 and serious adverse events also greater with vaccine (1.9% versus 1.3%).1 
RCT of 15,411 immunocompetent patients >50 years-old (mean age 62, 39% male) of new adjuvant zoster vaccine (not yet available in Canada) followed 3.2 years:  
  • Shingles: Vaccine 0.12%, placebo 3.05%, NNT=35 
  • PHN rates not reported 
  • Adverse events:  
    • 9% more patients had systemic adverse eventbut no difference in serious adverse events. 
Context:  
  • Although vaccine reduces relative risk of shingles 50-70%, we need to vaccine 60-70 patients to prevent 1 case of shingles over 3 years with currently-available vaccine.1,3 
  • Shingles rates increase with age: 3/1000 per year in age 40-64 to 7.5/1000 per year in age >75.6 
    • ~11% of patients age >60 who develop shingles develop PHN.1 
    • PHN risk increases with age,7,8 and is rare (~1%) when <50 years.7 
  • Low risk of recurrent shingle,1,9 but when including immunocompromised patients, may be as high as 5.7% over 7 years.10 
  • Guideline recommendations: 
    • Canada: Vaccinate >60 years, may vaccinate 50-59 year-olds11 
    • US: Vaccinate >60 years, do not recommend vaccinating 50-59 years 
  • Cost of Zostavax ~$200 
  • Remaining questions: 
    • Safe and effective in immunocompromised patients? 
    • Beneficial if previous shingles? 
    • Long-term efficacy (will booster be required)?  
updated aug 5 2016 Ricky Turgeon BSc(Pharm) ACPR PharmD


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Author(s)
Auteur(s)
  • Michael R Kolber MD CCFP MSc
  • Tony Nickonchuk BScPharm CDE

1. Oxman MN, Levin MJ, Johnson GR, et al. N Engl J Med 2005;352:2271-84.

2. Schmader KE, Oxman MN, Levin MJ, et al. Clin Infect Dis 2012;55:1320-8.

3. Schmader KE, Levin MJ, Gnann JW, et al. Clin Infect Dis 2012;54:922–8.

4. Simberkoff MS, Arbeit RD, Johnson GR, et al. Ann Intern Med 2010;152:545-54.

5. Lal H, Cunningham AL, Godeaux O, et al. N Engl J Med 2015;372:2087-96.

6. Boivin G, Jovey R, Elliott CT, Patrick DM. Can J Infect Dis Med Microbiol 2010; 21:45-52.

7. Drolet M, Brisson M, Schmader KE, et al. CMAJ 2010;182:1731-6.

8. Helgason S, Petursson G, Gudmundsson S, et al. BMJ 2000;321:794-6.

9. Tseng HF, Chi M, Smith N, et al. J Infect Dis 2012;206:190–6.

10. Yawn BP, Wollan PC, Kurland MJ, et al. Mayo Clin Proc 2011;86:88-93.

11. www.phac-aspc.gc.ca/publicat/cig-gci/p04-herp-zona-eng.php#ru [Accessed 5 Aug 2016]

12. www.cdc.gov/mmwr/preview/mmwrhtml/mm6333a3.htm [Accessed 5 Aug 2016]

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.