ACIP Recommends New Herpes Zoster Subunit Vaccine

Group Also Addresses Vaccination for Mumps Outbreaks, Approves 2018 Schedules

October 31, 2017 04:16 pm Chris Crawford

During the Oct. 25-26 meeting(www.cdc.gov) of the Advisory Committee on Immunization Practices (ACIP), the group voted to recommend preferential use of a new herpes zoster subunit (HZ/su; Shingrix) vaccine over the currently available herpes zoster live (Zostavax) vaccine for adults 50 and older.

[Shingles vaccine]

ACIP members also voted to, among other things, provide guidance on mumps-containing vaccines and approve the 2018 immunization schedules.

Herpes Zoster Subunit Vaccine

Two days before the ACIP meeting, the FDA approved GlaxoSmithKline's Shingrix vaccine(www.gsk.com) for the prevention of shingles in adults 50 and older.

Shingrix is a non-live, recombinant subunit vaccine given intramuscularly in a two-dose series (0.5 mL dose each), with the second dose given two to six months after the first.  

AAFP liaison to the ACIP Margot Savoy, M.D., M.P.H., of Wilmington, Del., told AAFP News the initial clinical trials on the HZ/su vaccine showed it was more effective and provided longer-lasting protection than the one-dose Zostavax vaccine.  

Story highlights
  • The Advisory Committee on Immunization Practices (ACIP) voted during its Oct. 25-26 meeting to recommend preferential use of a new herpes zoster subunit (HZ/su; Shingrix) vaccine over currently available herpes zoster live (Zostavax) vaccine for adults 50 and older.
  • In response to an uptick in mumps outbreaks the past few years, health officials have been revaccinating populations who received the recommended two doses of the measles, mumps and rubella vaccine with a third dose.
  • The ACIP also approved the 2018 Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger and the Recommended Schedule for Adults Aged 19 Years or Older.  

The ACIP held three separate votes on the HZ/su vaccine at the meeting, during which the committee said the vaccine is

  • recommended for the prevention of herpes zoster and related complications for immunocompetent adults 50 and older,
  • recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received Zostavax, and
  • preferred over Zostavax for the prevention of herpes zoster and related complications.

The previous ACIP recommendation(www.cdc.gov) for Merck & Co. Inc.'s Zostavax was for adults 60 and older.

Savoy said the ACIP's recommendation to vaccinate patients who previously received Zostavax with the new HZ/su vaccine changes the dynamics of this transition.

"Anyone in this age group (50 and older) should get the extra protection that this vaccine offers," she noted.

However, Savoy said in addition to getting patients to buy into getting revaccinated, a bigger issue might be getting Medicare to pay for a vaccine that likely would require two doses scheduled in the same year, which it typically hasn't done before.

"So, are you going to have to wait a year to get the second dose covered by Medicare or are two doses going to be approved in the same year because that is the series?" she asked. "Most vaccines given to patients ages 55 and older aren't multiple doses."

The Medicare representative at the ACIP meeting didn't have an immediate answer to this question.

As for the third recommendation from the ACIP on preferential use of the HZ/su vaccine, Savoy said the topic was vigorously debated by the committee and passed by only one vote.

"This basically kicked Zostavax off the market, because why would anybody choose to get a vaccine that you'd have to get another vaccine right afterward if it's available?" she asked.

"The preference for Shingrix doesn't mean there's anything wrong with the herpes zoster live vaccine, or that current supplies shouldn't be used," Savoy said. "This is a situation where you have something that was good that's being supplanted by something that is great."

Savoy said no recommendation has yet been made on what physicians should do while they wait for Shingrix to become widely available. She also noted that there wasn't discussion during the meeting about when the Shingrix vaccine would be available to order for purchase, but she anticipated it would begin to be widely available at the start of the year.

These recommendations will be included in the 2018 adult immunization schedule when it's released in February.

Mumps-containing Vaccine

In response to an uptick in mumps outbreaks the past few years, health officials have been revaccinating populations who received the recommended two doses of the measles, mumps and rubella (MMR) vaccine with a third dose. Of the three components in the MMR vaccine, the mumps portion confers the shortest period of protection, Savoy said; the third dose is given to boost this portion of the vaccine.

This topic was previously discussed during the ACIP's June 21-22 meeting.

At the October meeting, the group voted that patients who previously were vaccinated with two doses of a mumps-containing vaccine who are identified by public health officials as being at increased risk for mumps because of an outbreak should receive a third dose of a mumps-containing vaccine to improve protection against the disease and related complications.

"If there is an outbreak in your town, public health will say there's an outbreak of mumps and here's a list of people who, if they've been exposed, ought to be vaccinated," Savoy said. "And now you, Margot Savoy, in the office can give the kid a vaccine who comes in and says they go to that school, and it should be covered by insurance because it's an ACIP recommendation."

Preventing Vaccine Shoulder Injury

The ACIP also discussed shoulder injury related to vaccine administration (SIRVA) at the meeting because of a recent increase in the number of related incidents.

SIRVA is not the same as initial soreness for a day or two after vaccination.

"This is prolonged pain and stiffness in your shoulder a week or, in some cases, multiple weeks after your injection," Savoy said. "This is not local vaccine reaction. This is the immune response that you can have that creates either a deltoid bursitis or a joint inflammation if you accidentally inject the vaccine into the bursa or joint space."

In response to this issue, the CDC has created an ad campaign(www.cdc.gov) offering education and tools to help vaccine providers use the proper injection technique.

Savoy said SIRVA commonly spikes around influenza vaccine season in the fall and winter.

"They think this is because flu vaccines are given in such a wide range of places, that not everybody administering the vaccines has received the same training and people may be injecting patients a little higher in their injection space than they should," she said.

2018 Immunization Schedules

And finally, at this ACIP meeting, the group approved the 2018 Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger and the Recommended Schedule for Adults Aged 19 Years or Older.

Both the new Hz/su vaccine and mumps vaccination recommendations will be reflected in the 2018 schedule footnotes.

Related AAFP News Coverage
ACIP Offers Revised, Single-dose HepB Infant Revaccination Option
(2/28/2017)

Leader Voices Blog: Making Our Point on Immunizations With Vaccine Manufacturers
(12/14/2016)