Hirschmann asks about the basis of the Advisory Committee on Immunization Practices’ recommendation that persons with a history of zoster be vaccinated. Reasons for vaccinating such persons include (a) lack of certainty about the validity of a prior history of zoster, (b) uncertainty about the degree and duration of protection from prior zoster, and (c) safety of giving vaccine to persons with a history of zoster (1). While the risk of recurrent zoster is low during the first few years after zoster, the risk likely increases with time as VZV-specific cell immunity declines. Thus, one might delay vaccination for a few years after a well-documented case of zoster.
Katz points out that acute zoster pain may not respond to conventional therapy and suggests that injection of a local anesthetic with or without corticosteroids may reduce pain. Makharita et al. (2) recently performed a controlled, double-blind trial of repeat ganglion blockade injections in patients with zoster already receiving gabapentin and acknowledged that injections can potentially have serious complications and that a multicenter trial is needed to confirm their promising results. New treatments, tested in controlled trials, are needed for pain associated with zoster.
Fried raises an important question regarding the safety and efficacy of zoster vaccine in persons ≥80 years old. No significant difference was noted in the rate of serious adverse events in persons ≥80 years old in the Shingles Prevention Study (SPS) who received the vaccine versus those who received placebo (3). In another study, the relative risk of serious adverse events within 42 days of receiving zoster vaccine was 1.66 for subjects ages 60–69, 1.03 for those ages 70–79, and 1.18 for those ages ≥80 (4). Thus, the vaccine does not appear to be less safe in the elderly.
The SPS showed that while the efficacy of zoster vaccine to prevent shingles was reduced in older persons, the efficacy of the vaccine to prevent postherpetic neuralgia (PHN) did not decline in persons ≥70 years old (5). While the zoster vaccine package insert indicates that the efficacy of the vaccine to prevent PHN was lower in persons ≥80 years old, the total number of cases of PHN was very small (N=7). Since the elderly have the highest frequency of both zoster and PHN, they would be expected to receive the most benefit from the vaccine, even if its efficacy were modestly reduced compared to that in younger persons.
References
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