JCN 2014, Vol 28, No 6 59

Shingles (or herpes zoster) is a painful and often debilitating infection of the nerves and

surrounding skin. An individual’s first infection with varicella-zoster virus (VZV) causes chickenpox (varicella), a systemic illness that is more commonly seen in children and includes a widespread vesicular rash that is highly contagious in the early stages (Figure 1), as well as an associated fever.

However, once the chickenpox infection has resolved, the virus does not go away completely. Instead, it lies dormant in the root ganglion of the sensory nerve. A strong immune

How to identify and treat herpes zoster (shingles)Emma Corden

system will keep the virus inactive, however, it can be reactivated at a later date, causing shingles. This can develop decades after the original chickenpox infection, typically in adulthood.

As a result, the virus will spread along the affected nerve to the dermatome (the area of skin that is serviced by a single spinal nerve) and a localised cutaneous eruption occurs, which is known as shingles (Cohen, 2013). The cause of reactivation of the virus is not completely understood, but is associated with conditions that depress the immune system, including illness, certain medications, surgery or emotional stress.

INCIDENCE

The incidence of shingles increases

with age, primarily because there is a gradual reduction in the level of T-cell immunity to VZV. T-cells (a type of lymphocyte) play a vital role in cell-mediated immunity and the levels of T-cells correlate with protection against herpes zoster (Cohen, 2013).

Other individuals at increased risk of shingles and more likely to develop severe disease include: Those who are immunosuppressed

and have impaired T-cell immunity, either due to an immunosuppressive illness (e.g. cancer; human immunodeficiency virus [HIV]) or secondary to immunosuppressive treatment (such as with the drug prednisolone, which can be used to suppress the immune system in people with autoimmune conditions such as multiple sclerosis [MS] or rheumatoid arthritis) (Gnaan and Whiteley, 2002)

Those receiving immunosuppressant therapies following organ transplantation.

Shingles is relatively common with a lifetime risk of 20–30% (Schmader, 2001). The risk increases with age — the incidence in England and Wales is estimated to be 790 to 880 cases per 100,000 people each year in those aged 70–79 years (van Hoek at al, 2009). It is estimated that the risk of herpes zoster increases to 50% in those who are over 85 and who have not been vaccinated — the risk is also higher in females (Cohen, 2013).

Emma Corden is clinical fellow, dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London

Shingles, or herpes zoster, is a relatively common viral infection in the UK, which is caused by a reactivation of the varicella-zoster virus after patients have had an earlier infection with chickenpox. The condition results in a painful rash and in severe cases patients can develop post herpetic neuralgia (PHN), an intense chronic pain at the affected area, despite resolution of the skin lesions. Shingles can also affect the nerves in the eyes and ears, as well as causing scarring. It is important that community nurses are aware of this condition and able to advise on supportive treatments such as topical medications, pain relief and, in appropriate cases, vaccination.

KEYWORDS:Skin care Shingles Herpes zoster Rash Vaccination

Welcome to JCN’s learning zone. By reading the article in each issue, you can learn all about the key principles of subjects that are vital to your role as a community nurse. Once you have read the article, visit www.jcn.co.uk/learning-zone/ to evaluate your knowledge on this topic by answering the 10 questions in the e-learning unit; all answers can be found in the article. If you answer the questions correctly, you can download your certificate, which can be used in your continuing professional development (CPD) portfolio as evidence of your continued learning.

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DIAGNOSIS

A diagnosis of shingles can be made by the characteristic appearance and distribution of the rash (see below). Prodromal symptoms (early symptoms that can signal the beginning of a disease before the development of more positive symptoms) such as pain, malaise and fever may occur and sometimes there can be abnormal skin sensations such as (Public Health England, 2014): Burning Itching Hyperesthesia (oversensitivity) Paraesthesia (tingling, numbness)

or pain in the affected area of skin (dermatome) may precede the onset of the rash by a few days.

RashIn the initial stages of shingles, erythematous macules (small, distinct and discoloured areas of skin) and papules (solid circular bumps in the skin) develop, followed by vesicles (fluid-filled sacs), which eventually crust over.

A typical shingles rash is asymmetrical and will usually be visible according to the dermatomal distribution, corresponding with nerve root sites on the skin. It can occur on the face or body depending on which nerves are affected. The most common site for shingles in people who do not have a compromised immune system

This is known as Ramsay Hunt Syndrome or herpes zoster oticus, a rare complication of herpes zoster (Gondivkar et al, 2010).

Therefore, in most cases the diagnosis of shingles can be made clinically. However, in immunocompromised individuals the rash may involve multiple dermatomes or present with less characteristic rashes (Albrecht, 2010). In these more diagnostically challenging cases, laboratory tests may be required to confirm the diagnosis (Centers for Disease Control and Prevention, 2014). A skin swab can be sent for viral culture but a scraping of cells taken from the base of a lesion and sent for direct fluorescent antibody staining is quicker and more sensitive. Both viral culture and direct immunofluorescence testing can distinguish herpes simplex virus infections from varicella zoster virus infections.

A further useful test is polymerase chain reaction (PCR) (a biochemical technique used to amplify pieces of DNA), which is able to detect varicella-zoster virus DNA in fluid and tissue (Gnaan and Whiteley, 2002). Unfortunately, PCR will not distinguish from vaccine strains of varicella-zoster virus in those individuals who have previously been vaccinated for chickenpox. Serology (the study of plasma and other bodily fluids) is not commonly used as it is difficult to interpret.

TREATMENT

The mainstay of treatment is to limit the duration and severity of the illness and reduce complications.

is the thoracic nerves and, therefore, the skin overlying the ribs.

The rash typically resolves over two to four weeks, but there may be subsequent scarring and changes to the skin pigment.

NervesShingles can affect any nerve root. If a specific group of nerves are affected, for example the ocular nerves, it is classified as herpes zoster ophthalmicus. An affected individual will present with a blistering rash around the eye or eyelid, with associated swelling and redness or pain in the eye.

Conversely, if the facial nerve is affected (cranial nerve VII), a range of symptoms can develop, including: Otalgia (earache) A vesicular eruption in the auricle

(visible portion of external ear) Facial paralysis.

In severe cases, the virus may spread from the facial nerve to involve the vestibulocochlear nerve, with additional symptoms including: Hearing problems (e.g.

sensorineural hearing loss; tinnitus)

Vestibular symptoms such as dizziness and vertigo (the vestibular includes sections of the inner ear and brain that help to control balance and eye movements).

Figure 1.A typical shingles rash.

THE SCIENCE — IMMUNITYThe immune system is the body’s natural defence against the many

bacteria, microbes, viruses, toxins and parasites that cause illness and infection. It consists of a network of cells (including leukocytes, or white blood cells), tissues and organs (such as the spleen), which combine to identify and destroy disease-causing organisms. Problems with the immune system will mean that an individual will be more susceptible to conditions such as shingles, as the body’s ability to defend itself is compromised. This can happen as a result of: Decreasing immunity through age Stress (physical and psychological) Conditions such as HIV and AIDS where the immune system is weakened Bone marrow transplants Organ transplant medication suppressing the immune system so that the

body accepts the replacement organ Chemotherapy temporarily weakening the immune system.

Source: www.nhs.uk/Conditions/Shingles/Pages/causes.aspx

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ABBREVIATED PRESCRIBING INFORMATION: Cetraben® Emollient Bath Additive Light Liquid Paraffi n Please refer to Summary of Product Characteristics before prescribing. Presentations: Bath additive – Clear liquid containing light liquid paraffi n 82.8% w/w. Indications: Symptomatic relief of red, infl amed, damaged, dry or chapped skin, especially when associated with endogenous or exogenous eczema. Dosage: Bath additive – Adults: Add one or two capfuls; Children: add half/one capful to a warm water bath or apply with a wet sponge to wet skin before showering. Contra-indications: Hypersensitivity to any of the ingredients. Special Warnings and Precautions: Care should be taken if allergy to any of the ingredients is suspected. Care should also be exercised when entering or leaving the bath. Avoid contact with the eyes. Side Eff ects: (Refer to the SmPC for full list) Very rarely, mild allergic skin reactions including rash and erythema have been observed, in which case the product should be discontinued. Marketing Authorisation Numbers: Cetraben Emollient Bath Additive: PL 06831/0260 Basic NHS Price: Bath Additive – 500ml plastic bottle £5.75. Legal Category: GSL. Date of Preparation: September 2014. Further Information is available from: Genus Pharmaceuticals Ltd, Linthwaite, Huddersfi eld, HD7 5QH, UK. Cetraben® is a registered trademark. CETBA.API.V10 Cetraben® Cream Presentation: A thick white cream. Main ingredients: White soft paraffi n 13.2% w/w, Light liquid paraffi n 10.5% w/w. Indications: An emollient, moisturising and protective cream for the symptomatic relief of red, infl amed, dry or chapped skin, especially when associated with eczema. Dosage and Administration: Adults, the elderly and children: Apply to dry skin areas as often as required and rub in. Contraindications: Hypersensitivity to any of the ingredients. Precautions: For external use only. May cause local skin reactions. Avoid contact with eyes. Talk to your doctor before use if the skin is badly cracked, infected or bleeding. Do not use if allergic to any of the ingredients. Pregnancy and breastfeeding: Using Cetraben Lotion during pregnancy and breastfeeding is unlikely to have any ill eff ects. If unsure, talk to your doctor or pharmacist. Side eff ects: Mild allergic skin reactions. Pack size: 50g, 150g, 500g, 1050g Rx packs, 50ml & 200ml OTC packs. Trade Price: 50g: £1.40 150g: £3.98 500g: £5.99 1050g: £11.62 50ml OTC: £3.00 200ml OTC: £4.80 Medical Device: Class I. Legal Manufacturer: Thornton & Ross Limited, Huddersfi eld, HD7 5QH, UK. Date of preparation: 14.08.2014 Cetraben® Lotion Presentation: A smooth white lotion. Main ingredients: White soft paraffi n 5.0% w/w, Light liquid paraffi n 4.0% w/w. Indications: For the relief of the symptoms of eczema, dermatitis and other dry skin conditions. Dosage and Administration: Adults, the elderly and children: Apply to the skin and gently rub in until absorbed. Use as often as required, or as directed by your doctor or pharmacist. Contraindications: Hypersensitivity to any of the ingredients. Precautions: For external use only. Do not swallow. Avoid contact with eyes. May cause local skin reactions. Talk to your doctor before use if the skin is badly cracked, infected or bleeding. Do not use if allergic to any of the ingredients. Pregnancy and breastfeeding: Using Cetraben Lotion during pregnancy and breastfeeding is unlikely to have any ill eff ects. If unsure, talk to your doctor or pharmacist. Side eff ects: Mild allergic skin reactions. Pack size: 200ml & 500ml Rx packs, 50ml & 200ml OTC packs. Trade Price: 200ml: £4.00 500ml: £5.64. 50ml OTC: £3.00 200ml OTC: £4.80 Medical Device: Class I. Legal Manufacturer: Thornton & Ross Limited, Huddersfi eld, HD7 5QH, UK. Date of preparation: 14.08.2014.Date of preparation: October 2014.

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Genus Pharmaceuticals on 01484 842217.

Cetraben is helping patients to

We provide a wide and expanding emollient range: trusted, proven, uniquely formulated and preferred by patients**We are committed to the ongoing development of our patient materials to help them manage their condition more eff ectively

And we are helping HCPs to support and educate their patients on the importance of Complete Emollient Therapy

In the UK, one in fi ve children and one in twelve adults have eczema.*At Cetraben, we believe that only a combination of the right products, a wide range ofpatient education and strong HCP support can achieve Complete Emollient Therapy.

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If you would like to know what Cetraben can do for you and your patients then please visit us at www.cetraben.co.uk*www.eczema.org/what-is-eczema, Aug 2014 **Preference studies, Sept 2013. Data on fi le

Support for professionals Help and advice for patients A complete range

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Unfortunately, there is no medication to cure the disease.

Antiviral medicationAntiviral medication is typically given to affected individuals who are either: Over 50 Under 50 in either of the

following categories:• immunocompromised • demonstrating ophthalmic

involvement• symptomatic with moderate-to-

severe pain or with a moderate-to-severe rash.

Antiviral medication is most effective when taken within 72 hours of the rash developing. Therefore, if the community nurse suspects that an individual (with the above criteria) has shingles, it is important that they are reviewed by their GP as soon as possible, as early treatment may lessen the severity of the condition.

Antiviral medication may be initiated after 72 hours if the individual represents a higher risk for complications, including older people, those with new vesicles still developing, or those who are immunocompromised (National Institute for Health and Care Excellence [NICE], 2013).

Those with eye involvement need immediate review as without antiviral treatment for herpes zoster ophthalmicus it is estimated that half will develop ocular complications (Cobo et al, 1987). Patients may develop conjunctivitis, keratitis or uveitis, or permanent chronic ocular inflammation (Shaikh and Ta, 2002).

If an affected individual is also pregnant, the community nurse should seek specialist advice regarding antiviral medication in pregnancy.

Typically, in an immunocompetent individual, aciclovir 800mg is given five times a day for seven days (NICE, 2013). Alternative antiviral medications include valaciclovir or famciclovir. For immunocompromised individuals who are systemically well (i.e. no fever or haemodynamic disturbance) the same treatment is given but for 10 days (NICE, 2013).

AnalgesiaAn accurate pain assessment is important as the discomfort associated with shingles is often debilitating. However, simple analgesia may not be sufficient. Community nurses should use a ‘step-wise’ approach with analgesia, starting with paracetamol or ibuprofen and codeine if required (NICE, 2013). In more severe cases, morphine or neuropathic medications such as amitriptyline or pregabalin may be tried (NICE, 2013).

Supportive treatmentsThere are important supportive treatments that have a pivotal role in the management of shingles. Individuals should be advised to keep the affected areas clean with mild soap and water or even a mild soap substitute and to avoid scratching as this can increase the risk of scarring as well as secondary bacterial infections.

Over-the-counter antihistamines such as calamine lotion or topical creams can be used to help with the itching, although they may dry out the skin. Patients should be advised to use sterile, non-occlusive and non-adherent dressing pads to protect the area from contact with clothing. Loose-fitting clothing should also be considered to avoid friction with the rash.

A cloth dampened with cold water can be compressed over the weeping blisters for 20 minutes several times a

day to soothe and help dry the blisters — this also helps in removing scabs and reduces infection risk (Sanjay et al, 2011). Once the blisters are dry, any compresses must be stopped to prevent excessive drying of the skin and exacerbation of the itching.

General adviceShingles is only spread by direct skin contact with the affected area and the rash will remain contagious until the lesions dry out. Affected individuals need to be advised to avoid contact with pregnant women, those who have not had chickenpox, and anyone immunocompromised. If someone has not previously had chickenpox or a varicella vaccine, they can catch chickenpox from an individual with shingles.

COMPLICATIONS

The most common and severe side-effect of shingles is post herpetic neuralgia (PHN), an intense chronic pain at the affected area despite resolution of the skin lesions (Katz et al, 2004). This pain can be variously described as constant, intermittent, or as being triggered by gentle stimulation of the affected area, for example, a breeze on the face (Katz et al, 2004). PHN can also interfere with activities of daily life and cause sleep disturbances and depression (Gnaan and Whiteley, 2002).

Effective treatment options for patients who develop PHN are limited. This can be frustrating and often difficult in many cases where

This is a much-needed and comprehensive article on the incidence, recognition and

treatment of this very debilitating common condition. It is often community nurses who encounter the onset of shingles in at-risk patient groups and early detection is imperative. It is also crucial that treatment is instigated as soon as possible (within 72 hours) to lessen the chance of serious complications.

Post herpetic neuralgia may lead to hospitalisation and it is estimated that the death rate from shingles in people aged 70 and above is as high as one in 1,000 cases.

This article also highlights the vaccination program available to the over-70s and it is community nurses who will be ensuring that the most vulnerable in our society are adequately protected.

Expert commentaryDavid Haigh, clinical nurse specialist, Guy’s and St. Thomas’ NHS Foundation Trust, London

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For those patients with dry skin conditions such as eczema, The British Association of Dermatologists guidelines advise that the use of soap or detergent based products can exacerbate their symptoms. They recommend the use of soap substitutes.1

Doublebase Bath, Wash and Shower provide an effective alternative to the harshness of soap. They all contain a non-foaming soap substitute, which gently cleanses the skin, and a humectant which attracts water to moisturise the skin. The high oil content softens the skin and protects against dryness.

Doublebase™ Emollient Shower GelDoublebase™ Emollient Wash GelIsopropyl myristate 15% w/w, liquid paraffin 15% w/w.Uses: Highly moisturising and protective hydrating gels for dry skin conditions. Directions: Adults, children and the elderly: Use regularly, as required, as soap substitutes.Doublebase™ Emollient Bath AdditiveLiquid paraffin 65% w/w. Uses: For the relief of dry skin conditions. Directions: Adults, children and the elderly: Add to a bath of warm water. Soak and pat dry.

Contra-indications, warnings, side effects etc: Please refer to SPC for full details before prescribing. Do not use if sensitive to any of the ingredients. In the rare event of a reaction stop treatment. Take care not to slip in the bath or shower. Package quantities, NHS prices and MA numbers: Doublebase Shower: 200g shower pack £5.21, PL00173/0196. Doublebase Wash: 200g pump dispenser £5.21, PL00173/0402. Doublebase Bath: 500ml bottle £5.45, PL00173/0200. Legal categories: Doublebase Shower & Doublebase Wash P . Doublebase Bath GSL. MA holder: Dermal Laboratories, Tatmore Place, Gosmore, Hitchin, Herts, SG4 7QR. Date of preparation: January 2014. ‘Doublebase’ is a trademark.

Reference: 1. http://www.bad.org.uk/site/796/default.aspx

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Dermal.

DoublebaseTM Bath, DoublebaseTM Wash, DoublebaseTM ShowerIsopropyl myristate 15% w/w, liquid paraffin 15% w/w.Liquid paraffin 65% w/w.

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patients are resistant to analgesia (Wu and Raja, 2008). Stronger analgesics (e.g. tramadol, codeine) or opioids (i.e. morphine), can be used — alternatively anti-epileptic medications (i.e. gabapentin) or antidepressant medications (i.e. amitriptyline) can be considered.

Other complications of shingles, such as scarring and pigment alterations at the site of the lesion, can be permanent. Herpes zoster ophthalmicus or herpes zoster oticus can be associated with subsequent visual disturbance, corneal ulceration or hearing loss (Shaikh and Ta, 2002).

PREVENTION

In the UK, a vaccine was introduced to the NHS immunisation schedule in September 2013 with the aim of reducing the incidence and severity of shingles and shingles-related complications in older people (Department of Health [DH], 2013). The vaccine (Zostavax®; Sanofi Pasteur MSD) contains live, attenuated (reduced virulence) virus and is given as a single subcutaneous dose (Purssell, 2014).

The most recent guidance states that vaccination will be offered to those who are, or were, 70 years old on the 1 September 2014. As in the first year of the programme, a catch-up campaign will also run in 2014/15, this time for those aged 78 and 79 on 1 September 2014 (Public Health England, 2014) (Table 1). The vaccine is still relatively new and not well known by healthcare professionals, therefore, community nurses have an important role in recognising those at risk of shingles and recommending vaccination.

CONCLUSION

Caused by a reactivation of the varicella-zoster virus, shingles is a condition seen more commonly in older people and those who are immunocompromised due to illness or medications. It has associated complications, the worst of which is PHN, which can cause long-term severe pain and devastating consequences for an individual’s quality of life.

Community nurses need to be aware of the symptoms of shingles, particularly the characteristic rash that develops, so that they can make a referral to a GP for early initiation of antiviral medication. Community nurses also have an important role in the assessment and management of pain and supportive therapies, as well

as considering vaccination in patients over 70 years of age who have not already had shingles. JCN

REFERENCES

Albrecht MA (2010) Clinical manifestations of varicella-zoster virus infection: herpes zoster. Available at: http://nihlibrary.ors.nih.gov/jw/POC/URHS.htm (accessed 16 September, 2014)

Centers for Disease Control and Prevention (2014) Shingles (Herpes Zoster). Available at: www.cdc.gov/shingles/lab-testing (accessed 16 September, 2014)

Cobo M, Foulks GN, Liesegang T, et al (1987) Observations on the natural history of herpes zoster ophthalmicus. Curr Eye Res 6: 195–99

Cohen JI (2013) Herpes zoster. New Eng J Med 369: 255–63

DH (2013) Introduction of Shingles Vaccine for People aged 70 and 79. Available at: https://www.gov.uk/government/publications/introduction-of-shingles-vaccine-for-people-aged-70-and-79-years (accessed 18 September, 2014)

Gnann JW, Whitley RJ (2002) Herpes zoster. New Eng J Med 347: 340–46

Gondivkar S, Parikh V, Parikh R (2010) Herpes zoster oticus: a rare clinical entity. Contemp Clin Dentistry 1(2): 127-9

Katz J, Cooper EM, Walther RR, Sweeney EW, Dworkin RH (2004) Acute pain in herpes zoster and its impact on health-related quality of life. Infect Dis 39: 342–48

NICE (2013) Clinical Knowledge Summaries: shingles. Available at: http://cks.nice.org.uk/shingles (accessed 16 September, 2014)

Public Health England (2014) Green Book: chapter 28a — shingles (herpes zoster). Available at: https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

Purssell E (2014) Shingles vaccination: background and advice for community nurses. Br J Community Nurs 19(9): 442–46

Sanjay S, Huang P, Lavanya R (2011) Herpes zoster ophthalmicus. Curr Treat Options Neurol 13(1): 79–91

Shaikh S, Ta CN (2002) Evaluation and management of herpes zoster ophthalmicus. Am Fam Phys 66: 1723

Schmader K (2001) Herpes zoster in older adults. Clin Infect Dis 32(10): 1481–6

van Hoek AJ, Gay N, Melegaro A, et al (2009) Estimating the cost effectiveness of vaccination against herpes zoster in England and Wales. Vaccine 27(9): 1454–67

Wu CL, Raja AN (2008) An update on the treatment of post herpetic neuralgia. J Pain 9(1): 19–30

WHAT’S YOUR NEXT STEP?

To use the knowledge that you have gained from this article to inform your continuing professional development (CPD), you should take the following steps before logging onto the website (www.jcn.co.uk/learning-zone/) to take the learning zone test:ReflectAre you able to identify the main diagnostic markers for shingles?Are you able to identify the local signs and symptoms of shingles?Do you understand the reasons for vaccination shingles?EvaluateDo you understand why it is important to recognise shingles in the community setting and the principles of management?ActRead the article when you have a spare few minutes in the day.Make some notes on what you have learned, then visit the online test (www.jcn.co.uk/learning-zone/) to complete this subject. The whole test, which involves reading this article and answering the online questions, should take you 90 minutes to complete.Finally, download your certificate to show that you have completed the JCN e-learning unit on shingles as part of your CPD portfolio.

Table 1: Date of birth table for shingles vaccination eligibility

If patient born on or between:2 September, 1943 to 1 September, 1944

2 September, 1935 to 1 September, 1936

2 September, 1934 to 1 September, 1935

Source: http://www.unityhealth.info/intranet/library/s/shingles-aware-campaign/

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ABRIDGED PRESCRIBING INFORMATIONZOSTAVAX® powder and solvent for suspension for injection in a pre-filled syringe [shingles (herpes zoster) vaccine (live)]Refer to Summary of Product Characteristics for full product information.Presentation: Vial containing a lyophilised preparation of live attenuated varicella-zoster virus (Oka/Merck strain) and a pre-filled syringe containing water for injections. After reconstitution, one dose contains no less than 19400 PFU (Plaque-forming units) varicella-zoster virus (Oka/Merck strain). Indications: Active immunisation for the prevention of herpes zoster (“zoster” or shingles) and herpes zoster-related post-herpetic neuralgia (PHN) in individuals 50 years of age or older. Dosage and administration: Individuals should receive a single dose (0.65 ml) administered subcutaneously, preferably in the deltoid region. Do not inject intravascularly. It is recommended that the vaccine be administered immediately after reconstitution, to minimize loss of potency. Discard reconstituted vaccine if it is not used within 30 minutes. Contraindications: Hypersensitivity to the vaccine or any of its components (including neomycin). Individuals receiving immunosuppressive therapy (including high-dose corticosteroids)

or who have a primary or acquired immunodeficiency. Individuals with active untreated tuberculosis. Pregnancy. Warnings and precautions: Appropriate facilit ies and medication should be available in the rare event of anaphylaxis. Zostavax® is not indicated for the treatment of Zoster or PHN. Deferral of vaccination should be considered in the presence of fever. In clinical trials with Zostavax®, transmission of the vaccine virus has not been reported. However, post-marketing experience with varicella vaccines suggest that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-like rash and susceptible contacts (for example, VZV-susceptible infant grandchildren). Transmission of vaccine virus from varicella vaccine recipients who do not develop a varicella-like rash has also been reported. This is a theoretical risk for vaccination with Zostavax®. The risk of transmitting the attenuated vaccine virus from a vaccinee to a susceptible contact should be weighed against the risk of developing natural zoster and potentially transmitting wild-type VZV to a susceptible contact. As with any vaccine, vaccination with Zostavax® may not result in protection in all vaccine recipients. Zostavax® and 23-valent pneumococcal polysaccharide vaccine should not be given concomitantly

because concomitant use in a clinical trial resulted in reduced immunogenicity of Zostavax®. Pregnancy and lactation: Zostavax® is not intended to be administered to pregnant women. Pregnancy should be avoided for one month following vaccination. Caution should be exercised if Zostavax® is administered to a breast-feeding woman. Undesirable effects: Very common side effects: Pain/tenderness, erythema, swelling and pruritus at the injection site. Common side effects: Warmth, haematoma and induration at the injection site, pain in extremity, and headache. Other reported side effects that may potentially be serious include hypersensit ivity reactions including anaphylactic reactions, arthralgia, myalgia, lymphadenopathy, rash at the injection site, urticaria, pyrexia, rash and herpes zoster (vaccine strain). For a complete list of undesirable effects please refer to the Summary of Product Characteristics. Package quantities and basic cost: Vial and pre-filled syringe with two separate needles. The cost of this vaccine is £99.96. Supplier: Sanofi Pasteur MSD Ltd., Mallards Reach, Bridge Avenue, Maidenhead, Berkshire, SL6 1QP Marketing authorisation number: EU/1/06/341/011 Legal category: POM ® Registered trademark Date of last review: October 2014

References 1. Miller E, Marshall R, Vudien J. Epidemiology, outcome and control of varicella-zoster infection. Rev Med Microbiol. 1993; 4: 222-230 2. Gauthier A, Breuer J, Carrington D et al. Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom. Epidemiol Infect. 2008; 137(1): 38-47

Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Sanofi Pasteur MSD; reporting form can be

found at www.spmsd.co.uk/AE or via telephone 01628 785291

UK17602(1) 11/14

* Programme details may vary for each country. Please refer to local guidelines.

A new year, new patients

to protect

Help prevent shingles disrupting peoples’ lives

There’s a 1-in-4 chance of someone developing shingles during their lifetime.1 The risk

increases with age, as does the likelihood of complications.2

Year 2 of the national shingles immunisation programme

started on 1st September 2014* for eligible patients.

For full programme details and support items visit

www.shinglesaware.co.uk

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