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Shingles - Information for health professionals

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Background

Shingles (herpes zoster) is caused by the reactivation of a latent varicella zoster virus (VZV) infection, generally decades after the primary infection. Primary VZV infection typically occurs during childhood and causes chickenpox (varicella). 

Following primary VZV infection, the virus enters the sensory nerves and travels along the nerve to the sensory dorsal root ganglia and establishes a permanent latent infection. Reactivation of the latent virus causes a localised blistering rash which may be associated with local pain. The vesicle fluid is infectious and can cause chickenpox in non-immune individuals. 

The acute phase of shingles pain may be followed by a lengthy period of post herpetic neuralgia (PHN), which is also more common in the elderly. 

About 1 in 5 people who have had chickenpox will develop shingles.  Shingles can occur at any age and can occur more than once. Risk increases with age with an estimated lifetime risk of one in four. Risk is increased in those with certain conditions. 

Each year, approximately 750 cases of shingles are diagnosed by GPs per 100,000 people aged 65y and over in Wales (Data taken from Audit+ (2023)).   

In Wales approximately 60 cases of PHN are diagnosed by GPs per 100,000 people aged 65y and over each year (Data taken from Audit+ (2023)).  

During April 2021 to March 2022 there were 90 people aged 65 and over admitted to hospital with shingles (Data taken from Patient Episode Database Wales (PEDW)). 

It's estimated that around one in every 1,000 cases of shingles in adults over 70 results in death, although due to the nature of the population and risk of co-morbidities some deaths recorded as being shingles may not be directly attributable to the disease (UKHSA (2023) Immunisation against infectious disease. Chapter 28a Shingles [online]). 

On 01 September 2013 a shingles vaccination programme for people aged 70-79 years was introduced in Wales. The introduction was phased, with those aged 70 and 79 years eligible in the first year.  From 01 April 2019 individuals who reach their 70th birthday and have not had a shingles vaccine before can have a free shingles vaccine. They remain eligible until their 80th birthday. 

Key changes to the NHS Wales shingles vaccination programme from 01 September 2023: 

In February 2019, based on impact and cost effectiveness modelling, the Joint Committee on Vaccination and Immunisation (JCVI) recommended that the national shingles immunisation programme should be changed to offer Shingrix®: 

  • routinely at 60 years of age (in a phased approach) 

  • to immunocompromised (severely immunosuppressed) individuals aged 50 years and over 

JCVI also advised a catch-up of 60 to 70 year olds that should be implemented in two stages, starting with vaccination at ages 65 and 70 years (Phase 1), then moving to vaccination of those aged 60 and 65 years (Phase 2), following which time vaccination could then be routinely offered at 60 years of age. The advice was based on the high efficacy, safety and immunogenicity of Shingrix® observed in clinical trials.  

Table summary of changes to the shingles vaccination programme from 01 September 2023. 

Implementation phases 

Delivery period 

Eligible for first dose 

Phase One (5 year duration) 

1 Sept 2023 to 31 Aug 2028 

Those who reach age 65 or 70 years during this period should be called in on/after their 65th or 70th birthday* 

Phase Two (5 year duration) 

1 Sept 2028 to 31 Aug 2033 

Those who reach age 60 or 65 years during this period should be called in on/after their 60th or 65th birthday* 

Ongoing routine offer 

1 Sept 2033 onwards 

Those turning 60 years of age should be called in on/after their 60th birthday* 

*those that became eligible and missed out remain eligible until their 80th birthday. 

Evidence suggests that Shingrix® provides a substantially longer duration of protection from shingles than Zostavax®. There is now sufficient supply of Shingrix® to implement the JCVI recommendations. 

Phase 1 (01 September 2023 to 31 August 2028): 

The table below summarises the individuals eligible for the shingles vaccine from 01 September 2023: 

Individual’s age on or after 01 September each year from 2023 until 2028 

Is the individual severely immunosuppressed? 

When will they receive the Shingrix® vaccine? 

1st dose 

2nd dose 

Turned 65 years or 70 years^ 

(on/after 01 September each year from 2023 to 2028) 

No 

Aged 65 years  

 

Aged 70 years 

 

Between 6 and 12 months following first dose 
 

71 – 79 years who have not been given a shingles vaccine 

(NB. Individuals aged 70-79 years before 01 September 2023 are eligible until their 80th birthday) 

No 

Continue to use Zostavax® (single dose) whilst stocks last 

Once Zostavax® stocks are depleted use Shingrix®.  The second dose should be given 6-12 months after the first dose^^ 

50 years and over (no upper age limit)^^^ 

Yes^^^^ 

Given on or after their 50th birthday 

Between 8 weeks and 6 months following first dose 

^ In instances where an individual has already attained or passed the age of 65 but not yet 80 for phase one then general practices can accommodate opportunistic vaccination if operationally possible 

^^ Where an individual has turned 80 years of age following their first dose of Shingrix®, a second dose should be provided before the individual’s 81st birthday to complete the course 

^^^ The catch up of the immunosuppressed group (aged 50 years plus) should be prioritised in the first 12 months (September 2023 – September 2024) of the programme change 

^^^^ Individuals who should be offered Shingrix® amongst this age group are summarised in Shingles chapter 28a Green Book (Box) 

 

The table above summarises the individuals eligible for the shingles vaccine from 01 September 2023 which are: 

  • all severely immunosuppressed (eligibility as defined in the Green Book Shingles chapter 28a) from 50 years of age 

    • the second dose of Shingrix® should be given eight weeks to 6 months after the first dose 

    • rollout to all immunocompromised individuals aged 50 years and over should be completed by September 2024 

  • immunocompetent individuals: 

    • Shingrix® should be offered to those turning 65 and 70 years on or after 01 September 2023**  

    • The second dose of Shingrix® should be given 6 to 12 months after the first dose for this group 

    • Zostavax® (single dose) will be offered to individuals aged between 70 to 79 that were eligible for the vaccination programme before 01 September 2023. Once all stocks of Zostavax® are exhausted, these individuals can be offered Shingrix® if they have not previously been given a shingles vaccine. (Zostavax® is no longer being manufactured. Shingrix® will replace Zostavax® for the whole shingles programme.) 

**All immunocompetent individuals remain eligible for shingles vaccine until their 80th birthday.  

Where an individual has turned 80 years of age following their first dose of Shingrix®, a second dose should be provided before the individual’s 81st birthday to complete the course. 

For the immunocompromised cohort the:  

  • earliest eligible age will move down to 50 years and from 01 September, the eligible cohort will include all those aged 50 years and over (that is, for the immunocompromised cohort, there is no upper age limit)  

  • second dose should be given eight weeks to 6 months after the first dose 

  • rollout to all immunocompromised individuals aged 50 years and over should be completed by September 2024 

 

Phase 2 (01 September 2028 to 31 August 2033):   

During Phase 2 Shingrix® will be offered to those turning 60 and 65 years of age. Shingrix® will continue to be offered to immunocompromised (severely immunosuppressed) individuals from aged 50 (newly diagnosed unvaccinated immunocompromised individuals already over 50 years old should be vaccinated within 12 weeks of immunocompromised diagnosis). 

Thereafter, from 01 September 2033, Shingrix® will be offered routinely to all immunocompetent individuals at 60 years of age and to eligible immunocompromised (severely immunosuppressed) individuals aged 50 years or over. 

Further information about eligibility for the shingles vaccine from 01 September 2023 is available in the Guidance section.  

 

The vaccine 

There are two vaccines available: 

  • Zostavax® is a live vaccine 

  • Shingrix® is a non-live vaccine, and is available for individuals who are contraindicated for Zostavax® due to being immunocompromised and those newly eligible after 01 September 2023 

More information about the vaccine can be found in the Green Book Chapter 28a Shingles. There will be two Green Book Shingles chapters in use prior to 01 September 2023: 

  • the current chapter (dated 23 August 2021) which contains information about Zostavax. This chapter will be removed once Zostavax is no longer available to order through ImmForm  

  • the updated chapter (dated 17 July 2023) which includes information about the shingles vaccine programme from 1 September 2023 onwards 

Summary of product characteristics 

Guidance in the Green Book Chapter 28a Shingles supersedes the SmPC. 

The Complete Routine Immunisation Schedule includes information about routine and non-routine vaccinations. 

 

Guidance

Vaccination programme recommendations from the Joint Committee on Vaccination and Immunisation (JCVI) and Welsh Government policy can be found at the links below.

Joint Committee on Vaccination and Immunisation - GOV.UK (read JCVI publications and statements; search e.g. shingles)

 

Welsh Health Circulars and Welsh Government letters

Changes to shingles vaccinations (from September 2023) (WHC/2023/024) | GOV.WALES [Added August 2023] 

Introduction of Shingrix® for immunocompromised individuals from September 2021 (WHC/2021/021) | GOV.WALES 

Changes to the shingles immunisation programme (WHC/2019/008) | GOV.WALES 

 

Training resources and events

Online courses and training materials about a number of vaccines and diseases can be accessed via the E-learning page. 

Further immunisation training information and resources are provided on the Training Resources and Events page. 

 

Clinical resources and information

Shingles (herpes zoster): the green book, chapter 28a - GOV.UK

Shingles vaccination: guidance for healthcare professionals - GOV.UK 

Shingles vaccination visual aid for Healthcare Professionals  [Added August 2023, valid from 1 September 2023] 

Screening Tool for Contraindications for Shingles Vaccine - Public Health Scotland 

Shingles invitation template (no date for appointment) Bilingual v2 (May 2023) 

Shingles invitation template (date for appointment) Bilingual v2 (May 2023) 

 

Patient group directions (PGDs)

PGD templates for vaccines can be found on the   Welsh Medicines Advice Service page 

 

Further clinical resources and information

 

Other resources

Green Book Chapter 34: Varicella
Shingles vaccination - are you eligible? A3 Poster Bilingual [Valid from 1 September 2023]

 

Data and surveillance