Herpes zoster primary prevention: Difference between revisions

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__NOTOC__
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{{Herpes zoster}}
{{Herpes zoster}}
{{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}}
{{CMG}}; L. Katie Morrison, MD; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{AA}}


==Overview==
==Overview==
The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated.  A vaccine for shingles is licensed for persons aged 60 years and older.
The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated.  A vaccine for shingles is licensed for persons aged 60 years and older.<ref name=CDCVZV>https://www.cdc.gov/shingles/vaccination.html Accessed on October 24th, 2016</ref>
==Primary Prevention==
==Primary Prevention==
The intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruit, may reduce the risk of developing shingles.  In one study, patients who consumed less than one serving of fruit a day had three times the risk as those who consumed over three servings per day. For those aged 60 or more, micronutrient and vegetable intake had a similar lowering of risk.<ref name="pmid16330478">{{cite journal |author=Thomas SL, Wheeler JG, Hall AJ |title=Micronutrient intake and the risk of herpes zoster: a case-control study |journal=International Journal of Epidemiology |volume=35 |issue=2 |pages=307-14 |year=2006 |pmid=16330478 |doi=10.1093/ije/dyi270}}</ref> A recent study evaluated the effects of two types of behavioral intervention, [[Tai Chi Chuan|Tai Chi]] and health education, on healthy adults, who, after 16 weeks of the intervention, were vaccinated with VARIVAX, a live attenuated Oka/Merck Varicella zoster virus vaccine.<ref>{{cite journal|last=Irwin|first=MR|coauthors=Olmstead, R & Oxman, MN|title=Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi|date=2007|journal=Journal of the American Geriatrics Society|volume=55|issue=4|pages=511-517|url=http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01109.x|doi=10.1111/j.1532-5415.2007.01109.x|accessdate=2007-04-08}}</ref>
[[Zostavax]] vaccine is recommended for individuals aged 60 years and older to prevent Herpes zoster. Other primary prevention strategies include  intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruits.<ref name="pmid16330478">{{cite journal |author=Thomas SL, Wheeler JG, Hall AJ |title=Micronutrient intake and the risk of herpes zoster: a case-control study |journal=International Journal of Epidemiology |volume=35 |issue=2 |pages=307-14 |year=2006 |pmid=16330478 |doi=10.1093/ije/dyi270}}</ref><ref>{{cite journal|last=Irwin|first=MR|coauthors=Olmstead, R & Oxman, MN|title=Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi|date=2007|journal=Journal of the American Geriatrics Society|volume=55|issue=4|pages=511-517|url=http://www.blackwell-synergy.com/doi/abs/10.1111/j.1532-5415.2007.01109.x|doi=10.1111/j.1532-5415.2007.01109.x|accessdate=2007-04-08}}</ref>


===Vaccines===
===Vaccines===
[[Varicella (Chickenpox) Vaccine]] can prevent this disease. Currently, two doses of vaccine are recommended for children, adolescents, and adults.


A live attenuated VZV Oka/Merck strain [[vaccine]] is available and is marketed under the trade name ''Varivax''. It was developed by [[Merck & Co.|Merck, Sharp & Dohme]] in the 1980s from the Oka strain virus isolated and attenuated by Michiaki Takahashi and colleagues in the 1970s. It was submitted to the U.S. [[Food and Drug Administration]] for approval in 1990 and was approved in 1995. Since then, it has been added to the recommended vaccination schedules for children in Australia, the United States, and many other countries, causing controversy because it is only expected to be effective for about twenty years, leaving adults vulnerable to the most dangerous forms of infection by this virus. The use of varicella virus vaccine live (Varivax) has been limited by practitioner concerns that adults vaccinated as children could develop severe varicella infection complications if immunity provided by the vaccine is not long-lasting. However, clinical data has proved that the vaccine is effective for over 10 years in preventing varicella infection in healthy individuals and when breakthrough infections do occur, illness is typically mild.<ref>Centers for Disease Control and Prevention (CDC). Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1996;45(No.RR-11)</ref>
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 150px;" | {{fontcolor|#FFF|Varicella containing vaccines}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Indications}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Efficacy and immunogenicity}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Recommended dose}}
! style="background: #4479BA; width: 350px;" | {{fontcolor|#FFF|Contraindications}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''Herpes zoster vaccine (Zostavax)'''<ref name=CDC3>http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016</ref><ref>Poland, Gregory. "The Growing Paradigm of Preventing Disease." Annals of Internal Medicine. 2005;143539-541. </ref><ref>Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418</ref><ref name="pmid1658650">{{cite journal| author=Hardy I, Gershon AA, Steinberg SP, LaRussa P| title=The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 22 | pages= 1545-50 | pmid=1658650 | doi=10.1056/NEJM199111283252204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1658650  }} </ref><ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Approved for persons 50 years and older
*Not recommended by ACIP in adults younger than 60 years of age
| style="padding: 5px 5px; background: #F5F5F5;" |
*Vaccine recipients 60 to 80 years of age had 51% fewer episodes of zoster
:*Efficacy declines with increasing age
:*Significantly reduces the risk of postherpetic neuralgia
*Reduces the risk of zoster 69.8% in persons 50 through 59 years of age
| style="padding: 5px 5px; background: #F5F5F5;" |
*Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster)
| style="padding: 5px 5px; background: #F5F5F5;" |
*Severe allergic reaction to vaccine component or following a prior dose
*Immunosuppression
*Pregnancy
*Moderate or severe acute illness
|-
| style="padding: 5px 5px; background: #DCDCDC;" |'''New Herpes zoster vaccine (Shingrix)'''<ref name="pmid25916341">{{cite journal| author=Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ et al.| title=Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. | journal=N Engl J Med | year= 2015 | volume= 372 | issue= 22 | pages= 2087-96 | pmid=25916341 | doi=10.1056/NEJMoa1501184 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25916341  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Adults aged 50 years or older (first pivotal phase 3 trial)
*Adults aged 70 years and over (second pivotal phase 4 trial)
| style="padding: 5px 5px; background: #F5F5F5;" |
*Efficacy between 91-97% for all age groups
*Efficacy does not decrease with increasing age group
| style="padding: 5px 5px; background: #F5F5F5;" |
*Two doses 2 to 6 months apart
| style="padding: 5px 5px; background: #F5F5F5;" |
*Immunocompromised individuals
|-
|}


In 2006, the [[FDA]] approved [[Zostavax]] for the prevention of shingles. Zostavax is a more concentrated formulation of the Varivax vaccine, designed to elicit an immune response in the eldery whose immunity to VZV wanes with advancing age.  <ref>Poland, Gregory. "The Growing Paradigm of Preventing Disease." Annals of Internal Medicine. 2005;143539-541. </ref> It was recommended by the Advisory Committee on Immunization Practices (ACIP) in 2006 to reduce the risk of shingles and its associated pain in people age 60 years and older. Zostavax is developed by [[Merck & Co.]] and has proven successful in preventing half the cases of herpes zoster in a study of 38,000 people who received the vaccine. <ref>Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418</ref> The vaccine also reduced by two-thirds the number of cases of postherpetic neuralgia. <ref>Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418</ref> However, prior to the vaccine, it has long been known that adults received natural immune boosting from contact with children infected with [[varicella]]. This helped to suppress the reactivation of herpes zoster.<ref>{{cite journal | author = Brisson M, Gay N, Edmunds W, Andrews N | title = Exposure to varicella boosts immunity to herpes-zoster: implications for mass vaccination against chicken pox. | journal = Vaccine | volume = 20 | issue = 19-20 | pages = 2500-7 | year = 2002 | id = PMID 12057605}}</ref> In Massachusetts, herpes zoster incidence increased 90%, from 2.77/1000 to 5.25/1000 in the period of increasing varicella vaccination 1999-2003.<ref>{{cite journal | last=Yih|first=WK |coauthors =Brooks DR, Lett SM, Jumaan AO, Zhang Z, Clements KM, & Seward JF| title=The incidence of varicella and herpes zoster in Massachusetts as measured by the Behavioral Risk Factor Surveillance System (BRFSS) during a period of increasing varicella vaccination coverage, 1998-2003 | journal=BMC Public Health | volume=5| issue=1 | year=2005 | pages=68-68 | id=PMID 15960856}}</ref> The effectiveness of the varicella vaccine itself is dependent on this exogenous (outside) boosting mechanism. Thus, as natural cases of varicella decline, so has the effectiveness of the vaccine.<ref>{{cite journal | first=GS|last=Goldman| title=Universal varicella vaccination: efficacy trends and effect on herpes zoster | journal=International Journal of Toxicology| volume=24| issue=4 | year=2005 | pages=205-213 | id=PMID 16126614}}</ref>
===Infection control preventive measures===
Infection-control measures after exposure to herpes zoster depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated. In all cases, standard infection-control precautions should be followed.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>


The risk for developing shingles increases with age. The Shingles Prevention Study involved individuals age 60 years and older and found the shingles vaccine significantly reduced disease in this age group. The vaccine is currently recommended for persons 60 years of age and older. Even people who have had shingles can receive the vaccine to help prevent future occurrences of the disease.
'''If the patient is immunocompetent'''
*Localized herpes zoster: then standard precautions should be followed and lesions should be completely covered.
*Disseminated herpes zoster: defined as appearance of lesions outside the primary or adjacent dermatomes, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>


At this time, CDC does not have a recommendation for routine use of shingles vaccine in persons 50 through 59 years old. However, the vaccine is approved by FDA for people in this age group.
'''If the patient is immunocompromised'''
====Risk of Acquiring Herpes zoster after Vaccination====
*Localized herpes zoster: then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until lesions are dry and crusted.
The attenuated vaccine virus can reactivate and cause herpes zoster. People who get vaccinated against varicella may develop herpes zoster later in life. However, their risk is lower than people who were infected with wild-type VZV.
*Disseminated herpes zoster: then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>
*In a study of children with leukemia, those who got varicella vaccine had a 67% lower risk of herpes zoster than children who had had varicella<ref name="pmid1658650">{{cite journal| author=Hardy I, Gershon AA, Steinberg SP, LaRussa P| title=The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 22 | pages= 1545-50 | pmid=1658650 | doi=10.1056/NEJM199111283252204 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1658650  }} </ref>.
 
*Data on healthy children show a similar pattern of reduced risk of herpes zoster in those vaccinated against varicella.
====Management of Healthcare Personnel====
*The number of older adults who got varicella vaccine since it was licensed in 1995 is quite low. So, there is very little information on the risk of herpes zoster in people who got varicella vaccine as adults.
The following steps should be taken when healthcare personnel (HCP) are exposed to someone with varicella or herpes zoster:
*HCP who have received 2 doses of varicella vaccine should be monitored daily during postexposure days 8–21 for fever, skin lesions, and systemic symptoms suggestive of varicella. HCP can be monitored directly by employee health program or infection control practitioners or instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. If symptoms occur, the HCP should be immediately removed from patient care areas and receive antiviral medication. Healthcare personnel with varicella and disseminated herpes zoster should be excluded from work until all lesions have dried and crusted or, in the absence of vesicular lesions, until no new lesions have appeared for 24 hours.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>
*HCP who have received 1 dose of varicella vaccine should receive the second dose at any interval after exposure to someone with rash (provided 4 weeks have elapsed after the first dose). After vaccination, management is the same as that of HCP who have received 2 doses of varicella vaccine.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>
*Unvaccinated VZV-susceptible HCP are potentially infective from days 8 to 21 after exposure and should be furloughed or temporarily reassigned to locations remote from patient-care areas during this period. Exposed HCP without evidence of immunity should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash may modify the disease if infection occurred. Vaccination 6 or more days after exposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection). For unvaccinated VZV-susceptible HCP at risk for severe disease and for whom varicella vaccination is contraindicated (e.g., pregnant HCP), varicella-zoster immune globulin after exposure is recommended.<ref name=CDC4>http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016</ref>


===Preventing Transmission in Healthcare Settings===
===Preventing Transmission in Healthcare Settings===
To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.
To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.<ref name=CDC3>http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016</ref>


Evidence of immunity to VZV for healthcare personnel includes any of the following:
Evidence of immunity to VZV for healthcare personnel includes any of the following:
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==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WS}}
{{WH}}
[[Category:Infectious skin diseases]]
[[Category:Infectious skin diseases]]
[[Category:Viral diseases]]
[[Category:Viral diseases]]
[[Category:Herpesviruses]]
[[Category:Herpesviruses]]
[[Category:Infectious disease]]
[[Category:primary care]]
{{WS}}
{{WH}}

Latest revision as of 22:10, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; L. Katie Morrison, MD; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Aysha Anwar, M.B.B.S[3]

Overview

The only way to reduce the risk of developing shingles and the long-term pain that can follow shingles is to get vaccinated. A vaccine for shingles is licensed for persons aged 60 years and older.[1]

Primary Prevention

Zostavax vaccine is recommended for individuals aged 60 years and older to prevent Herpes zoster. Other primary prevention strategies include intake of micronutrients, including antioxidant vitamins, A, C, E and vitamin B, as well as fresh fruits.[2][3]

Vaccines

Varicella containing vaccines Indications Efficacy and immunogenicity Recommended dose Contraindications
Herpes zoster vaccine (Zostavax)[4][5][6][7][8]
  • Approved for persons 50 years and older
  • Not recommended by ACIP in adults younger than 60 years of age
  • Vaccine recipients 60 to 80 years of age had 51% fewer episodes of zoster
  • Efficacy declines with increasing age
  • Significantly reduces the risk of postherpetic neuralgia
  • Reduces the risk of zoster 69.8% in persons 50 through 59 years of age
  • Single dose at age 60 years or older (whether or not they report a prior episode of herpes zoster)
  • Severe allergic reaction to vaccine component or following a prior dose
  • Immunosuppression
  • Pregnancy
  • Moderate or severe acute illness
New Herpes zoster vaccine (Shingrix)[9]
  • Adults aged 50 years or older (first pivotal phase 3 trial)
  • Adults aged 70 years and over (second pivotal phase 4 trial)
  • Efficacy between 91-97% for all age groups
  • Efficacy does not decrease with increasing age group
  • Two doses 2 to 6 months apart
  • Immunocompromised individuals

Infection control preventive measures

Infection-control measures after exposure to herpes zoster depend on whether the patient with herpes zoster is immunocompetent or immunocompromised and on whether the rash is localized or disseminated. In all cases, standard infection-control precautions should be followed.[8]

If the patient is immunocompetent

  • Localized herpes zoster: then standard precautions should be followed and lesions should be completely covered.
  • Disseminated herpes zoster: defined as appearance of lesions outside the primary or adjacent dermatomes, then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.[8]

If the patient is immunocompromised

  • Localized herpes zoster: then standard precautions plus airborne and contact precautions should be followed until disseminated infection is ruled out. Then standard precautions should be followed until lesions are dry and crusted.
  • Disseminated herpes zoster: then standard precautions plus airborne and contact precautions should be followed until lesions are dry and crusted.[8]

Management of Healthcare Personnel

The following steps should be taken when healthcare personnel (HCP) are exposed to someone with varicella or herpes zoster:

  • HCP who have received 2 doses of varicella vaccine should be monitored daily during postexposure days 8–21 for fever, skin lesions, and systemic symptoms suggestive of varicella. HCP can be monitored directly by employee health program or infection control practitioners or instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. If symptoms occur, the HCP should be immediately removed from patient care areas and receive antiviral medication. Healthcare personnel with varicella and disseminated herpes zoster should be excluded from work until all lesions have dried and crusted or, in the absence of vesicular lesions, until no new lesions have appeared for 24 hours.[8]
  • HCP who have received 1 dose of varicella vaccine should receive the second dose at any interval after exposure to someone with rash (provided 4 weeks have elapsed after the first dose). After vaccination, management is the same as that of HCP who have received 2 doses of varicella vaccine.[8]
  • Unvaccinated VZV-susceptible HCP are potentially infective from days 8 to 21 after exposure and should be furloughed or temporarily reassigned to locations remote from patient-care areas during this period. Exposed HCP without evidence of immunity should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash may modify the disease if infection occurred. Vaccination 6 or more days after exposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection). For unvaccinated VZV-susceptible HCP at risk for severe disease and for whom varicella vaccination is contraindicated (e.g., pregnant HCP), varicella-zoster immune globulin after exposure is recommended.[8]

Preventing Transmission in Healthcare Settings

To prevent disease and nosocomial spread of VZV, health care institutions should ensure that all healthcare personnel have evidence of immunity to VZV. This information should be documented and readily available at the work location. healthcare personnel without evidence of immunity should be alerted to the risks of possible infection and offered 2 doses of varicella vaccine administered 4–8 weeks apart when they begin employment. In addition, health-care institutions should establish protocols and recommendations for screening and vaccinating healthcare personnel and for management of healthcare personnel after exposures in the workplace.[4]

Evidence of immunity to VZV for healthcare personnel includes any of the following:

  • Documentation of vaccination with 2 doses of varicella vaccine;
  • Laboratory evidence of immunity or laboratory confirmation of disease;
  • Diagnosis or verification of a history of varicella disease by a healthcare provider; or
  • Diagnosis or verification of a history of herpes zoster by a healthcare provider.

References

  1. ↑ https://www.cdc.gov/shingles/vaccination.html Accessed on October 24th, 2016
  2. ↑ Thomas SL, Wheeler JG, Hall AJ (2006). "Micronutrient intake and the risk of herpes zoster: a case-control study". International Journal of Epidemiology. 35 (2): 307–14. doi:10.1093/ije/dyi270. PMID 16330478.
  3. ↑ Irwin, MR (2007). "Augmenting Immune Responses to Varicella Zoster Virus in Older Adults: A Randomized, Controlled Trial of Tai Chi". Journal of the American Geriatrics Society. 55 (4): 511–517. doi:10.1111/j.1532-5415.2007.01109.x. Retrieved 2007-04-08. Unknown parameter |coauthors= ignored (help)
  4. ↑ 4.0 4.1 http://www.cdc.gov/vaccines/pubs/pinkbook/varicella.html Accessed on October 24, 2016
  5. ↑ Poland, Gregory. "The Growing Paradigm of Preventing Disease." Annals of Internal Medicine. 2005;143539-541.
  6. ↑ Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD et al. (2005). "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults". N Engl J Med 253 (22): 2271–84. PMID 15930418
  7. ↑ Hardy I, Gershon AA, Steinberg SP, LaRussa P (1991). "The incidence of zoster after immunization with live attenuated varicella vaccine. A study in children with leukemia. Varicella Vaccine Collaborative Study Group". N Engl J Med. 325 (22): 1545–50. doi:10.1056/NEJM199111283252204. PMID 1658650.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 8.5 8.6 http://www.cdc.gov/Mmwr/preview/mmwrhtml/rr57e0515a1.htm Accessed on October 24, 2016
  9. ↑ Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ; et al. (2015). "Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults". N Engl J Med. 372 (22): 2087–96. doi:10.1056/NEJMoa1501184. PMID 25916341.

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