Zoster vaccine

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# Overview
Zoster vaccine is a vaccine that is FDA approved for the prophylaxis of herpes zoster (shingles) in individuals 50 years of age and older.   Common adverse reactions include Headache and injection-site reactions.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### Prevention of herpes zoster
- Dosing information
- Administer Zoster vaccine as a single 0.65-mL dose subcutaneously in the deltoid region of the upper arm.

### Preparation for Administration
Use only sterile syringes free of preservatives, antiseptics, and detergents for each injection and/or reconstitution of Zoster vaccine. Preservatives, antiseptics and detergents may inactivate the vaccine virus.
Zoster vaccine is stored frozen and should be reconstituted immediately upon removal from the freezer.
When reconstituted, Zoster vaccine is a semi-hazy to translucent, off-white to pale yellow liquid.
Reconstitution:
- Use only the diluent supplied.
- Withdraw the entire contents of the diluent into a syringe.
- To avoid excessive foaming, slowly inject all of the diluent in the syringe into the vial of lyophilized vaccine and gently agitate to mix thoroughly.
- Withdraw the entire contents of reconstituted vaccine into a syringe and inject the total volume subcutaneously.
- ADMINISTER IMMEDIATELY AFTER RECONSTITUTION to minimize loss of potency. Discard reconstituted vaccine if not used within 30 minutes. Do not freeze reconstituted vaccine.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Zoster vaccine in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of zoster vaccine in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
Zoster vaccine is not indicated for prevention of primary varicella infection (Chickenpox) and should not be used in children and adolescents.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of zoster vaccine in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of zoster vaccine in pediatric patients.

# Contraindications

## [Hypersensitivity=
Do not administer Zoster vaccine to individuals with a history of anaphylactic/anaphylactoid reactionto gelatin, neomycin or any other component of the vaccine. neomycin allergy manifested as contact dermatitis is not a contraindication to receiving this vaccine. {1}

### Immunosuppression
Zoster vaccine is a live, attenuated varicella-zoster vaccine and administration may result in disseminated disease in individuals who are immunosuppressed or immunodeficient. Do not administer Zoster vaccine to immunosuppressed or immunodeficient individuals including those with a history of primary or acquired immunodeficiency states, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system, AIDS or other clinical manifestations of infection with human immunodeficiency viruses, and those on immunosuppressive therapy.

### Pregnancy
Do not administer Zoster vaccine to pregnant women. It is not known whether Zoster vaccine can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. However, naturally occurring varicella-zoster virus (VZV) infection is known to sometimes cause fetal harm. Therefore, Zoster vaccine should not be administered to pregnant women, and pregnancy should be avoided for 3 months following administration of Zoster vaccine.

# Warnings

### Hypersensitivity Reactions
Serious adverse reactions, including anaphylaxis, have occurred with Zoster vaccine. Adequate treatment provisions, including epinephrine injection (1:1,000), should be available for immediate use should an anaphylactic/anaphylactoid reactionoccur.

### Transmission of Vaccine Virus
Transmission of vaccine virus may occur between vaccinees and susceptible contacts.

### Concurrent Illness
Deferral should be considered in acute illness (for example, in the presence of fever) or in patients with active untreated tuberculosis.

### Limitations of Vaccine Effectiveness
Vaccination with Zoster vaccine does not result in protection of all vaccine recipients.
The duration of protection beyond 4 years after vaccination with Zoster vaccine is unknown. The need for revaccination has not been defined.

# Adverse Reactions

## Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, rates of adverse reactions observed in the clinical trials of a vaccine cannot be directly compared to rates in the clinical trials of another vaccine and may not reflect the rates observed in practice.
Zoster vaccine Efficacy and Safety Trial (ZEST) in Subjects 50 to 59 Years of Age
In the ZEST study, subjects received a single dose of either Zoster vaccine (N=11,184) or placebo  (N=11,212). The racial distribution across both vaccination groups was similar: White (94.4%); Black (4.2%); Hispanic (3.3%) and Other (1.4%) in both vaccination groups. The gender distribution was 38% male and 62% female in both vaccination groups. The age distribution of subjects enrolled, 50 to 59 years, was similar in both vaccination groups. All subjects received a vaccination report card (VRC) to record adverse events occurring from Days 1 to 42 ].
In the ZEST study, serious adverse events occurred at a similar rate in subjects vaccinated with Zoster vaccine (0.6%) or placebo  (0.5%) from Days 1 to 42 postvaccination.
In the ZEST study, all subjects were monitored for adverse reactions. An anaphylactic reaction was reported for one subject vaccinated with Zoster vaccine.
Most Common Adverse Reactions and Experiences in the ZEST Study
The overall incidence of vaccine-related injection site adverse reactions within 5 days post-vaccination was greater for subjects vaccinated with Zoster vaccine as compared to subjects who received placebo  (63.6% for Zoster vaccine and 14.0% for placebo ). injection site adverse reactions occurring at an incidence 1% within 5 days post-vaccination are shown in Table 1.
Systemic adverse reactions and experiences reported during Days 1-42 at an incidence of 1% in either vaccination group were Headache  (Zoster vaccine 9.4%, placebo  8.2%) and pain in the extremity (Zoster vaccine 1.3%, placebo  0.8%), respectively.
The overall incidence of systemic adverse experiences reported during Days 1-42 was higher for Zoster vaccine (35.4%) than for placebo  (33.5%).
Shingles Prevention Study (SPS) in Subjects 60 Years of Age and Older
In the SPS, the largest clinical trial of Zoster vaccine, subjects received a single dose of either Zoster vaccine (n=19,270) or placebo  (n=19,276). The racial distribution across both vaccination groups was similar: White (95%); Black (2.0%); Hispanic (1.0%) and Other (1.0%) in both vaccination groups. The gender distribution was 59% male and 41% female in both vaccination groups. The age distribution of subjects enrolled, 59-99 years, was similar in both vaccination groups.
The Adverse Event Monitoring Substudy of the SPS, designed to provide detailed data on the safety profile of the Zoster vaccine (n=3,345 received Zoster vaccine and n=3,271 received placebo ) used vaccination report cards (VRC) to record adverse events occurring from Days 0 to 42 postvaccination (97% of subjects completed VRC in both vaccination groups). In addition, monthly surveillance for hospitalization was conducted through the end of the study, 2 to 5 years postvaccination.
The remainder of subjects in the SPS (n=15,925 received Zoster vaccine and n=16,005 received placebo ) were actively followed for safety outcomes through Day 42 postvaccination and passively followed for safety after Day 42.
Serious Adverse Events Occurring 0-42 Days postvaccination
In the overall SPS study population, serious adverse events occurred at a similar rate (1.4%) in subjects vaccinated with Zoster vaccine or placebo .
In the AE Monitoring Substudy, the rate of SAEs was increased in the group of subjects who received Zoster vaccine as compared to the group of subjects who received placebo  (Table 2).
Among reported serious adverse events in the SPS (Days 0 to 42 postvaccination), serious cardiovascular events occurred more frequently in subjects who received Zoster vaccine (20 ) than in subjects who received placebo  (12 ) in the AE Monitoring Substudy. The frequencies of serious cardiovascular events were similar in subjects who received Zoster vaccine (81 ) and in subjects who received placebo  (72 ) in the entire study cohort (Days 0 to 42 postvaccination).
Serious Adverse Events Occurring Over the Entire Course of the Study
Rates of hospitalization were similar among subjects who received Zoster vaccine and subjects who received placebo  in the AE Monitoring Substudy, throughout the entire study.
Fifty-one individuals (1.5%) receiving Zoster vaccine were reported to have congestive heart failure (CHF) or pulmonary edema compared to 39 individuals (1.2%) receiving placebo  in the AE Monitoring Substudy; 58 individuals (0.3%) receiving Zoster vaccine were reported to have congestive heart failure (CHF) or pulmonary edema compared to 45 (0.2%) individuals receiving placebo  in the overall study.
In the SPS, all subjects were monitored for vaccine-related SAEs. Investigator-determined, vaccine-related serious adverse experiences were reported for 2 subjects vaccinated with Zoster vaccine (asthma exacerbation and polymyalgia rheumatica) and 3 subjects who received placebo  (Goodpasture's syndrome, anaphylactic reaction, and polymyalgia rheumatica).
Deaths
The incidence of death was similar in the groups receiving Zoster vaccine or placebo  during the Days 0-42 postvaccination period; 14 deaths occurred in the group of subjects who received Zoster vaccine and 16 deaths occurred in the group of subjects who received placebo . The most common reported cause of death was cardiovascular disease (10 in the group of subjects who received Zoster vaccine, 8 in the group of subjects who received placebo ). The overall incidence of death occurring at any time during the study was similar between vaccination groups: 793 deaths (4.1%) occurred in subjects who received Zoster vaccine and 795 deaths (4.1%) in subjects who received placebo .
Most Common Adverse Reactions and Experiences in the AE Monitoring Substudy of the SPS
injection site adverse reactions reported at an incidence 1% are shown in Table 3. Most of these adverse reactions were reported as mild in intensity. The overall incidence of vaccine-related ] was significantly greater for subjects vaccinated with Zoster vaccine versus subjects who received placebo  (48% for Zoster vaccine and 17% for placebo ).
Headache  was the only systemic adverse reaction reported on the vaccine report card between Days 0-42 by 1% of subjects in the AE Monitoring Substudy in either vaccination group (Zoster vaccine 1.4%, placebo  0.8%).
The numbers of subjects with elevated temperature (38.3C ) within 42 days postvaccination were similar in the Zoster vaccine and the placebo  vaccination groups .
The following adverse experiences in the AE Monitoring Substudy of the SPS (Days 0 to 42 postvaccination) were reported at an incidence 1% and greater in subjects who received Zoster vaccine than in subjects who received placebo , respectively: respiratory infection (65  vs. 55 ), fever (59  vs. 53 ), flu syndrome (57  vs. 52 ), diarrhea (51  vs. 41 ), rhinitis (46  vs. 36 ), skin disorder (35  vs. 31 ), respiratory disorder (35  vs. 27 ), asthenia (32  vs. 14 ).

## VZV Rashes Following Vaccination
Within the 42-day postvaccination reporting period in the ZEST, non injection-site zoster-like rashes were reported by 34 subjects (19 for Zoster vaccine and 15 for placebo ). Of 24 specimens that were adequate for Polymerase Chain Reaction (PCR) testing, wild-type VZV was detected in 10 (3 for Zoster vaccine, 7 for placebo ) of these specimens. The Oka/Merck strain of VZV was not detected from any of these specimens. Of reported varicella-like rashes (n=124, 69 for Zoster vaccine and 55 for placebo ), 23 had specimens that were available and adequate for PCR testing. VZV was detected in one of these specimens in the Zoster vaccine group; however, the virus strain (wild-type or Oka/Merck strain) could not be determined.
Within the 42-day postvaccination reporting period in the SPS, noninjection-site zoster-like rashes were reported by 53 subjects (17 for Zoster vaccine and 36 for placebo ). Of 41 specimens that were adequate for Polymerase Chain Reaction (PCR) testing, wild-type VZV was detected in 25 (5 for Zoster vaccine, 20 for placebo ) of these specimens. The Oka/Merck strain of VZV was not detected from any of these specimens.
Of reported varicella-like rashes (n=59), 10 had specimens that were available and adequate for PCR testing. VZV was not detected in any of these specimens.
In clinical trials in support of the initial licensure of the frozen formulation of Zoster vaccine, the reported rates of noninjection-site zoster-like and varicella-like rashes within 42 days postvaccination were also low in both Zoster vaccine and placebo  recipients. Of 17 reported varicella-like rashes and non-injection site zoster-like rashes, 10 specimens were available and adequate for PCR testing, and 2 subjects had varicella (onset Day 8 and 17) confirmed to be Oka/Merck strain.

## Postmarketing Experience
The following additional adverse reactions have been identified during postmarketing use of Zoster vaccine. Because these reactions are reported voluntarily from a population of uncertain size, it is generally not possible to reliably estimate their frequency or establish a causal relationship to the vaccine.
Gastrointestinal disorders: nausea
Infections and infestations: herpes zoster (vaccine strain)
Skin and subcutaneous tissue disorders: rash
Musculoskeletal and connective tissue disorders: arthralgia; myalgia
General disorders and administration site conditions: injection-site rash; pyrexia; injection-site urticaria; transient injection-site lymphadenopathy
Immune system disorders: hypersensitivity reactions including anaphylactic reactions
Reporting Adverse Events
The U.S. Department of Health and Human Services has established a Vaccine Adverse Event Reporting System (VAERS) to accept all reports of suspected adverse events after the administration of any vaccine. For information or a copy of the vaccine reporting form, call the VAERS toll-free number at 1-800-822-7967 or report online to www.vaers.hhs.gov.

# Drug Interactions

### Concomitant Administration with Other Vaccines
In a randomized clinical study, a reduced immune response to Zoster vaccine as measured by gpELISA was observed in individuals who received concurrent administration of PNEUMOVAX 23 and Zoster vaccine compared with individuals who received these vaccines 4 weeks apart. Consider administration of the two vaccines separated by at least 4 weeks.
For concomitant administration of Zoster vaccine with trivalent inactivated influenza vaccine.

### Antiviral Medications
Concurrent administration of Zoster vaccine and antiviral medications known to be effective against VZV has not been evaluated.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): 
Pregnancy Category: Contraindication.
Zoster vaccine should not be administered to pregnant females since wild-type varicella can sometimes cause congenital varicella infection. Pregnancy should be avoided for three months following vaccination with Zoster vaccine.
Pregnancy Registry
From 1995 to 2013, Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., maintained a Pregnancy Registry to monitor fetal outcomes following inadvertent administration of VARIVAX during pregnancy or within three months prior to conception. In 2006, reports of exposure to two other varicella (Oka/Merck)-containing vaccines, ProQuad (Measles, Mumps, Rubella and Varicella Virus Vaccine Live) and Zoster vaccine, were added to the Registry. The Pregnancy Registry has been discontinued. As of March 2011, 811 women with pregnancy outcome information available for analysis were prospectively enrolled following vaccination with VARIVAX, within three months prior to conception or any time during pregnancy. Of these women, 170 were seronegative at the time of exposure and 627 women had an unknown serostatus. The remaining women were seropositive. Nine exposures to either ProQuad or Zoster vaccine have been reported that met criteria for inclusion into the Registry.
None of the 820 women who received a varicella-containing vaccine delivered infants with abnormalities consistent with congenital varicella syndrome.
All exposures to VARIVAX, ProQuad, or Zoster vaccine during pregnancy or within three months prior to conception should be reported as suspected adverse reactions by contacting Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-877-888-4231 or VAERS at 1-800-822-7967 or www.vaers.hhs.gov.
Pregnancy Category (AUS): 
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Zoster vaccine in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Zoster vaccine during labor and delivery.

### Nursing Mothers
Zoster vaccine is not indicated in women who are nursing. It is not known whether VZV is secreted in human milk. Therefore, because some viruses are secreted in human milk, caution should be exercised if Zoster vaccine is administered to a nursing woman.

### Pediatric Use
Zoster vaccine is not indicated for prevention of primary varicella infection (Chickenpox) and should not be used in children and adolescents.

### Geriatic Use
The median age of subjects enrolled in the largest (N=38,546) clinical study of Zoster vaccine was 69 years (range 59-99 years). Of the 19,270 subjects who received Zoster vaccine, 10,378 were 60-69 years of age, 7,629 were 70-79 years of age, and 1,263 were 80 years of age or older.

### Gender
There is no FDA guidance on the use of Zoster vaccine with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Zoster vaccine with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Zoster vaccine in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Zoster vaccine in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Zoster vaccine in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Zoster vaccine in patients who are immunocompromised.

# Administration and Monitoring

### Administration
Subcutaneous administration only. Do not inject intravascularly or intramuscularly.

### Monitoring
There is limited information about the drug monitoring.

# IV Compatibility
There is limited information about the IV Compatibility.

# Overdosage
FDA Package Insert for Zoster vaccine contains no information regarding Overdose.

# Pharmacology

## Mechanism of Action
The risk of developing zoster appears to be related to a decline in VZV-specific immunity. Zoster vaccine was shown to boost VZV-specific immunity, which is thought to be the mechanism by which it protects against zoster and its complications. 
herpes zoster (HZ), commonly known as shingles or zoster, is a manifestation of the reactivation of varicella zoster virus (VZV), which, as a primary infection, produces chickenpox (varicella). Following initial infection, the virus remains latent in the dorsal root or cranial sensory ganglia until it reactivates, producing zoster. Zoster is characterized by a unilateral, painful, vesicular cutaneous eruption with a dermatomal distribution.
Pain associated with zoster may occur during the prodrome, the acute eruptive phase, and the postherpetic  phase of the infection. Pain occurring in the postherpetic phase of infection is commonly referred to as postherpetic neuralgia (PHN).
Serious complications, such as PHN, scarring, bacterial superinfection, allodynia, cranial and motor neuron palsies, pneumonia, encephalitis, visual impairment, hearing loss, and death can occur as the result of zoster.

## Structure
Zoster vaccine is a lyophilized preparation of the Oka/Merck strain of live, attenuated varicella-zoster virus (VZV). Zoster vaccine, when reconstituted as directed, is a sterile suspension for subcutaneous administration. Each 0.65-mL dose contains a minimum of 19,400 PFU (plaque-forming units) of Oka/Merck strain of VZV when reconstituted and stored at room temperature for up to 30 minutes.
Each dose contains 31.16 mg of sucrose, 15.58 mg of hydrolyzed porcine gelatin, 3.99 mg of sodium chloride, 0.62 mg of monosodium L-glutamate, 0.57 mg of sodium phosphate dibasic, 0.10 mg of potassium phosphate monobasic, 0.10 mg of potassium chloride; residual components of MRC-5 cells including DNA and protein; and trace quantities of neomycin and bovine calf serum. The product contains no preservatives.

## Pharmacodynamics
FDA Package Insert for Zoster vaccine contains no information regarding pharmacodynamics.

## Pharmacokinetics
FDA Package Insert for Zoster vaccine contains no information regarding pharmacokinetics.

## Nonclinical Toxicology

### Carcinogenesis, Mutagenesis, Impairment of Fertility
Zoster vaccine has not been evaluated for its carcinogenic or mutagenic potential, or its potential to impair fertility.

# Clinical Studies
In two large clinical trials (ZEST and SPS), Zoster vaccine significantly reduced the risk of developing zoster when compared with placebo  (see Table 4 and Table 5).

### Zoster vaccine Efficacy and Safety Trial (ZEST) in Subjects 50 to 59 Years of Age
Efficacy of Zoster vaccine was evaluated in the Zoster vaccine Efficacy and Safety Trial (ZEST), a placebo-controlled, double-blind clinical trial in which 22,439 subjects 50 to 59 years of age were randomized to receive a single dose of either Zoster vaccine (n=11,211) or placebo  (n=11,228). Subjects were followed for the development of zoster for a median of 1.3 years (range 0 to 2 years). Confirmed zoster cases were determined by Polymerase Chain Reaction (PCR)  or, in the absence of virus detection, by a Clinical Evaluation Committee . The primary efficacy analysis included all subjects randomized in the study (intent-to-treat  analysis).
Compared with placebo , Zoster vaccine significantly reduced the risk of developing zoster by 69.8% (95% CI ) in subjects 50 to 59 years of age (Table 4).
Immune responses to vaccination were evaluated in a random 10% subcohort (n=1,136 for Zoster vaccine and n=1,133 for placebo ) of the subjects enrolled in the ZEST study. VZV antibody levels (Geometric Mean Titers, GMT), as measured by glycoprotein enzyme-linked immunosorbent assay (gpELISA) 6 weeks postvaccination, were increased 2.3-fold  in the group of subjects who received Zoster vaccine compared to subjects who received placebo ; the specific antibody level that correlates with protection from zoster has not been established.

### shingles Prevention Study (SPS) in Subjects 60 Years of Age and Older
Efficacy of Zoster vaccine was evaluated in the shingles Prevention Study (SPS), a placebo-controlled, double-blind clinical trial in which 38,546 subjects 60 years of age or older were randomized to receive a single dose of either Zoster vaccine (n=19,270) or placebo  (n=19,276). Subjects were followed for the development of zoster for a median of 3.1 years (range 31 days to 4.90 years). The study excluded people who were immunocompromised or using corticosteroids on a regular basis, anyone with a previous history of HZ, and those with conditions that might interfere with study evaluations, including people with cognitive impairment, severe hearing loss, those who were non-ambulatory, and those whose survival was not considered to be at least 5 years. Randomization was stratified by age, 60-69 and 70 years of age. Suspected zoster cases were confirmed by Polymerase Chain Reaction (PCR) , viral culture , or in the absence of virus detection, as determined by a Clinical Evaluation Committee . Individuals in both vaccination groups who developed zoster were given famciclovir, and, as necessary, pain medications. The primary efficacy analysis included all subjects randomized in the study who were followed for at least 30 days postvaccination and did not develop an evaluable case of HZ within the first 30 days postvaccination (Modified Intent-To-Treat  analysis).
Zoster vaccine significantly reduced the risk of developing zoster when compared with placebo  (Table 5). In the SPS, vaccine efficacy for the prevention of HZ was highest for those subjects 60-69 years of age and declined with increasing age.
Forty-five subjects were excluded from the MITT analysis (16 in the group of subjects who received Zoster vaccine and 29 in the group of subjects who received placebo ), including 24 subjects with evaluable HZ cases that occurred in the first 30 days postvaccination (6 evaluable HZ cases in the group of subjects who received Zoster vaccine and 18 evaluable HZ cases in the group of subjects who received placebo ).
Suspected HZ cases were followed prospectively for the development of HZ-related complications. Table 6 compares the rates of PHN defined as HZ-associated pain (rated as 3 or greater on a 10-point scale by the study subject and occurring or persisting at least 90 days) following the onset of rash in evaluable cases of HZ.
The median duration of clinically significant pain (defined as 3 on a 0-10 point scale) among HZ cases in the group of subjects who received Zoster vaccine as compared to the group of subjects who received placebo  was 20 days vs. 22 days based on the confirmed HZ cases.
Overall, the benefit of Zoster vaccine in the prevention of PHN can be primarily attributed to the effect of the vaccine on the prevention of herpes zoster. vaccination with Zoster vaccine in the SPS reduced the incidence of PHN in individuals 70 years of age and older who developed zoster postvaccination. Other prespecified zoster-related complications were reported less frequently in subjects who received Zoster vaccine compared to subjects who received placebo . Among PHN cases, zoster-related complications were reported at similar rates in both vaccination groups (Table 7).
Visceral complications reported by fewer than 1% of subjects with zoster included 3 cases of pneumonitis and 1 case of hepatitis in the placebo  group, and 1 case of meningoencephalitis in the vaccine group.
Immune responses to vaccination were evaluated in a subset of subjects enrolled in the shingles Prevention Study (N=1,395). VZV antibody levels (Geometric Mean Titers, GMT), as measured by glycoprotein enzyme-linked immunosorbent assay (gpELISA) 6 weeks postvaccination, were increased 1.7-fold (95% CI: ) in the group of subjects who received Zoster vaccine compared to subjects who received placebo ; the specific antibody level that correlates with protection from zoster has not been established.

### Concomitant Use Studies
In a double-blind, controlled substudy, 374 adults in the US, 60 years of age and older (median age = 66 years), were randomized to receive trivalent inactivated influenza vaccine (TIV) and Zoster vaccine concurrently (N=188), or TIV alone followed 4 weeks later by Zoster vaccine alone (N=186). The antibody responses to both vaccines at 4 weeks postvaccination were similar in both groups.
In a double-blind, controlled clinical trial, 473 adults, 60 years of age or older, were randomized to receive Zoster vaccine and PNEUMOVAX 23 concomitantly (N=237), or PNEUMOVAX 23 alone followed 4 weeks later by Zoster vaccine alone (N=236). At 4 weeks postvaccination, the VZV antibody levels following concomitant use were significantly lower than the VZV antibody levels following nonconcomitant administration (GMTs of 338 vs. 484 gpELISA units/mL, respectively; GMT ratio = 0.70 (95% CI: ).

# How Supplied
No. 4963-00  Zoster vaccine is supplied as follows: (1) a package of 1 single-dose vial of lyophilized vaccine, NDC 0006-4963-00 (package A); and (2) a separate package of 10 vials of diluent (package B).
No. 4963-41  Zoster vaccine is supplied as follows: (1) a package of 10 single-dose vials of lyophilized vaccine, NDC 0006-4963-41 (package A); and (2) a separate package of 10 vials of diluent (package B).]

## Storage
To maintain potency, Zoster vaccine must be stored frozen between -58F and +5F (-50C and -15C). Use of dry ice may subject Zoster vaccine to temperatures colder than -58F (-50C).
Before reconstitution, Zoster vaccine SHOULD BE STORED FROZEN at a temperature between -58F and +5F (-50C and -15C) until it is reconstituted for injection. Any freezer, including frost-free, that has a separate sealed freezer door and reliably maintains a temperature between -58F and +5F (-50C and -15C) is acceptable for storing Zoster vaccine.
Zoster vaccine may be stored and/or transported at refrigerator temperature between 36F and 46F (2C to 8C) for up to 72 continuous hours prior to reconstitution. Vaccine stored between 36F and 46F (2C to 8C) that is not used within 72 hours of removal from +5F (-15C) storage should be discarded. Zoster vaccine should be reconstituted immediately upon removal from the freezer. The diluent should be stored separately at room temperature (68F to 77F, 20C to 25C), or in the refrigerator (36F to 46F, 2C to 8C).
For further product information call 1-800-MERCK-90.
Before reconstitution, protect from light.
DO NOT FREEZE RECONSTITUTED VACCINE.

# Images

## Drug Images

## Package and Label Display Panel

# Patient Counseling Information
Advise the patient to read the FDA-approved patient labeling (Patient Information).
- Question the patient about reactions to previous vaccines.
- Provide a copy of the patient information (PPI) located at the end of this insert and discuss any questions or concerns.
- Inform patient of the benefits and risks of Zoster vaccine, including the potential risk of transmitting the vaccine virus to susceptible individuals, such as immunosuppressed or immunodeficient individuals or pregnant women who have not had chickenpox.
- Instruct patient to report any adverse reactions or any symptoms of concern to their healthcare professional.
Dist. by: Merck Sharp & Dohme Corp., a subsidiary of
MERCK & CO., INC., Whitehouse Station, NJ 08889, USA
For patent information: www.merck.com/product/patent/home.html
Copyright  2006, 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. 
All rights reserved.
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Rx only
Patient Information about 
Zoster vaccine (pronounced "ZOS tah vax")
Generic name: Zoster vaccine Live
You should read this summary of information about Zoster vaccine before you are vaccinated. If you have any questions about Zoster vaccine after reading this leaflet, you should ask your health care provider. This information does not take the place of talking about Zoster vaccine with your doctor, nurse, or other health care provider. Only your health care provider can decide if Zoster vaccine is right for you.
What is Zoster vaccine and how does it work?
Zoster vaccine is a vaccine that is used for adults 50 years of age or older to prevent shingles (also known as zoster).
Zoster vaccine contains a weakened chickenpox virus (varicella-zoster virus).
Zoster vaccine works by helping your immune system protect you from getting shingles.
If you do get shingles even though you have been vaccinated, Zoster vaccine may help prevent the nerve pain that can follow shingles in some people. Zoster vaccine does not protect everyone, so some people who get the vaccine may still get shingles.
Zoster vaccine cannot be used to treat shingles, or the nerve pain that may follow shingles, once you have it.
What do I need to know about Shingles and the virus that causes it?
Shingles is caused by the same virus that causes chickenpox. Once you have had chickenpox, the virus can stay in your nervous system for many years. For reasons that are not fully understood, the virus may become active again and give you shingles. Age and problems with the immune system may increase your chances of getting shingles.
Shingles is a rash that is usually on one side of the body. The rash begins as a cluster of small red spots that often blister. The rash can be painful. shingles rashes usually last up to 30 days and, for most people, the pain associated with the rash lessens as it heals.
Who should not get Zoster vaccine?
You should not get Zoster vaccine if you:
- are allergic to any of its ingredients.
- are allergic to gelatin or neomycin.
- have a weakened immune system (for example, an immune deficiency, leukemia, lymphoma, or HIV/AIDS).
- take high doses of steroids by injection or by mouth.
- are pregnant or plan to get pregnant.
You should not get Zoster vaccine to prevent chickenpox.
Children should not get Zoster vaccine.
How is Zoster vaccine given?
Zoster vaccine is given as a single dose by injection under the skin.
What should I tell my health care provider before I get Zoster vaccine?
You should tell your health care provider if you:
- have or have had any medical problems.
- take any medicines, including non-prescription medicines, and dietary supplements.
- have any allergies, including allergies to neomycin or gelatin.
- had an allergic reaction to another vaccine.
- are pregnant or plan to become pregnant.
- are breast-feeding.
Tell your health care provider if you expect to be in close contact (including household contact) with newborn infants, someone who may be pregnant and has not had chickenpox or been vaccinated against chickenpox, or someone who has problems with their immune system. Your health care provider can tell you what situations you may need to avoid.
Can I get Zoster vaccine with other vaccines?
Talk to your health care provider if you plan to get Zoster vaccine at the same time as the flu vaccine.
Talk to your health care provider if you plan to get Zoster vaccine at the same time as PNEUMOVAX 23 because it may be better to get these vaccines at least 4 weeks apart.
What are the possible side effects of Zoster vaccine?
The most common side effects that people in the clinical studies reported after receiving the vaccine include:
- redness, pain, itching, swelling, hard lump, warmth, or bruising where the shot was given.
- Headache
The following additional side effects have been reported with Zoster vaccine:
- allergic reactions, which may be serious and may include difficulty in breathing or swallowing. If you have an allergic reaction, call your doctor right away.
- chickenpox
- fever
- hives at the injection site
- joint pain
- muscle pain
- nausea
- rash
- rash at the injection site
- Shingles
- swollen glands near the injection site (that may last a few days to a few weeks)
Tell your healthcare provider if you have any new or unusual symptoms after you receive Zoster vaccine. For a complete list of side effects, ask your health care provider.
Report the following to your doctor or your child's doctor:
- any adverse reactions following vaccination
- exposure to Zoster vaccine during pregnancy
- exposure to Zoster vaccine during the 3 months before getting pregnant.
You may also report these events to Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., at 1-877-888-4231, or directly to the Vaccine Adverse Event Reporting System (VAERS).The VAERS toll free number is 1-800-822-7967 or report online to www.vaers.hhs.gov.
What are the ingredients of Zoster vaccine?
Active Ingredient: a weakened form of the varicella-zoster virus.
Inactive Ingredients: sucrose, hydrolyzed porcine gelatin, sodium chloride, monosodium L-glutamate, sodium phosphate dibasic, potassium phosphate monobasic, potassium chloride.
This leaflet summarizes important information about Zoster vaccine. If you would like more information, talk to your health care provider or visit the website at www.Zoster vaccine.com or call 1-800-622-4477.
Dist. by: Merck Sharp & Dohme Corp., a subsidiary of
MERCK & CO., INC., Whitehouse Station, NJ 08889, USA
For patent information: www.merck.com/product/patent/home.html
Copyright  2006, 2014 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. 
All rights reserved.
Revised: 02/2014
usppi-v211-i-fro-1402r017
Printed in USA
Rx Only
PRINCIPAL DISPLAY PANEL - 0.65 mL Vial Carton
A
NDC 0006-4963-00
1 Single-dose Vial (0.65 mL)
Zoster vaccine Live 
Zoster vaccine
STORE FROZEN
Oka/Merck strain. Human
diploid cell (MRC-5) culture
-rigin. Each 0.65-mL
dose contains a
minimum of 19,400 PFU
(plaque-forming units).
Contains no preservative.
Contains trace quantities
-f neomycin.
Rx only

# Precautions with Alcohol
Alcohol-Zoster vaccine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
Zoster vaccine

# Look-Alike Drug Names
There is limited information about the look-alike drug names.

# Drug Shortage Status

# Price