Ask the Experts: Zoster (Shingles): Immunocompromised Adults

Results (15)

ACIP published its recommendations for the use of recombinant zoster vaccine in adults age 19 years or older who are or will be immunocompromised in January 2022, available at www.cdc.gov/mmwr/volumes/71/wr/pdfs/mm7103a2-H.pdf.

These recommendations should be implemented in conjunction with CDC’s Clinical Considerations for the Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged >19 Years: www.cdc.gov/shingles/vaccination/immunocompromised-adults.html.

Last reviewed: March 9, 2022

Shingrix has been studied in people with certain types of immunocompromise and has been shown to have moderate to high effectiveness against herpes zoster and postherpetic neuralgia. Because the causes of immunocompromise are so varied, the effectiveness and durability of protection provided by Shingrix also may vary depending upon the precise nature and severity of immunocompromise in a given individual.

Last reviewed: March 9, 2022

ACIP and the FDA have determined that Shingrix is acceptably safe in immunocompromised individuals. Immune-mediated diseases were evaluated in six studies in five immunocompromised groups and were not increased among RZV recipients. One study in patients with hematologic cancers reported on graft-versus-host-disease among hematopoietic cell transplant recipients and did not identify an increased risk among RZV recipients. One study among kidney transplant patients reported on graft rejection and did not identify an increased risk among RZV recipients. Local and systemic grade 3 reactions (reactions that interfere with daily activities) were evaluated in six studies in five immunocompromised groups. Local grade 3 reactions occurred in 10.7% to 14.2% of RZV recipients, and systemic grade 3 reactions occurred in 9.9% to 22.3% of RZV recipients. Systemic grade 3 reactions were also reported by 6.0% to 15.5% of placebo recipients in these studies.

Last reviewed: March 9, 2022

Timing of vaccination should be evaluated on a case-by-case basis. When possible, patients should be vaccinated before becoming immunosuppressed. If vaccination before initiating immunosuppressive treatment is feasible, a shortened interval of 4 weeks between doses 1 and 2 may be considered. If vaccination before immunosuppression is not possible, providers should consider timing vaccination when the immune response is likely to be most robust.

For additional information about timing of vaccination and specific conditions, see CDC’s Clinical Considerations for the Use of Recombinant Zoster Vaccines in Immunocompromised Adults Aged ≥ 19 Years: www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#clinical-guidance.

Last reviewed: March 9, 2022

People who have neither experienced primary varicella infection (chickenpox), nor received live-attenuated varicella vaccine (vaccine strain VZV, contained in Varivax, ProQuad, and Zostavax, all by Merck) are not at risk for shingles. More than 99% of Americans born before 1980 have had chickenpox, even if they don’t remember it, so additional screening is not recommended for immunocompetent people born before 1980 who are due for routine shingles vaccination. Children and adolescents who have received live-attenuated varicella vaccines (Varivax or ProQuad) are at risk for shingles, although they are at lower risk for shingles than are those who experienced chickenpox.

Shingrix (RZV) is not indicated and has not been studied for the prevention of chickenpox. Receipt of Shingrix is not considered proof of varicella immunity, and Shingrix cannot be considered as either of the two doses of the varicella vaccine series. In addition, there are limited data on the use of Shingrix in people without a history of chickenpox, with or without a history of varicella vaccination.

The consequences of primary varicella infection in immunocompromised adults can be severe. For adults who are or will be immunocompromised, evidence of immunity to varicella (confirming need for RZV) includes:

  • Documentation of two doses of varicella vaccine, or
  • Laboratory evidence of immunity or laboratory confirmation of disease, or
  • Diagnosis or verification of a history of varicella or herpes zoster by a healthcare provider.

Protection from primary varicella infection (chickenpox) is a priority for an adult who is or will be immunocompromised with no evidence of immunity to chickenpox. Refer to the ACIP varicella vaccine recommendations for further guidance, including post-exposure prophylaxis guidance for immunocompromised adults: www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm.

Last reviewed: March 9, 2022

An adult who has documentation of one dose of varicella vaccine is potentially at risk for chickenpox (from exposure to a person with chickenpox) AND herpes zoster (either from a possible previous unrecognized case of chickenpox or from the vaccine strain of the virus).

CDC subject matter experts advise that clinical management of a person with no proof of a past primary varicella infection and a history of only one varicella vaccination who is or will be immunocompromised depends upon the degree of immunocompromise of the patient:

  • If varicella vaccine is not already contraindicated due to significant immunocompromise, give the second varicella vaccine dose. Depending on the patient’s immunocompromising condition or therapy, the clinician may then consider initiating the Shingrix series at least 8 weeks after the second varicella vaccine dose to reduce the risk of herpes zoster.
  • If the patient already has significant immunocompromise and the second varicella vaccine dose is contraindicated, the clinician should:
    • Consider the patient’s herpes zoster risk (based on their immunocompromising condition or therapy). On a case-by-case basis and if the clinician determines it is indicated, administer the Shingrix series to reduce the risk of herpes zoster.
    • Be prepared to administer varicella immune globulin (VariZIG, Saol Therapeutics) in the event that the patient has a recognized exposure to a person with chickenpox, regardless of whether or not the patient received RZV.

For more information, see www.cdc.gov/shingles/vaccination/immunocompromised-adults.html.

Last reviewed: March 9, 2022

Immunocompromised adults age 19 years and older without evidence of exposure to live varicella virus through a history of chickenpox, zoster, or documentation of vaccination with live varicella vaccine (Varivax or ProQuad, Merck) or zoster vaccine live (Zostavax, Merck) should be evaluated further for their risk of zoster before receiving Shingrix. Birth before 1980 is not sufficient proof of a history of primary varicella infection (chickenpox) for immunocompromised adults.

Vaccination with varicella vaccine to prevent chickenpox may be considered for a patient with well-controlled HIV (e.g., CD4+ T-lymphocyte percentage of at least 15% and a count of at least 200 cells per microliter) and no evidence of a history of varicella disease or vaccination. Vaccination may be considered for a patient who has a CD4 count of at least 200 cells per microliter but no information on percentage. Vaccination is contraindicated if a patient has laboratory information on the CD4 percentage and/or count and either measure falls below the recommended acceptable threshold for vaccination.

For other situations involving immunocompromised adults with no evidence of a history of varicella disease or vaccination, see detailed guidance provided by CDC at www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#special-populations.

Last reviewed: March 9, 2022

Valacyclovir, acyclovir, and famciclovir are antiviral medications that are active against herpesviruses, including varicella zoster virus. The risk of shingles risk is reduced during antiviral treatment. Since Shingrix is not a live virus vaccine, Shingrix may be administered while patients are taking antiviral medications if indicated.

A patient who is taking a prophylactic antiviral for a fixed period of time while their immune system recovers from HCT, should ideally initiate vaccination with Shingrix about 2 months prior to discontinuation of antiviral therapy.

Regardless of the duration of antiviral therapy after HCT, CDC recommends that autologous HCT recipients wait at least 3 months after transplant before initiating Shingrix vaccination. Allogenic HCT recipients should wait at least 6 months after transplantation. For additional details on timing after HCT, see www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#clinical-guidance.

Last reviewed: March 9, 2022

The risk for zoster and its severe morbidity and mortality is much greater for immunosuppressed people. A 2-dose series of Shingrix should be administered as soon as possible while the person’s immune system is intact. In cases such as this, depending upon the timing of chemotherapy initiation, you may wish to consider a shorter interval of at least 4 weeks (1 month) in order to complete the series as soon as possible.

Last reviewed: March 9, 2022

A person who was on immunosuppressive chemotherapy in the past but is not expected to be immunocompromised again may follow routine recommendations for shingles vaccination at age 50 years or older. If the patient is age 19 or older and expected to require repeated exposure to immunosuppressive chemotherapy in the future, then it is preferable to vaccinate now while the patient’s immune system is more robust.

Last reviewed: March 9, 2022

Hepatitis C infection is not a contraindication for Shingrix vaccination. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider to discuss the clinical considerations for the timing of vaccination. Detailed guidance is available at www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#clinical-guidance.

Last reviewed: March 9, 2022

Yes. Shingrix can be administered in this situation. Optimally, vaccination should occur when the disease is well-controlled and not during an acute disease flare.

Last reviewed: March 9, 2022

For patients receiving anti-B cell therapies (e.g., rituximab), CDC recommends administering a dose of RZV approximately 4 weeks prior to the next scheduled therapy.

Last reviewed: March 9, 2022

Shingrix has not been evaluated for, and is not recommended for, the prevention of primary infection with varicella virus (chickenpox).

In this case, the patient is not yet immunocompromised and has no evidence of immunity to varicella. The simplest next step is to vaccinate the patient with two doses of varicella vaccine, spaced at least 4 weeks apart, before initiating immunosuppressing medication.

If you wish, you may order a commercial serologic assay to look for evidence of past varicella virus exposure. However, remember that the sensitivity and specificity of these tests vary, and while such commercial tests can detect evidence of past varicella infection, they are not sensitive enough to reliably detect evidence of past vaccination with varicella vaccine.

For patients who lack evidence of past infection or vaccination and who are immunocompromised already, CDC has provided additional detailed clinical considerations here: www.cdc.gov/shingles/vaccination/immunocompromised-adults.html#special-populations.

Last reviewed: March 9, 2022

No. Antiretroviral treatment for HIV may improve immune response to vaccination; however, vaccination for shingles does not have to be delayed in order to achieve viral suppression, especially if this will significantly delay vaccine administration. Patients with advanced HIV should receive RZV, because the risk of shingles is further increased in the setting of such immune compromise.

Last reviewed: March 9, 2022

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