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Protecting Our Patients With Immunocompromise From Shingles

Tracy Zivin-Tutela, MD

Infectious Diseases Specialist
Department of Infectious Diseases
Fountain Valley Regional Hospital
Los Alamitos Medical Center
Fountain Valley, California


Tracy Zivin-Tutela, MD, has no relevant conflicts of interest to report.


View ClinicalThoughts from this Author

Released: October 28, 2021

Before the COVID-19 pandemic, fewer than half of US adults received recommended immunizations, including shingles. With the onset of the pandemic, these immunization rates dropped even more dramatically. During this time of the ongoing pandemic and routine vaccination decline, the FDA approved a newly indicated patient population for shingles vaccination—our patients with immunocompromise. For many years, we have lived in the limbo of avoiding shingles vaccines in our patients who are immunocompromised for fear of provoking a disseminated herpes zoster infection while also leaving them vulnerable to developing this complication and more without the vaccine. The prescribing information for zoster vaccine live, which is no longer available in the United States as of November 2020, specifically warned against administration to patients with weakened immune systems (either due to a medical condition or immunosuppressive therapy). Given the poor rates of routine vaccination in adults before the pandemic and now the public response to COVID-19 vaccination, we don’t know if this newly indicated group will embrace the shingles vaccination.

Expanded Indication
In July 2021, the recombinant zoster vaccine (RZV) received FDA approval to be administered in patients with immunocompromise. This expanded indication includes any adult aged 18 years or older who is or will be at an increased risk for developing shingles due to immunodeficiency or treatment with immunosuppressive therapy. Of interest, it is recommended that patients with immunocompromise be administered their 2 doses of RZV 1-2 months apart (based on how the vaccine was studied in this population), rather than the 2-6–month spacing recommended for immunocompetent patients aged 50 years or older. This expanded indication is new enough that the CDC’s Advisory Committee on Immunization Practices has not yet updated their recommendations for RZV to include immunocompromised patients, but the recommendation is likely forthcoming.

Ensuring Vaccination in This Newly Indicated Population
This expanded indication for RZV in immunocompromised patients represents a huge shift for many healthcare professionals in how we think about whom to vaccinate. The expanded approval for RZV in immunocompromised patients means we should be screening even more of our patient population for vaccination eligibility. This necessitates having conversations with young patients and patients with immunocompromise about RZV eligibility. Before this expanded indication, shingles vaccination was not discussed with anyone under the age of 50. Now we can offer this vaccination to anyone 18 years of age or older with or at risk for immunocompromise. This also involves informing patients who were previously instructed not to get the vaccine that now it is recommended that they should. However, it may be difficult to have a conversation with a patient encouraging vaccination when they were previously told it was unsafe. These conversations about vaccine safety are important not only here, but also with patients who may be hesitant to receive a COVID-19 vaccine. For RZV, we should highlight the clinical trial evidence in patients undergoing stem cell transplants, patients being actively treated for hematologic malignancies, patients with HIV, and patients post–renal transplant who demonstrated that vaccination with RZV is both safe and effective in various populations with immunocompromise.

The expanded indication for patients with immunocompromise, coupled with the already less than optimal shingles vaccination rates among older adults prior to and during the COVID-19 pandemic, means that many patients today remain unprotected from this potentially debilitating condition. It is estimated that more than 17 million doses of routine vaccinations, including RZV, were missed by adults during the pandemic. Education of both healthcare professionals and patients on this expanded indication will be key to avoiding shingles vaccination hesitancy and omission in all patients indicated for the vaccine.

Your Thoughts?
Given the expanded indication, will you recommend RZV to your patients with immunocompromising conditions and/or those taking immunosuppressant medications? Answer the polling question and join the conversation by posting in the discussion section.

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