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A burning question: Should patients receive the zoster vaccine after an episode of shingles?

DII small banner By Warren R. Heymann, MD
Oct. 26, 2016

The question as to whether a patient should receive the vaccine after having had herpes zoster (HZ) has been asked since the initial release of the vaccine. There has been remarkably little data to help guide the clinician.
The importance of vaccination for herpes zoster in immunosuppressed hosts and its attendant controversies was recently discussed on this website and is in press in “the Heymann File” in Skinmed (Herpes zoster, immunosuppression, and vaccination: Far from a blistering pace. Posted July 5th, 2016).

The question remains — should immunocompetent patients receive the vaccine after they have already had zoster? What recommendations have you made?
Tseng et al performed a matched cohort study of immunocompetent elderly individuals ≥ 60 years old with a recent episode of HZ. Incidence of recurrent HZ was compared between the vaccinated and the unvaccinated matched cohorts. A total of 1036 vaccinated and 5180 unvaccinated members were included. On the basis of clinically confirmed cases, the incidence of recurrent HZ among persons aged <70 years was 0.99 (95% confidence interval [CI], .02-5.54) and 2.20 (95% CI, 1.10-3.93) cases per 1000 person-years in the vaccinated and unvaccinated cohorts, respectively. The adjusted hazard ratio was 0.39 (95% CI, .05-4.45) among persons aged <70 years and 1.05 (95% CI, .30-3.69) among persons aged ≥ 70 years. The authors concluded that the risk of HZ recurrence following a recent initial episode is fairly low among immunocompetent adults, regardless of vaccination status. Such a low risk suggests that one should evaluate the necessity of immediately vaccinating immunocompetent patients who had a recent HZ episode (1).

Nakamura et al conducted a large-scale prospective cohort study to characterize recurrent HZ by examining 12,522 participants aged at least 50 years followed them up for 3 years. They compared the incidence of HZ and postherpetic neuralgia, severity of skin lesions and acute pain, cell-mediated immunity, and varicella-zoster virus-specific antibody titer between primary and recurrent HZ. A total of 401 participants developed HZ: 341 with primary HZ and 60 with recurrent HZ. Skin lesions and acute pain were significantly milder and the incidence of postherpetic neuralgia was lower in patients aged 50 to 79 years with recurrent HZ than in those with primary HZ. Varicella-zoster virus skin test induced a stronger reaction in patients aged 50 to 79 years with recurrent HZ than in those with primary HZ. These differences were not observed in patients older than 80 years. The authors concluded that recurrent HZ was associated with milder clinical symptoms than primary HZ, probably because of stronger varicella-zoster virus-specific cell-mediated immunity in the patients with recurrence (2).

These studies offer affirm what I have told patients who have had zoster, as to whether or not they should be vaccinated. To date, I have stated that they are unlikely to have a recurrence, so I have not encouraged them to get the vaccine.   Now we can tell them that even if they get a recurrence, it will probably be milder with less of a risk of post-herpetic neuralgia (if they are < 80 years old). However, we must remind patients who have not had HZ to get vaccinated. In my prior post I mentioned that I am waiting to be vaccinated with the new, improved VZV subunit zoster vaccine that consists of recombinant VZV glycoprotein E and a liposome-based ASO1B adjuvant system (3). Once available I’m sure that patients who have had HZ will ask whether they should be vaccinated with the new agent. While my recommendation will likely be what it is today, I can certainly understand why some patients who have had severe cases of zoster want to minimize the risk of recurrence, not matter how small that risk is. I am curious to know if revaccination with the new vaccine will decrease the risk of recurrence. I am open to modifying my current advice in selected cases, based on future data.

1. Tseng HF, et al. Herpes zoster vaccine and the incidence of recurrent herpes zoster in an immunocompetent elderly population. J Infect Dis 2012; 206: 190-6.
2. Nakamura Y, et al. Clinical and immunologic features of recurrent herpes zoster (HZ). J Am Acad Dermatol 2016; 75: 950-6.
3. Gagliardi AM, Andriolo BN, Torloni MR, Soares BG. Vaccines for preventing herpes zoster in older adults. Cochrane Database Syst Rev 2016 Mar 3:3:CD008858.

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