From the Guidelines
The most appropriate additional vaccine to administer to this 45-year-old man with a history of chickenpox and no history of shingles is the recombinant zoster vaccine (Shingrix). This recommendation is based on the latest evidence from the study published in 2024 1, which suggests that the recombinant zoster vaccine is preferred over the live zoster vaccine due to its higher efficacy and longer-lasting protection. The study found that the recombinant zoster vaccine was over 90% effective in preventing shingles and postherpetic neuralgia, a painful long-term complication. Additionally, the 2020 recommended adult immunization schedule 1 also recommends the use of the recombinant zoster vaccine for adults 50 years or older, regardless of previous herpes zoster or history of ZVL vaccination. Although the patient is 45 years old, which is slightly younger than the recommended age, the risk of shingles increases with age, and the patient's history of chickenpox puts him at risk of developing shingles later in life. Therefore, administering the recombinant zoster vaccine to this patient would be a prudent decision to prevent shingles and its complications. Some key points to consider when administering the vaccine include:
- The vaccine should be administered as two intramuscular injections, with the second dose given 2-6 months after the first dose.
- The vaccine is recommended regardless of whether the person received the older zoster vaccine (Zostavax) in the past.
- The recombinant zoster vaccine provides stronger and longer-lasting protection than the older zoster vaccine.
From the Research
Vaccine Recommendation
The patient in question is a 45-year-old man with advanced chronic kidney disease due to IgA nephropathy and a history of chickenpox but no history of shingles. Considering his age and medical history, the most appropriate additional vaccine to administer at this visit would be the Herpes zoster recombinant vaccine.
Rationale
- The patient is at risk of developing herpes zoster (shingles) due to his age and compromised immune system resulting from chronic kidney disease 2, 3.
- The Herpes zoster recombinant vaccine (Shingrix) is recommended for immunocompetent adults aged 50 years and older, but its use in younger adults with compromised immune systems, such as those with chronic kidney disease, may also be beneficial 4, 5.
- The vaccine has been shown to be effective in preventing herpes zoster and postherpetic neuralgia in older adults, with a pooled vaccine effectiveness of 79.2% against herpes zoster 6.
- Although the patient is currently 45 years old, which is below the recommended age for the vaccine, his compromised immune system due to chronic kidney disease may increase his risk of developing herpes zoster, making vaccination a reasonable consideration.
Additional Considerations
- The patient's vaccination history includes completion of only required childhood vaccinations and recent COVID-19 immunization, but he has not received any other adult vaccinations, including the herpes zoster vaccine.
- The patient's laboratory studies show that he is not currently infected with hepatitis A, B, or C, and he has a positive hepatitis B surface antibody, indicating immunity to hepatitis B.
- The inactivated influenza vaccine has already been administered, which is appropriate given the patient's age and medical history.
Recommended Vaccine
Based on the patient's age, medical history, and vaccination history, the most appropriate additional vaccine to administer at this visit is the Herpes zoster recombinant vaccine (option C).