When should the shingles vaccine be administered to immunocompromised individuals after a herpes zoster infection?

Shingles Vaccination Timing After Herpes Zoster Infection in Immunocompromised Patients

Immunocompromised patients should receive the recombinant zoster vaccine (RZV) after recovery from herpes zoster infection, with no specific waiting period required after resolution of lesions. 1

Vaccine Selection for Immunocompromised Patients

The vaccine choice for immunocompromised patients is critical:

• Use recombinant zoster vaccine (RZV) ONLY: The live zoster vaccine (ZOS/ZVL) should NOT be administered to highly immunocompromised patients due to risk of disseminated viral infection 2, 1
• RZV is recommended for adults ≥18 years who are immunocompromised and at increased risk for herpes zoster 2, 1
• RZV is administered as 2 doses:
  • Standard schedule: 2-6 months apart
  • For immunocompromised patients: Can be given 1-2 months apart if a shorter vaccination schedule would be beneficial 2

Timing of Vaccination After Herpes Zoster Infection

Unlike with immunocompetent patients, there are no specific guidelines mandating a waiting period between herpes zoster resolution and vaccination in immunocompromised patients. The National Comprehensive Cancer Network recommends:

• RZV can be given after recovery from herpes zoster to prevent recurrence 1
• No specific waiting period is required after resolution of lesions
• Vaccination should be prioritized based on the patient's risk of recurrence

Considerations for Different Immunocompromised Populations

Transplant Recipients

• For planned transplantation, administer RZV ≥4 weeks before beginning immunosuppressive therapy if possible 2
• For those already on immunosuppression, RZV can be given when clinically stable

HIV Patients

• RZV is safe and immunogenic in HIV-infected adults on stable antiretroviral therapy 2
• Ensure CD4 count is ≥200 cells/mm³ for optimal immune response

Cancer Patients

• For patients undergoing chemotherapy, consider administering RZV before starting treatment when possible 3
• For those already on treatment, RZV can be given when clinically stable

Risk Factors for Herpes Zoster Recurrence

Immunocompromised patients have higher risk of recurrence:

• Recurrence rates of 0.0-18.2% reported in immunocompromised individuals 4
• Incidence rate of 17.0-55 cases per 1000 person-years in immunocompromised populations 4
• Other risk factors include female sex, family history, diabetes, and long-lasting pain after initial episode 4

Efficacy and Safety in Immunocompromised Populations

RZV has demonstrated significant benefits in immunocompromised patients:

• Reduces incidence of herpes zoster by approximately 81% (RR: 0.19,95% CI: 0.09,0.44) 3
• Significantly increases humoral and cellular immunity one month after the last dose 3
• More reactogenic with more local and systemic adverse events, but no difference in serious adverse events or death compared to placebo 3

Common Pitfalls to Avoid

1. Using live zoster vaccine: Never administer the live zoster vaccine (ZOS/ZVL) to immunocompromised patients 2, 1

2. Delaying vaccination unnecessarily: Unlike some other vaccines, there is no mandatory waiting period after herpes zoster resolution before administering RZV

3. Incomplete vaccination series: Ensure patients receive both doses of RZV for optimal protection

4. Ignoring immunosuppression level: While RZV is safe for immunocompromised patients, timing may need to be adjusted based on the degree of immunosuppression and current therapy

5. Overlooking the need for vaccination: Immunocompromised patients who have had herpes zoster remain at high risk for recurrence and should still be vaccinated 4