Can a patient with a history of non-Hodgkin's lymphoma (NHL) in remission receive the Shingrix (zoster vaccine) vaccine?

Shingrix Vaccination in Patients with Non-Hodgkin's Lymphoma in Remission

Patients with a history of non-Hodgkin's lymphoma (NHL) in remission can and should receive the Shingrix vaccine to prevent herpes zoster and its complications.

Rationale for Vaccination

Patients with hematological malignancies, including NHL, are at increased risk for herpes zoster infections due to:

• History of immunosuppression from prior treatments
• Underlying disease-related immune dysfunction
• Higher risk of complications if herpes zoster develops

The recombinant zoster vaccine (Shingrix) is specifically recommended for immunocompromised adults, including those with hematologic malignancies 1. It is a non-live vaccine, making it safe for patients with a history of immunosuppression.

Efficacy in NHL Patients

The adjuvanted recombinant zoster vaccine (Shingrix) has demonstrated effectiveness in patients with hematological malignancies:

• In patients with NHL, the vaccine showed 61% effectiveness at preventing herpes zoster 2 years after vaccination 2
• A phase 3 clinical trial in adults with hematological malignancies showed that 80.4% of patients developed a humoral vaccine response to Shingrix 3
• Cellular immune responses persisted above baseline for at least 13 months in patients with hematological malignancies 3

Vaccination Schedule

For patients with NHL in remission:

1. Administer two doses of Shingrix (0.5 mL each) intramuscularly
2. For immunocompromised adults, including those with a history of hematologic malignancies, doses should be given 1-2 months apart 1
3. If the patient previously received the older live zoster vaccine (Zostavax), they should still receive the complete Shingrix series, with a minimum interval of 8 weeks after Zostavax 1

Timing Considerations

The optimal timing for vaccination depends on the patient's treatment history:

• For patients who have completed chemotherapy: Vaccination can be initiated 3 months after completion of chemotherapy 2
• For patients who received anti-CD20 antibody therapy (rituximab/obinutuzumab): Consider delaying vaccination until at least 6 months after the last dose, as these medications significantly impair vaccine response 2, 4
• For patients who underwent autologous hematopoietic stem cell transplant: Vaccination can begin 3-12 months post-transplant 2

Safety Profile

Shingrix is generally well-tolerated in patients with hematological malignancies:

• Common side effects include injection site pain (79.5%), fatigue (58.3%), and myalgia 3
• The incidence of serious adverse events is similar between vaccine and placebo groups 3
• The only contraindication is a history of severe allergic reaction to any component of the vaccine or after a previous dose 5

Clinical Considerations

1. No screening needed: Testing for prior varicella exposure is not necessary before vaccination in adults over 50 years, as seroprevalence is high (88-91%) 1

2. Effectiveness: While real-world effectiveness (70.1% for 2 doses) may be lower than clinical trial efficacy (>90%), this still represents substantial protection 6

3. Delayed second dose: If the second dose is delayed beyond the recommended interval, administer as soon as possible; effectiveness is maintained even when the second dose is given ≥180 days after the first 6

4. Monitoring: Patients should be monitored for injection site reactions and systemic symptoms, which are generally mild to moderate and transient 3

In conclusion, Shingrix vaccination is recommended for patients with NHL in remission, as they are at increased risk for herpes zoster and its complications. The vaccine has demonstrated safety and efficacy in this population, and the benefits of vaccination outweigh the risks.