Shingles Vaccination in Patients with History of Non-Hodgkin's Lymphoma
Patients with a history of non-Hodgkin's lymphoma should receive the recombinant zoster vaccine (Shingrix) rather than the live-attenuated zoster vaccine (Zostavax), as Shingrix is both safer and more effective in immunocompromised populations. 1
Rationale for Vaccination
- Patients with NHL have increased risk of herpes zoster due to:
- Immunosuppression from prior treatments
- Underlying disease-related immune dysfunction
- Higher risk of complications if herpes zoster develops 1
Vaccine Options and Recommendations
Recombinant Zoster Vaccine (Shingrix)
- Strongly recommended for NHL patients
- Non-replicating subunit vaccine containing VZV glycoprotein E with AS01B adjuvant 1, 2
- Safe for immunocompromised patients as it cannot cause infection 3
- Demonstrated 61% effectiveness in NHL patients 2 years post-vaccination 1
- Overall efficacy of 97.2% in adults ≥50 years and 91.3% in adults ≥70 years 1
Live-Attenuated Zoster Vaccine (Zostavax)
- Contraindicated in immunocompromised patients due to risk of vaccine-strain VZV infection 4
- Contains live Oka strain of VZV that could potentially cause serious infection in those with reduced cell-mediated immunity 4
Vaccination Timing for NHL Patients
For patients who completed chemotherapy:
- Initiate Shingrix 3 months after completion of chemotherapy 1
For patients who received anti-CD20 antibody therapy (e.g., rituximab):
- Delay vaccination until at least 6 months after the last dose 1
For patients who underwent autologous stem cell transplant:
- Begin vaccination 3-12 months post-transplant 1
Dosing Schedule
- Standard regimen: Two doses of Shingrix
- For immunocompromised adults: Shortened dosing interval of 1-2 months between doses (rather than standard 2-6 months) 1
- Completing the full two-dose series is crucial for optimal protection 5
- Even if second dose is delayed beyond 6 months, effectiveness is not significantly impaired 5
Side Effects and Monitoring
- Common side effects: Injection site pain, fatigue, myalgia 1
- Higher incidence of grade 3 injection site reactions (9.5% vs 0.4%) and systemic symptoms (11.4% vs 2.4%) compared to placebo 1
- Most reactions are transient and mild to moderate in severity 1
- Monitor for 15 minutes after vaccination for immediate reactions
Special Considerations
- If patient previously received Zostavax, they should still receive the complete Shingrix series (minimum interval of 8 weeks after Zostavax) 1
- For VZV-seronegative individuals, consider immunization with 2 doses of varicella vaccine first, then proceed with Shingrix 1
- Safe to co-administer with other vaccines (e.g., influenza) 1
Effectiveness Comparison
| Vaccine | Population | Effectiveness |
|---|---|---|
| Shingrix | General population ≥50 years | 97.2% |
| Shingrix | NHL patients | 61% |
| Shingrix | Single dose | 56.9% |
| Shingrix | Two doses | 70.1% |
| Zostavax | 50-59 years | 70% |
| Zostavax | 80+ years | 18% |
Conclusion
The recombinant zoster vaccine (Shingrix) is the preferred option for patients with a history of NHL due to its safety profile in immunocompromised patients and superior effectiveness compared to the live-attenuated vaccine. Timing of vaccination should be coordinated with the patient's treatment history to optimize immune response.