Can a patient with active Guillain-Barre syndrome receive the shingles vaccine, specifically Shingrix (recombinant zoster vaccine) or Zostavax (live, attenuated zoster vaccine)?

Shingles Vaccination in Active Guillain-Barré Syndrome

A patient with active Guillain-Barré syndrome should NOT receive shingles vaccine until the acute phase has completely resolved and they have achieved clinical stability, typically waiting at least several months after disease onset.

Rationale for Deferring Vaccination

The acute phase of GBS represents a period of active immune-mediated peripheral nerve inflammation that typically evolves over 2-4 weeks, with most patients reaching their nadir by 4 weeks after symptom onset 1. During this critical period:

• The immune system is already dysregulated and mounting an aberrant autoimmune response against peripheral nerve components 1
• Introducing vaccine antigens and adjuvants during active neuroinflammation could theoretically exacerbate the underlying immune pathology
• The patient's ability to mount an appropriate vaccine response may be compromised during acute illness

Specific Vaccine Considerations

Shingrix (Recombinant Zoster Vaccine)

Shingrix is absolutely contraindicated during active GBS because:

• Recent research has identified a small but statistically significant increased risk of GBS following Shingrix vaccination, with approximately 3 excess cases per million doses administered (rate ratio 4.96,95% CI 1.43-17.27) occurring within 42 days post-vaccination 2
• Case reports document GBS onset as early as 8 days post-Shingrix vaccination 3, and recurrence of GBS following the second dose 4
• The adjuvanted formulation contains AS01B, which stimulates robust immune responses that could potentially worsen active neuroinflammation 5

Zostavax (Live Attenuated Zoster Vaccine)

Zostavax is also contraindicated during active GBS because:

• Live vaccines are generally contraindicated during moderate to severe acute illness 1
• Many patients with active GBS receive immunosuppressive treatments (IVIg or plasma exchange) 1, which would further contraindicate live vaccination
• Zostavax is largely obsolete and inferior to Shingrix regardless 6

Timing of Vaccination After GBS Recovery

Once the patient has recovered from GBS, vaccination can be reconsidered with the following approach:

Minimum Waiting Period

• Wait until complete resolution of the acute phase and achievement of clinical stability 1
• Most patients reach their nadir by 4 weeks, but recovery extends over months to years 1
• A practical minimum waiting period would be at least 6 months after GBS onset, allowing for substantial neurological recovery and immune system normalization

Risk-Benefit Assessment

• Prior GBS is NOT an absolute contraindication to vaccination, but requires careful consideration 1
• GBS recurrence risk is 2-5% over a lifetime, higher than the general population risk of 0.1% 1
• The risk of GBS from Shingrix (3 per million doses) must be weighed against the substantial benefits of preventing herpes zoster 2

Decision Algorithm for Post-GBS Vaccination

For patients who developed GBS >1 year ago with no temporal relationship to vaccination:

• Proceed with standard Shingrix vaccination if aged ≥50 years 6
• The benefits of preventing herpes zoster (97.2% efficacy) substantially outweigh the minimal GBS risk 6

For patients who developed GBS within 6 weeks of a previous vaccination (any vaccine):

• Exercise extreme caution and consider avoiding Shingrix 1
• The temporal association suggests possible vaccine-triggered GBS
• Consider antiviral prophylaxis as an alternative if herpes zoster risk is high 1

For patients who developed GBS <1 year ago:

• Consultation with a neurologist is strongly recommended 1
• If the patient is at high risk for severe herpes zoster complications (immunocompromised, advanced age), the benefits may justify vaccination after thorough discussion 1
• If not at high risk, deferring vaccination until >1 year post-GBS is prudent 1

Critical Pitfalls to Avoid

• Never vaccinate during the acute or subacute phase of GBS (first 8 weeks) 1
• Do not confuse "history of GBS" with "active GBS" - the former may allow vaccination after careful assessment, the latter is an absolute contraindication during the active phase
• Do not use live Zostavax in patients who received immunosuppressive therapy for GBS 1
• Recognize that GBS can have treatment-related fluctuations (TRFs) - if the patient has had recent clinical deterioration or repeated relapses, the disease is still active 1

Special Circumstances

If the patient has chronic inflammatory demyelinating polyneuropathy (CIDP) rather than GBS:

• CIDP is diagnosed when there are ≥3 treatment-related fluctuations or deterioration ≥8 weeks after onset 1
• These patients are often on chronic immunosuppression, making Shingrix (not Zostavax) the only appropriate option 1
• Vaccination should occur during a stable phase, ideally when immunosuppression is minimized 1

The risk-benefit calculation strongly favors deferring all shingles vaccination until the patient has achieved substantial recovery from active GBS, typically waiting at least 6 months and preferably longer, with neurologist consultation for complex cases.