People aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised are recommended to receive a zoster vaccine
People aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised are recommended to receive a 2-dose schedule of Shingrix, 1–2 months apart, for the prevention of herpes zoster and associated complications. This includes people who are currently or soon to be immunocompromised as a result of a primary or acquired medical condition, or medical treatment (including treatment that has recently ceased). See Considerations for timing of zoster vaccination.
Compared with immunocompetent people, people who are immunocompromised have higher rates of herpes zoster and of complications such as post-herpetic neuralgia (PHN).13,14 Herpes zoster can occur at a younger age in people who are immunocompromised, and there is also a higher risk of recurrence.15-18
In people who are immunocompromised or shortly expected to be immunocompromised Zostavax is not recommended, particularly in those with severe immunocompromise, in whom it is contraindicated. However, when Shingrix is not accessible, Zostavax may be used in people aged over 50 with mild immunocompromise where a patient is fully informed, has been instructed about monitoring for significant adverse events and what to do if they occur, and the anticipated benefit outweighs risk. Before use of Zostavax in people with mild immunocompromise, the degree of immunocompromise should be carefully assessed using the Live zoster vaccine (Zostavax) screening for contraindications tool. See Contraindications and precautions. This is because of the risk of disseminated varicella disease from the Oka strain vaccine virus in Zostavax, which can lead to death.19-22 The risk increases with the level of immunosuppression.
In people who are immunocompromised or shortly expected to be immunocompromised aged 18–49 years, Shingrix is the only vaccine available to prevent herpes zoster.
Shingrix provides good protection against herpes zoster and associated complications in some highly immunocompromised people aged ≥18 years for up to 2 years after vaccination,23,24 including people with a history of haematopoietic stem cell transplantation or haematologic malignancies.
See Vaccine information.
Considerations for timing of zoster vaccination
The optimal time to receive zoster vaccination depends on individual circumstances.
Age-related risk of herpes zoster and its complications
Herpes zoster can occur at any age, but the risk increases with age. The risk of herpes zoster in the general population increases from an estimated annual rate of 6 per 1000 in people aged 50–59 years to 15 per 1000 in people aged 70–79 years.8 The likelihood of complications such as PHN also increases with age.
Duration of protection
Shingrix has demonstrated high vaccine efficacy for at least 7 years after vaccination in people without apparent immunocompromise,9 and immunogenicity data suggest that protection may persist for at least 10 years.2-4 Effectiveness of Zostavax appears to wane more quickly, decreasing significantly by 5–10 years after vaccination.5-7
A person vaccinated at a younger age (such as in their 50s or 60s) could possibly have reduced protection from vaccination as they age, when the risk of zoster is higher. This should be balanced with consideration of reduced effectiveness for some zoster vaccines when administered at older age and the risk of zoster while unvaccinated.
There is no current recommendation for boosters for either vaccine.
Individual’s immune status
People who are immunocompromised are at significantly higher risk of herpes zoster and severe complications than those who are immunocompetent.10-12 However, the duration of protection provided by zoster vaccines in people who are immunocompromised is less certain. If there is uncertainty about the optimal timing of vaccination in people who are immunocompromised, this should be discussed with the patient’s specialist. See Vaccination for people who are immunocompromised and See Contraindications and precautions.
Individual’s personal preferences
People’s desire to protect themselves from herpes zoster and related complications may vary, and this will influence decision-making on when they should receive zoster vaccination.