Cleveland Clinic Journal of MedicinePreventing Herpes Zoster in Immunocompromised Patients: Current Concepts

Herpes Zoster Prevention in Immunocompromised Patients: Strategies and Challenges

Immunocompromised patients face a significantly higher risk of developing herpes zoster (HZ) and its complications compared to the general population. The recombinant zoster vaccine (RZV) has emerged as a primary preventive strategy for this vulnerable group. However, the heterogeneity of immunocompromised populations and gaps in evidence regarding vaccine efficacy and long-term protection present challenges in clinical decision-making. Recent data and expert recommendations are helping to guide physicians in identifying high-risk patients and implementing effective prevention strategies.

Key Points:

• Immunocompromised patients have a 6 to 11 times higher incidence of HZ compared to the general population.
• HZ complications in immunocompromised patients are more frequent and severe, including postherpetic neuralgia, disseminated infection, and end-organ involvement.
• The CDC identifies 7 groups as immunocompromised, including those with HIV, cancer, organ transplants, and autoimmune conditions on immunosuppressive therapies.
• RZV is approved for immunocompromised adults aged 19 and older.
• RZV efficacy in immunocompromised patients ranges from 68.2% in hematopoietic stem cell transplant recipients to 87.2% in those with hematologic malignancies.
• The safety profile of RZV appears similar in immunocompromised and general populations, with primarily reactogenicity-type responses.
• Flares of underlying autoimmune diseases after RZV vaccination are uncommon and mostly self-limited.
• Janus kinase (JAK) inhibitors are associated with the highest risk of HZ among immunosuppressive therapies.
• Glucocorticoids at doses greater than 20 mg per day of prednisone or equivalent increase HZ risk.
• The duration of RZV protection in immunocompromised populations is currently unknown and likely shorter than in the general population.
• Antiviral prophylaxis may be considered for patients who cannot receive RZV or experience breakthrough HZ after vaccination.
• Timing of RZV administration is ideally at least 2 weeks before planned immunosuppression, but vaccination during active immunosuppression is still recommended if necessary.
• RZV can be co-administered with other adult vaccines, but separation may be preferred to isolate potential reactogenicity.
• Collaboration between primary care physicians and specialists is crucial for effective vaccine administration in immunocompromised patients.
• Shared and informed decision-making with patients is essential, including discussing increased HZ risks, potential vaccine reactogenicity, and benefits of vaccination.

“Implicit in this pathogenic framework is the fact that immunocompromised patients often have far more severe deficits of immunologic function that may occur at any age. In contrast, healthy individuals’ major risk for loss of virologic control is immunosenescence.”

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