INFO - Herpes zoster (shingles) vaccine guidelines for immunosuppressed patients

[Guest guest]

American College of Rheumatology

Hotline

August 1, 2008

Herpes Zoster (Shingles) Vaccine Guidelines for Immunosuppressed Patients

On June 6, 2008, the CDC Advisory Committee on Immunization Practices

issued recommendations for the prevention of herpes zoster, with new

directives important for rheumatic disease patients receiving

immunosuppressive therapy. This Hotline will review these and other

guidelines for zoster vaccine use.

Shingles (H. zoster) affects nearly 1 million Americans annually

(incidence of 3-4/1000 pt-yrs) and will affect 1 in 3 adults during

their lifetime. Early in life, following natural infection (i.e.,

chickenpox) or vaccination, latent varicella zoster virus (VZV) takes

up residence in the dorsal root ganglia and over time, reactivation

may occur under varied circumstances, including alterations in

cell-mediated immunity. Shingles may be complicated by H. zoster

ophthalmicus (10-25%) and post-herpetic neuralgia (PHN; 10-18%).

Prevention is desirable, especially in immunosuppressed patients who

are at greater risk for m ore severe rashes, visceral dissemination or

death. The incidence of shingles increases with: advancing age (age >

60 yrs - 10 cases/1000 pt-yrs); immunosuppression from cancer,

transplantation, autoimmunity (SLE 15-91 cases/1000 pt-yrs; RA 10-15

cases/100 pt-yrs; Wegener's 45 cases/1000 pr-yrs4,5); and certain

immunosuppressive agents (e.g., cyclophosphamide, azathioprine, high

dose prednisone). A contributory role for methotrexate or biologic

therapies in VZV infection or reactivation has not been established.

The Vaccine. A lyophilized, live, attenuated zoster vaccine

(Zostavax®) has been available since 2006 for use in immunocompetant

persons aged > 60 yrs. Of note, the adult vaccine uses the same strain

of virus as the pediatric vaccine (Varivax®) but is at least 14

times more potent. The vaccine was studied for three years in 38,546

individuals > 60 years with a 51% reduction in shingles and a 67%

reduction in PHN. The vaccine has not been studied in immunosuppressed

patients – nonetheless, existing guidelines warn against its use in

the immunosuppressed or those on immunosuppressive therapy. The

vaccine is given as a single subcutaneous injection in the upper arm.

Side effects include injection site reactions (common) and headache

(uncommon). Vaccination rarely induces acute VZV infection. The

approximate cost of vaccine is $150 (U.S.).

**********************************************************************

Read the rest of the article here:

http://www.rheumatology.org/publications/hotline/2008_08_01_shingles.asp

Not an MD