June 2nd, 2008

Zoster Vaccine Guidelines — Official Answers, but Still Some Questions

The CDC’s Advisory Committee on Immunization Practices has just released the “official” guidelines for use of the zoster vaccine. And none too soon — if I had a dollar (or these days, make that a euro) for every curbside consult I’ve received about the zoster vaccine …

The vaccine’s indications are simple — age over 60, immunocompetent. Ah, but the devil is in the details, and that’s what make these guidelines so helpful.

Readers will find answers to many common questions about zoster vaccine, including:

  1. Should it be given to people younger than 60? Not at this point. It’s unlikely to be harmful, however, and I suspect some practitioners might stretch this age criterion downward, especially for patients who particularly fear getting shingles.
  2. Should it be given to people older than 80? Yes — although the vaccine appears not to work as well in this group. Still, not all 80-year-olds are created equal, and undoubtedly, some would respond and be protected.
  3. Should it be given to people who have already had zoster? Yes — but remember this group wasn’t in the licensing study. But it won’t be harmful and might help. And boy, do people who have had zoster want this vaccine.
  4. What about people who are taking antivirals with activity against VZV? Have them stop these antivirals for at least 14 days after getting vaccinated. (I love it when guidelines give precise information like this. And 14 days fits nicely into the “multiples of days of the week or fingers of the hand” rule that ID docs love.)
  5. Should we worry about secondary transmission of the vaccine’s virus? Generally not. Yet I guarantee we’ll still get calls on this one: “Hi Paul, my patient is visiting his baby grandson this weekend — is it safe to give him the zoster vaccine?” or “My patient’s husband is on chemo for CLL — should she get it?” or “He’s flying coach to Australia and will be on a jet for 15 hours — can he get the vaccine?”  (Yes and yes and yes, by the way.)
  6. Can we give it to people who can’t remember whether they had chicken pox? So long as they were born before 1980, the answer is yes — in all likelihood, they did have chicken pox and hence are at risk for zoster. (All people older than 60 were indeed born before 1980 — hey, I knew that pre-med calculus would come in handy someday.)
  7. What immunocompromised patients should not get the vaccine? Basically, those with impaired cellular immunity shouldn’t get it, and the guidelines offer a nice summary of who these folks are.

Which brings me to what I found most surprising about the guidelines — the reference to its use in those with HIV. I anticipated that the guidelines would say the vaccine is contraindicated for everyone with HIV, but instead they specify that the vaccine should not be given to:

“Persons with AIDS or other clinical manifestations of HIV, including persons with CD4+ T-lymphocyte values <200 per mm3 or <15% of total lymphocytes”

But does this mean we should give it to all our asymptomatic HIV patients with CD4s > 200/15%? Just those over age 60? Just those who’ve never been < 200/15%? All, some, or none of the above? These guidelines don’t say.

Clearly, this vaccine is of interest to HIV providers and their patients: the incidence of zoster is at least 15-fold higher in people with HIV, and of course, zoster can occur at any CD4-cell count.

Fortunately, an ACTG study is planned evaluating the zoster vaccine in people with HIV. Stay tuned.

10 Responses to “Zoster Vaccine Guidelines — Official Answers, but Still Some Questions”

  1. HH says:

    I am also surprised that they limited the HIV category to CD4 less than 200
    (CDC needs to redo the VIS.) I still will not be giving it to HIV patients and
    at most would reeducate about the signs and symptoms of zoster so they can get early treatment.

    I am being fairly rigid in the age 60 rule since we do not know anything about booster doses and I would presume that the immunity from the vaccine wanes. I would be concerned about giving it to someone at age 40 or 50 and then as the decades ago on and the risk of zoster increases the immunity they got from the vaccine might have waned too much. On the other hand, we might one day find out that getting it at age 50 is a better long-term strategy than waiting until age 60 just like we currently know that getting it at age 60 is better than 70 and 70 is better than 80.
    Do you give pneumococcal vaccine to 50-year-olds if they are fearful of
    pneumococcal pneumonia?

    I agree that people with zoster should still get the vaccine but think there
    should be a considerable waiting period. I wait two years.

  2. Paul Sax says:

    Excellent points all — esp about the age 60 rule, and the uncertainty about whether boosting doses will be needed.

    I suspect I would not refuse the pneumococcal vaccine to younger patients if they asked for it, but would offer up the pros and cons in the hope of convincing otherwise.

  3. Andysnat says:

    I’m afraid that you are wrong about point 5 in relation to CLL victims.

    They most definitely SHOULD NOT be receiving this vaccine. The CDC advice is wrong. All the experts on CLL (Prof Terry Hamblin, Prof John Byrd and others) agree that we, that is CLL victims, should NOT receive this vaccine.

    See my own blog posts here –


    and here –


    I do hope you will read these posts, and perhaps comment here accordingly as to your opinion after following the links in my blog.


  4. KP says:

    I have CLL, and my hematologist-oncologist and a CLL specialist both assert that anyone with CLL, whether in chemo or not, is at risk of contracting herpes zoster from the vaccine. They assert that the nature of the disease involves some loss of immune function (to varying degrees among individuals) and that, as a result, CLL patients are at higher risk of not only contracting but also have being unable to fight the disease effectively because of hampered immune systems. I strongly suggest that any individual with CLL, whether in treatment or not, read more on the web before requesting or accepting the HZ vaccine.

  5. Paul Sax says:

    Dear Andysnat and KP:

    I agree that patients with impaired cellular immunity (including those with CLL) should NOT receive the zoster vaccine. That’s point #7.

    My comment in #5 above was about household contacts: “My patient’s husband is on chemo for CLL — should she get it?”

    Here I believe the answer is yes. Transmission of the virus from someone who has been vaccinated for zoster has not yet occurred, and if it does happen, it is expected that this will lead to mild illness at most. I’ve pasted the relevant section from the Guidelines below.



    Risk for Transmission of Oka/Merck Strain after Receiving Zoster Vaccine

    Persons having close household or occupational contact with persons at risk for severe varicella need not take any precautions after receiving zoster vaccine except in rare instances in which a varicella-like rash develops, when standard contact precautions are adequate. Although transmission of Oka/Merck strain VZV has been documented following varicella vaccination, such transmission is rare and has only been documented when the vaccine recipient first developed a varicella-like rash. Rates of varicella-like rash appear to be less common following zoster vaccination than following varicella vaccination, and transmission of the Oka/Merck strain VZV from recipients of zoster vaccine has not been detected. The risk for transmitting the attenuated vaccine virus to susceptible persons should be weighed against the risk for developing wild-type zoster that could be transmitted to a susceptible person. If a susceptible, immunocompromised person is inadvertently exposed to a person who has a vaccine-related rash, VARIZIG™ need not be administered because disease associated with this type of transmission is expected to be mild. Acyclovir, valacyclovir, and famciclovir are active against live-attenuated Oka/Merck strain VZV and can be used in the unlikely situations in which a severe illness develops in the susceptible contact.

  6. Dr Terry Hamblin says:

    Doctors are still using this vaccine in CLL despite the warnings here. Patients with CLL are very poor at making immune responses to any vaccines even when they have minimal disease. Although the immune defect is most obviously hypogammaglobulinemia, they all have a T cell defect as well.

  7. Paul Sax says:

    Again, I agree with you that the vaccine should not be given to people with CLL (and at least the oncologists I work with are NOT doing so). However, it is ok to give it to household contacts of people with CLL.

  8. anonydoc says:

    thank you paul, some excellent points.

  9. Karen says:

    husband has amyloidosis and is on chemo-Revlimid…should I get it?

    • Paul Sax says:

      Household transmission of the vaccine virus (which is attenuated) is unlikely — and arguably less dangerous than if a person actually gets zoster, since recent research shows that transmission from zoster is more common than we thought.
      So my advice is yes, though of course you should check with your doctor first.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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