Herpes zoster vaccine recommendations questioned in patients on biologics

By Laura Cowen

Administration of the live attenuated herpes zoster (HZ) vaccine is not associated with an increased risk for shingles shortly after vaccination in patients receiving biologic treatments for immune-mediated diseases, researchers report in JAMA.

And contrary to recommendations suggesting that the HZ vaccine is contraindicated in these patients, Jeffrey Curtis (University of Alabama, Birmingham, USA) and colleagues also found that receipt of the vaccine was associated with a significantly reduced longer-term risk for shingles (also known as HZ) in patients with an immune-mediated disease.

The researchers examined the association between HZ vaccination and HZ incidence within and beyond 42 days of vaccination in 463,541 Medicare beneficiaries aged 60 years and older with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease.

During a median follow-up period of 2 years, 18,683 (4%) patients received the HZ vaccine.

The overall crude HZ incidence rate was 7.8 cases per 1000 person-years within 42 days after vaccination.

However, there were no cases of varicella or HZ among 633 patients exposed to biologics, including 551 patients exposed to antitumor necrosis factor biologics, during this high-risk postvaccination period.

A further 138 HZ cases were recorded during the period of more than 42 days after vaccination, for an incidence rate of 6.7 cases per 1000 person-years. The rate among unvaccinated patients was 11.6 cases per 1000 person-years.

After controlling for demographics, type of immune-mediated disease, healthcare utilization, and exposure to biologic and nonbiologic disease-modifying antirheumatic drugs, and oral glucocorticoids, HZ vaccination was associated with a 39% reduced risk for HZ after 42 days, compared with no vaccination.

"Despite the recognition that patients with immune-mediated conditions are at increased risk of HZ, this and previous studies have shown that only a small fraction of these patients received the vaccine, likely in part due to safety concerns," Curtis and co-authors remark.

They conclude: "Our data call into question the current recommendations that HZ vaccine is contraindicated in patients receiving biologics and suggest a need for a randomized controlled trial to specifically address the safety and effectiveness of HZ vaccination among patients receiving biologics."

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