Is Shingrix Recommended If You Have A Compromised Immune System?
In our latest question and answer, the pharmacist discusses getting the shingles vaccine, Shingrix, if you are immunocompromised.
I am getting my Shingrix vaccine series at the age of 58, because I am immunocompromised. I understand the dosing schedule of the series of 2 injections. I now see that the effectiveness is anticipated to significantly decrease within 9 yrs. I also see that chances of contracting shingles at the age of 70+, are 2:1. My question is, if someone is immunocompromised, what are they to do in their 70's when the effectiveness of the vaccine is at it's worst, yet the chances of contracting are higher? It doesn't appear that an individual can repeat the series again (say 10-12 yrs from their first series).
There currently is a lack of data regarding the safety and efficacy of Shingrix, the recommended vaccine for the prevention of shingles, in immunocompromised individuals. Similarly, are no current recommendations regarding re-vaccination with Shingrix, even after an extended period of time, due to the lack of available data.
You can read the full recommendations on the CDC (Centers for Disease Control) website, but the dosing schedule for the vaccine is listed only as a a single 'two-shot' series, with doses separated by 2 to 6 months. There are no recommendations regarding completing the dosing series again, regardless of the time that has elapsed since the initial vaccination.
As is comes to individuals who are immunocompromised, the CDC (Centers for Disease Control) doesn't explicitly recommend the vaccine:
Q: Can Shingrix be administered to immunocompromised individuals?
A: While Shingrix is not contraindicated in immunocompromised persons, it is not recommended by ACIP at this time. ACIP will begin reviewing evidence for Shingrix in immunocompromised people as soon as it becomes available and will modify vaccine policy as necessary. You can still give Shingrix to someone who is taking low-dose immunosuppressive medication, anticipating immunosuppression, or has recovered from an immunocompromising illness.
There are no recommendations for immunocompromised individuals simply due to a lack of safety and effectiveness data. Immunocompromised individuals were excluded from clinical trials for vaccine. The prescribing information for Shingrix states this specifically:
The study excluded, among others, subjects who were immunocompromised, had a history of previous HZ, were vaccinated against varicella or HZ, and patients whose survival was not expected to be at least 4 years or with conditions that might interfere with study evaluations.
Thus, there are no recommendations from the CDC regarding its use in that population.
The Canadian guidelines are slightly different. They recommend it only on a case-by-case basis:
Individuals who are immunocompromised, either due to underlying conditions or immunosuppressive agents, have an increased risk of developing HZ. They may be more likely to experience HZ recurrence, atypical and/or more severe disease and complications.
RZV should be considered based on a case-by-case assessment of benefits vs risks. When indicated, it should be administered before initiating immunosuppressive treatment that might lead to immunodeficiency. It is recommended that RZV be administered at least 14 days before the treatment.
It is important to speak with your doctor so you can assess the risks vs. benefits of receiving Shingrix while immunocompromised. We can certainly hope that the CDC will provide more guidance in the future in this regard.
In terms of the Shingrix vaccine decreasing in effectiveness after 9 years, this is really more of a case of not knowing how long it lasts. When talking about how long immune protection lasts, we really should say that for most individuals, it lasts at least 9 years. Past that time, we don't have enough data to draw conclusions. It makes sense that there would be some decrease in effectiveness over time, but just how much isn't well known.
The prescribing information for Shingrix doesn't discuss how long immune protection lasts, and it takes some digging to find studies addressing the matter.
One of the few studies that evaluated long-term effectiveness was published in the journal Human Vaccines & Immunotherapeutics. Based on the data collected, they concluded that the immunity conferred from Shingrix lasts at least 9 years post-vaccination:
In adults aged ≥60 years, HZ/su-induced [herpes zoster subunit vaccine] immunogenicity remained above pre-vaccination levels for at least nine years post-initial vaccination.
If you're so inclined, there is an in-depth 'poster presentation' reviewing the key points of this study available online.
Shingrix guidelines from ACIP [Advisory Committee on Immunization Practices] currently don't have any recommendations past the recommended two-dose series. They may alter their recommendations in the future, but until that time, it would be prudent not repeat the dosing series. As more data becomes available, we should get a better idea of whether or not re-vaccination is necessary.
Answer SummaryThere is limited data regarding the safety and efficacy of Shingrix in immunocompromised individuals. It therefore is not recommended by ACIP [Advisory Committee on Immunization Practices] in that population at the current time. Canadian guidelines state that it may be given on a case by case basis.
Shingrix is recommended to be given as a two-shot series. There are no recommendations regarding re-vaccination after the initial dosing series.
- Elsevier ClinicalKey: Shingrix (Accessed 1/14/19)
- CDC Shingrix Recommendations: Centers for Disease Control (Accessed 1/13/19)
- Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. Link (Accessed 1/13/19)
- Persistence of immune response to an adjuvanted varicella-zoster virus subunit vaccine for up to year nine in older adults. PubMed (Accessed 1/14/19)
- Herpes Zoster (Shingles) Vaccine: Canadian Immunization Guide. Link (Accessed 1/14/19)