Zoster vaccination of immunocompromised patients

Rodríguez-García, Juan; Fernández-Santos, Rafael; García-Erce, José Antonio

doi:10.1016/j.medcle.2018.09.014

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Therefore, we would like to review the recent advances in the prevention of herpes zoster (HZ) in immunocompromised patients through vaccination.HZ is caused by reactivation of the varicella-zoster virus (VZV) due to an impaired T cell immunity, specific for the virus. It affects more than 45,000 people in our country, being responsible for almost 20 deaths per year in Spain.<a class="elsevierStyleCrossRef" href="#bib0035">2</a> In the immunocompromised patient, the incidence, severity and mortality increase significantly, with an incidence almost 2 and a half times higher in the case of hematologic malignancies (15.2/105 vs. 6.2/105) and mortality rate two times higher for the immunocompromised patient compared to the one that is not immunocompromised (7.4/105 vs. 3.7/105).<a class="elsevierStyleCrossRef" href="#bib0040">3</a>To date, the only approved vaccine was an attenuated vaccine (Zostavax®) consisting of ≥19,400 plaque-forming units of the VZV, being therefore contraindicated in the immunocompromised patient. In fact, it has been the cause of disseminated varicella and death when it has been administered to this type of patients by mistake.<a class="elsevierStyleCrossRef" href="#bib0045">4</a>On 20 October, 2017, Shingrix®, a subunit vaccine that contains varicellazoster virus glycoprotein E antigen accompanied by with AS01B adjuvant, was approved by the Food and Drug Administration (FDA) for the prevention of HZ in adults aged 50 years and older. That same month the US Advisory Committee on Immunization Practices (ACIP) recommended the use of this vaccine over the attenuated one because it is estimated that it prevents more episodes of HZ and postherpetic neuralgia.As indicated by the manufacturer in the product data sheet, Shingrix® is not contraindicated in immunocompromised patients. It has not been specifically authorized for groups of patients with severe immunosuppression, since the 2 studies prior to marketing have not been designed to demonstrate efficacy in subgroups of patients with comorbidities. However, this type of patients were not excluded either. These clinical trials involved about 13,000 subjects with underlying medical conditions including immunosuppressed patients, noticing that the efficacy of the vaccine is comparable to the rest of the population. In addition, 2 phase 1/2 open trials were conducted in 135 subjects with autologous hematopoietic stem cell transplantation and HIV infection showing good immunogenicity and tolerance. Shingrix® was effective for different age groups (50–59 years, 60–69 years, 70–79 years and 80 years or more) with efficiencies of 96.6, 97.4, 91.3 and 91.4%, respectively, to prevent the first episode of HZ, and 100, 100, 93 and 71.2%, respectively, for the prevention of postherpetic neuralgia. In contrast, Zostavax® efficacy is 70, 64 and 38%, respectively for the age groups of 50–59 years, 60–69 years and 70–79 years.Zostavax® has been proven to reduce immunogenicity significantly from year 6, being reduced to below 35%, and 21–32% at years 7 and 8. This does not happen with the new Shingrix® vaccine, which is another important advantage since it is estimated that its response can last 19 years versus 4–12 years of the attenuated preparation. In fact, although Zostavax® has been approved by FDA in patients aged 50 years and older, ACIP does not recommend it to patients aged 50–59 years due to limited data that demonstrate protection beyond 5 years.<a class="elsevierStyleCrossRef" href="#bib0050">5</a>Shingrix® also obtained marketing approval in Europe through a procedure centralized by the European Medicines Agency on 21 April 2018, so it can be distributed in all states of the European Economic Area. However, approval by the Spanish Medicines Agency is not available and is currently not available in Spain. Early vaccination with this subunit vaccine in the 2 cases reported by Badiola J et al. might have prevented the outcome described by the authors with over 90% probability. The coordinated action between the scientific associations, the holder of the authorization and the regulatory agencies of our country is a priority in order to have this new vaccine for the prevention of HZ. This might prevent more than 3000 cases of HZ and up to 2 related deaths that occur in Spain every month that the availability of this vaccine is delayed. This particularly affects the immunocompromised patient." "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rodríguez-García J, Fernández-Santos R, García-Erce JA. Vacunación frente a herpes zóster en el paciente inmunodeprimido. Med Clin (Barc). 2019;152:e67–e68." ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Reactivation of varicella-zoster virus in immunosuppressed patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Badiola" 1 => "J.M. Puerta-Puerta" 2 => "L. Muñoz-Medina" 3 => "A. Molina-Leyva" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2018" "volumen" => "151" "paginaInicial" => "87" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Informe sobre la situación de la Varicela y el Herpes Zóster en España 1998-2012" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Centro Nacional de Epidemiología" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2014" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of herpes zoster in 16 selected immunocompromised populations in England: a cohort study in the Clinical Practice Research Datalink 2000–2012" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.A. Yanni" 1 => "G. Ferreira" 2 => "M. Guennec" 3 => "Y. El Hahi" 4 => "A. El Ghachi" 5 => "F. Haguinet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmjopen-2017-020528" "Revista" => array:5 [ "tituloSerie" => "BMJ Open" "fecha" => "2018" "volumen" => "8" "paginaInicial" => "e020528" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29880565" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Live zoster vaccination in an immunocompromised patient leading to death secondary to disseminated varicella zoster virus infection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K.E. Alexander" 1 => "P.L. Tong" 2 => "K. Macartney" 3 => "R. Beresford" 4 => "V. Sheppeard" 5 => "M. Gupta" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.vaccine.2018.05.078" "Revista" => array:6 [ "tituloSerie" => "Vaccine" "fecha" => "2018" "volumen" => "36" "paginaInicial" => "3890" "paginaFinal" => "3893" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29807711" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.L. Dooling" 1 => "A. Guo" 2 => "M. Patel" 3 => "G.M. Lee" 4 => "K. Moore" 5 => "E.A. Belongia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/ajt.14683" "Revista" => array:6 [ "tituloSerie" => "Am J Transplant" "fecha" => "2018" "volumen" => "18" "paginaInicial" => "756" "paginaFinal" => "762" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29462512" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015200000012/v1_201906160657/S2387020619301986/v1_201906160657/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015200000012/v1_201906160657/S2387020619301986/v1_201906160657/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619301986?idApp=UINPBA00004N"]

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Vol. 152. Issue 12.

Pages e67-e68 (June 2019)

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