To the Editor:
The report by Cheetham et al
1
in the July 2015 issue of Mayo Clinic Proceedings uniquely addresses the risk of disseminated varicella zoster in patients taking immunosuppressant drugs at the time of zoster vaccination. For those of us providing care to immunosuppressed patients, 2 key questions are (1) whether immunosuppression reduces the efficacy of vaccination and (2) whether there are any risks specifically related to the use of a live attenuated vaccine. The first question is not addressed in the study by Cheetham et al, but the fact that there were no cases of disseminated zoster in this study's 4826 immunosuppressed patients who were vaccinated provides reassuring evidence that the risk of dissemination is low in this population. The results are valuable because prior reports of disseminated herpes zoster following vaccination of immunocompromised patients do not address causality or quantify risk.The stated conclusion of the current study, however, is perplexing. These data are said to “support the current recommendations for zoster vaccination in that patients should withhold their immunosuppressant drugs for 4 weeks before immunization.” Rather, the observation that there were no cases of disseminated zoster among immunosuppressed patients provides no rationale for stopping immunosuppressive therapy before vaccination. In fact, in combination with data presented confirming that immunosuppression increases the risk of herpes zoster even after stopping immunosuppressive therapy, these results arguably support the opposite conclusion—that it would be prudent to vaccinate immunosuppressed patients as soon as possible to minimize the time-dependent risk of herpes zoster. Moreover, the data reported no evidence to support a 4-week delay compared with any other arbitrarily chosen interval before vaccination.
The observation that there is increased risk of herpes zoster during a specific time frame following vaccination in current relative to remote users of immunosuppressants should not be misunderstood as a rationale for withholding therapy before vaccination. This reasoning is correct only if vaccination is the cause of the increased risk, a result that would be counterintuitive for an intervention intended to prevent herpes zoster, and indeed, there were significantly fewer zosterlike rashes in the vaccine arm relative to placebo arm in the Zostavax Efficacy and Safety Trial during the 42 days postvaccination.
2
Rather, this observation1
presumably reflects the difference in background incidence rates for each population,3
again leading to the conclusion that any delay in vaccination can only increase the risk of herpes zoster.References
- Risk of herpes zoster and disseminated varicella zoster in patients taking immunosuppressant drugs at the time of zoster vaccination.Mayo Clin Proc. 2015; 90: 865-873
- Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years.Clin Infect Dis. 2012; 54: 922-928
- Risk factors for herpes zoster in a large cohort of unvaccinated older adults: a prospective cohort study.Epidemiol Infect. 2015; 143: 2871-2881
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- Risk of Herpes Zoster and Disseminated Varicella Zoster in Patients Taking Immunosuppressant Drugs at the Time of Zoster VaccinationMayo Clinic ProceedingsVol. 90Issue 7
- Risk of Disseminated Disease in Immunosuppressed Patients Receiving Live Zoster VaccineMayo Clinic ProceedingsVol. 91Issue 7
- PreviewI read with interest the letter by Bubb1 and the reply by Cheetham et al2 in the November 2015 issue of Mayo Clinic Proceedings regarding the risk of disseminated disease in immunosuppressed patients receiving live zoster vaccine. Although the vaccine has been found to be highly effective and there is a paucity of cases of vaccine-related infections, the following report serves to highlight the need for caution when immunizing highly immunosuppressed patients.
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- In reply—Risk of Disseminated Varicella Zoster in Immunosuppressed Patients Receiving Zoster VaccinationMayo Clinic ProceedingsVol. 90Issue 11
- PreviewWe thank Dr Bubb for his interest in our study and appreciate the opportunity to respond to his questions and concerns. Specifically, concern was raised about our conclusion that our findings “support the current recommendations for zoster vaccination in that patients should withhold their immunosuppressants for 4 weeks before immunization,”1 even though we found no cases of disseminated varicella zoster among 4826 vaccinated individuals who were taking immunosuppressant medication. Additional concerns centered on our findings related to herpes zoster, specifically that (1) our data revealing a higher risk of herpes zoster in immunosuppressed patients who stopped immunosuppressive therapy argue that it would be prudent to vaccinate immunosuppressed patients as soon as possible, (2) the data do not support withholding immunosuppressant therapy for a minimum of 4 weeks before vaccination compared with any other arbitrarily chosen interval, and (3) vaccination is unlikely to be the cause of the increased risk of zoster during the 42 days postvaccination in the current vs remote immunosuppressant users.
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