Shingles is painful. Anyone who has experienced shingles will tell you that in no uncertain terms. By now, we are quite aware of the increased risk of herpes zoster (HZ) in patients with autoimmune diseases due to immunosuppressive medication use or from immune dysregulation from the underlying disease. Unfortunately the very same risks for HZ reactivation are precisely those that raise concern for theoretical risks of contracting vaccine-strain varicella infection from the live-attenuated HZ vaccine (Zostavax, Merck); and this has resulted in undervaccination of many people with rheumatic diseases who would otherwise be eligible for vaccination. Until recombinant varicella vaccines become commercially available, the live-attenuated vaccine is the only protective measure available for our patients.
While it is easy to provide arguments for increased vaccination of patients with rheumatic disease in whom levels of immunosuppression are mild to moderate (with tofacitinib being a notable contraindication1), it is also time to focus on the available data for safety, efficacy, and duration of protection provided by the HZ vaccine when given to patients who may have blunted responses because of underlying autoimmune diseases and/or chronic …
Address correspondence to Dr. E.F. Chakravarty, Associate Member, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, 825 NE 13th St., Oklahoma City, Oklahoma 73104, USA. E-mail: chakravartye{at}omrf.org