Herpes zoster vaccine is now recommended for all immunocompromised adults

Herpes zoster (shingles) is a common and significant public health problem, with an estimated lifetime risk as high as 30% in the general population. Advanced age and immunosuppression are the most important risk factors for developing herpes zoster.1 On August 30, 2018, the National Advisory Committee on Immunization (NACI) published a statement on the use of the recombinant zoster vaccine (RZV, Shingrix). It recommended that RZV should be offered to immunocompetent adults 50 years of age or older (Strong NACI recommendation) and could be considered for adults 50 years of age or older who are immunocompromised (Discretionary NACI Recommendation). At that time, data on use of RZV in immunocompromised individuals was lacking.1 On November 24, 2021, Health Canada authorized RZV for adults 18 years of age or older who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy. Based on this updated authorized indication for RZV, NACI reviewed the existing recommendations and evidence supporting the use of RZV in individuals 18 years of age or older who are immunocompromised.1 Summary of the evidence:The risk of herpes zoster in younger adults who are immunocompromised is comparable to or higher than the general population aged 50 years or older. Complications of acute herpes zoster are potentially severe and more common in individuals who are immunocompromised.RZV has an acceptable safety profile when administered to adults who are immunocompromised.RZV is protective against herpes zoster and its complications, with an estimated (up to two-year) efficacy ranging from 65%–90%, which is similar to the efficacy seen in clinical trials in immunocompetent individuals. After a thorough review of the evidence on the risk of HZ in immunocompromised populations and the use of RZV in immunocompromised populations, NACI made the following recommendation to inform RZV immunization programs for Canadian provinces and territories.1RecommendationNACI now strongly recommends that individuals 18 years of age or older who are or will be immunocompromised should receive two doses of RZV to prevent herpes zoster and its associated complications.1Dosage RZV should be administered as a two-dose schedule, with doses given two to six months apart. However, if needed, for individuals who will be at increased risk of HZ due to immunodeficiency or immunosuppression (e.g., individuals about to start immunosuppressive therapy), the second dose can be administered at a minimum interval of at least four weeks after the first dose, as these individuals will benefit from completing the series before becoming immunosuppressed.1For optimal immune response, the two-dose RZV series is recommended to be completed at least 14 days before the start of immunosuppressive therapy.1 Immunocompromising conditions The following list of immunocompromising conditions can be used to help guide the prioritization of immunocompromised individuals for vaccination: Primary immunodeficiencies affecting innate, humoral and T cell-mediated immunityHematopoietic stem cell transplant (HSCT)Solid organ transplant (SOT)Hematologic malignanciesSolid tumour malignancies on immunosuppressive treatmentHIV infectionChronic or ongoing immunosuppressive therapyImmunosuppressive chemotherapyImmunosuppressive radiation therapyCalcineurin inhibitorsCytotoxic medicationsAntimetabolitesImmune effector cell therapies (e.g., CAR T cell therapy)Biological response modifiers, targeted therapies and antibodies that target lymphocytes and immune pathways (e.g., anti-CD20, ant-TNF-α, JAK inhibitors, etc.)Long-term, high-dose systemic corticosteroids (prednisone equivalent of ≥ 2 mg/kg/day, or 20 mg/day if weight > 10 kg, for ≥ 14 days).NOTE: This is not a comprehensive list of immunocompromising medical conditions or immunosuppressive drugs. A range of factors can affect the relative degree of immune suppression and risk of HZ; clinical judgement and/or consultation with the treating physician is advised.1Additional considerationsNo data are available on RZV administration during pregnancy or breastfeeding; caution should be used in these situations. Immunocompromised women and individuals should ideally be vaccinated prior to pregnancy or immunization should be deferred until after pregnancy. However, testing for pregnancy prior to vaccination is not necessary. RZV can be used in breastfeeding women and breastfeeding individuals if indicated.No statistically significant differences in reactogenicity or immunogenicity have been observed with concurrent administration of RZV with other adult vaccines, except for lower immune responses to one of the pertussis antigens in Tdap. Since there are no known clinically relevant impacts of this finding on Tdap vaccine effectiveness, NACI continues to recommend that RZV can be administered concurrently (i.e., same day) or at any time before or after other live or nonlive vaccines.1,2NACI encourages further research on several issues, including:Monitoring of adverse events of special interest, including onset or exacerbation of immune-mediated diseases, graft-versus-host disease and graft rejection.Duration of RZV protection and the need for booster doses, including the effect of a shorter interval between doses 1 and 2 on the duration of protection.Concurrent administration of RZV with two or more vaccines.Efficacy, safety and immunogenicity of RZV in women and individuals who are pregnant or breastfeeding.Efficacy, safety and immunogenicity of RZV in adults who have not been infected with varicella zoster virus or received varicella vaccine.1ReferencesNational Advisory Committee on Immunization (NACI). An Advisory Committee Statement (ACS). Updated recommendations on Herpes Zoster vaccination for adults who are immunocompromised. May 2025. [This document is not yet available online, but can be obtained by sending an email request to: naci.publications-ccni@phac-aspc.gc.ca] National Advisory Committee on Immunization (NACI). Summary of NACI statement of May 14, 2025: Updated recommendations on herpes zoster vaccination for adults who are immunocompromised. (accessed May 20, 2025).

Herpes zoster vaccine is now recommended for all immunocompromised adults

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