National Center for Immunization & Respiratory Diseases

Zoster Vaccines Session: Burden of Herpes Zoster in 

Immunocompromised Adults

ACIP Meeting

June 25, 2021

LCDR Tara Anderson, DVM, MPH, PhD

CDC Lead, Herpes Zoster Work Group

Division of Viral Diseases, Viral Vaccine Preventable Diseases Branch
Current ACIP Recommendations

▪ ACIP recommended recombinant zoster vaccine (RZV, 

Shingrix) in Oct 2017 for use in immunocompetent adults 

age ≥50 years

▪ ACIP recommendations include use of RZV in persons

– Taking low-dose immunosuppressive therapy

– Anticipating immunosuppression or who have recovered 

from an immunocompromising illness

Dooling et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR Morb Mortal Wkly Rep 2018;67:103–

108. DOI: http://dx.doi.org/10.15585/mmwr.mm6703a5.
Background

▪ Risk of herpes zoster (HZ), severe disease, and complications 

generally higher in immunocompromised (IC) populations

▪ IC populations are very heterogeneous, both within and 

across groups

▪ Zostavax, a live, attenuated HZ vaccine, was contraindicated 

for persons with IC conditions

▪ RZV can potentially address an unmet need for HZ 

prevention in IC populations
How many IC persons in the United States?*

▪ ~7 million IC adults1

▪ ~3 million among:

• Hematopoietic stem cell transplant 

recipients2

• Patients with hematologic 

malignancies3

• Renal or other solid organ 

transplant recipients4

• Patients with solid tumor 

malignancies3,5

• People living with HIV6

▪ ~22 million with 

autoimmune and/or 

inflammatory (AI) 

conditions7

• >80 diverse conditions (e.g., 

systemic lupus erythematosus, 

rheumatoid arthritis, inflammatory 

bowel disease)

• Often have underlying immune 

dysfunction, but generally not 

considered frankly IC unless 

iatrogenic (i.e., on IC treatments)

*References on slide 20
IC Populations under Consideration

1. Hematopoietic stem cell transplant (HCT) recipients

2. Patients with hematologic malignancies (HM) 

3. Renal or other solid organ transplant (SOT) recipients

4. Patients with solid tumor malignancies (STM)

5. People living with HIV

6. IC populations at increased risk of HZ not covered in groups 

1 through 5 (i.e., patients with primary immunodeficiencies, 

patients with autoimmune conditions, patients taking 

immunosuppressive medications)
Evidence to Recommendations (EtR) Framework

EtR Domain Question

Public Health Problem Is the problem of public health importance?

Benefits and Harms How substantial are the desirable anticipated effects?

How substantial are the undesirable anticipated effects?

Do the desirable effects outweigh the undesirable effects?

Values Does the target population feel the desirable effects are 

large relative to the undesirable effects?

Is there important variability in how patients value the 

outcomes?

Acceptability Is the intervention acceptable to key stakeholders?

Feasibility Is the intervention feasible to implement?

Resource Use Is the intervention a reasonable and efficient allocation of 

resources?

Equity What would be the impact of the intervention on health 

equity?
Clinical Presentations of Herpes Zoster

Courtesy of NIAID Courtesy of MN Oxman UCSD/San Diego VAMC Courtesy of CDC/Robert Sumpter
“Five years later, I still take prescription medication for 

pain. My shingles rash quickly developed into open, 

oozing sores that in only a few days required me to be 

hospitalized. I could not eat, sleep, or perform even 

the most minor tasks. It was totally debilitating. The 

pain still limits my activity levels to this day.”

—A 63-year-old harpist who was unable to continue playing due to shingles

https://www.cdc.gov/shingles/about/complications.html
HZ Incidence Common in Adults and Increases with Age

~1 million HZ 

cases per year 

in U.S. during 

pre- HZ vaccine 

era1

1. Harpaz et al. Prevention of Herpes Zoster, MMWR, June 6, 2008, Vol 57, #5

2. CDC, unpublished data; Updated from Harpaz et al. Clinical Infectious Diseases, Volume 69, Issue 2, 15 July 2019, Pages 341–

344, https://doi.org/10.1093/cid/ciy953
Public Health Importance

Risk of HZ in IC Groups 1–5

▪ Median HZ incidence 

estimates for these IC groups 

exceeded those reported for 

immunocompetent adults 

>50 years

McKay et al. Herpes zoster risk in immunocompromised adults in the

United States: A systematic review. CID 2020;71(7):e125–34. 

Figure 3. Herpes zoster incidence rates among patients with selected 

immunocompromising conditions. *Studies with low or medium risk of bias. 
▪ Postherpetic neuralgia (PHN)

– ~6–10% vs ~4% overall in administrative claims databases1

– Between 6% and 45% across IC conditions and studies2

▪ Disseminated HZ:

– ~3%2 of IC, but exceedingly uncommon in healthy persons

– 10–17% mortality associated with disseminated HZ among renal transplant 

recipients3,4

▪ Hospitalization: 8% of HCT recipients with HZ5 vs ~<1% of overall Medicare 

beneficiaries with HZ6

Public Health Importance

Severity of HZ in IC Groups 1–5

1Chen et al. Incidence of herpes zoster in patients with altered immune function. Infection 2014; 42(2): 325–34; 2McKay et al. Herpes zoster risk in immunocompromised adults in the United States: A systematic 

review. CID 2020;71(7):e125–34; 3Rommelaere et al. Disseminated varicella zoster virus infection in adult renal transplant recipients: Outcome and risk factors. Transplantation Proceedings. 2012; 44(9): 2814-2817; 

4Kirnap et al. Prevalence and outcome of herpes zoster infection in renal transplant recipients. Exp Clin Transplant. 2015; Apr;13 Suppl 1:280-3; 5Winston et al. Inactivated varicella zoster vaccine in autologous 

haemopoietic stem-cell transplant recipients: an international, multicentre, randomised, doubleblind, placebo-controlled trial. Lancet (London, England) 2018; 391(10135): 2116–27; 6Izurieta et al. Effectiveness 

and duration of protection provided by the live-attenuated herpes zoster vaccine in the Medicare population ages 65 years and older. CID 2017;64(6):785–93.
Antiviral Prophylaxis

▪ Antiviral prophylaxis is recommended post-transplant

– No universal standard prophylactic regimen for transplant recipients, 

and antiviral drug, duration, and dosage vary

– Studies of patients post HCT with follow up >2 years revealed that HZ 

incidence increases once prophylaxis is discontinued

▪ ACIP General Best Practice Guidelines, Altered 

Immunocompetence

– Most inactivated vaccines should be initiated 6 months after HCT 

https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html
IC Populations under Consideration

1. Hematopoietic stem cell transplant (HCT) recipients

2. Patients with hematologic malignancies (HM)

3. Renal or other solid organ transplant (SOT) recipients

4. Patients with solid tumor malignancies (STM)

5. People living with HIV

6. IC populations at increased risk of HZ not covered in groups 

1 through 5 

▪ Patients with primary immunodeficiencies

▪ Patients with autoimmune (AI) conditions

▪ Patients taking immunosuppressive medications
Public Health Importance

Risk of HZ in IC Group 6

▪ ~2 to 4-fold higher risk in 

patients with AI 

conditions than in healthy 

individuals1

▪ ~1.5-fold higher risk for 

unvaccinated Medicare 

beneficiaries with AI 

conditions vs not IC2

Figure adapted from Yun et al. Bars show the IRs of HZ with 95% confidence intervals. Cohorts of healthy 

adults without autoimmune diseases or diabetic conditions and adult patients with diabetes were used as 

controls. SLE=systemic lupus erythematosus; IBD=inflammatory bowel disease; RA=rheumatoid arthritis; 

PsA=psoriatic arthritis; PsO=psoriasis; AS=ankylosing spondylitis.

1. Yun et al. Risk of Herpes Zoster in Autoimmune and Inflammatory 

Diseases. Arthritis & Rheumatology 2016;68(9):2328-2337.

2. Izurieta et al. Recombinant Zoster Vaccine (Shingrix) real-world 

effectiveness in the first two years post-licensure. Clinical Infectious 

Diseases, 2021;, ciab125, https://doi.org/10.1093/cid/ciab125

Age and sex-standardized HZ incidence rates, among 

adults ≥20 years with selected autoimmune diseases 
Group 6 Examples: SLE, IBD, and RA

▪ Disease burden

– HZ risk ~2 to 4-fold higher

– Age-specific incidence rates among 21–50-year-olds comparable or 

substantially higher than corresponding rates in healthy adults >60 years

▪ Impact of immunosuppressive treatments

– Standard of care for patients to be on ≥1 IC drugs

– Not possible to define high risk subgroups based on anticipated drugs

• Disease modifying antirheumatic drugs, or DMARDs (e.g., methotrexate)

• Glucocorticoids

• Biologics (e.g., Janus Kinase inhibitors)
Work Group Interpretation

▪ Are HZ and HZ complications in IC adults ≥19 years of public 

health importance? 

– Yes

▪ Summary of work group discussions

– IC populations are very heterogeneous, both across and within groups and 

among individuals over time

– Risk of HZ and HZ complications generally higher in IC populations, 

although there is variability across and within IC groups

– Not feasible to define every possible IC condition/medication combination

– Important to consider broad recommendations and appropriate guidance 

for IC populations
EtR Framework

Next Steps

▪ GRADE analysis of existing evidence 

of RZV benefits and harms

▪ Review knowledge, attitudes, and 

current practices for RZV in IC 

populations

▪ Cost effectiveness analyses of use 

of RZV in IC populations

❑ Public Health 

Importance

❑ Benefits and Harms

❑ Values 

❑ Acceptability

❑ Feasibility

❑ Resource Use

❑ Equity
For more information, contact CDC

1-800-CDC-INFO (232-4636)

TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the 

official position of the Centers for Disease Control and Prevention.

Thank You
Backup Slides
Slide 4 References

1. Harpaz R, Dahl RM, Dooling KL, JAMA, 2016, 316(23):2547-8. 

2. D'Souza A, Fretham C. Current Uses and Outcomes of Hematopoietic Cell Transplantation (HCT): CIBMTR 

Summary Slides, 2018. Available at https://www.cibmtr.org.

3. American Cancer Society, https://cancerstatisticscenter.cancer.org; 2019 incidence estimates. 

4. United Network for Organ Sharing, https://unos.org/data/transplanttrends/#transplants_by_organ_type+year; 2018, Renal= Kidney + Kidney/Pancreas, Solid organ = all listed.

5. Halpern MT, Yabroff KR, Cancer Invest, 2008, 26(6):647-51; Derived from Halpern and Yabroff 2000-2004 

data on chemo/radiotherapy among all patients with cancers, adjusted based on proportion of all cancers in 

2007 due to solid organ cancers, further adjusted by projections that solid cancers increased by 20% 

between 2007 and 2018 (data from American Cancer Society website). 

6. CDC, https://www.cdc.gov/hiv/statistics/overview/ataglance.html; 2017 incidence, 2016 prevalence of 

diagnosed HIV infections.

7. Derived from Hayter SM. Autoimmun Rev. 2012 Aug;11(10):754-65 (prevalence 4.5% for all conditions 

excluding psoriasis) and Rachakonda TD. J Am Acad Dermatol. 2014 Mar;70(3):512-6 (prevalence of 3.2% for 

psoriasis alone), applied to projected adult US population in 2020 (US Census: 289.6 million).
IC Populations: Groups 1–5

IC Condition

Incident Cases 

(New cases per year)

Prevalent 

Cases

Hematopoietic stem cell transplant1 23,379

Hematologic malignancy2 ~176,200

Solid organ (including renal) 

transplant3

58,532 ~591,000

Solid tumor on chemotherapy2,4 ~1,200,000

HIV infection5 38,739 1,008,929

Total ~1,496,850 ~1,599,929

1. D'Souza A, Fretham C. Current Uses and Outcomes of Hematopoietic Cell Transplantation (HCT): CIBMTR Summary Slides, 2018. Available at https://www.cibmtr.org.

2. American Cancer Society, https://cancerstatisticscenter.cancer.org; 2019 incidence estimates. 

3. United Network for Organ Sharing, https://unos.org/data/transplant-trends/#transplants_by_organ_type+year; 2018, Renal= Kidney + Kidney/Pancreas, Solid organ = all listed.

4. Halpern MT, Yabroff KR, Cancer Invest, 2008, 26(6):647-51; Derived from Halpern and Yabroff 2000-2004 data on chemo/radiotherapy among all patients with cancers, adjusted 

based on proportion of all cancers in 2007 due to solid organ cancers, further adjusted by projections that solid cancers increased by 20% between 2007 and 2018 (data from 

American Cancer Society website). 

5. CDC, https://www.cdc.gov/hiv/statistics/overview/ataglance.html; 2017 incidence, 2016 prevalence of diagnosed HIV infections.
Policy question: “Should vaccination with RZV be 

recommended for immunocompromised adults 19 years of age 

and older?”

▪ Population: IC adults ≥19 years of age; split into two parts (19–49 years, 

≥50 years)

▪ Intervention: RZV, 2 doses at least 4 weeks apart

▪ Comparison: No vaccine

▪ Outcomes