Beth Longware Duff

Receipt of an mRNA COVID-19 vaccine is not associated with reactivation of the varicella zoster virus (VZV) that causes shingles (herpes zoster), according to study results published recently in the 

Journal of the American Academy of Dermatology

The retrospective cohort study was based on data from the TriNetX Analytics Network, a health research network that aggregates health records of 70 million patients from 63 health care organizations. It included patients aged 18 and older who received the mRNA COVID-19 vaccine either as a first orsecond dose between December 15, 2020 and July 15, 2021. Herpes zoster reactivation related to mRNA COVID-19 vaccine administration was defined as occurring within 28 days.

A control population of persons in the database with no history of COVID-19 vaccination was compiled. All of the individuals had been diagnosed with 1 or more dermatological conditions, which the study’s authors determined did not have a known relationship to VZV reactivation.

Cohorts were matched by age, sex, race, ethnicity, HIV status, malignancy, use of antineoplastics, use of immunosuppressants, and receipt of shingles vaccine. The control population was split into 2 cohorts: a historical cohort of individuals who received their diagnoses between January 1 and December 1, 2020, a period when COVID-19 vaccination was not readily available, and a contemporary cohort of individuals diagnosed between December 15, 2020 and July 15, 2021. The control cohorts were assembled to parallel the study cohort and to account for possible seasonal variation in VZV incidence.

More than 1.3 million individuals who received a dose of the mRNA COVID-19 vaccine were identified, with a mean age of 55.1 years. More than half (57%) were women; 14% were Black, 65% were White, 11% were Hispanic or Latino, and 6% were Asian.

The investigators calculated the relative risk of herpes zoster in the 28 days after index events in the respective cohorts.“ No difference in VZV reactivation was observed among persons receiving the mRNA COVID-19 vaccine within 28 days compared to both the historical cohort and the contemporary cohort,” they reported.

They acknowledged that the public’s fear of potential adverse effects might drive vaccine refusal and subsequent preventable disease and death. 

“Our data suggest mRNA COVID-19 vaccination is not associated with increased rates of VZV reactivation. We hope this reassures patients and the providers caring for them,” they wrote.

The CDC considers vaccination against shingles during the COVID-19 pandemic to be an essential preventive care service for older adults that should not be delayed or discontinued unless a patient is suspected or confirmed to have COVID-19.

Shingrixis the only vaccine against shingles available in the United States. It is FDA-approved for immunocompetent adults age 50 and older, and for immunocompromised adults 18 years and older—the first step toward providing protection against shingles to more at-risk individuals. Shingrix was also recently recommended by the CDC Advisory Committee on Immunization Practices for adults 19 years and older who are or will be immunodeficient or immunosuppressed due to disease or therapy.

1. Birabaharan M, Kaelber DC, Karris MY. 

Risk of herpes zoster reactivation after messenger RNA COVID-19 vaccination: A cohort study.

. 2021;S0190-9622(21):02892-02899. Doi:10.1016/j.jaad.2021.11.025

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Study investigators hope these results are reassuring. 

No Association Between mRNA COVID-19 and Herpes Zoster Identified

Shingles (herpes zoster, HZ) is an opportunistic infection that occurs when the latent varicella zoster virus (VZV) reactivatesand the body’s immune system is unable to fight it off. Two primary reasons for this are advanced age and immunosuppression due to illness or medical treatments. Cancer patients often fall into both of those categories and are at greater risk of developing shingles and experiencing more severe cases and complications.

 examined the risk of shingles before and after a new cancer diagnosis across a range of cancer types among approximately 240,000 adults in Australia. Researchers found that a cancer diagnosis of any kind was associated with about a 40% increase in risk for developing shingles compared to the risk in someone without cancer. Patients with hematological cancers had a more than 3-fold higher risk of developing shingles, while patients with solid tumor cancers had a 30% higher shingles risk.

“For hematological cancer, increases in zoster risk are apparent in the 2 years preceding diagnosis and treatment; for solid organ cancers, the increased risk appears to be largely associated with receipt of chemotherapy,” the study authors concluded. “Zoster vaccination now holds promise as a preventive strategy considered for cancer patients, particularly those expected to receive chemotherapy.”

A second study, conducted in the United States and published in 

 examined the risk of HZ and associated complications in several categories of immunocompromised adults, including those with cancer. Researchers of that study concluded that “HZ was common among all immunocompromised populations studied, exceeding the expected HZ incidence among immunocompetent adults aged ≥60 years.”

Protection against shingles is important for those with cancer—but not necessarily because shingles makes their cancer worse or prevents treatment, says Dale Shepard, MD, a medical oncologist at Cleveland Clinic.

“You’re looking at a population that likely has symptoms of their disease, and they may have symptoms of their treatments,” Shepard told 

®.“We don’t want people to have cancer, to have cancer treatments, to have those complications, and then deal with shingles as well.”

Shepard encourages his patients to include shingles vaccination as part of an overall immunization strategy. “We like to make sure that they’ve gotten a pneumonia vaccine if they’re eligible, we like to make sure they’ve had an influenza vaccine,” he said. “We make sure that the major health concerns are addressed, that they’ve covered the important health maintenance topics.”

The first line of defense against shingles for all at-risk individuals is vaccination with Shingrix, approved by the FDA in late 2017 for immunocompetent adults 50 years and older. It has been proven in clinical trials to be over 90% effective in preventing shingles.

The FDA recently expanded its approval of Shingrix to include immunocompromised adults 18 years and older based on clinical studies of the vaccine’s safety and efficacy in patients who had undergone an autologous hematopoietic stem cell transplant or treatment for hematological malignancies. Data on patients with solid tumors was also considered.

The CDC Advisory Committee on Immunization Practices has also recommended the use of Shingrix in adults 19 years and older who are or will be immunodeficient or immunosuppressed due to disease or therapy. The recommendation is under review by the director of the CDC and the U.S. Department of Health and Human Services.

Risk of herpes zoster in cancer patients and the promise of new vaccines.

. 2019;220(2):1-2. Doi:10.1093/infdis.jiy626

2. McKay SL, Guo A, Pergam SA, Dooling K. 

Herpes zoster risk in immunocompromised adults in the United States: A systematic review.

. 2020;71(17):e125-e134. Doi:10.1093/cid/ciz1090

Shingles vaccination can protect against infection and complications. 

Patients With Cancer at Greater Risk for Shingles

 its clinical considerations for the use of Shingrix (recombinant zoster vaccine; RZV) to help prevent shingles and related complications in immunocompromised adults aged 19 and older. The move follows the recent unanimous recommendation of the vaccine by the agency’s Advisory Committee on Immunization Practices (ACIP) for adults who are or who will be immunodeficient or immunosuppressed due to disease or therapy.

Shingles (herpes zoster; HZ) is caused by the varicella zoster virus (VZV), which initially causes chickenpox. The virus then remains inactive in the body until it reactivates decades later as shingles. It is estimated that virtually all Americans born before 1980 have had chickenpox and are consequently at risk for shingles.

 there are approximately 7 million immunocompromised adults in the United States, including 3 million stem cell transplant recipients, patients with hematologic or solid tumor malignancies, solid organ transplant recipients, and people living with HIV. Another 22 million Americans are living with autoimmune and/or inflammatory conditions like rheumatoid arthritis, systemic lupus erythematosus, and inflammatory bowel disease (IBD). All are at increased risk for developing shingles.

“Risk of herpes zoster (HZ), severe disease, and complications [is] generally higher in immunocompromised (IC) populations,” ACIP noted. “RZV can potentially address an unmet need for HZ prevention in IC populations.”

The CDC’s new clinical considerations for Shingrix and immunocompromised adults include:

Persons who are or will be immunodeficient or immunosuppressed and would benefit from completing the Shingrix 2-shot series in less than the recommended 2- to-6-month period may receive the second dose 1 to 2 months after the first. “A shorter interval between doses may facilitate avoiding vaccination during periods of more intense immunosuppression,” the CDC noted.

Patients should be vaccinated before becoming immunosuppressed. If this is not possible, vaccination should be timed for when the immune response is likely to be most robust. The general level of immune competence in a patient can be judged by a number of factors including disease severity and duration, clinical stability, complications and comorbidities, and any potentially immunosuppressing treatment.

Shingrix, like other recombinant and adjuvanted vaccines, can be administered at the same time as other vaccines, including the flu vaccine.

Evidence of immunity to varicella, which confirms the need for RZV, can be determined 3 ways: through documentation of 2 doses of chickenpox vaccine, or laboratory evidence of immunity or laboratory confirmation of the disease, or diagnosis/verification of a history of varicella or HZ by a healthcare provider.

Providers should counsel immunocompromised patients about expected local and system side effects of the vaccine prior to vaccination so they know what to expect.

The ACIP currently does not recommend RZV for use during pregnancy, so providers are advised to delay the vaccine until post pregnancy. “Recombinant vaccines such as RZV pose no known risk for mothers who are breastfeeding or their infants,” the CDC states. “Clinicians may consider vaccination without regard to breastfeeding status if RZV is otherwise indicated.”

History of severe allergic reaction to any component of the vaccine is a contraindication for vaccination. Moderate or severe acute illness with or without fever should delay vaccination until symptoms conclude. This includes a current episode of HZ.

Clinical considerations for use of recombinant zoster vaccine (RZV, Shingrix) in immunocompromised adults aged ≥19 years. CDC. Reviewed January 20, 2022. Accessed April 15, 2022.

Anderson T. Zoster vaccines session: Burden of herpes zoster in immunocompromised adults. National Center for Immunization & Respiratory Diseases. Division of Viral Diseases, Viral Vaccine Preventable Diseases Branch. June 25, 2021. Accessed April 15, 2022.

The CDC has updated recommendations for shingles vaccination.

Shingrix Guidelines for the Immunocompromised	

Physical activity has many proven benefits: it helps prevent or manage health issues, improves mood, boosts energy, enhances the body’s immune response, and promotes better sleep. But what about exercising during an illness like shingles; can it help? The answer is “yes,”—with some caveats.

Shingles, also known as herpes zoster (HZ), is an infection caused by the varicella zoster virus (VZV), which first causes chickenpox. The virus then lies dormant in the nervous system, usually for decades, before reactivating as shingles.

The primary symptom of the illness is a painful red blistering rash that can erupt just about anywhere on the body. Accompanying symptoms are fever, headache, tingling sensations on the skin, general fatigue, and sensitivity to light.

It can take up to 5 weeks for the rash to crust over and heal. Until it does, patients are advised to distance themselves from immunocompromised individuals, pregnant women, young children, and others who have not been vaccinated against or have had chickenpox so they do not become infected.

The physical symptoms and social isolation can add considerably to a shingles patient’s distress. Patients and their caregivers can take a number of simple steps to minimize discomfort and raise spirits. Light physical activity—including everyday pursuits and low-impact exercise—is one of them.

For patients who feel up to it, stress-reducing exercise is recommended. It’s important for them to assess their pain level on a scale of 0 to 10 before starting an activity, and to re-evaluate afterwards and back off if the pain level has increased. This is a time for gentle healing, not strenuous exercise.

 suggests simple activities such as stretching and walking. Bike riding is another good option. Tai chi, a traditional Chinese form of exercise involving controlled movement, reportedly not only increases immunity to VZV but is low-impact enough to be practiced during an outbreak.

 Yoga practitioners can continue their routine with modifications like avoiding poses that involve lying on areas of the body affected by the rash.

Those accustomed to intense cardiovascular workouts like long distance cycling or running that can irritate the rash and raise their body temperature should substitute less intense activities until the rash has scabbed over.

Wearing loose-fitting clothes made of natural fibers like cotton will allow for ventilation around the rash. Avoid physical activity that irritates the rash or results in a lot of sweating that could make it worse. Swimming, contact sports, and group exercise situations that could spread the virus should also be put on hold until after the rash heals.

As with all exercise, patients with shingles should listen to their body. If they feel worse after being active, it’s best to pull back and do something less taxing. Break up activity into manageable pieces. Three 10-minute sessions can be more beneficial than one 30-minute workout. And if those sessions can be done outside in fresh air, even better.

Balancing physical activity with adequate rest, healthy balanced meals, stress avoidance, and prescribed antibiotics will help the healing process go smoothly. To avoid a recurrence of shingles, get vaccinated. Shingrix (recombinant zoster vaccine) is the only HZ vaccine available. It is over 90% effective in preventing shingles in adults 50 years and older.

Shingles. National Institute on Aging. Reviewed October 12, 2021. Accessed April 15, 2022. 

https://www.nia.nih.gov/health/shingles#coping

Tai chi boosts immunity to shingles virus in older adults, NIH-sponsored study reports. News release. National Institutes of Health. April 6, 2007. Accessed April 15, 2022. 

https://www.nih.gov/news-events/news-releases/tai-chi-boosts-immunity-shingles-virus-older-adults-nih-sponsored-study-reports

What everyone should know about the shingles vaccine (Shingrix). CDC. Reviewed January 24, 2022. Accessed April 15, 2022. 

https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

Light exercise has both physical and emotional benefits

Staying Active During Shingles

 is now receiving more attention from medical researchers and health care providers alike. At least 2 studies have concluded that reactivation of the varicella zoster virus (

 based in Minnesota, involved more than 1600 adults 22 years and older with medically documented episodes of HZ. Of these patients, 95 had 105 recurrences of the infection, with a recurrence rate at 8 years of 6.2%.

Researchers found that recurrences were significantly more likely in persons with zoster-associated 

 lasting 30 days or more at the initial episode, in 

, and in those aged 50 or older. In some cases, recurrence occurred in as little as 3 months after the first outbreak. People with compromised immune systems were found to be about 2.4 times more likely to have a recurrence than immunocompetent individuals.

“Rates of HZ recurrence appear to be comparable to rates of first HZ occurrence in immunocompetent individuals, suggesting that recurrence is sufficiently common to warrant investigation of vaccine prevention in this group,” the researchers concluded.1 “Zoster vaccine is recommended for prevention of incident cases of HZ. Our high HZ recurrence rates suggest that zoster vaccination should be offered in people who have had an HZ episode to prevent potential recurrences.”

 conducted in Korea, concluded that HZ recurrence is much more common than generally expected, and that associated risk factors—including age and gender—can play an important role in predicting recurrence. The recurrence rate in patients over 50 years was 5.8%, compared with 4.5% in younger participants. Women had more frequent recurrence than men.

Vaccination is the first line of defense against shingles and its recurrence. In 2017, Shingrix was approved by the 

 to prevent shingles and related complications in adults aged 50 and older. More recently, the FDA 

 to include immunocompromised adults 18 and older. The CDC’s 

Advisory Committee on Immunization Practices

 followed suit, recommending Shingrix for adults 19 years and older who are or will be immunodeficient or immunosuppressed due to disease or therapy.

 was proven in clinical trials to be over 90% effective in preventing shingles and its complications. It is given as a 2-dose series administered over 2 to 6 months.

Virtually every person over the age of 50 in the United States carries the 

 that causes shingles, infected before there was an effective vaccine against it. As they age, their immune systems decline and become less resistant to the virus, increasing their risk of developing shingles. Shingrix works by boosting protection against the virus. It can be given before or after a shingles episode.

Yawn BP, Wollan PC, Kurland MJ, St Sauver JL, Saddier P. 

Herpes zoster recurrences more frequent than previously reported.

2011;86(2):88-93. Doi:10.4065/mcp.2010.0618

Recurrence rate of herpes zoster and its risk factors: A population-based cohort study.

2018;34(2):e1. Doi:10.3346/jkms.2019.34.e1

Learn who’s at risk and how vaccination can help.

Recurrent Shingles: More Common Than Once Thought

 (herpes zoster; HZ) by primary healthcare providers do very well when 

 with antivirals and analgesics for the blistering rash and accompanying pain. However, a consultation with a medical specialist may be necessary to help ensure the best outcome for some patients. This includes cases where 

 develop, or when the patient is compromised by 

“The main issue with shingles is in patients that are elderly and have more severe cases,” Lindsay C. Strowd, MD, FAAD, associate professor in the Department of Dermatology at Wake Forest School of Medicine told 

Other high-risk individuals include those receiving chemotherapy or other types of immunosuppressive medications that impair their ability to fight off infections. “They can get a more widespread rash that may not be confined to a local part of the skin,” explains Strowd. “They can get shingles that actually go into their bloodstream or into their cerebral spinal fluid and cause meningitis or other types of more serious infections. It’s one of the reasons that we want to diagnose it quickly and treat it quickly.”

 is 1 category of shingles that is more prone to complications. This includes herpes zoster ophthalmicus (

, which occurs when the varicella zoster virus that causes shingles reactivates in a facial nerve near the ear; and 

, which erupts in the mouth. All can cause serious permanent damage, including blindness, hearing loss, and facial paralysis. Patients are often referred to specialists for treatment, including ophthalmologists and oral facial pain specialists.

), a chronic pain syndrome that lasts weeks to months after an acute outbreak of shingles, is a serious complication that affects up to 20% of patients. Age and immunocompetence appear to be factors for developing PHN.

“In immunosuppressed individuals—for example, people who are on immunosuppressant drugs, people with HIV, people who have an underlying malignancy—shingles can be more severe, and the incidence of postherpetic neuralgia can have a higher frequency,” explains Justin C. McArthur, MBBS, MPH, professor and director of the Department of Neurology, the Johns Hopkins University School of Medicine and past-president of the American Neurological Association.

According to McArthur, prompt treatment of shingles seems to reduce the incidence of PHN and the risk of 

 the varicella zoster virus to susceptible individuals. Treatments include modifying anticonvulsants and narcotics, as well as interventional treatments like transcutaneous electrical nerve stimulation, onabotulinumtoxinA injections (Botox), acupuncture, and injections into the intercostal nerve.

“A primary healthcare provider would typically refer the patient to a pain treatment specialist, who might be a neurologist or anesthesiologist. Because these are interventional procedures, they’re usually done in a specialized pain treatment center,” McArthur said.

Both McArthur and Strowd recommend vaccination against shingles with 

, which is administered as a 2-dose series to adults 50 years and older. It can be given to individuals whether they’ve already had shingles or not.

“Even if you do happen to get it again, if you’ve been vaccinated it usually makes the disease course a lot milder and helps mitigate against some of the long-term complications,” Strowd concluded.

Some patients may benefit from specialized treatment.