Immunogenicity and Safety of the HZ/su Adjuvanted Herpes Zoster Subunit Vaccine in Adults Previously Vaccinated With a Live Attenuated Herpes Zoster Vaccine

Recommendations and guidance for herpes zoster vaccination for adults in Taiwan

Herpes zoster (HZ) is a painful, vesicular, cutaneous eruption from reactivation of varicella zoster virus (VZV), which can lead to potentially debilitating complications. The lifetime risk of HZ is estimated to be 20%-30% in the general population, with an increased risk in the elderly and immunocompromised populations. The most effective strategy to prevent HZ and its complications is by vaccination. Two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, have been approved for use. This guidance offers recommendations and suggestions for HZ vaccination in adults, aiming to reduce the disease burden of HZ and its complications. It is intended as a guide to first-line healthcare providers, but does not supersede clinical judgement when assessing risk and providing recommendations to individuals. The Working Group on Adult Immunization Practice was appointed by the Infectious Diseases Society of Taiwan (IDST) and recommendations were drafted after a full literature review, using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. The recommendations were reviewed and revised by expert review panels during a series of consensus meetings and endorsed by the IDST, Taiwan Association of Family Medicine, the Taiwanese Dermatological Association, the Taiwan Oncology Society, the Taiwan Society of Blood and Marrow Transplantation, the Transplantation Society of Taiwan, the Taiwan AIDS Society, and the Taiwan College of Rheumatology. This guidance describes the epidemiology of HZ and provides recommendations for HZ vaccination in adults with varying levels of risk, differing history of previous VZV infection and past varicella or zoster vaccinations.

Recommendations for Adult Immunization by the Korean Society of Infectious Diseases, 2023: Minor Revisions to the 3rd Edition

The Korean Society of Infectious Diseases has been regularly developing guidelines for adult immunization since 2007. In 2023, the guidelines for the following seven vaccines were revised: influenza, herpes zoster, pneumococcal, tetanus-diphtheria-pertussis (Tdap), human papillomavirus (HPV), meningococcal, and rabies vaccines. For the influenza vaccine, a recommendation for enhanced vaccines for the elderly was added. For the herpes zoster vaccine, a recommendation for the recombinant zoster vaccine was added. For the pneumococcal vaccine, the current status of the 15-valent pneumococcal conjugate vaccine and 20-valent PCV was described. For the Tdap vaccine, the possibility of using Tdap instead of tetanus-diphtheria vaccine was described. For the HPV vaccine, the expansion of the eligible age for vaccination was described. For the meningococcal vaccine, a recommendation for the meningococcal B vaccine was added. For the rabies vaccine, the number of pre-exposure prophylaxis doses was changed. This manuscript documents the summary and rationale of the revisions for the seven vaccines. For the vaccines not mentioned in this manuscript, the recommendations in the 3rd edition of the Vaccinations for Adults textbook shall remain in effect.

Immunogenicity of Recombinant Zoster Vaccine: A Systematic Review, Meta-Analysis, and Meta-Regression

BACKGROUND

The adjuvanted recombinant zoster vaccine (RZV), consisting of varicella-zoster virus glycoprotein E (gE) and the AS01B adjuvant system, effectively prevents herpes zoster (HZ). In the absence of a well-defined correlate of protection, it is important to monitor the RZV immune response, as a proxy of clinical effectiveness.

METHODS

This systematic review examined post-vaccination parameters: humoral and cell-mediated immunity, avidity index, geometric mean concentration of antibody (GMC), and immunity persistence. The meta-analysis used a random-effects model, and subgroup and meta-regression analyses were conducted.

RESULTS

Among 37 included articles, after one month from RZV-dose 2, the pooled response rate for anti-gE humoral immunity was 95.2% (95%CI 91.9-97.2), dropping to 77.6% (95%CI 64.7-86.8) during immunosuppression. The anti-gE cell-mediated immunity-specific response reached 84.6% (95%CI 75.2-90.9). Varying factors, such as age, sex, coadministration with other vaccines, prior HZ, or live-attenuated zoster vaccine, did not significantly affect response rates. RZV induced a substantial increase in gE avidity. Immunity persistence was confirmed, with more rapid waning in the very elderly.

CONCLUSIONS

This systematic review indicates that RZV elicits robust immunogenicity and overcomes immunocompromising conditions. The findings underscore the need for further research, particularly on long-term immunity, and have the potential to support HZ vaccination policies and programs.

Adjuvant AS01 activates human monocytes for costimulation and systemic inflammation

BACKGROUND

The adjuvanted recombinant zoster vaccine (RZV) is highly effective even in adults over 80 years old. The high efficacy of RZV is attributed to its highly reactogenic adjuvant, AS01, but limited studies have been done on AS01's activation of human immune cells.

METHODS

We stimulated peripheral blood mononuclear cells (PBMC) with AS01 and used flow cytometry and RNA Sequencing (RNAseq) to analyze the impacts on human primary cells.

RESULTS

We found that incubation of PBMC with AS01 activated monocytes to a greater extent than any other cell population, including dendritic cells. Both classical and non-classical monocytes demonstrated this activation. RNASeq showed that TNF-ɑ and IL1R pathways were highly upregulated in response to AS01 exposure, even in older adults.

CONCLUSIONS

In a PBMC co-culture, AS01 strongly activates human monocytes to upregulate costimulation markers and induce cytokines that mediate systemic inflammation. Understanding AS01's impacts on human cells opens possibilities to further address the reduced vaccine response associated with aging.

Recombinant zoster vaccine in immunocompetent and immunocompromised adults: A review of clinical studies

Herpes zoster (HZ) is a debilitating vaccine-preventable disease. Impairment of cell-mediated immunity, as observed with aging and immunosuppressive disorders and therapies, increases risk. Recombinant zoster vaccine (RZV) is efficacious against HZ in adults aged ≥50 years in different settings, and in immunocompromised adults aged ≥18 years who are at increased risk of developing HZ. RZV is the first and only HZ vaccine approved for use in immunocompromised adults globally, including in Europe and the US. RZV has a clinically acceptable safety profile and elicits robust immune responses in adults aged ≥50 years, and in immunocompromised adults aged ≥18 years who are at increased risk of HZ. Additionally, RZV is efficacious against HZ complications such as post-herpetic neuralgia and HZ-related pain. This review updates knowledge from a randomized controlled trial setting on the efficacy, safety, immunogenicity, and impact on quality of life of RZV.

Carrier-free subunit nanovaccine amplifies immune responses against tumors and viral infections

Codelivering subunit antigens and Toll-like receptor (TLR) molecular adjuvants via nanocarriers can stimulate potent innate and specific immune responses. Simple and effective nanovaccines fabrication is crucial for application. However, most nanovaccines were fabricated by introducing additional delivery materials, increasing safety risk, cost and processing complexity. Herein, a carrier-free nanovaccine was facilely prepared using a TLR1/TLR2 adjuvant, Diprovocim, rich in benzene rings that could interact with aromatic residues in subunit antigens through π-π stacking without additional materials. The carrier-free nanovaccines with a narrow size distribution could target lymph nodes (LNs) after intravenous injection to mice. The carrier-free nanovaccines based on ovalbumin (OVA) can stimulate strong antibody titers and CD4⁺ and CD8⁺ T cell immune responses in mice, and it synergized with anti-PD1 showing a potent tumor suppression in B16F10-OVA tumor model of mice. Furthermore, the carrier-free nanovaccine with glycoprotein E (gE), a glycoprotein of the varicella-zoster virus (VZV), also showed potent humoral and cellular immune responses. Therefore, using subunit proteins to support Diprovocim by π-π stacking provides a new approach for the preparation and application of novel vaccines for tumor therapy and prevention of infectious diseases. STATEMENT OF SIGNIFICANCE: Codelivering subunit antigens and adjuvants via nanocarriers stimulate potent innate and specific immune responses. However, existing delivery materials for fabricating nanovaccines will inevitably increase the cost of preparation, controllability, process complexity and safety assessment. Therefore, this study easily prepared carrier-free nanovaccines using the benzene ring-rich TLR1/TLR2 adjuvant Diprovocim, which can interact with aromatic residues in subunit antigens via π-π stacking without additional materials. The carrier-free nanovaccines of OVA demonstrated a potent tumor inhibition in treating melanoma in combination with anti-PD1. And the nanovaccines of gE stimulated a strong antibody titer and cellular immune response for herpes zoster. Thus, the present study provides a new approach for the preparation of subunit vaccines to combat various cancers and virus infections.

Age-associated alterations in immune function and inflammation

Immunosenescence is a term used to describe the age-related changes in the immune system. Immunosenescence is associated with complex alterations and dysregulation of immune function and inflammatory processes. Age-related changes in innate immune responses including alterations in chemotactic, phagocytic, and natural killing functions, impaired antigen presenting capacity, and dysregulated inflammatory response have been described. The most striking and best characterized feature of immunosenescence is the decline in both number and function of T cells. With age there is decreased proliferation, decreased number of antigen-naïve T cells, and increased number of antigen-experienced memory T cells. This decline in naïve T cell population is associated with impaired immunity and reduced response to new or mutated pathogens. While the absolute number of peripheral B cells appears constant with age, changes in B cell functions including reduced antibody production and response and cell memory have been described. However, the main alteration in cell-mediated function that has been reported across all species with aging is those observed in in T cell. These T cell mediated changes have been shown to contribute to increased susceptibility to infection and cancer in older adults. In addition to functional and phenotype alterations in immune cells, studies demonstrate that circulating concentrations of inflammatory mediators in older adults are higher than those of young. This low grade, chronic inflammatory state that occurs in the context of aging has been termed "inflammaging". This review will focus on age-related changes in the immune system including immunosenescence and inflammation as well as the functional consequences of these age-related alterations for the aged.

Herpes Zoster and Vaccination Strategies in Inflammatory Bowel Diseases: A Practical Guide

Herpes zoster is a painful dermatomal cutaneous eruption resulting from reactivation of the latent varicella-zoster virus. Patients with inflammatory bowel diseases have an increased risk of shingles compared with the general population and this risk can be increased with the use of immunosuppressive therapy. Live zoster vaccine and recombinant zoster vaccine have shown efficacy for the prevention of herpes zoster. The recombinant zoster vaccine seems to offer greater efficacy and long-term protection profile compared with the life zoster vaccine. However, their use in clinical practice still is unclear and updated vaccination recommendations are lacking. This review discusses the risk for shingles in patients with inflammatory bowel diseases, available vaccines, and their efficacy and safety profiles. We also provide guidance on who, when, and how to vaccinate for herpes zoster in routine clinical practice among patients with inflammatory bowel diseases.

The Adjuvanted Recombinant Zoster Vaccine in Adults Aged ≥65 Years Previously Vaccinated With a Live-Attenuated Herpes Zoster Vaccine

BACKGROUND

Efficacy of the live-attenuated herpes zoster (HZ) vaccine (ZVL) wanes substantially over time. We evaluated immunogenicity and safety of the adjuvanted recombinant zoster vaccine (RZV) in previous ZVL recipients.

METHODS

Adults aged ≥65 years who were previously vaccinated with ZVL ≥5 years earlier (n = 215) were group-matched with ZVL-naive individuals (n = 215) and vaccinated with RZV. Glycoprotein E (gE)-specific humoral and cell-mediated immune responses and the correlation between them, polyfunctional gE-specific CD4 T-cell responses, safety, and confirmed HZ cases were assessed.

RESULTS

Through 12 months after dose 2, anti-gE antibody concentrations, gE-specific CD4 T-cell frequencies, and activation marker profiles were similar between groups. Safety outcomes were also similar. No HZ episodes were confirmed.

CONCLUSIONS

RZV induced strong humoral and polyfunctional cell-mediated immune responses that persisted above prevaccination levels through 1 year after dose 2 in adults aged ≥65 years irrespective of previous ZVL vaccination. The RZV safety profile was not affected.

CLINICAL TRIALS REGISTRATION

NCT02581410.

COVID-19 vaccine platforms: Delivering on a promise?

The emergence of the novel SARS-CoV-2 and COVID-19 has brought into sharp focus the need for a vaccine to prevent this disease. Vaccines have saved millions of lives since their introduction to the public over 200 years ago. The potential for vaccination reached new heights in the mid-20th century with the development of technologies that expanded the ability to create novel vaccines. Since then, there has been continued technological advancement in vaccine development. The resulting platforms provide the promise for solutions for many infectious diseases, including those that have been with us for decades as well as those just now emerging. Each vaccine platform represents a different technology with a unique set of advantages and challenges, especially when considering manufacturing. Therefore, it is essential to understand each platform as a separate product and process with its specific quality considerations. This review outlines the relevant platforms for developing a vaccine for SARS-CoV-2 and discusses the advantages and disadvantages of each.

A practitioner's guide to the recombinant zoster vaccine: review of national vaccination recommendations

Introduction: The adjuvanted recombinant zoster vaccine (RZV) is currently licensed in over 30 countries for the prevention of herpes zoster (HZ) in adults aged ≥50 years. We conducted a review of available national guidelines or recommendations on RZV use to identify the similarities and differences and highlight any potential gaps.Areas covered: National recommendations from ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the UK and the USA) are summarized under the following seven topics: HZ vaccine preference, age group recommendations, considerations prior to vaccination, dose schedule, co-administration with other vaccines, vaccination of special populations, and vaccine safety profile. In seven of these countries, RZV is the preferred or the only recommended HZ vaccine. There were some differences in age group recommendations, reflecting evaluations dependent on public funding. There were also differences with respect to use in immunocompromised and other special populations.Expert opinion: The high efficacy and anticipated public health impact of RZV led to expanded national recommendations for RZV vaccination compared to previous HZ recommendation in many countries. Possible areas that could be considered in future revisions of national recommendations, including use in immunocompromised adults ≥18 years, are also highlighted.PLAIN LANGUAGE SUMMARY:The varicella-zoster virus causes chickenpox, usually in childhood. After the chickenpox episode, the virus remains in the body in a latent state and can reactivate later in life, causing herpes zoster, or shingles. Adults over 50 years of age or those who have a weakened immune system are more vulnerable to developing herpes zoster. Herpes zoster appears as a painful localized skin rash. While live attenuated vaccines against herpes zoster have existed for many years, a recombinant vaccine against herpes zoster (RZV) has recently become available in several countries. Guidelines issued by national health authorities or vaccination committees provide healthcare professionals with information on practical aspects of vaccination. However, given the novelty of the RZV vaccine, we identified such guidelines in only ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the United Kingdom, and the United States of America). We summarized these national RZV recommendations, focusing on herpes zoster vaccine preference, the age at which RZV is recommended, considerations before vaccination, vaccination schedule, the possibility of administering RZV together with other vaccines, vaccinating vulnerable populations and the safety of RZV. While national recommendations varied, most guidelines indicate that RZV is the preferred herpes zoster vaccine due to its high and persistent efficacy and as it can be administered to vulnerable populations who are at increased risk of herpes zoster and its complications. Recommendations have noted that side effects are common with RZV, however, most are of mild-moderate intensity and temporary (see also Figure 1).

Corneal Allograft Rejection Associated With Herpes Zoster Recombinant Adjuvanted Vaccine

PURPOSE

The purpose of this article is to report 3 cases of corneal allograft rejection that occurred in temporal proximity to administration of the zoster subunit vaccine (RZV).

METHODS

Three cases of corneal transplant rejection that developed after RZV administration were identified. Clinical history, including existence of other risk factors, timing of rejection, corticosteroid therapy at the time of onset of rejection, and course were reviewed.

RESULTS

The onset of symptoms occurred 5 weeks after the first RZV dose in 1 patient and 1 and 6 weeks after the second dose in the other 2 patients. Coexisting risk factors included history of endothelial keratoplasty in the fellow eye in 1 patient and previous failure of a penetrating keratoplasty because of rejection in a second patient. The third patient had a history of 1 episode of rejection in a previous graft that resolved and then experienced graft failure over several years. In 2 patients, rejection developed despite relatively high levels of topical steroid therapy: prednisolone acetate 1%, 4 × per day in 1 patient and difluprednate 0.05%, 3 × per day in a second patient.

CONCLUSIONS

RZV, which elicits a more robust immune reaction than the zoster live-attenuated vaccine, ZVL, may increase the risk of allograft rejection in immunocompetent patients with preexisting corneal endothelial or penetrating transplants. Based on the available data, it may be reasonable to increase the topical corticosteroid regimen before the first dose, until approximately 3 months after the second dose of ZVL.

Safety and immunogenicity of adjuvanted recombinant subunit herpes zoster vaccine in lung transplant recipients

Lung transplant recipients are at high risk for herpes zoster and preventive measures are a significant unmet need. We investigated the safety and immunogenicity of two doses of a recombinant zoster vaccine (RZV) in lung transplant recipients (≥50 years). We enrolled 50 patients of which 49 received at least one vaccine dose. Anti-glycoprotein E (gE) antibody levels (n = 43) increased significantly compared to baseline (median optical density [OD] 1.96; interquartile range [IQR]: 1.17-2.89) after the first (median OD 3.41, IQR 2.54-3.81, p < .0001) and second vaccine dose (median OD 3.63, IQR 3.39-3.86, p < .0001). gE-specific polyfunctional CD4+ T cell frequencies (n = 38) also increased from baseline (median 85 per 10⁶ CD4+ T cells; IQR: 46-180) to the first (median 128 per 10⁶ CD4+ T cells; IQR: 82-353; p = .023) and after the second dose (median 361 per 10⁶ CD4+ T cells; IQR: 146-848; p < .0001). Tenderness (83.0%; 95%CI: 69.2-92.4%) and redness (31.9%; 95%CI: 19.1-47.1%) at injection site were common. One rejection episode within 3 weeks of vaccination was observed. This is the first study demonstrating that RZV was safe and elicited significant humoral and cell-mediated immunity in lung transplant recipients. RZV is a new option for the prevention of shingles in this population.

Vaccines for older adults

The proportion of the global population aged 65 and older is rapidly increasing. Infections in this age group, most recently with SARS-CoV-2, cause substantial morbidity and mortality. Major improvements have been made in vaccines for older people, either through the addition of novel adjuvants-as in the new recombinant zoster vaccine and an adjuvanted influenza vaccine-or by increasing antigen concentration, as in influenza vaccines. In this article we review improvements in immunization for the three most important vaccine preventable diseases of aging. The recombinant zoster vaccine has an efficacy of 90% that is minimally affected by the age of the person being vaccinated and persists for more than four years. Increasing antigen dose or inclusion of adjuvant has improved the immunogenicity of influenza vaccines in older adults, although the relative effectiveness of the enhanced influenza vaccines and the durability of the immune response are the focus of ongoing clinical trials. Conjugate and polysaccharide pneumococcal vaccines have similar efficacy against invasive pneumococcal disease and pneumococcal pneumonia caused by vaccine serotypes in older adults. Their relative value varies by setting, depending on the prevalence of vaccine serotypes, largely related to conjugate vaccine coverage in children. Improved efficacy will increase public confidence and uptake of these vaccines. Co-administration of these vaccines is feasible and important for maximal uptake in older people. Development of new vaccine platforms has accelerated following the arrival of SARS-CoV-2, and will likely result in new vaccines against other pathogens in the future.

Impact of a pharmacist-driven recombinant zoster vaccine administration program

OBJECTIVE

To determine whether a pharmacist-driven recombinant zoster vaccine (RZV) administration pilot program within a human immunodeficiency virus/infectious diseases clinic setting increased the completion of the 2-dose series when compared with standard care.

METHODS

In this retrospective cohort study, the patients enrolled in a pharmacist-driven RZV administration pilot program (intervention) were compared with those in provider-directed RZV education (standard care) for completion of the 2-dose vaccine series.

RESULTS

One hundred nineteen patients were included (standard care [n = 84], intervention intention to treat [ITT, n = 35], and intervention modified ITT [mITT, n = 23]). There was increased completion of the 2-dose vaccine series in the intervention cohort compared with the standard care cohort (ITT 66% and mITT 100% vs. 23%; P < 0.001).

CONCLUSION

The pharmacist-driven RZV administration program resulted in increased completion of the 2-dose series. However, the revenue generated did not justify the cost of a pharmacist salary for the allocated time commitment.

Immunogenicity generated by mRNA vaccine encoding VZV gE antigen is comparable to adjuvanted subunit vaccine and better than live attenuated vaccine in nonhuman primates

Shingles is a painful, blistering rash caused by reactivation of latent varicella-zoster virus (VZV) and most frequently occurs in elderly and immunocompromised individuals. Currently, two approved vaccines for the prevention of shingles are on the market, a live attenuated virus vaccine ZOSTAVAX® (Merck & Co., Inc., Kenilworth, NJ, USA) and an AS01_B adjuvanted subunit protein vaccine Shingrix™ (Glaxo Smith Kline, Rockville, MD, USA). Human clinical immunogenicity and vaccine efficacy data is available for these two benchmark vaccines, offering a unique opportunity for comparative analyses with novel vaccine platforms and animal model translatability studies. The studies presented here utilized non-human primates (NHP) to evaluate humoral and cellular immune response by three vaccine modalities: the new platform of lipid nanoparticle (LNP) formulated mRNA encoding VZV gE antigen (VZV gE mRNA/LNP) as compared with well-established platforms of live attenuated VZV (VZV LAV) and adjuvanted VZV gE subunit protein (VZV gE protein/adjuvant). The magnitude of response to vaccination with a single 100-200 μg mRNA dose or two 50 μg mRNA doses of VZV gE mRNA/LNP were comparable to two 50 μg protein doses of VZV gE protein/adjuvant, suggesting the VZV gE mRNA/LNP platform has the potential to elicit a robust immune response, and both modalities generated markedly higher responses than VZV LAV. Additionally, the slopes of decay for VZV-specific antibody titers were roughly similar across all three vaccines, indicating the magnitude of peak immunogenicity was the driving force in determining immune response longevity. Finally, vaccine-induced immunogenicity with VZV LAV and VZV gE protein/adjuvant in NHP closely resembled human clinical trials immune response data for ZOSTAVAX® and Shingrix™, helping to validate NHP as an appropriate preclinical model for evaluating these vaccines.

Recombinant zoster vaccine (Shingrix®): a new option for the prevention of herpes zoster and postherpetic neuralgia

Postherpetic neuralgia (PHN) is a challenging condition for pain management specialists. The prevention of herpes zoster (HZ) and subsequent PHN in individuals aged 50 years and older, via the development of new vaccines, is an ongoing research project. The live zoster vaccine (LZV, Zostavax^®) was the first proof of concept that vaccination could prevent HZ, but LZV cannot be used in various immune-compromised patients. This led to the development of a new non-live recombinant zoster vaccine (RZV, Shingrix^®). This RZV has shown promising results in many clinical trials, with high reactogenicity and similar systemic adverse effects compared to those of LZV. The National Advisory Committee on Immunization has recommended LZV as a standard vaccine for HZ prevention in adults ≥ 50 years of age, but no studies directly comparing the safety and efficacy of RZV and LZV vaccines have been conducted. This article reviews the brief history, efficacy, and safety of the two vaccines and discusses the advantage of RZV over LZV based on the available literature.

Which patients should receive the herpes zoster vaccine?

The recombinant adjuvanted zoster vaccine (RZV, trade name Shingrix) is preferentially recommended by the Advisory Committee on Immunization Practices to prevent herpes zoster and related complications in immunocompetent adults age 50 years and older. This article reviews efficacy and safety of the vaccine, its use in special populations, and how to prevent administration errors to answer the question "Which patients should receive the herpes zoster vaccine?"

Practical points for applying herpes zoster vaccine recommendations

The recombinant zoster vaccine (Shingrix) was approved to help combat the incidence of shingles in patients age 50 years and older and the CDC now recommends it over the zoster vaccine live (Zostavax). This article highlights practical considerations to help clinicians appropriately apply the most recent vaccine recommendations to their patients.

Herpes Zoster Ophthalmicus Review and Prevention

Varicella-zoster virus (VZV) is the etiologic agent of both chickenpox and Herpes zoster (HZ). In the United States, there are around one million cases of HZ per year. Ten percent of HZ cases are subtyped as herpes zoster ophthalmicus (HZO) specifically and involve the V1 distribution. Herpes zoster ophthalmicus is a significant cause of blindness in the United States. This article will provide a basic overview of VZV, HZ, and HZO with a focus on preventative measures in an effort to prevent blindness through improving clinician awareness and education. The differences in clinical effectiveness and duration of effectiveness of the live (Zostavax) and recombinant vaccines (Shingrix) are illustrated. There is now a trend toward using the recombinant vaccine as recommended by the Advisory Committee for Immunization Practices (ACIP) for healthy adults 50 or older.

Safety and immune response of a live-attenuated herpes zoster vaccine in patients with systemic lupus erythematosus: a randomised placebo-controlled trial

OBJECTIVES

To study the safety and immunogenicity of a live-attenuated herpes zoster (HZ) vaccine in patients with systemic lupus erythematosus (SLE).

METHODS

Adult SLE patients having a SLEDAI <6 and stable immunosuppressive treatment for ≥6 months were recruited. Participants were randomly assigned to receive HZ vaccine (Zostavax) or placebo injection. Anti-varicella zoster virus (VZV) IgG reactivity (baseline and week 6) was measured by an enzyme-linked fluorescence assay. Cell-mediated response was assessed by a VZV-stimulated interferon-gamma (IFN-γ) enzyme-linked ELISPOT assay. Adverse events and immune responses of the two groups were compared.

RESULTS

90 SLE patients were recruited (age 45.6±14.1 years; 93% women) and assigned to Zostavax or placebo (in 1:1 ratio). Baseline clinical parameters were similar between the two groups. The change in anti-VZV IgG from week 0 to 6 was +59.8% in the vaccine and -2.1% in the placebo group. Week 6 anti-VZV IgG was significantly higher in vaccinated than placebo-treated patients, after adjustment for baseline (4.16±1.26 vs 3.32±1.01; p<0.001). The number of IFN-γ secreting T-cell spots decreased in the placebo-treated patients (-17%) but increased in vaccinated patients (+42%). The T-cell spots number at week 6 was significantly higher in vaccine-than placebo-treated patients after adjustment for baseline (38.1±78.2 vs 23.1±47.9; p=0.02). Significantly more vaccinated patients reported self-limiting injection site reaction than controls (31% vs 7%; p<0.01). Two vaccinated patients (4.4%) and one (2.2%) placebo-treated patient had mild/moderate SLE flares but no patients developed HZ eruption within 6 weeks postvaccination.

CONCLUSIONS

In patients with stable SLE not receiving intensive immunosuppression, Zostavax was well-tolerated and provoked an immune response.

TRIAL REGISTRATION NUMBER

US ClinicalTrials.gov registry (NCT02477150).

Comparative Immune Responses to Licensed Herpes Zoster Vaccines

Background

Live attenuated (ZV) and recombinant adjuvanted (HZ/su) zoster vaccines differ with respect to efficacy, effect of age, and persistence of protection. We compared cell-mediated immunity (CMI responses to ZV and HZ/su.

Methods

This was a randomized, double-blind, placebo-controlled trial stratified by age (50-59 and 70-85 years) and by HZ vaccination status (received ZV ≥5 years before entry or not). Varicella zoster virus (VZV)- and glycoprotein E (gE)-specific CMI were analyzed by interleukin 2 (IL-2) and interferon gamma (IFN-γ) FluoroSpot and flow cytometry at study days 0, 30, 90, and 365.

Results

Responses to ZV peaked on day 30 and to HZ/su (administered in 2 doses separated by 60 days) peaked on day 90. Age and vaccination status did not affect peak responses, but higher baseline CMI correlated with higher peak responses. HZ/su generated significantly higher VZV-specific IL-2+ and gE-specific IL-2+, IFN-γ+, and IL-2+/IFN-γ+ peak and 1-year baseline-adjusted responses compared with ZV. VZV-specific IFN-γ+ and IL-2+/IFN-γ+ did not differ between vaccines. HZ/su generated higher memory and effector-memory CD4+ peak responses and ZV generated higher effector CD4+ responses .

Conclusions

The higher IL-2 and other memory responses generated by HZ/su compared with ZV may contribute to its superior efficacy.

Clinical Trials Registration

NCT02114333.

Herpes Zoster Vaccines

Background

Immunization for herpes zoster (HZ) aims to reverse the decline in cell-mediated immunity to varicella zoster virus that occurs with advancing age or immunocompromise. There are 2 vaccines available, one live attenuated (Zoster vaccine, live attenuated [ZVL]) and, recently, a recombinant subunit vaccine (HZ/su).

Methods

The literature relevant to the two HZ vaccines was reviewed.

Results

ZVL has overall efficacies of 51% and 65% against HZ and postherpetic neuralgia, respectively, with a prominent decline in efficacy with advancing age of the vaccinee. This compares to approximately 90% efficacy against HZ for HZ/su that is minimally affected with advancing age. The efficacy of ZVL against HZ declines over 4 and 8 years, compared with minimal decline so far over 4 years with HZ/su, and immunogenicity that is maintained for 9 years. Local and systemic reactogenicity to HZ/su is much greater than to ZVL.

Conclusions

HZ/su establishes an important principle-that a single recombinant viral protein with an effective adjuvant combination can stimulate immunogenicity superior to that of a live attenuated vaccine, and that this can diminish immunosenescence. This provides hope for improvement of other vaccines for aging patients. However, key questions remain unanswered, including the durability of the efficacy of HZ/su, its efficacy as a booster for previous recipients of ZVL, and its efficacy in immunocompromised patients.

Varicella zoster virus vaccines: an update

Varicella zoster virus (VZV) is the etiological agent of varicella, a highly infectious, self-limiting disease with serious complications. The decline in cell-mediated immunity (CMI) that occurs with aging or immunodepression causes a reactivation of the latent VZV as herpes zoster (HZ). Prevention of VZV through varicella vaccination strategies allows to avoid the primary infection in newborns and susceptible subjects. Available monovalent and combined VZV vaccines are effective, safe and generally well tolerated. Universal varicella vaccination has significantly impacted on incidence, complications and deaths related to this disease. Prevention of HZ through vaccination is a priority to avoid the significant burden of its incidence and complications. Currently two HZ vaccines are available. The recombinant zoster vaccine (RZV), approved by the FDA in 2017 and Zoster Vaccine Live (ZVL) licensed in the United States by the FDA in 2006. The advisory committee on immunization practices (ACIP) preferentially recommends RZV. ZVL remains an option for prevention of HZ in immunocompetent adults aged ≥60 years, although the CMI tends to wane a few years after vaccination.

Herpesvirus Infections of the Nervous System

PURPOSE OF REVIEW

This article reviews the spectrum of neurologic disease associated with human herpesvirus infections.

RECENT FINDINGS

As more patients are becoming therapeutically immunosuppressed, human herpesvirus infections are increasingly common. Historically, infections with human herpesviruses were described as temporal lobe encephalitis caused by herpes simplex virus type 1 or type 2. More recently, however, additional pathogens, such as varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 have been identified to cause serious neurologic infections. As literature emerges, clinical presentations of herpesvirus infections have taken on many new forms, becoming heterogeneous and involving nearly every location along the neuraxis. Advanced diagnostic methods are now available for each specific pathogen in the herpesvirus family. As data emerge on viral resistance to conventional therapies, newer antiviral medications must be considered.

SUMMARY

Infections from the herpesvirus family can have devastating neurologic outcomes without prompt and appropriate treatment. Clinical recognition of symptoms and appropriate advanced testing are necessary to correctly identify the infectious etiology. Knowledge of secondary neurologic complications of disease is equally important to prevent additional morbidity and mortality. This article discusses infections of the central and peripheral nervous systems caused by herpes simplex virus type 1 and type 2, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6. The pathophysiology, epidemiology, clinical presentations of disease, diagnostic investigations, imaging characteristics, and treatment for each infectious etiology are discussed in detail.

Shingrix: A New Herpes Zoster Vaccine

Shingrix, a new vaccine for herpes zoster.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in older adults in the United States who have been previously vaccinated with zoster vaccine live

Zoster Vaccine Live (ZVL) is marketed in the US since 2008, and a non-live adjuvanted Recombinant Zoster Vaccine (RZV) was approved in 2017. Literature suggests that waning of ZVL efficacy may necessitate additional vaccination. The Advisory Committee on Immunization Practices recommended vaccination with RZV in immunocompetent adults aged 50+ years old, including those previously vaccinated with ZVL. The objective of this study was to determine the cost-effectiveness of vaccinating US adults aged 60+ years old, previously vaccinated with ZVL. The ZOster ecoNomic Analysis (ZONA) model, a deterministic Markov model, was adapted to follow a hypothetical 1 million(M)-person cohort of US adults previously vaccinated with ZVL. Model inputs included demographics, epidemiology, vaccine characteristics, utilities and costs. Costs and quality-adjusted life-years (QALYs) were presented over the lifetimes of the cohort from the year of additional vaccination, discounted 3% annually. The model estimated that, vaccination with RZV 5 years after previous vaccination with ZVL, would reduce disease burden compared with no additional vaccination, resulting in a gain of 1,633 QALYs at a total societal cost of $96M (incremental cost-effectiveness ratio: $58,793/QALY saved). Compared with revaccinating with ZVL, vaccination with RZV would result in a gain of 1,187 QALYs and societal cost savings of almost $84M. Sensitivity, scenario, and threshold analyses demonstrated robustness of these findings. Vaccination with RZV is predicted to be cost-effective relative to no additional vaccination, assuming a threshold of $100,000/QALY, and cost-saving relative to ZVL revaccination of US adults aged 60+ years old who have been previously vaccinated with ZVL.

Emerging Topics in Vaccine Therapeutics for Adolescents and Adults: An Update for Immunizing Pharmacists

Vaccine therapeutics and the practice of immunization provision are ever-changing. As pharmacy-based immunization services continue to flourish in the United States, more and more patients are requesting both routine and travel vaccines in community pharmacies. However, vaccine recommendations from the Centers for Disease Control and Prevention/Advisory Committee on Immunization Practices (CDC/ACIP) can sometimes differ from product-specific US Food and Drug Administration (FDA)-indicated uses. In addition, changes in vaccine schedules, product availability, and disease outbreaks can present immunizing pharmacists with scenarios requiring a high level of clinical judgment. Thus, it is of paramount importance that all immunizing pharmacists maintain competency in the most recent evidence in vaccine therapeutics, as well as practice standards for vaccine provision and administration. This review provides an update of the most recent literature surrounding emerging topics in adolescent and adult immunizations—highlighting influential studies and recent developments in the prevention of herpes zoster, human papillomavirus (HPV), measles, mumps, rubella (MMR), meningococcal disease, tetanus, diphtheria, and pertussis. Key concepts discussed include the emergence of the new recombinant zoster vaccine (RZV), meningococcal vaccine product selection, MMR revaccination during disease outbreaks, tetanus vaccine product selection, and duration of pertussis immunity with vaccination.

Th1 memory differentiates recombinant from live herpes zoster vaccines

The adjuvanted varicella-zoster virus (VZV) glycoprotein E (gE) subunit herpes zoster vaccine (HZ/su) confers higher protection against HZ than the live attenuated zoster vaccine (ZV). To understand the immunologic basis for the different efficacies of the vaccines, we compared immune responses to the vaccines in adults 50 to 85 years old. gE-specific T cells were very low/undetectable before vaccination when analyzed by FluoroSpot and flow cytometry. Both ZV and HZ/su increased gE-specific responses, but at peak memory response (PMR) after vaccination (30 days after ZV or after the second dose of HZ/su), gE-specific CD4+ and CD8+ T cell responses were 10-fold or more higher in HZ/su compared with ZV recipients. Comparing the vaccines, T cell memory responses, including gE-IL-2+ and VZV-IL-2+ spot-forming cells (SFCs), were higher in HZ/su recipients and cytotoxic and effector responses were lower. At 1 year after vaccination, all gE-Th1 and VZV-IL-2+ SFCs remained higher in HZ/su compared with ZV recipients. Mediation analyses showed that IL-2+ PMR were necessary for the persistence of Th1 responses to either vaccine and VZV-IL-2+ PMR explained 73% of the total effect of HZ/su on persistence. This emphasizes the biological importance of the memory responses, which were clearly superior in HZ/su compared with ZV participants.

A novel nonlive, adjuvanted herpes zoster subunit vaccine: a report on the emerging clinical data and safety profile

Herpes zoster (HZ) is an acute vesicular dermatitis with a typical dermatomal distribution, caused by the varicella zoster virus (VZV), often preceded and accompanied by prodromal pain or pruritus. HZ may be related to several complications such as postherpetic neuralgia (PHN). The incidence and severity of the disease increase with aging, due to immunosenescence and in particular to the decline of the specific cell-mediated immunity (CMI). The impact of HZ in terms of morbidity and short- and long-term complications, the availability of suboptimal treatment options to date, and the high costs for the diagnostic and clinical-therapeutic management of patients have motivated the search for a new preventive approach through the development of a vaccine. The vaccine currently in use with live-attenuated virus (ZVL) has been shown to be effective in reducing the incidence of HZ, its impact, and the onset of PHN, although the efficacy is lower in older subjects and tends to decrease some years after immunization. A new adjuvanted recombinant subunit vaccine (HZ/su), containing the VZV glycoprotein E (gE) and the AS01B adjuvant system, is now a very promising alternative to ZVL; in several clinical studies, it showed a good safety profile and was able to elicit high immune humoral and cell-mediated responses, both maintained up to 9 years. Furthermore, HZ/su vaccine was effective both in preventing HZ and in reducing the onset of PHN and other complications. HZ/su has been recommended and preferred over ZVL by the Advisory Committee on Immunization Practices (ACIP) for the prevention of HZ and its complications in immunocompetent adults aged ≥50 years, even if already vaccinated with ZVL, through a two-dose schedule. HZ/su has been approved in Canada, USA, Europe, and Japan and is currently being approved in Australia. The aim of this review was to describe the epidemiological data, HZ and PHN risks and their impact on the social life and common life of infected people, and ZVL and HZ/su vaccine development including various clinical trials and efficacy, safety, and tolerability profiles.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2017

Clinicians are challenged to identify new practice-changing articles in the medical literature. To identify the practice-changing articles published in 2017 most relevant to outpatient general internal medicine, 5 internists reviewed the following sources: 1) titles and abstracts from internal medicine journals with the 7 highest impact factors, including New England Journal of Medicine, Lancet, Journal of the American Medical Association, British Medical Journal, Public Library of Science Medicine, Annals of Internal Medicine, and JAMA Internal Medicine; 2) synopses and syntheses of individual studies, including collections in the American College of Physicians Journal Club, Journal Watch, and Evidence-Based Medicine; 3) databases of synthesis, including Evidence Updates and the Cochrane Library. Inclusion criteria were perceived clinical relevance to outpatient general medicine, potential for practice change, and strength of evidence. This process yielded 140 articles. Clusters of important articles around one topic were considered as a single-candidate series. A modified Delphi method was utilized by the 5 authors to reach consensus on 7 topics to highlight and appraise from the 2017 literature.

Development of adjuvanted recombinant zoster vaccine and its implications for shingles prevention

INTRODUCTION

GSK has developed a two-dose adjuvanted recombinant zoster vaccine (Shingrix, RZV) to protect people aged ≥50 years (50+) against herpes zoster (HZ) and its complications. RZV showed >90% efficacy against HZ, sustained over 4 years of follow-up, in all studied age groups.

AREAS COVERED

This article reviews the scientific rationale underlying the design of RZV; the clinical evidence demonstrating immunogenicity, safety, and efficacy in persons 50+; and the public health implications and cost-effectiveness.

EXPERT COMMENTARY

A decline in varicella zoster virus (VZV) immunity is associated with increased risk of HZ in adults 50+ and immunocompromised individuals. RZV was designed to restore levels of anti-VZV cellular and humoral immunity to prevent VZV reactivation. RZV includes the recombinant gE glycoprotein antigen, and Adjuvant System AS01_B which promotes cellular and antibody responses. In two Phase III studies in subjects aged 50+ and 70+ years, RZV efficacy against HZ compared to placebo was >90% and ≥89% against post-herpetic neuralgia (PHN). RZV is expected to dramatically impact HZ morbidity including its complications, and associated health-care costs. In the US population aged 50+ years, vaccination with RZV can be cost-effective compared to no vaccination and cost-saving compared to the currently available live-attenuated HZ vaccine (Zostavax, Merck).

Herpes Zoster and Diabetes Mellitus: A Review

Accumulating evidence suggests that diabetes mellitus (DM) represents an important risk factor for both herpes zoster and post-herpetic neuralgia. Moreover, post-herpetic neuralgia appears to be more severe and persistent in diabetic patients. On the other hand, a novel vaccine against varicella-zoster virus (VZV) was recently introduced in clinical practice. Given the increased risk and severity of herpes zoster infection in patients with DM, this vaccine might be useful in this population. However, there are limited data regarding the efficacy and safety of vaccination against herpes zoster in the diabetic population. The aim of the present review is to discuss the incidence and consequences of herpes zoster infection in DM and to comment on the role of vaccination against VZV in these patients.

Shingrix: The New Adjuvanted Recombinant Herpes Zoster Vaccine

OBJECTIVES

To review the immunogenicity, efficacy, and safety of the herpes zoster subunit vaccine (HZ/su) for use in adult patients for the prevention of shingles.

DATA SOURCES

A literature search through PubMed was conducted (June 2008 to October 2017) using the terms shingles vaccine and varicella zoster virus. References from retrieved articles and the prescribing information were also reviewed for any additional material.

STUDY SELECTION/DATA EXTRACTION

The literature search was limited to human studies published in English. Randomized controlled, multicenter trials were reviewed and included to evaluate the safety and efficacy of HZ/su. Literature on the epidemiology and pathology of herpes zoster virus infections and recommendations from the Advisory Committee on Immunization Practices (ACIP) were also reviewed.

DATA SYNTHESIS

HZ/su is a new adjuvanted recombinant vaccine approved by the Food and Drug Administration for the prevention of herpes zoster in adults 50 years of age and older. HZ/su significantly reduced the risk of developing herpes zoster by more than 90% as compared with placebo and displayed a comparable adverse effect profile. The most common local adverse events were injection site pain, redness, and swelling, and the most common systemic adverse events were myalgia, fatigue, and headache. The ACIP recommends the routine use of HZ/su as the preferred vaccine for the prevention of herpes zoster in immunocompetent adults 50 years of age and older.

CONCLUSIONS

Based on published immunogenicity, efficacy, and safety data, as well as the recent recommendations by the ACIP, HZ/su should be included on both hospital and community pharmacy formularies and recommended to all immunocompetent patients older than 50 years to prevent herpes zoster.