Risk of Herpes Zoster Ophthalmicus Recurrence After Recombinant Zoster Vaccination

Abstract

ImportanceThe recombinant zoster vaccine (RZV) is currently recommended for immunocompetent adults aged 50 years or older and immunocompromised adults aged 19 years or older and is effective in preventing herpes zoster ophthalmicus (HZO). However, questions about the safety of RZV in patients with a history of HZO remain.ObjectiveTo evaluate whether there is an increased risk of HZO recurrence after RZV in patients with a history of HZO.Design, Setting, and ParticipantsThis retrospective cohort study used medical and outpatient pharmacy claims data for commercial and Medicare Advantage enrollees from the Optum Labs Data Warehouse. Patients with incident HZO from January 1, 2010, to December 31, 2021, were identified; the study period ended on March 31, 2022. The vaccinated group consisted of patients with at least 1 dose of RZV more than 90 days following the initial HZO diagnosis. The unvaccinated group consisted of patients without any record of RZV in the study period. Vaccinated and unvaccinated patients were matched using exact k:1 matching without replacement.ExposureRecombinant zoster vaccination.Main Outcomes and MeasuresThe main outcome was the number of HZO recurrences with and without RZV exposure.ResultsA total of 16 408 patients were included in the matched analysis, of whom 12 762 were unvaccinated (7806 [61.2%] female; mean [SD] age at diagnosis, 68.8 [10.3] years) and 3646 were vaccinated (2268 [62.2%] female; mean [SD] age at diagnosis, 67.4 [9.8] years). Within the primary risk period of 56 days after the index date (ie, the start of follow-up for the outcome), the incidence of HZO recurrence after any RZV exposure was 37.7 per 1000 person-years compared with 26.2 per 1000 person-years in the unexposed group. After controlling for race and ethnicity, inpatient stays, emergency department visits, concomitant vaccines, and eye care practitioner visits, the association between vaccination status and HZO exacerbation in the primary risk period had an adjusted hazard ratio for any RZV exposure of 1.64 (95% CI, 1.01-2.67; P = .04).Conclusions and RelevanceIn this study, RZV exposure was associated with a higher likelihood of HZO recurrence in patients with a history of HZO compared with no RZV exposure. These findings support consideration that patients with a history of HZO may benefit from monitoring after receiving RZV in case of HZO recurrence.

Herpes Zoster Vaccine and Herpes Zoster Ophthalmicus Recurrence—Reply

“…In Reply We thank Shen and Chen for their comments on our article . We fully agree that there is strong evidence to support the benefits of the recombinant zoster vaccine in preventing herpes zoster and herpes zoster ophthalmicus (HZO), including large cohort studies from our group .…”

“…In addition, we adjusted for many additional potential confounders, including sex, race, and the use of immunosuppressive medications, which Shen and Chen mention as potential confounders. The full list of immunosuppressants are listed in eTable 6 in Supplement 1 of the article . We also adjusted for many other potential confounders, including Charlson Comorbidity Index score, which is an overall measure of health and health care utilization; antiviral use; COVID-19 infection; and receipt of other vaccines.…”

Herpes Zoster Ophthalmicus: Presentation, Complications, Treatment, and Prevention

“…There is concern that vaccination against HZ in individuals with a history of HZO may be associated with exacerbation or recurrence of HZO, with a few cases being reported following ZVL [ 109 , 110 ] and RZV [ 111 , 112 ] administration. A recent study reported an increased risk of exacerbation or recurrence in the 56-day period after vaccination with RZV (adjusted hazard ratio 1.64; 95% confidence interval 1.01–2.67; p = 0.04) [ 113 ]; there was no significant increase during the 28- or 42-day periods post vaccination [ 113 ]. The AAO notes that individuals with a history of HZO may be at risk of recurrent eye disease after vaccination and recommends that these individuals are examined by their ophthalmologist within several weeks before and after vaccination against HZ [ 108 ].…”

Herpes Zoster Vaccine and Herpes Zoster Ophthalmicus Recurrence

“…To the Editor We read with interest the article by Walia et al on the evaluation of whether patients with a history of herpes zoster ophthalmicus (HZO) have an increased risk of recurrence of HZO after receiving recombinant zoster vaccine (RZV). In their study, the authors found that exposure to RZV in patients with a history of HZO was associated with a higher likelihood of HZO recurrence in the eye compared with patients who were not exposed to RZV.…”