Zoster prophylaxis after allogeneic hematopoietic cell transplantation using acyclovir/valacyclovir followed by vaccination

Abstract

Key Points• Two years of antiviral prophylaxis and VZV vaccination reduce the incidence of VZV disease and nearly eliminate post-herpetic neuralgia. Patients who completed the old strategy had a significantly higher cumulative incidence of VZV disease (33% vs 17% at 5 years, P # .01) and PHN (8% vs 0% at 5 years, P 5 .02). In conclusion, VZV prophylaxis with 2 years of acyclovir/valacyclovir followed by vaccination appears to result in a low incidence of VZV disease and may eliminate PHN.

Severe Herpes Zoster Requiring Intravenous Antiviral Treatment in Allogeneic Hematopoietic Cell Transplantation Recipients on Standard Acyclovir Prophylaxis

“…Extending ACV through month 24 in all patients is one method of enhancing pharmacologic prophylaxis; however, cases still occur even with ACV prophylaxis, and 3 times daily dosing limits compliance. HZ vaccination to enhance HZ-specific immune reconstitution has been used in the post-HCT setting [24,27]. The recombinant zoster vaccine was found to be safe and effective in autologous HCT recipients [28,29]; however, immune responses to vaccinations may differ in autologous HCT and allogeneic HCT, and timing, target population, and concomitant use of prophylactic ACV requires further study [30,31].…”

“…ACV prophylaxis is typically recommended for a minimum of 12 months following HCT based on established benefit in the postengraftment period [13,14,[20][21][22]. However, antiviral prophylaxis strategies vary among transplantation centers [12,13,[23][24][25], and increased rates of late VZV infection after cessation of ACV, termed the "rebound effect," have not been definitively shown [12,13,15].…”

Hematopoietic cell transplant outcomes after myeloablative conditioning with fludarabine, busulfan, low‐dose total body irradiation, and rabbit antithymocyte globulin

“…No antifungal prophylaxis was given initially; since 2010, fluconazole was given from day +1 until day +28. Acyclovir or valacyclovir for zoster prophylaxis was given initially until 6 to 12 months and since 2008 until 24 months, longer if GVHD 21 . Cytomegalovirus (CMV) disease prevention was with CMV safe blood products and CMV antigenemia/DNAemia monitoring with preemptive therapy using typically ganciclovir or valganciclovir 9 .…”

Vaccination of the Stem Cell Transplant Recipient and the Hematologic Malignancy Patient

“…Because of possible interference by neutralizing antibodies, patients should also be without receipt of IVIG within the preceding 8-11 months 6 . VZV-specific T-cell immunity does not adequately reconstitute in all situations following SCT 68 , so preventive strategies that include vaccination of individuals irrespective of serostatus are required 69 . A single retrospective study assessed the impact of Varivax administration at 24 months after allogenic SCT, in a majority of seropositive recipients, and after antiviral prophylaxis was discontinued 69 .…”

“…VZV-specific T-cell immunity does not adequately reconstitute in all situations following SCT 68 , so preventive strategies that include vaccination of individuals irrespective of serostatus are required 69 . A single retrospective study assessed the impact of Varivax administration at 24 months after allogenic SCT, in a majority of seropositive recipients, and after antiviral prophylaxis was discontinued 69 . At 5 years, the overall rate of zoster and PHN was significantly lower in the Varivax vs non-vaccinated group (zoster, 17% vs 33%; PHN, 0% vs 8%).…”