[CIS PIDD] [cis-pidd] Zoster vaccine in CVID

Wed Jan 27 17:55:20 EST 2016

If I did not have VZV-specific LPA available, I would have given her a boost.  I don't think this test is generally available.  JC

From: CIS-PIDD [mailto:cis-pidd at lists.clinimmsoc.org]
Sent: Wednesday, January 27, 2016 12:58 PM
To: CIS-PIDD
Subject: RE:[cis-pidd] Zoster vaccine in CVID

Understood Joe

My point on the person having Ab to H. zoster was simply that the person had clearly been infected in the past, had residual wild virus.... I was thus concerned about the recurrence - zoster/shingles and not primary infection.  Since the person in my scenario has internal wild type virus that is currently controlled, why not give a boost with vaccine?

I think the point about measuring the VZV proliferative response is a good one. How available is this and the cost???

Andy Saxon, UCLA

From: CIS-PIDD [mailto:cis-pidd at lists.clinimmsoc.org]
Sent: Wednesday, January 27, 2016 12:39 PM
To: CIS-PIDD
Subject: RE:[cis-pidd] Zoster vaccine in CVID

Andy:

Antibody alone probably is not enough to protect patients from primary VZV infection; I think this also requires a specific T-cell response.  For example VariZig is only about 40% effective in preventing any varicella outbreak although it is better at preventing 'severe' chicken pox.  Also, we published years ago a letter describing 3 immunodeficient patients who developed chicken pox while receiving IVIG.

I recently had one of my CVID adults ask about receiving the 'adult' Zoster vaccine.  She had a past history of Zoster.  I measured her VZV-specific lymphoproliferative response which was excellent, and I decided not to give her an additional challenge.

On the other hand, if I have a younger patient who is on IVIG for CVID (and no evidence of T-cell deficiency) and has never received a VZV vaccine I would consider giving it.  My reasoning is

1.     Wild-type VZV is still prevalent and I would rather the patient be exposed to the attenuated VZV in the vaccine than catch wild-type VZV.

2.    Should the child develop chicken pox I have excellent meds to treat him/her with - valacyclovir, famciclovir.

Joe Church

From: CIS-PIDD [mailto:cis-pidd at lists.clinimmsoc.org]
Sent: Wednesday, January 27, 2016 11:36 AM
To: CIS-PIDD
Subject: [cis-pidd] Zoster vaccine in CVID

So what do you think about giving the live Zoster vaccine to a "standard" CVID adult (low but + ab titre to H. zoster) as the person already harbors the natural wild type virus. This is different than giving it to a CVID child/youngster who has never had infection with H. zoster.

Yes, I know the package insert says

"Immunosuppression ZOSTAVAX is a live, attenuated varicella-zoster vaccine and administration may result in disseminated disease in individuals who are immunosuppressed or immunodeficient. Do not administer ZOSTAVAX to immunosuppressed or immunodeficient individuals including those with a history of primary or acquired immunodeficiency states, leukemia, lymphoma or other malignant neoplasms affecting the bone marrow or lymphatic system, AIDS or other clinical manifestations of infection with human immunodeficiency viruses, and those on immunosuppressive therapy" SOURCE: ZOSTAVAX PACKAGE INSERT

Andy Saxon, MD, Clinical Immunology/Allergy, UCLA

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