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The use, safety, and effectiveness of herpes zoster vaccination in individuals with inflammatory and autoimmune diseases: a longitudinal observational study

Jie Zhang1, Elizabeth Delzell1, Fenglong Xie2, John W Baddley3, Claire Spettell4, Raechele M Mcmahan5, Joaquim Fernandes4, Lang Chen2, Kevin Winthrop6 and Jeffrey R Curtis12*

Author affiliations

1 Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1665 University Blvd, Birmingham, AL 35294, USA

2 Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, 510 20th Street South, Birmingham, AL 35294, USA

3 Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham and Birmingham Veteran Affairs Medical Center, 1900 University Blvd., Birmingham, AL 35294, USA

4 Aetna Informatics, Aetna, 980 Jolly Road, Blue Bell, PA 19422, USA

5 Aetna Specialty Pharmacy, 503 Sunport Lane, Orlando, FL 32809, USA

6 Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, 3181 SW Sam Jackson Park Road L457, Portland, OR 97239, USA

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Citation and License

Arthritis Research & Therapy 2011, 13:R174  doi:10.1186/ar3497

Published: 24 October 2011



Zostavax, a live attenuated vaccine, has been approved in the United States for use in older individuals to reduce the risk and severity of herpes zoster (HZ), also known as shingles. The vaccine is contraindicated in individuals taking anti-tumor necrosis factor alpha (anti-TNF) therapies or other biologics commonly used to treat autoimmune diseases because of the safety concern that zoster vaccine may be associated with a short-term HZ risk. The objective of the study was to examine the use, safety (short-term HZ risk after vaccination), and effectiveness of zoster vaccine in individuals with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, and/or inflammatory bowel diseases.


We conducted a cohort study of patients aged 50 years and older with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, and/or inflammatory bowel diseases by using administrative claims data from a nationwide health plan from January 1, 2005, to August 31, 2009. We examined the extent to which zoster vaccine was used; assessed factors associated with vaccine use (Cox proportional hazards regression); and compared the incidence rates of herpes zoster (HZ) between vaccinated and unvaccinated patients.


Among 44,115 patients with the autoimmune diseases, 551 (1.2%) received zoster vaccine, and 761 developed HZ. Zoster vaccine use increased continuously after approval in 2006. Younger and healthier patients, those who had an HZ infection within the past 6 months, and those who were not using anti-TNF therapies were more likely to receive the vaccine. Approximately 6% of vaccinated patients were using anti-TNF therapies at the time of vaccination. The incidence rates of HZ were similar in vaccinated and unvaccinated patients (standardized incidence ratio, 0.99; 95% confidence interval, 0.29 to 3.43).


Use of the zoster vaccine was uncommon among older patients with autoimmune diseases, including those not exposed to immunosuppressive medications. The short-term risk of HZ did not appear to be increased in vaccinated patients, even among those using immunosuppressive therapies (for example, biologics) at the time of vaccination. However, our study was limited by the small number of vaccinated patients, and further evidence is needed to confirm the vaccine's safety and efficacy in this population.