Herpes zoster vaccination in inflammatory bowel disease: Evidence, guidelines, and reality

Table 5 Differences between live attenuated zoster vaccine and recombinant zoster vaccine

Aspect	LZV (e.g., Zostavax)	RZV (e.g., Shingrix)	Ref.
Composition	Weakened live varicella-zoster virus (Oka/Merck strain) at high titer	Recombinant glycoprotein E antigen + AS01B adjuvant (MPL and QS-21)	[14,15,34,35]
Mechanism	Stimulates immunity via replication of attenuated virus	Boosts humoral and cell-mediated immunity without viral replication	[14,15,34]
Administration	Single subcutaneous injection	Two intramuscular injections, 2-6 months apart	[14,34,37]
Efficacy in general population	Approximately 51% against HZ in ≥ 60 years; approximately 67% against PHN; wanes to 20%-30% after 8-10 years	97% against HZ in ≥ 50 years; 91% in ≥ 70 years; > 90% against PHN; sustained for 7-10+ years	[15,34,35]
Efficacy in IBD/immunocompromised	Limited data; not recommended due to risks; approximately 50%-60% in non-IS but inferior long-term	65%-90% against HZ; 68%-90% in broader IS groups; reduces complications like PHN by 75%-89%	[35,37-39]
Safety	Generally safe in immunocompetent; mild local reactions common	Mild-moderate reactogenicity (pain, fatigue); no increased IBD flares (RR = 0.80)	[34,37,40]
Safety in immunosuppressed	Contraindicated; risk of dissemination and vaccine-strain infection	Safe; robust immunogenicity even on anti-TNF or vedolizumab; no flare risk	[14,15,34,35,40]
Contraindications	Immunosuppression (e.g., high-dose steroids, biologics, JAKi); pregnancy; history of anaphylaxis to gelatin/neomycin	History of anaphylaxis to components; acute febrile illness (delay until resolved)	[14,15,34,41]
Availability/preference	Phasing out; still used in some low-resource settings for immunocompetent	Preferred globally; widely available in United States/Europe; private/costly in India/Asia	[14,15,34,36]

IBD: Inflammatory bowel disease; HZ: Herpes zoster; PHN: Post-herpetic neuralgia; IS: Immunosuppressed; LZV: Live attenuated zoster vaccine; JAKi: Janus kinase inhabits; RZV: Recombinant zoster vaccine; AS01B: Adjuvant system 01B; MPL: 3-O-desacyl-4’-monophosphoryl lipid A; QS-21: Quillaja saponaria Molina fraction 21; RR: Relative risk; TNF: Tumor necrosis factor.