What is the optimal timing for Zoster vaccine administration for a patient who recently recovered from herpes zoster infection and is now planning to start B-cell depletion therapy?

This is a complicated question that must balance two competing factors.

First, in general, most experts counsel waiting, approximately one year after zoster before vaccination in attempt to take advantage of endogenously boosted immunity and a low rate of recurrence within 12 months. On the other hand this patient will start rituximab which is known to have profound effects on vaccine response particularly humoral. We can only assume that this will diminish response to rVZV.

Unfortunately, our knowledge of this is incomplete, and while we have many biomarkers that can be measured - we have no highly correlated biomarker for protection in response to the rVZV vaccine representing a gap in our knowledge, regarding the mechanism of protection ...