Yes, patients who previously received Zostavax should be updated with Shingrix
Patients who have received Zostavax (ZVL) should receive a 2-dose series of Shingrix (RZV), regardless of how long ago they received Zostavax. This recommendation is based on superior efficacy, longer-lasting protection, and robust immunogenicity data supporting revaccination.
Timing of Shingrix After Zostavax
The optimal timing depends on when Zostavax was given:
- If Zostavax was given >5 years ago: Strongly recommend Shingrix (strong recommendation, moderate evidence) 1
- If Zostavax was given <5 years ago: Still recommend Shingrix, though the recommendation is slightly weaker (weak recommendation, moderate evidence) 1
- Minimum interval: Wait at least 8 weeks (2 months) between Zostavax and the first Shingrix dose 2, 1
The 2020 U.S. Adult Immunization Schedule explicitly states to administer RZV "regardless of previous herpes zoster or history of ZVL vaccination (administer RZV at least 2 months after ZVL)" 2.
Why Shingrix is Superior
Efficacy Advantage
Zostavax efficacy wanes dramatically over time:
- Year 1: 62% efficacy
- Year 2: drops below 50%
- Year 10: only 14.1% efficacy 1
In contrast, adding Shingrix after Zostavax provides:
- 75.5% vaccine effectiveness against herpes zoster in adults ≥50 years who received Zostavax within 5 years 1
- Reduction in herpes zoster incidence from 7.54 to 2.39 per 1,000 person-years 1
Immunogenicity Data
The FDA label provides definitive evidence: In subjects aged ≥65 years previously vaccinated with Zostavax >5 years prior, Shingrix induced anti-gE antibody responses that were non-inferior to those never vaccinated with Zostavax (95% CI upper limit 1.17, success criterion <1.5) 3. There was no interference in immune response from prior Zostavax vaccination.
Practical Implementation
Complete the 2-dose Shingrix series:
- Dose 1: At least 8 weeks after Zostavax
- Dose 2: 2-6 months after dose 1 (minimum 4 weeks if given too soon, repeat the dose) 2
Common pitfall to avoid: Don't assume prior Zostavax provides adequate long-term protection. The waning efficacy means patients remain at significant risk for herpes zoster and postherpetic neuralgia without Shingrix revaccination.
Safety Profile
Revaccination with Shingrix after Zostavax was well-tolerated with comparable reactogenicity to those never vaccinated with Zostavax 1. While Shingrix is more reactogenic than Zostavax (41.9% vs 8.7% reporting any adverse events), most reactions are mild, transient, and only 0.6% require medical attention 4.
The most common reactions are injection-site pain, myalgia, and fatigue—all typically mild to moderate and self-limited 5.
Special Populations
Immunocompromised patients: Shingrix (not Zostavax) is the only option, as it's a non-live vaccine. This is particularly important for patients on immunosuppressive therapy, with HIV, or post-transplant 2, 1.
Pregnancy: Consider delaying Shingrix until after pregnancy, though it's not contraindicated like Zostavax 2.
This recommendation prioritizes preventing the significant morbidity of herpes zoster and postherpetic neuralgia, which directly impact quality of life, particularly in older adults where pain can be debilitating and long-lasting.