What is the recommended age for the shingles vaccine?

Recommended Age for Shingles Vaccination

Shingles vaccination is strongly recommended for all immunocompetent adults aged 50 years and older, with a preference for the recombinant zoster vaccine (RZV, Shingrix) over the live attenuated zoster vaccine (ZVL, Zostavax). 1

Vaccine Options and Efficacy

Recombinant Zoster Vaccine (RZV, Shingrix)

• Approved for adults aged 50 years and older
• Administered as two doses, 2-6 months apart
• Significantly higher efficacy compared to ZVL:
  • 97.2% efficacy in adults 50 years and older 1
  • 91.3% against herpes zoster in adults 70+ years 1
  • 88.8% against postherpetic neuralgia (PHN) in adults 70+ years 1
• Protection remains above 83.3% for up to 8 years, decreasing to 73% at 10 years 1
• Can be used in immunocompromised individuals (unlike the live vaccine) 1

Live Attenuated Zoster Vaccine (ZVL, Zostavax)

• Previously approved for adults 50-79 years
• Single dose administration
• Lower efficacy that decreases with age:
  • 70% in adults 50-59 years
  • 64% in adults 60-69 years
  • 41% in adults 70-79 years
  • 18% in adults 80+ years 1
• Protection wanes from 51.3% to 21.2% for herpes zoster incidence over 7-11 years 1
• Contraindicated in immunocompromised individuals as it contains live virus 1

Official Recommendations

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices recommends:

1. RZV for prevention of herpes zoster and related complications in immunocompetent adults aged 50 years or older 1
2. RZV for adults who previously received ZVL 1
3. RZV is preferred over ZVL for prevention of herpes zoster and related complications 1

While the older ZVL vaccine was initially recommended for adults aged 60 years and older 1, current guidelines have shifted to recommend vaccination starting at age 50 with the more effective RZV vaccine 1.

Special Considerations

Immunocompromised Patients

• Live zoster vaccine (ZVL) is contraindicated in significantly immunocompromised patients 1
• RZV (non-live vaccine) is suggested for immunocompromised adults, including those with solid cancers 1
• For patients on low-level immunosuppression (defined as prednisolone ≤20 mg/day for >14 days, methotrexate ≤25 mg/week, azathioprine ≤3 mg/kg/day or mercaptopurine ≤1.5 mg/kg/day), ZVL may be considered after careful risk-benefit assessment 1

Adverse Events

• Both vaccines are generally well-tolerated with similar rates of serious adverse events compared to placebo 1, 2
• RZV has higher rates of injection site reactions (67% vs placebo) and systemic symptoms (33% vs placebo) 2
• Most adverse reactions are mild to moderate in intensity and resolve within a few days 1, 3

Clinical Pitfalls to Avoid

1. Don't delay vaccination until age 60: While older recommendations suggested starting at age 60, current evidence supports beginning at age 50 with RZV for optimal protection 1

2. Don't use ZVL in immunocompromised patients: The live vaccine can cause serious infection in those with reduced cell-mediated immunity 1

3. Don't forget the second dose of RZV: The full two-dose series is essential for optimal protection with RZV 1

4. Don't assume one vaccine is equivalent to another: RZV has demonstrated significantly higher efficacy across all age groups compared to ZVL 1

5. Don't miss vaccination opportunities: Herpes zoster can cause significant morbidity, including postherpetic neuralgia, which can severely impact quality of life 2