Should an 85-year-old female patient with a history of herpes zoster (shingles) receive another varicella-zoster vaccine, such as Shingrix (recombinant zoster vaccine) or Zostavax (live attenuated zoster vaccine), if she cannot recall when she last received a shingles vaccine?

Shingles Vaccination for an 85-Year-Old Female with Prior Shingles History

Your 85-year-old female patient should receive the recombinant zoster vaccine (Shingrix) regardless of her inability to recall when she last received a shingles vaccine or her history of previous shingles infection. 1, 2

Vaccine Recommendation and Rationale

Primary Recommendation

• The CDC recommends that adults 50 years and older receive two doses of the recombinant zoster vaccine (RZV, Shingrix) 2-6 months apart as the preferred vaccine for shingles prevention 1
• This recommendation applies regardless of:
  • Previous shingles infection history
  • Previous vaccination with the older live zoster vaccine (Zostavax)
  • Age (though particularly important for elderly patients due to increased risk)

Specific Considerations for Your Patient

• Age factor: At 85 years, your patient is at high risk for shingles reactivation and complications
• Previous shingles history: Having had shingles in the past does not provide lifetime immunity; recurrences are common with a 10.3% cumulative incidence of recurrence at 10 years 1
• Unknown previous vaccination: When vaccination history is uncertain, vaccination is still recommended as there are no safety concerns with revaccination 2, 3

Vaccination Protocol

1. Vaccine type: Administer recombinant zoster vaccine (Shingrix) 1
2. Dosing schedule: Two doses, with the second dose given 2-6 months after the first dose 1
3. Timing: Can be administered immediately, as there is no required waiting period after a previous shingles episode that occurred "many years ago" 1, 2

Efficacy and Benefits

• RZV (Shingrix) demonstrates superior efficacy compared to the older live vaccine:
  • 97.2% efficacy in adults 50+ years
  • 91.3% efficacy in adults 70+ years 2
  • 70.1% real-world effectiveness with two doses in Medicare beneficiaries 4
• Provides protection against:
  • Herpes zoster recurrence
  • Post-herpetic neuralgia (76% effectiveness) 4
  • Other complications of shingles

Safety Considerations

• RZV is a non-live recombinant vaccine and is safe for older adults 1
• Previous vaccination with Zostavax is not a contraindication; RZV can be administered after Zostavax with a minimum interval of 8 weeks 2, 3
• Common side effects include injection site reactions, fatigue, myalgia, and headache, which are generally mild to moderate and resolve within 2-3 days

Important Clinical Pearls

• Complete the series: Ensure the patient returns for the second dose, as single-dose effectiveness is lower (56.9% vs. 70.1% for two doses) 4
• Documentation: Clearly document this vaccination to avoid future uncertainty
• No serologic testing needed: Testing for varicella immunity before vaccination is not necessary in immunocompetent adults with a history of chickenpox or shingles 1
• Concomitant vaccines: RZV can be administered with other vaccines such as influenza or pneumococcal vaccines if needed 3

The recombinant zoster vaccine represents a significant advancement in preventing shingles and its complications in older adults, with strong evidence supporting its use in patients like yours with previous shingles history and uncertain vaccination status.