When should a patient receive the shingles (herpes zoster) vaccine after having an episode of shingles?

Timing of Shingles Vaccination After a Shingles Episode

Patients should wait at least 2 months after a shingles episode has completely resolved before receiving the shingles vaccine. 1

Rationale for the 2-Month Waiting Period

The recommendation for a 2-month minimum interval between a shingles episode and vaccination is based on:

• Documented evidence showing that the minimum interval between an episode of herpes zoster and recurrence is 2 months 1
• This waiting period allows for complete resolution of the acute infection and symptoms
• Different countries have varying recommendations ranging from waiting until symptoms have abated to waiting up to 1 year, but the 2-month guideline represents a reasonable middle ground based on current evidence 1

Vaccine Selection After Shingles

Two vaccines are available for prevention of herpes zoster:

1. Recombinant Zoster Vaccine (RZV, Shingrix) - Preferred option:

   • Higher efficacy across all age groups 2
   • 97.2% efficacy in adults 50+ years 2
   • 91.3% efficacy in adults 70+ years 2
   • Safe and effective in immunocompromised patients 2
   • Two-dose series (0.5 mL each) administered 2-6 months apart 2

2. Live Zoster Vaccine (ZVL, Zostavax) - Less preferred:

   • Lower efficacy that declines more rapidly with age 2
   • 70% efficacy at ages 50-59, declining to 18% at age 80+ 2
   • Not recommended for immunocompromised patients 2

Important Considerations

• Prior shingles episode is NOT a contraindication to vaccination; in fact, vaccination is recommended to prevent recurrence 2
• Complete the full two-dose series of Shingrix for optimal protection (70.1% effectiveness with two doses vs. 56.9% with a single dose) 2
• For immunocompromised adults aged ≥18 years, a shortened dosing interval of 1-2 months between doses is recommended 2
• Patients who previously received Zostavax can receive Shingrix without any waiting period 2

Special Populations

• Immunocompromised patients:

  • Should receive RZV (not ZVL, which is contraindicated) 2
  • Should wait until they are clinically stable before vaccination 2
  • Fatal disseminated varicella zoster infection has been reported in an immunocompromised patient following zoster vaccination 3

• Adults 18-49 years with specific conditions:

  • Recommended for those with HIV/AIDS, cancer, autoimmune conditions, or organ transplant recipients 2

Risk of Recurrence

The risk of shingles recurrence is significant:

• Cumulative incidence of recurrence at 2,4,6,8, and 10 years is 2.5%, 4.8%, 6.6%, 8.0%, and 10.3%, respectively 1
• This underscores the importance of vaccination after a shingles episode

Clinical Pitfalls to Avoid

1. Don't delay vaccination unnecessarily: While waiting for complete resolution is important, extending beyond the recommended 2-month period may leave patients vulnerable to recurrence

2. Don't skip the second dose: Completing the full two-dose series of Shingrix is crucial for optimal protection

3. Don't use live vaccine (ZVL) in immunocompromised patients: This could lead to serious complications including disseminated infection 3

4. Don't restart the vaccine series if delayed: If more time than recommended passes between doses, simply administer the second dose as soon as possible without restarting the series 2