What are the guidelines for shingles (Herpes Zoster) vaccination?

Shingles Vaccination Guidelines

The Advisory Committee on Immunization Practices (ACIP) recommends Shingrix (recombinant zoster vaccine, RZV) as the preferred vaccine for prevention of herpes zoster for adults aged 50 years and older, and for adults aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression. 1, 2

Recommended Vaccines and Administration

Recombinant Zoster Vaccine (Shingrix, RZV)

• Primary recommendation: Two-dose series administered intramuscularly 1, 2
• Standard schedule:
  • First dose at Month 0
  • Second dose 2-6 months later for immunocompetent adults 2
  • Second dose 1-2 months later for immunodeficient or immunosuppressed individuals 2
• Efficacy:

  • 90% efficacy against herpes zoster in all age groups studied 1, 3

  • 91.3% efficacy in adults 70+ years 1
  • 88.8% efficacy against postherpetic neuralgia 1
  • Real-world effectiveness: 70.1% for two doses, 56.9% for one dose 4

Zoster Vaccine Live (Zostavax, ZVL)

• No longer the preferred vaccine due to lower efficacy compared to RZV 1
• Contraindicated in individuals with primary or acquired immunodeficiency states 5
• Efficacy varies by age:
  • 70% for ages 50-59
  • 64% for ages 60-69
  • 41% for ages 70-79
  • 18% for ages 80+ 1

Target Populations

By Age

• Adults aged 50 years and older (immunocompetent) 1, 2
• Adults aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression 1, 2, 6

High-Risk Groups

Individuals with:

• Diabetes mellitus (1.5-2 times higher risk) 1
• Rheumatoid arthritis (RR 1.51) 5
• Systemic lupus erythematosus (RR 2.08) 5
• Cancer 5
• HIV/AIDS 5, 1
• Organ transplant recipients 1
• Autoimmune conditions 1

Important Clinical Considerations

Series Completion

• Completing the full two-dose series is crucial for optimal protection 4, 7, 8
• Second doses administered beyond the recommended 6 months do not impair effectiveness 4
• If series is interrupted, continue with second dose as soon as possible (no need to restart) 1

Previous Vaccination or Shingles History

• Previous vaccination with Zostavax is not a contraindication for receiving Shingrix 1
• Wait at least 2 months after a shingles episode has completely resolved before receiving the shingles vaccine 1

Safety Considerations

• Most common adverse reactions: pain (78%), redness (38%), swelling (26%), myalgia (45%), fatigue (45%), headache (38%) 2
• An increased risk of Guillain-Barré syndrome was observed during the 42 days following vaccination with Shingrix in postmarketing studies 2
• Syncope can occur; procedures should be in place to avoid falling injury 2

Special Populations

• For patients with hyaluronic acid fillers: inform healthcare providers before vaccination and monitor for swelling at filler sites 1
• For patients with autoimmune conditions: consult with specialist before timing procedures 1

Public Health Impact

• RZV is expected to dramatically reduce herpes zoster morbidity, complications, and associated healthcare costs 3
• In the US, vaccination with RZV is cost-effective compared to no vaccination and cost-saving compared to ZVL 3

Common Pitfalls to Avoid

1. Incomplete vaccination: Only 70-80% of patients complete the two-dose series within 6-12 months 7, 8. Emphasize the importance of the second dose, which significantly improves effectiveness.
2. Contraindication confusion: Unlike Zostavax, Shingrix is not contraindicated in immunocompromised patients and is actually recommended for this population 6.
3. Delaying vaccination after shingles: There is no need to wait after a shingles episode has resolved before receiving Shingrix 1.
4. Missed opportunities: 96% of patients who received only one dose had a missed opportunity for second-dose vaccination during subsequent healthcare visits 8.