Is revaccination with Shingrix (recombinant zoster vaccine) indicated for individuals who develop shingles after initial immunization with Zostavax (live attenuated zoster vaccine) or Shingrix?

Revaccination with Shingrix After Herpes Zoster Infection

Revaccination with Shingrix is strongly recommended for individuals who develop shingles after initial immunization, with vaccination recommended at least 2 months after the acute stage has resolved and symptoms have abated.

Rationale for Revaccination

Individuals who develop herpes zoster after vaccination remain at significant risk for recurrence. The cumulative incidence of herpes zoster recurrence increases over time:

• 2.5% at 2 years
• 4.8% at 4 years
• 6.6% at 6 years
• 8.0% at 8 years
• 10.3% at 10 years 1

This high recurrence risk makes revaccination an important preventive measure.

Timing of Revaccination

• Minimum waiting period: At least 2 months after the acute stage of herpes zoster has resolved and symptoms have abated 1
• No maximum time limit: While earlier vaccination provides earlier protection, there is no upper time limit after which vaccination becomes ineffective

Revaccination After Different Initial Vaccines

After Zostavax (ZVL)

• Strong recommendation: Revaccination with Shingrix after an interval of more than 5 years since Zostavax 2, 1
• Weak recommendation: Revaccination with Shingrix within 5 years of Zostavax 2, 1
• A minimal interval of 8 weeks is suggested between administering Zostavax and Shingrix 2

After Shingrix (RZV)

While specific guidelines for revaccination after breakthrough herpes zoster following Shingrix are limited, the same principles apply:

• Wait until the acute infection resolves (minimum 2 months)
• Proceed with revaccination to prevent recurrence

Evidence Supporting Revaccination

• In individuals previously vaccinated with Zostavax, Shingrix induced strong humoral and cell-mediated immune responses that were non-inferior to those without prior Zostavax vaccination 2
• Compared to persons who received only Zostavax, additional vaccination with Shingrix lowered the incidence rate of herpes zoster from 7.54 to 2.39 per 1000 person-years 2
• A meta-analysis of 2 large US cohort studies showed that the pooled vaccine effectiveness against herpes zoster was 75.5% in adults aged ≥50 years who received Zostavax within 5 years before Shingrix 2
• FDA labeling for Shingrix specifically addresses revaccination after Zostavax, indicating no evidence for interference in the immune response to Shingrix in subjects previously vaccinated with Zostavax 3

Efficacy Considerations

Shingrix demonstrates superior efficacy compared to Zostavax:

• Shingrix: 97.2% efficacy in adults ≥50 years, 91.3% in adults ≥70 years 1
• Zostavax: Efficacy ranges from 70% (ages 50-59) to 18% (ages ≥80) 1

Real-world effectiveness of Shingrix:

• Two-dose effectiveness: 70.1% (95% CI, 68.6-71.5)
• One-dose effectiveness: 56.9% (95% CI, 55.0-58.8) 4

Important Considerations

Complete the Full Series

• Two doses of Shingrix provide significantly better protection than a single dose
• The second dose should be administered 2-6 months after the first dose for immunocompetent adults

Safety Profile

• Revaccination with Shingrix is well-tolerated without increased safety concerns 2
• Common side effects include pain, redness, swelling, myalgia, fatigue, and headache 1

Special Populations

• Immunocompromised individuals: Shingrix is recommended for adults aged 18 years and older who are or will be at increased risk of herpes zoster due to immunodeficiency or immunosuppression 1
• Patients with autoimmune conditions: Two-dose vaccine effectiveness was not significantly lower for individuals with autoimmune conditions 4

Clinical Approach to Revaccination

1. Identify patients who have had herpes zoster after vaccination
2. Wait at least 2 months after resolution of acute herpes zoster
3. Administer Shingrix as a two-dose series (0,2-6 months)
4. Complete the full two-dose series for optimal protection
5. Document revaccination in the patient's immunization record

Common Pitfalls to Avoid

• Delaying vaccination unnecessarily: Once the acute phase has resolved (minimum 2 months), vaccination should proceed to prevent recurrence
• Assuming prior vaccination provides sufficient protection: Even after vaccination, breakthrough cases can occur, and revaccination is beneficial
• Administering only one dose: Complete the full two-dose series for optimal protection
• Confusing Shingrix with Zostavax: Shingrix is a non-live recombinant vaccine and is the preferred vaccine for prevention of herpes zoster

By following these guidelines, clinicians can help reduce the risk of herpes zoster recurrence in patients who have experienced breakthrough infection after initial vaccination.