At age 50, should I receive the varicella (chickenpox) vaccine series or the recombinant herpes zoster (shingles) vaccine?

Recombinant Herpes Zoster Vaccine (Shingrix) is Recommended at Age 50

At age 50, you should receive the recombinant herpes zoster vaccine (Shingrix) rather than the varicella vaccine series, as Shingrix is specifically indicated for prevention of shingles in adults aged 50 years and older with superior efficacy. 1, 2, 3

Evidence-Based Rationale

Indications for Each Vaccine

• Varicella vaccine series: Indicated for prevention of primary varicella infection (chickenpox) in individuals who have never had chickenpox
• Recombinant zoster vaccine (Shingrix): Specifically indicated for prevention of herpes zoster (shingles) in adults aged 50 years and older 3

Efficacy of Recombinant Zoster Vaccine (Shingrix)

• Shingrix demonstrated 97.2% efficacy against herpes zoster in adults 50 years and older 1
• Efficacy remains high across all age groups, with comparable protection in adults 50-59,60-69, and 70+ years 1
• Protection is maintained above 83.3% for up to 8 years, decreasing to 73% at 10 years 1
• Provides 88.8% efficacy against postherpetic neuralgia (PHN), a painful complication of shingles 1

Comparison to Live Zoster Vaccine (Zostavax)

While both vaccines are approved for adults 50 years and older, Shingrix is strongly preferred because:

• Shingrix (97.2% efficacy) is significantly more effective than Zostavax (51.3-69.8% efficacy) 1, 4
• Zostavax efficacy wanes considerably over time (from 51.3% to 21.2% over 7-11 years) 1
• Zostavax efficacy decreases with age (70% at 50-59 years vs. 18% at 80+ years) 1
• Network meta-analysis demonstrated Shingrix was significantly more effective in preventing herpes zoster and PHN compared to Zostavax 1

Administration Schedule

• Shingrix requires a 2-dose series administered intramuscularly, with the second dose given 2 months after the first 5, 6

Safety Profile

• Both vaccines have acceptable safety profiles with no significant differences in serious adverse events compared to placebo 1, 4
• Shingrix is associated with higher rates of injection site reactions (pain, redness, swelling) and systemic symptoms (myalgia, fatigue, headache) compared to placebo, but these are generally mild to moderate in intensity 1, 4

Current Guidelines

• The American Academy of Ophthalmology and CDC strongly recommend Shingrix as the preferred vaccine for prevention of herpes zoster and its complications in adults aged 50 years and older 2
• The 2024 Taiwan guidelines for herpes zoster vaccination recommend RZV as the preferred HZ vaccine in immunocompetent adults aged 50 years and older 1
• The Advisory Committee on Immunization Practices (ACIP) recommends Shingrix as the preferred vaccine for herpes zoster prevention in immunocompetent adults 50 years and older 6

Important Considerations

• Varicella vaccine is not indicated for adults who have already had chickenpox (which is the case for most adults over 50)
• Shingrix is a non-live vaccine and can be safely administered to most patients, including those with certain immunocompromising conditions 3
• If you previously received Zostavax, you should still receive Shingrix for better protection 2

Conclusion

Based on the most recent and highest quality evidence, the recombinant herpes zoster vaccine (Shingrix) is clearly the recommended choice at age 50 due to its superior efficacy, longer duration of protection, and specific indication for prevention of herpes zoster in this age group.