Should a 90-year-old patient with a history of herpes zoster (shingles) receive the Zostavax (zoster vaccine live) vaccine?

Herpes Zoster Vaccination in a 90-Year-Old with History of Shingles

A 90-year-old patient with a history of shingles should NOT receive the Zostavax (zoster vaccine live) vaccine, but should instead be offered the recombinant zoster vaccine (Shingrix) for prevention of herpes zoster recurrence. 1, 2

Rationale for Recommendation

Age Considerations

• Zostavax (ZVL) is a live-attenuated vaccine that:
  • While licensed for use in adults ≥50 years, the Advisory Committee on Immunization Practices (ACIP) recommends beginning vaccination at age 60 years 2
  • Has decreasing efficacy with increasing age (only 18% effective in those ≥80 years) 2
  • Has waning protection over time (efficacy decreases from 51.3% to 21.2% for HZ incidence over 7-11 years) 2

Safety Concerns with Zostavax

• Zostavax is a live vaccine containing the Oka strain of VZV with at least 14 times the potency of the varicella vaccine 2
• Live vaccines pose risks in elderly patients who may have age-related immune senescence
• The vaccine is contraindicated in immunocompromised patients due to risk of disseminated viral infection 1

Prior History of Shingles

• While ACIP recommends zoster vaccination regardless of prior history of herpes zoster 2, the choice of vaccine is critical
• Recombinant zoster vaccine (Shingrix) is preferred over Zostavax for patients with prior history of shingles due to:
  • Higher efficacy across all age groups (91.3% in adults ≥70 years vs. 18% with Zostavax) 2
  • Longer duration of protection 2
  • Non-replicating nature making it safer in older adults 1, 3

Alternative Recommendation

• The recombinant zoster vaccine (Shingrix) is the preferred option for this patient 1, 2
• Shingrix is administered as 2 doses, 2-6 months apart 1
• Shingrix can be safely given to patients who have previously had herpes zoster 1
• Shingrix has demonstrated superior efficacy compared to Zostavax across all age groups 2

Important Considerations

• Ensure the patient is not severely immunocompromised before administering any zoster vaccine
• Monitor for potential adverse effects:
  • Shingrix has higher rates of injection site reactions and systemic symptoms compared to Zostavax 2
  • Grade 3 injection site reactions (9.5% vs 0.4%) and systemic symptoms (11.4% vs 2.4%) are more common with Shingrix 2
• Zoster vaccination is not indicated to treat acute zoster or to prevent persons with acute zoster from developing postherpetic neuralgia 4

Common Pitfalls to Avoid

1. Using Zostavax in very elderly patients (≥80 years) where efficacy is extremely low
2. Administering live zoster vaccine to immunocompromised patients
3. Failing to complete the 2-dose series of Shingrix, which is required for optimal protection 1
4. Assuming that prior history of shingles provides adequate protection against recurrence

In conclusion, for this 90-year-old patient with a history of shingles, Zostavax is not recommended due to age-related reduced efficacy and safety concerns. Instead, Shingrix should be offered as the preferred vaccine for prevention of herpes zoster recurrence.