Should a 90-year-old patient with a history (hx) of herpes zoster (shingles) receive the Shingrix (zoster vaccine recombinant) vaccine?

Shingrix Vaccination for a 90-Year-Old with History of Shingles

Yes, a 90-year-old patient with a history of shingles should receive the Shingrix (recombinant zoster vaccine) as it is recommended for all adults aged ≥50 years regardless of prior shingles history. 1

Rationale for Recommendation

The recombinant zoster vaccine (Shingrix) is specifically recommended for:

• Adults aged ≥50 years, including those with a history of herpes zoster 2, 1
• Adults aged ≥18 years who are at increased risk for herpes zoster 2
• Patients who have previously received the live-attenuated zoster vaccine (Zostavax) 1

Efficacy in Older Adults

• Shingrix demonstrates high efficacy even in advanced age:
  • 91.3% efficacy against herpes zoster in adults ≥70 years 3
  • 89.1% efficacy in adults ≥80 years 3
  • 88.8% efficacy against postherpetic neuralgia in adults ≥70 years 3

Prior Shingles History

Having a history of shingles does not contraindicate receiving Shingrix. In fact, vaccination is particularly important for these patients as:

• A prior episode of shingles does not provide lifelong immunity against recurrence
• The risk of recurrent shingles increases with age
• Older adults are at higher risk for complications like postherpetic neuralgia

Administration Guidelines

For a 90-year-old patient:

• Dosing schedule: Two doses of 0.5 mL administered intramuscularly 1
• Standard interval: 2-6 months between doses 1
• Alternative interval: For patients with concerns about follow-up, the second dose can be given as early as 1-2 months after the first dose 1

Safety Considerations

• Side effects: Higher incidence of injection site reactions (9.5% vs 0.4%) and systemic symptoms (11.4% vs 2.4%) compared to placebo, but most are transient and mild to moderate 1
• Contraindications: Active, severe acute infection with high fever (>101.3°F or 38.5°C) may require temporary deferral until fever resolves 1
• Real-world effectiveness: Post-marketing studies show two-dose effectiveness of 70.1% in adults ≥65 years, which is lower than clinical trial efficacy but still substantial 4

Important Distinctions

• Shingrix (recombinant zoster vaccine) is preferred over the older Zostavax (live zoster vaccine) due to:

  • Higher efficacy across all age groups 1, 5
  • Longer duration of protection 6
  • Safety in immunocompromised persons (as it is non-replicating) 6

• Unlike the live zoster vaccine, Shingrix:

  • Does not contain live virus
  • Maintains efficacy in advanced age 3
  • Provides stronger protection against postherpetic neuralgia 3

Clinical Pearls

• Completing the full two-dose series is crucial for optimal protection 4
• If the patient previously received Zostavax, Shingrix should still be administered (at least 2 months after Zostavax) 1
• The vaccine is not indicated for treating active shingles or postherpetic neuralgia 1
• Advise the patient that injection site pain may be more severe than with other vaccines but is typically short-lived (about 2 days) 5