Should a 53-year-old African American (AA) female with no history of varicella (chickenpox) receive the Shingrix (zoster vaccine) vaccination?

Shingrix Vaccination for a 53-Year-Old with No History of Chickenpox

A 53-year-old African American female with no history of chickenpox should receive the Shingrix (recombinant zoster vaccine) vaccination as recommended for all adults aged 50 years and older, regardless of prior varicella history. 1

Rationale for Vaccination

Shingrix is indicated for:

• Prevention of herpes zoster (shingles) in adults aged 50 years and older 2
• Prevention in adults aged 18 years and older at increased risk of herpes zoster due to immunodeficiency or immunosuppression 2

Important Considerations for Patients Without Chickenpox History

1. No Need for Serologic Testing:

   • Adults 50 years and older with normal immune function do not require serologic testing or a documented history of varicella before receiving the zoster vaccine 1
   • The CDC recommends not screening for a history of varicella or conducting laboratory testing when vaccinating immunocompetent adults aged 50 years and older 3

2. High Likelihood of Prior Exposure:

   • Studies show that varicella seroprevalence is very high in adults, with up to 88-91% of adults having antibodies to varicella zoster virus, even without recalled history of chickenpox 3
   • By age 53, it's highly likely this patient has been exposed to varicella zoster virus, even without clinical disease

3. Safety in Varicella-Seronegative Individuals:

   • Both Shingrix (RZV) and the older Zostavax (ZVL) have been shown to be safe and immunogenic in VZV-seronegative individuals 3

Vaccination Protocol

1. Dosing Schedule:

   • Administer 2 doses (0.5 mL each) intramuscularly 2
   • Standard schedule: 2-6 months apart 1
   • The second dose is crucial for optimal efficacy (70.1% with 2 doses vs. 56.9% with 1 dose) 1

2. Efficacy:

   • Shingrix has demonstrated 97.2% efficacy in preventing herpes zoster in adults 50 years and older 1, 2
   • Specifically for the 50-59 age group (relevant to this patient), efficacy is 96.6% 2

3. Side Effects to Discuss:

   • Higher incidence of injection site reactions (9.5% vs 0.4%) and systemic symptoms (11.4% vs 2.4%) compared to placebo 1
   • Most reactions are transient and mild to moderate in severity 1
   • Concerns about tolerability are a significant factor in vaccine series completion 4

Alternative Approach for Known VZV-Seronegative Patients

If the patient is specifically known to be VZV-seronegative (through previous testing):

• Consider immunization with 2 doses of varicella vaccine with an interval of 4 weeks 3
• Then proceed with Shingrix vaccination as recommended for adults 50 years and older

Important Limitations to Note

1. Shingrix is not indicated for:
   • Prevention of primary varicella infection (chickenpox) 2
   • Treatment of acute shingles 1
   • Prevention of postherpetic neuralgia in individuals with active shingles 1
   • Treatment of ongoing postherpetic neuralgia 1

Clinical Pearls

1. Completion of Series: Emphasize the importance of completing both doses, as incomplete vaccination significantly reduces protection 1, 4

2. Lifetime Risk: The lifetime risk of acquiring shingles without preventive vaccination is substantial - approximately 22% for males and 32% for females aged 45 years and older 5

3. Vaccine Preference: Shingrix is strongly preferred over the older Zostavax due to its higher efficacy and longer duration of protection 1