Is the shingles vaccine a live vaccine?

Shingles Vaccines: Live vs. Non-Live Options

There are two types of shingles vaccines available: Zostavax is a live attenuated vaccine, while Shingrix is a non-live recombinant subunit vaccine that is preferred for most patients, especially those who are immunocompromised. 1, 2

Types of Shingles Vaccines

Live Attenuated Vaccine

• Zostavax: Contains a weakened form of the live varicella-zoster virus 3
• Contraindicated in immunosuppressed patients 4
• Lower efficacy compared to the recombinant vaccine:
  • 70% effective in adults 50-59 years
  • Declining to only 18% effective in adults 80+ years 1

Non-Live Recombinant Vaccine

• Shingrix: Contains varicella zoster virus glycoprotein E antigen with AS01B adjuvant system 2
• Not a live vaccine, making it safe for immunocompromised patients 1
• Superior efficacy:
  • 97.2% effective in adults ≥50 years
  • 91.3% effective in adults ≥70 years 1
  • Maintains higher efficacy across all age groups 5

Clinical Recommendations

General Population

• Shingrix (non-live recombinant vaccine) is recommended for:
  • Adults aged 50 years and older 2
  • Adults aged 18 years and older who are or will be immunocompromised 2
  • Two doses administered intramuscularly:
    • 2-6 months apart for immunocompetent individuals
    • 1-2 months apart for immunocompromised individuals 2

Special Populations

• Immunosuppressed patients:

  • Live vaccines (including Zostavax) are contraindicated 4
  • Shingrix is the only appropriate option 1
  • This includes patients on:
    • Corticosteroids (prednisolone ≥20 mg/day for 2+ weeks)
    • Purine analogues
    • Methotrexate
    • Biologic therapies 4

• Timing considerations:

  • Immunomodulators should be withheld for 4 weeks after live vaccine administration 4
  • Live vaccines should be avoided for at least 3 months after discontinuing immunosuppressive therapies 4
  • For patients who previously received Zostavax, they should still receive the complete Shingrix series with a minimum interval of 8 weeks after Zostavax 1

Common Pitfalls and Caveats

1. Mistaking vaccine types: Clinicians sometimes confuse which shingles vaccine is live. Remember that Zostavax is the live vaccine, while Shingrix is non-live.

2. Inappropriate administration to immunocompromised patients: Live vaccines like Zostavax should never be given to immunocompromised patients due to risk of vaccine-strain infection.

3. Incomplete vaccination: Shingrix requires two doses for optimal protection. A single dose provides only 56.9% effectiveness compared to 70.1% with two doses 1.

4. Confusing with chickenpox vaccine: Shingrix is not indicated for prevention of primary varicella infection (chickenpox) 2.

5. Side effect management: Both vaccines can cause injection site reactions, but Shingrix tends to have more pronounced systemic reactions that patients should be warned about to ensure they return for the second dose 6, 1.

By selecting the appropriate shingles vaccine based on patient characteristics—particularly immunocompetence status—clinicians can maximize protection against herpes zoster and its complications while minimizing risks.