What is the recommended shingles vaccine for individuals aged 50 and older?

Shingles Vaccination Recommendations for Adults Aged 50 and Older

The recombinant zoster vaccine (RZV, Shingrix) is the preferred vaccine for prevention of herpes zoster (shingles) in adults aged 50 years and older, administered as a two-dose series with the second dose given 2 to 6 months after the first dose. 1, 2

Recommended Vaccines and Schedule

• Shingrix (RZV) is indicated for prevention of herpes zoster in adults aged 50 years and older, as stated in the FDA label 2
• Shingrix is administered as a two-dose series with doses given 2-6 months apart 1, 2
• For immunocompromised adults who would benefit from a shorter vaccination schedule, the second dose can be administered 1-2 months after the first dose 1, 2
• The minimum interval between doses is 4 weeks; if administered earlier, the dose should be repeated 1

Efficacy and Protection

• Shingrix demonstrates superior efficacy compared to the older Zostavax (ZVL) vaccine:
  • 97.2% efficacy in adults aged 50 years and older in the ZOE-50 trial 3, 1
  • 91.3% efficacy against herpes zoster and 88.8% against postherpetic neuralgia in adults 70 years and older 3
• Protection remains high for at least 8 years with minimal waning:
  • Maintained above 83.3% for up to 8 years 3, 1
  • Decreased to 73% at 10 years 3
• Real-world effectiveness studies show 70.1% effectiveness for 2 doses and 56.9% for 1 dose in Medicare beneficiaries aged >65 years 4

Advantages Over Previous Zoster Vaccine (Zostavax)

• Shingrix maintains high efficacy across all age groups, while Zostavax efficacy decreased significantly with age (70% in ages 50-59 vs. 18% in those ≥80 years) 3, 1
• Zostavax protection waned rapidly, with efficacy declining from 62% within 1 year to less than 50% after year 2, and only 14.1% by year 10 3
• Zostavax is no longer recommended in the US and some Western European countries 3
• Unlike Zostavax (a live vaccine), Shingrix can be safely administered to most immunocompromised patients 1, 5

Common Side Effects and Safety

• Injection-site reactions are common (pain 78%, redness 38%, swelling 26%) 2
• Common systemic reactions include myalgia (45%), fatigue (45%), headache (38%), shivering (27%), fever (21%), and gastrointestinal symptoms (17%) 2
• Grade 3 injection site reactions (9.5% vs. 0.4% with placebo) and systemic symptoms (11.4% vs. 2.4% with placebo) are more common with Shingrix 3, 1
• No serious safety concerns have been identified in large clinical trials, with similar rates of serious adverse events between vaccine and placebo groups 1

Special Considerations

After a Shingles Episode

• Vaccination is recommended after a prior episode of herpes zoster 3
• A minimum 2-month interval between an episode of herpes zoster and vaccination is recommended 3, 6
• Without vaccination, the cumulative incidence of recurrence is 2.5% at 2 years, 4.8% at 4 years, 6.6% at 6 years, 8.0% at 8 years, and 10.3% at 10 years 3, 6

For Those Previously Vaccinated with Zostavax

• For patients previously vaccinated with Zostavax, Shingrix should be administered at least 2 months after Zostavax 1
• Shingrix may further lower the incidence of herpes zoster in persons previously vaccinated with Zostavax 3

For Those with Unknown Varicella History

• Adults 50 years and older who do not have a history of varicella or have an unclear history of varicella should receive the herpes zoster vaccine, with Shingrix being preferred 3
• For persons known to be seronegative for varicella zoster virus, immunization with 2 doses of varicella vaccine with an interval of 4 weeks is suggested 3

Completion Rates

• Real-world data shows that approximately 70% of patients complete the two-dose series within 6 months and 80% within 12 months 7, 8
• Among those who received only 1 dose with at least 12 months of follow-up time, 96% had a missed opportunity for a second-dose vaccination 8

Pitfalls to Avoid

• Delaying the second dose beyond the recommended interval (though second doses administered beyond 6 months still provide effective protection) 4
• Failing to complete the 2-dose series, as a single dose provides lower effectiveness (56.9%) compared to the complete series (70.1%) 4
• Confusing the waiting period after shingles with the interval between vaccine doses 6
• Missing vaccination opportunities in older adults who have had shingles, as they remain at risk for recurrence 6