What are the guidelines for shingles (Herpes Zoster) vaccination?

Shingles Vaccination Guidelines

Primary Recommendation for Immunocompetent Adults

All adults aged 50 years and older should receive Shingrix (recombinant zoster vaccine, RZV) as a 2-dose series, with the second dose administered 2-6 months after the first dose. 1, 2

• The minimum acceptable interval between doses is 4 weeks, though the 2-6 month window is preferred for optimal immune response 1
• If the second dose is given beyond 6 months, effectiveness remains intact—do not restart the series 1
• Shingrix demonstrates 97.2% efficacy in preventing shingles in adults aged 50+ years, with protection persisting above 83.3% for at least 8 years 1

Vaccine Selection: Why Shingrix Over Zostavax

Shingrix is vastly superior to the older Zostavax vaccine and is the only recommended option for new vaccinations. 1, 3

• Zostavax efficacy plummets with age (70% in ages 50-59 vs. only 18% in those ≥80 years), while Shingrix maintains high efficacy across all age groups 1
• By 10 years post-vaccination, Zostavax efficacy drops to just 14.1%, making revaccination with Shingrix essential 1
• Shingrix is a non-live recombinant vaccine, making it safe for immunocompromised patients, whereas Zostavax is contraindicated in this population 4, 5

Special Population: Immunocompromised Adults Aged 18-49 Years

Adults aged 18 years and older who are or will be immunocompromised should receive Shingrix, regardless of age. 2, 5

Who Qualifies as Immunocompromised:

• Patients on chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 4
• Those with solid organ or hematologic malignancies 4
• Hematopoietic stem cell transplant recipients 1
• Patients with HIV/AIDS or other immunodeficiency diseases 4
• Those on immunosuppressive therapy including JAK inhibitors, biologics, or other disease-modifying agents 1, 4

Modified Dosing Schedule for Immunocompromised:

• Use a shortened interval: administer the second dose 1-2 months after the first dose (rather than the standard 2-6 months) 1, 4
• For hematopoietic stem cell transplant recipients specifically, give RZV 50-70 days post-transplantation 1

Vaccination After Prior Shingles Episode

Vaccinate all patients who have had shingles, as prior infection does not provide reliable protection against recurrence. 1

• Wait at least 2 months after acute symptoms resolve before administering the vaccine 1
• The 10-year cumulative recurrence risk after a shingles episode is 10.3%, making vaccination critical 1
• Use the standard 2-dose schedule (2-6 months apart) for immunocompetent adults, or the shortened schedule (1-2 months apart) for immunocompromised patients 1

Transitioning from Zostavax to Shingrix

All patients who previously received Zostavax should be revaccinated with the full 2-dose Shingrix series. 1

• Wait at least 2 months after the last Zostavax dose before starting Shingrix 1
• Complete both doses of Shingrix for optimal protection—do not assume prior Zostavax provides adequate coverage 1
• There is no maximum interval after previous Zostavax vaccination; patients can receive Shingrix years later 1

Administration and Co-Administration

• Administer intramuscularly (IM) 1
• Shingrix can be co-administered with other vaccines, though specific timing recommendations vary by vaccine type 6
• For patients starting immunosuppressive therapy (e.g., tofacitinib), ideally complete the full 2-dose Shingrix series before initiating therapy 1
• If urgent immunosuppression is needed, give at least the first dose before starting therapy, then complete the second dose 1-2 months later 1

Important Contraindications and Limitations

Shingrix is NOT indicated for prevention of primary chickenpox (varicella). 2

• Patients without prior varicella immunity should receive varicella vaccine first if not contraindicated 4
• However, 88-91% of adults have VZV antibodies even without recalled chickenpox history, so most adults without chickenpox history can still develop shingles 7
• Consider varicella serology only if the patient is confirmed VZV-seronegative and under age 50 without immunocompromise 7

Common Pitfalls to Avoid

• Never use live Zostavax in immunocompromised patients—only Shingrix is appropriate 1, 4
• Do not delay vaccination to conduct varicella serology in immunocompetent adults aged 50 and older 7
• Do not assume absence of chickenpox history means no shingles risk—most adults have been exposed to VZV even without clinical disease 7
• Do not restart the series if the second dose is given beyond 6 months—late doses are still effective 1
• Do not skip the second dose—real-world data shows 70% complete the series within 6 months and 80% within 12 months, but both doses are essential for optimal protection 8

Expected Side Effects

• Injection-site reactions (pain, redness, swelling) occur in 9.5% of recipients (grade 3 reactions) compared to 0.4% with placebo 1
• Systemic symptoms (fatigue, myalgia, headache) occur in 11.4% of vaccine recipients versus 2.4% in placebo recipients 1
• Transplant recipients aged 18-49 years experience higher rates: pain (88%), fatigue (64%), myalgia (58%), and headache (44%) 4
• No serious safety concerns have been identified in large clinical trials 1
• For patients with autoimmune conditions on glucocorticoids, mild disease flares occur in 4-17% after vaccination, with no serious adverse events 1

No Booster Doses Currently Recommended

No additional booster doses beyond the initial 2-dose series are recommended. 1

• Protection remains above 83.3% for at least 8 years, with minimal waning 1
• Current guidelines from the CDC and American College of Physicians do not recommend any booster doses 1