Do I need to get the varicella (chickenpox) vaccine before receiving the shingles (herpes zoster) vaccine, such as Shingrix (zoster vaccine), if I've never had chickenpox?

Shingles Vaccination Without Prior Chickenpox History

Yes, you should receive the shingles vaccine (Shingrix) at age 50 or older even if you've never had chickenpox, because 88-91% of adults without recalled chickenpox history are actually VZV-seropositive from subclinical childhood infection and therefore at risk for shingles. 1

Understanding Your True VZV Status

The critical issue is that absence of chickenpox history does not mean absence of varicella zoster virus (VZV) exposure:

• Seroprevalence studies demonstrate that 88-91% of adults have VZV antibodies even when they don't recall having chickenpox, indicating subclinical or forgotten childhood infection 1
• Varicella seropositivity reached 88% in adults aged 21-30 years in the pre-vaccine era, meaning the vast majority without recalled chickenpox were actually VZV-exposed 1
• Only truly VZV-seronegative individuals (the minority) have essentially zero risk of herpes zoster because you cannot reactivate a virus you've never been infected with 1

Recommended Vaccination Strategy

For adults aged 50 years and older, Shingrix is indicated regardless of chickenpox history 2:

• Administer the 2-dose Shingrix series (doses given 2-6 months apart) without requiring prior varicella serology testing 1, 3
• The FDA indication explicitly states Shingrix is for prevention of herpes zoster in adults aged 50 years and older, with no requirement for documented prior chickenpox 2
• The vaccine demonstrates >90% efficacy in preventing shingles across all age groups 50 and older, with protection sustained for at least 8-10 years 1, 3

Alternative Approach: Varicella Vaccination if Confirmed Seronegative

If you want to confirm your VZV status before proceeding, consider varicella serology testing 1:

• If VZV IgG antibody testing confirms you are seronegative (the 9-12% minority), you should receive the varicella vaccine instead of or before the shingles vaccine 4
• Varicella vaccination requires 2 doses of single-antigen varicella vaccine at least 4 weeks apart 4
• After completing varicella vaccination, you would then be eligible for Shingrix at age 50 or older 1

Special Considerations for Immunocompromised Adults Under 50

If you are aged 18-49 years and immunocompromised (or will be), Shingrix is indicated regardless of chickenpox history 2:

• This includes patients on biologics, JAK inhibitors, or other immunomodulators 4, 1
• The recombinant zoster vaccine (Shingrix) is safe for immunocompromised patients because it contains only a recombinant protein, not live virus 4, 1
• For immunocompromised adults, consider a shorter schedule with the second dose given 1-2 months after the first dose 5, 3

Key Clinical Pitfalls to Avoid

Do not assume absence of recalled chickenpox means VZV-seronegative status - most adults have been exposed even without clinical disease 1

Do not unnecessarily delay appropriate vaccination to conduct varicella serology in immunocompetent adults aged 50 and older - the vaccine is indicated regardless of serostatus 1

Never administer live zoster vaccine (Zostavax) to immunocompromised patients - use Shingrix instead, or consider varicella vaccine if truly seronegative 4, 1

Safety Profile

Shingrix causes more injection-site reactions and systemic symptoms compared to placebo, but these are transient and mild-to-moderate 1:

• 9.5% experience grade 3 injection-site reactions versus 0.4% with placebo 1
• 33% experience systemic symptoms versus minimal rates with placebo 1
• No serious safety concerns or increased mortality have been identified in large trials 1