Comparison of Zoster Vaccines: Shingrix vs Zostavax
Primary Recommendation
Shingrix (recombinant zoster vaccine, RZV) is the strongly preferred vaccine over Zostavax (zoster vaccine live, ZVL) for all adults aged 50 years and older, with Zostavax no longer recommended in the US and many Western European countries. 1
Efficacy Comparison
Shingrix (RZV) - Superior Performance
- Vaccine efficacy of 97.2% against herpes zoster in adults aged ≥50 years, maintained consistently across all age groups 1, 2
- 89.8% efficacy in adults aged ≥70 years, demonstrating robust protection in the elderly population 1
- 91.3% efficacy against herpes zoster and 88.8% against postherpetic neuralgia (PHN) in pooled analysis of adults ≥70 years 1
- Protection maintained above 83.3% for up to 8 years, decreasing to 73% at 10 years 1, 2
- Real-world effectiveness of 70.1% for the 2-dose series and 56.9% for single dose 3
Zostavax (ZVL) - Inferior and Waning Protection
- Vaccine efficacy of only 51.3% for herpes zoster incidence, declining dramatically to 21.2% during 7-11 years post-vaccination 1
- Efficacy against PHN decreased from 66.5% to 35.4% over the same follow-up period 1
- Network meta-analysis confirmed RZV is significantly more effective than ZVL for preventing both HZ and PHN 1
Safety Profile Comparison
Shingrix (RZV) - More Reactogenic but Safe
- Significantly higher injection-site reactions (9.5% vs 0.4% grade 3) and systemic symptoms (11.4% vs 2.4% grade 3) compared to placebo 1
- No difference in serious adverse events (SAEs) or deaths compared to placebo 1
- Most reactions are transient and mild-to-moderate in severity 4
Zostavax (ZVL) - Less Reactogenic
- Lower rates of injection-site reactions (RR 2.99) and systemic adverse events (RR 1.29) compared to RZV 1
- No significant increase in deaths or vaccine-associated SAEs 1
Critical Advantage: Immunocompromised Patients
Shingrix is the only appropriate zoster vaccine for immunocompromised individuals, while Zostavax is contraindicated in this population due to its live-attenuated nature 1, 2, 5
Shingrix Indications in Immunocompromised Adults:
- Recommended for adults aged ≥18 years who are or will be immunocompromised due to disease or therapy 1, 2
- Preferred vaccine for solid cancers, hematologic malignancies, and multiple myeloma 1
- Effective in hematopoietic stem cell transplant recipients (68.2% efficacy with 90% reduction in PHN) 1
- Safe and effective in patients on chronic glucocorticoids or JAK inhibitors 2
Zostavax Contraindications:
- Absolutely contraindicated in primary or acquired immunodeficiency states due to theoretical risk of serious disease from live virus 1, 5
Dosing Schedule Differences
Shingrix (RZV):
- Two-dose series administered 2-6 months apart 6
- Shortened schedule (1-2 months apart) for immunocompromised adults 5
- Second doses given beyond 6 months (≥180 days) do not impair effectiveness 3
Zostavax (ZVL):
Clinical Pitfalls and Caveats
- Patients who previously received Zostavax should be revaccinated with Shingrix, with a minimum 2-month interval between vaccines 5
- Prior herpes zoster infection is not a contraindication to Shingrix vaccination; wait at least 2 months after acute symptoms resolve 6, 5
- Completing the 2-dose Shingrix series is essential for optimal protection, as single-dose effectiveness (56.9%) is substantially lower than 2-dose effectiveness (70.1%) 3
- Shingrix does not prevent primary varicella (chickenpox); patients without varicella immunity should receive varicella vaccine first if not contraindicated 5
Global Guideline Consensus
International guidelines increasingly favor Shingrix with explicit preference statements in Canada and the United Kingdom, while the US and Western Europe no longer recommend Zostavax 1. The superior efficacy, longer duration of protection, and safety in immunocompromised populations make Shingrix the clear evidence-based choice despite higher reactogenicity 1, 4, 7.