Should a patient in their late 30s with a history of herpes zoster (shingles) receive the shingles vaccine earlier than the standard recommended age of 50?

Should a Patient in Their Late 30s with Prior Shingles Get the Vaccine Early?

No, current guidelines do not support routine shingles vaccination for immunocompetent adults in their late 30s, even with a history of prior herpes zoster, as the recombinant zoster vaccine (Shingrix/RZV) is recommended starting at age 50 years. 1, 2

Standard Age Recommendations

• The Advisory Committee on Immunization Practices (ACIP) recommends Shingrix for adults aged ≥50 years, with this being the FDA-approved age threshold for both immunocompetent and immunocompromised populations 1, 2
• Multiple international guidelines from Taiwan, Canada, the United Kingdom, and the United States consistently recommend vaccination starting at age 50, not earlier for immunocompetent individuals 1
• The older live-attenuated vaccine (Zostavax) was licensed for adults ≥50 years but recommended for ≥60 years; however, Shingrix has superseded this with a clear age 50 threshold 2, 3

Why Age 50 Is the Threshold

• Herpes zoster incidence increases substantially with age, with the risk being relatively low in individuals under 50 years compared to older adults 1, 4
• The pivotal ZOE-50 trial that established Shingrix's 97.2% efficacy enrolled adults aged ≥50 years, not younger populations 1, 2
• Cost-effectiveness analyses support vaccination at age 50 or older, as the disease burden and complication rates (particularly postherpetic neuralgia) are significantly higher in this age group 1, 5

Prior Herpes Zoster Does Not Change the Age Recommendation

• Having had shingles does not justify earlier vaccination in immunocompetent adults, as guidelines recommend vaccination after a prior episode but still at the standard age threshold of ≥50 years 1, 2
• The recommended interval after a shingles episode is at least 2 months before vaccination, but this applies to patients who are already at the appropriate age for vaccination 1, 2
• Recurrence risk is documented (10.3% cumulative risk at 10 years), but this elevated risk does not lower the age threshold for immunocompetent individuals 2

Exception: Immunocompromised Patients

• The only scenario where vaccination before age 50 is recommended is for immunocompromised adults aged ≥18 years, including those with:
  • Hematologic malignancies 1, 2
  • Solid organ or stem cell transplant recipients 2
  • HIV infection 6
  • Autoimmune diseases requiring immunosuppressive therapy 1
• For immunocompromised patients under 50, providers should consider vaccination history and serology testing before administering RZV 1

Clinical Algorithm for This Patient

For an immunocompetent patient in their late 30s with prior shingles:

1. Do not vaccinate now - the patient does not meet age criteria 1, 2
2. Counsel the patient to return for vaccination at age 50 1, 2
3. If the patient develops an immunocompromising condition before age 50, reassess for early vaccination eligibility 1, 2
4. Document the prior shingles episode so that when the patient reaches age 50, you ensure at least 2 months have passed since any recent episode before vaccinating 1, 2

For an immunocompromised patient in their late 30s with prior shingles:

1. Vaccinate now with Shingrix (RZV) - immunocompromised adults ≥18 years are eligible 1, 2
2. Wait at least 2 months after the most recent shingles episode 1, 2
3. Use the shorter dosing schedule: second dose at 1-2 months after the first dose (rather than 2-6 months for immunocompetent adults) 2
4. Never use live-attenuated Zostavax in immunocompromised patients 1, 7

Important Caveats

• Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination - if the patient were VZV-seronegative (never had chickenpox), they would need varicella vaccine (2 doses, 4 weeks apart), not shingles vaccine 1
• The patient's prior shingles episode confirms VZV seropositivity, so varicella vaccination is not indicated 1
• Off-label use of Shingrix before age 50 in immunocompetent adults is not supported by evidence and would not be cost-effective given the low disease burden in this age group 1, 5