Herpes Zoster Vaccination After Herpes Infection
Yes, herpes zoster vaccination with Shingrix (recombinant zoster vaccine, RZV) is strongly indicated for adults aged 50 years and older regardless of prior herpes zoster infection history. 1, 2
Primary Recommendation
The recombinant zoster vaccine (Shingrix/RZV) should be administered as a 2-dose series to all adults ≥50 years with a history of herpes zoster infection, as prior infection does not provide reliable protection against future episodes. 2
- The 10-year cumulative recurrence risk after a herpes zoster episode is 10.3%, making vaccination essential even after experiencing shingles 2
- Multiple international guidelines from Taiwan, the United States, and other countries consistently recommend vaccination regardless of prior herpes zoster history 1, 2
Timing After Acute Herpes Zoster Episode
Administer Shingrix once acute symptoms have resolved, typically waiting at least 2 months after the episode. 2
- No absolute minimum waiting period is mandated by guidelines, but a practical interval of 2 months allows for complete symptom resolution and immune system recovery 2
- The 2-month interval is based on documented minimal intervals between herpes zoster episodes and recurrence 2
Dosing Schedule
Administer the first dose immediately (after the 2-month post-infection waiting period), followed by the second dose 2-6 months later. 2
- The minimum interval between doses is 4 weeks, though 2-6 months is preferred for optimal immune response 2
- For immunocompromised adults aged ≥18 years, a shorter schedule with the second dose given 1-2 months after the first dose is recommended 2
Vaccine Efficacy and Protection
Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 years and older, with protection persisting for at least 8 years. 2, 3
- Vaccine efficacy remains above 83.3% during the 8-year follow-up period with minimal waning 2
- In adults 70 years and older, vaccine efficacy against herpes zoster was 89.8% (95% CI, 84.2-93.7), with similar efficacy in those 70-79 years (90.0%) and those ≥80 years (89.1%) 3
- Vaccine efficacy against postherpetic neuralgia was 88.8% (95% CI, 68.7-97.1) in pooled analyses 3
Superiority Over Previous Vaccination
If the patient previously received Zostavax (live-attenuated zoster vaccine), they should still receive the full 2-dose Shingrix series. 2
- Zostavax efficacy declines dramatically to only 14.1% by year 10, providing inadequate long-term protection 2
- Shingrix should be administered at least 2 months after any prior Zostavax dose 2
- Additional vaccination with RZV after prior Zostavax lowered the incidence rate of herpes zoster from 7.54 to 2.39 per 1000 person-years 2
Special Population Considerations
For immunocompromised adults aged ≥18 years with prior herpes zoster, Shingrix is both indicated and safe, as it contains only a recombinant protein fragment, not live virus. 2
- Immunocompromised patients should receive the 2-dose series with a shorter interval (1-2 months between doses) 2
- This includes patients with hematologic malignancies, solid organ or stem cell transplant recipients, HIV infection, and autoimmune diseases requiring immunosuppressive therapy 2
- For recipients of autologous hematopoietic stem cell transplant, RZV should be given 50-70 days post-transplantation 2
Safety Profile
Shingrix causes more injection-site reactions and systemic symptoms than placebo, but these are transient and mild-to-moderate with no serious safety concerns. 2, 3
- Injection-site reactions occur in 79.0% of recipients versus 29.5% with placebo, with 9.5% experiencing grade 3 reactions 2, 3
- Systemic symptoms occur in 11.4% of vaccine recipients versus 2.4% in placebo recipients 2
- Serious adverse events and deaths occur with similar frequencies in vaccinated and placebo groups 3
- Most side effects resolve within 4 days 2
Important Clinical Caveats
Never use live-attenuated Zostavax in immunocompromised patients—only Shingrix (RZV) is appropriate for this population. 2
- Zostavax is contraindicated in individuals with primary or acquired immunodeficiency states due to theoretical risk of serious disease from the live attenuated virus 1
- Shingrix is non-replicating and thus safe in immunocompromised persons 4
Do not confuse the waiting period after an acute herpes zoster episode (2 months) with the interval between vaccine doses (2-6 months). 2
One potential exception requires monitoring: patients with a history of herpes zoster ophthalmicus (HZO) may have a slightly increased risk of HZO recurrence after RZV. 5
- A 2024 study found an adjusted hazard ratio of 1.64 (95% CI, 1.01-2.67) for HZO recurrence within 56 days after RZV exposure in patients with prior HZO 5
- These patients may benefit from monitoring after receiving RZV in case of HZO recurrence, though vaccination is still generally recommended 5
No Booster Doses Required
No additional booster doses beyond the initial 2-dose series are currently recommended. 2