Herpes Zoster Prevention in Adults Over 50
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, regardless of prior shingles history or previous Zostavax vaccination. 1, 2
Vaccine Selection and Superiority
Shingrix is the only recommended vaccine for herpes zoster prevention in adults over 50, demonstrating 97.2% efficacy in preventing shingles compared to Zostavax's initial efficacy of 51% that declines to only 14.1% by year 10 2, 3
Protection with Shingrix persists for at least 8 years with minimal waning, maintaining efficacy above 83.3% during this period 2
The older live-attenuated vaccine (Zostavax) is no longer recommended due to poor long-term protection and contraindications in immunocompromised patients 1, 2
Standard Dosing Schedule
Administer the first dose immediately upon reaching age 50, followed by the second dose 2-6 months later 2
The minimum interval between doses is 4 weeks; if the second dose is given earlier than this, it should be repeated 2
If the second dose is delayed beyond 6 months, effectiveness is not impaired—simply complete the series without restarting 2
Special Population Considerations
Immunocompromised Adults
For immunocompromised adults aged ≥18 years, use a shortened schedule with the second dose given 1-2 months after the first dose 2, 4
Shingrix is safe for immunocompromised patients because it contains only a recombinant protein fragment, not live virus 1, 4
Eligible immunocompromised populations include those with hematologic malignancies, solid organ transplant recipients, HIV infection, and patients on chronic immunosuppressive therapy (including biologics, JAK inhibitors, or high-dose glucocorticoids ≥20 mg/day prednisone equivalent) 2, 4
Prior Zostavax Recipients
Adults who previously received Zostavax should receive the full 2-dose Shingrix series at least 2 months after the last Zostavax dose 2
This recommendation applies regardless of how long ago Zostavax was given, as it provides inadequate long-term protection 2
Prior Shingles Episode
Vaccinate all adults ≥50 years regardless of prior shingles history, waiting at least 2 months after acute symptoms resolve 2
Having shingles once does not provide reliable protection, with a 10-year cumulative recurrence risk of 10.3% 2
Administration Details
Administer intramuscularly (IM) 2
Shingrix can be given simultaneously with inactivated influenza vaccines without any required waiting period 2
Wait until acute illness symptoms (fever, severe malaise) have resolved before vaccinating, but no specific waiting period is required after recovery 2
Common Pitfalls to Avoid
Never use live-attenuated Zostavax in immunocompromised patients—only Shingrix is appropriate for this population 1, 2
Do not delay vaccination to conduct varicella serology in adults ≥50 years—vaccinate based on age alone 5
Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination; if a patient is truly VZV-seronegative (never had chickenpox), they need varicella vaccine first, not Shingrix 5
Do not assume that patients without recalled chickenpox history are at zero risk—88-91% of adults have VZV antibodies even without remembered infection 5
Expected Side Effects
Injection-site reactions (pain, redness, swelling) occur commonly, with 9.5% experiencing grade 3 reactions compared to 0.4% with placebo 2
Systemic symptoms (fatigue, myalgia, headache) were reported in 11.4% of vaccine recipients versus 2.4% in placebo recipients 2
Most side effects resolve within 4 days and are transient 2
No serious safety concerns have been identified in large clinical trials 2