What are the recommendations for the shingles vaccine in adults aged 50 and older, including those with a history of shingles or weakened immune systems?

Shingles Vaccine Recommendations

Primary Recommendation for Immunocompetent Adults

All adults aged 50 years and older should receive Shingrix (recombinant zoster vaccine) 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

Key Points for Standard Vaccination

• Age threshold: Current guidelines recommend starting vaccination at age 50, not age 60, reflecting the superior efficacy of Shingrix compared to the older Zostavax vaccine 1, 2
• Efficacy: Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 and older, with protection persisting for at least 8 years with minimal waning (maintaining >83.3% efficacy) 1
• Administration: Given intramuscularly, with a minimum interval of 4 weeks between doses if the standard 2-6 month interval cannot be met 1, 2

Important Note on Historical Guidelines

While older ACIP recommendations from 2011 suggested starting vaccination at age 60 for the live-attenuated Zostavax vaccine 3, 4, 5, current 2025 guidelines universally recommend starting at age 50 with Shingrix due to its dramatically superior efficacy across all age groups 1, 2. Do not confuse these outdated age-60 recommendations with current practice.

Vaccination After Prior Shingles Episode

Patients with a history of shingles should still receive the full 2-dose Shingrix series, waiting at least 2 months after acute symptoms have resolved. 1, 2

Rationale

• Having shingles once does not provide reliable protection against future episodes, with a 10-year cumulative recurrence risk of 10.3% 1, 2
• Vaccination after a prior episode significantly reduces the risk of future recurrences 1
• The 2-month waiting period allows for complete symptom resolution and immune system recovery 1

Immunocompromised Patients: Critical Differences

For immunocompromised adults aged ≥18 years, Shingrix is recommended with a shorter dosing schedule (second dose at 1-2 months after the first dose). 1, 2

Who Qualifies as Immunocompromised

• HIV infection 3, 2
• Active cancer or hematologic malignancies 3, 2
• Solid organ or stem cell transplant recipients 3, 2
• Autoimmune diseases requiring immunosuppressive therapy 3, 2
• Patients on JAK inhibitors (e.g., tofacitinib) or other disease-modifying antirheumatic drugs 1

Critical Safety Point

Never use live-attenuated Zostavax in immunocompromised patients—only Shingrix is appropriate for this population. 1, 2 Zostavax is absolutely contraindicated due to the risk of disseminated varicella zoster virus infection from the live virus 1.

Patients Previously Vaccinated with Zostavax

All adults who previously received Zostavax should receive the full 2-dose Shingrix series, with a minimum interval of 2 months after the last Zostavax dose. 1, 2

Why Revaccination is Essential

• Zostavax efficacy declines dramatically over time, dropping to only 14.1% by year 10 1, 2
• Real-world data shows that adding Shingrix after prior Zostavax lowers herpes zoster incidence from 7.54 to 2.39 per 1,000 person-years 1
• Shingrix maintains >90% efficacy across all age groups, while Zostavax efficacy was only 18% in adults ≥80 years 1

Special Clinical Scenarios

Patients on Immunosuppressive Medications

• Glucocorticoids: Shingrix can be safely administered to patients on low-dose glucocorticoids (<10 mg/day prednisone equivalent) without adversely impacting vaccine response 1
• JAK inhibitors (e.g., tofacitinib): Complete the full 2-dose Shingrix series before starting therapy whenever possible to maximize immune response 1
• Chemotherapy patients: Shingrix can be administered during neutropenic periods, as it is not contraindicated, though timing between chemotherapy cycles (>7 days after last treatment) may optimize response 1

Timing with Other Vaccines

• Shingrix can be administered simultaneously with inactivated influenza vaccines without any required waiting period 1
• No mandatory spacing intervals are required between Shingrix and other inactivated vaccines 1
• Wait until acute flu symptoms have resolved before vaccination, but no specific waiting period is required after influenza illness 1

Real-World Effectiveness

In post-market surveillance, Shingrix demonstrates 70.1% effectiveness for the 2-dose series and 56.9% for a single dose in preventing herpes zoster. 6

Key Findings

• Two-dose effectiveness against postherpetic neuralgia is 76.0% 6
• Effectiveness is not significantly lower in adults >80 years or when the second dose is delayed beyond 6 months 6
• The vaccine remains effective in patients with autoimmune or immunosuppressive conditions 6

Common Side Effects and Safety

• Local reactions: Injection-site pain, redness, and swelling occur commonly (9.5% experience grade 3 reactions vs. 0.4% with placebo) 1
• Systemic symptoms: Myalgia, fatigue, and headache occur in 11.4% of vaccine recipients vs. 2.4% in placebo recipients 1
• Duration: Most adverse events resolve within 4 days 1, 2
• Safety profile: No serious safety concerns identified in large clinical trials, with similar rates of serious adverse events between vaccine and placebo groups 1, 2

Critical Pitfalls to Avoid

• Do not delay vaccination in adults ≥50 years waiting for them to reach age 60—current guidelines recommend starting at age 50 1, 2
• Do not skip the second dose—completing the 2-dose series is essential for optimal protection (70.1% vs. 56.9% effectiveness) 6
• Do not use Zostavax in immunocompromised patients—only Shingrix is safe for this population 1, 2
• Do not assume prior shingles provides protection—vaccination is still recommended regardless of prior history 1, 2