What are the guidelines for administering the Shingrix (zoster) vaccine to adults, particularly those with a history of shingles or weakened immune system due to disease or therapy?

Shingrix Vaccination Guidelines

Primary Recommendation for Standard Adults

All adults aged 50 years and older should receive the 2-dose Shingrix series, administered intramuscularly 2-6 months apart, regardless of prior shingles history or previous Zostavax vaccination. 1, 2

• The minimum interval between doses is 4 weeks, though the standard 2-6 month schedule is preferred 2
• If the second dose is given beyond 6 months, effectiveness remains intact with no impairment 2, 3
• Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50+ years, with protection sustained above 83.3% for at least 8 years 2, 4

Immunocompromised Adults: Earlier Vaccination and Modified Schedule

Adults aged 18 years and older who are immunocompromised or will become immunocompromised should receive Shingrix with a shortened schedule: second dose at 1-2 months after the first dose. 2, 5

Who Qualifies as Immunocompromised:

• Patients on chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 5
• Those with hematologic malignancies, solid organ malignancies, or HIV/AIDS 5
• Hematopoietic stem cell transplant recipients (administer 50-70 days post-transplant) 2
• Patients on immunosuppressive therapy including biologics, JAK inhibitors (like tofacitinib), or disease-modifying antirheumatic drugs 2, 5
• Solid organ transplant recipients 5

Critical distinction: Shingrix is a non-live recombinant vaccine, making it safe for immunocompromised patients, whereas Zostavax (live-attenuated) is absolutely contraindicated in this population. 1, 2, 4

Vaccination After a Shingles Episode

Administer Shingrix once acute symptoms have resolved, typically waiting at least 2 months after the episode. 2

• Prior herpes zoster does not provide reliable protection against recurrence (10.3% cumulative recurrence risk at 10 years) 2
• Vaccination is recommended regardless of prior shingles history because natural immunity is insufficient 2
• The 2-month waiting period allows for complete symptom resolution and immune system recovery 2

Patients Previously Vaccinated with Zostavax

All adults who previously received Zostavax should receive the full 2-dose Shingrix series, with at least 2 months between the last Zostavax dose and first Shingrix dose. 2

• Zostavax efficacy declines dramatically to only 14.1% by year 10, making revaccination essential 2
• Shingrix demonstrates superior and sustained efficacy compared to Zostavax across all age groups 2, 4
• Real-world data shows additional vaccination with Shingrix after prior Zostavax lowered herpes zoster incidence from 7.54 to 2.39 per 1000 person-years 2

Special Timing Considerations for Immunosuppressive Therapy

Before Starting JAK Inhibitors (e.g., Tofacitinib):

Complete the full 2-dose Shingrix series before initiating tofacitinib whenever possible to maximize immune response while not yet immunosuppressed. 2

Algorithm for timing:

• Elective start: Give first Shingrix dose immediately → wait 2-6 months → give second dose → start tofacitinib after completing vaccination series 2
• Urgent start: Give first Shingrix dose → start tofacitinib 2-3 weeks after first vaccine dose → complete second Shingrix dose 1-2 months later 2

During Active Chemotherapy or Neutropenia:

Shingrix can be administered during neutropenic periods, as it is a non-live vaccine with no contraindication during neutropenia. 2

• Consider administering between chemotherapy cycles (>7 days after last treatment) when feasible to optimize vaccine response 2
• Never use live-attenuated Zostavax in patients receiving chemotherapy or immunosuppressive therapy 2

Common Pitfalls and Caveats

Do NOT:

• Use Zostavax in immunocompromised patients of any age—only Shingrix is appropriate 1, 2, 5
• Delay vaccination in adults ≥50 years to conduct varicella serology testing 6
• Confuse varicella (chickenpox) vaccination with herpes zoster vaccination 6
• Assume that having had shingles provides adequate protection against future episodes 2

Important Clinical Considerations:

• Shingrix causes more injection-site reactions (9.5% grade 3 reactions) and systemic symptoms (11.4%) compared to placebo, but these are transient and mild-to-moderate 2, 4
• Patients on low-dose glucocorticoids (<10 mg/day prednisone) maintain adequate vaccine response 2
• No serious safety concerns have been identified in large clinical trials 2, 4
• Mild disease flares (4-17%) may occur in patients with autoimmune conditions, but no serious adverse events have been documented 2

Breakthrough Cases: Understanding Residual Risk

Even with Shingrix's 92% real-world effectiveness at 3.2 years, approximately 8 out of 100 vaccinated individuals may still develop shingles. 2, 3

• Vaccinated individuals who develop breakthrough shingles generally experience less severe disease and lower rates of postherpetic neuralgia 2
• Vaccine-induced immunity varies based on baseline immune function, age, and concurrent immunosuppressive conditions 2
• The substantial risk reduction (92% for Shingrix vs. 51% for Zostavax) far outweighs the residual breakthrough risk 2

No Booster Doses Currently Recommended

No additional booster doses beyond the initial 2-dose series are recommended by any current guidelines. 2

• Protection remains above 83.3% for at least 8 years, with efficacy of 73% at 10 years 2, 5

Vaccination Timing with Other Vaccines

Shingrix can be administered simultaneously or sequentially with inactivated influenza vaccines, with no required waiting period between them. 2

• Wait until acute flu symptoms (fever, severe malaise) have resolved before receiving Shingrix 2
• No specific waiting period is required after influenza illness before receiving Shingrix 2
• Live vaccines require a 4-week interval if not given simultaneously, but this does not apply to Shingrix (non-live vaccine) 2