Can a Patient with a History of Chickenpox Receive the Herpes Zoster Vaccine?
Yes, patients with a history of chickenpox (varicella) should absolutely receive the herpes zoster vaccine—in fact, having had chickenpox is precisely why they need it. The recombinant zoster vaccine (Shingrix) is specifically designed to prevent shingles, which only occurs in people who have previously been infected with varicella-zoster virus, whether through natural chickenpox or varicella vaccination 1.
Key Principles
Prior chickenpox infection or varicella vaccination is not a contraindication to zoster vaccination—it is the fundamental prerequisite. The zoster vaccine prevents reactivation of latent varicella-zoster virus that remains dormant in nerve ganglia after the initial chickenpox infection 1, 2.
Vaccine Eligibility and Timing
Standard Recommendations
All adults aged 50 years and older with a history of chickenpox should receive the recombinant zoster vaccine (Shingrix), regardless of their immune status 3, 1
Two doses should be administered, with the standard interval being 2-6 months, though this can be reduced to 4 weeks if early protection is desired 1, 3
The vaccine remains immunogenic even if the patient previously received varicella vaccination rather than having natural chickenpox 1
Special Populations Requiring Earlier Vaccination
Patients aged 18 and older starting JAK inhibitors should receive zoster vaccination regardless of age 3
Patients aged 50 or over receiving any immunomodulators or advanced therapies (including biologics, corticosteroids ≥20 mg/day prednisolone for ≥2 weeks, purine analogues, methotrexate) should be vaccinated 3
Cancer patients should receive the vaccine, ideally immediately after diagnosis and before starting immunosuppressive treatments for optimal response, though it remains effective even after treatment has begun 3
Critical Safety Distinction: Recombinant vs. Live Vaccine
The recombinant zoster vaccine (Shingrix) is NOT a live vaccine and is safe for immunocompromised patients 1, 2. This is a crucial distinction from the older live attenuated zoster vaccine (Zostavax), which:
- Is no longer marketed in the United States 1
- Was contraindicated in immunocompromised patients 3
- Should not be confused with the current recombinant vaccine 1
Timing Considerations for Immunosuppressed Patients
Optimal Timing
Ideally administer ≥4 weeks before starting highly immunosuppressive therapy to allow for optimal immune response 3
For patients aged 60 years and older, vaccination should be given before beginning highly immunosuppressive therapy 3
During Immunosuppression
The recombinant vaccine can be safely administered during immunosuppressive therapy, though humoral and cellular responses may be somewhat lower than if given before treatment 3, 1
Patients on low-level immunosuppression can receive the vaccine without waiting 3
After Immunosuppression
- Live vaccines (not applicable to recombinant zoster vaccine) should be avoided for at least 3 months after discontinuing immunosuppressive therapies 3—but again, the recombinant zoster vaccine is not a live vaccine and does not have this restriction 1
Previous Shingles Episode
Patients who have already experienced herpes zoster should still receive the vaccine to prevent future episodes 3. There is no specific waiting period before immunization, as long as the acute episode has resolved 3.
Common Pitfalls to Avoid
Do not confuse the recombinant zoster vaccine (Shingrix) with the old live vaccine (Zostavax)—the safety profiles and indications are completely different 1, 2
Do not withhold vaccination from immunocompromised patients based on outdated contraindications that applied only to the live vaccine 1
Do not assume that a history of varicella vaccination (rather than natural chickenpox) is a contraindication—the vaccine works in both populations 1
Do not delay vaccination in cancer patients waiting for an "optimal" window—the vaccine remains effective even during treatment 3
Expected Adverse Events
Grade 3 local adverse events (injection-site pain) occur in 12-13% of vaccine recipients 3
Grade 3 general adverse events (fatigue, myalgia) occur in 16-22% of vaccine recipients compared to 6-16% with placebo 3
These reactions, while common, should not deter vaccination given the significant morbidity associated with herpes zoster and postherpetic neuralgia 4, 5