Is the Shingrix (zoster vaccine) recommended for young people, particularly those with weakened immune systems due to medical conditions or treatment, such as chemotherapy or immunosuppressive therapy?

Shingrix for Young People

Shingrix is recommended for young adults aged ≥18 years ONLY if they are immunocompromised due to disease or therapy—it is NOT recommended for healthy young adults under age 50. 1, 2

Standard Age Recommendation

• The FDA-approved and ACIP-recommended age threshold for immunocompetent adults is ≥50 years, not younger 3, 1
• Multiple international guidelines consistently recommend vaccination starting at age 50 for healthy individuals, as herpes zoster incidence increases substantially with age and risk is relatively low in those under 50 1
• The pivotal ZOE-50 trial establishing Shingrix's 97.2% efficacy enrolled adults aged ≥50 years, not younger populations 3, 1

Exception: Immunocompromised Young Adults

Young adults aged 18-49 years qualify for Shingrix vaccination if they meet specific immunocompromised criteria:

Who Qualifies (Ages 18-49)

• Patients with immunodeficiency disease or on immunosuppressive therapy 1, 2
• Chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 1
• Hematologic malignancies (multiple myeloma, leukemia, lymphoma) 1
• Solid organ malignancies receiving chemotherapy 1
• HIV/AIDS 1
• Solid organ or hematopoietic stem cell transplant recipients 1
• Autoimmune conditions requiring chronic immunosuppression (inflammatory bowel disease, rheumatoid arthritis on biologics or JAK inhibitors) 1, 4

Modified Vaccination Schedule for Immunocompromised

• Shortened schedule: First dose at Month 0, second dose at 1-2 months (rather than the standard 2-6 months for immunocompetent adults) 1, 4
• Minimum interval between doses remains 4 weeks 4

Why Shingrix Is Safe for Immunocompromised Patients

• Shingrix is a recombinant subunit vaccine containing only viral glycoprotein E—it contains NO live virus 1, 5
• This makes it fundamentally different from the older Zostavax (live-attenuated vaccine), which is absolutely contraindicated in immunocompromised individuals 1, 5
• Shingrix can be safely administered to patients on immunosuppressive therapy, including biologics, JAK inhibitors, and chemotherapy 4, 2

Important Caveats

Varicella Immunity Required First

• Shingrix is NOT indicated for prevention of primary varicella (chickenpox) 1
• Patients without prior varicella immunity (never had chickenpox or varicella vaccine) should receive varicella vaccine first if not contraindicated 1
• Do not confuse varicella vaccination with herpes zoster vaccination—they address different clinical scenarios 1

Higher Adverse Reaction Rates in Young Immunocompromised Patients

• Transplant recipients aged 18-49 years experience more frequent adverse reactions: pain (88%), fatigue (64%), myalgia (58%), and headache (44%) 1
• Most reactions are transient and mild-to-moderate in severity 3, 5
• Grade 3 injection-site reactions occur in 9.5% (vs. 0.4% placebo), and systemic symptoms in 11.4% (vs. 2.4% placebo) 3

Clinical Decision Algorithm

For a young person asking about Shingrix:

1. Age <50 and immunocompetent? → Do NOT vaccinate; wait until age 50 1
2. Age 18-49 and immunocompromised (see criteria above)? → Vaccinate with 2-dose series (1-2 months apart) 1, 2
3. Age ≥50 (regardless of immune status)? → Vaccinate with standard 2-dose series (2-6 months apart) 3, 4

Common Pitfall to Avoid

• Do not vaccinate healthy young adults under 50 simply because they had a prior shingles episode—prior herpes zoster does not change the age recommendation for immunocompetent individuals 1
• Having had shingles confirms VZV seropositivity but does not justify earlier vaccination in healthy adults 1