Can a 50-year-old adult with no history of chickenpox (varicella) take the shingles vaccine?

Can a 50-Year-Old Adult Without Chickenpox History Take the Shingles Vaccine?

Yes, a 50-year-old adult without a history of chickenpox can and should receive Shingrix (recombinant zoster vaccine), as the vaccine is indicated for all adults aged 50 years and older regardless of varicella history or chickenpox antibody status. 1, 2

Understanding the Clinical Context

The absence of recalled chickenpox does not mean the patient is varicella zoster virus (VZV) seronegative. Seroprevalence studies demonstrate that 88-91% of adults have VZV antibodies even when they don't recall having chickenpox, indicating subclinical or forgotten childhood infection. 2 This means most adults without chickenpox history were actually exposed to VZV and can develop shingles.

Primary Recommendation

Administer the full 2-dose Shingrix series starting immediately, with the second dose given 2-6 months after the first dose (minimum interval 4 weeks). 1, 3

Key Points:

• Shingrix is FDA-approved and indicated for prevention of herpes zoster in adults aged 50 years and older, with no requirement for prior chickenpox history or varicella serology testing. 3
• The vaccine demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 years and older, with protection sustained for at least 8 years. 1, 4
• Shingrix is a recombinant vaccine containing only varicella zoster virus glycoprotein E antigen with AS01B adjuvant—it contains no live virus and cannot cause chickenpox or shingles. 3, 4

Clinical Algorithm for Decision-Making

Step 1: Determine if Patient Meets Age Criteria

• Age ≥50 years: Proceed with Shingrix vaccination without serology testing. 1, 2, 3
• Age 18-49 years and immunocompetent: Vaccination not routinely recommended; consider varicella serology if concerned about VZV status. 2, 5
• Age 18-49 years and immunocompromised: Administer Shingrix regardless of chickenpox history. 1, 2

Step 2: For This 50-Year-Old Patient

Do not delay vaccination to obtain varicella serology. 2 The patient meets age criteria for Shingrix, and the vaccine is appropriate whether they are VZV-seropositive or seronegative:

• If VZV-seropositive (88-91% probability): Shingrix prevents herpes zoster reactivation. 2
• If VZV-seronegative (9-12% probability): Shingrix provides no benefit or harm, but the patient should subsequently receive varicella vaccine (2 doses, 4 weeks apart) for primary prevention of chickenpox. 2, 6

Important Caveats and Pitfalls

Common Misconception to Avoid

Do not confuse Shingrix (herpes zoster vaccine) with varicella vaccine (chickenpox vaccine). 2 These are different vaccines for different purposes:

• Shingrix: Prevents shingles in adults ≥50 years who have had prior VZV exposure. 3
• Varicella vaccine: Prevents primary chickenpox infection in VZV-seronegative individuals. 6

When to Consider Varicella Serology

Only consider checking VZV IgG antibodies if:

• The patient specifically requests confirmation of VZV status. 2
• The patient is immunocompromised and you need to determine if varicella vaccine is also needed. 2

If serology confirms VZV-seronegative status, administer varicella vaccine (2 doses, 4 weeks apart) in addition to or instead of Shingrix, depending on the clinical scenario. 2, 6

Administration Details

• Route: Intramuscular injection in the deltoid region. 3
• Dosing: 0.5 mL per dose after reconstitution. 3
• Timing: Second dose should be given 2-6 months after the first dose; if given beyond 6 months, effectiveness is not impaired. 1

Expected Side Effects

Counsel the patient that Shingrix causes more injection-site reactions and systemic symptoms than placebo, but these are transient and mild-to-moderate. 1, 4

• Injection-site reactions (pain, redness, swelling): 9.5% experience grade 3 reactions versus 0.4% with placebo. 1
• Systemic symptoms (myalgia, fatigue): 11.4% versus 2.4% with placebo. 1
• Most reactions resolve within 4 days. 1
• No serious safety concerns or increased mortality identified in large trials. 1, 4

Contraindications

Do not administer Shingrix if the patient has a history of severe allergic reaction (anaphylaxis) to any vaccine component or after a previous dose. 3

Special Considerations

If Patient Is or Will Become Immunocompromised

• Shingrix is safe and preferred for immunocompromised patients because it contains only recombinant protein, not live virus. 1, 2, 4
• Consider a shorter dosing schedule with the second dose at 1-2 months for immunocompromised adults. 1, 2
• Never use live-attenuated Zostavax in immunocompromised patients. 1, 4

Guillain-Barré Syndrome Risk

An increased risk of Guillain-Barré syndrome was observed during the 42 days following Shingrix vaccination in postmarketing surveillance, though this remains a rare adverse event occurring less than 1% of the time. 3, 7