What is the recommended schedule for administering the shingles vaccine, specifically the recombinant zoster vaccine (RZV), and the pneumonia vaccine, including the pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPSV), in older adults, including the timing and interval for revaccination?

Shingles and Pneumonia Vaccination Schedule for Older Adults

Shingles Vaccine (Shingrix/RZV)

For all adults aged 50 years and older, administer the recombinant zoster vaccine (Shingrix/RZV) as a 2-dose series with doses given 2-6 months apart, regardless of prior shingles history or previous Zostavax vaccination. 1, 2

Initial Vaccination Schedule

• First dose: Administer immediately upon reaching age 50 1
• Second dose: Give 2-6 months after the first dose 1, 2
• Minimum interval: 4 weeks between doses (if given too soon, repeat the dose) 1, 2

Special Timing Considerations

• After a shingles episode: Wait until acute symptoms resolve, typically at least 2 months after the episode 1, 3
• After previous Zostavax: Wait at least 2 months (8 weeks minimum) before starting Shingrix 1, 2
• For immunocompromised adults aged ≥18 years: Use a shorter schedule with the second dose at 1-2 months after the first 2

Revaccination Guidance

No booster doses are currently recommended after completing the initial 2-dose series. 2 Protection persists for at least 8 years with efficacy maintained above 83% during this period 2. The guidelines from the CDC and American College of Physicians do not recommend any additional doses beyond the initial series 2.

Critical Pitfall to Avoid

• Never use live-attenuated Zostavax in immunocompromised patients - only Shingrix is appropriate for this population 2, 3
• Even if previously vaccinated with Zostavax years ago, still give the full 2-dose Shingrix series, as Zostavax efficacy drops to only 14.1% by year 10 1, 2

---

Pneumonia Vaccines (PCV13/PCV20 and PPSV23)

For immunocompetent adults aged 65 years or older who have never received pneumococcal vaccination, the recommended sequence is PCV13 first, followed by PPSV23 at least 1 year later. 1

Standard Schedule for Adults ≥65 Years (Immunocompetent)

• If never vaccinated:

  • Give PCV13 first 1
  • Follow with PPSV23 at least 1 year after PCV13 1
  • Ensure at least 5 years have passed since any previous PPSV23 dose 1

• If previously received PPSV23 but not PCV13:

  • Give PCV13 at least 1 year after the last PPSV23 dose 1

Revaccination with PPSV23

For immunocompetent adults aged 65 or older: Only ONE dose of PPSV23 is recommended at age 65 or older. 1 Routine revaccination of immunocompetent persons is not recommended 4.

High-Risk Adults (Ages 19-64 Years)

• Chronic medical conditions (chronic heart disease excluding hypertension, lung disease, liver disease, diabetes), alcoholism, or cigarette smoking: Give 1 dose PPSV23 1

Immunocompromised Adults or Functional Asplenia

• Initial series: PCV13 followed by PPSV23 at least 8 weeks later 1
• Revaccination: Give another dose of PPSV23 at least 5 years after the previous PPSV23 1
• At age 65 or older: If already received both vaccines when younger, give one additional PPSV23 dose at least 5 years after the previous PPSV23 (note: only 1 dose PPSV23 recommended at age 65 or older) 1

Special Populations

• CSF leak or cochlear implant: PCV13 followed by PPSV23 at least 8 weeks later; at age 65 or older, give another PPSV23 at least 5 years after the previous PPSV23 1
• Dialysis patients: Both PCV13 and PPSV23 recommended; if PCV13 given first, wait 8 weeks or longer for PPSV23; if PPSV23 given first, wait 1 year for PCV13; give second PPSV23 dose 5 years after prior dose 1

Key Interval Summary

• Between PCV13 and PPSV23: At least 8 weeks for high-risk patients 1; at least 1 year for routine vaccination at age 65+ 1
• Between PPSV23 doses: At least 5 years 1, 4
• Between PPSV23 and PCV13 (if PPSV23 given first): At least 1 year 1