Is the recombinant zoster vaccine (RZV), such as Shingrix (zoster vaccine), recommended for elderly patients who have already had herpes zoster (shingles)?

Shingles Vaccination After Prior Infection in the Elderly

Direct Recommendation

Yes, the recombinant zoster vaccine (Shingrix/RZV) is strongly recommended for elderly patients who have already had shingles, as having one episode does not provide reliable protection against future recurrences. 1

Rationale for Vaccination After Prior Shingles

• Prior shingles infection does not confer adequate immunity - the 10-year cumulative recurrence risk is 10.3%, meaning approximately 1 in 10 patients will experience another episode within a decade. 1

• Natural immunity from a shingles episode is insufficient to prevent future reactivations, making vaccination essential even after documented infection. 1

• The vaccine demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50 years and older, with protection maintained above 83.3% for at least 8 years. 1, 2

Timing of Vaccination After Shingles Episode

• Wait until acute symptoms have resolved before administering the vaccine, with a practical interval of at least 2 months commonly recommended to allow for complete symptom resolution and immune system recovery. 1, 3

• There is no absolute minimum waiting period mandated by guidelines, but the 2-month interval is based on documented minimal intervals between herpes zoster episodes and allows the immune system to stabilize. 1, 3

Vaccination Schedule

• Administer the standard 2-dose series with the second dose given 2-6 months after the first dose for immunocompetent elderly patients. 1, 3

• The minimum interval between doses is 4 weeks, though the 2-6 month schedule is preferred for optimal immune response. 1

• For immunocompromised elderly patients, a shortened schedule with the second dose at 1-2 months after the first dose is recommended. 1

Key Advantages of Shingrix in This Population

• Superior efficacy compared to the older Zostavax vaccine - Zostavax efficacy declined to only 14.1% by year 10, whereas Shingrix maintains >83% efficacy for at least 8 years. 1

• Safe for immunocompromised patients - unlike the live-attenuated Zostavax, Shingrix is a recombinant vaccine containing only a viral glycoprotein fragment, making it appropriate for patients on immunosuppressive medications or with underlying immune conditions. 1, 4

• High efficacy across all age groups - efficacy remains >90% even in adults aged 70 years and older, unlike Zostavax which showed only 18% efficacy in those ≥80 years. 1

Important Clinical Considerations

• Do not delay vaccination - the patient remains vulnerable to recurrent shingles while unvaccinated, and there is no benefit to waiting beyond the 2-month post-acute episode interval. 1

• Complete both doses - full vaccination with both doses is strongly recommended for optimal protection, with 82% of vaccinated patients who develop breakthrough shingles experiencing less severe disease. 1

• Common side effects are transient - injection-site reactions occur in 9.5% (grade 3) and systemic symptoms in 11.4% of recipients, but most resolve within 4 days with no serious safety concerns identified in large trials. 1, 5

Special Populations

• Patients on glucocorticoids - concomitant low-dose glucocorticoids (prednisone equivalent <10 mg/day) do not adversely impact vaccine response, and the vaccine can be safely administered. 1

• Patients with autoimmune conditions - Shingrix is preferred over live vaccines due to safety considerations, with only mild disease flares (4-17%) reported and no statistically significant increase in flares in large database studies. 1

• Previous Zostavax recipients - patients who received Zostavax should still receive the full 2-dose Shingrix series at least 2 months after the last Zostavax dose due to inadequate long-term protection from the live vaccine. 1

Common Pitfalls to Avoid

• Never use live-attenuated Zostavax in immunocompromised patients or those about to start immunosuppressive therapy - only Shingrix is appropriate for these populations. 1, 2

• Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination - patients with prior shingles are VZV-seropositive and need shingles vaccine, not varicella vaccine. 1

• Do not assume natural immunity is sufficient - the substantial recurrence risk (10.3% at 10 years) necessitates vaccination regardless of prior infection history. 1