At what age should adults be vaccinated against herpes zoster (shingles), and which vaccine (recombinant adjuvanted Shingrix vs live‑attenuated Zostavax) is preferred?

Shingles Vaccine Age and Selection

Direct Recommendation

Adults aged 50 years and older should receive the recombinant adjuvanted vaccine (Shingrix), which is strongly preferred over the live-attenuated vaccine (Zostavax) due to superior efficacy (97.2% vs 51%) and sustained protection. 1, 2

Standard Age Threshold

• Age 50 is the FDA-approved and guideline-recommended threshold for routine Shingrix vaccination in immunocompetent adults 1, 2
• The Advisory Committee on Immunization Practices (ACIP) established age 50 as the standard recommendation, superseding older guidelines that recommended starting at age 60 for Zostavax 1, 3
• This age threshold reflects the substantial increase in herpes zoster incidence that occurs after age 50, combined with the pivotal ZOE-50 trial demonstrating 97.2% efficacy in adults ≥50 years 1

Vaccine Selection: Shingrix Over Zostavax

Shingrix is the only recommended vaccine for herpes zoster prevention due to the following critical advantages: 1

• Efficacy: Shingrix demonstrates 97.2% efficacy in adults aged 50+ years compared to Zostavax's 51% (range 46-70%) 1, 4
• Durability: Shingrix maintains >83.3% efficacy for at least 8 years, while Zostavax efficacy plummets to only 14.1% by year 10 1
• Age-independent protection: Shingrix maintains high efficacy across all age groups (89.8% in adults ≥70 years), whereas Zostavax efficacy drops dramatically with age (70% in ages 50-59 vs. 18% in those ≥80 years) 1
• Safety in immunocompromised patients: Shingrix is a non-live recombinant vaccine, making it safe for immunocompromised individuals, while Zostavax is absolutely contraindicated in this population 1, 5, 2

Dosing Schedule

• Standard schedule: Two doses given 2-6 months apart, with a minimum interval of 4 weeks 1
• Immunocompromised adults: Shortened schedule with the second dose at 1-2 months after the first dose 1, 5
• If the second dose is given beyond 6 months, effectiveness is not impaired 1

Special Population: Immunocompromised Adults Under Age 50

The only exception to the age 50 threshold is for immunocompromised adults aged ≥18 years, including those with: 5, 2

• Hematologic malignancies or solid organ malignancies
• HIV/AIDS
• Solid organ or stem cell transplant recipients
• Autoimmune diseases requiring immunosuppressive therapy (including chronic high-dose glucocorticoids ≥20 mg/day prednisone equivalent)
• Patients on biologics, JAK inhibitors, or other immunomodulators

These patients should receive Shingrix regardless of age due to their substantially elevated herpes zoster risk 5

Revaccination for Previous Zostavax Recipients

Adults who previously received Zostavax should receive the full 2-dose Shingrix series due to Zostavax's inadequate long-term protection: 1

• Administer Shingrix at least 2 months after the last Zostavax dose 1
• No maximum interval exists—patients who received Zostavax years ago should still receive Shingrix 1
• Real-world data shows additional vaccination with Shingrix after prior Zostavax lowered herpes zoster incidence from 7.54 to 2.39 per 1000 person-years 1

Vaccination After Prior Herpes Zoster Episode

• Prior shingles does not preclude vaccination—in fact, it strengthens the indication, as the 10-year cumulative recurrence risk is 10.3% 1
• Wait until acute symptoms have resolved, typically at least 2 months after the episode 1
• Administer the full 2-dose series on the standard schedule 1

Common Pitfalls to Avoid

• Never use Zostavax in immunocompromised patients—only Shingrix is appropriate due to the risk of disseminated VZV infection from live virus 1, 5
• Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination—Shingrix is not indicated for primary varicella prevention 5, 2
• Do not delay vaccination in adults ≥50 years to conduct varicella serology—vaccination is recommended regardless of recalled chickenpox history, as 88-91% of adults are VZV-seropositive even without recalled infection 6
• Do not assume immunocompetent adults under age 50 need vaccination—unless they meet immunocompromised criteria, vaccination before age 50 is not indicated 1, 5

Side Effect Profile

• Injection-site reactions (pain, redness, swelling) occur in 9.5% at grade 3 intensity vs. 0.4% with placebo 1
• Systemic symptoms (myalgia, fatigue, headache) occur in 11.4% vs. 2.4% with placebo 1
• Most side effects resolve within 4 days 1
• No serious safety concerns have been identified in large clinical trials 1