Shingles Vaccine Age Recommendations
The shingles vaccine (Shingrix) is recommended starting at age 50 years for all immunocompetent adults, and starting at age 18 years for immunocompromised adults. 1, 2, 3
Standard Age Recommendation for Immunocompetent Adults
All adults aged ≥50 years should receive the recombinant zoster vaccine (Shingrix/RZV) as a two-dose series, with the second dose administered 2-6 months after the first dose. 1, 2, 3
The minimum interval between doses is 4 weeks; if the second dose is given earlier than this, it must be repeated. 4, 2
This recommendation supersedes older guidelines that recommended starting vaccination at age 60 years with the live-attenuated vaccine (Zostavax), which is no longer preferred due to significantly inferior efficacy. 2, 5
Rationale for Age 50 Threshold
Herpes zoster incidence increases substantially with age, with the risk being relatively low in individuals under 50 years compared to older adults. 4
The pivotal ZOE-50 trial that established Shingrix's 97.2% efficacy enrolled adults aged ≥50 years, demonstrating high efficacy across all age groups 50 and older. 1, 4, 2
Protection persists for at least 8 years with efficacy maintained above 83.3%, and decreases to 73% at 10 years. 1, 4
Immunocompromised Adults: Different Age Threshold
For immunocompromised adults, vaccination is recommended starting at age 18 years, regardless of the specific condition. 1, 4, 2
Eligible Immunocompromised Populations Include:
Adults with hematologic malignancies (including multiple myeloma) receiving or having completed cancer therapy 1
Autologous hematopoietic stem cell transplant (HSCT) recipients, with the first dose given 50-70 days post-transplantation 1, 4, 6
Solid organ transplant recipients (e.g., renal transplant patients 4-18 months post-transplant) 1, 6
Patients with autoimmune inflammatory rheumatic diseases on immunosuppressive therapy 1, 4
Adults receiving JAK inhibitors, biologics, or other immunomodulators 4, 7
Modified Schedule for Immunocompromised Patients:
The second dose should be given 1-2 months after the first dose (shorter than the standard 2-6 month interval) to ensure earlier protection in this high-risk population. 1, 4, 2, 6
Prior Herpes Zoster Does Not Change Age Recommendations
Having had shingles does not justify earlier vaccination in immunocompetent adults under age 50. 4
Vaccination is recommended after a prior shingles episode once acute symptoms have resolved (typically waiting at least 2 months), but still at the standard age threshold of ≥50 years for immunocompetent individuals. 4, 2
The 10-year cumulative recurrence risk after a shingles episode is 10.3%, supporting vaccination even after prior infection. 4, 2
Important Clinical Pitfalls to Avoid
Never use the live-attenuated zoster vaccine (Zostavax) in immunocompromised patients—only Shingrix is appropriate for this population due to the risk of disseminated VZV infection from the live virus. 1, 4, 7, 6
Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination; if a patient is truly VZV-seronegative (never had chickenpox), they need varicella vaccine (2 doses, 4 weeks apart), not shingles vaccine. 4, 7
Do not delay vaccination to obtain varicella antibody titers in adults ≥50 years; guidelines explicitly state that serologic testing should not be performed before administering herpes zoster vaccination to immunocompetent adults in this age group. 4, 7
For immunocompromised adults aged 18-49 years, consider documented varicella history and serology to determine whether varicella vaccine or zoster vaccine is appropriate. 4, 7
Safety Profile
Shingrix causes significantly higher rates of injection-site reactions (9.5% grade 3 reactions vs 0.4% with placebo) and systemic symptoms (11.4% vs 2.4% with placebo), but these are transient and mild-to-moderate in intensity. 1, 2, 8
There is no difference in serious adverse events or deaths between vaccinated and placebo groups. 1, 2, 6, 8, 5