What are the current herpes zoster (shingles) vaccination recommendations for adults, including age criteria, immunocompetent versus immunocompromised status, prior Zostavax receipt, contraindications, and coadministration with other vaccines?

Shingles Vaccine Guidelines

Primary Recommendation for Immunocompetent Adults

All immunocompetent adults aged ≥50 years should receive the 2-dose Shingrix (recombinant zoster vaccine, RZV) series, with the second dose administered 2–6 months after the first dose, regardless of prior herpes zoster history or previous Zostavax vaccination. 1

Standard Dosing Schedule

• Administer the first dose immediately upon reaching age 50 1
• Give the second dose 2–6 months after the first dose 1
• The minimum interval between doses is 4 weeks; if given earlier, the dose must be repeated 1
• Administer intramuscularly (IM) 1

Efficacy and Duration

• Shingrix demonstrates 97.2% efficacy in preventing herpes zoster in adults aged 50+ years 1
• Protection remains ≥83.3% for at least 8 years, declining to approximately 73% at 10 years 1
• Efficacy is maintained consistently across all age groups ≥50 years, unlike Zostavax which dropped to only 18% efficacy in those ≥80 years 1

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Immunocompromised Adults: Expanded Indications

Immunocompromised adults aged ≥18 years should receive Shingrix using a shortened 2-dose schedule, with the second dose given 1–2 months after the first dose. 1, 2

Eligible Immunocompromised Populations

• Hematologic malignancies (multiple myeloma, leukemia, lymphoma) 1
• Solid organ transplant recipients (administer 4–18 months post-transplant) 1
• Autologous hematopoietic stem cell transplant recipients (give 50–70 days post-transplant) 1
• Solid tumors receiving chemotherapy 1
• HIV/AIDS 2
• Autoimmune inflammatory rheumatic diseases on immunosuppressive therapy 1
• Chronic high-dose glucocorticoids (≥20 mg/day prednisone equivalent) 2
• JAK inhibitor therapy (tofacitinib, baricitinib, upadacitinib) 1
• Inflammatory bowel disease on immunomodulators or advanced therapies 1

Modified Schedule Rationale

• The shortened 1–2 month interval achieves earlier protection in high-risk patients 1
• Demonstrated 87.2% vaccine efficacy in hematologic malignancy patients using this schedule 1
• The 4-week minimum interval still applies 1

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Contraindications

The only absolute contraindication to Shingrix is a history of severe allergic reaction (anaphylaxis) to any component of the vaccine. 3

Critical Safety Points

• Live-attenuated Zostavax is absolutely contraindicated in all immunocompromised patients due to risk of disseminated VZV infection 1, 2
• Shingrix (RZV) is a non-live recombinant vaccine and is safe for immunocompromised patients 1
• Moderate or severe acute illness is a precaution, not a contraindication; defer vaccination until symptoms resolve 1

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Prior Zostavax Recipients

Adults who previously received Zostavax should receive the full 2-dose Shingrix series, waiting at least 2 months after the last Zostavax dose. 1

Rationale for Revaccination

• Zostavax efficacy declines dramatically to only 14.1% by year 10 1
• Shingrix provides superior and sustained protection 1
• Real-world data show revaccination with Shingrix after Zostavax lowered herpes zoster incidence from 7.54 to 2.39 per 1000 person-years 1
• No maximum interval exists; patients vaccinated with Zostavax a decade ago should receive Shingrix immediately 1

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Vaccination After Herpes Zoster Episode

Administer Shingrix once acute symptoms (rash, pain, fever) have resolved, typically waiting at least 2 months after the episode. 1

Clinical Rationale

• Prior herpes zoster does not provide reliable protection against recurrence 1
• The 10-year cumulative recurrence risk is 10.3% 1
• Vaccination is recommended regardless of prior shingles history 1
• For immunocompetent adults, use the standard 2–6 month interval between doses 1
• For immunocompromised adults, use the shortened 1–2 month interval 1

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Coadministration with Other Vaccines

Shingrix can be administered simultaneously with inactivated influenza vaccines and other inactivated vaccines without any required waiting period. 1

Practical Implementation

• No spacing interval is required between Shingrix and other inactivated vaccines 1
• Administer at different anatomic sites if given simultaneously 1
• Wait until acute flu symptoms have resolved before vaccinating 1
• Live vaccines require a 4-week interval if not given simultaneously, but this does not apply to Shingrix 1

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Timing with Immunosuppressive Therapy

Complete the full 2-dose Shingrix series before starting immunosuppressive therapy (e.g., JAK inhibitors, biologics) whenever possible to maximize immune response. 1

Algorithm for Tofacitinib or Other JAK Inhibitors

• Elective start: Give first Shingrix dose immediately → wait 2–6 months → give second dose → start JAK inhibitor 1
• Urgent start: Give first Shingrix dose → start JAK inhibitor 2–3 weeks later → complete second dose 1–2 months after first dose 1
• Never use live Zostavax in patients on or about to start JAK inhibitors 1

Glucocorticoid Considerations

• Shingrix can be safely administered to patients on low-dose glucocorticoids (<10 mg/day prednisone equivalent) without adversely impacting vaccine response 1
• Consider holding immunosuppressive medications for an appropriate period before and 4 weeks after vaccination to optimize immune response when feasible 1

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Delayed Second Dose Management

If the second dose is delayed beyond 6 months, administer it as soon as possible; do not restart the series. 1

Key Points

• There is no maximum interval after the first dose 1
• The first dose remains valid regardless of elapsed time 1
• Do not give a third dose under any circumstance 1
• Do not order serologic testing to assess whether the first dose "still counts" 1
• Real-world data show second doses given ≥180 days maintain full effectiveness 1

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Serologic Testing: Not Recommended

Do not perform varicella-history review or laboratory testing before administering Shingrix to adults ≥50 years. 1

Evidence-Based Rationale

• 88–91% of adults are VZV-seropositive despite lacking recalled chickenpox history 1
• Herpes zoster arises from reactivation of latent VZV due to declining cell-mediated immunity, not from low antibody titers 1
• Antibody levels do not reliably predict zoster risk 1
• Routine serologic screening adds unnecessary cost and delays protective vaccination 1
• No safety concerns exist when giving Shingrix to VZV-seronegative individuals 1

Exception: Immunocompromised Adults <50 Years

• Consider age, documented prior varicella (or vaccination), and serology when deciding on RZV for immunocompromised adults under 50 1
• If documented VZV-seronegative, give 2-dose varicella vaccine series (4 weeks apart) rather than zoster vaccine 1

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Booster Doses

No additional booster doses beyond the initial 2-dose series are currently recommended. 1

• Protection persists for at least 8 years with minimal waning 1
• No guideline recommends a third dose at this time 1

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Common Adverse Reactions

Shingrix causes significantly more injection-site reactions and systemic symptoms than placebo, but these are transient and resolve within approximately 4 days. 1

Frequency of Adverse Events

• Grade 3 injection-site reactions: 9.5% (vaccine) vs. 0.4% (placebo) 1
• Systemic symptoms (fever, fatigue, myalgia, headache): 11.4% (vaccine) vs. 2.4% (placebo) 1
• Serious adverse events and mortality: no difference between vaccine and placebo groups 1

Special Population Considerations

• Transplant recipients aged 18–49 years report higher rates: pain (88%), fatigue (64%), myalgia (58%), headache (44%) 2
• Patients with autoimmune conditions on glucocorticoids showed only mild disease flares (4–17%) with no serious adverse events 1

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Critical Pitfalls to Avoid

• Never use Zostavax in immunocompromised patients—only Shingrix is appropriate 1, 2
• Do not delay vaccination to obtain antibody titers; this contradicts guidelines and leaves patients vulnerable 1
• Do not restart the series if the second dose is delayed; simply give the second dose 1
• Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination—they are different vaccines for different indications 1
• Do not withhold Shingrix from patients on low-dose glucocorticoids—the vaccine remains effective 1
• Do not give a third dose—the series consists of only two doses 1