Should a patient aged 50 years or older receive the recombinant zoster vaccine (Shingrix), and what is the recommended dosing schedule and contraindications?

Shingles Vaccine for Elderly Patients

Primary Recommendation

All adults aged 50 years and older 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, regardless of prior herpes zoster history or previous Zostavax vaccination. 1

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Dosing Schedule and Administration

• Administer the first dose immediately upon patient presentation, followed by the second dose 2–6 months later (minimum interval: 4 weeks). 1
• The vaccine is given intramuscularly (IM) in the deltoid region. 1
• For immunocompromised adults aged ≥18 years, use a shortened schedule with the second dose given 1–2 months after the first dose to achieve earlier protection. 1
• If the second dose is delayed beyond 6 months, do not restart the series—simply administer the second dose as soon as possible, as there is no maximum allowable interval. 1

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Efficacy and Protection

• Shingrix demonstrates 97.2% efficacy against herpes zoster in adults aged 50 years and older, with consistent protection across all age groups. 1, 2
• In adults aged ≥70 years, efficacy remains 89.8% overall and 89.1% in those aged ≥80 years. 2
• Protection persists for at least 8 years with minimal waning, maintaining efficacy above 83.3% during this period. 1
• Real-world effectiveness studies show 70.1% effectiveness for the two-dose series and 56.9% for a single dose, confirming the importance of completing both doses. 3
• Vaccine effectiveness against postherpetic neuralgia is 76.0% in real-world settings. 3

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Superiority Over Previous Vaccine

• Shingrix (RZV) is strongly preferred over the older live-attenuated Zostavax (ZVL) due to significantly higher efficacy (97% vs. 70% initially, with Zostavax declining to only 14.1% by year 10). 1
• Adults who previously received Zostavax should still receive the full 2-dose Shingrix series, waiting at least 2 months after the last Zostavax dose. 1
• Shingrix maintains high efficacy across all age groups, while Zostavax efficacy decreased dramatically with age (70% in ages 50–59 vs. 18% in those ≥80 years). 1

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Special Populations

Immunocompromised Patients

• Shingrix is safe and recommended for immunocompromised adults aged ≥18 years, including those with:

  • Hematologic malignancies (e.g., multiple myeloma) receiving or having completed cancer therapy 1
  • Solid organ transplant recipients (4–18 months post-transplant) 1
  • Autologous hematopoietic stem cell transplant recipients (50–70 days post-transplant) 1
  • Autoimmune inflammatory rheumatic diseases on immunosuppressive therapy 1
  • HIV infection 1

• Zostavax is absolutely contraindicated in immunocompromised individuals due to risk of disseminated VZV infection. 1, 4

Patients on Glucocorticoids

• Shingrix can be safely administered to patients taking glucocorticoids, including those on low-dose prednisone (<10 mg/day). 1
• Concomitant low-dose glucocorticoids do not adversely impact vaccine response. 1

Patients Starting JAK Inhibitors (e.g., Tofacitinib)

• Complete the full 2-dose Shingrix series before starting tofacitinib whenever possible to maximize immune response. 1
• If urgent tofacitinib initiation is required, administer at least the first dose before starting therapy, with the second dose completed 1–2 months later. 1

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Contraindications

• Severe allergic reaction (e.g., anaphylaxis) to any component of Shingrix or after a previous dose. 2
• Active, untreated tuberculosis—defer vaccination until treatment is initiated. 1
• Acute moderate-to-severe illness—defer vaccination until symptoms resolve, though mild illness is not a contraindication. 1

Important: Shingrix is not contraindicated in immunocompromised individuals, unlike Zostavax. 1, 5

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Vaccination After Prior Herpes Zoster Episode

• Vaccinate regardless of prior herpes zoster history, as natural infection does not provide reliable protection against recurrence (10-year cumulative recurrence risk: 10.3%). 1
• Wait at least 2 months after acute symptoms resolve before administering the first dose. 1
• The same 2-dose schedule applies (2–6 months apart for immunocompetent adults; 1–2 months apart for immunocompromised adults). 1

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Common Side Effects

• Injection-site reactions (pain, redness, swelling) occur in 9.5% of recipients (grade 3) compared to 0.4% with placebo. 1
• Systemic symptoms (myalgia, fatigue, fever) occur in 11.4% of recipients versus 2.4% in placebo recipients. 1
• Most adverse reactions are transient, mild-to-moderate, and resolve within approximately 4 days. 1
• No serious safety concerns have been identified in large clinical trials, with similar rates of serious adverse events between vaccine and placebo groups. 1

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Important Clinical Considerations

No Serologic Testing Required

• Do not order VZV antibody titers before vaccination—guidelines explicitly recommend against serologic screening in adults aged ≥50 years. 1
• Approximately 88–91% of adults are VZV-seropositive despite lacking recalled chickenpox history, making routine testing unnecessary and cost-ineffective. 1

No Booster Doses Needed

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

Timing with Other Vaccines

• Shingrix can be administered simultaneously or sequentially with inactivated influenza vaccines, with no required waiting period. 1
• Wait until acute flu symptoms (fever, severe malaise) have resolved before receiving Shingrix. 1

Breakthrough Herpes Zoster

• Approximately 8% of vaccinated individuals may still develop shingles, but they generally experience less severe disease and lower rates of postherpetic neuralgia. 1
• If breakthrough herpes zoster occurs after the first dose, continue with the second dose 2–6 months later (or 1–2 months in immunocompromised adults). 1

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Common Pitfalls to Avoid

• Do not delay vaccination to obtain antibody titers—this contradicts guideline recommendations and leaves patients unnecessarily exposed. 1
• Do not restart the series if the second dose is delayed beyond 6 months—simply administer the second dose as soon as possible. 1
• Do not use Zostavax for revaccination or in immunocompromised patients—only Shingrix is appropriate. 1
• Do not confuse varicella (chickenpox) vaccination with herpes zoster vaccination—if a patient is VZV-seronegative, they need varicella vaccine (2 doses, 4 weeks apart), not shingles vaccine. 1
• Do not withhold vaccination in patients on low-dose immunosuppressive therapy—Shingrix is safe and effective in this population. 1