Ask the Experts: Zoster (Shingles): Vaccine Recommendations

Recombinant zoster vaccine (RZV, Shingrix, GSK) was licensed by the Food and Drug Administration (FDA) in October 2017. It is a subunit vaccine that contains recombinant varicella zoster virus (VZV) glycoprotein E in combination with a novel adjuvant (AS01B). Shingrix does not contain live VZV. It is FDA-approved and recommended by the Advisory Committee on Immunization Practices (ACIP) for all people 50 years and older and for adults age 19 years or older who are or will be immunodeficient or immunosuppressed because of disease or therapy. It has not been evaluated and is not approved for the prevention of primary varicella infection (i.e., chickenpox). Shingrix is administered as a 2-dose series by the intramuscular route. The second dose should be given 2 to 6 months after the first dose, with a minimum interval of 1 month (4 weeks) between doses.

Zoster vaccine live (ZVL, Zostavax, Merck) is a live attenuated vaccine that was licensed by the FDA in 2006 for adults age 50 and older and recommended by ACIP for people age 60 and older. Zostavax has been unavailable for use in the United States since November 18, 2020.

Shingrix was studied in immunocompetent adults in 2 pre-licensure clinical trials. Efficacy against shingles was 97% for people 50–59 years of age, 97% for people 60–69 years of age, and 91% for people 70 years and older. Among people 70 years and older vaccine efficacy was 85% four years after vaccination.

Vaccine effectiveness (VE) has been evaluated for a limited number of specific immunocompromising conditions. VE estimates vary depending upon the underlying cause of immunocompromise. Studies have estimated VE of 68.2% for autologous hematopoietic cell transplant recipients, and 87.2% and 90.5% for patients with hematologic malignancies and potential immune-mediated diseases, respectively.

Yes. In clinical trials among immunocompetent adults age 50 years or older, Shingrix reduced the risk of PHN by 91%. One study among hematopoietic stem cell transplant recipients reported that vaccination reduced the risk of PHN by 89%.

Yes. ACIP recommends that people who received Zostavax (the live zoster vaccine manufactured by Merck) now receive 2 doses of Shingrix recombinant zoster vaccine. The first dose of Shingrix may be given as little as 8 weeks after Zostavax. Zostavax has been unavailable in the United States since November 18, 2020.

Yes. Adults with a history of herpes zoster should receive Shingrix. If a person is experiencing an episode of zoster, vaccination should be delayed until the acute phase of the illness is over and symptoms abate.

There is no waiting period in such a situation. Shingles is not caused by exposure to another person with shingles. Shingles is caused by the reactivation of varicella zoster virus (VZV) in people who have had a prior VZV infection or varicella vaccination. However, exposure to someone with shingles can possibly cause primary varicella infection (i.e., chickenpox) in a person with no immunity to varicella zoster virus (VZV) from either vaccination or prior chickenpox infection.

Yes, unless they have a contraindication to vaccination.

No. Documented receipt of Shingrix cannot be used as proof of immunity to varicella. Shingrix has not been studied or approved for the prevention of primary varicella (i.e., chickenpox). Additionally, a dose of Shingrix cannot be counted as a dose of varicella vaccine.