Shingles Vaccine: FAQs

What information should you know about the recombinant zoster vaccine (RZV; Shingrix)?

Vaccine type:^13,14 RECOMBINANT, non-live, adjuvanted^c (to boost immunity) vaccine.

Dosing:^13,14 two IM doses 0.5 mL each. Second dose given two to six months AFTER the first dose.

• If giving to a patient who is or will be immunocompromised and the patient would benefit from a shorter immunization schedule, the second dose can be given 4 weeks (one two month) AFTER the first dose.^13,14,17
• Series does NOT need to be restarted if more than six months have elapsed between the first and second dose.
• The second dose should be repeated if given less than four weeks after the first dose.¹⁷
• It is NOT necessary to re-administer Shingrix if accidentally given subcutaneously instead of IM.¹⁷

Adverse Reactions:

• Incidence of injection site pain:^13,14,b 69% to 88%
• Systemic reactions occurring more commonly than with placebo:^13,14 myalgia, fatigue, headache, fever/chills, GI
• Adverse reactions with the first dose are not strongly predictive of adverse reactions to the second dose.¹⁷ However, headache and chills may be more common with the second dose compared to the first.¹³

Storage:^13,14 36°F to 46°F (2°C to 8°C) (lyophilized antigen [vaccine] and adjuvant suspension [diluent])

Reconstitution and stability:^13,14 Reconstitute with the diluent provided and use immediately or refrigerate between 36°F and 46°F (2°C and 8°C) and use within six hours.

What information should you know about the live-attenuated zoster vaccine (ZVL; Zostavax II [Canada])?

Vaccine type:³ LIVE-ATTENUATED vaccine

Dosing:³ single subcutaneous dose 0.65 mL

Adverse Reactions:

• Incidence of injection site pain:^3,a,b 54%
• Systemic reaction occurring more commonly than with placebo:^3,a headache

Storage:³ 2°C to 8°C or colder (vaccine); 2°C to 8°C or 20°C to 25°C (diluent)

Reconstitution and Stability:³ reconstitute with the diluent provided and use within 30 minutes of reconstitution.

At what age should the shingles vaccine be given?

Risk of getting zoster or prolonged PHN pain rises with age, primarily after 60 years of age.^5,8

Shingrix is the preferred shingles vaccine.^2,27,28 Vaccination with Shingrix is recommended:

• for people ≥50 years old.^2,13,14,28  
• for adults ≥19 years old (≥18 years [Canada]) considered at risk for shingles and who are or will be immunocompromised due to disease or therapy.^14,34,35
• even in patients who have previously been vaccinated with Zostavax (previously available in the U.S. until November 18, 2020) or Zostavax II (Canada).^2,28
  • Give Shingrix (full series) as early as one year after Zostavax II (Canada) [Evidence Level C], but especially if it has been >5 years since Zostavax (not available in U.S. since November 18, 2020) or Zostavax II was given (most of the protection is lost by then).^2,9,27,28

Zostavax II is Health Canada-approved and guideline recommended for people 50 years of age and older.^2,3

• It is NOT known if vaccination between the ages of 50 to 59 provides ongoing protection at older ages when zoster incidence and risk of complications is higher.² (See duration of Zostavax II immunity below.)

Should patients who’ve had shingles receive the vaccine?

For immunocompetent patients with an indication for Shingrix, vaccination is recommended regardless of shingles or chickenpox history.^2,28

• More than 99% of adults ≥50 years old have been exposed to the varicella-zoster virus.²⁸

Yes, immunocompromised patients ≥19 years old (≥18 years old [Canada]) who’ve previously been diagnosed with shingles by a healthcare provider should receive Shingrix.³⁵

Different safety concerns are not expected in persons with a history of shingles.^2,12

How long after a shingles episode can the vaccine be given?

Re-occurrence risk is low for up to 18 months after shingles due to residual immunity in immunocompetent patients.¹⁰

CDC: Wait until the acute stage shingles illness is over (i.e., symptoms subsided) to be vaccinated with Shingrix.²⁸

NACI: Wait until one year has elapsed between the last shingles episode and zoster vaccination.²

• Herpes ophthalmicus has recurred following shingles vaccination (Zostavax II).² Causality has NOT been established, but inform patients that the risk/benefit is unknown.²

Can the shingles vaccine be administered with other vaccines or medications?

Shingrix can be given concomitantly (at separate sites) with live or inactivated vaccines, including the pneumococcal vaccine and Tdap [Evidence Level B-1].^2,16,17,27

• There are theoretical concerns about more side effects when giving two adjuvanted vaccines at the same time.¹⁵
  • Co-administration with adjuvanted flu vaccines (e.g., Fluad) has not been studied. However, don’t delay vaccination if only an adjuvanted flu vaccine is available.¹⁵ If an adjuvanted flu vaccine needs to be given with Shingrix, administer at separate sites.¹⁵

Zostavax II can be given concomitantly (at separate sites) with other live and inactivated vaccines.²

• If Zostavax II is not given simultaneously (at separate injection sites) with another live injectable vaccine, separate the vaccines by ≥4 weeks.² Four-week separation does NOT apply to live oral or intranasal vaccines.²
• When possible, administer Zostavax II ≥24 hours after discontinuation of an antiviral agent active against herpes viruses (acyclovir, famciclovir, etc). Avoid restarting the antiviral for at least 14 days after vaccination.²
  • This is NOT a concern with Shingrix, as it is a recombinant vaccine (e.g., does not contain live virus).¹⁷

How long does immunity last?

Shingrix

• Immune response appears to be maintained at least nine years after vaccination based on cellular response.^20,21
  • It is unclear if this correlates to continued protection against shingles and PHN.^20,21
• Maintains >90% efficacy regardless of age at least four years after vaccination.¹⁹
  • Maintains about 88% efficacy four years after vaccination in patients vaccinated at 70 years of age or older.⁷

Zostavax II

• Protection against zoster seems to last up to three years. Efficacy five years after vaccination is not known.²
• Though studies are ongoing, there is no current recommendation for a booster or revaccination.²

How effective is the shingles vaccine?

Shingles

• Shingrix: NNT ~37 patients to prevent one case of shingles over about three years in patients ≥50 years old.¹¹
  • Clinical trials have NOT been conducted to evaluate the efficacy of Shingrix if just one dose is received.²⁶
  • There is insufficient data available from post-hoc analyses to accurately predict the efficacy of Shingrix in patients that have only received one dose.²⁶
• Zostavax II NNT: ~59 patients to prevent one case of shingles over about three years in patients >60 years old.^3,a

Postherpetic neuralgia (PHN)

• All available vaccines have an NNT ~350 to prevent one case of PHN over about three years.^7,25

What are considerations for immunocompromised patients and the shingles vaccine?

Shingrix (Canada: generally preferred over the live shingles vaccines in immunocompromised patients.²²)

• Data are growing about the safety and efficacy in immunocompromised patients, specifically in patients with HIV, hematologic cancers, post-transplant (renal and hematologic), and during chemotherapy.13,14,29-32
  • Shingrix is approved for use in adults ≥19 years old (≥18 years old [Canada]) who are considered at risk for shingles and are or will be immunocompromised due to disease or therapy.^13,14,34
    • patients ≥50 years old (age group has a higher baseline risk of PHN³⁷): recommend vaccination in patients with low- or high-level immunosuppression.^{13,14,34,38,e}
    • patients 19 to 49 years old (Canada: 18 to 49 years old) (age group has a lower baseline risk of PHN³⁷):
      • recommend vaccination in patients with high-level immunosuppression.^38,e
      • consider use (weighing possible benefits and risks) in patients with low-level immunosuppression (e.g., taking prednisone chronically at doses <20 mg/day).^38,e
  • Assess and document the need for Shingrix vaccination (varicella immunity) using one of the following: previously received two doses of a varicella vaccine, lab evidence of immunity or confirmation of disease, or diagnosis or verification of a history of chicken pox or shingles by a healthcare provider.^35,f
  • If giving Shingrix as a part of a standing order, consider involving the medical director or the patient’s prescriber for the immunocompromising condition.³⁶
  • Optimal timing of Shingrix vaccination may vary based on the patient’s immunocompromising condition. CDC provides guidance on timing at https://www.cdc.gov/shingles/vaccination/immunocompromised-adults.html.³⁵ 

Zostavax II (Canada)

• Contraindicated (expert consultation is advised in complex cases) in patients with:^2,3,22
  • primary immune deficiency (e.g., disorders of T-cell function)
  • acquired immune deficiency (e.g., blood dyscrasia, chemotherapy, radiation therapy, organ or stem cell transplant, cancer affecting the bone marrow or lymphatics, HIV if CD4 count is <200 10⁶ cells/L).
  • leukocyte adhesion defect, Chediak-Higashi syndrome and other defects in cytotoxic granule release, and in undefined phagocytic cell defects.
• When indicated (though Shingrix is preferred) can give to patients:²²
  • with complement deficiency, neutropenia, or certain phagocytic defects (e.g., chronic granulomatous disease), or HIV with CD4 counts ≥200 x 10⁶/L.²²
  • taking antitumor necrosis factor biologics (TNF inhibitors), or on low-level immunosuppressive therapy (e.g., less than 14 days’ corticosteroid use, prednisone <20 mg daily or its equivalent, topical or inhaled corticosteroid, corticosteroid joint injection, methotrexate ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine ≤1.5 mg/kg/day).^18,22
  • at least four weeks before immunosuppressive therapy, four weeks after high-dose corticosteroids, or three months after other immunosuppressive drugs (e.g., cyclosporine, chemo).

What are considerations for pregnant and lactating patients and the shingles vaccine?

• It is generally not necessary to avoid being around pregnant patients or young children after receiving either shingles vaccine, as there are not any documented cases of transmission from vaccinated adults.³³
  • If a patient develops a rash after receiving a live zoster vaccine (Zostavax II), recommend covering the rash until the bumps crust over as a precaution against possible transmission.³³

Shingrix

• There are not enough data available to establish if there is risk with use in pregnant or breastfeeding patients.^13,14

Zostavax II

• Contraindicated during pregnancy.^2,3
• Patients should not become pregnant until at least three months after getting the vaccine.^2,3

What are COVID-19 pandemic-related considerations with the shingles vaccine?

In the U.S.:²³ Continue to give due or overdue shingles vaccine doses during the pandemic.

• Vaccine series does NOT need to be restarted if more than six months have elapsed since the first dose before the second dose is given.¹⁷

In Canada:²⁴ When possible, combine the shingles vaccination visit with another medical visit, to limit possible COVID-19 exposure risk. Consider deferring the second dose of Shingrix up to six months (12 months between the first and second dose). Base the timing of the second vaccination on local COVID-19 community transmission risk.

See our chart, FAQs: Immunizations During COVID-19, for answers to common questions, including guidance on counseling patients about systemic side effects that might mimic COVID-19 symptoms.

In the U.S., what are cost considerations with the shingles vaccine?

Shingrix costs about $340 total for the two-dose series and is covered by:^1,4,d

• Medicare Part D or Medicare Advantage Plan Part C
• most private insurance plans (i.e., for patients between the ages of 50 and 65)

In Canada, what are cost considerations with the shingles vaccine?

In Ontario, patients 65 to 70 years of age can receive Shingrix free of charge from their primary care provider (transitioned from providing Zostavax II to Shingrix in October 2020).⁶ Patients who:⁶

• received publicly funded Zostavax II are NOT eligible to receive publicly funded Shingrix.
• paid out-of-pocket for Zostavax II ARE eligible to receive publicly funded Shingrix.
• were born in 1949 or 1950 but missed the chance to receive the publicly funded shingles vaccine due to the COVID-19 pandemic are eligible to receive Shingrix through this program.
• are from other provinces or who do NOT meet the age criteria can pay about $280 for the two-dose Shingrix series (preferred over Zostavax II²) or about $200 for Zostavax II.^d