Shingles Vaccine: FAQs
(Updated March 2022)
The FAQ below addresses common clinical questions about the herpes zoster or shingles vaccines (Shingrix, Zostavax II [Canada]).
Question |
Answer/Pertinent Information |
What information should you know about the recombinant zoster vaccine (RZV; Shingrix)? |
Vaccine type:13,14 RECOMBINANT, non-live, adjuvantedc (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.
Adverse Reactions:
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:
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:
Zostavax II is Health Canada-approved and guideline recommended for people 50 years of age and older.2,3
|
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
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
|
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
Zostavax II can be given concomitantly (at separate sites) with other live and inactivated vaccines.2
|
How long does immunity last? |
Shingrix
Zostavax II
|
How effective is the shingles vaccine? |
Shingles
Postherpetic neuralgia (PHN)
|
What are considerations for immunocompromised patients and the shingles vaccine? |
Shingrix (Canada: generally preferred over the live shingles vaccines in immunocompromised patients.22)
Zostavax II (Canada)
|
What are considerations for pregnant and lactating patients and the shingles vaccine? |
Shingrix
Zostavax II
|
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.
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
|
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
|
- Zostavax II product monograph references U.S. efficacy and adverse reaction trial data from Zostavax (no longer available in the U.S. as of November 18, 2020).3
- Shingrix causes more injection site pain; however, Zostavax II causes more redness and swelling (indirect comparisons).3,13,a
- Quillaja saponaria Molina, fraction 21 (QS-21), and 3-0-desacyl-4-monophosphoryl lipid A (MPL) act as adjuvants to boost immune response.13,14
- Pricing based on wholesale acquisition cost (WAC). U.S. medication pricing by Elsevier, accessed March 2021.
- In general, patients with higher levels of immunosuppression (e.g., hematopoietic stem cell transplant recipients) have a higher risk of developing shingles than patients with lower levels of immunosuppression (e.g., people living with HIV, autoimmune or inflammatory conditions).37
- When there is no available documentation of varicella immunity, consider other factors to weigh risks and benefits for Shingrix vaccination (e.g., does patient recall having the chicken pox, is it highly likely that the patient previously had the chicken pox [e.g., born before 1980]).35 Patients without varicella immunity would be at risk of chicken pox, not shingles.
Abbreviations: CDC = Centers for Disease Control and Prevention; FDA = U.S. Food and Drug Administration; GI = gastrointestinal (e.g., nausea, vomiting, diarrhea, abdominal pain); HIV = human immunodeficiency syndrome; NACI = National Advisory Committee on Immunization; NNT = number needed to treat; PHN = postherpetic neuralgia.
Levels of Evidence
In accordance with our goal of providing Evidence-Based information, we are citing the LEVEL OF EVIDENCE for the clinical recommendations we publish.
Level |
Definition |
Study Quality |
A |
Good-quality patient-oriented evidence.* |
|
B |
Inconsistent or limited-quality patient-oriented evidence.* |
|
C |
Consensus; usual practice; expert opinion; disease-oriented evidence (e.g., physiologic or surrogate endpoints); case series for studies of diagnosis, treatment, prevention, or screening. |
*Outcomes that matter to patients (e.g., morbidity, mortality, symptom improvement, quality of life).
RCT = randomized controlled trial; SR = systematic review [Adapted from Ebell MH, Siwek J, Weiss BD, et al. Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004;69:548-56. http://www.aafp.org/afp/2004/0201/p548.pdf.]
References
- CDC. Protect your patients with the new shingles vaccine. https://www.cdc.gov/shingles/downloads/shingles-factsheet-hcp.pdf. (Accessed March 3, 2021).
- Herpes zoster (shingles) vaccine: Canadian immunization guide: part 4-active vaccines. Complete revision August 2018. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-8-herpes-zoster-(shingles)-vaccine.html. (Accessed March 4, 2021).
- Product monograph for Zostavax II. Merck Canada. Kirkland, QC H9H 4M7. November 2018.
- CDC. Vaccine information for adults: how to pay for vaccines. March 31, 2017. https://www.cdc.gov/vaccines/adults/pay-for-vaccines.html. (Accessed March 4, 2021).
- CDC. Shingles (herpes zoster): shingles burden and trends. August 14, 2019. https://www.cdc.gov/shingles/surveillance.html. (Accessed March 4, 2021).
- Ministry of Health. Ontario publicly funded shingles (herpes zoster) immunization program: Shingrix vaccine information for patients. http://www.health.gov.on.ca/en/public/programs/immunization/docs/shingles_patient_fact_sheet_en.pdf. (Accessed March 4, 2021).
- Cunningham AL, Lal H, Kovac M, et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med 2016;375:1019-32.
- Mayo Clinic. Postherpetic neuralgia. https://www.mayoclinic.org/diseases-conditions/postherpetic-neuralgia/symptoms-causes/syc-20376588#. (Accessed March 4, 2021).
- CDC. Vaccines and preventable diseases: what everyone should know about Zostavax. October 5, 2020. https://www.cdc.gov/vaccines/vpd/shingles/public/zostavax/index.html. (Accessed March 4, 2021).
- Tseng HF, Chi M, Smith N, et al. Herpes zoster vaccine and the incidence of recurrent herpes zoster in an immunocompetent elderly population. J Infect Dis 2012;206:190-6.
- Lal H, Cunningham AL, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med 2015;372:2087-96.
- Mills R, Tyring SK, Levin MJ, et al. Safety, tolerability, and immunogenicity of zoster vaccine in subjects with a history of herpes zoster. Vaccine 2010;28:4204-9.
- Product information for Shingrix. GlaxoSmithKline Biologicals. Research Triangle Park, NC 27709. July 2021.
- Product monograph for Shingrix. GlaxoSmithKline. Mississauga, Ontario L5N 6L4. November 2021.
- CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices-United States, 2020-21 influenza season. August 21, 2020. https://www.cdc.gov/mmwr/volumes/69/rr/rr6908a1.htm. (Accessed March 4, 2021).
- Strezova A, Lal H, Enweonye I, et al. The adjuvanted recombinant zoster vaccine co-administered with a tetanus, diphtheria and pertussis vaccine in adults ≥50 years: a randomized trial. Vaccine 2019;37:5877-85.
- Immunize Action Coalition. Ask the experts: zoster (shingles). Updated March 9, 2022. https://www.immunize.org/askexperts/experts_zos.asp. (Accessed March 15, 2021).
- American College of Rheumatology. Press release: live zoster vaccine safe and effective for people taking TNF inhibitors. November 9, 2019. https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1056. (Accessed March 4, 2021).
- CDC. Advisory Committee on Immunization Practices (ACIP): summary report. October 25-26, 2017. https://www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-2017-10-508.pdf. (Accessed April 14, 2021).
- CDC. ACIP summary report February 2017. https://www.cdc.gov/vaccines/acip/meetings/downloads/min-archive/min-2017-02.pdf. (Accessed April 14, 2021).
- Pauksens K, Volpe S, Schwarz TF, et al. Persistence of immune response to an adjuvanted varicella-zoster virus subunit candidate vaccine for up to year 9 in older adults. Poster presentation 1343. October 6, 2017. ID Week 2017. https://idsa.confex.com/idsa/2017/webprogram/Paper66091.html. (Accessed March 4, 2021).
- Immunization of immunocompromised persons. Page 8: Canadian immunization guide: part 3 – vaccination of specific populations. Updated May 2018. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-8-immunization-immunocompromised-persons.html#doa. (Accessed April 14, 2021).
- CDC. Pandemic guidance: interim guidance for routine and influenza immunization services during the COVID-19 pandemic. October 20, 2020. https://www.cdc.gov/vaccines/pandemic-guidance/index.html. (Accessed March 4, 2021).
- Health Canada. Interim guidance on continuity of immunization programs during the COVID-19 pandemic. May 13, 2020. https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/interim-guidance-immunization-programs-during-covid-19-pandemic.html. (Accessed March 4, 2021).
- Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005;352:2271-84.
- Public Health Madison & Dane County. Vaccine efficacy after one dose of Shingrix in adults ≥50 years of age. https://publichealthmdc.com/documents/Efficacy%20After%20One%20Dose%20i.pdf. (Accessed March 4, 2021).
- CDC. Morbidity and mortality weekly report (MMWR). Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. January 26, 2018. https://www.cdc.gov/mmwr/volumes/67/wr/mm6703a5.htm. (Accessed March 3, 2021).
- CDC. Vaccines and preventable diseases. Shingrix recommendations. October 5, 2020. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html. (Accessed March 4, 2021).
- Berkowitz EM, Moyle G, Stellbrink HJ. Safety and immunogenicity of an adjuvanted herpes zoster subunit candidate vaccine in HIV-infected adults: a phase 1/2a randomized, placebo controlled study. J Infect Dis 2015;211:1279-87.
- Poster presentation (1349). Infectious Diseases Society of America Conference. October 2017. Immunogenicity and safety of a candidate subunit adjuvanted herpes zoster vaccine in adults with solid tumors vaccinated before or during immunosuppressive chemotherapy treatment: a phase II/III, randomized clinical trial. https://idsa.confex.com/idsa/2017/webprogram/Paper62593.html. (Accessed March 4, 2021).
- Poster presentation (1348). Infectious Diseases Society of America Conference. October 2017. Immunogenicity and safety of a candidate subunit adjuvanted herpes zoster vaccine (HZ/su) in adults post renal transplant: a phase III randomized clinical trial. https://idsa.confex.com/idsa/2017/webprogram/Paper65338.html. (Accessed March 4, 2021).
- Poster presentation (1344). Infectious Diseases Society of America Conference. October 2017. Immunogenicity and safety of an adjuvanted herpes zoster subunit candidate vaccine in adults with hematologic malignancies: a phase III, randomized clinical trial. https://idsa.confex.com/idsa/2017/webprogram/Paper66049.html. (Accessed March 4, 2021).
- Mayo Clinic. Shingles vaccine: can I transmit the vaccine virus to others? July 14, 2020. https://www.mayoclinic.org/diseases-conditions/shingles/expert-answers/shingles-vaccine/faq-20058137. (Accessed March 8, 2021).
- CDC. Advisory Committee on Immunization Practices (ACIP). ACIP recommendations: October 2021. https://www.cdc.gov/vaccines/acip/recommendations.html. (Accessed November 16, 2021).
- CDC. Clinical considerations for use of recombinant zoster vaccine (RZV, Shingrix) in immunocompromised adults aged ≥19 years. January 20, 2022. https://www.cdc.gov/shingles/vaccination/immunocompromised-adults.html. (Accessed March 15, 2022).
- Immunize Action Coalition. Standing orders for administering recombinant zoster vaccine to adults. March 2022. https://www.immunize.org/catg.d/p3092.pdf. (Accessed March 16, 2022).
- CDC. Economics of vaccinating immunocompromised 19-49-years-old adults against herpes zoster in the US. September 29, 2021. https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-09-29/02-ZosterVaccines-OrtegaSanchez-508.pdf. (Accessed March 18, 2022).
- Personal communication (written). Sarah: Immunization Services Division. CDC. March 16, 2022.
Cite this document as follows: Clinical Resource, Shingles Vaccine: FAQs. Pharmacist’s Letter/Prescriber’s Letter. April 2021. [370435]