Shingles Vaccination for Immunocompromised Adults

In January 2022, the Centers for Disease Control and Prevention (CDC) updated recommendations for shingles (herpes zoster) vaccination to include people 19 years and older who are or will be immunocompromised. This will enable providers to vaccinate immunocompromised patients against shingles at a time most appropriate for their medical circumstances.

Here’s what you should know about the expanded recommendation.

Why is this update important?

Shingles vaccination is the best way to protect against shingles and postherpetic neuralgia, the most common complication from shingles. Although there is heterogeneity within and across groups, immunocompromised adults generally have a higher risk of developing shingles and having severe disease such as disseminated zoster, which can lead to death. Prior to this update, CDC had recommended two doses of recombinant zoster vaccine (Shingrix), separated by 2-6 months, for immunocompetent adults 50 years and older. Additionally, zoster vaccine live (Zostavax), which was in use from 2006 until November 2020 when it was no longer available in the United States, was contraindicated for most immunocompromised patients. Shingrix can address an unmet need for shingles prevention in immunocompromised adults.

Who is included?

The updated recommendation includes people 19 years and older who are or will be immunocompromised because of an underlying condition or therapy, such as hematopoietic cell transplant recipients, solid organ transplant recipients, patients with cancer, people living with HIV, and people with autoimmune and inflammatory conditions.

For more detailed guidance for selected immunocompromising conditions and other special populations, see Clinical Considerations for Use of Recombinant Zoster Vaccine (RZV, Shingrix) in Immunocompromised Adults Aged ≥19 Years | CDC.

What is the best time for vaccination?

When possible, patients should be vaccinated before becoming immunosuppressed, such as before transplant or before starting immunosuppressive therapy. If vaccination before immunosuppression is not possible, providers should consider timing vaccination when the immune response is likely to be most robust. To assess the general level of immune competence in a patient, clinicians should consider various factors, including disease severity and duration, clinical stability of the patient, their complications and comorbidities, and any ongoing or planned potentially immunosuppressing treatment. Consulting with the clinician most responsible for managing the patient’s immunocompromising condition or therapy can also be helpful. For more guidance on timing, see Herpes Zoster Shingrix Vaccine Recommendations | CDC.

What is the dosing in this population?

Two doses of Shingrix are necessary regardless of previous history of herpes zoster or previous receipt of Zostavax. The second dose of Shingrix should typically be given 2-6 months after the first. However, for immunocompromised patients who would benefit from completing the series in a shorter period, the second dose can be administered 1-2 months after the first dose. For example, a shorter interval between doses may help a person avoid vaccination during periods of more intense immunosuppression.

Will my immunocompromised patient experience side effects from the vaccine?

Most patients experience mild to moderate side effects following vaccination with Shingrix, and some experience side effects that prevent everyday activities. Before vaccination, providers should counsel patients about expected local and systemic reactions. Local (eg, redness, pain, swelling at the injection site) or systemic (eg, fever, chills, headache, body aches) reactions typically resolve within 72 hours after vaccination. Patients should be encouraged to complete the vaccination series even if they experienced a (nonanaphylactic) reaction after the first dose of Shingrix. For tips on patient counseling, see About Herpes Zoster Shingrix Vaccine: For Providers | CDC.

Should people younger than 50 years who previously had shingles get vaccinated with Shingrix?

Shingles can recur, so people with a history of herpes zoster who are eligible for Shingrix (adults 50 years and older and immunocompromised adults 19 years and older) should receive Shingrix. However, a history of shingles alone is not considered an immunocompromising condition. Therefore, Shingrix would not be recommended for a patient younger than 50 years solely because they previously had shingles. If an immunocompromising condition is suspected in such a patient, they should be further evaluated, and if diagnosed with an immunocompromising condition, vaccination with Shingrix should then be considered.