Version July 2025
INTRODUCTION —
Varicella-zoster virus (VZV) infection causes two clinically distinct diseases. Primary infection with VZV results in varicella, also known as chickenpox, which is characterized by a VZV viremia that is the source of a rash, macules that become papules, and then vesicles over a five to seven-day interval. The lesions, which may be at different stages of development, are concentrated on the face and trunk and to a lesser extent on the extremities.
Herpes zoster, also known as shingles, results from reactivation of latent VZV (established during varicella infection) in neurons within sensory and cranial nerve ganglia. Herpes zoster is characterized by a painful, unilateral vesicular eruption that occurs in a restricted dermatomal distribution.
Vaccines are available for the prevention of both infections. This topic will address the use of vaccines to prevent herpes zoster. The use of vaccines to prevent varicella (chickenpox) is discussed in a separate topic review. (See "Vaccination for the prevention of chickenpox (primary varicella infection)".)
IMPORTANCE OF CELL-MEDIATED IMMUNITY —
Varicella-zoster virus (VZV)-specific cell-mediated immune responses play a critical role in controlling VZV latency and limiting its potential to reactivate to cause herpes zoster [1]. A decline in cell-mediated immunity has been documented in older individuals and in patients with lymphoproliferative malignancies, both populations that experience high rates of herpes zoster. These epidemiologic observations are supported by in vitro data that demonstrate reduced VZV-specific T-cell frequency in such patients [2-4]. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster".)
Immunity and risk of reactivation — An age-related decline in VZV-specific cell-mediated immunity is regarded as the major precipitant for VZV reactivation (figure 1) [4]. Approximately 30 to 40 percent of persons over the age of 55 do not have any detectable VZV-specific T-cell responses by some assay methods [4].
Among those who develop herpes zoster, in vitro data suggest that robust VZV cell-mediated immunity at the onset of rash is correlated with reduced severity of disease and less risk of postherpetic neuralgia [5]. Immunocompromised individuals who lack adequate VZV-specific cellular immune responses are at greater risk for prolonged episodes of reactivation and disseminated disease, which can be fatal [6]. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster".)
Several observations suggest that a decline in cell-mediated immunity, rather than humoral immunity, is linked directly to herpes zoster. As an example, in allogeneic hematopoietic cell transplants, both cell-mediated and humoral immune responses are ablated, and although antibody may be replaced with intravenous gamma-globulin (which contains VZV antibody), these patients have very high rates of herpes zoster [7]. In addition, children with hypogammaglobulinemia, but normal cell-mediated immunity, do not experience severely protracted or fulminant primary varicella infection or increased rates of herpes zoster [8].
Boosting of T-cell-specific immunity to VZV — Cell-mediated immune responses may improve with periodic subclinical VZV reactivation (endogenous boosting), which may limit virus replication and decrease the risk of developing herpes zoster [4,9]. Environmental boosting of T-cell responses has also been documented among VZV-immune healthy adults after household exposures to children with varicella [4,10-12]. This may decrease the risk of herpes zoster. The impact of varicella vaccination on the incidence of herpes zoster is discussed elsewhere. (See "Epidemiology, clinical manifestations, and diagnosis of herpes zoster".)
Immunization to prevent herpes zoster is associated with a boost in VZV-specific T-cell immune responses (along with an antibody response), which contributes to its efficacy in preventing or attenuating disease [5,13-16]. Data demonstrating the efficacy of vaccination are described below. (See 'Immunocompetent persons ≥50 years of age' below.)
VACCINATION WITH THE RECOMBINANT ZOSTER VACCINE —
The recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]; sold as Shingrix) was approved for use in the United States in October 2017 [17] and is the only zoster vaccine available in nearly all countries. RZV contains varicella-zoster virus (VZV) glycoprotein E in combination with an adjuvant (AS01B).
Indications — Vaccination with RZV reduces the risk of developing herpes zoster and postherpetic neuralgia in those at increased risk for disease (immunocompetent individuals ≥50 years of age, immunocompromised patients ≥18 years of age) (figure 2 and figure 3) [18]. Vaccination is not indicated for the treatment of these conditions.
Immunocompetent persons ≥50 years of age — We recommend RZV for immunocompetent individuals ≥50 years of age. In clinical trials, RZV retained good efficacy against herpes zoster (eg, >70 percent) through at least 10 years of follow-up [19,20]. Vaccination should be included as part of routine preventive care for adults. (See "Overview of preventive care in adults", section on 'Immunization'.)
It is not necessary to confirm immunity to VZV prior to zoster vaccination [21]. Most adults born before 1980 have had varicella (eg, 99 percent of those born in the United States). In addition, serology is problematic because waning antibodies in previously exposed individuals, particularly older adults, may lead to negative antibody results despite past infection or vaccination.
RZV is effective in reducing the incidence of herpes zoster and postherpetic neuralgia. Two randomized controlled trials have evaluated the efficacy of RZV. In both trials, participants received the recombinant vaccine or placebo at zero and two months [22,23].
In one trial, 15,411 individuals ≥50 years old were evaluated [22]. During a mean follow-up of approximately three years, RZV reduced the risk of developing herpes zoster by 97.2 percent (95% CI 93.7-99.0); herpes zoster was confirmed in six individuals in the RZV group and 210 individuals in the placebo group. No cases of postherpetic neuralgia were reported in the RZV group compared with 18 cases reported in the placebo group.
In a subsequent trial in 13,900 adults aged 70 years or older who were followed for a mean of 3.7 years [23], the efficacy of RZV in preventing herpes zoster was 90 percent (95% CI 84.2-93.7); herpes zoster developed in 23 patients who received the vaccine versus 223 who received placebo. In addition, the vaccine efficacy against postherpetic neuralgia was 89 percent (95% CI 68.7-97.1). In both trials, efficacy was high regardless of the age of the vaccine.
RZV is efficacious in patients with diabetes mellitus or chronic heart, lung, liver, or kidney disease [24]. RZV is immunogenic even in patients who are considered frail or prefrail [25]; such patients are at risk for adverse health outcomes and have been found to have low immune responses to certain vaccines. (See "Frailty".)
The long-term efficacy of RZV was evaluated in extension studies of the two large clinical trials. An interim analysis suggested that immune response and efficacy against herpes zoster remained high (>72 percent) through 10 years of follow-up [19]. Immune responses (antibody and T-cell immunity) remained elevated in more than 85 percent of a limited number of vaccines [20].
In an observational study that included nearly 7.6 million person-years of follow-up, vaccine effectiveness was 79 percent during the first year and 73 percent during the third and fourth years [26]. The efficacy did not vary with the age of the patient. In those who only received one dose, vaccine effectiveness was 70 percent during the first year but decreased to 52 percent after the third year. Vaccine effectiveness was reduced to 65 percent in persons who received corticosteroids before vaccination.
Immunocompromised adults — Vaccination against herpes zoster is indicated for immunocompromised adults (or those who will become immunocompromised) who have a history of prior varicella infection or varicella vaccination and are (or will be) at increased risk for herpes zoster. Vaccination should be administered prior to immunosuppression whenever possible. (See 'Future immunosuppression planned' below.)
The US Food and Drug Administration (FDA) approved RZV for persons 18 years of age and older, and this is the age cut off used in many countries [27,28]. However, the Advisory Committee on Immunization Practices (ACIP) recommendations only focus on persons ≥19 years of age [18].
This section will provide an overview of the use of RZV in immunocompromised patients. More detailed recommendations on the timing and efficacy of vaccination in selected populations are discussed in separate topic reviews:
●(See "Immunizations in patients with inborn errors of immunity".)
●(See "Immunizations in persons with HIV".)
●(See "Immunizations in adults with cancer".)
●(See "Immunizations in hematopoietic cell transplant candidates, recipients, and donors".)
●(See "Immunizations in solid organ transplant candidates and recipients".)
●(See "Immunizations in autoimmune inflammatory rheumatic disease in adults".)
Future immunosuppression planned — For patients ≥18 years old who are planning immunosuppressive therapy that puts them at increased risk for herpes zoster, we recommend RZV vaccination prior to immunosuppression. This includes patients awaiting solid organ transplantation, patients scheduled to receive selected immunomodulatory therapies (including high-dose glucocorticoids), and patients with cancer scheduled for chemotherapy. This recommendation is based on evidence that RZV is effective in reducing the incidence of zoster in persons who are at increased risk [29,30]. Recommendations for the timing of vaccination in specific patient groups are discussed in the individual topic reviews listed above.
In patients with autoimmune conditions, such as multiple sclerosis, inflammatory bowel disease, rheumatoid arthritis, and other autoimmune diseases, there was concern that the underlying condition may flare due to the immune response elicited by the adjuvant; however, data suggest RZV appears safe and immunogenic in patients with immune-mediated diseases [31-36]. As an example, in a post-hoc analysis of the trials described above [22,23], the safety and efficacy of RZV were evaluated in 1934 patients with autoimmune diseases not receiving immunosuppressive therapies [34]. Similar to other participants who received RZV, the overall efficacy against herpes zoster was 90.5 percent, and serious and fatal adverse events were similar to controls.
Currently immunocompromised — Immunocompromised persons should receive RZV if their immunocompromising condition puts them at increased risk for herpes zoster. Ideally, vaccination should be administered when the immune response is likely to be most robust (eg, during periods of lower immunosuppression and stable disease) [18].
We recommend RZV for those 18 years of age and older if they have a history of VZV infection, have not previously received RZV, and have an immunocompromising condition that puts them at increased risk for herpes zoster. This includes those:
●Receiving immunomodulatory therapies (both high- and low-dose, including corticosteroids).
●Living with HIV.
●With a primary immunodeficiency (eg, severe antibody or combined immunodeficiency, leukocyte-adhesion deficiency, and cytotoxic granule defects).
●Being treated for cancer with chemotherapy.
●Who have undergone hematopoietic or solid organ transplantation.
We also suggest RZV for such patients who received the varicella vaccine, although the benefit of vaccination to prevent herpes zoster from the vaccine strain of VZV is unknown. (See 'Patients who received zoster vaccine live or varicella vaccine' below.)
RZV appears safe and immunogenic in these patient groups [29,30,37-41]. As an example, in a randomized trial of 1846 autologous hematopoietic cell transplantation (HCT) recipients (mean age, 55), vaccine efficacy for preventing RZV was approximately 68 percent [29]. In another randomized trial that included 562 patients (mean age 57) with hematologic malignancies, vaccine efficacy was 87 percent [30]. More detailed information on vaccine recommendations and the efficacy of vaccination in these populations is found in the individual topic reviews noted above. (See 'Immunocompromised adults' above.)
The risks and benefits of RZV should also be discussed with persons 19 to 49 years of age who are less severely immunocompromised, such as persons with impaired splenic function [42].
Considerations for those without a history of varicella or the varicella vaccine are discussed below. (See 'Persons without prior varicella or varicella vaccination' below.)
Additional considerations for persons who meet the criteria for vaccination
Patients with prior herpes zoster — Prior herpes zoster is not an exclusion when vaccination is indicated since recurrent herpes zoster can occur. For immunocompetent persons, we initiate the vaccine series when they are 50 years of age or older, regardless of when they had their initial herpes zoster infection. (See 'Immunocompetent persons ≥50 years of age' above.)
We typically delay RZV for approximately one year after an episode of herpes zoster since infection itself will boost VZV-specific immunity for several years. However, the proper timing of vaccination in patients with prior herpes zoster is uncertain. Guidelines from the United States Centers for Disease Control and Prevention (CDC) do not specify a specific time frame but suggest that RZV be delayed until the acute illness is over and symptoms resolve (eg, the rash has gone away) [18,37,43].
RZV can be safely administered to most immunocompetent patients ≥50 years of age with a prior history of herpes zoster [44-46]. One possible exception is patients with prior herpes zoster ophthalmicus (HZO). In a retrospective study, the risk of recurrent HZO was somewhat increased in those who had received RZV compared to those who were not vaccinated (38 versus 26 per 1000 person-years; adjusted hazard ratio 1.64; 95% CI, 1.01-2.67) [47]. This association is somewhat uncertain, so we do not avoid vaccination in such patients; however, we do monitor them for signs and symptoms of recurrent HZO.
Patients who received zoster vaccine live or varicella vaccine — When vaccination is indicated (age, immunocompromising condition), we suggest RZV for patients who previously received the varicella vaccine. This is consistent with recommendations from the ACIP [37]. Herpes zoster due to the vaccine strain of virus has been reported [48-51], although there are no data on the efficacy of RZV in reducing vaccine-strain herpes zoster.
We also suggest the two-dose RZV series for patients who previously received zoster vaccine live (ZVL). The ACIP recommends that the first dose of the RZV be given at least eight weeks after ZVL [37]. Revaccination is warranted given the reduced efficacy of ZVL compared with RZV (particularly in patients ≥70 years of age) as well as waning immunity, which manifests within five to eight years of receiving ZVL. Clinical trial data have demonstrated that RZV can be safely administered to patients who have previously received ZVL [52].
Persons without prior varicella or varicella vaccination — It is not necessary to confirm immunity to varicella prior to administering zoster vaccination. The vast majority of patients have had varicella or have been vaccinated against varicella, and serologic testing may not be reliable as antibody titers may have waned, especially in people who are immunocompromised. (See 'Indications' above.)
However, some patients may be assessed for varicella for other reasons (eg, part of the routine pretransplant evaluation, medical care for newly arrived refugees). (See "Medical care of adult refugees, immigrants, and migrants to the United States", section on 'Immunizations' and "Evaluation for infection before solid organ transplantation", section on 'Laboratory testing'.)
If this occurs and the patient is without evidence of immunity to VZV, the approach to vaccination depends on whether the patient is immunocompromised.
●Immunocompetent patients – For persons born and raised in the United States, we administer the varicella vaccine (a live, attenuated vaccine) to immunocompetent persons born after 1980 if they do not have a history of prior VZV infection or serologic evidence of immunity. By contrast, we administer varicella vaccine regardless of age to patients born or raised outside of the United States, unless they have documentation of vaccination or infection.
●For those with planned immunosuppression – For immunocompetent patients who will receive immunosuppressive medications in the future, we administer the varicella vaccine if immunosuppressive therapy can be delayed by at least eight weeks. Durable immunity requires a two-dose schedule with a minimum of one month between doses. Immunosuppressive medications should be delayed for at least four weeks after receiving the second dose of the varicella vaccine. (See "Immunizations in solid organ transplant candidates and recipients", section on 'Varicella' and "Immunizations in autoimmune inflammatory rheumatic disease in adults", section on 'Live vaccines'.)
●Immunocompromised patients – For those who are already immunocompromised, the approach to vaccination is less clear since the varicella vaccine is generally contraindicated. Many providers would immunize with RZV since it has been shown to be safe and immunogenic in immunocompromised patients [53]. However, since the efficacy against infection has not been evaluated, some providers may decide to administer additional post-exposure prophylaxis (eg, with antiviral therapy) in the setting of a varicella exposure. (See "Post-exposure prophylaxis against varicella-zoster virus infection".)
Household contacts of immunocompromised hosts — The indications for herpes zoster vaccination in household contacts of immunocompromised patients are the same as those for the general population, and RZV is preferred. (See 'Immunocompetent persons ≥50 years of age' above.)
Dosing and administration — The RZV requires two doses administered intramuscularly for optimal protection. For most patients, the second dose should be administered two to six months after the first [27]. However, for immunocompromised patients who would benefit from an expedited vaccine series (eg, those getting vaccinated prior to receiving immunosuppression), the second dose can be delivered one to two months after the first dose. (See 'Future immunosuppression planned' above.)
The two-dose vaccine schedule should be used for all patients, including those with a history of prior herpes zoster and those who previously received ZVL. The timing of vaccination in these patients is discussed above. (See 'Patients with prior herpes zoster' above and 'Patients who received zoster vaccine live or varicella vaccine' above.)
If there is a deviation from the recommended schedule for RZV, the ACIP provides the following guidance [37]:
●If there is a delay in administering the second dose (ie, more than six months after the first dose), the second dose can be administered at any time; the series does not need to be restarted. However, the efficacy of the vaccine in this setting is unclear.
●If the second dose is received less than four weeks after the first, the second dose should be repeated at least four weeks after the dose given too early [18].
Coadministration with other vaccines — The ACIP advises that recombinant vaccines, such as RZV, can be administered at the same time as other routine vaccines in adults but at different anatomic sites [18,37]. Although data are limited, studies have demonstrated that RZV can be safely administered with several of the commonly used vaccines (eg, diphtheria and acellular pertussis [Tdap] vaccine, the 23-valent pneumococcal polysaccharide vaccine, pneumococcal conjugate vaccine, the quadrivalent influenza vaccine), without affecting the immune response of either vaccine [54-59]. (See "Standard immunizations for nonpregnant adults" and "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults' and "COVID-19: Vaccines".)
The zoster vaccine can also be administered at the same time as the COVID-19 vaccine [18,60]. However, clinicians may choose to separate these vaccines since both are associated with adverse side effects that can limit the ability to participate in routine activities for one to two days. (See "Standard immunizations for nonpregnant adults" and "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults' and "COVID-19: Vaccines".)
Adverse events
Common reactions — RZV can cause injection site and systemic reactions [61]. Adverse events are often less severe after the second dose [62] and are less severe in persons aged 70 years or older compared to 50 to 69 years of age [63]. The side effects seen with RZV typically resolve in one to three days [22,23,64]. In most cases, they do not prevent individuals from completing the RZV vaccine series.
●Injection site reactions – The most common side effect after administering RZV is pain at the injection site. This occurred in 78 percent of subjects in clinical trials [22,23]. Reactions that prevented normal, everyday activities (pain, redness, and swelling) occurred in 9.4 percent of vaccine recipients.
●Systemic reactions – In clinical trials, the most common systemic effects were myalgia (44.7 percent), fatigue (44.5 percent), headache (37.7 percent), shivering (26.8 percent), fever (20.5 percent), and gastrointestinal symptoms (17.3 percent) [22,23]. Systemic effects that prevented normal, everyday activities were reported by 10.8 percent of vaccine recipients versus 2.4 percent in those who received placebo [37]. Combined local and systemic reactions that prevented everyday activities were more common among those who received RZV compared with placebo (16.5 versus 3.1 percent) [22,23,37]. There were no significant differences in the percentage of participants who experienced serious adverse events, immune-mediated diseases, or death in the vaccine and placebo groups.
Most systemic reactions lasted one to three days, and their frequency and severity rarely resulted in refusal of the second vaccine dose. In a study of 401 adults who received RZV, physical functioning and quality-of-life measures were generally not affected after the first dose of RZV [65]. Similar findings were seen after administration of the second dose [66]. However, in these studies, participants with severe (Grade 3) reactions did have a temporary decline in physical function for the first two days after the first or second dose of RZV was administered.
The safety of RZV was further evaluated in a post-licensure surveillance study that was conducted over an eight-month period and included 4381 adverse event reports [63]. There was a low rate of serious adverse events (eg, hospitalization, life-threatening illness), which was consistent with findings in prelicensure clinical trials. The types of adverse events (eg, fever, injection site reactions, chills, headache, fatigue) were also similar to those seen in the early clinical trials, and there were very few complications suggesting immune-mediated diseases. In this study, 65 percent of the adverse events were reported in females. In addition, individuals aged 50 to 69 years were more likely to experience systemic signs and symptoms compared with those ≥70 years, who were more likely to report local symptoms (eg, injection site erythema and pain).
When counseling patients about the potential adverse reactions associated with RZV, it is useful to tell them that about one in six persons have reactions that prevent them from doing normal activities but that these usually resolve within one to two days and they should avoid strenuous activities for a few days after vaccination [37].
Risk of Guillain-Barré syndrome — There may be an association with RZV and Guillain-Barré syndrome (GBS) [67,68]. In a post-marketing observational study using Medicare claims data that identified 3,729,863 vaccinations with RZV, there was an increased risk of GBS in adults aged ≥65 years during the 42 days following vaccination, with an estimated three excess cases of GBS per million doses administered [67]. In secondary analyses, there was an estimated excess of six cases of GBS per million doses of RZV during the 42 days following the first dose of RZV, but no increased risk of GBS was observed following the second dose. The risk of GBS in patients 50 to 65 years of age was not evaluated. A more detailed discussion of GBS is presented elsewhere. (See "Guillain-Barré syndrome in adults: Pathogenesis, clinical features, and diagnosis", section on 'Vaccinations'.)
Contraindications and precautions — RZV should not be given to patients with a known allergy to the components of the vaccine. We also avoid administering RZV to patients with a history of GBS, given the possible association between RZV and GBS, as described above. (See 'Risk of Guillain-Barré syndrome' above.)
RZV should generally be avoided during pregnancy since it has not been studied in such persons. However, when RZV is indicated, the ACIP states clinicians can consider RZV vaccination without regard to breastfeeding status, since recombinant vaccines such as RZV pose no known risk to mothers who are breastfeeding or to their infants [18].
LIMITED AVAILABILITY OF ZOSTER VACCINE LIVE —
A live attenuated vaccine (designated zoster vaccine live [ZVL]; sold in the United States as Zostavax), was approved for use in 2006 [69-72]. In July 2020, ZVL was discontinued in the United States and is now no longer produced given evidence of its lower efficacy and durability compared with recombinant zoster vaccine (RZV) [73,74]. (See 'Vaccination with the recombinant zoster vaccine' above.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Varicella-zoster virus".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Vaccines for adults (The Basics)" and "Patient education: What you should know about vaccines (The Basics)" and "Patient education: Shingles (The Basics)")
●Beyond the Basics topic (see "Patient education: Shingles (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Pathogenesis of herpes zoster – Herpes zoster (shingles) results from reactivation of varicella-zoster virus (VZV) infection latent in sensory nerves and is characterized by a painful, unilateral blister-like eruption in a dermatomal distribution. A decline in VZV-specific cell-mediated immunity, which occurs in immunocompromised and older individuals, is regarded as the major precipitant for VZV reactivation. (See 'Importance of cell-mediated immunity' above.)
●Types of vaccines – The recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]; sold as Shingrix) was approved for use in the United States in October 2017 [17]. RZV contains VZV glycoprotein E in combination with an adjuvant (AS01B).
A live attenuated vaccine (designated zoster vaccine live [ZVL]) was previously the only vaccine available. Production of this vaccine has been discontinued.
●Vaccination in immunocompetent patients ≥50 years of age – For immunocompetent patients ≥50 years of age, we recommend RZV (Grade 1B). In such patients, vaccination with RZV reduces the risk of developing herpes zoster and postherpetic neuralgia. Vaccine efficacy against herpes zoster remains high (eg, >70 percent) through at least ten years of follow-up.
It is not necessary to determine whether patients have a history of prior varicella (chickenpox) or herpes zoster or to check antibodies prior to vaccination. (See 'Vaccination with the recombinant zoster vaccine' above.)
●Vaccination in adults who are or are expected to be immunocompromised – For patients ≥18 years of age with a known history of varicella who are currently immunocompromised or are planning to receive immunosuppressive therapy in the near future, we recommend vaccination with RZV (Grade 1B). This includes patients receiving chemotherapy or immunomodulatory therapy and those with a primary or secondary immunodeficiency. (See 'Immunocompromised adults' above.)
In some settings, the history of varicella and varicella vaccination is unknown. When this occurs, the approach to vaccination must be individualized based on the patient's immune status. (See 'Persons without prior varicella or varicella vaccination' above.)
Information on the timing of vaccination and the efficacy of RZV vaccination in specific populations is presented in separate topic reviews. (See "Immunizations in adults with cancer" and "Immunizations in hematopoietic cell transplant candidates, recipients, and donors" and "Immunizations in solid organ transplant candidates and recipients" and "Immunizations in persons with HIV" and "Immunizations in patients with inborn errors of immunity" and "Immunizations in autoimmune inflammatory rheumatic disease in adults".)
●Considerations for persons who received the varicella vaccine – When vaccination is indicated (immunocompromising condition, age), we suggest RZV for patients who previously received the varicella vaccine (Grade 2C). Herpes zoster due to the vaccine strain of the virus has been reported, although there are no data on the efficacy of RZV in reducing vaccine-strain herpes zoster.
●Timing of vaccination in persons with prior herpes zoster – Prior herpes zoster is not an exclusion to RZV if vaccination is indicated. We typically delay vaccination for approximately one year after herpes zoster, which itself will boost VZV-specific immunity. (See 'Patients with prior herpes zoster' above.)
●Vaccine administration and contraindications – RZV requires two doses administered intramuscularly two to six months apart. For immunocompromised patients who would benefit from an expedited vaccine series, the second dose can be delivered one to two months after the first dose. (See 'Dosing and administration' above.)
RZV can cause injection site and systemic reactions, but symptoms usually resolve within one to two days. Patients may choose to avoid strenuous activities for a few days after vaccination. (See 'Adverse events' above.)
RZV should be avoided in patients with a known allergy to the components of the vaccine. Precautions for specific patients (eg, pregnant persons, persons with a prior Guillain-Barré syndrome [GBS]) are discussed above. (See 'Contraindications and precautions' above.)
