Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines

Kathleen L. Dooling, MD; Angela Guo, MPH; Manisha Patel, MD; Grace M. Lee, MD; Kelly Moore, MD; Edward A. Belongia, MD; Rafael Harpaz, MD


Morbidity and Mortality Weekly Report. 2018;67(3):103-108. 

In This Article

Clinical Guidance

General Use

RZV may be used in adults aged ≥50 years, irrespective of prior receipt of varicella vaccine or ZVL, and does not require screening for a history of chickenpox (varicella). ZVL remains a recommended vaccine for prevention of herpes zoster in immunocompetent adults aged ≥60 years.[6] Care should be taken not to confuse ZVL, which is stored in the freezer and administered subcutaneously, with RZV, which is stored in the refrigerator and administered intramuscularly.

Dosing Schedule

Following the first dose of RZV, the second dose should be given 2–6 months later.[1] The vaccine series need not be restarted if more than 6 months have elapsed since the first dose; however, the efficacy of alternative dosing regimens has not been evaluated, data regarding the safety of alternative regimens are limited,[30] and individuals might remain at risk for herpes zoster during a longer than recommended interval between doses 1 and 2. If the second dose of RZV is given less than 4 weeks after the first, the second dose should be repeated. Two doses of the vaccine are necessary regardless of prior history of herpes zoster or prior receipt of ZVL.

Timing of RZV for Persons Previously Vaccinated With ZVL

Age and time since receipt of ZVL may be considered to determine when to vaccinate with RZV. Studies examined the safety and immunogenicity of RZV vaccination administered ≥5 years after ZVL;[21] shorter intervals have not been studied. However, there are no data or theoretical concerns to indicate that RZV would be less safe or less effective when administered at an interval of <5 years. Clinical trials indicated lower efficacy of ZVL in adults aged ≥70 years; therefore, a shorter interval may be considered based on the recipient's age when ZVL was administered. Based on expert opinion, RZV should not be given <2 months after receipt of ZVL.

Coadministration With Other Vaccines

CDC's general best practice guidelines for immunization advise that recombinant and adjuvanted vaccines, such as RZV, can be administered concomitantly, at different anatomic sites, with other adult vaccines.[31] Concomitant administration of RZV with Fluarix Quadrivalent (influenza vaccine) (QIV) has been studied, and there was no evidence for interference in the immune response to either vaccine or safety concerns.[32] Evaluation of coadministration of RZV with 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed (Tdap, Boostrix) is ongoing. The safety and efficacy of administration of two adjuvanted vaccines (e.g., RZV and adjuvanted influenza vaccine [Fluad]), either concomitantly or at other intervals, have not been evaluated.

Counseling for Reactogenicity

Before vaccination, providers should counsel RZV recipients about expected systemic and local reactogenicity. Reactions to the first dose did not strongly predict reactions to the second dose;[33] vaccine recipients should be encouraged to complete the series even if they experienced a grade 1–3 reaction to the first dose of RZV. The impact of prophylactic analgesics in conjunction with RZV has not been studied.