Shingles, or herpes zoster, is a painful rash caused by the reactivation of the varicella-zoster virus (VZV) in people who have previously had chickenpox. The virus remains dormant in nerve tissue after the initial infection. As immunity declines with age, the virus can emerge years later, leading to the characteristic blistering rash and potential long-term nerve pain. Vaccines were engineered to boost the body’s immune response against this dormant virus, aiming to prevent its reactivation.
The Approval of the First Shingles Vaccine
The first shingles vaccine was Zostavax, a live, attenuated virus vaccine that used a weakened version of the varicella-zoster virus to stimulate an immune response. The U.S. Food and Drug Administration (FDA) initially approved this single-dose vaccine in 2006 for use in adults aged 60 years and older. This approval marked the first time a medical intervention was available to reduce the risk of this common condition.
Following the initial licensure, the Advisory Committee on Immunization Practices (ACIP) issued its recommendation in 2008, advising routine use for adults 60 and older. The vaccine reduced the incidence of shingles by about 51% overall in clinical trials. However, its effectiveness decreased substantially with increasing age and over time.
The FDA expanded the approved age range in 2011 to include adults aged 50 through 59 years. Despite this, ACIP maintained its routine recommendation only for those 60 years and older due to concerns over the vaccine’s limited long-term protection. Zostavax remained the only available option for over a decade, though studies showed its protective effect waned significantly over the years.
The Transition to the Current Standard
A significant shift occurred in 2017 with the introduction of a new product that changed the landscape of shingles prevention. The FDA approved the recombinant zoster vaccine, Shingrix, in October 2017 for adults aged 50 years and older. This vaccine uses a non-live subunit of the virus combined with an adjuvant, a substance that enhances the immune response.
The Advisory Committee on Immunization Practices quickly recommended Shingrix as the preferred vaccine over Zostavax later that month. This preference was rooted in the new vaccine’s higher and more durable efficacy demonstrated in clinical trials. For adults aged 50 to 69, Shingrix proved to be approximately 97% effective, and protection remained above 90% for those 70 and older.
This level of protection was sustained for at least four years, addressing the waning effectiveness seen with the earlier live vaccine. The recombinant nature of Shingrix also allowed it to be safely administered to immunocompromised individuals, a group previously excluded from receiving the live Zostavax vaccine. Due to its superior performance, Zostavax production for the U.S. market was discontinued in 2020.
Who Should Be Vaccinated Today
Current health guidance recommends the use of the recombinant vaccine, Shingrix, for the prevention of shingles. The routine recommendation applies to all immunocompetent adults beginning at age 50 years. This holds true regardless of whether the person recalls having had chickenpox or a prior episode of shingles, as most adults have the dormant virus in their system.
Unlike the original single-dose vaccine, the current standard requires a two-dose series to achieve maximum protection. The second dose should be administered intramuscularly between two and six months after the first. Completing this series is necessary for the long-term effectiveness demonstrated in clinical trials.
The recommendation also includes adults who previously received the Zostavax vaccine. These individuals should still receive the two doses of Shingrix, waiting at least eight weeks after their Zostavax shot before starting the new series. Additionally, for adults who are or will be immunocompromised, the vaccine is recommended starting at age 19 years.