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Vaccination for the prevention of shingles (herpes zoster)

Authors: Mary A Albrecht, MD, Myron J Levin, MD

Section Editor: Martin S Hirsch, MD
Deputy Editor: Jennifer Mitty, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: May 2018. | This topic last updated: Mar 23, 2018.

INTRODUCTION — Varicella-zoster virus (VZV) infection causes two clinically distinct diseases. Primary infection with VZV results in varicella, also known as
chickenpox, characterized by vesicular lesions in different stages of development concentrated on the face and trunk, and less so on the extremities. Herpes zoster, also
known as shingles, results from reactivation of latent VZV (from the varicella infection) in neurons within the sensory ganglia. Herpes zoster is characterized by a painful,
unilateral vesicular eruption that occurs in a restricted dermatomal distribution.

Vaccines are available for prevention of both infections. This topic will address the use of the two vaccines licensed to prevent herpes zoster. A discussion of the vaccine
to prevent varicella (chickenpox) is found elsewhere. (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 the potential for reactivation [1]. A decline in cell-mediated immunity has been documented in older individuals and in patients with lymphoproliferative
malignancies, both populations that experience higher rates of herpes zoster (figure 1) [2-4]. These epidemiologic observations are supported by in vitro data that
demonstrate reduced VZV-specific T cell frequency in aging patients who are more susceptible to virus activation [5]. (See "Epidemiology and pathogenesis of varicella-
zoster virus infection: Herpes zoster".)

Immunity and risk of reactivation — A decline in VZV-specific cell-mediated immunity is regarded as the major precipitant for VZV reactivation [4]. Approximately 30
to 40 percent of persons over the age of 55 years 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 [6]. Immunocompromised patients who lack adequate VZV-specific cellular immune responses are at greater risk for prolonged
episodes of reactivation and disseminated disease, which can be fatal [7]. (See "Clinical manifestations of varicella-zoster virus infection: Herpes zoster".)

Several observations suggest that a decline in cell-mediated immunity, rather than humoral immunity, is linked directly to reactivated VZV syndromes. As an example, in
allogeneic stem cell transplants, both cell-mediated and humoral immune responses are ablated, and although antibody is replaced with intravenous gamma-globulin
(which contains VZV antibody), these patients have very high rates of herpes zoster [8]. In addition, children with hypogammaglobulinemia do not experience severely
protracted or fulminant primary varicella infection or increased rates of herpes zoster [9].

Boosting of T cell specific immunity to VZV — Cell-mediated immune responses improve with periodic subclinical varicella-zoster virus (VZV) reactivation
(endogenous boosting), which may limit virus replication and decrease the risk of developing herpes zoster [4,10]. Environmental boosting of T cell responses has also
been documented among VZV-immune healthy adults who have had household exposures to children with primary varicella, which may also decrease the risk of herpes
zoster [4,11-13]. The impact of varicella vaccination on the incidence of herpes zoster is discussed elsewhere. (See "Epidemiology and pathogenesis of varicella-zoster
virus infection: Herpes zoster", section on 'Impact of varicella vaccine on incidence of herpes zoster'.)

Zoster immunization, with either of the available vaccines, is associated with a boost in VZV-specific T cell immune responses, which contribute to the vaccine's efficacy
in preventing or attenuating disease [6,14-18]. Data demonstrating the efficacy of these vaccines are described below. (See 'Efficacy of the different vaccines' below.)

APPROACH TO VACCINATION

Indications for vaccination — Herpes zoster vaccination is indicated for individuals ≥50 years of age to reduce the risk of developing herpes zoster and postherpetic
neuralgia. Vaccination is not indicated for the treatment of herpes zoster or postherpetic neuralgia. There are certain precautions and contraindications to vaccination,
particularly in immunocompromised hosts. This is discussed in detail below. (See 'Immunocompromised hosts' below and 'Contraindications to RZV' below and
'Contraindications and precautions for ZVL' below.)

It is not necessary to determine whether patients have a history of varicella or herpes zoster prior to vaccination because waning antibodies in previously exposed
patients (particularly older adults) may lead to negative results despite past infection. In addition, a self-reported history of shingles is often of questionable reliability
[19]. More than 96 percent of individuals who have resided 30 years in the United States have serologic evidence of prior varicella, and a majority of people claiming no
prior varicella have varicella-zoster virus (VZV) antibody [20]. Moreover, inadvertent administration of zoster vaccine live (ZVL) to VZV-naïve individuals has been well
tolerated in immune competent individuals [21]. (See "Diagnosis of varicella-zoster virus infection", section on 'Serologic testing'.)

Choice of vaccine — There are two types of zoster vaccine:

● A non-live recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]; sold as Shingrix). RZV contains varicella-zoster virus glycoprotein E
in combination with an adjuvant (AS01B).

● A live attenuated vaccine (designated zoster vaccine live [ZVL]; sold as Zostavax). ZVL contains 18,700 (at expiry) to 60,000 plaque-forming units of virus,
considerably more than the approximately 1350 plaque-forming units found in the Oka/Merck vaccine for prevention of varicella. (See "Vaccination for the
prevention of chickenpox (primary varicella infection)".)

We suggest RZV rather than ZVL for most immunocompetent patients. Special considerations for immunocompromised hosts and other patient groups, as well as
information on vaccine administration, are discussed below. (See 'Patients aged 50 to 59' below and 'Comorbid conditions' below and 'Patients who received live
attenuated herpes zoster or varicella vaccine' below and 'Vaccine administration' below.)

We generally prefer RZV based upon evidence that it has greater efficacy, especially among people in their seventh to ninth decade (table 1) (see 'Efficacy of the
different vaccines' below). In addition, there is less concern for waning immunity with RZV [22]. Although long-term data are not available for RZV, protection has
extended to four years [23], and immune responses are elevated for at least six years [24]. With ZVL, protection appears unchanged through year 5 [25], but wanes
significantly after about eight years (from approximately 50 percent to 20 to 30 percent) [25-31]. In one study, there was no benefit from ZVL in reducing herpes zoster
after year 8, butThis site uses
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There are a few advantages of ZVL as compared with RZV. As an example, ZVL requires administration of one dose of the vaccine, versus two for RZV. In addition, ZVL
has a lower incidence of side effects that prevent everyday activities. Systemic side effects such as myalgia, fatigue, headache, shivering, and fever typically occur in <1
percent of those who receive ZVL [32], but developed in approximately 11 percent of those who received RZV (table 1) [23,33]. However, these side effects usually
resolve in one to three days [23,33,34], and rarely prevent patients from completing the RZV vaccine series. A more detailed discussion of the side effects of RZV and
ZVL is presented below. (See 'Adverse events associated with RZV' below and 'Adverse events associated with ZVL' below.)

The choice of RZV as the preferred type of vaccine is consistent with recommendations from the Advisory Committee on Immunization Practices (ACIP), which were
accepted by the United States Centers for Disease Control and Prevention [22]. However, not all members of the ACIP agreed with this preferential recommendation
(vote split eight to seven), citing concerns about the lack of data on its performance among minority groups, relatively limited data on long-term vaccine safety and
efficacy, including limited data when administered in a nonclinical trial setting, and issues related to a two-dose schedule.

Efficacy of the different vaccines — While the two vaccines have not been compared head-to-head, the efficacy of RZV observed in two randomized trials appears
superior to that observed for ZVL.

● Efficacy of ZVL – The efficacy of zoster vaccination for reducing the risk of herpes zoster and postherpetic neuralgia was first demonstrated in the Shingles
Prevention Study (SPS), a placebo-controlled clinical trial that evaluated the ZVL in 38,546 adults 60 years of age or older [35]. More than 95 percent of the
subjects completed three years of surveillance with the following results:

• Confirmed herpes zoster occurred in 957 patients (2.5 percent). ZVL reduced the incidence of herpes zoster over approximately three years by 51 percent
compared with placebo (1.6 versus 3.3 percent, respectively), but vaccine efficacy was significantly greater in individuals aged 60 to 69 years compared with
those ≥70 years (63.9 versus 37.6 percent).

• In those who developed herpes zoster, the median duration of pain and discomfort was modestly reduced in the vaccine group compared with the placebo
group (21 versus 24 days, respectively).

• The incidence of postherpetic neuralgia was reduced by 67 percent in the vaccine group (0.46 versus 1.38 cases per 1000 person-years). Unlike the incidence
of herpes zoster, the benefit was greater in patients ≥70 years of age (0.71 versus 2.13 per 1000 person-years). (See "Postherpetic neuralgia".)

• An immunology substudy of 1395 patients demonstrated increases in VZV-specific antibody and cell-mediated immunity at six weeks after vaccination
compared with placebo [14]. These increases persisted during the three years of follow-up, although the magnitude of T cell responses declined over time.

A 2016 systematic review and meta-analysis confirmed the benefits observed in the earlier definitive SPS study and calculated that 50 people need to be
vaccinated to protect one person [36].

A post-licensure observational study of ZVL effectiveness reinforced the potential of the vaccine to reduce significant morbidity in patients 60 years of age or older.
This retrospective study evaluated immunocompetent patients (75,761 patients were vaccinated and 227,283 matched patients were unvaccinated) during a two-
year period [37]. A total of 5434 cases of herpes zoster were identified; in an adjusted analysis, vaccination was associated with a significantly reduced risk of
herpes zoster (hazard ratio, 0.45; 95% CI 0.42-0.48). This risk reduction occurred in all age strata (60 to >80 years of age) and among individuals with chronic
diseases (eg, diabetes, liver disease, coronary artery disease). The risk of ophthalmic herpes zoster and hospitalization was also reduced by approximately two-
thirds among vaccine recipients. An even larger effectiveness trial confirmed these findings for herpes zoster and postherpetic neuralgia [26].

The efficacy of vaccination among patients 50 to 59 years of age was evaluated in the Zostavax Efficacy and Safety Trial (ZEST). In this trial, 22,439 patients aged
50 to 59 years from the United States and Europe were randomly assigned to vaccine or placebo and followed for a mean of 15 months for the development of
herpes zoster [38]. The vaccine efficacy for preventing herpes zoster was 70 percent (95% CI 54.1-80.6); zoster vaccine reduced the incidence of herpes zoster
from 99 cases in the placebo group (6.6 per 1000 person-years) to 30 cases in the vaccine group (2 per 1000 person-years).

● Efficacy of RZV – Two randomized controlled trials have evaluated the efficacy of RZV. In both trials that evaluated RZV, participants received the recombinant
vaccine or placebo at zero and two months [23,33].

In one trial, 15,411 individuals ≥50 years old were evaluated [33]. 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. In addition, no
cases of postherpetic neuralgia were reported in the RZV group compared with 18 cases reported in the placebo group.

RZV was subsequently evaluated in 13,900 adults 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).

Special considerations

Patients aged 50 to 59 — Although both vaccines are approved for patients ≥50 years old, the ACIP does not recommend ZVL for patients aged 50 to 59 years [39],
in part because of the limited long-term protection provided by ZVL [25-31]. Moreover, because of the lower rate of herpes zoster in this age group compared with
persons ≥60 years old, routine vaccination with ZVL was not supported in a cost-effectiveness analysis [40].

Comorbid conditions

Patients with prior herpes zoster infection — Patients age 50 years or older with a history of herpes zoster should receive zoster vaccine. However, it is
unclear when after infection patients should be vaccinated. We typically delay vaccination for approximately three years, since herpes zoster itself will boost VZV-
specific immunity for several years.

Studies have found that ZVL can be safely administered to patients ≥50 years of age with a prior history of herpes zoster, although efficacy in this situation has not been
established [41,42]. Studies of RZV in such patients are currently underway, but there is no reason to believe that there would be any safety concerns.

Immunocompromised hosts — There are insufficient data to make definitive recommendations regarding zoster vaccination in immunocompromised hosts ≥50
years old. Vaccination is not indicated for people <50 years old.
As with immunocompetent hosts, RZV is generally preferred. However, in certain patients, such as those with autoimmune conditions and transplant recipients, there
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The approach to vaccination in immunocompromised patients depends upon when immunosuppression is planned, the patient's underlying condition, and the choice of
vaccine.

● Planned immunosuppression – Patients ≥50 years of age should ideally be vaccinated prior to receiving immunosuppressive therapy. Since RZV requires two
doses, the interval would be two months, plus an additional two to four weeks after the second dose for an optimal response to develop. If ZVL is used, it should be
administered ≥4 weeks before the initiation of immunosuppressive therapy [43].

● Patients receiving low-dose immunosuppressive therapy – Patients receiving low-dose immunosuppressive therapy would be expected to respond to
vaccination. These therapies include [43]:

• Low-dose prednisone (<2 mg/kg: maximum ≤20 mg/day) or equivalent

• Methotrexate (≤0.4 mg/kg/week)

• Azathioprine (≤3 mg/kg/day)

• 6-mercaptopurine (≤1.5 mg/kg/day)

The ACIP recommends RZV in such patients [22]. ZVL can also be used in patients receiving low-level immunosuppression, but disseminated herpes zoster with
vaccine type virus has occurred rarely in such patients who have received ZVL [44].

● Patients with underlying immunodeficiency and/or receiving moderate- to high-dose immunosuppressive therapy – We generally avoid vaccinating
immunocompromised hosts who have an underlying immunodeficiency or are receiving moderate- to high-dose immunosuppressive therapy. This includes
[39,43,45,46]:

• Patients who have primary or acquired immunodeficiency – These disorders include leukemia, lymphoma, or other malignancies affecting the bone marrow or
lymphatic system. (See "Immunizations in adults with cancer", section on 'Zoster vaccine (live)' and "Primary immunodeficiency: Overview of management".)

• Solid organ and hematopoietic stem cell transplant patients – The use of antiviral medications to prevent herpes zoster in transplant candidates and recipients
is discussed elsewhere. (See "Immunizations in solid organ transplant candidates and recipients" and "Prophylaxis of infections in solid organ transplantation"
and "Immunizations in hematopoietic cell transplant candidates and recipients" and "Prevention of infections in hematopoietic cell transplant recipients".)

• HIV-infected patients with a CD4 cell count <200 cells/microL. (See "Immunizations in HIV-infected patients", section on 'Zoster vaccine'.)

• Patients receiving immunomodulatory therapies such as disease-modifying anti-rheumatic, anti-multiple sclerosis, or biologic therapies (eg, corticosteroid
therapy with a dose ≥20 mg/day of prednisone or equivalent for ≥14 days, rituximab, tofacitinib, tumor necrosis factor (TNF)-alpha, or Janus kinase inhibitors)
[43,46]. (See "Overview of immunosuppressive and conventional (non-biologic) disease-modifying drugs in the rheumatic diseases".)

ZVL is contraindicated in these patients since they are at risk for developing disseminated VZV infection. ZVL can be administered to those who have completed
immunosuppressive therapy after a certain period of time, provided that there is no evidence of ongoing immune compromise. As an example, patients who have
received chemotherapy or radiation, and are in remission, should wait at least three months before receiving ZVL [45]. Among patients receiving other
immunosuppressive agents (eg, high-dose corticosteroids, TNF-alpha inhibitors), vaccination should be deferred at least one month after completion of the
treatment course.

There are no contraindications to administering RZV in immunocompromised hosts who have an underlying immunodeficiency or are receiving moderate- to high-
dose immunosuppressive therapy, but there are insufficient data at this time to recommend routine vaccination with RZV [22]. Early studies suggest that RZV is safe
and immunogenic in autologous hematopoietic stem cell populations [47], and additional data and guideline recommendations for these patients are forthcoming.

Other conditions — RZV is preferred for patients with diabetes mellitus; chronic heart, lung, liver, or kidney disease; functional or anatomical asplenia; or
complement deficiencies who meet the age criterion [39], although either vaccine can be used. The safety and efficacy of vaccination in these populations has not been
specifically evaluated; however, such patients were not excluded from the clinical trials of ZVL and RZV described above, and additional studies are underway. (See
'Efficacy of the different vaccines' above.)

The safety of RZV in patients with other comorbid conditions, such as multiple sclerosis, rheumatoid arthritis, and other autoimmune diseases, is less clear. Until more
data are available, the benefits of using RZV must be weighed against the theoretical risks, such as a flare of underlying condition due to the immune response elicited
by the adjuvant.

Household contacts of immunocompromised hosts — The RZV is preferred for household contacts of immunocompromised patients. ZVL is not contraindicated
in this group, but immunocompromised patients should avoid contact with household contacts who develop skin lesions resulting from ZVL until the lesions clear [43].
Transmission of vaccine virus has not been reported in clinical trials [48]; however, the vaccine package insert mentions the possibility that transmission of vaccine virus
to immunocompromised contacts may occur rarely from vaccine recipients who develop a varicella-like rash [49].

Patients who received live attenuated herpes zoster or varicella vaccine — We suggest that patients who previously received ZVL receive the two-dose series
of RZV (see 'Vaccine administration' below). Data support that RZV can be safely administered to patients who have previously received ZVL [50].

The optimal timing of revaccination is unclear. However, for patients who received ZVL, the ACIP recommends that the first dose of the RZV be given at least eight
weeks after ZVL [22].

Revaccination for patients who received ZVL is warranted given the reduced efficacy of ZVL compared with RZV (particularly in patients ≥70 years), as well as waning
immunity, which is seen within five to eight years of receiving ZVL. Data supporting these findings are described above. (See 'Choice of vaccine' above and 'Efficacy of
the different vaccines' above.)

The ACIP states that RZV may also be used in patients irrespective of prior receipt of varicella vaccine [22]. However, there are no data on the efficacy of the RZV in
reducing vaccine strain herpes zoster in older people.

VACCINE ADMINISTRATION
Non-live recombinant glycoprotein E vaccine (RZV) — The non-live recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]) was
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vaccine for most patients because it provides greater protection, especially among people in their seventh to ninth decade (figure 2 and figure 3) [22]. (See 'Efficacy of
the different vaccines' above.)

Dose and route of RZV — The recombinant zoster vaccine (RZV) requires two doses administered intramuscularly (IM) for protection. The second dose should be
administered two to six months after the first [52].

This schedule should be used for all patients, including those with a history of prior herpes zoster and those who previously received zoster vaccine live (ZVL). The
timing of vaccination in these patients is discussed above. (See 'Patients with prior herpes zoster infection' above and 'Patients who received live attenuated herpes
zoster or varicella vaccine' above.)

If there is a deviation from the recommended schedule, the ACIP provides the following guidance [22]:

● If there is a delay in administering the second dose, 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.

Administration of RZV with other vaccines — Although data are limited, the Centers for Disease Control and Prevention advises that recombinant vaccines, such
as recombinant zoster vaccine (RZV), can be administered at the same time as other adult vaccines, but at different anatomic sites [22]. (See "Standard immunizations
for nonpregnant adults".)

One study found that RZV can be safely administered with the quadrivalent influenza vaccine without affecting the immune response of either vaccine [53]. Studies
evaluating the safety of RZV administered with other commonly used vaccines (eg, pneumococcal vaccines, and Tdap) are ongoing.

Adverse events associated with RZV — RZV can cause injection site and systemic reactions.

● Injection site reactions – The most common side effect after RZV administration is pain at the injection site in 78 percent of subjects in the two trials [23,33].
Reactions that prevented normal everyday activities (pain, redness, and swelling) occurred in 9.4 percent of vaccine recipients.

● Systemic reactions – The most common systemic effects in the trials 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). 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 [22].

In the clinical trials of RZV, 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) [22,23,33]. However, most of these reactions only lasted one to three days, and the frequency and severity of these reactions
rarely resulted in refusal of the second vaccine dose. 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.

Contraindications to RZV — RZV should not be given to patients with a known allergy to the components of the vaccine.

Zoster vaccine live (ZVL) — ZVL may not continue to be widely available as the herpes zoster subunit vaccine (RZV) becomes increasingly available. However, since
RZV was licensed only in October 2017 and was not readily available until early 2018, some providers may prefer to immunize with ZVL given the long-term experience
with that vaccine. Other obstacles to early uptake of RZV include the side effect profile and the requirement for two doses. (See 'Non-live recombinant glycoprotein E
vaccine (RZV)' above.)

Dose and route of ZVL — ZVL is administered as a one-time subcutaneous injection.

Administration of ZVL with other vaccines — ZVL may be administered at the same visit as other vaccines. However, other live vaccines (eg, measles, mumps,
and rubella) should be separated by at least 28 days if they are not given on the same day.

There have been concerns that coadministration of PPSV23 may reduce the immunogenicity of ZVL [54-56]. Although the manufacturer states that clinicians should
consider administering these two vaccines at least four weeks apart, the United States Centers for Disease Control and Prevention recommends that they be
administered at the same visit to eligible patients [57,58]. This approach avoids barriers to receiving indicated vaccines. This is supported by an observational study that
did not find a difference in the rate of herpes zoster among those who received both vaccines concurrently compared with those who received them four weeks apart
[59]. (See "Pneumococcal vaccination in adults".)

Adverse events associated with ZVL — Zoster vaccine live (ZVL) is generally well tolerated [32,60,61].

● Injection site reactions – The most common side effect after ZVL administration is pain at the injection site. In the randomized placebo-controlled pivotal trial,
injection site pain was reported in 48 and 16 percent of vaccine and placebo recipients, respectively; the median duration was three days [32]. For most patients,
the erythema, swelling, and pain were described as mild.

● Acute retinal necrosis – Six cases of optic neuritis, acute retinal necrosis, uveitis, or keratitis following vaccination with ZVL have been reported; the patients
developed loss of vision from six days to two months following vaccination, respectively [62]. Most were over 75 years of age and one was immunocompromised,
having undergone renal transplantation. Although varicella-zoster virus (VZV) was detected from the vitreous or aqueous fluid by polymerase chain reaction in two
patients, it was identified as the Oka strain of VZV (the viral strain used in both the varicella and zoster vaccines) only in the vitreous aspirate and core vitrectomy
specimen of the immunosuppressed patient who developed retinitis approximately one month after receiving the varicella vaccine [63].

● Vaccine-associated zoster – Vaccine-associated VZV can establish latency and, in rare cases, can reactivate to cause clinical herpes zoster. In a single
immunocompetent patient, localized herpes zoster infection occurred nine months after vaccination with ZVL, and virologic studies confirmed that the infection was
caused by the vaccine strain of virus [64].

Contraindications and precautions for ZVL — Contraindications to the administration of zoster vaccine live (ZVL) include:

● Allergy – Patients with anaphylactic reactions to gelatin or neomycin [60]. (See "Allergic reactions to vaccines".)

● Immunocompromise – ZVL should be avoided in populations that are at high risk for developing disseminated VZV infection. This is discussed in detail above.
(See 'Immunocompromised hosts' above.)
 ● Pregnancy – ZVL should not be administered to pregnant women; however, this scenario is unlikely since it is not indicated for women of childbearing age. (See
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Precautions to administration of ZVL include receipt of acyclovir, famciclovir, or valacyclovir 24 hours before vaccination and for 14 days after vaccination, as these
antiviral agents may interfere with the vaccine [39].

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: Vaccines (The Basics)" and "Patient education: Shingles (The
Basics)")

● Beyond the Basics topic (see "Patient education: Shingles (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Herpes zoster (shingles) results from reactivation of varicella-zoster virus (VZV) infection latent in sensory ganglia and is characterized by a painful, unilateral
vesicular eruption in a dermatomal distribution. (See 'Introduction' above.)

● A decline in VZV-specific cell-mediated immunity, which occurs in immune compromised and older individuals, is regarded as the major precipitant for VZV
reactivation. (See 'Importance of cell-mediated immunity' above.)

● Herpes zoster vaccination decreases the risk of developing herpes zoster and postherpetic neuralgia. 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 'Indications for vaccination' above.)

● There are two types of vaccines, a non-live recombinant glycoprotein E vaccine (designated recombinant zoster vaccine [RZV]; approved for use in the United
States in October 2017) and a live attenuated vaccine (designated zoster vaccine live [ZVL]). (See 'Efficacy of the different vaccines' above and 'Non-live
recombinant glycoprotein E vaccine (RZV)' above and 'Zoster vaccine live (ZVL)' above.)

● We consider vaccination in the following groups of patients:

• For immunocompetent patients ≥60 years of age, we recommend zoster vaccination to prevent herpes zoster (Grade 1A). We also suggest zoster vaccination
for such individuals who are 50 years of age or older (Grade 2A). (See 'Indications for vaccination' above and 'Patients aged 50 to 59' above.)

• For patients with prior herpes zoster infection, we suggest vaccination against herpes zoster (Grade 2C). We delay vaccination for approximately three years
since herpes zoster itself will boost VZV-specific immunity. However, the efficacy and appropriate timing of vaccination has not been studied in this setting. (See
'Patients with prior herpes zoster infection' above.)

• For patients ≥50 years old who are planning immunosuppressive therapy (eg, transplant patients, chronic autoimmune disease), we recommend zoster
vaccination as long as vaccination can be completed within a certain period of time prior to immunosuppression (Grade 1B). The timing of vaccination depends
upon which type of vaccine is used. (See 'Immunocompromised hosts' above.)

• If vaccination prior to immunosuppression is not possible, we suggest vaccination for patients receiving low-level immunosuppression (Grade 2B). However, for
most other immunocompromised patients (eg, those who have a primary immunodeficiency or are receiving moderate- to high-dose immunosuppressive
therapy), there are insufficient data to recommend routine vaccination with RZV, and ZVL is contraindicated. (See 'Immunocompromised hosts' above.)

● We suggest RZV rather than ZVL for most patients (Grade 2B). RZV appears to provide greater protection against herpes zoster. In addition, there is less concern
for waning immunity. Disadvantages of RZV are the need for two doses (versus one with ZVL), and an increased risk of mild to moderate side effects (including
those that prevent everyday activities). However, the side effects typically resolve in one to three days, and these factors rarely prevent patients from completing the
RZV series. (See 'Choice of vaccine' above and 'Vaccine administration' above.)

• The only contraindication to RZV is hypersensitivity to the vaccine components. However, the safety of RZV in patients with comorbid conditions, such as
multiple sclerosis, rheumatoid arthritis, and other autoimmune diseases, as well as transplant recipients, is still to be determined. Until more data are available,
the benefits of using RZV in such patients must be weighed against the theoretical risks (eg, a flare of the underlying condition, rejection of the graft) due to the
immune response elicited by the adjuvant. (See 'Contraindications to RZV' above and 'Other conditions' above.)

• ZVL is contraindicated in most immunocompromised patients, as well as in patients with anaphylactic reactions to gelatin or neomycin and pregnant women.
(See 'Contraindications and precautions for ZVL' above and 'Immunocompromised hosts' above.)

● For patients who previously received ZVL, we suggest revaccination with RZV (Grade 2C). Such patients should receive the two-dose series, which should be
initiated at least eight weeks after ZVL. (See 'Patients who received live attenuated herpes zoster or varicella vaccine' above.)

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Topic 8343 Version 41.0

GRAPHICS This site uses cookies. By continuing to browse this site you are agreeing to our use of cookies. Continue or find out more.

Rates* of zoster and postherpetic neuralgia (PHN)•, by age -

United States

* Per 1000 person-years.

• Defined as ≥30 days of pain.

Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of Herpes Zoster: Recommendations of

the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008; 57:1.

Graphic 79262 Version 2.0

Comparison ofsite
This zoster
usesvaccine
cookies. live (ZVL) and
By continuing torecombinant zoster
browse this site vaccine
you are (RZV)
agreeing to our use of cookies. Continue or find out more.
Systemic side effects
that prevented
Efficacy (incidence
Vaccine normal everyday Follow-up Comment
HZ)
activities (vaccine
versus placebo)

ZVL (single dose)
Population ≥60 [1]:
51% reduction in risk of HZ
compared with placebo (95%
CI 44.2-57.6%; 11.12 versus
5.42 per 1000 person-years)
Population 50 to 59 [2]:
70% reduction in risk of HZ
compared with placebo (95%
CI 54.1-80.6%; 6.57 versus
1.99 per 1000 person-years)
<1% reported in post-hoc
analysis [5]
3.1 years Vaccine efficacy was significantly greater in
individuals aged 60 to 69 years compared with those
≥70 years (63.9 versus 37.6%). Protection against
postherpetic neuralgia was 67% [1].
Observational studies found the protection from ZVL
1.3 years wanes significantly after five to eight years (from
approximately 50% to 20 to 30% for those ≥60
years) [6-8]. Protection against postherpetic neuralgia
was maintained significantly longer.

RZV (2 doses separated by 2
months)
Population ≥70 [3]:
89% reduction in risk of HZ
compared with placebo (95%
CI 84.2-93.7%; 9.2 versus
0.9 per 1000 person-years)
6 versus 2% 3.7 years Myalgia was the most common systemic reaction.
Protection against postherpetic neuralgia in patients
≥70 years was 89%.

Population ≥50 [4]: 11.4 versus 2.4% 3.2 years

96.2% reduction in risk of HZ
compared with placebo (95%
CI 92.7-98.3%; 9.1 versus
0.3 per 1000 person-years)

RZV: recombinant zoster vaccine; ZVL: zoster live vaccine; HZ: herpes zoster.

References:
1. 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.
2. Schmader KE, Levin MJ, Gnann JW Jr, et al. Efficacy, safety, and tolerability of herpes zoster vaccine in persons aged 50-59 years. Clin Infect Dis 2012; 54:922.
3. 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.
4. 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.
5. Simberkoff MS, Arbeit RD, Johnson GR, et al. Safety profile of a herpes zoster Vaccine. A Detailed Review of Data from CSP #403: the Shingles Prevention Study. Ann Intern Med
2010; 152:545.
6. Baxter R, Bartlett J, Fireman B, et al. Long-Term Effectiveness of the Live Zoster Vaccine in Preventing Shingles: A Cohort Study. Am J Epidemiol 2018; 187:161.
7. Morrison VA, Johnson GR, Schmader KE, et al. Long-term persistence of zoster vaccine efficacy. Clin Infect Dis 2015; 60:900.
8. Tseng HF, Harpaz R, Luo Y, et al. Declining Effectiveness of Herpes Zoster Vaccine in Adults Aged ≥60 Years. J Infect Dis 2016; 213:1872.

Graphic 116904 Version 1.0

Recommended immunization
This site uses cookies.schedule for adults
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site or older
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United States, 2018

* Influenza vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
General information:
Administer one dose of age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV)
annually.
NOTE: Live attenuated influenza vaccine (LAIV) is not recommended for the 2017 to 2018 influenza season. A list of
currently available influenza vaccines is available at www.cdc.gov/flu/protect/vaccine/vaccines.htm.
Special populations:
Administer age-appropriate IIV or RIV to:
Pregnant women.
Adults with hives-only egg allergy.
Adults with egg allergy other than hives (eg, angioedema or respiratory distress): Administer IIV or RIV in a medical
setting under supervision of a health care provider who can recognize and manage severe allergic conditions.
¶ Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
General information:
Administer to adults who previously did not receive a dose of Tdap as an adult or child (routinely recommended at age 11
to 12 years) one dose of Tdap, followed by a dose of Td booster every 10 years.
Information on the use of Tdap or Td as tetanus prophylaxis in wound management is available at
www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.
Special populations:
Pregnant women: Administer one dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27
to 36.
Δ Measles, mumps, and rubella (MMR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html
General information:
Administer one dose of MMR vaccine to adults with no evidence of immunity to measles, mumps, or rubella.
Evidence of immunity is:
Born before 1957 (except for health care personnel, refer below).
Documentation of receipt of MMR.
Laboratory evidence of immunity or disease.
Documentation of a health care provider-diagnosed disease without laboratory confirmation is not considered evidence of
immunity.
Special populations:
Pregnant women and nonpregnant women of childbearing age with no evidence of immunity to rubella: Administer one
dose of MMR (if pregnant, administer MMR after pregnancy and before discharge from health care facility).
HIV infection and CD4 cell count ≥200 cells/mcL for at least six months and no evidence of immunity to measles, mumps,
or rubella: Administer two doses of MMR at least 28 days apart.
Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised
persons: Administer two doses of MMR at least 28 days apart (or one dose of MMR if previously administered one dose of
MMR).
Health care personnel born in 1957 or later with no evidence of immunity: Administer two doses of MMR at least 28 days
apart for measles or mumps, or one dose of MMR for rubella (if born before 1957, consider MMR vaccination).
Adults who previously received ≤2 doses of mumps-containing vaccine and are identified by public health authority to be
at increased risk for mumps in an outbreak: Administer one dose of MMR.
 MMR is contraindicated for pregnant women and adults with severe immunodeficiency.
◊ Varicella (VAR) vaccine
This site uses cookies. By continuing to browse this site you are agreeing to our use of cookies. Continue or find out more.
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/varicella.html
General information:
Administer to adults without evidence of immunity to varicella two doses of VAR vaccine four to eight weeks apart if
previously received no VAR-containing vaccine (if previously received one dose of VAR-containing vaccine, administer one
dose of VAR vaccine at least four weeks after the first dose).
Evidence of immunity to varicella is:
United States-born before 1980 (except for pregnant women and health care personnel, refer below).
Documentation of receipt of two doses of VAR vaccine or VAR-containing vaccine at least four weeks apart.
Diagnosis or verification of history of varicella or herpes zoster by a health care provider.
Laboratory evidence of immunity or disease.
Special populations:
Administer two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if
previously received one dose of VAR-containing vaccine, administer one dose of VAR vaccine at least four weeks after the
first dose) to:
Pregnant women without evidence of immunity: Administer the first of the two doses or the second dose after
pregnancy and before discharge from health care facility.
Health care personnel without evidence of immunity.
Adults with HIV infection and CD4 cell count ≥200 cells/mcL: May administer, based on individual clinical decision, two
doses of VAR vaccine three months apart.
VAR vaccine is contraindicated for pregnant women and adults with severe immunodeficiency.
§ Zoster vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/shingles.html
General information:
Administer two doses of recombinant zoster vaccine (RZV) two to six months apart to adults aged 50 years or older
regardless of past episode of herpes zoster or receipt of zoster vaccine, live (ZVL).
Administer two doses of RZV two to six months apart to adults who previously received ZVL at least two months after ZVL.
For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).
Special populations:
ZVL is contraindicated for pregnant women and adults with severe immunodeficiency.
¥ Human papillomavirus (HPV) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html
General information:
Administer HPV vaccine to females through age 26 years and males through age 21 years (males aged 22 through 26
years may be vaccinated based on individual clinical decision).
The number of doses of HPV vaccine to be administered depends on age at initial HPV vaccination:
No previous dose of HPV vaccine: Administer three-dose series at 0, 1 to 2, and 6 months (minimum intervals: 4 weeks
between doses 1 and 2, 12 weeks between doses 2 and 3, and 5 months between doses 1 and 3; repeat doses if given
too soon).
Aged 9 to 14 years at HPV vaccine series initiation and received one dose or two doses less than five months apart:
Administer one dose.
Aged 9 to 14 years at HPV vaccine series initiation and received two doses at least five months apart: No additional
dose is needed.
Special populations:
Adults with immunocompromising conditions (including HIV infection) through age 26 years: Administer three-dose series
at zero, one to two, and six months.
Adult females and males through age 26 years with immunocompromising conditions (described below), including those
with HIV infection, should receive a three-dose series of HPV vaccine at zero, one to two, and six months.
Men who have sex with men (MSM) through age 26 years: Administer two- or three-dose series depending on age at initial
vaccination (refer above); if no history of HPV vaccine, administer three-dose series at zero, one to two, and six months.
Pregnant women through age 26 years: HPV vaccination is not recommended during pregnancy, but there is no evidence
that the vaccine is harmful and no intervention needed for women who inadvertently receive HPV vaccine while pregnant;
delay remaining doses until after pregnancy; pregnancy testing is not needed before vaccination.
‡ Pneumococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
General information:
Administer to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine
(PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23)
at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year
after PPSV23.
When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered
during the same visit); additional information on vaccine timing is available at
www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.
Special populations:
Administer to adults aged 19 through 64 years with the following chronic conditions one dose of PPSV23 (at age 65 years
or older, administer one dose of PCV13, if not previously received, and another dose of PPSV23 at least one year after
PCV13 and at least five years after PPSV23):
Chronic heart disease (excluding hypertension).
Chronic lung disease.
Chronic liver disease.
Alcoholism.
Diabetes mellitus.
Cigarette smoking.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of
PPSV23 at least eight weeks after PCV13, and a second dose of PPSV23 at least five years after the first dose of PPSV23 (if
the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose
of PPSV23 at least five years after the last dose of PPSV23):
Immunodeficiency disorders (including B- and T-lymphocyte deficiency, complement deficiencies, and phagocytic
disorders).
HIV infection.
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
Chronic renal failure and nephrotic syndrome.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of
PPSV23 at least eight weeks after PCV13 (if the dose of PPSV23 was administered before age 65 years, at age 65 years or
older, administer another dose of PPSV23 at least five years after the last dose of PPSV23):
Cerebrospinal fluid leak.
Cochlear implant.
† Hepatitis A (HepA) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html
 General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, two-dose series of
This site uses cookies. By continuing to browse this site you are agreeing to our use of cookies. Continue or find out more.
single-antigen HepA vaccine (Havrix at 0 and 6 to 12 months or Vaqta at 0 and 6 to 18 months; minimum interval: 6
months) or a three-dose series of combined hepatitis A and hepatitis B (HepA-HepB) vaccine at 0, 1, and 6 months;
minimum intervals: 4 weeks between first and second doses, 5 months between second and third doses.
Special populations:
Administer HepA vaccine or HepA-HepB vaccine to adults with the following indications:
Travel to or work in countries with high or intermediate HepA endemicity.
MSM.
Injection or noninjection drug use.
Work with HepA virus in a research laboratory or with nonhuman primates infected with HepA virus.
Clotting factor disorders.
Chronic liver disease.
Close, personal contact with an international adoptee (eg, household or regular babysitting) during the first 60 days
after arrival in the United States from a country with high or intermediate endemicity (administer the first dose as soon
as the adoption is planned).
Healthy adults through age 40 years who have recently been exposed to HepA virus; adults older than age 40 years
may receive HepA vaccine or HepA-HepB vaccine if HepA immunoglobulin cannot be obtained.
Adults who travel in countries with high or intermediate levels of endemic HepA infection or anticipate close personal
contact with an international adoptee (eg, reside in the same household or regularly babysit) from a country with high or
intermediate level of endemic HepA infection within the first 60 days of arrival in the United States should receive a HepA
series.
** Hepatitis B (HepB) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, three-dose series of
single-antigen HepB vaccine or combined HepA-HepB vaccine at zero, one, and six months (minimum intervals: Four
weeks between doses 1 and 2 for HepB vaccine and HepA-HepB vaccine; between doses 2 and 3, eight weeks for HepB
vaccine and five months for HepA-HepB vaccine).
Special populations:
Administer HepB vaccine or HepA-HepB vaccine to adults with the following indications:
Chronic liver disease (eg, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune
hepatitis, alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level greater than twice the upper limit
of normal).
HIV infection.
Percutaneous or mucosal risk of exposure to blood (eg, household contacts of hepatitis B surface antigen [HBsAg]-
positive persons; adults younger than age 60 years with diabetes mellitus or aged 60 years or older with diabetes
mellitus based on individual clinical decision; adults in predialysis care or receiving hemodialysis or peritoneal dialysis;
recent or current injection drug users; health care and public safety workers at risk for exposure to blood or blood-
contaminated body fluids).
Sexual exposure risk (eg, sex partners of HBsAg-positive persons; sexually active persons not in a mutually
monogamous relationship; persons seeking evaluation or treatment for a sexually transmitted infection; and MSM).
Receive care in settings where a high proportion of adults have risks for HepB infection (eg, facilities providing
sexually transmitted disease treatment, drug-abuse treatment and prevention services, hemodialysis and end-stage
renal disease programs, institutions for developmentally disabled persons, health care settings targeting services to
injection drug users or MSM, HIV testing and treatment facilities, and correctional facilities).
Travel to countries with high or intermediate HepB endemicity.
¶¶ Meningococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mening.html
Special populations: Serogroups A, C, W, and Y meningococcal vaccine (MenACWY)
Administer two doses of MenACWY at least eight weeks apart and revaccinate with one dose of MenACWY every five
years, if the risk remains, to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
HIV infection.
Persistent complement component deficiency.
Eculizumab use.
Administer one dose of MenACWY and revaccinate with one dose of MenACWY every five years, if the risk remains, to
adults with the following indications:
Travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the
African meningitis belt or during the Hajj.
At risk from a meningococcal disease outbreak attributed to serogroup A, C, W, or Y.
Microbiologists routinely exposed to Neisseria meningitidis.
Military recruits.
First-year college students who live in residential housing (if they did not receive MenACWY at age 16 years or older).
General Information: Serogroup B meningococcal vaccine (MenB)
May administer, based on individual clinical decision, to young adults and adolescents aged 16 to 23 years (preferred age
is 16 to 18 years) who are not at increased risk two-dose series of MenB-4C (Bexsero) at least one month apart or two-
dose series of MenB-FHbp (Trumenba) at least six months apart.
MenB-4C and MenB-FHbp are not interchangeable.
Special populations: MenB
Administer two-dose series of MenB-4C at least one month apart or three-dose series of MenB-FHbp at zero, one to two,
and six months to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease).
Persistent complement component deficiency.
Eculizumab use.
At risk from a meningococcal disease outbreak attributed to serogroup B.
Microbiologists routinely exposed to N. meningitidis.
ΔΔ Haemophilus influenzae type b (Hib) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hib.html
Special populations:
Administer Hib vaccine to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: Administer one
dose if not previously vaccinated (preferably at least 14 days before elective splenectomy).
Hematopoietic stem cell transplant (HSCT): Administer three-dose series with doses 4 weeks apart starting 6 to 12
months after successful transplant regardless of Hib vaccination history.

Reproduced from: Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices
Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2018. Available at:
http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (Accessed on February 9, 2018).

Graphic 82634 Version 26.0

Recommended immunization
This site uses cookies.schedule for adults
By continuing aged
to browse this19 years
site or older
you are by to
agreeing medical
our usecondition
of cookies.and otherorindications
Continue - United States,
find out more.
2018

* Influenza vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
General information:
Administer one dose of age-appropriate inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) annually.
NOTE: Live attenuated influenza vaccine (LAIV) is not recommended for the 2017 to 2018 influenza season. A list of currently available influenza vaccines is available at
www.cdc.gov/flu/protect/vaccine/vaccines.htm.
Special populations:
Administer age-appropriate IIV or RIV to:
Pregnant women.
Adults with hives-only egg allergy.
Adults with egg allergy other than hives (eg, angioedema or respiratory distress): Administer IIV or RIV in a medical setting under supervision of a healthcare provider who can
recognize and manage severe allergic conditions.
¶ Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
General information:
Administer to adults who previously did not receive a dose of Tdap as an adult or child (routinely recommended at age 11 to 12 years) one dose of Tdap, followed by a dose of Td booster
every 10 years.
Information on the use of Tdap or Td as tetanus prophylaxis in wound management is available at www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm.
Special populations:
Pregnant women: Administer one dose of Tdap during each pregnancy, preferably in the early part of gestational weeks 27 to 36.
Δ Measles, mumps, and rubella (MMR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mmr.html
General information:
Administer one dose of MMR vaccine to adults with no evidence of immunity to measles, mumps, or rubella.
Evidence of immunity is:
Born before 1957 (except for healthcare personnel, refer below).
Documentation of receipt of MMR.
Laboratory evidence of immunity or disease.
Documentation of a healthcare provider-diagnosed disease without laboratory confirmation is not considered evidence of immunity.
Special populations:
Pregnant women and nonpregnant women of childbearing age with no evidence of immunity to rubella: Administer one dose of MMR (if pregnant, administer MMR after pregnancy and
before discharge from healthcare facility).
HIV infection and CD4 cell count ≥200 cells/mcL for at least six months and no evidence of immunity to measles, mumps, or rubella: Administer two doses of MMR at least 28 days apart.
Students in postsecondary educational institutions, international travelers, and household contacts of immunocompromised persons: Administer two doses of MMR at least 28 days apart
(or one dose of MMR if previously administered one dose of MMR).
Healthcare personnel born in 1957 or later with no evidence of immunity: Administer two doses of MMR at least 28 days apart for measles or mumps, or one dose of MMR for rubella (if
born before 1957, consider MMR vaccination).
Adults who previously received ≤2 doses of mumps-containing vaccine and are identified by public health authority to be at increased risk for mumps in an outbreak: Administer one dose
of MMR.
MMR is contraindicated for pregnant women and adults with severe immunodeficiency.
◊ Varicella (VAR) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/varicella.html
General information:
 Administer to adults without evidence of immunity to varicella two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if previously received
one dose of VAR-containing vaccine, administer one dose of VAR vaccine at least four weeks after the first dose).
This site uses cookies. By continuing to browse this site you are agreeing to our use of cookies. Continue or find out more.
Evidence of immunity to varicella is:
United States-born before 1980 (except for pregnant women and healthcare personnel, refer below).
Documentation of receipt of two doses of VAR vaccine or VAR-containing vaccine at least four weeks apart.
Diagnosis or verification of history of varicella or herpes zoster by a healthcare provider.
Laboratory evidence of immunity or disease.
Special populations:
Administer two doses of VAR vaccine four to eight weeks apart if previously received no VAR-containing vaccine (if previously received one dose of VAR-containing vaccine, administer one
dose of VAR vaccine at least four weeks after the first dose) to:
Pregnant women without evidence of immunity: Administer the first of the two doses or the second dose after pregnancy and before discharge from healthcare facility.
Healthcare personnel without evidence of immunity.
Adults with HIV infection and CD4 cell count ≥200 cells/mcL: May administer, based on individual clinical decision, two doses of VAR vaccine three months apart.
VAR vaccine is contraindicated for pregnant women and adults with severe immunodeficiency.
§ Zoster vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/shingles.html
General information:
Administer two doses of recombinant zoster vaccine (RZV) two to six months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster
vaccine, live (ZVL).
Administer two doses of RZV two to six months apart to adults who previously received ZVL at least two months after ZVL.
For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).
Special populations:
ZVL is contraindicated for pregnant women and adults with severe immunodeficiency.
¥ Human papillomavirus (HPV) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html
General information:
Administer HPV vaccine to females through age 26 years and males through age 21 years (males aged 22 through 26 years may be vaccinated based on individual clinical decision).
The number of doses of HPV vaccine to be administered depends on age at initial HPV vaccination:
No previous dose of HPV vaccine: Administer three-dose series at 0, 1 to 2, and 6 months (minimum intervals: 4 weeks between doses 1 and 2, 12 weeks between doses 2 and 3, and
5 months between doses 1 and 3; repeat doses if given too soon).
Aged 9 to 14 years at HPV vaccine series initiation and received one dose or two doses less than five months apart: Administer one dose.
Aged 9 to 14 years at HPV vaccine series initiation and received two doses at least five months apart: No additional dose is needed.
Special populations:
Adults with immunocompromising conditions (including HIV infection) through age 26 years: Administer three-dose series at zero, one to two, and six months.
Adult females and males through age 26 years with immunocompromising conditions (described below), including those with HIV infection, should receive a three-dose series of HPV
vaccine at zero, one to two, and six months.
Men who have sex with men [MSM] through age 26 years: Administer two- or three-dose series depending on age at initial vaccination (refer above); if no history of HPV vaccine,
administer three-dose series at zero, one to two, and six months.
Pregnant women through age 26 years: HPV vaccination is not recommended during pregnancy, but there is no evidence that the vaccine is harmful and no intervention needed for
women who inadvertently receive HPV vaccine while pregnant; delay remaining doses until after pregnancy; pregnancy testing is not needed before vaccination.
‡ Pneumococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/pneumo.html
General information:
Administer to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of
23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after
PPSV23.
When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during the same visit); additional information on vaccine timing is
available at www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf.
Special populations:
Administer to adults aged 19 through 64 years with the following chronic conditions one dose of PPSV23 (at age 65 years or older, administer one dose of PCV13, if not previously
received, and another dose of PPSV23 at least one year after PCV13 and at least five years after PPSV23):
Chronic heart disease (excluding hypertension).
Chronic lung disease.
Chronic liver disease.
Alcoholism.
Diabetes mellitus.
Cigarette smoking.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight weeks after PCV13, and a second dose of
PPSV23 at least five years after the first dose of PPSV23 (if the most recent dose of PPSV23 was administered before age 65 years, at age 65 years or older, administer another dose of
PPSV23 at least five years after the last dose of PPSV23):
Immunodeficiency disorders (including B- and T-lymphocyte deficiency, complement deficiencies, and phagocytic disorders).
HIV infection.
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
Chronic renal failure and nephrotic syndrome.
Administer to adults aged 19 years or older with the following indications one dose of PCV13 followed by one dose of PPSV23 at least eight weeks after PCV13 (if the dose of PPSV23 was
administered before age 65 years, at age 65 years or older, administer another dose of PPSV23 at least five years after the last dose of PPSV23):
Cerebrospinal fluid leak.
Cochlear implant.
† Hepatitis A (HepA) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepa.html
General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, two-dose series of single antigen HepA vaccine (Havrix at 0 and 6 to 12 months or
Vaqta at 0 and 6 to 18 months; minimum interval: 6 months) or a three-dose series of combined hepatitis A and hepatitis B (HepA-HepB) vaccine at 0, 1, and 6 months; minimum
intervals: 4 weeks between first and second doses, 5 months between second and third doses.
Special populations:
Administer HepA vaccine or HepA-HepB vaccine to adults with the following indications:
Travel to or work in countries with high or intermediate HepA endemicity.
MSM.
Injection or noninjection drug use.
Work with HepA virus in a research laboratory or with nonhuman primates infected with HepA virus.
Clotting factor disorders.
Chronic liver disease.
Close, personal contact with an international adoptee (eg, household or regular babysitting) during the first 60 days after arrival in the United States from a country with high or
intermediate endemicity (administer the first dose as soon as the adoption is planned).
Healthy adults through age 40 years who have recently been exposed to HepA virus; adults older than age 40 years may receive HepA vaccine or HepA-HepB vaccine if HepA
immunoglobulin cannot be obtained.
Adults who travel in countries with high or intermediate levels of endemic HepA infection or anticipate close personal contact with an international adoptee (eg, reside in the same
household or regularly babysit) from a country with high or intermediate level of endemic HepA infection within the first 60 days of arrival in the United States should receive a HepA
series.
** Hepatitis B (HepB) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hepb.html
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General information:
Administer to adults who have a specific risk (refer below), or lack a risk factor but want protection, three-dose series of single antigen HepB vaccine or combined HepA-HepB vaccine at
zero, one, and six months (minimum intervals: Four weeks between doses one and two for HepB vaccine and HepA-HepB vaccine; between doses two and three, eight weeks for HepB
vaccine and five months for HepA-HepB vaccine).
Special populations:
Administer HepB vaccine or HepA-HepB vaccine to adults with the following indications:
Chronic liver disease (eg, hepatitis C infection, cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, alanine aminotransferase [ALT] or aspartate
aminotransferase [AST] level greater than twice the upper limit of normal).
HIV infection.
Percutaneous or mucosal risk of exposure to blood (eg, household contacts of hepatitis B surface antigen [HBsAg]-positive persons; adults younger than age 60 years with diabetes
mellitus or aged 60 years or older with diabetes mellitus based on individual clinical decision; adults in predialysis care or receiving hemodialysis or peritoneal dialysis; recent or
current injection drug users; healthcare and public safety workers at risk for exposure to blood or blood-contaminated body fluids).
Sexual exposure risk (eg, sex partners of HBsAg-positive persons; sexually active persons not in a mutually monogamous relationship; persons seeking evaluation or treatment for a
sexually transmitted infection; and MSM).
Receive care in settings where a high proportion of adults have risks for HepB infection (eg, facilities providing sexually transmitted disease treatment, drug-abuse treatment and
prevention services, hemodialysis and end-stage renal disease programs, institutions for developmentally disabled persons, healthcare settings targeting services to injection drug
users or MSM, HIV testing and treatment facilities, and correctional facilities).
Travel to countries with high or intermediate HepB endemicity.
¶¶ Meningococcal vaccines
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/mening.html
Special populations: Serogroups A, C, W, and Y meningococcal vaccine (MenACWY)
Administer two doses of MenACWY at least eight weeks apart and revaccinate with one dose of MenACWY every five years, if the risk remains, to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies).
HIV infection.
Persistent complement component deficiency.
Eculizumab use.
Administer one dose of MenACWY and revaccinate with one dose of MenACWY every five years, if the risk remains, to adults with the following indications:
Travel to or live in countries where meningococcal disease is hyperendemic or epidemic, including countries in the African meningitis belt or during the Hajj.
At risk from a meningococcal disease outbreak attributed to serogroup A, C, W, or Y.
Microbiologists routinely exposed to Neisseria meningitidis.
Military recruits.
First-year college students who live in residential housing (if they did not receive MenACWY at age 16 years or older).
General Information: Serogroup B meningococcal vaccine (MenB)
May administer, based on individual clinical decision, to young adults and adolescents aged 16 to 23 years (preferred age is 16 to 18 years) who are not at increased risk two-dose series
of MenB-4C (Bexsero) at least one month apart or two-dose series of MenB-FHbp (Trumenba) at least six months apart.
MenB-4C and MenB-FHbp are not interchangeable.
Special populations: MenB
Administer two-dose series of MenB-4C at least one month apart or three-dose series of MenB-FHbp at zero, one to two, and six months to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease).
Persistent complement component deficiency.
Eculizumab use.
At risk from a meningococcal disease outbreak attributed to serogroup B.
Microbiologists routinely exposed to Neisseria meningitidis.
ΔΔ Haemophilus influenzae type b (Hib) vaccine
www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hib.html
Special populations:
Administer Hib vaccine to adults with the following indications:
Anatomical or functional asplenia (including sickle cell disease) or undergoing elective splenectomy: Administer one dose if not previously vaccinated (preferably at least 14 days
before elective splenectomy).
Hematopoietic stem cell transplant (HSCT): Administer three-dose series with doses 4 weeks apart starting 6 to 12 months after successful transplant regardless of Hib vaccination
history.

Reproduced from: Advisory Committee on Immunization Practices (ACIP). Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or
Older: United States, 2018. Available at: http://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf (Accessed on February 8, 2018).

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