Guidance

Shingles immunisation programme: information for healthcare practitioners

Updated 7 September 2023

Applies to England

Background history

In 2010, the Joint Committee on Vaccination and Immunisation (JCVI) was asked by the Secretary of State for Health to review the available evidence relevant to the introduction of a universal vaccination programme to protect against shingles (Herpes Zoster).

JCVI considered a range of issues including disease epidemiology, vaccine efficacy, vaccine safety and the cost effectiveness of introducing a routine shingles vaccination programme in the UK. Based on the findings of the cost-effectiveness analysis, JCVI recommended a universal routine herpes zoster (shingles) vaccination programme using a single dose of the live Zostavax shingles vaccine for adults aged 70 with a catch-up programme for those aged 71 to 79 years. Individuals who reached their 80th birthday were not eligible for a shingles vaccination due to the reduced efficacy of Zostavax vaccine with increased age.

From September 2013, a single dose of Zostavax shingles vaccine was offered routinely to individuals aged 70 years (born on or after 1 September 1942) with a phased catch-up programme based on age as of 1 September that year.

From 1 April 2017, it was agreed that individuals could be opportunistically immunised at any time of the year once they reached the eligible age. Most immunisation was still carried out in the autumn months, so from March 2018 practices were further encouraged to vaccinate throughout the year to provide the earliest possible protection.

In February 2018, JCVI recommended that the non-live Shingrix shingles vaccine should be offered to all immunosuppressed individuals where Zostavax was contraindicated but who were eligible for vaccination under the programme, so that they could gain a similar level of protection to those who were not immunosuppressed. The Committee noted that vaccination in this group was particularly important, due to the higher incidence of herpes zoster. This advice was consistent with the original recommendation for vaccination of all adults aged 70 to 79 years with herpes zoster vaccine but, at this time, there were insufficient supplies of Shingrix vaccine to be able to implement this recommendation.

From 1 September 2021, Shingrix vaccine was offered to all those who were eligible for shingles vaccination but who were clinically contraindicated to receive the live vaccine, Zostavax, due to their immunosuppressed status.

At this point, Shingrix could only be given to those who were clinically contraindicated for Zostavax (for example due to immunosuppressed status) in order to ensure that there was sufficient vaccine supply for all those who were eligible to receive the vaccine. Immunocompetent eligible patients continued to be offered Zostavax.

In February 2019, based on impact and cost effectiveness modelling, JCVI recommended that the national shingles immunisation programme should be changed to offer Shingrix routinely at 60 years of age, and Shingrix should be offered to immunocompromised individuals aged 50 and over.

JCVI further advised that those aged between 60 and 70 years should also be offered Shingrix in stages starting with vaccination at ages 65 and 70 years, then moving to vaccination of those aged 60 and 65 years, following which time vaccination could then be routinely offered at 60 years of age. The advice was based on the high efficacy, safety and immunogenicity of Shingrix observed in clinical trials. Evidence to support introducing it at an earlier age suggests that Shingrix provides a substantially longer duration of protection from shingles than Zostavax.

From 1 September 2023, the Shingrix shingles vaccine should be offered to:

• all severely immunosuppressed (eligibility as defined in the Green Book Shingles chapter 28a) from 50 years of age
• immunocompetent individuals who will become eligible for the Shingrix vaccine from 60 years of age in a phased implementation over a 10-year period starting with those turning 65 and 70 years of age.

The shingles vaccine is available through GP surgeries in primary care, and GPs are required to identify and put in place a call or recall arrangement to offer the shingles vaccination to eligible patients. The shingles vaccine can be offered throughout the year.

Shingles

Shingles (herpes zoster) is a viral infection of an individual nerve and the skin surface that is served by that nerve. Shingles infection develops as a result of a reactivation of latent varicella zoster virus, the same virus that causes chickenpox. Once a person has recovered from chickenpox, the varicella zoster virus lies dormant in the nerve cells and can reactivate at a later stage when the immune system is weakened. Reactivation of the virus, resulting in shingles infection, is thought to be associated with a decline in cell mediated immunity. This can occur in individuals of any age, but the risk and severity of shingles increases with age (Van Hoek and others, 2009), immunosuppression and HIV.

The burden of disease among adults aged 70 and above is considerably greater than for younger adults. Older adults tend to experience a severe form of the disease which can result in secondary complications including persistent pain or post herpetic neuralgia (PHN) and secondary bacterial skin infections that may require hospitalisation.

Images of shingles are available to view on the NHS.UK website.

The Green Book Shingles chapter 28a

The Green Book Shingles (herpes zoster) chapter 28a includes detailed information on shingles and the shingles vaccination programme.

Healthcare practitioners should familiarise themselves with the information in the Green Book chapter before offering shingles vaccination.

There will be 2 Green Book Shingles chapters listed prior to 1 September 2023:

• the current chapter that includes information about Zostavax
• the updated chapter for use from 1 September 2023 onwards

The original chapter will be removed once supply of Zostavax is no longer available through ImmForm.

The shingles vaccination programme

The aim of the shingles immunisation programme is to reduce the incidence and severity of shingles disease and subsequent PHN. Although shingles can occur at any age, the risk and severity of shingles and its complications increases with age and is high in individuals who are severely immunosuppressed. The programme is designed to ensure that those at greatest risk are vaccinated at an earlier age.

Eligible cohorts – until 31 August 2023

Under the current shingles programme, all individuals become eligible for the shingles vaccine (Zostavax or Shingrix) once they reach 70 years of age and they remain eligible for the shingles vaccine up to 79 years of age. The Shingrix vaccine is available for immunosuppressed individuals contraindicated to receive Zostavax.

Eligible cohorts – from 1 September 2023

Severely immunosuppressed individuals

From 1 September 2023, severely immunosuppressed individuals (eligibility as defined in the Green Book Shingles chapter 28a) aged 50 years and over who have not received the shingles vaccine before will be eligible for 2 doses of the Shingrix vaccine. The second dose should be given 8 weeks to 6 months after the first dose for this cohort. There is no upper age limit but individuals should be offered the vaccine as soon as they become eligible to provide protection as early as possible.

Severely immunosuppressed individuals represent the highest priority for vaccination given their risk of severe disease and therefore the programme aims to catch up all severely immunosuppressed individuals aged 50 years and over in the first year of the programme implementation. For full details and summary of individuals and conditions where Shingrix should be offered at 50 years of age refer to the ‘Definition of severe immunosuppression’ section in the Green Book Shingles chapter 28a. The decision should be based on a clinical assessment and, where appropriate, discussion with the individual patient’s treating physician.

Immunocompetent cohort

From 1 September 2023, the routine age for the shingles programme is changing from routinely offering Zostavax at 70 years of age to routinely offering Shingrix at 60 years of age. This change will be undertaken in a phased approach over 2 stages during a 10 year implementation period.

Immunocompetent individuals from 70 to 79 years of age who have not received the shingles vaccine before are already eligible for the shingles vaccine and they remain eligible up to their 80th birthday.

For this group of immunocompetent individuals, a single dose of Zostavax will continue to be offered until stocks from ImmForm are exhausted, at which time everyone in this eligible group will instead be offered 2 doses of Shingrix vaccine. The second dose of Shingrix may be offered 8 weeks after the first dose but for operational reasons a longer interval is being used with an interval of 6 months to 12 months between the 2 doses.

Immunocompetent individuals turning 65 and 70 years of age from 1 September each year will be offered the Shingrix vaccine and will remain eligible up to their 80th birthday.

During stage 1 (1 September 2023 to 31 August 2028) Shingrix will be offered to those turning 70 and 65 years of age.

During stage 2 (1 September 2028 to 31 August 2033) Shingrix will be offered to those turning 65 and 60 years of age.

Thereafter, from 1 September 2033, Shingrix will be offered routinely to all immunocompetent individuals at 60 years of age.

Further information about the shingles national vaccination programme is available.

Eligibility for Shingrix vaccine on the routine immunisation programme from 1 September 2023

Eligible cohorts	Age	Number of doses	Schedule: Two doses a minimum of 8 weeks apart
Individuals who are severely immunosuppressed (eligibility as defined in the Green Book Shingles chapter 28a)	From 50 years of age [note 1].	2 doses	0 and 8 weeks to 6 months
Immunocompetent individuals who have not previously received shingles vaccine [note 2]	All 70 to 79 years of age (already eligible) [note 3]. Those turning 65 and 70 years of age from 1 September 2023 (and then turning 65 and 70 years of age from 1 September in subsequent years) [note 4].	2 doses	0 and 8 weeks to 12 months

[note 1] Individuals who are severely immunosuppressed remain eligible with no upper age limit but should be offered a vaccine as soon as they become eligible by age. They should be offered the second dose of vaccine after 8 weeks to ensure they are protected as early as possible.

[note 2] See section on Individuals given Zostavax prior to becoming eligible for the national shingles vaccination programme.

[note 3] Zostavax (one dose) should continue to be offered to immunocompetent individuals aged 70 to 79 years of age until stock has run out to avoid vaccine wastage. See Green Book Shingles chapter 28a for details on underlying health conditions where Zostavax is contraindicated or not suitable.

[note 4] Immunocompetent individuals remain eligible until their 80th birthday; the second dose should be completed before the 81st birthday. The second dose should be offered at 6 months to 12 months (local operational guidelines may differ).

Shingles vaccine

There are 2 shingles vaccines currently available for use within the national programme:

• Zostavax: a live vaccine given as a single dose – offered to everyone from 70 to 79 years of age (unless contraindicated due to underlying medical condition or immunosuppressive treatment)
• Shingrix: a non-live recombinant sub-unit vaccine given as a 2-dose schedule

Prescription only medicines

All vaccines (including shingles vaccines) are classified as prescription only medicines (POMs). This means that they are subject to legal restrictions and there needs to be an appropriate legal framework in place before they can be supplied and/or administered. Any person who supplies and administers a vaccine must have a legal authority to do so. This legal authority may be in the form of a written patient specific prescription, a Patient Specific Direction (PSD) or a Patient Group Direction (PGD).

The UK Health Security Agency (UKHSA) develops and publishes PGD templates for all vaccines used in the routine immunisation programme to support their delivery and these are available on the Immunisation Patient Group Direction (PGD) templates collection on GOV.UK.

The UKHSA immunisation PGD templates require further authorisation in section 2 of the PGD document before they can be used. The PGD is not legal or valid without signed authorisation.

Vaccine ordering

Vaccines for the national shingles vaccination programme should be ordered via the ImmForm website. Healthcare practitioners should refer to this website and Vaccine update (the vaccination newsletter for healthcare practitioners) for up-to-date information on vaccine availability. As the programme is a year-round programme and not a seasonal programme, vaccines should be ordered regularly throughout the year.

Healthcare practitioners are reminded to only order what they need for a 2 to 4 week period rather than over-ordering or stockpiling vaccines. Vaccines should be ordered, stored and monitored as described in the Green Book chapter 3 (Storage, distribution and disposal of vaccines).

Vaccines required for individuals who are not in the eligible cohort – for example where a clinician has decided that it is clinically appropriate to vaccinate the patient but they are not within the eligible age cohorts for the national vaccination programme – would require the GP practice to purchase the vaccine directly from the manufacturer and then reclaim the cost of the vaccine. This direct purchasing also applies to vaccine for stem cell transplant recipients aged 18 to 49 years.

Vaccine storage

Zostavax and Shingrix should be stored in a vaccine refrigerator between +2°C and +8°C. The vaccines should be stored in the original packaging to protect them from light.

Further information on vaccine storage is available in the Summary of product characteristics (SPC) (Zostavax, Shingrix), the Patient Group Direction and from the manufacturer.

Zostavax vaccine

Zostavax is a live, attenuated varicella-zoster vaccine that contains a high antigen content of varicella zoster virus (Oka/Merck strain, not less than 19,400 plaque-forming units).

Zostavax does not contain latex or thiomersal but it does contain hydrolysed gelatine derived from pork as one of its additives (see section below on gelatine). Zostavax may contain traces of neomycin so Zostavax vaccine should not be given to individuals who have had a confirmed anaphylactic reaction to neomycin. For the full list of vaccine components and excipients, immunisers should refer to the Summary of product characteristics (SPC).

Gelatine

Gelatine is commonly used in a range of pharmaceutical products, including many capsules and some vaccines. The gelatine in Zostavax is a highly purified product and is used as a stabiliser to protect the live virus against the effects of temperature and ensure that the vaccine remains safe and effective during storage.

It is recognised that the inclusion of gelatine may raise issues of acceptability for some people who do not consume animal products, or those whose faith avoids consumption of products from specific animals.

The use of gelatine in certain live vaccines is discussed in detail in the UKHSA publication Guide to the use of human and animal products in vaccines and a specific leaflet on the use of porcine gelatine in vaccines is available to read and order in several different languages on the GOV.UK website. Shingles vaccinators are encouraged to read these leaflets and to refer individuals to them where further information is requested.

The Shingrix vaccine does not contain gelatine as it is a non-live vaccine and therefore does not require the use of this stabiliser.

Zostavax: contraindications and precautions

The contraindications and precautions to Zostavax are:

• confirmed anaphylactic reaction to a previous dose of varicella-containing vaccine or any component of the vaccine
• pregnancy
• severe immunosuppression due to underlying condition or treatment as defined in the Green Book Shingles chapter 28a

The immunisation of individuals who are acutely unwell should be postponed until they have recovered fully. This is to avoid confusing the diagnosis of any acute illness by wrongly attributing any sign or symptoms to the adverse effects of the vaccine.

For full details refer to the Green Book Shingles chapter 28a and Zostavax PGD.

Zostavax: vaccine administration

Zostavax should be reconstituted according to the manufacturer’s instructions. Once reconstituted, the vaccine should be administered immediately.

Zostavax is licensed to be given via either the intramuscular (IM) or subcutaneous (SC) route, preferably in the deltoid region of the upper arm. Intramuscular administration is the preferred route as injection-site adverse reactions were significantly less frequent in those who received the vaccine via this route.

Zostavax: vaccine dosage and schedule

Zostavax should be administered as a 0.65ml dose after reconstitution.

The schedule for Zostavax is a single dose of vaccine.

Shingrix vaccine

Shingrix is a non-live recombinant adjuvanted subunit shingles vaccine. It does not contain any live virus. Shingrix contains a single protein glycoprotein E (gE) found in the outer shell of the herpes zoster virus, and an adjuvant AS01B to enhance the body’s immune response to the antigen. By combining the varicella zoster virus (VZV) specific antigen (gE) with the AS01B adjuvant, Shingrix is designed to induce antigen-specific cellular and humoral immune responses in individuals with pre-existing immunity against VZV.

Shingrix does not contain latex, thiomersal or gelatine.

The Shingrix vaccine was approved for use in adults 50 years of age or over in the US, Canada and Australia in 2017, and for use in the European Union and Japan in 2018. It is also licensed for use in the UK, New Zealand, Singapore and China. Current usage of Shingrix has been related to the availability and supply of the vaccine in different countries.

For the full list of vaccine components and excipients, refer to the manufacturer’s Summary of product characteristics (SPC).

Shingrix: contraindications and precautions

The contraindications and precautions to Shingrix are:

• systemic allergic reaction (including immediate-onset anaphylaxis) to a previous dose of Shingrix vaccine or any component (excipient) of Shingrix

Immunisation of individuals who are acutely unwell should be postponed until they have recovered fully. This is to avoid confusing the diagnosis of any acute illness by wrongly attributing any sign or symptoms to the adverse effects of the vaccine.

For full details refer to the Green Book Shingles chapter 28a and Shingrix PGD.

Shingrix: vaccine administration

Shingrix should be reconstituted according to the manufacturer’s instructions. Once reconstituted, the vaccine should be administered immediately.

Shingrix vaccine should be administered by intramuscular (IM) injection only, preferably into the deltoid muscle. Subcutaneous (SC) administration is not recommended due to an increase in transient local reactions (see section on Vaccination for individuals with bleeding disorders).

Shingrix: vaccine dosage and schedule

Shingrix should be administered as a 0.5ml dose after reconstitution.

The schedule for Shingrix consists of 2 doses a minimum of 8 weeks apart.

The recommendation for severely immunosuppressed individuals is to give the second dose 8 weeks to 6 months after the first dose to ensure individuals are protected as soon as possible.

For immunocompetent individuals the second dose can be administered 8 weeks to 12 months after the first dose. For operational reasons a longer dose interval is being recommended in England and Wales (6 to 12 months) but the second dose may be offered from 8 weeks after the first dose. Local operational guidance should be followed and either schedule is clinically effective.

Zostavax and Shingrix: booster doses

The need for, and the timing of a booster dose, for either Zostavax or Shingrix has not yet been determined. Therefore no booster dose is currently recommended.

Vaccination for individuals with bleeding disorders

Individuals with bleeding disorders may be vaccinated intramuscularly if, in the opinion of a doctor familiar with the individual’s bleeding risk, vaccines or similar small volume intramuscular injections can be administered with reasonable safety by this route. If the individual receives medication or treatment to reduce bleeding, for example treatment for haemophilia, intramuscular vaccination can be scheduled shortly after such medication or treatment is administered.

Individuals on stable anticoagulation therapy, including individuals on warfarin who are up to date with their scheduled international normalised ratio (INR) testing and whose latest INR was below the upper threshold of their therapeutic range, can receive intramuscular vaccination. A fine needle (equal to 23 gauge or finer calibre such as 25 gauge) should be used for the vaccination, followed by firm pressure applied to the site (without rubbing) for at least 2 minutes.

If in any doubt, consult with the clinician responsible for prescribing or monitoring the individual’s anticoagulant therapy. On occasion the treating clinician may conclude, in discussion with the patient, that the benefit of protection against shingles could outweigh the increased risk of a transient local reaction with intramuscular immunisation. Subcutaneous administration is off-label and a Patient Specific Direction (PSD) would be required.

The individual or carer should be informed about the risk of haematoma from the injection.

Adverse reactions commonly associated with the administration of Zostavax

The most commonly reported adverse reactions following vaccination with Zostavax in clinical trials were injection site reactions (affecting at least 1 in 10 of those receiving the vaccine), erythema (redness), pain, swelling and pruritus (itching) at the injection site, and headache.

Adverse reactions commonly associated with the administration of Shingrix

The most commonly reported adverse reactions following Shingrix in clinical trials as noted on the SPC were pain at the injection site, myalgia, fatigue, headache, fever and gastrointestinal symptoms (including nausea, vomiting, diarrhoea and/or abdominal pain) lasting 2 to 3 days. Reactions can be following either the first, second or both doses of Shingrix vaccine. Reactions are generally reported to be lower in those 70 years of age and above.

In 4 phase III, controlled, open-label clinical studies, fever and shivering were more commonly reported when pneumococcal polysaccharide vaccine (PPV23) was given at the same time as the Shingrix vaccine when compared to when Shingrix was given alone.

Development of a vesicular rash after receiving Zostavax

Although transmission of the Zostavax vaccine virus (Oka/Merck strain) has not been reported during clinical trials, any person developing a vesicular rash after receiving Zostavax should be tested, as recommended below.

Manufacturer experience with varicella (chickenpox) vaccines that use a lower dose of the same virus strain, suggests that transmission of vaccine virus may occur rarely between vaccinees who develop a varicella-zoster virus (VZV) like rash and susceptible close contacts.

As a precautionary measure, any person who develops a vesicular rash after receiving Zostavax should ensure the rash area is kept covered when in contact with a susceptible (chickenpox naïve) person until the rash is dry and crusted. If the person who received the vaccine is themselves immunosuppressed, they should avoid contact with susceptible people until the rash is dry and crusted, due to the higher risk of virus shedding.

Immunosuppressed individuals who develop a rash following inadvertent vaccination with Zostavax should be urgently assessed and offered prompt treatment with aciclovir – see the guidance in the section titled ‘Action to take if immunosuppressed individual inadvertently given Zostavax’.

In addition to the precautionary measures outlined above, a vesicle fluid sample should also be sent for analysis to confirm the diagnosis and determine whether the rash is vaccine associated or wild type. This service is available at the UKHSA Virus Reference Department (VRD), Colindale. Please note sampling kits are not supplied by the VRD at UKHSA. Health professionals are requested to obtain vesicle swabs from their local hospital laboratories. Varicella zoster virus referral form and instructions on how to take a vesicle fluid sample are available from GOV.UK.

Contact tracing is not required if an immunocompetent person develops a localised vesicular rash following vaccination.

Development of a rash after Shingrix vaccine

As the Shingrix vaccine is a non-live vaccine, it should not cause the development of a vesicular rash. If a vesicular rash does develop after the Shingrix vaccine, the patient should be referred for assessment and management as it is likely that they have developed shingles naturally (not due to the vaccine).

Reporting adverse reactions to Zostavax and Shingrix vaccines

Serious suspected adverse reactions to Zostavax and Shingrix should be reported to the Medicines and Healthcare Products Regulatory Agency (MHRA) using the yellow card reporting scheme.

Recommendations for the use of shingles vaccines

Definition of severe immunosuppression

For details about which conditions and medications or therapies indicate that an individual is severely immunosuppressed, and should be offered the Shingrix vaccine from 50 years of age, immunisers should refer to the Green Book Shingles chapter 28a. The decision should be based on a clinical assessment and, where appropriate, discussion with the patient’s treating physician.

Patients receiving antiviral agents (oral or intravenous)

Zostavax should be delayed for eligible patients currently receiving oral or intravenous antivirals (such as aciclovir) until 48 hours after cessation of treatment – see Green Book Shingles chapter for further details. This also applies to individuals receiving aciclovir prophylaxis which should be ceased for 48 hours before vaccination and individuals who have received high dose intravenous immunoglobulin (IVIG) or varicella zoster immunoglobulin (VZIG) in the previous 6 weeks. This is due to the potential to lower the effectiveness of the vaccine as the therapy may reduce the response to the vaccine.

Where possible, antiviral therapies should not be started within 2 weeks after receiving Zostavax as this may adversely affect the effectiveness of the vaccine.

The response to the Shingrix vaccine will not be affected by current receipt of oral or intravenous antivirals.

The use of topical aciclovir is not a contraindication to either Zostavax or Shingrix vaccination.

Topical or inhaled corticosteroids or corticosteroid replacement therapy

Zostavax is not contraindicated for use in individuals who are receiving topical or inhaled corticosteroids or corticosteroid replacement therapy.

Anticipating immunosuppressive therapy

The risk and severity of shingles is considerably higher among severely immunosuppressed individuals and therefore individuals from 50 years of age anticipating immunosuppressive therapy should ideally be assessed for vaccine eligibility and offered a shingles vaccine before starting treatment. Eligible individuals who have not previously been vaccinated should commence a course of Shingrix at the earliest opportunity and ideally at least 14 days before starting immunosuppressive therapy, although leaving one month would be preferable if a delay is possible.

Individuals aged 18 to 49 years of age receiving stem cell transplant

Individuals who have received a stem cell transplant have an increased risk of developing herpes zoster which may have severe and debilitating effects. In recognition of this, it is reasonable to give adult stem cell transplant recipients who are not otherwise eligible 2 doses of Shingrix vaccine as part of their overall treatment plan. This includes adult recipients of allogenic transplant, autologous transplant or a CAR-T (chimeric antigen receptor T-Cell) therapy. Refer to the Green Book Shingles chapter 28a for full details.

Shingrix vaccine for this group should be purchased directly from the manufacturer and then the cost of the vaccine reclaimed.

Individuals who present early and before they become eligible for shingles vaccine

Individuals who present early and outside the eligible age for shingles vaccine should be advised of the year when they become eligible for shingles vaccine on the national immunisation programme according to the implementation stage. The expansion of the vaccine programme and the lowering of the age for eligibility is being introduced gradually over a 10 year period.

Individuals outside the eligible cohorts requesting shingles vaccine

Individuals who are not eligible to receive the shingles vaccine as part of the national programme but who wish to pay for the vaccine privately should discuss their request with an independent provider and should be made aware that they will be liable for the full cost of the vaccine and any additional administration charges that the private provider may apply.

GPs are not able to charge patients registered at their practice a private fee for the vaccine and should not use centrally procured stock for the national programme to vaccinate private patients.

A supply of shingles vaccine would need to be sourced privately for use outside the national programme.

Vaccination of individuals outside of the national immunisation programme recommendations

GPs or clinicians can apply their clinical discretion and provide the shingles vaccine, following a clinical assessment, to those who are not currently eligible for the national programme but who would benefit medically, for example those with underlying conditions which increase their risk of shingles. Vaccine supplied to practices free of charge via ImmForm cannot be used for this purpose. GP surgeries should order shingles vaccine directly from the manufacturer and then reclaim the cost of the vaccine.

Vaccination and previous history of infection

Vaccination of individuals with no previous history of chickenpox infection

Although an individual may present without a clinical history of chickenpox, the majority of adults in the UK are immune and many would have had a subclinical infection without being aware. A previous clinical history of chickenpox infection is not a pre-requisite for receiving the Shingrix vaccine and therefore the Shingrix shingles vaccine should still be offered.

Individuals with no history of chickenpox infection but with evidence of 2 doses of varicella vaccine should still be offered the Shingrix shingles vaccine when they reach the eligible age. The risk of shingles among recipients of varicella vaccine (which contains a live-attenuated strain of varicella virus) is much lower and particularly when a vaccine was given in childhood. There is little information on the risk of shingles in individuals who received a varicella vaccine in adulthood.

Vaccination of individuals with a recent chickenpox infection

Individuals presenting with a recent chickenpox infection should be offered the Shingrix vaccine when they have fully recovered.

Interval for vaccination after exposure to a person with chickenpox or shingles

The Zostavax and Shingrix vaccines can still be offered if an individual has been exposed to another person with chickenpox or shingles without any interval providing the patient is well and there are no known contraindications to the vaccine.

Individuals with a recent history of shingles

Individuals with a previous history of a shingles infection are still eligible for a shingles vaccine.

The shingles vaccine can be given at any time following natural infection. As long as the individual is eligible, has recovered from acute infection and has no active vesicles, there is no additional wait period.

Recurrent shingles

Patients who have 2 or more episodes of shingles in one year should have immunological investigation prior to vaccination. Clinicians may wish to discuss such cases with local specialist teams.

Individuals with post herpetic neuralgia or residual nerve pain

The shingles vaccine is not licensed or recommended for the treatment of shingles or shingles related postherpetic neuralgia (PHN).

As PHN can persist for many months or years, if the patient is eligible for the shingles vaccine by age and they have no other symptoms, then the recommendation would be to offer the shingles vaccine without any specific interval before offering the vaccine.

Individuals given Zostavax prior to becoming eligible for the national shingles vaccination programme

People who are severely immunosuppressed

Severely immunosuppressed individuals (definition in the Green Book Shingles chapter 28a) who were given Zostavax, for example pre immunosuppressive treatment, should be given 2 doses of Shingrix vaccine when they reach, or if they have reached, the eligible age for vaccination on the national programme (currently 50 years for severely immunosuppressed). There is no reason to leave any interval after previous Zostavax vaccine for this group.

People who are immunocompetent and mildly immunosuppressed

Immunocompetent and mildly immunosuppressed individuals given Zostavax prior to becoming eligible for the national programme should be offered shingles vaccine once they reach the eligible age for the routine programme, leaving an interval of at least one year since they received Zostavax vaccine.

If those who are immunocompetent and mildly immunosuppressed were 70 years or above before 1 September 2023, they can be offered Zostavax if there are no contraindications and whilst there is still stock of this vaccine remaining (after which point 2 doses of Shingrix should be offered). Those who are contraindicated to receive Zostavax should be offered Shingrix.

For those who became eligible for Shingrix on the national programme from 1 September 2023 but have received Zostavax previously, 2 doses of Shingrix should be offered (as long as at least one year has elapsed since Zostavax was given).

Patient Group Directions (PGDs) should be checked as to whether prior Zostavax administration is an exclusion criteria – a Patient Specific Direction (PSD) may be required.

Vaccination of individuals who have received Shingrix before

If 2 doses of the Shingrix vaccine have been administered, with an interval of at least 8 weeks, no further vaccine is required for either immunocompetent or individuals with severe immunosuppression. This would be regardless of the number of years since the administration of the Shingrix vaccine or the age at which they received these doses. At present, there is no recommendation to give a booster dose after the primary schedule has been completed.

If a single dose of Shingrix vaccine has been given to a severely immunosuppressed individual over 50 years of age then a second dose of Shingrix vaccine should be given with a minimum interval of 8 weeks to complete the 2 dose course, regardless of the interval between doses. The course does not need to be restarted.

If an immunocompetent healthy individual has received a single dose of the Shingrix vaccine, then they should wait until they reach the eligible age for the Shingrix vaccine via the national programme and then be offered a second dose to complete the course for full protection. Where the course of immunisation is interrupted, there is no need to restart the course.

Individuals who received Zostavax as part of the routine programme

Individuals who received Zostavax previously on the routine immunisation programme (between 70 and 79 years of of age) are not eligible for additional doses of shingles vaccine and should not be revaccinated or offered Shingrix now.

The need for, and the timing of a booster dose has not yet been determined. Therefore no booster dose is currently recommended.

Administering Zostavax at the same time as other vaccines

Zostavax can be administered at the same time, or at any interval before or after any other vaccine, with the exception of the measles, mumps and rubella vaccine (MMR). If the MMR vaccine is required and this cannot be administered at the same time as Zostavax, a 4 week minimum interval should be observed between vaccines. Full details on the administration of live vaccine combinations are available in the Green Book chapter 11 Table 11.3.

Where more than one vaccine is administered at the same time, the vaccines should be given at a separate site, preferably in a different limb. If more than one vaccine is given in the same limb, they should be given at least 2.5cm apart. The sites at which each vaccine is given should be noted in the individual’s health records.

Administering Shingrix at the same time as other vaccines

In line with general advice about co-administration of inactivated and non-live vaccines, Shingrix can be given concomitantly with inactivated influenza vaccine. Initially, a 7 day interval was recommended between Shingrix and adjuvanted influenza vaccine because the potential reactogenicity from 2 adjuvanted vaccines may reduce tolerability in those being vaccinated. Interim data from a US study on co-administration of Shingrix with adjuvanted seasonal influenza vaccine is reassuring. Therefore, an appointment for administration of the seasonal influenza vaccine can be an opportunity to also provide shingles vaccine, although the latter should be offered all year round, rather than purely as a seasonal programme.

Shingrix can also be given concomitantly with the 23-valent pneumococcal polysaccharide vaccine (PPV23). In phase III controlled open label clinical studies of Shingrix in adults aged 50 years and older, individuals received PPV23 with their first dose of Shingrix. The immune responses of the co-administered vaccines were unaffected, although fever and shivering were more commonly reported when PPV23 was given with Shingrix.

As Shingrix® is a non-live vaccine, where individuals in an eligible cohort present having recently received another inactivated or live vaccine, Shingrix vaccination should still be offered. In such circumstances, patients should be informed about the likely timing of potential adverse events relating to each vaccine.

Previous incomplete course of Shingrix vaccine

If the course of the Shingrix vaccine is interrupted or delayed it should be resumed as soon as possible to provide protection. The first dose does not need to be repeated.

If the second dose of the Shingrix vaccine is given earlier than the recommended 8 weeks from the first dose

The recommended schedule for the Shingrix vaccine is 2 doses, with the second dose given a minimum of 8 weeks after the first dose. If the second dose is inadvertently given at least 4 weeks from the first dose, it will count as a valid dose. However, if the second dose is given earlier than 4 weeks from the first dose then the dose should be repeated with an interval of at least 8 weeks from the dose given too early.

Patients previously eligible for shingles vaccine but where Zostavax was contraindicated

Individuals who have not received shingles vaccination before because the live vaccine (Zostavax) was contraindicated due to an underlying medical condition or treatment, should be re-assessed and offered the Shingrix vaccine if they meet the eligibility criteria.

Patients aged 80 years and above

The Shingrix vaccine is available via the routine immunisation programme for immunocompetent individuals up to the 80th birthday. Where an individual has turned 80 years of age following their first dose of Shingrix, a second dose should be provided to complete the 2 dose schedule. Immunocompetent individuals will no longer be eligible to receive the second dose once they have reached their 81st birthday.

For severely immunosuppressed individuals there is no upper age limit for starting or completing the 2 dose course but individuals should be offered the vaccine as soon as they become eligible to provide protection as early as possible.

Inadvertent vaccine administration errors

Healthcare practitioners should report all inadvertent vaccine administration errors via their local governance system(s) so that appropriate action can be taken, lessons can be learned and the risk of future errors minimised.

Inadvertent administration of Zostavax during pregnancy

As a precautionary measure, health professionals should treat the inadvertent administration of the Zostavax vaccine to a pregnant woman in the same way as a natural exposure to chickenpox infection and should urgently assess the woman’s susceptibility to chickenpox. Guidelines on post exposure prophylaxis (PEP) for varicella and shingles (January 2023) and Guidance on chickenpox and shingles vaccines: advice for pregnant women are available on the GOV.UK website.

For those women who are unable to give a reliable history of chickenpox infection or documented evidence of varicella vaccination, an urgent varicella antibody test (VZV IgG) should be performed. For those women who are found to be VZV IgG negative on testing, contact the immunisation team at UKHSA for further advice via email: immunisation.lead@ukhsa.gov.uk

Samples from those pregnant women found to be VZV IgG negative on local testing will be requested to be sent to the VRD for storage.

All incidents of inadvertent administration of Zostavax during pregnancy should also be reported to UKHSA using the vaccines administered in pregnancy (VIP) reporting form. This national surveillance collects additional information on such exposures so that UKHSA can better inform health professionals and pregnant women in the future.

Inadvertently administering Zostavax during pregnancy is a serious clinical incident that should be reported immediately.

Administration of Shingrix during pregnancy

There is no data on the use of Shingrix in pregnant women but as a precautionary measure, it is preferable to avoid the use of Shingrix during pregnancy.

If the Shingrix vaccine is inadvertently administered to a pregnant woman, the individual should be informed and reassured that there is no known risk associated with giving Shingrix during pregnancy since, as it is a non-live vaccine, it cannot replicate and therefore cannot cause infection in the mother or foetus. The individual should be advised to seek medical advice for any concerns, and report the inadvertent administration to UKHSA using the vaccines administered in pregnancy (VIP) reporting form.

Inadvertent administration of Zostavax to immunosuppressed individuals

Immunosuppressed individuals who are inadvertently vaccinated with Zostavax should be urgently assessed by a clinician to establish the degree of immunosuppression. As individuals of this age group are highly likely to be VZV antibody positive, prophylactic aciclovir may be considered in those in whom the attenuated vaccine virus poses a significant risk.

These individuals should be monitored for at least 4 weeks for evidence of localised or generalised infection. Immunosuppressed individuals who develop a vesicular rash following inadvertent vaccination should be urgently assessed by a hospital specialist and offered prompt treatment with high dose IV aciclovir given the risks and severity of disseminated zoster. See section on Development of a vesicular rash after receiving Zostavax above as to further action that should be taken. Adverse events following the administration of Zostavax should be reported to the MHRA via the Yellow Card scheme.

Whether an individual develops a rash or not, a 2 dose course of Shingrix should be given once the observation period has been completed and they have clinically recovered.

Individuals eligible for Shingrix who are inadvertently given Zostavax

If the individual is immunosuppressed, follow the advice in the Inadvertent administration of Zostavax to immunosuppressed individuals section above.

If the individual is not immunosuppressed, they should be offered a 2 dose course of Shingrix at least one year after the inadvertent dose of Zostavax.

Inadvertent administration of a second dose of Zostavax

Inadvertent administration of a second dose of Zostavax is unlikely to cause harm in an immunocompetent individual but the patient should be assessed to ensure that they have no contraindications.

If there are no contraindications to receiving Zostavax and the individual is not immunosuppressed, they should be reassured that any pre-existing antibodies from the first dose may potentially be boosted by a subsequent dose. Possible side effects are likely to be similar to those from the first dose.

If the patient is immunosuppressed, follow the advice in the section Inadvertent administration of Zostavax to immunosuppressed individuals above.

Inadvertent administration of Shingrix to a child

Shingrix is licensed from 18 years of age. Parents should be advised of the error and of possible side effects such as pain at the injection site, fatigue, myalgia, headache, fever, and told to seek medical advice with any concerns.

If Shingrix was inadvertently given to a child instead of varicella vaccine, the dose does not count and varicella vaccine should be administered as soon as possible after the error is realised. There is no recommended interval between the inadvertent administration of the Shingrix vaccine and the administration of the varicella vaccine.

Incomplete dose given

If an incomplete dose of Zostavax or Shingrix has been given inadvertently, this dose should be discounted. If the patient is still in the clinic, administer a replacement full dose immediately. If the replacement dose cannot be given on the same day, administer it 4 weeks after the invalid (incomplete or partial) dose. This interval is necessary because of potential reactogenicity.

If this was an incomplete first dose of Shingrix, the completing dose should be given at the appropriate interval after the replacement dose (8 weeks for a severely immunosuppressed individual and 8 weeks to 12 months (according to local operational guidance) for immunocompetent individuals).

Inadvertent administration of Shingrix suspension only

As the suspension contains AS01B adjuvant system which can be highly reactogenic, it is recommended that an interval of 4 weeks is observed before giving the correctly reconstituted dose. If the Shingrix vaccine is being offered prior to immunosuppressive treatment then a risk assessment should be carried out on an individual patient basis for timings on giving the correctly reconstituted dose.

Resources

UKHSA Immunisation against infectious diseases (The Green Book): chapter 28a Shingles

UKHSA Shingles: guidance and vaccination programme

NHS.UK shingles

Vaccine uptake guidance and the latest coverage data – shingles

The use of human and animal products in vaccines

Viral rash in pregnancy guidelines

Shingles leaflets, posters and graphics

GSK Shingrix including reconstitution instructions

To order shingles social media graphics, invitation postcards, posters, patient leaflets and the Shingrix flyer to be delivered to you, please visit Health Publications, register and search for Shingles. Note: digital resources such as the social media graphics are download only.

References

Amirthalingam G and others. Evaluation of the effect of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study (thelancet.com Lancet Online 2018: pages 82 to 90

Andrews N and others. Impact of the herpes zoster vaccination programme on hospitalised and general practice consulted herpes zoster in the 5 years after its introduction in England: a population-based study British Medical Journal Open 2020: volume 10, page e037458 doi: 10.1136/bmjopen-2020-037458

Izurieta HS and others. Recombinant Zoster Vaccine (Shingrix) real-world effectiveness in the first 2 years post licensure Clinical Infectious Diseases 2021 February 13: ciab125 doi: 10.1093/cid/ciab125. Online ahead of print.

Koenig HC and others. Vaccinating HIV patients: focus on human papillomavirus and herpes zoster vaccines AIDS Reviews 2013: volume 15 issue 2, pages 77 to 86. PMID

Levin MJ and others. Cellular and Humoral Responses to a Second Dose of Herpes Zoster Vaccine Administered 10 Years After the First Dose Among Older Adults Journal of Infectious Diseases 2016: volume 213 issue 1, pages 14 to 22

Oxman MN and Levin MJ. Vaccination against Herpes Zoster and Postherpetic Neuralgia Journal of Infectious Diseases 2008: volume 197 supplement 2, pages S228 to 236

Oxman MN and others. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults New England Journal of Medicine 2005: volume 352 issue 22, pages 2271 to 2284

van Hoek AJ and others. Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales Vaccine 27 2009: pages 1454 to 1467

Document history

Version number	Change details	Date
1	New information document.	2013
2	Document revised to include updated information on vaccination programme eligibility.	March 2018
3	Entire document reviewed and updated. Information on the Shingrix vaccine included, vaccine available for eligible individuals who were clinically contraindicated for Zostavax (for example due to immunocompromised status). Immunocompetent eligible patients continued to be offered Zostavax	August 2021
4	Document transferred to UKHSA template, no changes to text.	February 2022
5	Document updated to incorporate move towards the introduction of the Shingrix vaccine for the whole programme and expansion of eligible cohorts. From 1 September 2023: Severely immunosuppressed individuals (eligibility as defined in the Green Book Shingles chapter 28a) to be offered the Shingrix vaccine from 50 years of age. Immunocompetent individuals to become eligible for the Shingrix vaccine from 60 years of age in a phased implementation over a 10-year period starting with those turning 65 and 70 years of age. Eligible individuals between 70 and 79 years of age (who have not received the shingles vaccine) continue to be offered the shingles vaccine.	July 2023
5.1	Section on ‘Administering Shingrix at the same time as other vaccines’ updated to reflect revised advice on giving Shingrix vaccine at the same time as the adjuvanted influenza vaccine.	17 July 2023
5.2	Further detail added about ordering of vaccine for stem cell transplant recipients, revisions made to advice for individuals given Zostavax prior to becoming eligible for the national shingles vaccination programme and new section added about inadvertent administration of Zostavax to individuals who were eligible for Shingrix.	30 August 2023