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Herpes zoster (shingles) vaccine: Canadian Immunization Guide

For health professionals

Last partial content update: June 2025

The chapter was updated based on the following guidance from the National Advisory Committee on Immunization (NACI):

This information is captured in the table of updates.

Last complete chapter revision: August 2018

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Key information

What

Who

How

Why

Epidemiology

Disease description

Infectious agent

Herpes zoster (shingles) is a manifestation of reactivation of the varicella-zoster virus (VZV), a DNA virus of the Herpesvirus family, which, as a primary infection, causes varicella (chickenpox).

Reservoir

Humans

Transmission

VZV can be spread from a person with HZ to an individual that has never had varicella by direct contact with localized skin lesions. Less commonly, VZV can be spread by the airborne route if the affected person has disseminated HZ. Less frequently, transmission can occur from fomites, such as articles freshly soiled by discharges from vesicles or, in the case of disseminated HZ, mucous membrane secretions. The person who acquires VZV through these routes will develop varicella (chickenpox). The incubation period is from 10 to 21 days, usually in the range of 14 to 16 days. HZ is less likely to result in transmission of VZV than varicella. Persons with HZ are infectious until all lesions are crusted over.

Risk factors

Any person who has had varicella is at risk of developing HZ. However, HZ occurs most frequently among older adults and immunocompromised persons. Advanced age and immunosuppression are the most important risk factors for development of HZ.

Over two-thirds of the cases occur in individuals over 50 years of age. This age-related risk may be explained by both waning immunity over time following the initial varicella infection, and the loss of components of VZV-specific cell mediated immunity as a result of natural aging processes. The severity of illness associated with HZ and its complications also increases markedly with age. Up to 10% of persons over 65 years of age will be admitted to hospital with an episode of HZ.

The risk of HZ among younger adults who are immunocompromised is comparable to or higher than the general population aged 50 years and older. Individuals who are immunocompromised are at significantly increased risk of developing HZ that requires emergency room consultation or hospitalization.

The risk of HZ is lower for individuals who have only been exposed to VZV through vaccination compared to those who have only been exposed through VZV infection.

Spectrum of clinical illness

VZV causes two distinct clinical syndromes: primary infection (varicella, also called chickenpox) and reactivation of latent infection (HZ, also called shingles). Following varicella, VZV establishes latency in the sensory nerve ganglia, and may reactivate later as HZ. HZ infection is characterized by pain and a unilateral vesicular eruption, usually in a single dermatome. Complications of acute HZ are potentially severe.

The most frequent complication of acute HZ is PHN which is characterized by prolonged and often debilitating neurogenic pain that lasts for more than 90 days from the onset of rash. Because treatment options for PHN are of limited effectiveness, PHN often has major adverse impacts on quality of life. Older adults, people living with chronic conditions such as diabetes or autoimmune diseases, and persons who are immunocompromised may be at greater risk of developing PHN. They are also at risk of experiencing longer lasting HZ rash than the general population. Other potential complications of HZ include ophthalmic sequelae (herpes zoster ophthalmicus), central nervous system infection, nerve palsies including the Ramsay-Hunt Syndrome, neuromuscular disease including Guillain-Barré Syndrome, pneumonia, hepatitis and secondary bacterial infections.

The risk of mortality from VZV-associated disease is low.

Disease distribution

Incidence/prevalence

In recent studies, the lifetime risk of HZ has been estimated to be as high as 30% in the general population. In Canada, it is estimated that each year there are 130,000 new cases of HZ, 17,000 cases of PHN and 2,000 hospitalizations.

Preparations authorized for use in Canada

Herpes zoster vaccine

For complete prescribing information, consult the product leaflet or information contained within the product monograph available through Health Canada's Drug product database. Also refer to Contents of Immunizing Agents Authorized for Use in Canada in Part 1.

Immunogenicity, efficacy and effectiveness

Immunogenicity

There are currently no established humoral and/or cellular correlates of protection following immunization against HZ. In studies that assessed vaccine immunogenicity, the response to RZV was found to be more robust (independent of age and with more stable antibody concentrations over time) than the response to live zoster vaccine (LZV). Additionally, vaccine immunogenicity has been demonstrated to persist up to 10 years post-immunization in adults 50 years of age and older.

RZV is immunogenic in individuals who are immunocompromised. Following immunization in immunocompromised populations, humoral immune response rates range from approximately 65% to 95%, while cell-mediated immune responses rates range from approximately 50% to 95%

Efficacy and effectiveness

HZ vaccines significantly reduce the incidence of HZ and PHN as well as the duration and severity of HZ. While protection against HZ remains statistically significant up to 3 years following immunization with LZV, significant waning of protection has been observed one-year post immunization, particularly in older age groups. In contrast, RZV efficacy in the four years post immunization remains consistent and above 90% in all age groups, and over 70% up to 10 years following immunization.

RZV is efficacious at preventing HZ, PHN and HZ-related hospitalizations in immunocompromised populations. The duration of protection among adults 18 years of age and older who are immunocompromised is currently unknown.

Recommendations for use

Adults

Adults (50 years of age and older)

Immunization with a 2-dose series of RZV is recommended for the prevention of HZ and PHN for adults 50 years of age or older without contraindications.

For adults 50 years of age and older without contraindications who have previously been immunized with LZV, immunization with a 2-dose series of RZV should be offered. Re-immunization with RZV may be considered at least one year after LZV.

For adults 50 years of age and older without contraindications who have had a previous episode of HZ, immunization with a 2-dose series of RZV should be offered. Immunization with RZV may be considered at least one year after the episode of HZ. Persons with active HZ should not be immunized with HZ vaccine.

Adults with or without a history of varicella

RZV should be administered to individuals for whom vaccine is indicated regardless of whether the person has a history of varicella infection. Nearly all Canadians eligible for HZ immunization will have had prior varicella exposure, even if a diagnosis of varicella cannot be recalled. There is no known safety risk associated with immunization of healthy individuals who are susceptible to VZV.

Special populations

Pregnancy and breastfeeding

Because no data are available on RZV administration during pregnancy or breastfeeding, precautions should be used in these situations.

Immunocompromised women and individuals should ideally be vaccinated with RZV prior to pregnancy and immunization should be deferred until after pregnancy. However, testing for pregnancy prior to vaccination is not necessary.

RZV can be used in breastfeeding women and breastfeeding individuals if indicated.

For more information, refer to Immunization in Pregnancy and Breastfeeding in Part 3.

Residents in health care institutions

Residents of long-term care facilities should receive all routine immunizations appropriate for their age and risk factors, including RZV.

For more information, refer to Immunization of Patients in Health Care Institutions in Part 3.

Immunocompromised persons

Immunization with a 2-dose series of RZV is recommended for the prevention of HZ and its associated complications for adults 18 years of age and older who are or will be immunocompromised.

Individuals who are immunocompromised, either due to underlying conditions or immunosuppressive agents, have an increased risk of developing HZ. They may be more likely to experience HZ recurrence, atypical and/or more severe disease and complications.

For optimal immune response, the 2-dose series of RZV should be completed at least 14 days before initiating immunosuppressive treatment that might lead to immunodeficiency.

NACI's Updated recommendations on Herpes Zoster vaccination for adults who are immunocompromised (PDF) provides a list of immunocompromising conditions or therapies that can be used to help identify individuals who may benefit from RZV, in consultation with the treating physician.

For more information, refer to Contraindications, Precautions and to Immunization of Immunocompromised persons in Part 3.

Persons with chronic diseases

Autoimmune disease

Although definitive data are lacking, individuals with autoimmune disease not being treated with immunosuppressive drugs are not considered significantly immunocompromised. Individuals 50 years of age and older without contraindications should receive RZV.

For more information, refer to Immunization of Immunocompromised Persons, and Immunization of Persons with Chronic Diseases in Part 3.

Workers

Workers are not at increased risk of developing HZ because HZ is due to reactivation of a latent VZV infection. However, it is important to promote varicella (chickenpox) immunization to those who are at occupational risk of exposure or transmission to high-risk individuals.

For more information, refer to Varicella (Chickenpox) Vaccine and to Immunization of Workers in Part 3.

Post-exposure immunization

HZ vaccine is not indicated for post-exposure management of individuals who are susceptible to varicella after exposition to HZ. Refer to Varicella (Chickenpox) Vaccine, Post-exposure immunization for appropriate management options.

Close contact to a person with HZ includes:

Vaccine administration

Dose, route of administration, and schedule

Dose

Each dose is 0.5 mL (the entire contents of the reconstituted vial).

Route of administration

Intramuscular, into the deltoid region of the upper arm.

Administration of the RZV as a subcutaneous injection is a vaccine administration error and should be avoided. However, if Shingrix is inadvertently administered subcutaneously, that dose will be considered as valid in the vaccine series. The second dose will be given as per vaccine schedule.

For more information, refer to Vaccine Administration Practices in Part 1.

Schedule

2 doses, 2 to 6 months apart.

Alternatively, 2 doses 12 months apart may be considered for improved adherence to the 2nd dose (which could be administered at the next annual visit, or at the time of the next annual influenza immunization).

For individuals who will be at increased risk of HZ due to immunodeficiency or immunosuppression (for example, individuals who are about to start immunosuppressive therapy), the second dose can be administered at a minimum interval of at least 4 weeks after the first dose, as these individuals will benefit from completing the series before being immunosuppressed.

Providers should consider different strategies (e.g. education, recalls/reminders) to promote adherence to the 2-dose schedule for RZV (as vaccine efficacy and duration of protection is unclear after only one dose).

Booster doses and re-immunization

There is no current recommendation for booster doses of RZV vaccine. It is not known whether booster doses of HZ vaccines are beneficial. This is an area of ongoing research.

Serologic testing

Serologic testing is not recommended before or after receiving HZ vaccine. There is no known safety risk associated with HZ immunization of healthy individuals who are VZV susceptible.

In the rare circumstance that an adult aged 50 years and older or an immunocompromised adult 18 years of age and older is known to be susceptible to VZV based on previous serological testing for another reason, vaccine providers should refer to the current varicella vaccine recommendations, noting that for many immunocompromising conditions, live vaccines including varicella vaccine are contraindicated.

Storage requirements

RZV should be stored refrigerated at +2°C to +8°C or according to the product monograph, and should not be frozen. Vaccines should be stored in the original package to protect them from light.

For more information, refer to Storage and Handling of Immunizing Agents in Part 1.

Concurrent administration with other vaccines

RZV may be administered concurrently with live vaccines given by the parenteral, oral, or intranasal routes. For concurrent parenteral injections, different injection sites and separate needles and syringes should be used.

In general, inactivated vaccines including RZV may be administered concurrently with, or at any time before or after, other inactivated vaccines or live vaccines protecting against a different disease.

For more information, refer to Timing of Vaccine Administration in Part 1.

Safety and adverse events

Very common and common adverse events

Very common adverse events occur in 10% or more of vaccinees. Common adverse events occur in 1% to less than 10% of vaccinees.

Injection site reactions are very commonly reported by recipients of RZV. Among clinical trial vaccine recipients, up to 90% reported injection site pain, and up to approximately 40% experienced redness at the site of injection. For all ages, the majority of these events were rated mild or moderate in intensity and typically lasted 1 to 3 days.

Due to the adjuvant in RZV, which induces a high cellular immune response and helps address the natural age-related decline in immunity, RZV is more reactogenic than LZV.

Systemic adverse events, primarily fatigue and myalgia, are very common in RZV recipients (reported by up to 65% of clinical trial vaccine recipients). Headache was reported by up to nearly half of clinical trial vaccine recipients.

Local and systemic reactions that were severe enough to interfere with normal activities have been more frequently reported following the receipt of RZV than LZV. However, these reactions have been temporary (lasting 2-3 days). Patient education on the short-term reactogenicity of the RZV is recommended prior to vaccine administration to promote adherence to the second dose.

In adults 50 years of age and older, fever and shivering were more commonly reported when Pneu-P-23 was administered concurrently with RZV (16% and 21%, respectively) compared to when RZV was administered alone (7% for both adverse reactions).

Uncommon, rare and very rare adverse events

Uncommon adverse events occur in 0.1% to less than 1% of vaccinees. Rare and very rare adverse events occur, respectively, in 0.01% to less than 0.1% and less than 0.01% of vaccinees.

RZV is safe with serious adverse events reported very rarely in immunocompetent individuals.

There may be an increased rate of Guillain-Barré syndrome after vaccination with the first dose of RZV in adults aged 65 years or older. The available information is insufficient to determine a causal relationship with the vaccine. NACI will continue to monitor the evidence on the safety of RZV in adults and will update guidance accordingly.

For immunocompromised individuals, RZV is safe and well-tolerated, and the risk of serious adverse events were comparable between RZV recipients and placebo recipients.

A recently published observational study reported an increased risk of herpes zoster ophthalmicus (HZO) recurrence in RZV recipients. NACI will continue to monitor the evidence related to this issue.

For more information, refer to Adverse Events Following Immunization in Part 2 and the product monograph in Health Canada's Drug Product Database.

Guidance on reporting adverse events following immunization (AEFI)

Vaccine providers are asked to report AEFIs through local public health officials and to follow AEFI reporting requirements that are specific to their province or territory. In general, any serious or unexpected adverse event felt to be temporally related to vaccination should be reported.

For definitions of serious and unexpected adverse events, refer to Adverse Events Following Immunization in Part 2.

For more information refer to Reporting Adverse Events Following Immunization (AEFI) in Canada.

Contraindications

RZV is contraindicated in persons with a history of anaphylaxis after previous administration of the vaccine and in persons with proven immediate or anaphylactic hypersensitivity to any component of the vaccine or its container. Refer to Contents of Immunizing Agents Authorized for Use in Canada in Part 1.

Refer to Immunization of Immunocompromised Persons in Part 3 for more detailed information.

Precautions

In situations of suspected hypersensitivity or non-anaphylactic allergy to RZV components, investigation is indicated which may lead to immunization in a controlled setting. Consultation with an allergist is advised.

RZV should be administered at least 14 days prior to the initiation of immunosuppressive drugs.

A number of clinical trials are still ongoing in the use of RZV in immunocompromised populations.

Precaution should be used if considering use of RZV in pregnancy or breastfeeding given the absence of data on its safety for these groups.

Administration of RZV should be postponed in persons suffering from severe acute illness with or without fever.

Refer to Immunization of Immunocompromised Persons in Part 3 and to Contraindications and Precautions in part 2 for additional information.

Drug interactions

There are no known drug interactions with RZV.

Chapter revision process

This chapter was updated to align with guidance in the National Advisory Committee on Immunization (NACI) Statement on Updated recommendations on Herpes Zoster vaccination for adults who are immunocompromised published on May 14, 2025.

Acknowledgments

This chapter was updated with the support of A Nunn, L Coward, O Baclic, C Jensen and R Harrison.

The CIG gratefully acknowledges the contribution of N Haddad.

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