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Shingles Guide

Shingles is a painful reactivation of the varicella-zoster virus, most common in older adults and immunocompromised people. This guide covers symptoms, complications like post-herpetic neuralgia, prevention, treatment, and vaccination recommendations including Shingrix.

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Key Summary

  • What it is: Shingles is a painful rash caused by the reactivation of the chickenpox virus. Most adults have had chickenpox in the past, which means almost everyone is at risk.
  • Symptoms: A tingling or burning feeling followed by a painful, blistering rash that usually lasts 10–15 days.
  • Who is at risk: Anyone who has had chickenpox, but the risk increases as you get older—especially after age 50.
  • Complications: Shingles can lead to long-lasting nerve pain (post-herpetic neuralgia), eye problems, and—in rare cases—serious illness. Hospitalisations and deaths mostly occur in people aged 80 and over.
  • Prevention: Shingrix®, a highly effective two-dose vaccine, is free for:
    • Adults 65 years and over
    • First Nations people aged 50 and over
    • Immunocompromised adults aged 18 and over
  • Treatment: If you develop shingles, see your doctor straight away—antiviral medicines work best when started early.

About

Shingles (Herpes Zoster) occurs most commonly in older age groups, and can cause severe pain. It is a reactivation of the virus which causes chickenpox (varicella-zoster virus VZV). After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles.

This guide provides useful information about clinical features of the disease, as well as information on transmission, complications, and vaccination recommendations.

As a healthcare professional you play an active role in protecting thousands of older Australians who are at a higher risk of shingles and its complications, as well as providing treatment during a zoster infection.

As a healthcare professional you also advise patients about the importance and safety of vaccination and obtain medical history prior to vaccination with zoster vaccine.

‘Always be on the lookout for shingles in adults over 50 years, and upon diagnosis provide early pain management and antiviral treatment as indicated.

Cause Of Shingles

Reactivation of the virus which causes chickenpox (varicella-zoster virus VZV) in a person who has previously had varicella (chickenpox).

After developing chickenpox, the virus lies dormant in the dorsal root or trigeminal ganglia and can become reactivated later in life to cause shingles.[1][2]

Features Of Shingles

Generally, shingles presents as an acute, self-limiting vesicular rash which is often painful and lasts around 10–15 days.

The rash is usually unilateral, most commonly affecting the lumbar or thoracic dermatomes. The virus works down the nerves that branch out from the spinal cord.

In 80% of cases, early phase occurs 2–3 days before the rash.[3] Early symptoms may be severe pain (e.g. ‘burning’, ‘stabbing’), itching and numbness around the affected areas. This may be accompanied by headache, photophobia and malaise.

Shingles Complications

Severe pain (where the rash was) known as post-herpetic neuralgia (PHN):

  • Persistent chronic neuropathic pain which persists for more than 90 days from the onset of the rash.
  • Can interfere with carrying out everyday activities and can be difficult to treat.
  • Increased risk of PHN with age: affects around 30% of people with shingles over 80 years of age.[4]

Serious complications involving the eye called herpes zoster ophthalmicus (in about 10–20% of shingles patients)[5]

Very rarely, shingles can lead to pneumonia, hearing problems, blindness, encephalitis or death.

Transmission Of Shingles

Shingles cannot be passed from one person to another. However, a person with shingles can pass the varicella zoster virus to a person who has never had chickenpox or who has not had the chickenpox vaccine. In such cases, the person exposed to the virus may develop chickenpox but not shingles.[6]

The virus is spread by direct contact with the fluid contained in the blisters, which can transfer to sheets and clothing.

Until the blisters scab over, the person is infectious. It is important to counsel contagious patients to avoid contact with people who have a weakened immune system, are pregnant, or newborns.

Shingles is less contagious than chickenpox and the risk of a person with shingles spreading the virus is low if the rash is covered.

Who Is At Risk?

In a national serosurvey conducted in 2007, more than 95% of the adult population in Australia had antibodies to VZV by the age 30, indicating that they had been previously infected with the virus.[7] Therefore almost the entire adult population is at risk of shingles.

Overall, 20–30% of people will develop shingles in their lifetime, most after the age of 50 years. People who are immunocompromised are also at risk.[8]

Age-Related Risk

In Australia, there are approximately 560 cases of herpes zoster per 100,000 population per year across all age groups. For immunocompetent adults aged ≥50 years, incidence rises steeply with age, from ~630 per 100,000 (50–59 years) to ~1,531 per 100,000 (70–79 years).9

A 2023 review of pre-vaccination Australian data reported similar incidence (~5.6 cases per 1,000 persons per year) and confirmed older age as the primary risk factor. 10

Hospitalisation and Mortality

According to the Australian Institute of Health and Welfare (AIHW), in 2022 there were 2,412 hospital admissions for shingles, with the highest rates among people aged 80 years and older.11

The same report noted 65 deaths from shingles in 2022. Over the 20-year period from 2003–2022, 616 deaths were recorded, 87% of which occurred in adults aged 80+ years.11

Higher Risk Of Shingles From Acute COVID-19

In 2022 a study, published in Open Forum Infectious Diseases, measuring the risk of developing shingles in adults 50 years and over with COVID-19, found that where was a 15% higher herpes zoster risk than those without COVID-19. For those hospitalised following SARS-CoV-2 infection there was a 21% increased risk of developing shingles.[12]

Aged Care Residents

Older adults living in residential aged care are at especially high risk of shingles and its complications due to advanced age, frailty, and high prevalence of chronic conditions.

A 2025 retrospective cohort study across 31 aged care homes (n = 1,108 residents) reported:

  • Median age 87 years
  • 100% had at least one comorbidity
  • Only 16.8% had received a shingles vaccine

Low shingles vaccination uptake in aged care is concerning given the heightened risk of severe disease and post-herpetic neuralgia.13

Treatment

Antiviral treatment (Famciclovir, Valaciclovir or Aciclovir*) may help to reduce pain and shorten the duration of shingles. The treatment is best taken within 72 hours of the onset of the rash but may still be helpful if taken after this time. These antiviral treatments are all considered safe with limited side effects (nausea, headache).

*There is evidence that Famciclovir and Valaciclovir are more effective than Aciclovir in reducing acute pain[14] and may be associated with greater patient compliance due to their more convenient dosing.

Prevention And Vaccination

Preventing herpes zoster is the best way to avoid post-herpetic neuralgia and other complications. Shingrix is the only herpes zoster vaccine available in Australia. Zostavax was deregistered in Australia and the vaccine was removed from the Australian Immunisation Handbook in December 2024.15 

Recommendations

Shingrix

From 1 November 2023, the shingles vaccine Shingrix® replaced Zostavax® on the National Immunisation Program (NIP) schedule for the prevention of shingles and postherpetic neuralgia. It is available for eligible people most at risk of complications from shingles.

A 2-dose course of Shingrix® is free* for:

  • People aged 65 years and older
  • First Nations and/or Torres Strait Islander peoples aged 50 years and older
  • Immunocompromised people aged 18 years and older with specified medical conditions.

*If individuals have received Zostavax® through the NIP, they will need to wait 5 years before accessing Shingrix® for free. If individuals have received Zostavax® privately, they are eligible for Shingrix®.  An interval of 12 months is recommended from the date of Zostavax® vaccination.16

Shingrix® does not contain any live virus so it can be given to people aged 18 years and over who are immunocompromised.[17]

Who Should Not Receive Shingrix?

Previous anaphylaxis to the vaccine.

There is currently no data on the use of Shingrix during pregnancy or breastfeeding, although no theoretical concern exists.18

Shingrix is generally not recommended for people with a history of GBS whose first episode occurred within 6 weeks of receiving any vaccine. 19

Vaccine Safety

Shingrix causes moderately high rates of local and systemic infections. Common reactions include: injection-site pain (up to 79%), redness (up to 39%), and swelling (up to 26%), and systemic symptoms such as fatigue and myalgia (up to 46%), headache (up to 39%), shivering (up to 28%), fever (up to 22%), and gastrointestinal symptoms (up to 18%).

Can I Give Zoster Vaccine On The Same Day As Other Vaccines?

People can receive Shingrix with other inactivated vaccines (such as tetanus-containing vaccines, pneumococcal vaccines, influenza vaccines, RSV vaccines and COVID-19 vaccines), either at the same time or any time thereafter.[20-22]

Note: There is the potential for an increase in mild to moderate adverse events when more than one vaccine is given at the same time. 

It is acceptable to co-administer Shingrix and FluadQuad (an adjuvanted influenza vaccine) on the same day if necessary.[23] However, given the lack of co-administration data for these two adjuvanted vaccines, it is preferred to separate their administration by a few days and ensure that any adverse events following immunisation with the first vaccine have resolved before administration of the other vaccine.[2][8]

References

  1. Zoster vaccine for Australian adults/NCIRS Fact sheet: November 2021
  2. Zoster vaccine: Frequently asked questions | NCIRS Fact sheet: July 2021
  3. Dworkin RH,Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clinical Infectious Diseases 2007; 44 Suppl 1: S1-26
  4. Yawn BP, Saddier P, Wollan PC et al. A population based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clinic Proceedings 2007;82:1341-9.
  5. Cunningham AL, Breuer J, Dwyer DE, et al. The prevention and management of herpes zoster. Medical Journal of Australia 2008;188:171-6.
  6. Centers for Disease Control and Prevention (CDC) https://www.cdc.gov/shingles/about/index.html Reviewed 10 May 2024
  7. Ward K, Dey A, Hull B, et al. Evaluation of Australia’s varicella vaccination program for children and adolescents. Vaccine 2013;31:1413-9.
  8. Australian Technical Advisory Group on Immunisation (ATAGI) The Australian Immunisation Handbook, Australian Government Department of Health, Canberra2023, immunisationhandbook.health.gov.au
  9. Australian Technical Advisory Group on Immunisation (ATAGI). Zoster (herpes zoster). In: Australian Immunisation Handbook. Canberra: Australian Government Department of Health and Aged Care; 2023. Available from: https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/zoster-herpes-zoster#herpes-zoster-in-australia
  10. Huang YA, Li-Kim-Moy J, Jayasinghe S, Chiu C, Macartney K, Liu B, Burns P, Giles M, Crawford N; Australian Technical Advisory Group on Immunisation (ATAGI). ATAGI Targeted Review 2022: Vaccination for prevention of herpes zoster in Australia. Commun Dis Intell (2018). 2023 Apr 27;47 (21). DOI: 10.33321/cdi.2023.47.21. Available from: https://pubmed.ncbi.nlm.nih.gov/37106452/
  11. Australian Institute of Health and Welfare (AIHW). Shingles in Australia. Canberra: AIHW; 2025. Available from: https://www.aihw.gov.au/getmedia/1760c6cb-f9e0-44e4-a33d-3ea71419b672/aihw-phe-236_shingles_2025.pdf
  12. MacIntyre R, Stein A, Harrison C, Britt H, Mahimbo A, Cunningham A. Increasing trends of herpes zoster in Australia. PLoS One. 2015 Apr 30;10(4):e0125025. doi: 10.1371/journal.pone.0125025. eCollection 2015.
  13. Wiblin S, Lai Y, Soulsby N, Hillen J. Vaccination in aged care in Australia: a retrospective study of influenza, herpes zoster, and pneumococcal vaccination. Vaccines (Basel). 2025 Jul 20;13(7):766. doi: 10.3390/vaccines13070766. Available from: https://pubmed.ncbi.nlm.nih.gov/40733743/
  14. The Royal Australian College of General Practitioners. COVID-19 linked to higher shingles risk for over-50s. newsGP. 2023 Mar 13. Available from: https://www1.racgp.org.au/newsgp/clinical/covid-19-linked-to-higher-shingles-risk-for-over-5
  15. National Centre for Immunisation Research and Surveillance (NCIRS). Zoster (shingles) vaccine: frequently asked questions (FAQs). Sydney: NCIRS; 2024. Available from: https://ncirs.org.au/zoster-shingles/zoster-shingles-vaccine-frequently-asked-questions-faqs#:~:text=In%20December%202024%2C%20Zostavax%20was%20deregistered%20in,was%20removed%20from%20the%20Australian%20Immunisation%20Handbook
  16. Australian Government Department of Health and Aged Care. National Immunisation Program Schedule. Canberra: Department of Health and Aged Care; 2025. Available from: https://www.health.gov.au/sites/default/files/2025-09/national-immunisation-program-schedule_0.pdf
  17. National Immunisation Program – changes to shingles vaccination from 1 November 2023: October 2023
  18. Australian Technical Advisory Group on Immunisation (ATAGI). Zoster (herpes zoster). In: Australian Immunisation Handbook. Canberra: Australian Government Department of Health and Aged Care; 2023. Available from: https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/zoster-herpes-zoster#women-who-are-pregnant-or-breastfeeding
  19. Australian Technical Advisory Group on Immunisation (ATAGI). Zoster (herpes zoster). In: Australian Immunisation Handbook. Canberra: Australian Government Department of Health and Aged Care; 2023. Available from: https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/zoster-herpes-zoster#people-with-a-history-of-guillainbarr-syndrome
  20. Maréchal C, Lal H, Poder A, Oostvogels L, Borys D, David MP, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine co-administered with the 23-valent pneumococcal polysaccharide vaccine in adults ≥50 years of age: a randomized trial. Vaccine. 2018;36(32):4278-86.
  21. Schwarz TF, Aggarwal N, Moeckesch B, Zepp F, Bailleux F, Borkowski A, et al. Immunogenicity and safety of an adjuvanted herpes zoster subunit vaccine coadministered with seasonal influenza vaccine in adults aged 50 years or older. J Infect Dis. 2017;216(11):1352-61.
  22. Strezova A, Lal H, Enweonye I, Da Silva FT, Oostvogels L, Boutriau D. The adjuvanted recombinant zoster vaccine co-administered with a tetanus, diphtheria, and pertussis vaccine in adults aged ≥50 years: a randomized trial. Vaccine. 2019;37(42):5877-85.
  23. Australian Government Department of Health and Aged Care. Influenza (flu) [Internet]. Canberra: Australian Government Department of Health and Aged Care; 2023 [cited 2024 Aug 12]. Available from: https://immunisationhandbook.health.gov.au/contents/vaccine-preventable-diseases/influenza-flu

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