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Screening Β· Β§141
Shingles and RSV Vaccines
Two shots do more for an adult over 50 than almost anything else here, and on Medicare both are free. The shingles shot (Shingrix, two doses) cuts your odds of shingles by about 90% Cunningham et al. 2016, and the odd part: it also lowers new-dementia diagnoses by roughly a fifth Eyting et al. 2025. The RSV shot (one dose, before winter) cuts your odds of being hospitalized by a virus most can't name by about 75% Payne et al. 2025. The only real cost is a rough day after the second shingles dose.
Do Β· Once Evidence Strong Chapter Screening

Both fix the same failure: an aging immune system that stops holding viruses in check. Shingles is a virus you already carry. Anyone who had chickenpox has varicella-zoster sleeping in the nerve roots, and in your 50s the guarding T cells let it wake up as a stripe of rash. The shot rebuilds that defense with a strong adjuvant, which is also why you feel rough afterward. RSV is the opposite, a winter virus that turns from a cold into pneumonia in older lungs.

For shingles the numbers are unusually large, and barely fade with age. The shot cut cases by 97% in adults over 50 1 and 91% over 70 2. Postherpetic neuralgia, the months of nerve pain that is the frightening part, dropped about 90%, and protection still sits near 73% at ten years 3. The RSV shot cuts hospitalization about 82% the first season 4, then wanes to about half by the second 5.

The dementia finding is the surprise. Wales rolled out the shingles shot using date of birth as the cutoff, an accidental randomized trial, and over seven years the people offered it had 20% less dementia 6. A separate records analysis found the newer Shingrix did better still 7. That is the effect size of a dedicated drug.

Skip them and the odds add up. One in three Americans gets shingles, closer to one in two by 85 8, and for 10 to 18% the nerve pain never fully clears. RSV hospitalizes 60,000 to 160,000 older US adults each winter 9, with deaths clustered in people who have COPD, heart failure, or diabetes and assume a cold is just a cold.

The protocol is short. Finishing it is the hard part.

Who qualifies: shingles for everyone over 50, or over 19 with a weakened immune system 10. RSV for everyone over 75, or 50 to 74 with COPD, heart failure, or diabetes 11.

For most readers over 50, both shots cost nothing. Medicare Part D and ACA commercial plans cover them with no copay 12. Paying cash: about $400 for the Shingrix series, $280 to $320 for RSV.

Most of the payoff is invisible: the shingles episode that never happens, the winter cold that stays a cold. It lands as a lifetime shift in odds, so you mostly notice it by watching the people who skipped the shots go through what you didn't. If the dementia signal holds, the shot you were getting anyway is also one of the better dementia bets available, which matters most if you carry the APOE Ξ΅4 gene.

The fine print β€” when to skip it, and what people get wrong

Only absolute stop: severe allergy to a prior dose or ingredient. Defer during active shingles. The adjuvanted RSV shots carry a Guillain-BarrΓ© warning, about 7 to 9 extra cases per million doses; the mRNA shot (mResvia) did not show the signal 13.

"I already had shingles." Recurrence hits 5 to 10% within 8 years; still vaccinate 12. "The old Zostavax shot covered me." It worked worse and faded fast; get Shingrix anyway. "I'll wait until I'm older." Wrong way; the shots work best while your immune system is still strong.

The big one is never returning for the second shingles dose because your arm is sore and you remember the couch day; set the reminder up front. The other is booking RSV in February and missing the season; aim for August through October 14.

References
  1. 1Lal H, Cunningham AL, Godeaux O, et al. (2015). Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults. New England Journal of Medicine. link
  2. 2Cunningham AL, Lal H, Kovac M, et al. (2016). Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. New England Journal of Medicine. link
  3. 3Strezova A, Diez-Domingo J, Al Shawafi K, et al. (2022). Long-term Protection Against Herpes Zoster by the Adjuvanted Recombinant Zoster Vaccine: Interim Efficacy, Immunogenicity, and Safety Results up to 10 Years After Initial Vaccination. Open Forum Infectious Diseases. link
  4. 4Papi A, Ison MG, Langley JM, et al. (2023). Respiratory Syncytial Virus Prefusion F Protein Vaccine in Older Adults. New England Journal of Medicine. link
  5. 5Payne AB, Watts JA, Mitchell PK, et al. (2025). Respiratory Syncytial Virus (RSV) Vaccine Effectiveness Against RSV-Associated Hospitalizations and Emergency Department Encounters Among Adults Aged β‰₯60 Years. MMWR Morbidity and Mortality Weekly Report. link
  6. 6Eyting M, Xie M, Michalik F, et al. (2025). A natural experiment on the effect of herpes zoster vaccination on dementia. Nature. link
  7. 7Taquet M, Dercon Q, Todd JA, Harrison PJ (2024). The recombinant shingles vaccine is associated with lower risk of dementia. Nature Medicine. link
  8. 8Kawai K, Gebremeskel BG, Acosta CJ (2014). Systematic review of incidence and complications of herpes zoster: towards a global perspective. BMJ Open. link
  9. 9Hansen CL, Chaves SS, Demont C, Viboud C (2022). Mortality Associated With Influenza and Respiratory Syncytial Virus in the US, 1999-2018. JAMA Network Open. link
  10. 10Anderson TC, Masters NB, Guo A, et al. (2022). Use of Recombinant Zoster Vaccine in Immunocompromised Adults Aged β‰₯19 Years: Recommendations of the Advisory Committee on Immunization Practices β€” United States, 2022. MMWR Morbidity and Mortality Weekly Report. link
  11. 11Fleming-Dutra KE, Britton A, Roper LE, et al. (2025). Use of Respiratory Syncytial Virus Vaccines in Adults Aged β‰₯60 Years: Updated Recommendations of the Advisory Committee on Immunization Practices β€” United States, 2024. MMWR Morbidity and Mortality Weekly Report. link
  12. 12CDC (2024). Shingles Vaccination: What Everyone Should Know. link
  13. 13FDA (2025). FDA Requires Guillain-BarrΓ© Syndrome (GBS) Warning in the Prescribing Information for RSV Vaccines Abrysvo and Arexvy: FDA Safety Communication. link
  14. 14CDC (2025). RSV Vaccine Guidance for Older Adults. link
Related in the handbook (6)
Helps
  • β€” The shingles shot does double duty: Shingrix recipients show roughly a fifth lower dementia risk, a rare preventive lever if you carry this gene.
Related
  • β€” Past 50, the shingles and RSV shots are the two on this schedule that move the needle most. Here's the deeper dive.
  • β€” Cheaper than any drug here: the shingles vaccine appears to lower dementia risk by roughly 20%. Worth it from 50 on.
  • β€” If you're catching up on HPV, check whether the shingles and RSV shots are due too β€” both are big.
  • β€” An adjacent topic in the handbook.
  • β€” The shingles shot belongs right next to this one if you're over 50 β€” same visit, both usually free.
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