Zoster vaccine (Zostavax®) FAQs

MVEC’s Zoster vaccine (Zostavax®) FAQ’s have been designed for providers to use in conjunction with the MVEC: Zoster immunisation reference page as well as the Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications. Where further clarification of circumstances or patient history is required, it is safest to delay vaccination until more information is available.

General zoster vaccine questions

  • Who should be immunised?

    Zostavax® is registered for use in Australia as a single dose from 50 years of age for the prevention of zoster (shingles). It is recommended for immunocompetent adults aged over 60 years. Zostavax® is funded on the National Immunisation Program (NIP) for people aged 70 years, with a catch up program for people aged 71-79-years (ending October 2021). It is also available for private purchase for patients wishing to be immunised outside of this funded age group. There is currently no recommendations for booster doses when early vaccination is given.

  • Can Zostavax® be recorded on the Australian Immunisation Register (AIR)?

    Zostavax® should be recorded on the AIR to ensure that immunisation records are accurate and up to date. Patient recall should never be relied on for vaccine history and therefore accurate documentation will assist in avoiding any errors where multiple doses are administered. From July 2021, the recording of all NIP vaccines to AIR will become mandatory.

  • What are the side effects of Zostavax® vaccine?

    Common side effects include pain, swelling and redness at the injection site. These symptoms usually occur in the first 72 hours following immunisation.

    Very rarely a non-localised varicella (chickenpox)-like rash can occur 2-4 weeks following immunisation. Should this occur, medical attention is recommended for advice and management of symptoms which may include diagnostic testing and antiviral treatment. This event must also be reported to the relevant vaccine safety service (SAEFVIC in Victoria).

  • Vaccinating patients with a clinical history of zoster (shingles) disease?

    Vaccinating patients with a history of shingles disease is still recommended. However, evidence suggests that waiting 12 months after disease is optimal.

  • Vaccinating patients with a negative history of varicella disease?

    Most adults are unlikely to have negative varicella serology even if they cannot recall having clinical varicella disease. Performing serology prior to vaccination is not routinely recommended.

    If serology is known, and a patient is seronegative, injection site reactions may occur at a slightly higher rate, however immunisation is still safe and effective.

    If patients are known to be seronegative, then they could receive a 2 dose course of varicella vaccine at least 4 weeks apart rather than Zostavax®.

  • What should I advise patients who cannot receive Zostavax®, but are worried about developing shingles disease?

    The reason immunosuppressed patients cannot receive Zostavax® despite an increased risk of infection is that the live-attenuated Zostavax® (Oka) strain can itself cause an infection. Fatal cases of disseminated vaccine (Oka) strain infection have been reported, noting that Zostavax® is a 14-fold higher titre, than the varicella (Oka) live-attenuated vaccine.

    Antiviral treatments are available for patients who develop shingles.

Administration queries

  • What is the dose and route of administration for Zostavax®?

    Zostavax® should be administered as 0.65ml to be given subcutaneously. It is a once only dose.

    Zostavax® is a live-attenuated zoster vaccine, containing approximately 14-times the amount of virus than the standard varicella (chickenpox) vaccine.

  • Are there limitations to administering Zostavax® before or after blood product administration?

    No. Even though Zostavax® is a live-attenuated vaccine, there are no concerns with efficacy when administering it before or after a blood product.

  • Is it ok to give Zostavax® on the same day as other vaccines?

    All inactivated vaccines, including Prevenar 13® and influenza vaccines, may be co-administered with Zostavax®. The exception to this is COVID-19 vaccines. Due to a lack of safety and efficacy information surrounding COVID-19 vaccines, ATAGI recommends a 14 day minimum interval between receipt of COVID-19 vaccines and any other vaccine. Please refer to COVID-19 vaccination – ATAGI clinical guidance on COVID-19 vaccine in Australia in 2021 for more information.

    Zostavax® is a live-attenuated vaccine, so if it is not given on the same day as other live-attenuated vaccines (e.g. MMR, yellow fever), it should be separated by 4 weeks to avoid potential interference between the vaccines.

  • For what patient groups is Zostavax® contraindicated?

    Zostavax® is contraindicated for patients who are anaphylactic to any component of a VZV-containing vaccine or previous doses of a VZV-containing vaccine. Zostavax® is also contraindicated in patients who are immunocompromised either due to a medical condition or due to medical treatment and medication. It should not be given in pregnancy.

    If there is uncertainty about a patient’s level of immunocompromise and whether vaccination is contraindicated, best practice is to delay vaccination until expert advice can be sought. The Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications should be used for all patients presenting for Zostavax® vaccine prior to administration to assist in the identification of patients who may be contraindicated for the shingles vaccine.

Safety questions

  • My patient is currently receiving 5mg prednisolone daily for a rheumatological condition. Is it ok to receive Zostavax®?

    Individuals on long-term, stable, low dose corticosteroid therapy (defined as < 20mg prednisone per day for > 14 days) either alone, or in combination with low dose oral immune-modulating drugs can receive the vaccine following individual assessment. Patients on corticosteroids, plus a biological medication or combination DMARDS, or high dose DMARDS should not receive the vaccine. Please refer to Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications for clarification.

    Zostavax® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or corticosteroid replacement therapy (e.g for adrenal insufficiency).

  • I inadvertently gave a patient a zoster vaccine and later realised that it had been administered 4 months prior, what should we do?

    Currently, zoster vaccine is recommended as a single dose only. It is important to document the event and report it to SAEFVIC as a drug administration error. Immunisation providers should also establish procedures to minimise similar incidents from re-occurring.

    To avoid errors of multiple doses being administered, thoroughly check patient records and the AIR. Do not rely on patient recall for a vaccine history. Check vial label 3 times to make sure you’re administering the product you intended.

  • How long should I wait after chemotherapy or radiotherapy before vaccinating a patient?

    Patients should wait at least 6 months after the end of treatment and after patients are demonstrated to be in remission before considering immunisation with Zostavax®. The timeline will be different for patients following an allogeneic transplant, refer to the Australian Immunisation Handbook for further information.

  • My patient is currently being treated for genital herpes. Is this a contraindication to zoster vaccination?

    There is no evidence that zoster vaccine has any effect on herpes simplex virus. However, some people with genital herpes may be receiving an antiviral drugs (such as valaciclovir or famciclovir) as treatment or prophylaxis. These antivirals may prevent virus replication causing decreased vaccine effectiveness, but would not lead to safety concerns (assuming no other medical contraindications). For patients being treated for a herpes infection, defer Zostavax® until at least 24 hours after the treatment course has been completed. For patients on long term prophylaxis, consideration could be given for the antiviral medication to be discontinued at least 24 hours prior to zoster vaccination, and where applicable re-commenced approximately 2 weeks following vaccination.

  • What do I do if my patient develops a vesicular rash following the Zostavax® vaccine?

    After receiving Zostavax®, a vesicular (chickenpox-like) rash may occur (rarely) within 3-4 weeks of vaccine administration which may be associated with being unwell/ fever. Take a swab of the skin lesion where possible, following consultation with SAEFVIC. Take a photo if possible as part of the documentation, and manage the rash with administration of antivirals and analgesics, as appropriate. Antiviral therapy should be initiated within 72 hours for optimal benefit.

  • Can patients on Plaquenil 200-400mg be given Zostavax®?

    Plaquenil (Hydroxychloroquine) alone is not regarded as significantly immunosuppressive. Check to confirm that the patient is not on any other immunosuppressing medication. If more information on the extent of immunocompromise in an individual patient is required, do not vaccinate but wait to seek the advice of their treating specialist and/or an immunisation expert. Refer to the Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications for further information.

  • Can Zostavax® be administered to patients on Tofacitinib (Xeljanz) for rheumatoid arthritis?

    No. Tofacitinib (Xeljanz) is a DMARD that modifies the immune response by inhibiting the Janus kinase (JAK) enzyme. It is associated with an increased incidence of infections, including shingles. The product information states that live-attenuated vaccines, including Zostavax®, are contraindicated.

  • What do I do if my immunocompromised patient is inadvertently administered Zostavax®?

    If an immunocompromised patient is inadvertently administered a dose of Zostavax®, prompt action is required. Medical review by an infectious diseases specialist or immunisation expert must be facilitated and the appropriate anti-viral therapy and monitoring commenced.

    The error must also be reported to the relevant authority to ensure appropriate follow up and support can be provided. In Victoria, this service is SAEFVIC.

    If the error occurs out of hours, seek specialist advice from the patient’s treating specialist or an infectious diseases specialist at your local tertiary hospital.

  • What systems will help ensure the zoster vaccine is used safely?

    Always check the AIR and patient medical records prior to considering vaccine administration. The pre-immunisation checklist, and the Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications should also be completed before administration.

    If in doubt, delay vaccination until further information/expert advice can be obtained.

SAEFVIC contact information

SAEFVIC the Victorian vaccine safety service.

Telephone: 1300 882 924 (option 1), from Monday to Friday 09:00 AM to 4:00 PM
Email: saefvic@mcri.edu.au

Authors: Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Allen Cheng (Professor of Infectious Diseases Epidemiology, Monash University, School of Public Health and Preventative Medicine) and Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute)

Reviewed by: Rachael McGuire (MVEC Education Nurse Coordinator)

Date: March 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.


Zoster

What is it?

Herpes zoster (shingles) is caused by a reactivation of the varicella zoster virus (VZV), the same virus that causes varicella infection (chickenpox). After a person recovers from a chickenpox infection, the virus stays dormant (inactive) within the dorsal root ganglia of the spinal nerves but can later be reactivated, presenting as shingles. It occurs more commonly in adults > 50 years, those who are immunocompromised and those who were diagnosed with a varicella infection < 1 year of age.

What to look for

Shingles is a painful, vesicular rash. It usually presents on one side of the face or body, typically appearing in a dermatomal distribution (an area of skin supplied by a spinal nerve). Prior to the emergence of rash, there is often pain, itching, or tingling in the area where the rash will develop. This may happen anywhere from 1 to 5 days before the rash appears. Other symptoms of shingles can include fever, headache, chills, and malaise (generally feeling unwell). The blisters will typically scab over in 7 – 10 days after onset and resolve within 2 – 4 weeks.

Post-herpetic neuralgia (PHN) is the most common complication of a shingles infection and is more likely to occur in older people (> 70 years of age) than younger people. PHN is a chronic neuropathic pain which can affect 1 in 4 cases of shingles diagnosed in those > 80 years. It can persist for months to years with pain control being difficult to manage, impacting quality of life.

Other complications of shingles include skin pigmentation and scarring, secondary bacterial infections, as well as herpes zoster opthalmicus (eye involvement with differing degrees of symptoms including conjunctivitis, ocular-cranial nerve palsies, loss of vision and debilitating pain).

How is it transmitted?

Shingles is the reactivation of a previous VZV infection and therefore it cannot be passed from one person to another. Exposure to the fluid filled vesicles of a shingles rash can result in a VZV infection (as chickenpox) in a seronegative person (a person with no previous VZV disease).

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

Am I already protected?

Shingles can only develop in people who have previously been infected with VZV.

The lifetime risk of a reactivation of the VZV virus to cause shingles is 20-30% and affects half of all people who live to 80 years. Repeated shingles infections occur in around 5% of immunocompetent people.

Vaccination to prevent infection

The only way to reduce the risk of developing shingles and its complications is through vaccination.

Zostavax® is funded on the National Immunisation Program (NIP) as a single dose for those aged 70 years (with a catch up program for those 71-79 years, ending October 2021). It registered for use in persons > 50 years and has been shown to reduce the incidence of shingles by approximately 50% and the incidence of PHN by 66%. Zostavax is a live-attenuated vaccine and contains the same strain of varicella zoster virus as Varivax®, however it is 14 times more potent. It can be administered to individuals who have previously had shingles. There are no concerns regarding the co-administration of Zostavax® and other vaccines on the NIP.

Side effects

Zostavax® has been demonstrated to be safe and well tolerated. The most common side effects include injection site reactions and a localised varicella-like rash, commonly occurring in the first 72 hours.

Very rarely a non-localised VZV-like rash can occur 2-4 weeks following immunisation. Should this occur, medical attention is recommended for advice and management of symptoms which may include diagnostic testing and antiviral treatment. This event must also be reported to the relevant vaccine safety service (SAEFVIC in Victoria).

Contraindications and precautions

Zostavax® is contraindicated in immunocompromised individuals due to the risk of vaccine-related disease. Immunosuppression may be caused by medical conditions or specific medications or therapies. The pre-immunisation screening of patients prior to administering Zostavax® is essential to avoid the risk of inadvertent immunisation in patients contraindicated to receive Zostavax® [please refer to Australian Immunisation Handbook: Table. Live shingles vaccine (Zostavax) screening for contraindications for more information].

If there is uncertainty about how severely a person is immunocompromised and whether it is safe for them to receive a vaccine, do not vaccinate them. Seek expert advice from their treating physician or an immunisation specialist.

The TGA has issued an alert regarding the use of Zostavax® in people with compromised immune function. Further information can be found at TGA: Safety advisory- risk of infection with a vaccine virus.

Inadvertent administration of Zostavax® in immunocompromised individuals

If an immunocompromised patient is inadvertently administered a dose of Zostavax®, prompt action is required. Medical review by an infectious diseases specialist or immunisation expert must be facilitated and the appropriate anti-viral therapy and monitoring commenced.

The error must also be reported to the relevant authority to ensure appropriate follow up and support can be provided. In Victoria, this service is SAEFVIC.

If the error occurs out of hours, seek specialist advice from the patient’s treating specialist or an infectious diseases specialist at your local tertiary hospital.

Documentation

It is important that immunisation records are accurately maintained and reviewed prior to vaccine administration to avoid any dosing errors. Patient recall is not always reliable and as such reviewing an individual’s immunisation history is essential. From July 2021, new legislation will come into effect mandating the reporting of all NIP vaccines to the Australian Immunisation Register (AIR).

Resources

Authors: Nigel Crawford (Director, SAEFVIC, Murdoch Children’s Research Institute) and Georgina Lewis (Clinical manager, SAEFVIC, Murdoch Children’s Research Institute)

Reviewed by: Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator)

Date: March 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.