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 Zostavax® GP Decision Aid. 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
1. 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.
2. 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.
3. What are the side effects of Zostavax® vaccine?
Common side effects include pain, swelling and redness at the injection site.
4. 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.
5. 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®.
6. 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 – make sure you see a doctor early if you get pain associated with a one-sided (dermatomal) rash.
1. 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 varicella-zoster vaccine, containing approximately 14-times the amount of virus than the standard varicella (chickenpox) vaccine.
2. 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.
3. Is it ok to give Zostavax® on the same day as other vaccines?
Yes, all inactivated vaccines, including pneumococcal polysaccharide (Pneumovax 23®) and influenza vaccines, as well as live-attenuated vaccines, may be co-administered with Zostavax®.
Zostavax® is a live-attenuated vaccine, so if it is not given on the same day as other live vaccines (e.g. MMR, yellow fever), it should be separated by 4-weeks to avoid potential interference between the vaccines.
4. 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 Zostavax® GP Decision Aid 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.
1.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) can receive the vaccine, either alone, or in combination with low dose oral immune modulating drugs, for example:
- methotrexate (< 25mg per week)
- azathioprine (< 3.0mg/kg/ day)
- 6-mercaptopurine (< 1.5mg/kg/day)
Specialist advice should be sought for other treatment regimes. Zostavax® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or corticosteroid replacement therapy (e.g for adrenal insufficiency). Patients on corticosteroids, plus a biological medication or combination DMARDS, or high dose DMARDS (see above for maximum doses), should not receive the vaccine.
2. 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.
3. How long should I wait after chemotherapy or radiotherapy before vaccinating a patient?
At least 6 months after the end of treatment and after patients are demonstrated to be in remission. The timeline will be different for patients following an allogeneic transplant, refer to the Australian Immunisation Handbook for further information.
4. 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 medical (e.g. immune) 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.
5. What do I do if my patient develops a vesicular rash following the Zostavax® vaccine?
After receiving Zostavax® vaccine 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 the 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.
6. Can patients on Plaquenil 200-400mg be given Zostavax®?
Plaquenil (Hydroxychloroquine) alone is not regarded as significantly immunosuppressive. Check to confirm not on any other immunosuppressing medication. If more information on the extent of immunocompromise in an individual patient is required, seek the advice of their treating specialist and/or an immunisation expert. Refer to the Zostavax® GP Decision Aid for further information.
7. Can Zostavax® be administered to patients on Tofacitinib (Xeljanz) for rheumatoid arthritis?
Tofacitinib (brand name: 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.
8. What do I do if my immunocompromised patient is inadvertently administered Zostavax®?
Urgently contact the treating specialist or infectious disease specialist to determine the level of immunocompromise. The patient should be monitored closely for the next two weeks for symptoms that might indicate an adverse reaction related to the vaccine – virus associated disease, such as fever and rash. Strong consideration will be given to the immediate commencement of antivirals. A report should also be made to SAEFVIC as a drug administration error (vaccine contraindicated). For information on Zostavax® safety advisory, refer to the TGA: Zostavax® alert
9. What systems will help ensure the zoster vaccine is used safely?
Check the patient medical record for medical conditions and medications. Check the vaccination history on the AIR and personal immunisation records. Do not rely on patient recall.
If in doubt, delay vaccination until further information/expert advice can be obtained.
SAEFVIC contact information
SAEFVIC the Victorian vaccine safety service.
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: Nigel Crawford (Director SAEFVIC, Murdoch Children’s Research Institute), Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute) and Karen Bellamy (Immunisation Nurse, Monash Immunisation)
Date: March 2020
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.