SAEFVIC has updated its Zoster resources and developed a new frequently asked questions (FAQ) page for use by providers. The Zoster vaccine FAQs page provides answers to questions on the use of Zostavax® and can be used in conjunction with existing resources in the MVEC: Zoster page.
1. My patient is currently receiving 5mg prednisolone per day for a rheumatological condition. Is it ok to vaccinate with zoster vaccine?
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. We 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 (vaccine safety service) as a drug administration error. Immunisation providers should also establish procedures to minimise similar incidents from re-occurring.
Avoid such errors by checking patient records and the AIR. Do not rely on patient recall. 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 a allogeneic transplant, refer to the Australian Immunisation Handbook for further information.
4. Is it ok to give the zoster vaccine 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 zoster vaccine.
The zoster vaccine 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.
5. 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.
6. What about Zostavax® for pts who don’t recall having chickenpox in the past?
All persons age 70 – 79 years -whether they have a history of chickenpox or shingles or not should be given zoster vaccine unless they have a medical contraindication to vaccination. It is also usually not necessary to test for varicella antibody prior to or after giving the vaccine, as <5% of 70 year olds are seronegative. The same principal applies if a clinician decides to vaccinate a person from 50 years of age however the zoster vaccine is not funded in this group.
If patients are known to be seronegative (for example, if they have had negative varicella serology in the past for some reason), then they could receive 2-dose course of varicella vaccine at least 4 weeks apart rather than Zostavax®.
7. My patient has been given the zoster vaccine and developed a vesicular rash 5 days later. What do I do?
Take a swab of the skin lesion where possible, following consultation with the Victorian vaccine safety service (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.
8. 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 GP Decision Aid for further information.
9. 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.
10. A 79 year old immunocompromised person with a past history of chronic lymphocytic leukaemia is inadvertently given Zostavax®. What should I do?
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, click here https://www.tga.gov.au/alert/zostavax-vaccine
11. What should I advise patients that can’t receive Zostavax® who are worried about getting shingles?
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 get shingles – make sure you see a doctor early if you get pain associated with a one-sided (dermatomal) rash.
12. What systems will help ensure zoster vaccine is used safely?
Check the patient medical record
Check the vaccination history on Australian Immunisation Register (AIR) or personal records
Use a checklist in case the patient hasn’t told you something relevant
Use the Shingles screening tool to determine any contraindications GP Decision Aid If in doubt, defer pending further information and/or specialist advice
SAEFVIC contact information
SAEFVIC the Victorian vaccine safety service
Reviewed by: 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)
Date: September 2018
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.