Zoster (herpes zoster)
Information about herpes zoster (shingles) disease, vaccines and recommendations for vaccination from the Australian Immunisation Handbook.
Recently added
This page was added on 06 June 2018.
Updates made
This page was updated on 01 November 2023. View history of updates
On 1 September 2024, the eligibility for free Shingrix vaccination under the National Immunisation Program (NIP) was expanded to include people at moderate to high-risk of severe infection and complications from shingles. This is detailed in the Program advice for health professionals. This chapter will be updated in the coming weeks.
Shingrix is funded under the National Immunisation Program (NIP) for certain groups of people.
Overview
What
Herpes zoster, commonly known as shingles, is a reactivation of the varicella-zoster virus (VZV) in a person who has previously had varicella (chickenpox). Herpes zoster commonly presents as a painful, self-limiting vesicular rash in a dermatomal distribution.
Who
Zoster vaccines are recommended for:
- people aged ≥50 years who are immunocompetent
- people aged ≥18 years who are immunocompromised
- people aged ≥50 years who are household contacts of a person who is immunocompromised
How
For Shingrix, a 2-dose schedule is recommended, 2–6 months apart, for people who are immunocompetent. For people who are immunocompromised, 2 doses of Shingrix are recommended at an interval of 1–2 months. Shingrix is funded under the National Immunisation Program (NIP) for all adults aged ≥65 years, Aboriginal and Torres Strait Islander people aged ≥50 years and selected groups aged ≥18 years with severe immunocompromise.
For Zostavax, a single dose is recommended. Zostavax is no longer used in the NIP.
There is currently no booster recommendation for either zoster vaccine.
Why
The risk and severity of herpes zoster and its complications increases with age. The lifetime risk of herpes zoster for people who live to 80 years of age is around 50%. The risk is higher in those who are immunocompromised.
Recommendations
People aged ≥50 years who are immunocompetent
All people aged ≥50 years who are immunocompetent should be offered zoster vaccine.
People who are immunocompetent are recommended to receive a 2-dose schedule of Shingrix, 2–6 months apart, for the prevention of herpes zoster and associated complications.
The optimal timing of receiving zoster vaccine depends on individual circumstances, including:
- Age-related risk of herpes zoster and its complications: Herpes zoster can occur at any age after primary infection with VZV, but the risk increases with age. The risk of herpes zoster in the general population increases from an estimated annual rate of 6 per 1000 in people aged 50–59 years to 15 per 1000 in people aged 70–79 years.1 The likelihood and severity of complications such as post-herpetic neuralgia also increases with age.
- Duration of protection: Shingrix has demonstrated high vaccine efficacy for at least 7 years after vaccination in people without immunocompromise,1 and immunogenicity data suggest that protection may persist for at least 10 years.1 A person vaccinated at a younger age such as 50 years may have reduced protection from vaccination as they age, when the risk of zoster is higher. There are no current recommendation for boosters for either zoster vaccine.
- Individual’s personal preferences: People’s desire to protect themselves from herpes zoster and related complications may vary, and this will influence decision-making on when they should receive zoster vaccination.
- NIP-funding for vaccination: An immunocompetent non-Indigenous adult will become eligible for Shingrix funded through the NIP from 65 years of age.
Shingrix is funded through the NIP for non-Indigenous people aged ≥65 years. Shingrix is funded through the NIP for Aboriginal and Torres Strait Islander peoples aged ≥50 years of age. For details see the National Immunisation Program Schedule.
A single dose of Zotavax may be used in people who are immunocompetent if Shingrix is not accessible. However, Shingrix is more efficacious,2 particularly in the elderly, and will likely offer longer-lasting protection against herpes zoster than Zostavax.3-8 Zostavax is no longer funded through the NIP. The person’s immune status should be carefully assessed before administering Zostavax, using the Live zoster vaccine (Zostavax) screening for contraindications tool, to confirm that they are not immunocompromised. See Contraindications and precautions. If the person’s immune status is uncertain, do not administer Zostavax, and consult the person’s specialist or an immunisation specialist before proceeding.
See Vaccine information.
View recommendation detailsPeople aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised
People aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised are recommended to receive a 2-dose schedule of Shingrix, 1–2 months apart, for the prevention of herpes zoster and associated complications. This includes people who are currently or soon to be immunocompromised as a result of a primary or acquired medical condition, or medical treatment (including treatment that has recently ceased).
Compared with immunocompetent people, people who are immunocompromised have higher rates of herpes zoster and of complications such as post-herpetic neuralgia (PHN).9,10 Herpes zoster can occur at a younger age in people who are immunocompromised, and there is also a higher risk of recurrence.11-14
Shingrix provides good protection against herpes zoster and associated complications in severely immunocompromised people aged ≥18 years,15,16 including people with a history of haematopoietic stem cell transplantation or haematologic malignancies.
The optimal time to receive Shingrix in immunocompromised individuals aged ≥18 years depends on individual circumstances:
- Age-related risk of herpes zoster and its complications: Herpes zoster can occur at any age, but the risk increases with age similar to in immunocompetent people. The likelihood of complications such as PHN also increases with age. While the risk will be elevated compared to a similarly aged immunocompetent person, the risk in a young person with an immunocompromising condition may still be lower than an older immunocompetent individual.17,18
- Individual’s immune status and duration of protection: People who are immunocompromised are at significantly higher risk of herpes zoster and severe complications than those who are immunocompetent.19-21 However, the extent of immunocompromise and risk of zoster will vary by the person’s underlying condition and the type and duration of immunocompromising medical treatment. People who are eligible for funded Shingrix under the NIP due to severe immunocompromise (see below) are recommended to consider vaccination as soon as eligible (for people anticipating a solid organ transplant, the preference is to wait until post-transplant and cessation of anti-viral prophylaxis before vaccinating). People with lesser degrees of immunocompromise may benefit from discussion of optimal timing of vaccination with their treating physician. See Vaccination for people who are immunocompromised.
- Individual’s personal preferences: People’s desire to protect themselves from herpes zoster and related complications may vary, and this will influence decision-making on when they should receive zoster vaccination.
Shingrix is funded through the NIP for people aged ≥18 years with selected severe immunocompromising conditions that put them at the highest risk of herpes zoster:
- haemopoietic stem cell transplant
- solid organ transplant
- haematological malignancy
- advanced or untreated HIV
For details see the National Immunisation Program Schedule.
Other immunocompromised people can receive Shingrix, obtained by private prescription; inclusion of additional immunocompromised people through the NIP is currently being considered.
Zostavax is contraindicated in individuals with severe immunocompromise and generally not recommended in people with other levels of immunocompromise or who are shortly expected to be immunocompromised. Zostavax is no longer funded through the NIP. Zostavax may only be used in people aged 50 years and over with mild immunocompromise where a patient is fully informed, has been instructed about monitoring for significant adverse events and what to do if they occur, and the anticipated benefit outweighs risk. Before use of Zostavax in people with mild immunocompromise, the degree of immunocompromise should be carefully assessed using the Live zoster vaccine (Zostavax) screening for contraindications tool. See Contraindications and precautions. This is because of the risk of disseminated varicella disease from the Oka strain vaccine virus in Zostavax, which can lead to death.22,23 The risk increases with the level of immunosuppression.
View recommendation detailsHousehold contacts of people who are immunocompromised
People who are immunocompromised should receive Shingrix to reduce their risk of zoster.
People aged ≥50 years who are household contacts of a person who is, or is expected to become, immunocompromised are recommended to receive a zoster vaccine. This indirectly protects the immunocompromised household member from exposure to varicella-zoster virus. Shingrix is recommended.
Although Zostavax is a live virus vaccine, the rate of varicella-like rashes from Zostavax is very low. It is unlikely that vaccine-associated virus would be transmitted from a recently vaccinated person to a susceptible immunocompromised contact.24
If a vaccinated person develops a varicella- or zoster-like rash, they should:
- cover the rash
- avoid contact with people who are immunocompromised until the rash clears
View recommendation details
Receiving Shingrix if previously vaccinated with Zostavax
People who have previously received Zostavax can receive Shingrix to increase their protection against herpes zoster, since protection using Zostavax wanes significantly from around 5 years after vaccination.
The optimal interval between receipt of Zostavax and Shingrix may vary, but an interval of at least 12 months is recommended between receiving Zostavax and a subsequent dose of Shingrix. The person will still need to complete the 2-dose schedule of Shingrix.
If a person has previously received Zostavax through the NIP, they are not eligible to receive Shingrix through the NIP until 5 years after the Zostavax dose. If a person paid privately for a previous dose of Zostavax, they are eligible to receive Shingrix through the NIP at any time after the optimal interval.
View recommendation detailsReceiving Zostavax if previously vaccinated with Shingrix
Zostavax is not recommended for people who have already received a zoster vaccine. Vaccination of a person with Zostavax if they have previously received Shingrix should be assessed on a case-by case basis including: the reason Zostavax is required e.g. medical contraindication to previous dose of Shingrix, and potential benefits and risks consider the person’s age and level of immunocompromise. There is currently no evidence on the use of Zostavax following Shingrix.
View recommendation detailsPeople who have had a previous episode of herpes zoster
People who have had a previous episode of herpes zoster can receive zoster vaccine at the recommended age.
For up to 8 years after an initial episode of zoster, the risk of a repeat episode in immunocompetent people is 6–8%.14,25,26 Note that a history of previous zoster may be inaccurate.
It is suggested that immunocompetent people should wait at least 12 months after an episode of herpes zoster before they receive a zoster vaccine. An episode of herpes zoster boosts cellular and humoral immunity above baseline levels in most people. Studies suggest that this boost persists for at least 1 year and up to 3 years,27 and a lower recurrence rate is observed in the first 12 months20 after the initial episode. Studies have not established an optimal time for vaccination after zoster, but no safety or immunogenicity concerns have been identified.28,29
Immunocompromised people are at higher risk of recurrence of zoster17-19,30 and can receive Shingrix from 3 months after the acute illness. The length of this interval should be determined on an individual basis and should consider:
- the uncertainty about duration of protection after vaccination in people who are immunocompromised
- the absence of recommendations for booster doses later in life
People previously vaccinated with varicella vaccine
People who have received varicella vaccine when it was indicated are not recommended to receive a zoster vaccine. Studies of the safety and immunogenicity of zoster vaccines in this setting are limited, and data are currently insufficient to suggest a benefit from vaccination. Preliminary information suggests that the incidence of herpes zoster in people who have received varicella vaccine is lower than in people infected with wild-type varicella.31-33
People who are uncertain if they have received a previous varicella vaccine, or have a history of varicella infection before or after varicella vaccination can be considered for zoster vaccination.
View recommendation detailsIf a person received varicella vaccine inadvertently when a zoster vaccine was indicated, there are no specific safety concerns unless the person was immunocompromised, but the dose should not be considered valid.
In this situation, Shingrix can be given at the same visit or at any time after the varicella vaccine. The person will still need to complete the 2-dose schedule. If Shingrix is not available and Zostavax is used in this situation, a dose of zoster vaccine should be given at the same visit. If this is not possible Zostavax can be given at least 4 weeks after the varicella vaccine.
View recommendation detailsSerological testing before and after zoster vaccination
It is not necessary to have serological evidence of immunity to varicella-zoster virus (VZV) or a history of previous varicella infection before administering either zoster vaccine in immunocompetent people. More than 97% of people in Australia are seropositive to VZV by 30 years of age,34 even if they cannot recall having varicella at a younger age.
Serological testing is not required before administration of Shingrix in people who are immunocompromised or shortly expected to be immunocompromised.
Zoster vaccine effectively boosts humoral and cellular immune responses from prior infection. For people known to be VZV-seronegative, varicella vaccine is preferred over a zoster vaccine. However, in studies3,5,35-37 of both zoster vaccines given to VZV-seronegative people there were no safety or immunogenicity concerns.
A person’s immune status should be carefully assessed before administration of Zostavax using the Live zoster vaccine (Zostavax) screening for contraindications tool.
View recommendation detailsIf a provider chooses to administer Zostavax to a person who is immunocompromised or shortly expected to be immunocompromised, where there are no other contraindications after assessment with the Live zoster vaccine (Zostavax) screening for contraindications tool, serological testing should be performed before vaccination to confirm that the person is varicella-zoster virus (VZV) IgG-positive.
People who are immunocompromised or shortly expected to be immunocompromised and are seronegative for VZV IgG should not receive Zostavax. This is because they may have very severe outcomes after receiving Zostavax.38 See also Contraindications and precautions. If there is uncertainty, consult with the patient’s specialist or immunologist before administering Zostavax. A cautious approach, with detailed individual clinical assessment, is required before administering Zostavax.
See recommendations for adolescents and adults in the Varicella chapter for more information about vaccination for people who are seronegative for VZV IgG.
Serological testing is not required before administration of Shingrix in people who are immunocompromised or shortly expected to be immunocompromised.
View recommendation detailsLaboratory testing to check for an immune response after Zostavax is not recommended.
Zostavax boosts both humoral and cellular immune responses. It is not necessary to confirm an immune response because it does not predict the level of protection against zoster.
In addition, routinely available serological assays are not designed to detect antibody levels after zoster vaccination, which may be lower than antibody levels after natural infection.
View recommendation detailsVaccines, dosage and administration
Zoster vaccines available in Australia
There are 2 vaccines available in Australia for the prevention of herpes zoster and associated complications — Shingrix and Zostavax.
The Therapeutic Goods Administration website provides product information for each vaccine.
See also Vaccine information and Variations from product information for more details.
Zoster vaccines
Registered for use in:
- adults aged ≥50 years
- adults aged ≥18 years who are at increased risk of herpes zoster
Recombinant Varicella Zoster Virus glycoprotein E antigen (ASO1B adjuvanted vaccine)
Powder and suspension
Each 0.5 mL reconstituted dose contains:
- 50 micrograms of gE antigen
- Sucrose
- Polysorbate 80
- Monobasic sodium phosphate dihydrate
- Dibasic potassium phosphate
These are adjuvanted with ASO1B Adjuvant System (Suspension). The adjuvant includes:
- plant extract Quillaja saponaria saponin (QS-21) (50 micrograms)
- 3-O-desacyl-4’-monophosphoryl lipid A (MPL) from Salmonella minnesota (50 micrograms)
- Dioleoylphosphatidylcholine
- Cholesterol
- Sodium chloride
- Dibasic sodium phosphate
- Monobasic potassium phosphate
For Product Information and Consumer Medicine Information about Shingrix visit the Therapeutic Goods Administration website.
View vaccine detailsRegistered for use in people aged ≥50 years.
Live herpes zoster vaccine
Lyophilised powder in a monodose vial with separate diluent.
Each 0.65 mL reconstituted dose contains:
- ≥19,400 plaque-forming units of live attenuated varicella-zoster virus (Oka/Merck strain)
- 41.05 mg sucrose
- 20.53 mg hydrolysed porcine gelatin
- 8.55 mg urea
- 0.82 mg monosodium glutamate
- residual components of MRC-5 cells
Also contains traces of:
- neomycin
- bovine serum albumin
For Product Information and Consumer Medicine Information about Zostavax visit the Therapeutic Goods Administration website.
View vaccine detailsDose and route
Shingrix consists of 2 doses of 0.5 mL given 2–6 months apart in immunocompetent people or 1–2 months apart in people who are immunocompromised or shortly expected to be immunocompromised, given by intramuscular injection, preferably in the deltoid muscle. Evidence suggests that extended intervals 6 months and longer between first and second doses does not appear to affect vaccine effectiveness.39 Therefore, the second dose of Shingrix does not need to be repeated if the recommended interval between the first and second doses is exceeded.
The dose of Zostavax is a single dose of 0.65 mL given by subcutaneous injection.
Co-administration with other vaccines
Shingrix
People can receive Shingrix with other inactivated vaccines (such as tetanus-containing vaccines, pneumococcal vaccines, influenza vaccines and COVID-19 vaccines), either:40-42
- at the same time, or
- at any time after
There is the potential for an increase in mild to moderate adverse events when more than one vaccine is given at the same time. Separation of Shingrix from other vaccines should be considered, particularly for vaccines for which co-administration data are currently limited — for example, adjuvanted influenza vaccine and COVID-19 vaccines.
Zostavax
People can receive Zostavax with other inactivated vaccines (such as tetanus-containing vaccines, influenza vaccine43 and pneumococcal polysaccharide vaccine44-46), either:
- at the same time, or
- at any time after
If a person needs both Zostavax and another live parenteral vaccine (such as measles-mumps-rubella or yellow fever), they can receive the vaccines either:
- on the same day, or
- at least 4 weeks apart
Contraindications and precautions
Contraindications
Anaphylaxis to vaccine components
Shingrix is contraindicated in people who have had:
- anaphylaxis after a previous dose of Shingrix
- anaphylaxis after any component of Shingrix
Zostavax is contraindicated in people who have had:
- anaphylaxis after a previous dose of any live varicella-zoster virus (VZV)–containing vaccine (Zostavax or varicella vaccine)
- anaphylaxis after any component of a live VZV-containing vaccine
People who are immunocompromised or shortly expected to be immunocompromised
Shingrix is the recommended vaccine for people aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised because it is safe and efficacious in this population. See People aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised.
Zostavax is not recommended in people who are immunocompromised or shortly expected to be immunocompromised. It is contraindicated in people who are considered severely immunocompromised because it contains live attenuated VZV.
Severe immunocompromise may be from either:
- a primary or acquired medical condition, or
- medical treatment
People who are immunocompromised include those who:
- are receiving high-dose systemic immunosuppressive therapy, such as chemotherapy, radiation therapy or oral corticosteroids (≥20 mg per day of prednisolone equivalent dose)
- are receiving biologic or targeted synthetic disease-modifying anti-rheumatic drugs (bDMARDs or tsDMARDs)
- have malignant conditions of the reticuloendothelial system (such as lymphoma, leukaemia or Hodgkin disease, even if they are not receiving active treatment)
- have AIDS or symptomatic HIV infection
- have similar immunocompromising conditions due to a disease or treatment
Refer to Table. Recommendations for use of Zostavax in people aged ≥50 years on immunosuppressive therapy and see Live zoster vaccine (Zostavax) screening for contraindications tool. If there is uncertainty about the person’s level of immunocompromise and whether vaccination is safe, do not administer Zostavax.
People aged ≥50 years who have stopped treatment with high-dose systemic immunosuppressive therapy may receive Zostavax after an appropriate time. See Table. Recommendations for use of Zostavax in people aged ≥50 years on immunosuppressive therapy and Vaccination for people who are immunocompromised. See Live zoster vaccine (Zostavax) screening for contraindications tool.
In some cases, the level of immunocompromise that absolutely contraindicates live attenuated vaccines can last for 1 year or longer after the previous dose of therapy. This can occur after therapy with biologics such as rituximab, which can have long-term effects on the immune system. Blood tests may be needed before considering vaccination with Zostavax to ensure that the immune system has recovered and biologic drug levels are low. If there is uncertainty about the level of immunocompromise in any person who has received a biologic therapy, do not give Zostavax or any other live attenuated vaccine. Consult with a medical specialist who can help determine the appropriate interval since last treatment and, in some cases, can assess the person’s immunological recovery.
Immunosuppressive therapy | Safe dose to vaccinate | Dose at which Zostavax is contraindicated | Acceptable timing of Zostavax if dose is contraindicated |
---|---|---|---|
Corticosteroid monotherapy | ≤20 mg per day of prednisolone or equivalenta | ≥20 mg/day of prednisolone or equivalent for less than 14 days |
|
≥20 mg per day of prednisolone or equivalent for 14 days or longer |
|
||
csDMARD — azathioprine | ≤3.0 mg per kg per day (if used as a single agent, with or without low-dose corticosteroids) | >3.0 mg per kg per day |
|
csDMARD — 6-mercaptopurine | ≤1.5 mg per kg per day (if used as a single agent, with or without low-dose corticosteroids) | >1.5 mg per kg per day |
|
csDMARD — methotrexate | ≤0.4 mg per kg per week (if used as a single agent, with or without low-dose corticosteroids) | >0.4 mg per kg per week |
|
csDMARDs — sulfasalazine or hydroxychloroquine | Any dose | None | Not applicable |
csDMARD — mycophenolate | None | All regimens |
|
Other csDMARDs | None | All regimens |
|
T-cell inhibitors or activators (eg tacrolimus, cyclosporine; except denosumab, for which there is no evidence of significant immunosuppression) | None | All regimens |
|
Other unspecified immunosuppressants (eg chemotherapy, radiotherapy) | None | All regimens |
|
Anti-TNF agents (eg etanercept, infliximab, adalimumab) | None | All regimens |
|
tsDMARDs — Janus kinase inhibitors (eg tofacitinib), phosphodiesterase-4 inhibitors (eg apremilast), or bDMARDs — monoclonal antibodies, IL inhibitors (eg anakinra, tocilizumab), costimulation blockers (eg abatacept), B-cell depleting agents (eg rituximab) |
None | All regimens |
|
b = biologic; cs = conventional synthetic; DMARD = disease-modifying anti-rheumatic drug; IL = interleukin; TNF = tumour necrosis factor; ts = target synthetic a If person is on long-term corticosteroid monotherapy or corticosteroid therapy combined with other disease-modulating or immunosuppressive therapy, consider delaying Zostavax and consulting with both the treating doctor and an immunisation specialist. |
Managing people who are immunocompromised and who inadvertently receive Zostavax
If an immunocompromised person is inadvertently vaccinated with Zostavax:
- promptly assess them and monitor closely for symptoms or signs of disseminated VZV infection, such as fever or a chickenpox-like rash, within 2–4 weeks of receiving the vaccine
- discuss their appropriate management with an infectious diseases and/or immunisation expert
- notify the relevant state or territory health authority, and the Therapeutic Goods Administration (TGA)
For mechanisms for reporting to the TGA, see Adverse events following immunisation.
It is important to establish the person’s degree of immunocompromise and risk of vaccine-associated adverse effects. Patient management may include:
- pre-emptive or therapeutic use of antiviral medication as soon as possible after inadvertent administration of Zostavax
- consider the use of ZIG in people with severe immunocompromise
- clinical investigations, such as laboratory testing for VZV from any rash or other affected sites
Women who are pregnant or breastfeeding
There are no data on the use of Shingrix in pregnant or breastfeeding women, although no theoretical concern exists.
Women of child-bearing age who are immunocompromised are recommended to receive Shingrix vaccine either:
- before a planned pregnancy, or
- as soon as practicable after delivery
Because Zostavax contains live attenuated VZV, it is contraindicated in pregnant women.
Women should avoid pregnancy for 28 days after vaccination with Zostavax. See also Varicella.
People can still receive Zostavax if they have a household contact who is pregnant.
See Table. Vaccines contraindicated in pregnancy: live attenuated vaccines in Vaccination for women who are planning pregnancy, pregnant or breastfeeding for more details.
Breastfeeding women can receive Zostavax if they are eligible for vaccination.
Precautions
Zoster vaccines should not be used for the prevention of primary varicella infection (chickenpox). Varicella vaccine should be considered (see Varicella). They also should not be used for the treatment of acute herpes zoster illness or post-herpetic neuralgia.
People with mild immunocompromising conditions or who are shortly expected to be immunocompromised
People aged ≥18 years with any level of immunocompromise are recommended to receive Shingrix.
For people aged 18–49 years with any level of immunocompromise, or who are shortly expected to be immunocompromised, Shingrix is the only available vaccine.
Zostavax is not recommended in people who are immunocompromised and is contraindicated in those who are severely immunocompromised. Where Shingrix is not accessible, people aged ≥50 years with mild immunocompromising conditions or who are shortly expected to be immunocompromised may receive Zostavax. They are recommended to:
- be assessed on a case-by-case basis
- undergo serological testing before vaccination to confirm that they are VZV IgG-positive
Appropriate specialist advice should be sought before vaccinating. See Table. Recommendations for use of Zostavax in people aged ≥50 years on immunosuppressive therapy, Live zoster vaccine (Zostavax) screening for contraindications tool and Vaccination for people who are immunocompromised. If uncertain about the person’s level of immunocompromise and whether vaccination is safe, do not administer Zostavax.
People who are shortly expected to be immunocompromised may include those:
- with solid tumours that will require future chemotherapy or radiation therapy
- with inflammatory diseases, such as rheumatoid arthritis, systemic lupus erythematosus, inflammatory bowel disease or psoriasis, that may need further immunosuppressive medical treatment
These people may have a functioning immune system now, but may be significantly immunocompromised in the future because of their disease or treatment. Because they have a high risk of developing zoster in the future, it is recommended to vaccinate them with a zoster vaccine at least 4 weeks before they become immunocompromised.47
If a 4-week interval is not possible, Shingrix can be considered. Do not give Zostavax, and seek specialist advice.
For those anticipating solid organ transplantation, the preference is to wait until post-transplant and cessation of treatment with anti-viral prophylaxis, at which point Shingrix should be given.
See Adverse events in people with immunocompromising conditions or on immunosuppressive therapy.
Serological confirmation of VZV infection
For people aged ≥50 years with mild immunocompromising conditions or who are shortly expected to be immunocompromised, it is recommended to confirm previous VZV infection using serological testing before vaccination with Zostavax. Detection of VZV-specific antibody may help confirm previous VZV infection and therefore immune memory. In someone with a mild level of immunocompromise, pre-existing immunity provides additional reassurance about the safe use of Zostavax in that person. See Live zoster vaccine (Zostavax) screening for contraindications tool. If uncertain about the person’s level of immunocompromise and whether vaccination is safe, do not administer Zostavax. See Serological testing before and after zoster vaccination and Considerations for timing of zoster vaccination.
People with HIV infection
People with asymptomatic HIV infection are likely to have a higher relative risk of developing herpes zoster in the future.48 People aged ≥18 years with HIV infection can receive Shingrix, which is the preferred vaccine. Shingrix is safe and immunogenic in people with HIV infection.49
People aged ≥50 years with asymptomatic HIV infection can receive Zostavax, if Shingrix is not accessible, if they:
- are on antiretroviral therapy and
- have a very low or undetectable viral load and
- have a CD4+ count ≥350 per µL
If there is a strong indication to vaccinate, some experts suggest that a CD4+ count >200 per µL is safe.50
Before vaccinating a person with asymptomatic HIV infection with Zostavax:
- seek expert advice from the treating physician and/or an immunisation specialist (see also People with HIV in Vaccination for people who are immunocompromised)
- check for previous VZV infection using serological testing
- see Live zoster vaccine (Zostavax) screening for contraindications tool
See Serological testing before and after zoster vaccination and Considerations for timing of zoster vaccination.
Vaccination before or after administration of immunoglobulin or a blood product
No precautions are required around immunoglobulins and blood product administration and administration of Shingrix in people aged ≥18 years.
People aged ≥50 years can receive Zostavax at any time before or after receiving immunoglobulin or any antibody-containing blood product. This is because Zostavax is indicated in people who, because of their age, are assumed to have had previous infection with VZV. This means they already have serum antibody levels that are comparable to those found in blood products. See also Vaccination for people who have recently received normal human immunoglobulin and other blood products.
People receiving long-term aspirin or salicylate therapy
People aged ≥18 years receiving long-term salicylate therapy (aspirin) can receive any registered zoster vaccine for their age. Natural varicella infection and salicylate use has been associated with an increased risk of developing Reye syndrome. There have been no reports of an association between Reye syndrome and varicella vaccination.
People receiving antiviral medicines
No precautions are required around antiviral medications and administration of Shingrix.
Antivirals with anti-VZV activity may interfere with the replication of the Zostavax live attenuated virus. These antivirals include:
- aciclovir
- famciclovir
- valaciclovir
People taking an antiviral medicine should:47,50
- stop taking it at least 24 hours before vaccination with Zostavax
- start taking it again at least 14 days after vaccination with Zostavax
See Live zoster vaccine (Zostavax) screening for contraindications tool.
Adverse events
Adverse events after Shingrix
Shingrix is a non-live vaccine and is safe for use in both immunocompetent and immunocompromised people. Local and systemic adverse events following vaccination with Shingrix are substantially more common than after placebo but generally do not prevent normal activities. It is important for people to receive the second dose of Shingrix to be adequately protected against herpes zoster.
Injection site reactions were experienced by 82% of trial participants aged ≥50 years who received Shingrix (compared with 12% who received placebo) and 74% of participants aged ≥70 years (compared with 10% who received placebo).3,5
Systemic adverse events (such as fever, fatigue, gastrointestinal symptoms, headache, shivering or myalgia) were experienced by 66% of trial participants aged ≥50 years who received Shingrix (compared with 30% who received placebo) and 53% of participants aged ≥70 years (compared with 25% who received placebo). There was no difference in the rates of serious adverse events compared with placebo.3,5
In a small proportion of people (approximately 10%), reactions may be severe enough to disrupt normal daily activities; these are generally short-lived (1–3 days) and go away without treatment.
Rates of local and systemic reactions appear to be slightly higher after Shingrix than after Zostavax.24,51,52
Before vaccination with Shingrix, immunisation providers should counsel people about what local and systemic reactions to expect, and the importance of completing the 2-dose schedule for an adequate level and duration of protection.
Guillain–Barré syndrome
Data from the United States suggest a possible but very rare risk of Guillain–Barré syndrome (GBS), a demyelinating neurological condition, following Shingrix (an estimated 3 additional cases per million doses administered).53 However, GBS may also be triggered by zoster itself,54 and modelling suggests that the overall benefits of vaccination outweigh the risks of GBS.55
Adverse events after Zostavax
The Shingles Prevention Study was a very large clinical trial on live attenuated zoster vaccine (Zostavax). Together with other smaller studies, it demonstrated that Zostavax is safe and generally well tolerated among people aged ≥50 years.24,52
Injection site reactions occurred in 48% of clinical trial participants who received Zostavax, regardless of their history of herpes zoster, compared with 17% of participants who received placebo. Injection site symptoms included erythema, pain, swelling and itching at the injection site.52,56
Mild to moderate adverse events, particularly injection site reactions, were more common in vaccine recipients aged 50–59 years than in those aged ≥60 years.52,56
Fever of >38.3°C was not more common in vaccine recipients than in placebo recipients, and occurred in <0.1% of clinical trial participants overall.24
Systemic symptoms occurred in vaccine recipients (6.3%) more commonly than in placebo recipients (4.9%). The most common systemic symptoms reported were headache52 and fatigue.24
Zostavax is a live attenuated vaccine and is contraindicated in people who are, or are soon to be, severely immunocompromised.
A thorough assessment of each person’s immune status should be undertaken before administering Zostavax. See Live zoster vaccine (Zostavax) screening for contraindications tool and Adverse events in people with immunocompromising conditions or on immunosuppressive therapy.
In clinical trials, both non-localised and localised (injection site) varicella-like rashes in Zostavax recipients were rare: 0.1% of vaccine recipients developed a rash, and this was more common than in placebo recipients.24
A non-localised varicella-like rash can occur around 2–4 weeks after vaccination with Zostavax.57 This type of rash may be due to disseminated VZV infection from the Oka vaccine strain. Always advise people who have received Zostavax to:
- seek immediate medical attention if they develop a generalised varicella-like rash
- inform their medical practitioner that they have recently received Zostavax
If the person has suspected disseminated VZV infection:
- collect a sample for appropriate diagnostic testing and notify testing laboratory to conduct sequencing for Oka vaccine strain
- start empirical antiviral treatment
- consult with an infectious diseases specialist
- stop immunosuppressive therapy, if relevant
- notify the relevant state or territory health authority and the Therapeutic Goods Administration (TGA) — see Reporting AEFIs
Post-marketing surveillance of Zostavax in the United States found that the most common adverse events were injection site reactions and that vaccination did not increase the risk of adverse events such as cerebrovascular events or encephalitis.58
Adverse events in people with immunocompromising conditions or on immunosuppressive therapy
There are no additional safety concerns for people with immunocompromising conditions or on immunosuppressive therapy who receive Shingrix.
Zostavax is contraindicated in severely immunocompromised people. Administering Zostavax to people who are severely immunocompromised can result in disseminated disease from the Oka vaccine virus.
Without an adequate immune response, the vaccine virus can replicate unchecked.59,60 There have been 2 case reports, including one in Australia, of disseminated Oka vaccine virus disease, leading to death, in people with chronic lymphocytic leukaemia who were given Zostavax.38,59,60 They were not receiving immunosuppressive treatment when they were vaccinated. Two further cases of vaccine-related deaths in Australia and one in Canada in people with varying levels of immunosuppression have been reported, occurring several weeks after receiving Zostavax.22,23,61 These cases highlight the difficulty of assessing immunocompromise and the significant consequences that can result from inadvertent administration in an immunocompromised person. It is recommended that all people due to receive Zostavax are screened with the Live zoster vaccine (Zostavax) screening for contraindications tool before vaccination.
The TGA and the Australian Technical Advisory Group on Immunisation continue to monitor global evidence on the safety of Zostavax.
Nature of the disease
Varicella-zoster virus (VZV) is a DNA virus of the Herpesviridae family.
Pathogenesis
Primary infection with VZV is known as varicella or chickenpox.62 After primary infection, the virus resides in the sensory ganglia.62
Herpes zoster, or shingles, occurs when latent VZV reactivates. This could be due, in part, to a decline in cellular immunity to the virus.11 Virus-specific cellular immunity most commonly declines with ageing or with immunocompromising medical conditions or immunosuppressive treatment.
Transmission
VZV spreads through direct contact with fluid from the rash blisters caused by herpes zoster. This can cause primary varicella in exposed susceptible people.47
Clinical features
Most cases present with a unilateral vesicular rash in a dermatomal distribution.
80% of cases have a prodromal phase 48–72 hours before the rash appears.11 Associated symptoms may include:63,64
- headache
- photophobia
- malaise
- itching, tingling or severe pain in the affected dermatome
In most people, herpes zoster is an acute and self-limiting disease. The rash usually lasts 10–15 days.13,62 However, complications can occur, especially with increasing age.
PHN and other complications
Post-herpetic neuralgia (PHN) is the most frequent debilitating complication of herpes zoster. PHN is a neuropathic pain syndrome that persists or develops after the dermatomal rash has healed.
PHN is most commonly defined as the persistence of pain for longer than 3 months after the onset of the rash. But definitions can vary by the period of persistent pain.65,66
Other complications depend on the site of reactivation, and may include:67
- ophthalmic disease, such as keratitis and chorioretinitis
- neurological complications, such as meningoencephalitis and myelitis
- secondary bacterial skin infection
- scarring
- pneumonia
Rarely, some people may develop disseminated herpes zoster. This is characterised by widespread vesicular rash, and visceral, central nervous system and pulmonary involvement. Disseminated disease is more common in people who are immunocompromised, and may be fatal.63
Some people may also experience dermatomal pain without a rash. This is known as zoster siné herpéte.
Treating herpes zoster
Antiviral therapy can reduce the severity and duration of herpes zoster if therapy starts within 3 days of onset.
Antiviral therapy may also reduce the risk of developing PHN.68-72 However, PHN can be difficult to treat and may persist for years.73
Epidemiology
Herpes zoster occurs most commonly in people who:
- are older — particularly >50 years
- are immunocompromised
- had varicella in the 1st year of life
The lifetime risk of herpes zoster for people who live to 80 years of age is around 50%.62,74-76
For up to 8 years after an initial episode of zoster, the risk of a repeat episode in immunocompetent people is 6–8%.25,26 Repeat episodes of herpes zoster are more common in people who are immunocompromised.17
In a large clinical trial of Zostavax in the United States (the Shingles Prevention Study), active surveillance in the unimmunised (placebo) participants estimated the herpes zoster incidence at 1112 cases per 100,000 person-years in people ≥60 years of age.24
Herpes zoster in Australia
In Australia, there are about 560 cases of herpes zoster per 100,000 population per year in all age groups.1
Rates of herpes zoster in immunocompetent adults increase from age 50 with 1174 cases per 100,000 population in people aged ≥50 years.1 Herpes zoster incidence continues to rise with age, from an estimated rate of 630 per 100,000 population in people aged 50–59 years to 1366 per 100,000 population in people aged 60 to 69 to 1531 per 100,000 population in people aged 70–79 years.1
Hospitalisations from herpes zoster in Aboriginal and Torres Strait Islander people
Aboriginal and Torres Strait Islander people have an increased risk of hospitalisation from herpes zoster from an earlier age when compared to non-Indigenous people. The average annual hospitalisation rate for Aboriginal and Torres Strait Islander people aged 50-59 years is estimated to be 16 per 100,000, which is similar to non-Indigenous people aged 60-69 years with an estimated rate of 19 per 100,000.77 The estimated rate for Aboriginal and Torres Strait Islander people aged 60-69 years is 34 per 100,000.77
Herpes zoster in people who are immunocompromised
People who are immunocompromised have an increased risk of herpes zoster compared with non-immunocompromised people. Rates of herpes zoster are up to 15 times higher in people who are immunocompromised due to HIV infection. In the 1st year after haematopoietic stem cell transplantation, up to 30% of patients may develop herpes zoster.13,48
Rate of complications from herpes zoster
Overall, 13–26% of patients with herpes zoster develop complications. Complications occur more often in older people and people who are immunocompromised.9,10
Post-herpetic neuralgia (PHN) is the most common complication of herpes zoster, but it occurs very infrequently in children and young adults. PHN occurs in approximately 1 in 5 herpes zoster cases in people aged >80 years, compared with approximately 1 in 10 cases in people aged 50–59 years.26,78,79 The population-based incidence of PHN is 3 times higher in people aged 70–79 years (235 per 100,000) than in people aged 50–59 years (73 per 100,000).79
Vaccine information
Two zoster vaccines are available for use in Australia for the prevention of herpes zoster.
Shingrix is a recombinant VZV glycoprotein E (gE) subunit vaccine, with AS01B adjuvant to stimulate the vaccine-related immune response. Shingrix is the preferred vaccine for use in people who are immunocompromised.
Zostavax is a live attenuated vaccine formulated from the same varicella-zoster virus (VZV) strain (Oka) as the registered varicella (chickenpox) vaccine Varivax. But Zostavax has higher potency (on average, at least 14 times greater) than Varivax. The higher viral titre in Zostavax is needed to boost the immune response in people who usually remain seropositive for VZV after primary infection, but have declining cellular immunity as they get older.80
It is important to review a person’s medical history and medication use before vaccination with Zostavax because it is contraindicated in people who are immunocompromised. See Contraindications and precautions.
Shingrix
Efficacy
In 2 large clinical trials, Shingrix provided 97% protection against herpes zoster in immunocompetent people ≥50 years of age and 91% protection in immunocompetent people ≥70 years of age.3,5
Vaccine efficacy of Shingrix against post-herpetic neuralgia (PHN), a persistent pain syndrome after herpes zoster, was 91% in immunocompetent people ≥50 years of age and 89% in immunocompetent people ≥70 years of age.3,5
In a small number of clinical trials of highly immunocompromised populations (autologous haematopoietic stem cell transplantation and haematological malignancy), including patients ≥18 years of age, Shingrix provided good protection against herpes zoster, PHN and herpes zoster–related hospitalisation.15,16
Although data are lacking on the efficacy of Shingrix in a broad range of immunocompromised groups, trials demonstrate a robust immune response to the vaccine in a sufficient range of immunocompromised populations (HIV infection, renal transplant, solid organ malignancies receiving immunosuppressant/cytotoxic medications) to support a recommendation for the vaccine’s use in immunocompromised populations more generally.15,16,49,81,82
Duration of immunity
High vaccine efficacy (>80%) has been demonstrated for at least 7 years after vaccination with 2 doses of Shingrix,83 and immunogenicity data suggest that protection may persist beyond 10 years.3-5 In contrast, the effectiveness of Zostavax appears to decrease significantly by 5–10 years after vaccination.2,6-8
Zostavax
Efficacy
The Shingles Prevention Study was a single large, randomised, double-blind, placebo-controlled efficacy study of the frozen formulation of Zostavax. The study included 38,546 people aged ≥60 years. Zostavax significantly reduced the likelihood of developing both herpes zoster and PHN.24 Over a median of more than 3 years follow-up, Zostavax vaccination of people aged ≥60 years reduced the:24
- incidence of herpes zoster by 51.3%
- incidence of PHN by 66.5%
- burden of illness associated with herpes zoster by 61.1%
Zostavax was better at reducing herpes zoster in people aged 60–69 years (64% efficacy) than in those aged 70–79 years (41% efficacy). However, efficacy against PHN was similar in both age groups.24 Efficacy against herpes zoster in the ≥80 years age group was lower (18% and not statistically different from placebo). However, there were fewer participants of this age in the study.47
In people who developed herpes zoster despite vaccination with Zostavax, the pain associated with the episode was less severe.84
Another randomised controlled study in >22,000 people aged 50–59 years showed that compared to placebo, the incidence of herpes zoster was lower in those who received Zostavax over an average follow-up period of 1.3 years (range 0–2 years). The vaccine efficacy for preventing herpes zoster was 69.8%.52
Duration of immunity
A single dose of Zostavax appears to lose efficacy over time. One short-term follow-on study of Shingles Prevention Study participants showed a decline in vaccine efficacy. However, estimates remained statistically significant for up to 5 years after vaccination, with uncertain efficacy beyond that.8,85
A longer-term study of Shingles Prevention Study participants suggested that Zostavax significantly protected against herpes zoster for up to 8 years after vaccination. However, the study’s methods limit confidence in this result.6
One large observational study investigated vaccine effectiveness among community-dwelling people aged ≥60 years. Vaccine effectiveness decreased with each year of follow-up (from 69% in the 1st year to 4% in the 8th year).8
Transporting, storing and handling zoster vaccines
Transport according to National Vaccine Storage Guidelines: Strive for 5.86 Store at +2°C to +8°C. Do not freeze. Protect from light.
Zostavax and Shingrix must be reconstituted. Add the entire contents of the diluent container to the vial and shake until the powder completely dissolves. Reconstitute immediately after taking the vaccine out of the refrigerator.
For Zostavax, the reconstituted vaccine must be used within 30 minutes.
For Shingrix, the reconstituted vaccine can be kept up to 6 hours if refrigerated at +2°C to +8°C.
Public health management
Herpes zoster is a notifiable disease in most states and territories in Australia.
State and territory public health authorities can provide advice about the public health management of herpes zoster, including management of cases and their contacts.
Variations from product information
Co-administration of Shingrix with influenza vaccine
The product information for Shingrix states that the vaccine can be given concurrently with unadjuvanted seasonal influenza vaccine.
ATAGI recommends that Shingrix may be given concurrently with any influenza vaccine.
Administration of Shingrix to people with immunosuppression or immunodeficient conditions
The product information for Shingrix states that immunogenicity data for use of Shingrix in people with HIV infection or haematopoietic stem cell transplantation are available. Immunogenicity is still under investigation for people with other confirmed or suspected immunosuppressive or immunodeficient conditions.
ATAGI recommends that Shingrix is the preferred vaccine for people aged ≥50 years who are, or are soon to be, immunocompromised. Shingrix is the only vaccine available for use in people aged 18–49 years who are immunocompromised.
Administration of Shingrix to people previously vaccinated with a live attenuated zoster vaccine
The product information for Shingrix states that clinical trial data on the use of Shingrix in people who were previously vaccinated with a live attenuated zoster vaccine was in people aged ≥65 years, with an interval of ≥5 years between a live attenuated zoster vaccine and Shingrix.
ATAGI recommends that Shingrix can be administered to people aged ≥50 years who have previously received a live attenuated zoster vaccine when the interval between the live attenuated vaccine and the 1st dose of Shingrix is at least 12 months.
Co-administration of Zostavax with influenza vaccine and 23vPPV
The product information for Zostavax states that the vaccine can be given concurrently with inactivated influenza vaccine but not with 23-valent pneumococcal polysaccharide vaccine (23vPPV).
The Australian Technical Advisory Group on Immunisation (ATAGI) recommends that Zostavax may be given concurrently with other vaccines, including 23vPPV.
Administration of Zostavax in people with HIV infection
The product information for Zostavax states that the safety and efficacy of Zostavax have not been established in people with known HIV infection, with or without evidence of immunosuppression.
ATAGI recommends that Zostavax may be given to people who have HIV infection but are not immunocompromised, after confirming pre-existing immunity to varicella-zoster virus.
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- Schmader K. Herpes zoster in older adults. Clinical Infectious Diseases 2001;32:1481-6.
- Thomas SL, Hall AJ. What does epidemiology tell us about risk factors for herpes zoster? The Lancet Infectious Diseases 2004;4:26-33.
- Sheel M, Beard FH, Dey A, Macartney K, McIntyre PB. Rates of hospitalisation for herpes zoster may warrant vaccinating Indigenous Australians under 70. Med J Aust 2017;207:395-6.
- Gauthier A, Breuer J, Carrington D, Martin M, Rémy V. Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom. Epidemiology and Infection 2009;137:38-47.
- Stein AN, Britt H, Harrison C, et al. Herpes zoster burden of illness and health care resource utilisation in the Australian population aged 50 years and older. Vaccine 2009;27:520-9.
- Oxman MN. Vaccination to prevent herpes zoster and postherpetic neuralgia. Human Vaccines 2007;3:64-8.
- Vink P, Mingorance ID, Alonso CM, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in patients with solid tumors, vaccinated before or during chemotherapy: a randomized trial. Cancer 2019;125:1301-12.
- Vink P, Ramon Torrell JM, Sanchez Fructoso A, et al. Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in chronically immunosuppressed adults following renal transplant: a phase 3, randomized clinical trial. Clinical Infectious Diseases 2020;70:181-90.
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- Australian Government Department of Health and Aged Care. National Vaccine Storage Guidelines: Strive for 5. (3rd edn) Canberra: Australian Government Department of Health and Aged Care; 2019. https://www.health.gov.au/resources/publications/national-vaccine-storage-guidelines-strive-for-5
Page history
Updates to clinical guidance throughout the chapter to reflect the listing of Shingrix vaccine on the National Immunisation Program for eligible groups.
Funding information update
Recommendation updates and additions including
- Recommendation updates for all Recommendations
- Recommendation added for people ages ≥18 years who are immunocompromised
- Recommendation added for People who have previously received Zostavax can receive Shingrix
- Recommendation added for People who have previously received Shingrix need to be assessed on a case-by-case basis to receive Zostavax
Chapter updates have occurred throughout the document in detail, including detailed changes to accommodate the Shingrix vaccine. Sections of particular note are:
- Women who are pregnant or breastfeeding,
- People who are immunocompromised
- Precautions
- Adverse events
- Transporting, storing and handling zoster vaccines
- Variations from product information
- References
There is updated clinical guidance on the use of both zoster vaccines, Zostavax and Shingrix, that is relevant for people aged ≥18 years. Please refer to the ATAGI clinical statement on the clinical use of Zoster vaccine in Australia.
More detailed guidance provided on the use of Zostavax in people who are immunocompromised or on immunosuppressive therapy, including:
- more details on pre-vaccination screening, including serological testing for past varicella-zoster virus (VZV) infection when relevant
- expanded list of immunosuppressive therapies that are considered safe for administration of Zostavax
Adverse events section updated to include:
- detailed information on VZV-like rash that could rarely occur following Zostavax administration
- relevant advice to vaccine recipients
- management and reporting of these episodes
Changes to 4.24.7 Recommendations, 4.24.9 Contraindications, 4.24.10 Precautions, and 4.24.11 Adverse events
4.24.7 Recommendations
Addition of text reiterating importance of obtaining a medical history in patients prior to vaccination, to reiterate the contraindications regarding use of Zostavax in immunocompromised people and to provide further detail on what constitutes immunocompromise and how to manage inadvertent vaccination in these people.
4.24.9 Contraindications
Addition of text and table to reiterate the contraindications regarding use of Zostavax in immunocompromised people and to provide further detail on what constitutes immunocompromise and how to manage inadvertent vaccination in these people.
4.24.10 Precautions
Addition of text providing more specific detail of CD4 levels at which a person infected with HIV can receive Zostavax. (Refer also Chapter 3.3 Groups with special vaccination requirements).
4.24.11 Adverse events
Addition of text providing details of select serious outcomes where immunocompromised people have received Zostavax.
Updates to clinical guidance throughout the chapter to reflect the listing of Shingrix vaccine on the National Immunisation Program for eligible groups.
Funding information update
Recommendation updates and additions including
- Recommendation updates for all Recommendations
- Recommendation added for people ages ≥18 years who are immunocompromised
- Recommendation added for People who have previously received Zostavax can receive Shingrix
- Recommendation added for People who have previously received Shingrix need to be assessed on a case-by-case basis to receive Zostavax
Chapter updates have occurred throughout the document in detail, including detailed changes to accommodate the Shingrix vaccine. Sections of particular note are:
- Women who are pregnant or breastfeeding,
- People who are immunocompromised
- Precautions
- Adverse events
- Transporting, storing and handling zoster vaccines
- Variations from product information
- References
There is updated clinical guidance on the use of both zoster vaccines, Zostavax and Shingrix, that is relevant for people aged ≥18 years. Please refer to the ATAGI clinical statement on the clinical use of Zoster vaccine in Australia.
More detailed guidance provided on the use of Zostavax in people who are immunocompromised or on immunosuppressive therapy, including:
- more details on pre-vaccination screening, including serological testing for past varicella-zoster virus (VZV) infection when relevant
- expanded list of immunosuppressive therapies that are considered safe for administration of Zostavax
Adverse events section updated to include:
- detailed information on VZV-like rash that could rarely occur following Zostavax administration
- relevant advice to vaccine recipients
- management and reporting of these episodes
Changes to 4.24.7 Recommendations, 4.24.9 Contraindications, 4.24.10 Precautions, and 4.24.11 Adverse events
4.24.7 Recommendations
Addition of text reiterating importance of obtaining a medical history in patients prior to vaccination, to reiterate the contraindications regarding use of Zostavax in immunocompromised people and to provide further detail on what constitutes immunocompromise and how to manage inadvertent vaccination in these people.
4.24.9 Contraindications
Addition of text and table to reiterate the contraindications regarding use of Zostavax in immunocompromised people and to provide further detail on what constitutes immunocompromise and how to manage inadvertent vaccination in these people.
4.24.10 Precautions
Addition of text providing more specific detail of CD4 levels at which a person infected with HIV can receive Zostavax. (Refer also Chapter 3.3 Groups with special vaccination requirements).
4.24.11 Adverse events
Addition of text providing details of select serious outcomes where immunocompromised people have received Zostavax.