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Vaccine preventable diseases

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 07 February 2025. View history of updates

Shingrix is funded under the National Immunisation Program (NIP) for certain groups of people.

On this page

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

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 moderate or severe immunocompromise.

There is currently no booster recommendation for zoster vaccine. Current data supports good protection at 10 years following 2 doses of Shingrix. Advice on the need for booster doses will be considered if data becomes available that shows significant waning of protection and benefit from a booster dose.

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 are recommended to receive 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: 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. However, current evidence shows Shingrix continues to have high efficacy for at least 10 years after vaccination in people without immunocompromise.2,3 There is no recommendation for a booster dose of zoster vaccine. Advice on the need for booster doses will be considered if data becomes available that shows significant waning of protection, and benefit from receiving a booster dose.
    • 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.
    • Household contacts of people who are immunocompromised: people aged ≥50 years who are household contacts of a person who is immunocompromised or shortly expected to become immunocompromised may factor this into their decision making. Vaccination will provide some indirect protection to the immunocompromised household member from exposure to varicella-zoster virus if the household member is at risk of primary varicella infection.
    • NIP-funding for vaccination: Shingrix is funded through the NIP for non-Indigenous people aged ≥65 years and Aboriginal and Torres Strait Islander peoples aged ≥50 years of age. For details see the National Immunisation Program Schedule.
    View recommendation details

People 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. A shorter interval can be chosen should an immunocompromised person need to be protected earlier. This includes people who are currently or soon to be immunocompromised because 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).4,5 Herpes zoster can occur at a younger age in people who are immunocompromised, and there is also a higher risk of recurrence.6-9

    Shingrix provides good protection against herpes zoster and associated complications in severely immunocompromised people aged ≥18 years,10,11 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.4,12
    • 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.13-15 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. Ideally vaccination should occur prior to onset or initiation of immunosuppression. If vaccination prior to becoming immunocompromised is not possible, then further guidance on timing of vaccination should be sought from the Vaccination for people who are immunocompromised chapter.
    • 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 moderate and severe immunocompromise that put them at the highest risk of herpes zoster. Table. Risk conditions and immunosuppressive therapies for zoster vaccination and eligibility for NIP funding provides a detailed list of NIP-funded immunocompromising conditions and therapies. Other immunocompromised people can receive Shingrix, obtained by private prescription.

    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.

    View recommendation details

People 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%.9,16,17 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,18 and a lower recurrence rate is observed in the first 12 months14 after the initial episode. Studies have not established an optimal time for vaccination after zoster, but no safety or immunogenicity concerns have been identified.19,20

    Immunocompromised people are at higher risk of recurrence of zoster4,5,12,13 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

    Shingrix is funded through the NIP for non-Indigenous people aged ≥65 years, Aboriginal and Torres Strait Islander people aged ≥50 years and people aged ≥18 years with moderate or severe immunocompromising conditions that put them at the highest risk of herpes zoster.

    View recommendation details

People previously vaccinated with varicella vaccine

  • People who have received varicella vaccine (Varivax or Varilrix) when it was indicated (such as in childhood or as a catch-up vaccine) and are indicated to receive zoster vaccine (that is, are aged ≥50 years, or ≥18 years with immunocompromise) can consider zoster vaccine. A history of varicella infection can be incorrect or uncertain before vaccination.

    Herpes zoster in people who have been vaccinated against varicella is rare, and can be due to reactivation of either wild-type virus or vaccine virus. The incidence of herpes zoster in people who have received varicella vaccine is up to 5 times lower than in unvaccinated people infected with wild-type varicella (48 per 100,000 person-years compared with 230 per 100,000 person-years, in a study of children aged <18 years).21 However, when herpes zoster does occur in varicella-vaccinated people, up to 45% of cases may be due to vaccine strain virus.21,22

    Studies of the safety and immunogenicity of Shingrix in people who have received varicella vaccine are limited. Studies have not specifically investigated whether Shingrix vaccination provides protection following breakthrough varicella infection, or against vaccine-type herpes zoster, however there are no theoretical safety concerns.

    Data suggest that the risk of herpes zoster following varicella vaccination is greater in people who are immunocompromised than in immunocompetent people.21 Shingrix is therefore likely to have greater benefit for people who have previously received varicella vaccine who are immunocompromised.

    Shingrix is funded through the NIP for non-Indigenous people aged ≥65 years, Aboriginal and Torres Strait Islander people aged ≥50 years and people aged ≥18 years with moderate or severe immunocompromising conditions that put them at the highest risk of herpes zoster.

    View recommendation details

  • If 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.

    View recommendation details

Serological 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 or after administering zoster vaccine to either immunocompetent or immunocompromised people. Zoster vaccine effectively boosts humoral and cellular immune responses from prior infection. More than 97% of people in Australia are seropositive to VZV by 30 years of age,23 even if they cannot recall having varicella at a younger age.

    View recommendation details

Vaccines, dosage and administration

Zoster vaccines available in Australia

Shingrix is the only vaccine available in Australia for the prevention of herpes zoster and associated complications.

The Therapeutic Goods Administration website provides product information for this vaccine.

See also Vaccine information and Variations from product information for more details.

Zoster vaccines

  • Sponsor:
    GlaxoSmithKline Australia
    Administration route:
    Intramuscular injection

    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 details

Dose 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.24 Therefore, the second dose of Shingrix does not need to be repeated if the recommended interval between the first and second doses is exceeded.

Co-administration with other vaccines

People can receive zoster vaccine with other inactivated vaccines (such as tetanus-containing vaccines, pneumococcal vaccines, RSV vaccines, influenza vaccines and COVID-19 vaccines), either:25-27

  • 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. Vaccine safety surveillance data from Australia reports similar rates of adverse events following Shingrix when co-administered with other vaccines as compared to Shingrix administered alone.28 

Contraindications and precautions

Contraindications

Anaphylaxis to vaccine components

Shingrix is contraindicated in people who have had:

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

Precautions

Zoster vaccine should not be used for the prevention of primary varicella infection (chickenpox). Varicella vaccine should be considered (see Varicella). It also should not be used for the treatment of acute herpes zoster illness or post-herpetic neuralgia.

People with a history of Guillain–Barré syndrome

Shingrix is generally not recommended for people with a history of GBS whose first episode occurred within 6 weeks of receiving any vaccine (e.g. influenza vaccine or dose 1 of Shingrix).

People with a history of GBS not associated with Shingrix should discuss with their provider the risks and benefits of receiving Shingrix.

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).29,30

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.29,30

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.

Vaccine safety surveillance data from Australia shows the types of symptoms experienced following Shingrix are similar to those experienced in the clinical trials, and are reported at lower rates.28

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 dose 1 of Shingrix (an estimated 6 additional cases per million doses administered to adults aged ≥65 years).31,32 There was no increased risk of GBS observed following dose 2 of Shingrix.31,32 GBS may also be triggered by zoster itself,33 and modelling suggests that the overall benefits of vaccination outweigh the risks of GBS.34

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.35 After primary infection, the virus resides in the sensory ganglia.35

Herpes zoster, or shingles, occurs when latent VZV reactivates. This could be due, in part, to a decline in cellular immunity to the virus.6 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.36

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.6 Associated symptoms may include:37,38

  • 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.8,35 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.39,40

Other complications depend on the site of reactivation, and may include:41

  • 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.37

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.42-46 However, PHN can be difficult to treat and may persist for years.47

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%.35,48-50

For up to 8 years after an initial episode of zoster, the risk of a repeat episode in immunocompetent people is 6–8%.16,17 Repeat episodes of herpes zoster are more common in people who are immunocompromised.12

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.51

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 100,000.52 The estimated rate for Aboriginal and Torres Strait Islander people aged 60-69 years is 34 per 100,000.52

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.8,53 The risk of herpes zoster in people receiving therapy for conditions such as cancer, transplants or autoimmune conditions varies depending on their age, condition, the therapy they are receiving, and whether there is concomitant therapies. The risk in these people ranges from less than 1 to 40 times54-65 greater than those who are immunocompetent or not receiving therapy.

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.66,67

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.17,68,69 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).69

Vaccine information

One zoster vaccine is 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.

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.29,30

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.29,30

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.10,11

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.10,11,70-72

Duration of immunity

High vaccine efficacy (>80%) has been demonstrated for at least 7 years after vaccination with 2 doses of Shingrix,3 and immunogenicity data suggest that protection may persist beyond 10 years.29,30,73

Transporting, storing and handling zoster vaccines

Transport according to National Vaccine Storage Guidelines: Strive for 5.74 Store at +2°C to +8°C. Do not freeze. Protect from light.

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 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 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.

References

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  2. Strezova A, Diez-Domingo J, Al Shawafi K, et al. Long-term protection against herpes zoster by the adjuvanted recombinant zoster vaccine: Interim efficacy, immunogenicity, and safety results up to 10 years after initial vaccination. Open Forum Infectious Diseases 2022;9:ofac485.
  3. Boutry C, Hastie A, Diez-Domingo J, et al. The adjuvanted recombinant zoster vaccine confers long-term protection against herpes zoster: Interim results of an extension study of the pivotal phase 3 clinical trials ZOE-50 and ZOE-70. Clinical Infectious Diseases 2022;74:1459-67.
  4. Yanni EA, Ferreira G, Guennec M, et al. Burden of herpes zoster in 16 selected immunocompromised populations in England: a cohort study in the Clinical Practice Research Datalink 2000-2012. BMJ Open 2018;8:e020528.
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  6. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clinical Infectious Diseases 2007;44 Suppl 1:S1-26.
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  28. AusVaxSafety. Shingrix® safety data. Sydney, Australia: AusVaxSafety; 2024. (Accessed 23 September 2024). https://ausvaxsafety.org.au/shingrixr/shingrixr-safety-data-all-participants
  29. Cunningham AL, Lal H, Kovac M, et al. Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. New England Journal of Medicine 2016;375:1019-32.
  30. Lal H, Cunningham AL, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. New England Journal of Medicine 2015;372:2087-96.
  31. U.S. Food & Drug Administration. FDA requires a warning about Guillain-Barré syndrome (GBS) be included in the prescribing information for Shingrix. 2021. (Accessed 23 September 2024). https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/fda-requires-warning-about-guillain-barre-syndrome-gbs-be-included-prescribing-information-shingrix
  32. Goud R, Lufkin B, Duffy J, et al. Risk of Guillain-Barré syndrome following recombinant zoster vaccine in Medicare beneficiaries. JAMA Intern Med 2021;181:1623-30.
  33. Kang JH, Sheu JJ, Lin HC. Increased risk of Guillain-Barré Syndrome following recent herpes zoster: a population-based study across Taiwan. Clinical Infectious Diseases 2010;51:525-30.
  34. Janusz CB, Anderson TC, Leidner AJ, et al. Projected risks and health benefits of vaccination against herpes zoster and related complications in US adults. Human Vaccines and Immunotherapeutics 2022;18:2060668.
  35. Levin MJ. Zoster vaccines. In: Plotkin SA, Orenstein WA, Offit PA, Edwards KM, eds. Plotkin's vaccines. 7th ed. Philadelphia, PA: Elsevier; 2018.
  36. Centers for Disease Control and Prevention (CDC), Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. Recommendations and Reports 2008;57(RR-5):1-30.
  37. Gnann JW, Jr., Whitley RJ. Clinical practice. Herpes zoster. New England Journal of Medicine 2002;347:340-6.
  38. Whitley RJ. Varicella-zoster virus. In: Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas, and Bennett's principles and practice of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2010.
  39. Dworkin RH, Portenoy RK. Proposed classification of herpes zoster pain. The Lancet 1994;343:1648.
  40. Kost RG, Straus SE. Postherpetic neuralgia – pathogenesis, treatment, and prevention. New England Journal of Medicine 1996;335:32-42.
  41. Gross G, Doerr HW. Herpes zoster guidelines of the German Dermatological Society [letter]. Journal of Clinical Virology 2003;27:308-9.
  42. Jackson JL, Gibbons R, Meyer G, Inouye L. The effect of treating herpes zoster with oral acyclovir in preventing postherpetic neuralgia: a meta-analysis. Archives of Internal Medicine 1997;157:909-12.
  43. Johnson RW, Dworkin RH. Treatment of herpes zoster and postherpetic neuralgia. BMJ 2003;326:748-50.
  44. Meister W, Neiss A, Gross G, et al. Demography, symptomatology, and course of disease in ambulatory zoster patients: a physician-based survey in Germany. Intervirology 1998;41:272-7.
  45. Simmons A. Management of shingles and post-herpetic neuralgia. Current Therapeutics 2000;41:61-6.
  46. Tyring SK, Beutner KR, Tucker BA, Anderson WC, Crooks RJ. Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valacyclovir and famciclovir therapy in immunocompetent patients 50 years and older. Archives of Family Medicine 2000;9:863-9.
  47. Dworkin RH, Schmader KE. Treatment and prevention of postherpetic neuralgia. Clinical Infectious Diseases 2003;36:877-82.
  48. Brisson M, Edmunds WJ, Law B, et al. Epidemiology of varicella zoster virus infection in Canada and the United Kingdom. Epidemiology and Infection 2001;127:305-14.
  49. Schmader K. Herpes zoster in older adults. Clinical Infectious Diseases 2001;32:1481-6.
  50. Thomas SL, Hall AJ. What does epidemiology tell us about risk factors for herpes zoster? The Lancet Infectious Diseases 2004;4:26-33.
  51. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. New England Journal of Medicine 2005;352:2271-84.
  52. 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.
  53. Vafai A, Berger M. Zoster in patients infected with HIV: a review. American Journal of the Medical Sciences 2001;321:372-80.
  54. Jeong S, Choi S, Park SM, et al. Incident and recurrent herpes zoster for first-line bDMARD and tsDMARD users in seropositive rheumatoid arthritis patients: a nationwide cohort study. Arthritis Res Ther 2022;24:180.
  55. Tanaka M. [The risk of varicella zoster virus infection in multiple sclerosis patients treated with fingolimod]. Rinsho Shinkeigaku. Clinical Neurology 2016;56:270-2.
  56. Chiu HY, Hung YT, Huang SW, Huang YH. Comparative risk of herpes zoster in patients with psoriatic disease on systemic treatments: a systematic review and network meta-analysis. Ther Adv Chronic Dis 2022;13:20406223221091188.
  57. Schmidt SAJ, Vestergaard M, Baggesen LM, et al. Prevaccination epidemiology of herpes zoster in Denmark: Quantification of occurrence and risk factors. Vaccine 2017;35:5589-96.
  58. Hansson E, Forbes HJ, Langan SM, Smeeth L, Bhaskaran K. Herpes zoster risk after 21 specific cancers: population-based case-control study. British Journal of Cancer 2017;116:1643-51.
  59. Hata A, Kuniyoshi M, Ohkusa Y. Risk of herpes zoster in patients with underlying diseases: a retrospective hospital-based cohort study. Infection 2011;39:537-44.
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  61. Gupta G, Lautenbach E, Lewis JD. Incidence and risk factors for herpes zoster among patients with inflammatory bowel disease. Clin Gastroenterol Hepatol 2006;4:1483-90.
  62. Chen YJ, Chen YM, Huang WN, et al. Herpes zoster in rheumatoid arthritis patients receiving tofacitinib, a single center experience from Taiwan. Medicine 2020;99:e22504.
  63. Onozawa M, Hashino S, Haseyama Y, et al. Incidence and risk of postherpetic neuralgia after varicella zoster virus infection in hematopoietic cell transplantation recipients: Hokkaido Hematology Study Group. Biology of Blood and Marrow Transplantation 2009;15:724-9.
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  65. Simon TA, Dong L, Winthrop KL. Risk of opportunistic infections in patients with rheumatoid arthritis initiating abatacept: cumulative clinical trial data. Arthritis Res Ther 2021;23:17.
  66. Edmunds WJ, Brisson M, Rose JD. The epidemiology of herpes zoster and potential cost-effectiveness of vaccination in England and Wales. Vaccine 2001;19:3076-90.
  67. Scott FT, Johnson RW, Leedham-Green M, et al. The burden of herpes zoster: a prospective population based study. Vaccine 2006;24:1308-14.
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  70. Berkowitz EM, Moyle G, Stellbrink HJ, et al. Safety and immunogenicity of an adjuvanted herpes zoster subunit candidate vaccine in HIV-infected adults: a phase 1/2a randomized, placebo-controlled study. Journal of Infectious Diseases 2015;211:1279-87.
  71. 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.
  72. 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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  74. Australian Government Department of Health and Ageing. National Vaccine Storage Guidelines: Strive for 5. Canberra: Australian Government Department of Health and Ageing; 2005. https://www.health.gov.au/resources/publications/national-vaccine-storage-guidelines-strive-for-5
Related vaccines
Shingrix
Related immunoglobulins
Zoster immunoglobulin (ZIG)

Page history

Last updated
Last reviewed

Updates to reflect the removal of Zostavax.

Update to reflect recent changes in eligibility for zoster vaccination under the National Immunisation Program (NIP), including a new Table. Risk conditions and immunosuppressive therapies for zoster vaccination and eligibility for NIP funding.

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 reflect the removal of Zostavax.

Update to reflect recent changes in eligibility for zoster vaccination under the National Immunisation Program (NIP), including a new Table. Risk conditions and immunosuppressive therapies for zoster vaccination and eligibility for NIP funding.

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.

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