People aged ≥18 years who are immunocompromised or shortly expected to be immunocompromised are recommended to receive a zoster vaccine

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.