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Table. Live zoster vaccine (Zostavax) screening for contraindications

See the Australian Immunisation Handbook for more details.

Zostavax® is a live attenuated herpes zoster vaccine for use in people aged over 50 years. It can rarely cause disseminated varicella zoster disease if inadvertently given to people who are immunocompromised. This tool provides a series of questions to guide providers, patients or guardians in assessing the safety of Zostavax® in a person being considered for vaccination.

If you have any doubt about whether a person is suitable to receive the vaccine, do not vaccinate, and seek further advice.

Live zoster vaccine (Zostavax®) screening for contraindications

Patient name:  
Date of birth:  
Practice record number:  

Questions for vaccine recipient

This section can be completed by the health care provider, patient or guardian.

For patients/guardians, if you are unsure about an answer, leave it blank and discuss with your health care provider.

1 Have you/they ever had a zoster vaccine before? Yes/No When:
  Outcome if Yes: Do not vaccinate. Zostavax® is not recommended for people who have already received a completed schedule of a zoster vaccine.
2 Do you/they feel unwell today? Yes/No Details:
  Outcome if Yes: Delay vaccination. If acutely unwell with fever or systemic symptoms, delay vaccinating until they have fully recovered. This is to avoid confusing the diagnosis of any acute illness by attributing signs or symptoms to adverse effects of the vaccine. Proceed with vaccination if experiencing minor illness without fever or systemic symptoms.
3 Have you/they had shingles or post-herpetic neuralgia (nerve pain after shingles) in the past year? Yes/No Details:
 

Outcome if Yes:

  • If the person has had shingles in the past year, AND they are not immunocompromised (i.e. they do not have any of the conditions listed on the following pages), AND are not currently experiencing symptoms of shingles or PHN, delay vaccination for at least 1 year and rescreen at that time.
  • In people who have 2 or more episodes of shingles in 1 year, do not vaccinate. They should have investigations for an underlying cause of immune suppression before vaccination with Zostavax® and may wish to consider Shingrix.
4 Have you/they had a serious allergic reaction (anaphylaxis) to a previous dose of shingles or varicella (chickenpox) vaccine, or any vaccine components it contains, including neomycin or gelatin? Yes/No Details:
  Outcome if Yes: Do not vaccinate. Zostavax® is contraindicated. Consider Shingrix.
5 Have you/they ever had cancer, leukaemia, lymphoma, an organ transplant, a bone marrow transplant, stem cell therapy, or another health condition that weakens your immune system, including blood disorders, graft versus host disease or HIV/AIDS? Yes/No Details:
  Outcome if Yes: Do not vaccinate. Zostavax® is contraindicated if there is ongoing immunosuppression. Discuss with an immunisation specialist. Shingrix is the recommended vaccine for people who are severely immunocompromised. See Box 1. Immunocompromising conditions that contraindicate Zostavax®.
6 In the past 12 months, have you/they: a) been on any treatment for conditions like rheumatoid arthritis, multiple sclerosis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease or other inflammatory conditions? Yes/No and/or b) taken medicine that weakens your immune system, such as oral prednisolone or other steroids, anti-cancer drugs, biologic therapy, radiotherapy or chemotherapy? Yes/No Details:
 

Outcome if Yes (for either): Assess for the potential for immunocompromise. Shingrix is the preferred vaccine for all people who are immunocompromised. If Shingrix is not available to the patient, administration of Zostavax® to a person who is mildly immunocompromised can be considered but should be based on a detailed clinical risk-benefit assessment for each individual patient. This is because Zostavax® is a live attenuated vaccine with a 14-fold higher amount of varicella-zoster virus than monovalent varicella (chickenpox) vaccines (eg Varilrix, Varivax).

  • Guidance is provided in Table. Recommendations for use of zoster vaccine in people on immunosuppressive therapy.
  • If the person is under specialist care, and it is not possible to obtain full information about their treatment history, do not vaccinate, and seek advice from the specialist or an immunologist/haematologist.
  • If you have concerns about the nature of therapies (including biologics) or the degree of immunosuppression, do not vaccinate, and seek advice from the relevant specialist.
  • Zostavax® is not contraindicated for use in people who are receiving topical or inhaled corticosteroids, or corticosteroid replacement therapy.
7 Have you/they been treated recently with oral antiviral medication such as aciclovir for conditions such as herpes? Or other antivirals for conditions such as COVID-19 Yes/No Details:
 

Outcome if Yes:

  • One-off or ad-hoc use: delay vaccination for 24 hours after such treatment.
  • If the person is on long-term therapy, consider stopping treatment, vaccinating 24 hours later, and resuming antiviral treatment 14 days later.
  • The use of topical aciclovir is not a contraindication to zoster vaccination.
  • There is no specific data on COVID-19 antivirals but theoretically they are not expected to interact. It is unlikely that Zostavax would be recommended during a period of acute illness with COVID-19 when these antivirals are expected to be used.

Outcome

This section is to be completed by the medical practitioner only. Put an X next to the row that applies. If you have any doubt about whether a person is suitable to receive the vaccine, do not vaccinate, and seek further advice.

No contraindications to Zostavax vaccination (answered "no" to all of the above questions)

  • ≥50 years of age
  • Discussed side effects of vaccination
  • Obtained informed consent for vaccination
  • Advised patient that if a chickenpox-like rash develops 2 to 4 weeks after vaccination:
    • seek medical attention
    • tell the attending medical practitioner they have recently had zoster vaccine
  

Zostavax is contraindicated (mark which option applies):

  

Zostavax is not recommended (mark which option applies):

  

Zostavax should be delayed (mark which option applies):

  • until recovered from acute illness
  • until treatment is complete and for ___months afterwards
  • until current episode of shingles has resolved and for at least 1 year afterwards
  

Level of immunocompromise is uncertain — Shingrix can be administered. Zostavax can only be considered an alternative vaccine if:

  • Confirmed positive serology for past varicella-zoster virus infection
  • Completed assessment of immune status (e.g. this may require medication history from other providers, laboratory investigations)
  • Reviewed recent specialist/other reports of patient health status if available
  • Consulted treating physician and/or immunisation specialist
  • ≥50 years of age
  

Provider details

Provider name:  
Date:  

Immunocompromising conditions that contraindicate Zostavax®

Box 1. Immunocompromising conditions that contraindicate Zostavax®

Primary or acquired immunodeficiency

  • Haematological neoplasms — leukaemia, lymphoma, myelodysplastic syndromes, including people under follow-up for chronic lymphoproliferative disorders, and people who are currently not receiving treatment or who have never received treatment
  • Post-transplant — solid organ transplant recipients who are on immunosuppressive therapy or have used immunosuppressive therapy within the past 6 months, people who have had a haematopoietic stem cell transplant within the past 24 months (or longer if they have immunosuppression or graft versus host disease)
  • Symptomatic HIV infection or AIDS
  • Other significantly immunocompromising conditions

Immunosuppressive therapy (current or recent) See Table. Recommendations for use of Zostavax in people aged ≥50 years on immunosuppressive therapy)

  • Chemotherapy or radiotherapy
  • Corticosteroids (high dose)
  • All biologics and most disease-modifying anti-rheumatic drugs (DMARDs)

More information Contact your state or territory immunisation service. Adapted from Health Protection Scotland, and National Centre for Immunisation Research & Surveillance fact sheets:

Related diseases
Zoster (herpes zoster)

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