ZOSTAVAX When not to vaccinate

Herpes Zoster Herpes Zoster (shingles) is a reactivation of the varicella zoster infection in some-one who has previously had varicella(chicken pox) disease Painful, unilateral, self-limiting vesicular rash in a dermatomal distribution May have systemic symptoms such as headaches and malaise Pain may precede the rash

Who is at risk? 20-30% of people will develop shingles in the lifetime most are over 50 95% of the population over 30 have had varicella as a child and therefore at risk Increases with age Increased in immunosuppressed Post herpetic Neuralgia PHN highest over 70

Zoster Vaccine Zostavax (MSD) has been registered in Australia since 2006 for adults over 50 Live vaccine – 14x that of chicken pox vaccine Efficacy declines with age Protection for PHN is the same for those 70-79 as for some-one in 60s If vaccinated may still develop shingles but less severe At this time boosters not advised

Who should be vaccinated? Zostavax funded for adults age 70 with a catch up 71-79 50-69 private script cost approx. $200 Over 79 private script though efficacy diminished RPBS will fund via Authority system (also DTPa) Those over 50 with chronic conditions – private script Household contacts of immunocompromised- private script

Who should not be vaccinated? Immunocompromised patients Pregnant women Anaphylaxis to the vaccine or components(inc gelatin or neomycin)

Primary or Acquired immunodeficiency Haematological Neoplasm:leukaemias, lymphomas, myelodysplastic syndromes Post-transplant solid organ(on immunosuppressive therapy) haematopoietic stem cell transplant (within 24 months) Immunocompromised due to primary or acquired(HIV/AIDS) immunodeficiency Other significant immunocompromising conditions

Immunosuppressive therapy(current or recent) Chemotherapy or Radiotherapy Corticosteroids(short-term high dose, longer term lower dose) All biologics and most disease-modifying ant-rheumatic drugs(DMARDs)

warning Some elderly patients are regularly taking corticosteroids and/or DMARDs This can include patients with RA, IBD, skin conditions, renal disease, MS and other autoimmune conditions . A detailed medication history is needed before vaccination – a number of these drugs are prescribed by the specialist and may not be recorded in the medication list

Mechanism of action Examples* Safe dose** Anti-TNF Etanercept NONE Infliximab Adalimumab IL-1 inhibition Anakinra NONE Costimulation blockade Abatacept NONE   B-cell depletion/inhibition Rituximab NONE Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation

Mechanism of action Examples* Safe dose**   Immunomodulators (antimetabolites) Azathioprine ≤3.0 mg/kg/day 6-Mercaptopurine ≤1.5 mg/kg/day Methotrexate ≤0.4 mg/kg/week Corticosteroids Prednisone <20 mg/day for <14 days If on higher dose, vaccinate 1 month before treatment initiation OR 3 months after treatment cessation

Mechanism of action Examples* Safe dose**   T-cell activation/inhibition Tacrolimus NONE Cyclosporine NONE Others Cyclophosphamide NONE Mycophenolate NONE Sulfasalazine NONE Vaccinate 1 month before treatment initiation OR 3 months after treatment cessation

NOTE: This is not a complete list of all licensed biologics, or medications within each class, but serves as a guide only. ** Refer to The Australian Immunisation Handbook 10th edition, Chapters 3.3.3 and 4.24. Also always check the product information of the drug that you are concerned about

Patients on Low Dose Steroids and DMARDs Potentially but only if each drug is not a contraindication e.g. Prednisolone and MTX Consultation with the treating specialist or immunisation expert is recommended

HIV positive patients Asymptomatic HIV not AIDS CD4+ counts>200 Serological proof of previous VZV infection prior to vaccination

How long after vaccination before starting immune modulating therapy? At least 1 month though in extenuating circumstances on a case by case 14 days could be considered safe but I would consult with the specialist involved

How long after chemotherapy or radiotherapy? At least 6 months after the end of treatment and after patients are demonstrated to be in remission

What if my patient has had shingles? Vaccination is safe but recommended to wait for at least 1 year preferably 3 as the episode itself boosts immunity

DO I need to check VZV serology ? No unless special circumstances (HIV, pre-transplant) Studies show well tolerated and immunogenic in VZV- seronegative adults. Acceptable to give if seronegative but 2 doses of varicella vaccine is the recommended alternative in a VZV – seronegative adult eligible for zoster vaccine

. Can be given with other vaccinations such as pneumococcal Separate from other live vaccines for 4 weeks if not on same day Single dose – at this stage boosters not recommended – some studies on boosters at 10 years Systemic antivirals may decrease vaccine effectiveness. Where possible antivirals should be stopped for 48 hours before vaccination and withheld for at least 14 days

warning If you have assessed as not eligible record this somewhere clearly so that some-one else does not vaccinate This could include in warnings Could be in immunised as refused on medical grounds

What if an immunocompromised patient receives zoster vaccination? Seek immediate specialist advice to determine if severely immunocompromised Will need close monitoring for adverse effects related to the vaccine virus associated disease May require antiviral therapy

Additional resources for primary medical care/vaccination providers The Australian Immunisation Handbook, 10th edition – the most up-to-date clinical recommendations are contained in the online version of the Handbook www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10- home Immunise Australia website www.immunise.health.gov.au For more detailed information and complete reference list see the NCIRS factsheet Zoster vaccine for Australian adults: information for immunisation providers