There’s a grey area.

When deciding whether to administer Zostavax or not, it’s useful to keep the three types of immunocompromised patients in mind – the mild, the moderate and the severe, says infectious disease physician and virologist Professor Tony Cunningham.

“For severely immune compromised patients, they should not get any live attenuated vaccines of any kind, including the live attenuated zoster vaccine (Zostavax). That’s very clear,” he says. For moderately immunocompromised patients due to immunosuppressive drugs the vaccine can only be used one month before or 3-12 months after drug use, which limits its effectiveness.

Professor Tony Cunningham will deliver a lecture on shingles vaccination at the upcoming Healthed webcast.

For patients who are mildly immunocompromised, Zostavax can be administered after careful consideration using the pre-screening tool, he says.

For the severely immunocompromised group of patients, as well as for patients in the moderate group, Cunningham recommends that GPs administer Shingrix (the recombinant zoster vaccine), not Zostavax (the live attenuated vaccine).

“These days, given the superior efficacy and durability of recombinant zoster vaccine in all three categories, that’s the vaccine I would use,” he says.

For the patients who are moderately immunocompromised, as yet there’s a lack of clear data on the efficacy of Shingrix (the recombinant zoster vaccine). More data is needed to understand the impact of this type of vaccine on this patient group.

“We know the recombinant zoster vaccine works in the severely immunocompromised group, so we make the assumption it will work in the moderate group,” he says.

“Certainly, it will work in the mild group, but we need data on the moderate immune compromised group and the trials are ongoing,” he says. Shingrix also carries an out-of-pocket cost for patients.

People who are immunocompromised are contraindicated for Zostavax because there’s a risk the virus in the vaccine could replicate and cause disseminated disease, leading to encephalitis, hepatitis, pneumonitis and death.

A recent survey reported that one in five GPs are unaware that Zostavax is not recommended in immunocompromised patients, despite cases in recent years where inappropriate use caused deaths.

Zostavax is funded under the National Immunisation Program for people aged 70, with a catch-up program for people aged 71-79 funded until October 2023.

Professor Tony Cunningham is the director of the Centre for Virus Research at the Westmead Institute for Medical Research and Vaccine Theme leader at the University of Sydney Infectious Diseases Institute.

He will deliver a lecture on shingles vaccination at the upcoming Healthed webcast.