Zostavax is fully subsidised for people aged 65 years – that means that a patient is eligible for a vaccine from when
they turn 65 years until they turn 66 years.
There is currently also a two-year catch-up period for people aged 66 to 80 years – that means that from now until 31
March, 2020, people aged over 65 years can also receive a subsidised vaccine, before they turn 81 years. This includes
people who turned 65 years before 1 April, 2018, when Zostavax was first subsidised.
As Zostavax is a live vaccine, it is generally contraindicated in people taking immunosuppressive treatment. However,
there are some exceptions to this for patients considered to be only mildly immunosuppressed.
In the article, we referred readers to The Ministry of Health Immunisation Handbook for further details on this, which
can be found in Sections 4.3.3 and 22.6.2:
www.health.govt.nz/publication/immunisation-handbook-2017
The Handbook states that:
“As a general guide, low-level immunosuppression includes treatment with prednisone <2 mg/kg with a maximum
of 20 mg/day; methotrexate ≤0.4 mg/kg/week; azathioprine ≤3 mg/kg/day; or 6-mercaptopurine ≤1.5 mg/kg/day. High-level
immunosuppression regimens include treatment regimens with higher than the above doses, and those on biological agents
such as tumour necrosis factor antagonists or rituximab. Combination therapies increase the level of immunosuppression.”
Therefore, Zostavax is considered safe to administer in patients taking < 20 mg/day prednisone. However, some rheumatologists
would recommend a lower threshold for safe administration of Zostavax vaccination, e.g. < 10 mg/day prednisone. A pragmatic
solution is to routinely offer Zostavax vaccine to patients taking < 10 mg/day prednisone, and for patients taking
10 – 20 mg/day prednisone, consider their specific clinical scenario before deciding to vaccinate, e.g. duration of prednisone
treatment, co-morbidities.
Patients taking a methotrexate dose of ≤ 0.4 mg/kg/week can safely receive Zostavax. Therefore, this would encompass
most adults taking a standard once-weekly dose of <15-20 mg methotrexate.
Patients taking combination treatment, e.g. methotrexate with leflunomide, should not receive Zostavax vaccine as taking
two treatments at once increases the level of immunosuppression.
Patients taking other DMARDS* and biologic medicines, such as the “mab” medicines, tacrolimus and cyclosporin,
will not be able to receive a Zostavax vaccine until at least three to 12 months after treatment has stopped – in some
cases immunisation with a live vaccine is absolutely contraindicated (discuss with the patient’s rheumatologist or other
treating clinician).
Sulfasalazine, hydroxychloroquine and sodium aurothiomalate (gold injection) are not considered to be significantly
immunosuppressive, so patients taking these treatments at any dose may still receive Zostavax vaccine, unless they are
taking it in combination with another immunosuppressive medicine.
Patients should not receive Zostavax vaccine within four weeks of the start of planned chemotherapy or radiotherapy and for at least
three to six months after treatment has finished. Patients who have undergone stem cell or bone marrow transplant should not
receive Zostavax until at least two years after treatment.
* Disease Modifying Anti-Rheumatic Drugs
| Zostavax vaccine may be given to patients taking: |
Zostavax vaccine is contraindicated in patients taking: |
Prednisone < 10-20 mg/day
Methotrexate ≤ 0.4 mg/kg/week
Azathioprine ≤ 3.0 mg/kg/day
Mercaptopurine ≤ 1.5 mg/kg/day
Sulfasalazine
Hydroxychloroquine
Sodium aurothiomalate (gold injection)
Topical or inhaled corticosteroids |
Prednisone ≥ 20 mg/day
Methotrexate > 0.4 mg/kg/week
Azathioprine > 3.0 mg/kg/day
Mercaptopurine > 1.5 mg/kg/day
Other DMARDs and biologic medicines, e.g. abatacept, adalimumab, anakinra, cyclophosphamide, cyclosporin, etanercept,
infliximab, leflunomide, mycophenolate, rituximab, tacrolimus, tocilizumab, ustekinumab
Chemotherapy, radiotherapy
Any of the above medicines used in combination at any dose. |
The primary study used to assess efficacy of Zostavax was the Shingles Prevention Study, which was a randomised controlled
trial.1 Vaccine efficacy for preventing herpes zoster was calculated at 18% for people aged 80 years and over.
This means that the vaccine reduced the incidence of herpes zoster by 18% compared to an age-matched group of people who
did not receive the vaccine. This result was not statistically significant as it had a large confidence interval, which
included zero. It was therefore concluded that Zostavax was not reliably effective in this age group. Randomised controlled
trials are considered the gold standard for basing clinical guidelines upon.
A subsequent observational cohort study reported a statistically significant vaccine efficacy of 42% for Zostavax preventing
herpes zoster in people aged over 80 years.2 However, results of this type of study are more likely to be affected
by confounding than a randomised controlled trial, i.e. the two groups may have differences that could influence the results.
It can be agreed that the efficacy of Zostavax declines with age and vaccination is likely to be most beneficial in
the age group for which it is subsidised. Decisions about the benefit of vaccination in a patient aged over 80 years should
be made on an individual basis, taking into account vaccine efficacy data, as well as other factors such as general health,
co-morbidities and expected longevity.
- Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults.
N Eng J Med 2005;352(22):2271–84.
- Tseng H, Harpaz R, Luo Y, et al. Declining effectiveness of herpes zoster vaccine in adults aged ≥60 years. J Infect
Dis 2016;213:1872-5
The Immunisation Advisory Centre has a dedicated section for resources on Zostavax, including a checklist for deciding
whether vaccination is appropriate for a patient, frequently asked questions and patient resources.
See: www.immune.org.nz/zostavax-health-professionals
