LIVE SHINGLES VACCINE (Zostavax) SCREENING FOR CONTRAINDICATIONS
Name:  <PtName>
Date of Birth: <PtDoB>

Questions – This section can be completed by the Health Care Provider/Patient/Guardian 
Note for Patient/Guardian: If you are unsure about an answer, please leave it blank and discuss with your Health Care Provider	

1. Have you ever had a shingles vaccine before? 	Y/N	
When:		

2. Do you feel unwell today?	Y/N	
Details:		

3.  Have you had shingles or post herpetic neuralgia (nerve pain following shingles) in the past year?	Y/N	
Details:		

4. Have you had a serious allergic reaction (anaphylaxis) to a previous dose of shingles or varicella (chickenpox) vaccine or any vaccine components including neomycin or gelatin?	Y/N	
Details:		

5. Have you ever had cancer, leukaemia, lymphoma, an organ, 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?	Y/N	
Details:		

6. In the past 12 months, have you been on any treatment for rheumatoid arthritis, multiple sclerosis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease or other inflammatory conditions?		Y/N	
Details:		

7. In the last 12 months have you taken medicine that weakens your immune system such as oral prednisolone, or other steroids, anti-cancer drugs, biological therapy, radiotherapy or chemotherapy? 	Y/N	
Details:		

8. Have you been treated recently with oral antiviral medication such as aciclovir for conditions such as herpes?	Y/N	
Details:		

Outcome – This section is to be completed by Health Care Providers ONLY (check relevant boxes)	

	   There are no contraindications to Zostavax vaccination. Discussion of side effects of vaccination has 	
	   occurred and informed consent for vaccination obtained	
		
	   Zostavax is contraindicated	
		
	   Zostavax should be delayed   -   until recovery from acute illness 	
	                                                       -   until treatment is completed and for ____ months afterwards 	
	                                                        -   until current episode of shingles has resolved and for a minimum of 1 year 	
		
	   Specialist advice regarding immune status is required. Not for vaccination at this time.	

Date: <TodaysDate>	Provider: <DrName>  <DrProviderNo>
Notes for Health Care Providers

Shingles vaccine is a live attenuated vaccine. 
If there is any doubt to the person’s suitability then do not vaccinate and seek further advice.

1. Have you ever had a shingles vaccine before?
Currently in Australia, Zostavax® is recommended as a single dose only and is provided free for people aged 70 years under the National Immunisation Program. There is also a five year catch-up program for people aged 71 – 79 years until 31 October 2021. Revaccination with Zostavax® is not recommended for people who have received a shingles vaccination at this time. 

2. Do you feel unwell today? 
Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation. Immunisation of individuals who are acutely unwell should be postponed until they have recovered fully. This is to avoid confusing the diagnosis of any acute illness by wrongly attributing any sign or symptoms to the adverse effects of the vaccine.

3.  Have you had shingles or post herpetic neuralgia (nerve pain following shingles) in the past year?
Zostavax® is not recommended for the treatment of shingles or post-herpetic neuralgia (PHN). Individuals with shingles or PHN should wait until symptoms have ceased before being considered for vaccination. If the individual has had shingles in the last year and they have a fully functioning immune system (i.e. the individual does not have any of the conditions listed below), vaccination should be delayed for one year. Patients who have two or more episodes of shingles in one year should have investigation for an underlying cause of immune suppression prior to vaccination. Investigations performed will depend on findings from history and examination. 

4. Have you had a serious allergic reaction (anaphylaxis) to a previous dose of shingles or varicella (chickenpox) vaccine or any vaccine components including neomycin or gelatin? 
Anaphylaxis following vaccine is rare. The vaccine should not be given to an individual who has had a confirmed anaphylactic reaction to a previous dose of shingles or varicella vaccine or any of the vaccine components including neomycin or gelatin.

5. Have you ever had cancer, leukaemia, lymphoma, an organ or 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?; 
6. In the past 12 months, have you been on any treatment for rheumatoid arthritis, multiple sclerosis, psoriasis, polymyositis, sarcoidosis, inflammatory bowel disease or other inflammatory conditions?; and
7. In the last 12 months have you taken medicine that weakens your immune system such as oral prednisolone, or other steroids, anti-cancer drugs, biological therapy, radiotherapy or chemotherapy?
Zostavax® is a live vaccine. The decision to administer Zostavax® to immunosuppressed individuals should be based on a clinical risk assessment. If the individual is under specialist care, and it is not possible to obtain full information on that individual’s treatment history, then vaccination should not proceed until the advice of the specialist or a local immunologist/haematologist has been sought. If healthcare professionals administering the vaccine have concerns about the nature of therapies (including biologicals) or the degree of immunosuppression they should contact the relevant specialist for advice.
 
Immunocompromising conditions that would contraindicate Zostavax®  include: 
· Primary or acquired immunodeficiency 
•	Haematologic neoplasms: leukaemias, lymphomas, myelodysplastic syndromes (including: those who remain under follow up for chronic lymphoproliferative disorders; and individuals who are currently not receiving treatment or who have never received treatment)
•	Post-transplant: certain solid organ (on immunosuppressive therapy or who have used immunosuppressive therapy within last 6 months), haematopoietic stem cell transplant (within 24 months, or longer if immunosuppression or graft versus host disease is present) and only if in remission.
•	Immunocompromised due to primary or acquired (e.g. HIV/AIDS) immunodeficiency 
•	Other significantly immunocompromising conditions

· Immunosuppressive therapy (current or recent) 
•	Chemotherapy or radiotherapy  - within the last 6 months, even if for a condition other than cancer 
•	Corticosteroids (short-term high dose, long-term lower dose) – see below 
•	All biologics and most disease-modifying anti-rheumatic drugs (DMARDs) – see below
Guide to safe doses of immunosuppressive therapy for Zostavax administration:
Mechanism of action	Examples*	Safe dose**	Comments	
Anti-TNF	Etanercept 
Infliximab
Adalimumab	NONE	Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation	
IL-1 inhibition	Anakinra	NONE	Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation	
Costimulation blockade	Abatacept	NONE	Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation	
B-cell depletion/inhibition	Rituximab	NONE	Vaccinate 1 month before treatment initiation OR 12 months after treatment cessation	
Immunomodulators (antimetabolites)	Azathioprine
6-Mercaptopurine
Methotrexate	≤3.0 mg/kg/day
≤1.5 mg/kg/day
≤0.4 mg/kg/week	Vaccinate 1 month before treatment initiation OR 3 months after treatment cessation	
Corticosteroids	Prednisone	Any dose when duration <14 days
OR
<20 mg/day when duration ≥14 days	If ≥20mg/day for ≥14 days, vaccinate 
1 month before treatment initiation OR 
1 month after treatment cessation	
T-cell activation/inhibition	Tacrolimus
Cyclosporine	NONE	Vaccinate 1 month before treatment initiation OR 3 months after treatment cessation	
Others	Cyclophosphamide
Mycophenolate	NONE	Vaccinate 1 month before treatment initiation OR 12 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.
	
Individuals on long term stable low dose corticosteroid therapy (defined as ≤20mg prednisone per day for ≥ 14 days) either alone or in combination with low dose non-biological oral immune modulating drugs (e.g. methotrexate ≤0.4 mg/kg/week, azathioprine ≤3.0mg/kg/day or 6-mercaptopurine ≤1.5mg/kg/day) can receive the vaccine. Specialist advice should be sought for other treatment regimes. Zostavax® is not contraindicated for use in individuals who are receiving topical/inhaled corticosteroids or corticosteroid replacement therapy.

8. Have you been treated recently with oral antiviral medication such as aciclovir for conditions such as herpes?	
Zostavax®  may have a lower effectiveness if given while an individual is being treated with oral or intravenous antivirals  (such as aciclovir) or within 48 hours of such treatment. Delay vaccination until after this time. The use of topical aciclovir is not a contraindication to vaccination. 

Adapted from:  
•	Health Protection Scotland 
•	Zostavax and individuals who are immunocompromised at Immunise Australia Program website
•	National Centre for Immunisation Research & Surveillance fact sheets: Zoster Vaccine - Frequently asked questions: Informaiton for immunisation providers, and Herpes Zoster - Zoster vaccine for Australian Adults: Information for Immunisation Providers
For Further Information
State or territory immunisation service   https://www.dhhs.tas.gov.au/publichealth/communicable_diseases_prevention_unit/immunisation.