What are the contraindications for the shingles vaccine in patients with a history of severe allergic reactions, Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS), immunosuppression, or other medical conditions?

Shingles Vaccine Contraindications

The shingles vaccine (Zoster vaccine) is absolutely contraindicated in patients with severe allergic reactions to any vaccine component or previous dose, and in those with known severe immunodeficiency including active hematologic/solid tumors, chemotherapy recipients, congenital immunodeficiency, long-term immunosuppressive therapy, or severely immunocompromised HIV/AIDS patients. 1

Absolute Contraindications

Severe Allergic Reactions

• Severe allergic reaction (e.g., anaphylaxis) after a previous dose of zoster vaccine or to any vaccine component is an absolute contraindication. 1
• History of anaphylactic reaction to gelatin or neomycin contraindicates zoster vaccination, as these are vaccine components. 1
• Neomycin allergy manifested as contact dermatitis (delayed-type hypersensitivity) is NOT a contraindication—only anaphylactic reactions to neomycin contraindicate the vaccine. 1

Known Severe Immunodeficiency

The following conditions absolutely contraindicate live zoster vaccine: 1, 2

• Hematologic malignancies (leukemia, lymphomas) or solid tumors affecting bone marrow or lymphatic systems 1
• Active chemotherapy or radiation therapy—defer vaccination until at least 3 months after treatment completion 2
• Congenital immunodeficiency disorders 1, 2
• Long-term immunosuppressive therapy, including high-dose corticosteroids (≥20 mg/day prednisone or ≥2 mg/kg/day for ≥14 days)—defer until at least 3 months after discontinuation 2
• Severely immunocompromised HIV/AIDS patients—the vaccine is contraindicated in patients with severe immunosuppression from HIV 1, 2

Precautions (Not Absolute Contraindications)

Moderate to Severe Acute Illness

• Defer vaccination in patients with moderate or severe acute illness with or without fever until recovery from the acute phase. 2
• Mild illnesses (mild upper respiratory infection, low-grade fever, diarrhea) do NOT require postponing vaccination. 2

Recent Blood Product Administration

• Defer zoster vaccination for 11 months after receiving antibody-containing blood products, as these may interfere with vaccine response. 1, 2

Antiviral Medications

• Avoid acyclovir, famciclovir, or valacyclovir 24 hours before zoster vaccination and for 14 days after vaccination, as these antivirals can interfere with vaccine virus replication. 1, 2

Special Populations

HIV/AIDS Patients (Not Severely Immunocompromised)

• Asymptomatic HIV patients or those with mild immunosuppression may be considered for vaccination after careful risk-benefit assessment, though this represents off-label use as the vaccine is primarily contraindicated in severe immunodeficiency. 2, 3
• Zoster occurs with increased frequency and severity in HIV-infected individuals, making prevention particularly important in this population. 3

Pregnancy

• Live vaccines including zoster vaccine should be postponed during pregnancy. 2
• Breastfeeding is NOT a contraindication to zoster vaccination. 2

Common Clinical Pitfalls

Do NOT Confuse These with Contraindications:

• History of previous herpes zoster episode—prior zoster is NOT a contraindication; vaccination is still recommended. 4
• Chronic medical conditions (diabetes, heart disease, kidney disease, asthma)—these are NOT contraindications to zoster vaccination. 4
• Contact dermatitis to neomycin—only anaphylactic reactions to neomycin contraindicate the vaccine. 1
• Lack of documented varicella history—serologic testing or varicella history verification is NOT required before zoster vaccination. 4

Critical Safety Measures:

• All vaccination sites must have epinephrine (1:1000) immediately available for anaphylactic reactions. 1
• Consider 15-minute post-vaccination observation for all patients, with 30-minute observation for those with any history of severe allergic reactions. 5
• Providers must be certified in cardiopulmonary resuscitation and familiar with emergency protocols. 1

Documentation Requirements:

• Screen for absolute contraindications (severe immunodeficiency, anaphylaxis history to vaccine components) before proceeding. 5
• Document any moderate/severe acute illness requiring deferral. 2
• Report any suspected severe adverse reactions through appropriate pharmacovigilance systems. 6