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Malaysian Society of Infectious Diseases & Chemotherapy

Guidelines for Adult Immunisation

Content

Message from Editor

Editorial Panel

Adult Immunisation Schedule

Contraindications and Special Considerations

Temporary Deferral of Immunisation

Route and Site of Administration

Post Vaccination

Anaphylaxis

Vaccine Storage and Disposal of Vaccines

Vaccine Combinations

Multiple Vaccinations

Adverse Event Following Immunisation (AEFI)

Immunosenescence

Cholera

COVID-19

Dengue

Diphtheria

Tetanus

Pertussis

Haemophilus influenzae type b

Hepatitis A

Hepatitis B

Human Papillomavirus (HPV)

Influenza

Japanese Encephalitis (JE)

Measles

Mumps

Rubella

Meningococcal Disease

Mpox

Pneumococcal Disease

Poliomyelitis

Rabies

Respiratory Syncytial Virus (RSV)

Typhoid Fever

Chickenpox (Varicella)

Yellow Fever

Shingles (Zoster)

Passive Immunisation

Avian Influenza

Chikungunya

Clostridioides difficile

Ebola

Human Immunodeficiency Virus (HIV)

Malaria

Zika

Adults Who Missed Childhood Immunisation

Older Adults and Patients With Chronic Ilnesses

Healthcare workers

Human Immunodeficiency Virus (HIV)

Immunocompromised Patients

Miscellaneous Groups

Travelers

Vets & Animal Handlers

Abbreviations

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Available Vaccines

Shingles (Zoster)

In this chapter:

Introduction

Shingles is caused by the reactivation of the latent varicella–zoster virus (VZV) from previous infection with chickenpox and often occurs following waning VZV cellular immunity, which presents as a painful vesicular rash with a dermatomal distribution. Latency also occurs after chickenpox vaccination. Prodromal pain lasts 3–4 days, but it can extend to a week. A maculopapular rash develops into clusters of vesicles. In immunocompromised persons, multidermatomal disease may occur. Postherpetic neuralgia (PHN) is the most common complication of shingles. This pain can be extremely severe and may persist over years. Other complications include ophthalmic involvement, bacterial superinfection, cranial and peripheral nerve palsies, meningoencephalitis, pneumonitis, hepatitis, and acute retinal necrosis. Observational studies in older adults suggest that shingles is associated with increased risk of stroke and myocardial infarction, particularly in the first 6 months post-infection.

For further information on shingles in older adults, please refer to the ‘Malaysian Society of Geriatric Medicine Position Statement for Vaccine Preventable Diseases in Older Adults’ (www.msgm.com.my).

Table 27.1 Vaccines Registered in Malaysia

Table 27.2 High-Risk Groups in Malaysia

Implications for Healthcare Workers (HCWs)

There are no specific recommendations for RZV for HCWs.

Co-administration

Studies on co-administration of RZV with influenza, PPSV23, PCV13, and Tdap have found no evidence of interference in the immune response and no safety concerns.

Evidence of Safety & Effectiveness

Immunocompetent persons

  • Efficacy of the recombinant zoster vaccine (RZV) for prevention of herpes zoster in 3- year studies, was 97.2% in persons aged >50 years and 89.9% in participants aged >70 years.
  • Efficacy for prevention of postherpetic neuralgia was 91.2% in adults aged >50 years and 88.8% in those aged >70 years.
  • Humoral and cellular immune responses persisted for 10 years in older adults after the initial 2-dose RZV.
  • Humoral immune response to RZV post-2-dose was comparable in adults >65 years who were previously vaccinated with live attenuated zoster vaccine, Zostavax (ZVL), >5 years ago compared to ZVL-naïve adults. RZV was well tolerated in both study groups and no safety concerns were identified up to one month post dose 2.
  • Vaccination with RZV has been linked to a decreased incidence of major adverse cardiovascular events.
  • Recent, highly publicized, evidence confirms previous findings of a protective effect against dementia by demonstrating that RZV reduced the probability of a new dementia diagnosis by approximately one-fifth over a seven-year follow-up period.

Evidence for immunocompromised patients

  • The efficacy of RZV in prevention of shingles in immunocompromised autologous haematopoietic stem cell transplantation (HSCT) recipients was 68.2%.
  • Immunogenicity and safety studies on patients with haematological malignancies showed that humoral and cellular immune responses persisted above the baseline 13 months after vaccination. Post-hoc analysis showed vaccine efficacy of 87.2% against shingles in the population of immunocompromised adults, 18 years and older. The safety profile was acceptable in adults with haematological malignancies.
  • Recombinant zoster vaccines were immunogenic in patients with solid tumours receiving immunosuppressive therapy regimen. Immunogenicity persisted 12 months after vaccination regardless of timing of the first vaccination in relation to the start of chemotherapy.
  • Recombinant zoster vaccine was immunogenic in renal transplant patients > 18 years of age under chronic daily suppression and the immunogenicity persisted through one year after vaccination.
  • The most common solicited adverse reactions (grade1-3) following RZV vaccine were pain (78%), myalgia (45%), and fatigue (45%).

References

  1. Dooling,Kl., Guo, A., Patel, M., et al. (2018) Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. MMWR, Morb Mortal Wkly Rep, 67(3):103-108. DOI: http://dx.doi.org/10.15585/mmwr.mm6703a5
  2. Zhang, Y., Luo, G., Huang, Y., Yu, Q., Wang, L., & Li, K. (2017). Risk of Stroke/Transient Ischemic Attack or Myocardial Infarction with Herpes Zoster: A Systematic Review and Meta-Analysis. Journal of Stroke and Cerebrovascular Diseases : The official Journal of National Stroke Association, 26(8), 1807–1816. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.04.013
  3. Lal, H., Cunningham, A. L., Godeaux, O., Chlibek, R., Diez-Domingo, J., Hwang, S. J., Levin, M. J., McElhaney, J. E., Poder, A., Puig-Barberà, J., Vesikari, T., Watanabe, D., Weckx, L., Zahaf, T., Heineman, T. C., & ZOE-50 Study Group (2015). Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. The New England Journal of Medicine, 372(22), 2087–2096. https://doi.org/10.1056/NEJMoa1501184
  4. Cunningham, A. L., Lal, H., Kovac, M., et a (2016). Efficacy of the Herpes Zoster Subunit Vaccine in Adults 70 Years of Age or Older. The New England Journal of Medicine, 375(11), 1019–1032. https://doi.org/10.1056/NEJMoa1603800
  5. Maréchal, C., Lal, H., Poder, A., et al. (2018). Immunogenicity and safety of the adjuvanted recombinant zoster vaccine co-administered with the 23-valent pneumococcal polysaccharide vaccine in adults ≥50 years of age: A randomized trial. Vaccine, 36(29), 4278–4286. https://doi.org/10.1016/j.vaccine.2018.05.110
  6. Schwarz, T. F., Aggarwal, N., Moeckesch, B., et al. (2017). Immunogenicity and Safety of an Adjuvanted Herpes Zoster Subunit Vaccine Coadministered With Seasonal Influenza Vaccine in Adults Aged 50 Years or Older. The Journal of Infectious Diseases, 216(11), 1352–1361. https://doi.org/10.1093/infdis/jix481
  7. López-Fauqued, M., Co-van der Mee, M., Bastidas, A., et al. (2021). Safety Profile of the Adjuvanted Recombinant Zoster Vaccine in Immunocompromised Populations: An Overview of Six Trials. Drug Safety, 44(7), 811–823. https://doi.org/10.1007/s40264-021-01076-w
  8. Bastidas, A., de la Serna, J., El Idrissi, M., et al. (2019). Effect of Recombinant Zoster Vaccine on Incidence of Herpes Zoster After Autologous Stem Cell Transplantation: A Randomized Clinical Trial. JAMA, 322(2), 123–133. https://doi.org/10.1001/jama.2019.9053
  9. Dagnew, A. F., Ilhan, O., Lee, W. S., et al. (2019). Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in adults with haematological malignancies: a phase 3, randomised, clinical trial and post-hoc efficacy analysis. The Lancet. Infectious Diseases, 19(9), 988–1000. https://doi.org/10.1016/S1473-3099(19)30163-X
  10. Vink, P., Ramon Torrell, J. M., Sanchez Fructuoso, A., et al. (2020). Immunogenicity and Safety of the Adjuvanted Recombinant Zoster Vaccine in Chronically Immunosuppressed Adults Following Renal Transplant: A Phase 3, Randomized Clinical Trial. Clinical infectious Diseases: an official publication of the Infectious Diseases Society of America, 70(2), 181–190. https://doi.org/10.1093/cid/ciz177
  11. Vink, P., Delgado Mingorance, I., Maximiano Alonso, C., et al. (2019). Immunogenicity and safety of the adjuvanted recombinant zoster vaccine in patients with solid tumors, vaccinated before or during chemotherapy: A randomized trial. Cancer, 125(8), 1301–1312. https://doi.org/10.1002/cncr.31909
  12. Grupping, K., Campora, L., Douha, M., Heineman, T. C., Klein, N. P., Lal, H., Peterson, J., Vastiau, I., & Oostvogels, L. (2017). Immunogenicity and Safety of the HZ/su Adjuvanted Herpes Zoster Subunit Vaccine in Adults Previously Vaccinated with a Live Attenuated Herpes Zoster Vaccine. The Journal of Infectious Diseases, 216(11), 1343–1351. https://doi.org/10.1093/infdis/jix482
  13. Xinyi Xu, Isabel Ray, Emily Tang, Benjamin F Arnold, Nisha R Acharya. (2025) Protective Effects of Recombinant Zoster Vaccine and Antiviral Therapy Against Cardiovascular Disease Following Herpes Zoster Infection. The Journal of Infectious Diseases,232(2),465-473. https://doi.org/10.1093/infdis/jiaf105
  14. Eyting, M., Xie, M., Michalik, F. HeB, S.,Chung, A., and Geldsetzer P. (2025). A natural experiment on the effect of herpes zoster vaccination on dementia. Nature 641, 438–446 https://doi.org/10.1038/s41586-025-08800-x