The death of an immunocompromised patient who received a live zoster vaccine highlights the importance of screening all patients to avoid administering to those who are contraindicated.

A case report published in the journal Vaccine details the case of the 71-year-old Australian man who received the vaccine from his GP, despite being diagnosed with chronic lymphocytic leukaemia (CLL) assessed as Rai Stage II, for which he was not being actively treated due to co-morbidities including end-stage renal disease, type 2 diabetes and ischaemic heart disease.

Twenty days later the man, who had no history of varicella infection or prior immunisation, developed a bilateral vesicular facial rash, and soon after was admitted to hospital where he was diagnosed with disseminated varicella-zoster virus (VZV) infection complicated by meningoencephalitis. He died 10 days later following cardiac arrest.

The administration of the vaccine – which contains live attenuated Oka-strain VZV –  likely led to the man’s death from dissemination of the vaccine virus, according to lead author Dr Kate Alexander from South Western Sydney Local Health District’s public health unit.

The case “highlights the challenge of safely implementing a high titre live vaccine in a population where contraindications are prevalent,” she writes.

Zostavax was added to the Australian Immunisation Program for people aged 70-79.

Studies have shown the vaccine is well tolerated among adults 50 years and older, but due to the potential for disease arising from unchecked vaccine virus replication due to immune dysfunction, contraindications include people with haematological localised or general malignancies, including those not on treatment.

This presents a major challenge for policy makers and healthcare professionals but there is an alternative for immunocompromised patients – a non-live recombinant herpes zoster subunit vaccine Shingrix, recently approved by the US FDA.

Meanwhile, the researchers suggest all patients being considered for zoster vaccine should be screened by reviewing their clinical history regarding current or recent immunocompromising conditions or therapy prior to vaccination.

“If in doubt, it is essential that immunisation providers defer Zostavax administration and seek specialist advice regarding a patient’s suitability to receive the vaccine.”