Vaccination Rates

The United States is falling short in immunizing older adults against HZ. Findings from the National Health Interview Survey revealed that shingles vaccination rates among adults 60 years and older increased from 6.7% in 2008 to 33.4% in 2016, and then remained relatively constant through 2018, reaching 34.5%.9 Shingles vaccination rates did not differ by gender in 2018. However, non-Hispanic White adults (38.6%) were approximately twice as likely as non-Hispanic Black (18.8%) and Hispanic (19.5%) adults to have ever received a shingles vaccination.9

Vaccination coverage was highest for those with higher incomes and those who had more than a high school education. For example, adults with incomes under the federal poverty level ($12,760 for an individual) were only half as likely to get immunized as those with annual incomes of more than $25,000.9 These findings are consistent with disparities seen with other adult vaccines.10

The cost of RZV can have a negative impact on vaccination rates, especially among patients of low socioeconomic status, many of whom do not have health insurance. Commercial health insurance plans generally cover RZV when it is given at a provider’s office. However, RZV is covered under Medicare Part D plans, unlike most other vaccinations, including influenza and pneumococcal, which are covered under Part B. Part D vaccinations typically are administered at a retail site of care, such as a pharmacy, and the out-of-pocket cost to the patient can vary greatly due to different plan designs. Medicaid may or may not cover the vaccine.11


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To improve shingles vaccination rates, the CDC encourages health care providers to increase awareness among patients of the severity of HZ and efficacy of the RZV as well as use of tools for implementing the Standards for Adult Immunization Practice.10,12 To address racial and ethnic disparities in vaccination rates, providers should include regular assessment of adult vaccination needs and offer to administer vaccinations as part of routine clinical care. In addition, the CDC suggests that providers consider developing immunization quality improvement projects at their practices to increase adult immunization rates.10,12

Information for Providers

Health care providers who previously had used ZVL should be aware of the differences in administration and storage for RZV. For example, RZV is supplied as 2 components: a single-dose vial of lyophilized varicella virus glycoprotein and a single-dose vial of adjuvant suspension. Both the antigen and adjuvant should be kept refrigerated between 2 ºC and 8 ºC (36 ºF and 46 ºF). If the components are frozen, they should be discarded.

The vaccine should be administered immediately after being reconstituted or refrigerated and used within 6 hours. If it is not used within 6 hours after reconstitution, it should be discarded. RZV must be given by intramuscular injection, unlike ZVL, which was given by subcutaneous injection. Two doses of RZV are required with the second dose given 2 to 6 months after the first dose.13 The vaccine series does not have to be restarted if more than 6 months have elapsed since the first dose, but the efficacy of alternate dosing regimens has not been studied.7

Information regarding mRNA COVID-19 vaccine coadministration with other vaccines is available from the CDC website Clinical Considerations for COVID-19 Vaccination.

Summary

Greater efforts are needed by all health care providers to increase shingles vaccination rates among older adults. RZV has been shown to reduce the risk for shingles and PHN by more than 90% in people 50 years and older. During patient counseling, providers should emphasize the painful disease process, complications, and possible long-term sequelae of HZ as well as the proven safety and efficacy of RZV. Targeted efforts are needed to increase vaccination rates among older adults of low socioeconomic status and racial/ethnic minorities.

Mary Jane S. Hanson, PhD, CRNP, FNP-BC, FAANP, FAAN, is professor and director of the graduate nursing program at the University of Scranton and works at Lehigh Valley Physician Group – Family Medicine in Lehighton, Pennsylvania.

References

1.  Centers for Disease Control and Prevention. Shingles (Herpes zoster). Accessed April 28, 2021. https://www.cdc.gov/shingles/

2. Centers for Disease Control and Prevention. Shingles (Herpes zoster): clinical overview. Accessed June 17, 2021. https://www.cdc.gov/shingles/hcp/clinical-overview.html

3.  Centers for Disease Control and Prevention. Shingles (Herpes zoster) complications of shingles.  Accessed April 28, 2021. https://www.cdc.gov/shingles/about/complications.html

4. Wareham DW, Breuer J. Herpes zoster. BMJ. 2007;334(7605):1211-1215. doi:10.1136/bmj.39206.571042.AE

5.  Centers for Disease Control and Prevention. Frequently asked questions about Shingrix. Accessed June 16, 2021, https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/faqs.html

6.  Harpaz R, Ortega-Sanchez IR, Seward JF; Advisory Committee on Immunization Practices (ACIP). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2008;57(RR-5):1-30.

7.  Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67(3):103-108. doi:10.15585/mmwr.mm6703a5

8.  Hesse EM, Shimabukuro TT, Su JR, et al. Postlicensure safety surveillance of recombinant zoster vaccine (Shingrix) — United States, October 2017–June 2018. MMWR Morb Mortal Wkly Rep. 2019;68(4)91-94. doi:10.15585/mmwr.mm6804a4

9. Terlizzi EP, Black LI. Shingles vaccination among adults aged 60 and over: United States, 2018. NCHS Data Brief, no 370. Hyattsville, MD: National Center for Health Statistics. 2020.

10. Centers for Disease Control and Prevention. Vaccination coverage among adults in the United States, National Health Interview Survey, 2016. Updated February 8, 2018.  Accessed June 16, 2021. https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/pubs-resources/NHIS-2016.html#ref03.

11. Centers for Disease Control and Prevention. Shingles vaccination. Updated January 25, 2018.  Accessed June 16, 2021. https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html

12. Centers for Disease Control and Prevention.  Standards for adult immunization practice. Updated May 2, 2016.  Accessed June 16, 2021.   https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html 

13. Shimabukuro TT, Miller ER, Strikas RA, et al. Notes from the field: vaccine administration errors involving recombinant zoster vaccine — United States, 2017–2018. MMWR Morb Mortal Wkly Rep. 2018;67(20):585-586. doi: 0.15585/mmwr.mm6720a

This article originally appeared on Clinical Advisor