Alexandra Hanretty, PharmD

Since the FDA authorized emergency use of COVID-19 vaccines—and recently granted full approval to the Pfizer-BioNTech COVID-19 vaccine

—vaccination has been on people’s minds. Nevertheless, among Medicare beneficiaries, receipt of 3 routine adult vaccines declined during the first 6 months of 2020 (ie, the beginning of the COVID-19 pandemic) when compared with the same period in 2019.

 During those 6 months, vaccinations against shingles declined by 43% among this population.

Worldwide, older adults get vaccinated against shingles at lower rates than they do against influenza and pneumonia. For instance, in a recent study of 372 adults 65 years and older living independently (eg, not in a care facility) in the United Kingdom, 83.6% of participants had received the influenza vaccine, but only 58.9% had received the shingles vaccine.

 This low rate of shingles vaccination partially was due to both a lack of a sense of collective responsibility regarding shingles and concerns about commercial profiteering.

In the United States, nearly half of adults 50 years and older have similar “vaccine hesitancy.” Rather than choosing to get all recommended vaccines or refusing vaccines altogether, these older adults decide to be vaccinated on a case-by-case basis.

The CDC recommends that immunocompetent adults 50 years and older receive the shingles vaccine.5 However, in 2017, shingles vaccination rates among adults aged 50 to 59 years or 60 years and older were only 5.7% and 34.9%, respectively.

 Addressing factors that drive shingles vaccine hesitancy may improve rates for this recommended vaccination.

Almost 1 of 3 US residents will develop shingles (ie, herpes zoster infection) during their lifetimes.

 Over 99% of Americans 40 years and older have had chickenpox, which helps to explain this high prevalence: In affected individuals, the varicella-zoster virus enters the body, causes chickenpox, lies dormant for many years, and then reactivates to cause shingles.

 The disease can induce postherpetic neuralgia (PHN), which involves severe pain in the shingles rash area. Whereas chickenpox generally occurs in younger individuals, shingles and PHN are associated with greater risks and severity as people get older.

 Although there is no cure for shingles, administration of the vaccine is very effective in preventing infection and infectious complications.

Currently, Shingrix is the only vaccine available in the United States to prevent shingles.5 Shingrix is an adjuvanted, recombinant (non-live–attenuated) vaccine that is more than 90% effective in preventing shingles and PHN when given at the recommended dosage.

Shingrix is administered in 2 doses given 2 to 6 months apart.

No recommendation has been issued to separate administration of Shingrix and the COVID-19 vaccines. Interim clinical considerations issued by the CDC for use of COVID-19 vaccines currently approved or authorized in the United States state that Shingrix and other vaccines may be given on the same day that the COVID-19 is given or within 14 days of its administration.

 Further, Shingrix may be given simultaneously with any live or inactive vaccines.11 However, administration of different vaccines to separate injection sites during the same office visit is recommended.

Adverse events (AEs) associated with Shingrix overlap with those of COVID-19 infection and include body aches and fever.

 However, Shingrix does not cause respiratory symptoms such as cough and shortness of breath, which are commonly noted among patients infected with the COVID-19 virus.

 Shingrix AEs normally resolve within 72 hours after vaccination.

Misconceptions may contribute to hesitancy to receive the shingles vaccine. By preemptively addressing the following concerns, health care providers can encourage appropriate preventive care.

I’ve already had shingles, so I don’t need a vaccine.

The CDC recommends that individuals who have had shingles in the past receive the shingles vaccination to help prevent future occurrences and lessen complications.

I never had chickenpox, so I’m not at risk of getting shingles.

Over 99% of Americans 40 years or older have had chickenpox even if they do not remember having had the infection.

 Therefore, almost all adults are at risk of developing shingles. The CDC recommends that adults over 50 years of age be given the shingles vaccine regardless of their recollection of chickenpox exposure or disease.

I’ve already received the Zostavax vaccine.

The CDC recommends that adults who previously received Zostavax still be given Shingrix, because the Shingrix vaccination sustains immunogenicity and is safe.

 As of November 18, 2020, Zostavax no longer is available for use in the United States.

 Results of a robust study of more than 38,000 adults 60 years or older showed that Zostavax vaccination reduced the risk of shingles by 51% and the risk of associated PHN by 67%; however, its effectiveness waned in older individuals.

 Conversely, Shingrix vaccination is more than 90% effective in preventing herpes zoster; importantly, 4 years after inoculation, no decrease in protection has been detected among adults older than 70 years of age.

I’m not exposed to any factors that trigger shingles.

Although factors that trigger shingles are not completely understood, older age and immunodeficiency place individuals at higher risk.

 Administration of Shingrix is important for all adults older than 50 years of age, especially as they grow older; however, the CDC’s Advisory Committee on Immunization Practices (ACIP) does not recommend administration of Shingrix to immunocompromised people at this time. As more evidence of Shingrix in this population becomes available, the ACIP will modify its policy as necessary. Individuals taking low doses of immunosuppressants (eg, prednisone 20 mg/d or its equivalent) can receive Shingrix, since it is not a live vaccine.

 The best mechanism for shingles prevention is vaccination.

Vaccine hesitancy and lower rates of routine vaccination are unfortunate consequences of the COVID-19 pandemic. However, health care providers must continue to encourage patients to receive preventive services. In particular, providers should encourage all eligible patients older than 50 years of age to receive the Shingrix vaccine, which the CDC has deemed “essential” and “should not be delayed or discontinued” because of the pandemic.

The COVID-19 pandemic is, of course, highly concerning, but the risk of developing herpes zoster has not diminished. Providers should habitually engage their patients about this important preventive measure and educate them about potential misconceptions about and great advantages of Shingrix vaccination.

is a clinical pharmacy specialist in infectious diseases at Cooper University Healthcare in Camden, New Jersey.

is an advanced practice pharmacist in infectious diseases at Thomas Jefferson University Hospitals in Philadelphia, Pennsylvania.

FDA approves first COVID-19 vaccine. News release. FDA. August 23, 2021. https://www.fda.gov/news-events/press-announcements/fda-approves- first-covid-19-vaccine

Hong K, Zhou F, Tsai Y, et al. Decline in receipt of vaccines by Medicare beneficiaries during the COVID-19 pandemic—United States, 2020. MMWR Morb Mortal Wkly Rep. 2021;70(7):245-249. doi:10.15585/mmwr.mm7007a4 

Nicholls LAB, Gallant AJ, Cogan N, Rasmussen S, Young D, Williams L. Older adults’ vaccine hesitancy: psychosocial factors associated
with influenza, pneumococcal, and shingles vaccine uptake. Vaccine. 2021;39(26):3520-3527. doi:10.1016/j.vaccine.2021.04.062

McSpadden J. Vaccine hesitancy among older adults, with implications for COVID-19 vaccination and beyond. AARP Public Policy Institute. February 26, 2021. Accessed August 26, 2021. https://www.aarp.org/ppi/info-2021/ vaccine-hesitancy-among-older-adults.html

Shingles vaccination. CDC. January 25, 2018. Accessed August 26, 2021. https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html 

Lu PJ, Hung MC, Srivastav A, Williams WW, Dooling KL. Shingles vaccination of U.S. adults aged 50-59 years and ≥ 60 years before recommendations for use of recombinant Zoster vaccine. Am J Prev Med. 2020;59(1):21-31. doi:10.1016/j.amepre.2020.01.017

Shingles burden and trends. CDC. August 14, 2019. Accessed August 26, 2021. https://www.cdc.gov/shingles/surveillance.html

What everyone should know about Zostavax. CDC. October 5, 2020. Accessed August 26, 2021. https://www.cdc.gov/vaccines/vpd/shingles/ public/zostavax/index.html

Bharucha T, Ming D, Breuer J. A critical appraisal of ‘Shingrix’, a novel herpes zoster subunit vaccine (HZ/Su or GSK1437173A) for varicella zoster virus. Hum Vaccin Immunother. 2017;13(8):1789-1797. doi:10.1080/21645515.2017.1317410

Lal H, Cunningham AL, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015;372(22):2087- 2096. doi:10.1056/NEJMoa1501184

Frequently asked questions about Shingrix. CDC. August 4, 2021. Accessed August 26, 2021. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/ faqs.html

Interim clinical considerations for use of COVID-19 vaccines currently authorized in the United States. CDC. August 31, 2021. Accessed September 13, 2021. https://www.cdc.gov/vaccines/covid-19/clinical-considerations/ covid-19-vaccines-us.html

Cunningham AL, Lal H, Kovac M, et al; ZOE-70 Study Group. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016;375(11):1019-1032. doi:10.1056/NEJMoa1603800

Harpaz R, Leung JW, Brown CJ, Zhou FJ. Psychological stress as a trigger for herpes zoster: might the conventional wisdom be wrong? Clin Infect Dis. 2015;60(5):781-785. doi:10.1093/cid/ciu889

Articles

Shingles Doesn’t Care: Re-Engaging Older Patients to Get Vaccinated

The beginning of the 2020-2021 influenza season brought much anticipation about how the cocirculation of influenza and SARS-CoV-2 might affect the health care system. Social distancing measures and mask wearing were likely to lower the influenza rates, as was seen at the start of the SARS-CoV-2 pandemic, but it was unclear by how much. Ensuring individuals were up-to-date on vaccine-preventable illnesses was a CDC priority that could help preserve the health care system's capacity and prevent influenza-related visits.

Throughout the 2020-2021 season, influenza rates were noticeably low, and at the end of the season, rates were at an historic low. Between September 27, 2020, and June 19, 2021, the proportion of patient visits for influenza-like-illness remained between 0.8% and 1.6%, which is well below the national baseline of 2.6%.

This is compared with 38 million cases of influenza during the 2019-2020 influenza season with percentages around 6%—which had been described as being moderately severe.

 The low influenza rate in the 2020-2021 season was likely attributable to social distancing measures and mask wearing.

Since the start of the pandemic, politicization and misinformation campaigns have led to vaccine hesitancy about the COVID-19 vaccine. However, vaccine hesitancy is not a new behavior. For example, there is still a substantial amount of vaccine hesitancy surrounding the influenza vaccine, though it was developed in the 1940s.

 During the 2018-2019 influenza season, just 45.3% of adults aged 18 and older in the United States received a seasonal influenza vaccine.

 The Strategic Advisory Group of Experts (SAGE) established the SAGE Working Group on Vaccine Hesitancy in March 2012 because of concerns about hesitancy and the effect it can have on vaccine uptake rates and national immunization programs.

 The decision was based on declining immunization rates among individuals from developing and developed countries.

 The working group defined vaccine hesitancy as a "...delay in acceptance or refusal of vaccines despite availability of vaccine services....It is influenced by factors such as complacency, convenience, and confidence."

Vaccine hesitancy is a global issue, despite considerable evidence that vaccines are safe and effective.

 In 2019, the World Health Organization (WHO) stated that vaccine hesitancy was a global health threat,

 and in the United States there has been an uptick in vaccine-preventable diseases, such as measles, along with growing vaccine hesitancy.

 The COVID-19 pandemic has been associated with vaccine skepticism. The results of a recent survey on COVID-19 and vaccine hesitancy in the United States found that during the first 6 months of the pandemic there was an increase in vaccine hesitancy and a decrease in the intention to get the anticipated COVID-19 vaccination and the seasonal influenza vaccine.

On December 11, 2020, the FDA authorized the use of the first COVID-19 vaccine, from Pfizer-BioNTech, under an emergency use authorization (EUA).

 Since that time, the FDA has also granted EUAs to the Moderna and Johnson & Johnson COVID-19 vaccines.

 As of June 30, 2021, 179 million individuals (54.2%) in the United States have received at least 1 dose of a COVID-19 vaccine and 154 million (46.4%) are fully vaccinated.

 As adult COVID-19 vaccination rates continue to increase and with the recent FDA authorization of the Pfizer COVID-19 vaccine for emergency use in children aged 12 to 15 years, there likely will be continued easing or social distancing and mask-wearing restrictions.

 Therefore, for the 2021-2022 season, influenza vaccinations will remain a priority.

REDUCING INFLUENZA BURDEN THROUGH VACCINATIONS

Throughout the pandemic, pharmacists have stood out as frontline vaccinators. Going into the 2021-2022 influenza season, pharmacists will likely encounter patients with some degree of vaccine hesitancy or vaccine fatigue. Pharmacists should encourage patients to get not only a COVID-19 vaccine but also an annual influenza vaccine.

Influenza can cause significantly morbidity and mortality and is associated with an economic burden from lost work productivity.

 To reduce the burden of influenza-related illness, the Advisory Committee on Immunization Practices recommends an annual influenza vaccine for individuals 6 months or older without medical contraindications.

 Vaccination is especially important in individuals at increased risk for medical complications from influenza, including individuals 50 years or older, children aged 6 months to 8 years, pregnant women, and those with underlying health conditions.

 An influenza vaccine can reduce the risk of illness, hospitalization, and death.

 Vaccine efficacy varies yearly and is dependent on patient-specific factors such as age and immune status, the type of vaccine administered, and how well matched the vaccine is between circulating viruses and those in the vaccine. Nonetheless, vaccination protects against influenza and reduces the severity of illness in vaccinated individuals who become infected.

VACCINE ACCESS IN HEALTH CARE, PHARMACY DESERTS

Health care providers cite patient deliberation about the pros and cons of vaccinations and distrust of the health care system as reasons individuals of racial minorities may choose not to be vaccinated.

 However, limited access to vaccines also can lead to lower vaccination rates. Vaccines need to be available not only at clinics but also in pharmacies and other locations in more isolated communities, with more flexibility of hours for those who have to work during business hours.

Influenza vaccination is offered at most community pharmacies nationwide. Because pharmacists are accessible individuals may feel comfortable talking with them about vaccine-related fears. As described in a recent 

 article, many individuals live in health care deserts where access to care is limited

 and pharmacies are the closest locations to access vaccines. Nine out of 10 Americans live within 5 miles of a pharmacy, with the average distance being 1.6 miles for those living in a region based around an urban center and 5.6 miles for those not near an urban center.

 Even then, if a patient lives in this health care desert or a rural area outside of urban centers, it might be difficult for them to travel every year for the vaccine. Those who live in cities also may not be able to easily access a pharmacy or clinic. Areas where the average distance to a pharmacy is 1 mile or more have been classified as pharmacy deserts, and in low-income neighborhoods where 100 households or more have no vehicle, the distance to be classified as a pharmacy desert is 0.5 miles.

 Studies evaluating the proximity of individuals to pharmacies have shown that these distances and circumstances can be challenging, particularly if the individual is elderly or relies on walking or public transportation.

 Getting to the bus or directly walking to a pharmacy may be nearly impossible.

CVS corporate leaders discussed the role of pharmacies in equitable vaccine distribution and announced in February 2021 that they will be working with nonprofits, such as the YMCA, to increase vaccine access. They also will partner with the ride-sharing company Lyft to help those in lower-income areas with free rides or discounts.

 This initiative will increase access to vaccines for those who may have difficulty getting to their regular clinic.

It is important to distinguish between vaccine hesitancy and refusal, as the approach to each is different. Patients who are hesitant may only need questions answered before choosing to vaccinate, whereas it may be more challenging to persuade someone who outright refuses vaccines.

 There is no one-size-fits all way to overcome vaccine hesitancy, as the reasons behind each individual's fears and concerns are different. Health care providers need to listen to their patients and address their unique concerns rather than simply trying to explain the science behind vaccines.

American Journal of Pharmaceutical Education

 in 2018 discussed vaccine hesitancy and how to prepare pharmacy students for vaccinating patients and providing information about vaccines. Student pharmacists and doctors were evaluated on how they spoke with multiple "standardized patients" and were assessed on rhetoric, communication skills, and social-emotional competence.

 Studies evaluating parents' acceptance of influenza vaccines for their children have noted that it works well when pharmacists use presumptive phrasing such as "Today we are going to give your child the recommended vaccines to keep your child healthy."

Displaying empathy toward patient concerns while dispelling myths and describing benefits of vaccination also has been shown to be effective. For example, if a patient argues that it is still possible to become infected with influenza after receiving a vaccine, providers can explain that, yes, this is true, but the symptoms are milder and outcomes are better after receiving a vaccine.

 Scientists and physicians estimate the prevalent influenza strains each year to the best of their ability,

 but, it is not possible to know which strains will be the most common. A universal influenza vaccine, one that can protect against multiple subtypes of influenza, is being investigated by National Institute of Allergy and Infectious Diseases' influenza research program. This vaccine would protect more individuals against influenza without the need to investigate and predict which strains will be most common each year.

The SAGE working group suggests a communication plan for health care providers to use when addressing patients who are vaccine hesitant.

anticipating antivaccine remarks or behaviors and planning responses in advance,

understanding the population and considering determinants of vaccine hesitancy to deliver a tailored and persuasive message,

providing knowledge but also identifying underlying issues and taking action based on those issues, and 

using a variety of methods to deliver information. Marketing and social media campaigns have been effective in improving vaccine uptake in some places, but using multiple delivery methods focusing on the population in question is ideal.

Although using a script may sound insincere to patients, having a few notes to use as a guide for fielding patient concerns is reasonable. Providers should consider addressing concerns that cannot be answered with statistics. For example, sometimes patients need time to process information, so expecting them to receive a vaccine at that moment may not be logical. Offering the patient options to come back and receive a vaccine may allow them to feel more in control of their health. Conversely, if it would be difficult for a patient to return, the vaccine should be provided that visit.

The WHO puts vaccine hesitancy into 3 categories: complacency, confidence, convenience. Many factors can affect each of these, including misinformation spread on social media or through word of mouth. If the perceived risk is lower than the perceived benefit, patients become complacent. Effective and safe vaccines, reliable and competent health services delivering the vaccines, and policy-making motivations affect patient confidence. Convenience is measured by physical availability, affordability, willingness to pay, accessibility, ability to understand, and appeal of immunization services.

However, access to vaccines and vaccine affordability remain a challenge. For patients without insurance, vaccines may be cost prohibitive. For others, travel to a health care facility may not be an option. In addition, patients may not be confident about the vaccine or health care providers in general, based on prior experiences with the health care system.

It is important for health care providers to be prepared to address patient concerns. Examples of common concerns are stated next and in the table.

For patients who think they receive too many shots, it is important to empathize with their concern, be understanding if they are more fearful of pain or adverse effects from vaccines, and reiterate that administering multiple vaccines at once is safe and effective.

"How will a flu shot interact with the COVID-19 vaccination?"

Initially, there were limited data regarding the interaction of an influenza vaccine with a COVID-19 vaccine, and the CDC recommended a 14-day interval between any vaccinations. However, with more data becoming available, the CDC now says that COVID-19 vaccines can be administered simultaneously with other vaccines, such as the influenza vaccine, and coadministration within 14 days is also permissible. There have been no reported interactions between the COVID-19 and influenza vaccines.

With the development of COVID-19 vaccines, there has been an increase in hesitancy and fatigue surrounding vaccines. Hesitancy surrounding a COVID-19 vaccine also seems to have increased hesitancy toward influenza vaccines. As the 2021-2022 influenza season approaches, health care providers should prepare to overcome vaccine hesitancy and fatigue. Science alone is often not enough to alleviate patients' fears and concerns, and there are many cultural and societal inequities that influence patients' beliefs. All of these factors should be taken into consideration when addressing vaccine hesitancy and fatigue.

is a clinical pharmacy specialist in infectious diseases at Cooper University Health Care in Camden, New Jersey.

is an assistant professor of clinical pharmacy at the Philadelphia College of Pharmacy in Pennsylvania. King also is an infectious disease clinical pharmacist at Cooper University Hospital in Camden, New Jersey.

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2. Weekly U.S. influenza surveillance report. CDC. May 21, 2021. Accessed May 24, 2021. https://www.cdc.gov/flu/weekly/index.htm

3. Estimated influenza illnesses, medical visits, hospitalizations, and deaths in the United States — 2019-2020 influenza season. CDC. October 6, 2020. Accessed May 16, 2021. https://www.cdc.gov/flu/about/burden/2019-2020.html

4. Pandemic influenza: influenza historic timeline. CDC. October 6, 2020. Accessed May 24, 2021. https://www.cdc.gov/flu/pandemic-resources/pandemic-timeline-1930-and-beyond.htm

5. World Health Organization. Report of the SAGE Working Group on Vaccine Hesitancy. October 1, 2014. Accessed May 25, 2021. https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf

6. Flu vaccination coverage, United States, 2018-19 influenza season. CDC. September 26, 2019. Accessed May 24, 2021. https://www.cdc.gov/flu/fluvaxview/coverage-1819estimates.htm

7. Phadke VK, Bednarczyk RA, Salmon DA, Omer SB. Association between vaccine refusal and vaccine-preventable diseases in the United States. JAMA. 2016;315(11):1149-1158. doi:10.1001/jama.2016.1353

8. Interim clinical considerations for use of COVID-19 vaccines. CDC. May 14, 2021. Accessed May 25, 2021. https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

9. Ten threats to global health in 2019. Accessed May 25, 2021. https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019

10. Measles cases in the U.S. are highest since measles was eliminated in 2000. CDC. April 25, 2019. Accessed June 14, 2021. https://www.cdc.gov/media/releases/2019/s0424-highest-measles-cases-since-elimination.html

11. Fridman A, Gershon R, Gneezy A. COVID-19 and vaccine hesitancy: a longitudinal study. PLoS ONE. 2021;16(4):e0250123. doi:10.1371/journal.pone.0250123

12. Coronavirus (COVID-19) update: FDA authorizes Pfizer-BioNTech COVID-19 vaccine for emergency use in adolescents in another important action in fight against pandemic. FDA. May 10, 2021. Accessed May 25, 2021. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use

13. COVID-19 vaccinations in the United States. CDC. Updated June 29, 2021. Accessed June 30, 2021. https://covid.cdc.gov/covid-data-tracker/#vaccinations

14. Gordon A, Reingold A. The burden of influenza: a complex problem. Curr Epidemiol Rep. 2018;5(1):1-9. doi:10.1007/s40471-018-0136-1

15. Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices — United States, 2020-21 influenza season. MMWR Recomm Rep. 2020;69(8):1-24. doi:10.15585/mmwr.rr6908a1

16. People at high risk for flu complications. CDC. May 6, 2021. Accessed May 25, 2021. https://www.cdc.gov/flu/highrisk/index.htm

17. Vaccine effectiveness: how well do the flu vaccines work? CDC. May 6, 2021. Accessed May 25, 2021. https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm

18. Corbie-Smith G. Vaccine hesitancy is a scapegoat for structural racism. JAMA Health Forum. 2021;2(3):e210434. doi:10.1001/jamahealthforum.2021.0434

19. US Department of Health & Human Services. Guidance for licensed pharmacists and pharmacy interns regarding COVID-19 vaccines and immunity under the PREP Act. September 3, 2020. Accessed October 9, 2020. https://www.hhs.gov/sites/default/files/licensed-pharmacists-and-pharmacy-internsregarding-covid-19-vaccines-immunity.pdf

20. Hippensteele A. Mobile clinics, same-day appointments introduced across the country by Walgreens to ensure ease of COVID-19 vaccine access. Pharmacy Times . May 3, 2021. Accessed June 14, 2021. https://www.pharmacytimes.com/view/mobile-clinics-same-day-appointmentsintroduced-across-the-country-by-walgreens-to-ensure-ease-of-covid-19-vaccine-access

21. Coppock K. Pharmacies extending Friday hours in June to increase access to COVID-19 vaccination. Pharmacy Times . June 10, 2021. Accessed June 14, 2021. https://www.pharmacytimes.com/view/pharmacies-extendingfriday-hours-in-june-to-increase-access-to-covid-19-vaccination

22. Weitzman D. The importance of provider status for pharmacists. Pharmacy Times . November 17, 2020. Accessed May 25, 2020. https://www.pharmacytimes.com/view/the-importance-of-provider-status-for-pharmacists

23. Face-to-face with community pharmacies. National Association of Chain Drug Stores. Accessed June 15, 2021. https://www.nacds.org/pdfs/about/rximpact-leavebehind.pdf

24. Understanding the federal retail pharmacy program for COVID-19 vaccination. CDC. Updated April 12, 2021. Accessed May 25, 2021. https://www.cdc.gov/vaccines/covid-19/retail-pharmacy-program/index.html

25. Hopper L. One-third of neighborhoods in big U.S. cities have been ‘pharmacy deserts.’ USC News. May 3, 2021. Accessed May 25, 2021. https://news.usc.edu/185748/pharmacy-deserts-american-cities-healthdisparities-usc-research/

26. CVS Health builds on community-based strategy to address COVID-19 vaccine education and equity. CVS Health. February 19, 2021. Accessed May 25, 2021. https://cvshealth.com/news-and-insights/press-releases/cvshealth-builds-on-community-based-strategy-to-address-covid-19

27. Shen SC, Dubey V. Addressing vaccine hesitancy: clinical guidance for primary care physicians working with parents. Can Fam Physician. 2019;65(3):175-181.

28. Vyas D, Galal SM, Rogan EL, Boyce EG. Training students to address vaccine hesitancy and/or refusal. Am J Pharm Educ. 2018;82(8). doi:10.5688/ajpe6338

29. Misconceptions about seasonal flu and flu vaccines. CDC. May 21, 2021. Accessed May 25, 2021. https://www.cdc.gov/flu/prevent/misconceptions.htm

30. Universal influenza vaccine research. National Institutes of Health. September 5, 2019. Accessed May 25, 2021. https://www.niaid.nih.gov/diseases-conditions/universal-influenza-vaccine-research

31. Rawson SJ, Conway JH, Hayney MS. Addressing vaccine hesitancy in the pharmacy. J Am Pharm Assoc. 2016;56(2):209-210. doi:10.1016/j.japh.2016.02.008

32. Anderson EL. Recommended solutions to the barriers to immunization in children and adults. Mo Med. 2014;111(4):344-348.

33. Hippensteele A. Mobile clinics, same-day appointments introduced across the country by Walgreens to ensure ease of covid-19 vaccine access. Pharmacy Times. May 3, 2021. Accessed June 14, 2021. https://www.pharmacytimes.com/view/mobile-clinics-same-day-appointmentsintroduced-across-the-country-by-walgreens-to-ensure-ease-of-covid-19-vaccine-access

34. Preparing for questions parents may ask about vaccines. CDC. April 11, 2018. Accessed June 14, 2021. https://www.cdc.gov/vaccines/hcp/conversations/preparing-for-parent-vaccine-questions.html

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Since the start of the pandemic, politicization and misinformation have led to hesitancy about the COVID-19 vaccine. However, vaccine hesitancy is not a new behavior.

Just One More Shot: Influenza Vaccine Hesitancy During a Pandemic

Following the national emergency declaration on March 13, 2020, due to the coronavirus disease 2019 (COVID-19) pandemic, there has been a drastic drop in childhood immunizations. According to a May 2020 CDC report, 2.5 million fewer doses of vaccines were ordered through the Vaccines for Children program in 2020 compared with the same time period in 2019. The decline in vaccinations was likely related to families avoiding well-child visits due to concerns about possible exposure to SARS-CoV-2, the virus that causes COVID-19.

When children miss routine vaccinations, it poses a major public health threat for increased outbreaks of preventable diseases.

 To combat this, the US Department of Health & Human Services (HHS) issued an amendment to the declaration of a national public health emergency made under the Public Readiness and Emergency Preparedness Act. On August 24, 2020, HHS expanded availability of vaccination administration options by allowing pharmacists in all states to administer vaccines to children as young as 3 years of age.

 Previously, the minimum age of a child a pharmacist could immunize was state dependent, and only 28 states permitted pharmacists to vaccinate children in general.

 The amendment also applies to pharmacy interns who are licensed or registered by their state’s Board of Pharmacy and acting under a pharmacist’s supervision.

 This amendment aims to provide additional options to help prevent outbreaks of vaccine-preventable diseases during this challenging time when stay-at-home orders are in effect and many parents are placing preventive care lower on their list of priorities.

The amendment also will relieve some of the strain that pediatric offices are facing, both in trying to catch up with wellness visits missed during the peak of the pandemic and in responding to COVID-19 visits. In particular, with schools and day care facilities beginning to reopen, there may be a rise in cases of communicable diseases.

A Unique Siderophore Cephalosporin for the Treatment of Difficult-to-Treat Gram-negative Infections

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There are a number of important considerations for pharmacists in regard to this amendment (

). When pharmacists administer vaccines to children, they have a duty to inform the child’s caregivers of the importance of a wellchild visit with their primary care provider and refer patients when appropriate.

 Any licensed pharmacist, or licensed intern under the supervision of a licensed pharmacist, is eligible to vaccinate children as young as 3 years if they meet all of the requirements. Pharmacists must have completed an Accreditation Council for Pharmacy Education (ACPE)—approved practical training program of at least 20 hours. These training programs are intended to be hands-on and contain comprehensive information on immunizations. During each state license renewal period, pharmacists also must complete a minimum of 2 hours of ACPE– approved, immunization-related continuing education courses. Lastly, they must have a current certificate in basic cardiopulmonary resuscitation. Vaccines must be ordered and administered according to the CDC’s Advisory Committee on Immunization Practices (ACIP) standard immunization schedule.

 Pharmacists also must comply with necessary recordkeeping and reporting requirements of the state or jurisdiction where they are practicing and administering vaccines. In summary, pharmacists must inform the patient’s primary care provider, when available; submit information to a vaccine registry or other state or local immunization information system; report adverse events; and review the vaccine registry or other relevant records prior to administering a vaccine.

CHALLENGES WITH VACCINATING YOUNGER PATIENTS 

Vaccinating a younger population brings a number of new challenges for pharmacists. The amendment likely will require pharmacies to stock child-specific vaccines that were previously unnecessary to carry (table3,7). Pharmacists also must pay close attention to the differences in dosing between children and adults. Additionally, some immunizations (eg, influenza) require a 2-dose series for vaccine-naïve patients; however, this will likely not be relevant, as most children would have received their first series of influenza vaccine at age 6 months.

 Although pharmacists have ample experience counseling parents on their child’s medications, it may take practice to become comfortable immunizing a small child and easing both their anxiety and that of their parents. The change in environment also may be an adjustment for parents, as they are likely used to the privacy of the exam room compared with that of the retail pharmacy setting. It may take time for pharmacists to achieve a similar level of comfort. The decision to allow pharmacists to provide immunizations to children was accompanied by much controversy, as the American Academy of Pediatrics (AAP) and American Medical Association vehemently opposed the amendment. AAP President Sally Goza, MD, FAAP, stated that “rather than create an unnecessary alternative method to deliver immunizations to children, our federal government should invest in the one we have: pediatricians.” In addition, the AAP stated that many pharmacies do not participate in the Vaccines for Children Program, a federal program that provides immunizations to children at no cost for families who cannot afford them, which has the potential to widen the gap in health disparity.9 Pharmacists immunizing uninsured children should make every effort to provide the immunization at no cost or refer them somewhere that is able to provide the service for free. Because the decrease in vaccination rates is a public health threat, HHS is ultimately most concerned with making pediatric vaccines more accessible, keeping vaccination rates high, and protecting children against vaccine-preventable diseases during the pandemic.

The new HHS amendment has expanded the ability of pharmacists to immunize children aged 3 to 18 years in all 50 states. Although this came with some controversy from various medical organizations, including the AAP,9,10 from a public health perspective, maintaining high rates of immunity to vaccine-preventable illnesses is critical, particularly as the COVID-19 pandemic continues.

, is a clinical pharmacy specialist in infectious diseases at Cooper University Health Care in Camden, New Jersey.

Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration—United States, 2020. 

. 2020;69(19):591-593. doi:10.15585/ mmwr.mm6919e2

Hoffman J. Vaccine rates drop dangerously as parents avoid doctor’s visits. 

. April 23, 2020. Accessed September 30, 2020. https://www.nytimes.com/2020/04/23/health/coronavirus-measles-vaccines.html

Third amendment to declaration under the Public Readiness and Emergency Preparedness Act for medical countermeasures against COVID—19. HHS. Accessed September 22, 2020. https://www.hhs.gov/sites/default/files/ third-amendment-declaration.pdf

Stobbe, M. Pharmacists can give childhood shots, U.S. officials say. Associated Press. August 19, 2020. Accessed October 23, 2020. https://apnews.com/ article/6147846d7fc3e9e24c5da70d62f814de

State “shelter-in-place” and “stay-at-home” orders. Financial Industry Regulatory Authority. Updated August 4, 2020. Accessed September 30, 2020. https://www.finra.org/rules-guidance/key-topics/covid-19/shelter-in-place

Vaccine rates drop dangerously as parents avoid doctor’s visits. American Pharmacists Association. April 24, 2020. Accessed October 23, 2020. https:// www.pharmacist.com/article/vaccine-rates-drop-dangerously-parents-avoiddoctors-visits

Immunization schedules. CDC. Reviewed February 3, 2020. Accessed October 1, 2020. https://www.cdc.gov/vaccines/schedules/

Grohskopf LA, Alyanak E, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices—United States, 2020-21 influenza season. 

. 2020;69(8):1-24. doi:10.15585/mmwr.rr6908a1

American Academy of Pediatrics opposes HHS action on childhood vaccines; calls it ‘incredibly misguided.’ News release. American Academy of Pediatrics; August 19, 2020. Accessed September 30, 2020. https://services.aap.org/en/newsroom/news-releases/aap/2020/american-academy-of-pediatrics-opposes-hhsaction-on-childhood-vaccines-calls-it-incredibly-misguided/

AMA opposes expanding pharmacists’ ability to provide child vaccines. News release. American Medical Association; August 21, 2020. Accessed October 23, 2020. https://www.ama-assn.org/press-center/ama-statements/ama-opposesexpanding-pharmacists-ability-provide-child-vaccines

New HHS Regulations Expand Pharmacists’ Role in Childhood Immunizations

Shingles, also known as herpes zoster, results from a reactivation of latent varicella-zoster virus (VZV, chickenpox) and usually occurs decades after primary infection.

 Rates of chickenpox infection in the United States have been very low since the advent of VZV vaccination in 1995; however, many individuals who were infected prior to the vaccine being made available are still at risk of developing shingles.

 Ninety-nine percent of people 40 years and older have been infected with wild-type VZV in the United States and are thus at risk of developing shingles, underscoring the importance of vaccination.

Although the coronavirus disease 2019 (COVID- 19) pandemic has changed how health care services are provided, ensuring immunization services are maintained is essential to public health.

 The CDC recommends that routine vaccinations not be delayed and be given according to the Advisory Committee on Immunization Practices (ACIP) immunization schedule as long as there are no contraindications.

 In this article, we discuss counseling pearls and considerations for the shingles vaccine, such as navigating insurance coverage, managing adverse events, and handling a missed dose in the series.

Until recently, 2 vaccines were available in the United States to protect against shingles: a live, attenuated vaccine (Zostavax, Merck) and an adjuvanted, nonlive recombinant vaccine (Shingrix, GlaxoSmithKline).

 As of July 1, 2020, Zostavax is no longer manufactured in the United States (although any remaining supply may be used until the vaccine expires on or before November 18, 2020).

 Shingrix is now the vaccination recommended by the ACIP for immunocompetent patients aged 50 years or older (including those with chronic health conditions such as renal failure, diabetes mellitus, rheumatoid arthritis, or chronic pulmonary disease) regardless of whether they have had shingles in the past.

 The vaccine is administered as a 2-dose series by intramuscular injection, spaced 2 to 6 months apart.

 Vaccination administration can be delayed in patients who are experiencing an acute episode of shingles.

 Patients who are prescribed low-dose immunosuppressive therapy (that is, prednisone < 20 mg/day or its equivalent) can still receive Shingrix.

Although shingles can occur at any age, it is most common in people 50 years or older because of age-related decline in the functionality of T-cell—mediated immunity to VZV, which, when functioning appropriately, prevents viral reactivation.

 Because of the waning immune response, it is important that patients in this population receive Shingrix to prevent VZV reactivation and subsequent shingles, as well as complications such as postherpetic neuralgia (PHN), encephalitis, hearing and vision loss, and death.

The Shingrix vaccine contains VZV antigen glycoprotein E that is essential for viral replication and viral spread from cell to cell; it is also a primary target of the VZV immune response.

Counseling pearls and considerations for the shingles vaccine, such as navigating insurance coverage, managing adverse events, and handling a missed dose in the series, are discussed.