1. American Academy of Pediatrics. Recommended Childhood and Adolescent Immunizaiton Schedules: United States, 2018. http://pediatrics.aappublications.org/content/early/2018/02/02/ peds.2018-0083. Accessed February 6, 2018.

2. Centers for Disease Control and Prevention. www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html#changes. Accessed February 6, 2018.

Articles

Immunization and Vaccination

Guide to Adult Immunizations

Herpes zoster, also known as zoster or, more commonly, shingles, is caused by the reactivation of the varicella-zoster virus, the same virus that causes varicella (chicken pox). An estimated 1 million cases (1 in 3 Americans affected) of herpes zoster occur in the United States annually. The incidence among people 60 years and older is about 10 cases per 1000 individuals in the US population annually and is gradually increasing. Groups at greatest risk for developing herpes zoster are US adults over 50 years and immunosuppressed or immunocompromised individuals. 

The FDA and the CDC’s Advisory Committee on Immunization Practices (ACIP) recently approved and recommended Shingrix (Zoster Vaccine, Recombinant Adjuvanted), manufactured by GlaxoSmithKline, for prevention of herpes zoster in patients 50 years and older. Shingrix is a refrigerated reconstituted, adjuvanted, inactivated 2-dose vaccine given at 0 and 2 to 6 months intramuscularly. Clinical trials have demonstrated greater than 90% efficacy in patients 50 years and older. Common adverse effects observed were local site reactions (redness, pain, and swelling) and general adverse reactions (myalgia, fatigue, and headache).

ACIP recommends that immunocompetent adults 50 years and older be vaccinated with Shingrix to prevent herpes zoster and related com- plications. In addition, ACIP prefers Shingrix over zoster vaccine live.

Pharmacists should discuss with their patients the following risks of developing shingles, the best way for patients to protect themselves against this vaccine-preventable disease, and adverse reactions of the vaccine and how to best manage them:

One in 3 people will develop shingles in their lifetime.

Anyone who has had chicken pox can get shingles.

Ninety-nine percent of people 50 years and older are at risk of developing shingles.

The risk increases with age, especially after age 50.

A new shingles vaccine is available with 90% efficacy against shingles in patients 50 years and older.

The best way to protect yourself is to be vaccinated with the shingles vaccine.

Nearly 80% of patients experienced local pain or redness. Therefore most patients will experience local site reactions (redness, pain, and swelling) and may experience general adverse reactions (myalgia, fatigue, and headache).

Pharmacists should counsel every patient on these potential adverse effects and how to best manage them.

Most patients will visit their local pharmacy more often than their primary care provider’s office. The pharmacist is in a key position to assess and communicate about a patient’s specific vaccine needs. Pharmacists will need to use a team approach to improve the likelihood of adult vaccine awareness. Pharmacy technicians should be trained to regularly ask patients for updates to their immunization history at the prescription drop-off window. The technician can refer patients to consult with the pharmacist about their specific vaccination needs. Student pharmacists and interns can assist with reviewing patient profiles during dispensing activities to identify patients who may be eligible for a vaccination(s) and assist with providing recommendations to patients. Pharmacists should routinely assess a patient’s vaccination needs to ensure they are up-to-date with ACIP recommendations. The pharmacist can use patient care opportunities, such as medication therapy and disease management consultations, to recommend necessary vaccinations.

Because the Shingrix vaccine is a 2-dose series, pharmacies will need to develop solutions to remind patients when they are due for their next vaccine dose in order to increase patient adherence. Consider creating a patient takeaway that reminds the patient when their next dose is due. Another option to consider is creating a patient call list, identifying patients who are due for their next dose in the vaccine series and performing reminder calls to increase adherence.

Pharmacists should also suggest that their patients create a calendar entry in their smartphone to remind them to return for their second dose in 2 to 6 months, while emphasizing the importance of completing the vaccine series to be fully protected.

PHARMACISTS’ ROLE AS IMMUNIZATION PROVIDERS

Pharmacists are considered an important component within the immunization neighborhood and should stay up-to-date on immunization guidelines and recommendations. In addition, pharmacists are urged to follow the immunization practice standards established by the National Vaccine Advisory Committee. Pharmacists should assess the immunization status of patients at each encounter and ensure that they are routinely reviewed. Industry studies have shown that patients are more likely to receive an immunization when pharmacists make a strong recommendation. After pharmacists assess patients’ immunization needs, pharmacists should then make strong recommendations on the immunizations that patients need while addressing any questions and concerns patients may have about receiving an immunization. If the patient accepts the pharmacist’s recommendation, the pharmacist should administer the immunization and document the immunization in the patient’s profile or the state’s immunization registry. If a pharmacy does not stock immuniza- tions, pharmacists should refer their patients to another provider who stocks vaccines to meet patients’ immunization needs.

This is an exciting time for pharmacists as immunization providers because we now have an opportunity to protect patients with a more effective vaccine against shingles. We have a responsibility to educate and counsel patients about shingles and the best way to protect themselves against this vaccine-preventable disease.

Alex Novielli, PharmD, is senior manager of pharmacy operations (immunization services) at Walgreens in Deerfield, Illinois.

1. Shingrix [package insert]. Rixensart, Belgium: GlaxoSmithKline Biologicals; 2017.

2. Shingles (herpes zoster): vaccination. CDC website. cdc.gov/shingles/vaccina- tion.html. Accessed January 19, 2018.

3. Shingles (herpes zoster): clinical overview. CDC website. cdc.gov/shingles/ hcp/clinical-overview.html. Updated October 17, 2017. Accessed January 19, 2018.

4. Standards for adult immunization practice. CDC website. cdc.gov/vaccines/ hcp/adults/for-practice/standards/index.html. Updated July 19, 2017. Accessed January 19, 2018.

The pharmacist is in a key position to assess and communicate about a patient’s specific vaccine needs.

Herpes Zoster: Talking Points on the New Vaccine for Patients

Community pharmacists have become an integral part of the fight to prevent herpes zoster (shingles). Since the FDA approval of the zoster vaccine live (ZVL, Zostavax) in 2006, community pharmacists have helped immunize several thousand eligible patients.

The CDC reports that rates of zoster immunization have increased by 16.2% from 2010 to 2015, and pharmacists have played a key role in this improvement. In October 2017, the FDA announced the approval of zoster vaccine recombinant (HZ/su, Shingrix), which gives pharmacists an updated vaccine to assist in the reduction of herpes zoster in their patients.

 Armed with an understanding of herpes zoster immunization updates, community pharmacists can better engage their pharmacy teams and patients in the opportunity to improve immunization rates to further reduce disease incidence.

According to the CDC, herpes zoster, a reactivation of latent varicella-zoster virus (VZV), affects 1 in 3 individuals in their lifetime. Individuals who either developed or were exposed to VZV are at risk for developing herpes zoster, which includes 99.5% of the US population over 40 years of age. The exact mechanism by which VZV is reactivated is unknown; however, it is likely attributed to a decline in immunity. As such, the risk of developing herpes zoster increases with age, with half of cases occurring over the age of 60. Additional at-risk groups include those who are immunocompromised, individuals with specific cancers or HIV, those who have undergone bone marrow or organ transplants, and those who are taking immunosuppressive medications.

Declining immunity as a natural result of aging increases not only the prevalence of herpes zoster but also the likelihood of developing severe associated long-term complications for patients who do develop the disease. Severity of postherpetic neuralgia (PHN) and ocular effects demonstrates an age-related relationship. With almost 13% of herpes zoster cases in individuals over 60 years resulting in PHN, the long-term impact of herpes zoster can be life-altering for many.

Immunization plays a key role in reducing the development of herpes zoster altogether and also in reducing disease severity and long-term complications in those who develop herpes zoster despite vaccination. To date, ZVL has been the mainstay of prevention; however, advancements in the recently released HZ/su vaccine offer promising improvements. Trial data demonstrated an overall reduction in herpes zoster of 97.2% for all patients older than 50 years and a 91.3% reduction in patients older than 70 years—a major improvement to the overall 51% reduction seen with ZVL.

Unlike its live attenuated predecessor, HZ/su is a recombinant adjuvanted vaccine.

 As a result, HZ/su may not necessarily exclude individuals based solely on contraindication to receiving live vaccines. Other major differences include the refrigerated, not frozen, storage requirement and intramuscular administration. HZ/su is a 2-dose series that requires administration at 0 and 2 to 6 months, in comparison with the single-dose ZVL. Both vaccines need to be reconstituted; however, HZ/su is supplied with an adjuvant for reconstitution rather than a sterile diluent. Unlike ZVL, which needs to be discarded if not used within 30 minutes after reconstitution, HV/su is stable for 6 hours when refrigerated.

HZ/su is indicated for the prevention of herpes zoster in patients 50 years and older and is also recommended for administration to this age group by the Accreditation Council of Immunization Practices (ACIP).

 This is a notable change from the ACIP recommendations for the ZVL vaccine that, despite the FDA- approved labeling for patients 50 years and older, never received approval for the 50- to 59-year-old population based on reported duration of immunity.

The HZ/su vaccine boasts increased longevity, an attribute that ZVL lacks. ZVL has demonstrated declining efficacy within the first 3 to 5 years after vaccination, while HZ/su has demonstrated sustained immunity in patients who were followed for up to 4 years.

 Those vaccinated early (prior to age 60) with ZVL may be underprotected, as vaccine-induced immunity wanes while they enter decades of life that present the highest risk for devel- oping herpes zoster. New ACIP recommendations indicate an HZ/su series in patients who have previously received ZVL and that HZ/su is now preferable to ZVL for the prevention of herpes zoster and related complications.

Community pharmacists are in a unique position to identify and target the expanded group of patients who now fall under the ACIP recommendations to receive HZ/su. The Pharmacists’ Patient Care Process, a 5-step process developed by the Joint Commission of Pharmacy Practitioners, is a model that engages pharmacists to collect and assess information to establish patient needs, make a plan/recommendation, implement/administer, and follow up.

Collecting and assessing are the first steps to identifying any needed immunization for a patient, and pharmacists are making this a part of daily practice for HZ/su. A thorough assessment includes review of patient-specific factors such as age, health conditions, occupation, travel and lifestyle, and knowledge of current immunization schedules.

 With age being the most prev- alent indicator for patients needing ZVL, assessing patients for HZ/su is simple. Patients falling into the age group of 50 years or older can be easily recognized during the prescription verification process or while verifying date of birth upon prescription pickup.

The accessibility of community pharmacists offers expanded opportunities for conversations about needed immunizations during patient encounters.

 Pharmacists can leverage prescription counseling sessions and self-care consults to initiate discussion about recommended immunizations. In addition, pharmacists can use opportunities to educate and recommend specific immunizations to groups of patients in their local communities through health fairs, presentations, and “brown bag” events. Review of vaccine status and further recommendations should also be a mainstay of medication therapy management sessions, including comprehensive medication reviews.

Talking to patients about gaps in their immunization status can sometimes be challenging; however, as health care providers, pharmacists have the responsibility to voice recommendations. The use of “personal selling” techniques has demonstrated impact on immunization rates.

 In this scenario, the pharmacist initiates patient conversations, effectively questions, and actively listens to decipher unmet patient needs, and presents the recommended service persuasively to bridge common goals.

Similarly, a pharmacist can make a “CASE” for a particular patient: Corroborate, About me, Science, and Explain.

 Discussing personal experiences, including those with friends and family members, regarding vaccine-preventable disease can help validate the pharmacist’s recommendations.

 Probing patients about their hesitation or concerns with a specific vaccine can provide a starting point for education. Pharmacists can then tailor an evidence-based recommendation that specifically addresses the needs of the patient. For example, some patients may not have received ZVL because of concerns with the almost 50% possibility that they would still develop a case of herpes zoster even after being immunized. Recognizing these concerns, a pharmacist can incorporate key points regarding the vast improvements with HZ/ su in terms of efficacy and duration of response. Most important, pharmacists should focus on specifically recommending identified immunizations, rather than asking patients whether they would like it or suggesting it might be beneficial.

Pharmacists are the central force in immunizing patients; however, pharmacy team members play an integral role in the process. Successful implementation of immunization programs relies on well-trained technicians. Pharmacy technicians can be involved in the assessment of patient immunization status, highlighting opportunities for pharmacists to intervene.

 Education for technicians should include the ability to review patient profiles for immunization history within the pharmacy dispensing system, as well as the use of immunization registries, where available.

 Team members can also be educated about key identifiers for specific vaccines and refer patients who fit these criteria to the pharmacist. For example, technicians should be able to recognize all adults over 50 years as potential candidates for the HZ/su vaccine and refer them to a discussion with the pharmacist.

Effective communication practices by the pharmacy team, including technician staff, are another key component of successful immunization programs. Daily technician communication practices have a substantial impact on referral relationships, the ability to relay billing and third-party information, verification of patient-received vaccines, and immunization-related documentation within the patient’s chart.

 Pharmacists have the responsibility to ensure team members are well adapted to speaking with both patients and providers. In addition, barriers exist for access to patient immunization histories because of inconsistent reporting and communication among health care professionals.

 For this reason, pharmacy practice is beginning to include more staff education on reporting to immunization registry programs and sharing immunization histories with a patient’s network of providers.

Knowledge of vaccine-related inventory and how to source product is another important technician role. Patients cannot be immunized without product on hand, so technicians are being trained (where states allow) about where to look for specific vaccines and how to reorder when they are out of stock.

In some areas, technicians are taking a more active role in immunization programs, including vaccine delivery. In December 2016, Albertsons Companies produced the first technician immunizer in Idaho through an innovative program.

 While the opportunity to administer immunizations is not widely available yet, technicians can become trained and/or certified in other areas (where states allow)—eg, cardiopulmonary resuscitation&mdash;to further support their role.

Pharmacists in the community are well positioned to continue to positively affect immunization trends, particularly with the addition of HZ/su to the vaccine repertoire. Staying up-to-date with current recommendations, engaging patients in discussion about gaps in immunization history, and working together with health care team members will continue to keep pharmacists as premier providers for immunization health.

Caitlin Malone, PHarmD, is the residency program director and experiential coordinator for the Jewel-Osco market of Albertsons Companies. She earned a bachelor’s degree from the University of Illinois in Urbana-Champaign and a PharmD from the University of Illinois at Chicago College of Pharmacy in 2010. She completed a PGY1 community practice residency with Jewel-Osco in 2011. Prior to her current role, she held several positions, including pharmacy manager, primary residency preceptor, wellness pharmacist, and clinical point person.

1. Williams WW, Lu P, O’Halloran A, et al. Surveillance of vaccination cov- erage among adult populations — United States, 2015. 

. 2017;66(11):1-28. doi: 10.15585/mmwr.ss6611a1.

2. Foster SL. CDC’s ACIP recommends preferred use of new herpes zoster vaccine. American Pharmacists Association website. pharmacist.com/article/cdc- s-acip-recommends-preferred-use-new-herpes-zoster-vaccine. Published October 31, 2017. Accessed January 22, 2018.

3. Shingles (herpes zoster). CDC website. cdc.gov/shingles. Updated October 17, 2017. Accessed January 18, 2018.

4. Shingrix [package insert]. Research Triangle Park, NC: GlaxoSmithKlein; 2017.

Zostavax [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2017.

5. ACIP live meeting archive — October 2017. CDC website. cdc.gov/vaccines/ acip/meetings/live-mtg-2017-10.html. Updated November 29, 2017. Accessed January 18, 2018.

6. Shingles (herpes zoster) vaccination information for healthcare providers. CDC website. cdc.gov/vaccines/vpd/shingles/hcp/. Updated December 5, 2017. Accessed January 18, 2018.

7. American Pharmacists Association. Applying pharmacists’ patient care process to immunization services. pharmacist.com/sites/default/files/Pharma- cists%20Patient%20Care%20Process%20Module%20for%20Immunizations%20 Services%20-%20FINAL.pdf. Updated January 27, 2017. Accessed January 22, 2018.

8. Standards for adult immunization practice. CDC website. cdc.gov/vaccines/ hcp/acip-recs/vacc-specific/shingles.html. Updated December 22, 2014. Accessed January 18, 2018.

9. Bach AT, Goad JA. The role of community pharmacy-based vaccination in the USA: current practice and future directions. 

. 2015;4:67- 77. doi: 10.2147/IPRP.S63822.

10. Bryan AR, Liu Y, Kuehl PG. Advocating zoster vaccination in a com- munity pharmacy through use of personal selling. 

 (2003). 2013;53(1):70-77. doi: 10.1331/JAPhA.2013.11097.

11. Anderson MC, Brown MT, Leger MM, et al. How to give a strong recommen- dation to adult patients who require vaccination. Medscape website. medscape. com/viewarticle/842874. Published April 16, 2015. Accessed January 18, 2018.

12. Teeter BS, Garza KB, Stevenson TL, et al. Factors associated with herpes zoster vaccination status and acceptance of vaccine recommendation in community pharmacies. 

. 2014;32(43):5749-5754. doi: 10.1016/j.vac- cine.2014.08.040.

13. Wang J, Ford LJ, Wingate L, et al. Effect of pharmacist intervention on herpes zoster vaccination in community pharmacies. 

(2003). 2013;53(1):46-53. doi: 10.1331/JAPhA.2013.12019.

14. Rothholz MC. The role of community pharmacies/pharmacists in vaccine delivery in the United States. American Pharmacists Association website. media. pharmacist.com/imz/ACIPpresentationRothholzJune2013.pdf. Accessed January 22, 2018.

15. Powers MF, Hohmeier KC. Pharmacy technicians and immuniza- tions. 

. 2011;27(3):111-116. journals.sagepub.com/doi/ pdf/10.1177/875512251102700303. Accessed January 22, 2018.

16. Bright D, Adams AJ. Pharmacy technician-administered vaccines in Idaho. 

. 2017;74(24):2033-2034. doi: 10.2146/ajhp170158.

Community pharmacists have become an integral part of the fight to prevent herpes zoster (shingles).

What Is the Pharmacist's Continued Role in Preventing Herpes Zoster?

Shingrix (Zoster Vaccine Recombinant, Adjuvanted) was approved in October 2017 for adults 50 years and older for the prevention of herpes zoster (shingles).

 Shingles develops after the reactivation of the varicella-zoster virus (VZV), the same virus that causes chicken pox. It is a painful rash that generally occurs on one side of the body, usually the face or torso. Complications may include postherpetic neuralgia (PHN) ophthalmic involvement, and bacterial infection. These complications can lead to hospitalization or even death. About 1 out of 3 people in the United States will develop shingles, and there are about 1 million cases each year. The risk of shingles and PHN increases with age.

Shingrix is administered as a 2-dose vaccine series (0.5 ml each) as an intramuscular injection.

 The second dose should be administered anytime between 2 and 6 months after the first dose. The vaccine series does not need to be restarted if more than 6 months have passed since the first dose.

 Shingrix should be prepared by reconstituting the glycoprotein E (gE) antigen component (brown cap) with the accompanying adjuvant suspension (blue-green cap). Both vial stoppers should be cleansed, and a sterile needle and syringe should be used to withdraw the entire contents of the vial containing the adjuvant suspension component by slightly tilting the vial. Next, the entire contents of the syringe should be transferred into the antigen component vial. Then, gently shake the vial to thoroughly mix the contents until the powder is completely dissolved. After reconstitution, 0.5 ml should be withdrawn from the vial containing the reconstituted vaccine and administered intramuscularly in the deltoid region of the upper arm. Pharmacists should not administer the vaccine if after visual inspection the products contain particulate matter and discoloration.

Shingrix has been shown to boost VZV-specific immune response with the adjuvant known as ASO1B, which is thought to protect against shingles.

 Additionally, VZV glycoprotein E is essential for viral replication and cell-to-cell spread, and is the primary target of VZV-specific immune responses. Shingrix does not contain preservatives.

Shingrix is supplied as 2 components, including the adjuvant and antigen (table 1).

Before reconstitution, both vials should be refrigerated between 36° and 46°F and protected from light.

 The vials should be discarded if they have been frozen. Shingrix should be used immediately after reconstitution or stored refrigerated between 36° and 46°F and used within 6 hours.

Immunosuppressive therapies may reduce the effectiveness of Shingrix. Shingrix is contraindicated in patients with a history of a severe allergic reaction to any vaccine component or after a previous dose of Shingrix.

Pharmacists should review the immunization history for possible sensitivity and previous vaccination-related adverse reactions. Epinephrine should be administered in the event of an anaphylactic reaction.

Clinical studies have demonstrated that Shingrix is safe, with the most common adverse effects being mild-to-moderate in severity (table 2). Pharmacists should report adverse reactions to the CDC’s Vaccine Adverse Events Reporting System. This is a great way for pharmacists to play an important role in postmarketing surveillance.

There are no available human data to establish any risks asso- ciated with administering Shingrix to pregnant women. It is unknown whether Shingrix is excreted into human milk.

The safety and efficacy of Shingrix have not been evaluated in patients younger than 18 years of age.

During clinical studies, patients could receive the inactivated influenza vaccine up to 8 days before each Shingrix dose or at least 14 days after the vaccine.

 The influenza vaccine did not affect the Shingrix immune response. The influenza vaccine can be administered on the same day as Shingrix as separate injections.

Shingrix is more effective than Zostavax; however there are no head-to-head trials comparing both. Two phase 3 placebo controlled trials were the basis of FDA approval and demonstrated the safety and efficacy of Shingrix.

 One study evaluated the safety and efficacy of Shingrix in 15,411 adults 50 years of age and older in 18 countries in Europe, North America, Latin America, and Asia-Australia.

 Study participants received 2 intramuscular doses or Shingrix or placebo 2 months apart. The primary objective was to evaluate the efficacy of the vaccine compared to placebo in reducing the risk of herpes zoster in older adults. Secondary end points included assessing the vaccine efficacy in each age group (50 to 59 years, 60 to 69 years, and at least 70 years). During the average follow-up of 3.2 years, there were 6 herpes zoster cases in the Shingrix group and 210 in the placebo group. The overall vaccine efficacy against herpes zoster was 97.2% (P<0.001) and was between 96.6% and 97.9% for all age groups. The demographics were similar in the 2 study groups, and the average age was 62 years. The most common reported adverse reaction was pain at the injection site.

The second trial was conducted at the same sites as the study involving adults 50 years of age and older.

 This was a randomized, placebo-controlled, phase 3 study conducted in 18 countries and involved 13,900 adults 70 years of age and older. Patients received 2 doses of Shingrix administered intramuscularly 2 months apart. Study participants were followed for at least 30 months after the second dose through monthly contacts and yearly clinic visits. The primary objective was to evaluate the efficacy of Shingrix compared with placebo in reducing the risk of shingles in adults 70 years of age and older. The average age of the study participants was 75.6 years. The average follow-up time was 3.7 years, and shingles occurred in 23 patients administered Shingrix and 223 in the placebo group. Overall vaccine efficacy against shingles was 89.8% (P<.001) and for PHN was 88.8%.

Evidence has demonstrated that the Zostavax vaccine reduces the overall incidence of shingles by 51% and the incidence of PHN by 67% for patients 60 years of age or older. The Zostavax vaccine efficacy decreases with age and is only about 38% effective for individuals older than 70 years of age.

The Advisory Committee on Immunization Practices (ACIP) voted that Shingrix is recommended as the preferred vaccine for healthy adults aged 50 years and older to prevent shingles and related complications.

 This is a change from the previous recommendations that individuals 60 years and older receive the Zostavax vaccine, and will likely result in more patients being vaccinated. Evidence indicates that a person’s risk of developing shingles increases after 50 years of age. Patients who have previously received the Zostavax vaccine should still receive 2 doses of Shingrix.

 It is important to note that Shingrix is not indicated for chicken pox prevention.

Because Shingrix is not a live vaccine like Zostavax, issues should not be expected with administering it to patients who may be immunocompromised. However, the studies excluded patients with confirmed or suspected immunosuppressive conditions (eg, cancer or HIV infection) or immunosuppressive therapy (eg, chemotherapy, organ transplantation medications, or autoimmune disorder treatment).

 Data are being gathered and should be published by the ACIP regarding administration of Shingrix to immunocompromised patients.3 Individuals who are immunocompromised with the following conditions have an increased risk of developing shingles: cancer, HIV, bone marrow or solid organ transplantation, taking immunosuppressive medications. The ACIP recommends that Shingrix can be administered to patients taking low-dose immunosuppressive therapy (eg, less than 20 mg/day of prednisone or equivalent or using inhaled or topical steroids) and individuals anticipating immunosuppression or those who have recovered from an immunocompromising condition.

 Patients with chronic medical conditions should receive Shingrix.

The vaccine cost is expected to be $280 for 2 doses.

 Shingrix is available for ordering, and pharmacies are starting to receive the vaccine. Because the recommendations were just published in the CDC’s Morbidity and Mortality Weekly Report, insurance companies will likely begin to cover Shingrix. It is also expected that Shingrix will be covered under Medicare Part D. Billing codes are available for administering and prescribing Shingrix (table 3). This can play a large role for pharmacists in reimbursement for medication therapy management services.

Pharmacists can play an important role in educating patients about the importance of completing the vaccine series. There is little information available regarding the efficacy of just one dose of Shingrix. Compliance may be increased by follow-up reminder phone calls and counseling during refill pick-ups. Patients may inquire whether they can develop shingles from Shingrix. Pharmacists should explain that because Shingrix is not live, individuals cannot develop shingles from the vaccine. It is also important to educate patients who have experienced shingles to still receive the vaccine to prevent future recurrences. Two to 3 shingles repeat episodes can occur in someone’s lifetime.

 Patients should generally wait until the shingles rash has disappeared before being vaccinated with Shingrix.

Encourage patients who have already received Zostavax to still get vaccinated with Shingrix, as the efficacy for shingles prevention is greater with Shingrix. A recent study examined the safety of Shingrix in patients who received the Zostavax vaccine at least 5 years ago.

 The study found that Shingrix produced a strong immune response and was safe in patients previously vaccinated with Zostavax.

 In fact, protection from Zostavax is lost after about 5 years, so it is important to target these patients for Shingrix vaccination.

 Recommend that patients wait at least 8 weeks after Zostavax administration to receive Shingrix.

Encourage patients 50 years and older to get the Shingrix vaccine. Patients may inquire how long it takes for Shingrix to become effective after the second vaccine dose. Studies have gen- erally evaluated the immune response 4 weeks after the second dose demonstrating the vaccine efficacy.

 Pain and redness are the most common injection site adverse reactions for patients to expect with Shingrix, but these should last for only a few days.

Discuss that Shingrix can help prevent PHN, which is the most common complication of shingles.

 This is persistent pain in the area where the rash once existed, and it can last from weeks to many years. Individuals are at a greater risk of experiencing PHN if they are over 50 years of age, have a severe case of shingles, or have a chronic disease such as diabetes.

Jennifer Gershman, PharmD, CPh is a medical writer and a 

 contributor who resides in South Florida.

1. Centers for Disease Control and Prevention. Shingles (herpes zoster). https://www.cdc.gov/shingles/. Accessed January 10, 2018.

2. Shingrix [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; 2017.

3. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for Use of Herpes Zoster Vaccines. 

. 2018;67:103-108. DOI:http://dx.doi.org/10.15585/ mmwr.mm6703a5

4. Lal H, Cunningham AL, Godeaux O, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. 

5. Cunningham AL, LaI H, Chlibek MK, et al. Efficacy of the herpes zoster sub- unit vaccine in adults 70 years of age or older. 

. 2016; 375:1019-32. 6. The new shingles vaccine: What you should know about Shingrix. Consumer Reports website. https://www.consumerreports.org/shingles-vaccine/new-shin- gles-vaccine-shingrix-what-you-should-know/. Accessed January 11, 2018.

7. GlaxoSmithKline. Shingrix coding. https://www.gsksource.com/pharma/ content/gsk/source/us/en/brands/shingrix/pi/coding.html. Accessed January 25, 2018.

8. Grupping K, Campora L, Douha M, et al. Immunogenicity and safety of the HZ/su adjuvanted herpes zoster subunit vaccine in adults previously vaccinated with a live attenuated herpes zoster vaccine. 

9. Centers for Disease Control and Prevention. Considerations for the use of herpes zoster vaccines. https://www.cdc.gov/vaccines/acip/meetings/downloads/ slides-2017-10/zoster-04-dooling.pdf. Accessed January 15, 2018.

10. Mayo Clinic. Postherpetic neuralgia. https://www.mayoclinic.org/diseas- es-conditions/postherpetic-neuralgia/symptoms-causes/syc-20376588. Accessed January 16, 2018.  

About 1 out of 3 people in the United States will develop shingles, and there are about 1 million cases each year.

Shingrix Vaccine for Shingles Prevention: What Pharmacists Should Know

Vaccination remains one of the most cost-effective interventions to reduce morbidity and mortality from vaccine-preventable diseases.

 Childhood immunization programs have increased the life expectancy during the 20th century and have helped to prevent 14 million cases of disease. National childhood vaccination rates remain high, and since the year 2000, government spending on vaccines and immunization have been increasing at a steady rate.

 Despite this progress, children are still at risk for vaccine-preventable diseases. In addition, adult vaccination coverage remains low for most routinely recommended vaccines and the prevalence of vaccine-preventable illnesses among older adults is notably high.

 To counteract this, the US Department of Health and Human Services has introduced Healthy People 2020, a nationwide health promotion and disease prevention program that includes goals for improving the immunization rates in the United States.

 Healthy People 2020 objectives and targets can be found on its website.

According to statistics from the CDC’s 2015 National Immunization Survey, the coverage for all vaccines among adults remained relatively low. However, the study did find modest gains in vaccination coverage for influenza in adults aged ≥19 years, pneumococcal in adults aged 19 to 64 years with increased risk, Tdap in adults aged ≥19 years, herpes zoster in adults aged ≥60 years, and hepatitis B in health care personnel aged ≥19 years of age. Nonetheless, even with these small gains, the rates are still well below the Healthy People 2020 goals. As a whole, adult vaccination coverage has remained unchanged without significant improvement.

Almost 1 out of every 3 individuals in the United States will develop shingles, also known as herpes zoster.

 Shingles is caused by the reactivation of the varicella zoster virus, the same virus that causes chicken pox. The risk of getting shingles increases as you age, especially when your immune system loses the ability to suppress reactivation of the varicella zoster virus. Shingles typically presents as a painful, itchy rash that develops on 1 side of the body and can last for 2 to 4 weeks.

 Once the rash is gone, the most common complication of shingles is postherpetic neuralgia, which is severe pain in the areas where the shingles rash occurred. Postherpetic neuralgia causes substantial morbidity that can interfere with activities of daily living and reduce the quality of life.

 There are an estimated 1 million cases of shingles in the United States each year. Shingles is increasing among adults in the United States, and it remains unclear as to what is causing this increase.

 In 2015, 31% of adults aged 60 years and older reported receiving the shingles vaccine, which is an increase from the 28% reported the previous year. The increased prevalence of shingles reinforces the importance of continuing efforts to increase the vaccination rate among older adults.

There are 2 vaccines for the prevention of herpes zoster. Zostavax (Merck & Co., Inc.), a live, attenuated vaccine, is licensed in the United States for the prevention of shingles in individuals 50 years of age and older and has been in the market since 2006.

 Zostavax is administered as a single subcutaneous injection. Shingrix (GlaxoSmithKline PLC) was recently approved by the FDA and is an inactivated, adjuvanted recombinant zoster vaccine denoted as HZ/su. HZ/su is administered intramuscularly (IM) in 2 doses (0.5 mL each) according to the following schedule: the first dose at month 0 followed by a second dose given anytime between 2 and 6 months later. After reconstituting Shingrix, it should be administered immediately or stored refrigerated and used within 6 hours.

 It is unknown how effective 1 dose of HZ/ su is, so completion of doses is crucial to ensure the expected protective immune response.

Zostavax (ZVL, new CDC abbreviation) pre- and post-licensure show about a 51% reduction in shingles cases.

 In comparison in phase 3 trials, HZ/su showed 97.2% and 89.8% efficacy in those over 50 years and those over 70 years, respectively.

 The findings from these trials resulted in the Advisory Committee on Immunization Practices (ACIP) vote to recommend preferential use of Shingrix over Zostavax for all adults 50 years and older (ZVL is only ACIP routinely recommended for those 60 years and older). ACIP further recommended that healthy adults aged 50 years and older who had been previously vaccinated with Zostavax to now be vaccinated with Shingrix. These recommendations have been published in the

 Other notable differences between HZ/ su and ZVL are that HZ/su is refrigerated instead of frozen and HZ/su appears to have a more sustained immune response.

 Since 2006, Zostavax has been the only vaccine in the market for the prevention of shingles. According to the CDC, vaccination rates for herpes zoster improved from 30.6% in 2013 to 34.2% in 2014.

 Even though Shingrix may have better efficacy than Zostavax, Shingrix is a 2-dose series vaccine with more adverse reactions, which may pose a new set of challenges when it comes to compliance with completing this vaccination series.

Adolescents and adults who receive only the first dose of a multi-series vaccine remain only partially protected from vaccine-related disease. It is not until they receive the final dose of the schedule that they will be protected.

 Completing the vaccine dose series within 1 year of the first dose has proven to be an obstacle in some settings. Most of the current literature has focused on evaluating the compliance and completion rates for human papillomavirus (HPV) vaccine. In 2015, coverage with ≥1 HPV vaccine dose was 49.8% and with ≥3 doses was 28.1% among males. Among females, coverage with ≥1 dose was 62.8% and with ≥3 doses was 41.9%.

 This indicates that there must be improved efforts focused on completing the additional required doses. For both cases, these vaccinations rates are far from the 2020 target of 80%,

 and many adolescents and young adults remain unprotected. Multiseries vaccinations completion may be hampered because it requires patients to come back to receive the additional doses. Improved systems of care need to be implemented to ensure every series of a vaccine that is started is finished. Providers and program planners should be aware that obtaining good initiation rates is not enough and efforts should be placed on the second or third vaccine.

Taking advantage of visits to a health care provider and avoiding missed opportunities could help improve vaccine completion rates. A missed opportunity is a health care encounter in which a person is likely to receive a vaccination but is not vaccinated completely.

 Missed opportunities occur for several reasons: inability to screen patients for vaccination eligibility, perceived contraindications to vaccination, inconvenient clinic hours, and parental or community resistance to immunizations.

 Strategies to combat these common missed opportunities include identifying any person eligible for vaccination, incorporating immunization needs assessment into every clinical encounter

 and offering vaccinations to those who come into a health facility or pharmacy. One study showed that higher number of visits to a health care provider was associated with a 15% increased likelihood of HPV vaccine completion and a 4% to 6% increase in hepatitis B virus (HBV) vaccine completion.

Understanding the barriers to immunization are necessary to develop interventions that effectively increase immunization coverage in both adolescents and adults. Some common obstacles that hinder vaccination rates include: lack of knowledge on which vaccines are recommended for adults and adolescents and misinformation about immunization on the internet and social media. Successful interventions include improving community awareness of services available and engaging with adults and health care providers in multiple settings.

Pharmacists’ can act as a source of information to dispel misperceptions regarding vaccines and are able to identify patients at risk for vaccine-preventable diseases through use of pharmacy dispensing data and patient interviews. Pharmacists are also able to use an “inferred diagnosis” based on patient prescriptions when the medical record is not available, and identify specific populations at need for a specific vaccination. For example, a pharmacist that is dispensing medications indicated for diabetes to an adult patient should talk to the patient about possible need of the pneumococcal and hepatitis B vaccine. Other interventions that have led to an increase in the uptake of vaccinations among children, adolescents, and adults have been reminder interventions, such as contacting patients with a telephone call, letter or postcard in the mail, or electronic text message—with telephone reminders being the most effective. It was found that reminding patients to receive their vaccinations, can lead to an average of 8% increase in the number of people who get vaccinated.

Other proposed solutions for pharmacists in the community is to collaborate with local health departments, health organizations, and provider offices to ensure completion of series vaccines that are started in these settings. For example, pharmacists can partner with obstetrician-gynecologists (OB-GYN) to have the OB-GYN administer the first dose of the HPV vaccine, and have the patient follow-up with the pharmacist to complete the remaining 2 doses in the pharmacy. This can be done for any vaccine that requires multiple doses for completion.

The recommendation from a health care provider is one of the most important predictors of patients uptake of vaccines. One study found that parents who receive a provider recommendation for vaccinations were more likely to have children who had completed the regimen.

 It is important for health care providers to encourage patients to vaccinate using dialogue-based interventions, which are considered most effective.

 Health care providers should routinely assess their patients for vaccination needs and provide a strong recommendation for any needed vaccines.

A strong and motivational recommendation should be tailored specifically for each individual and should address: (1) why the vaccine is recommended, (2) underscore consequences of the vaccine-preventable disease to the patient, and (3) benefits that are offered by the vaccine. The 2013 Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice is a useful document that provides other approaches that all health providers should incorporate into their routine immunization practice to increase vaccination coverage.

Providing vaccinations outside of a traditional physician’s office in settings such as pharmacies offers opportunities for expanded access and convenience. In one study, providing immunization services during hours outside of traditional medical clinic hours allowed the working population to be vaccinated when it was convenient to them. The results of the study showed that about 30% of the study population received 1 or more vaccinations during these off-clinic hours.

Aside from offering vaccinations at provider offices and pharmacies, some studies have even looked at vaccination completion rates when offered at schools. There is also strong evidence for high completion rates with school-delivery in high and low-middle income countries. For example, in a Canadian study, in-school HPV vaccination completion rates were 75% compared to 36% for those provided with a community-delivery model.

 This strengthens the need to create more access for community members to receive and complete their series vaccinations. Pharmacists can get involved in expanding access to immunizations by hosting vaccination clinics and events beyond the community pharmacy to other community settings such as schools, places of worship, colleges, malls, and workplaces.

As the pharmacists’ role continues to expand in immunization delivery, it will have a direct positive impact on the national efforts to increase immunization rates to the Healthy People 2020 goals.

 Pharmacists’ should follow the American Pharmacists Association’s Pharmacist Patient Care Process for Immunization Services which includes a systematic approach to collecting and assessing immunization information, planning for and implementing immunization administration; and follow-up and monitoring of series completion and safety.

 With more than 86% of Americans living within 5 miles of a community pharmacy, pharmacists are one of the most accessible, but underutilized health care providers in the US health care system.

Amy Lei, PharmD, is a pharmacy resident at Kindred Hospital in La Mirada, California. She has no conflicts of interest to report.

Albert Bach, PharmD, is an assistant professor of pharmacy practice at Chapman University School of Pharmacy in Irvine, California, and faculty in residence at Newport Coast Pharmacy in Newport Beach, California. He has no conflicts of interest to report.

Jeff Goad, PharmD, MPH is a professor and the chair of the Department of Pharmacy Practice at Chapman University School of Pharmacy in Irvine, California. He is a speaker for Merck Vaccine and a consultant for GSK.

1. Zhou F, Shefer A, Wenger J, et al. Economic evaluation of the routine childhood immunization program in the United States, 2009. 

2. Immunization and Infectious Disease. Healthy People 2020. https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectives Accessed 17 January 2018.

3. CDC. Vaccination Coverage Among Children in Kindergarten—United States, 2014-2015. 

4. CDC. Estimates of deaths associated with seasonal influenza—United States, 1976—2007. 

5. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. 

6. CDC. Surveillance of Vaccination Coverage Among Adult Populations—United States, 2015. 

7. Hales CM, Harpaz R, Joesoef MR, Bialek SR. Examination of links between herpes zoster incidence and childhood varicella vaccination. 

9. CDC. Prevention of herpes zoster: Recommendations of the advisory committee on immunization practices (ACIP). 2008/57(05); 1-30 Accessed 20 January 2018.

10. Shingles (Herpes Zoster) Vaccination Information for Healthcare Providers. 

https://www.cdc.gov/vaccines/vpd/shingles/hcp/index.html

11. Leung J, Harpaz R, Molinari NA, Jumaan A, Zhou F. Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination. 

12. ZOSTAVAX® (Zoster Vaccine Live) [Package Insert] Merck & Co., Inc. 2006 Accessed 18 January 2018.

As a whole, adult vaccination coverage has remained unchanged without significant improvement.

February 2018 Immunization Supplement

Guide to Adult Immunizations

Herpes Zoster: Talking Points on the New Vaccine for Patients

What Is the Pharmacist's Continued Role in Preventing Herpes Zoster?

Shingrix Vaccine for Shingles Prevention: What Pharmacists Should Know

Improving Adherence With Immunization Schedules