Herpes zoster (HZ), also known as zoster or shingles, is caused by the reactivation of the varicella zoster virus. After an individual has been exposed to the varicella virus through chickenpox or via vaccination, the virus remains dormant in the dorsal root ganglia.

According to the CDC, 1 million cases of HZ occur in the United States per year and 1 of every 3 people will have HZ at some point during their lifetime.

The likelihood of contracting HZ is higher in certain patient populations, especially those with an immunosuppressive medical condition such as leukemia, lymphoma, or HIV and those who take immunosuppressive medications like corticosteroids and antirejection medications after organ transplantation.

One study estimates that HZ is the underlying cause of death of 78 people in the United States annually.

The risk of contracting HZ increases with age. Those over 50 years are at a higher risk of having HZ with more severe, long-term complications.

Postherpetic neuralgia (PHN) is the most common complication of HZ, causing persistent pain in the lesion-affected area, and can last years after the HZ rash has resolved. Among those 60 years and older, 13% will develop PHN after contracting HZ.

 Other complications include ophthalmic involvement, which can cause permanent vision loss, bacterial infection due to increased susceptibility in the zoster lesions, and palsies resulting from involvement of cranial and peripheral nerves.

 Complications in other organ systems affected by HZ can include hepatitis, pneumonitis, meningoencephalitis, and acute retinal necrosis.

Community pharmacists have the opportunity to play a key role in the early detection and treatment of HZ. Pharmacists are one of the most trusted and accessible health care providers, with the majority of the United States population living within 5 miles of a community pharmacy.

 By knowing the signs and symptoms of HZ, pharmacists can help their patients identify HZ and seek immediate treatment. Early identification is critical, as antiviral therapy can be initiated for patients who are treated within 72 hours of the onset of symptoms. Antiviral therapy can lessen the severity and duration of the pain, prevent formation of new lesions, promote rapid healing of existing lesions, and reduce the spread of HZ to others.

 However, if the patient has had symptoms for over 72 hours, the benefit of antivirals is less clear and they are often not prescribed. By helping triage patients and referring them to seek immediate care, pharmacists can help reduce the severity of the disease and the likelihood of its spreading to others. See 

 for a list of questions that may be helpful if HZ is suspected.

Often laboratory testing is not needed because the signs and symptoms of HZ are distinct enough to make an accurate clinical diagnosis once the rash has appeared. A unique feature is the location of the rash. HZ usually affects 1 dermatome, although it can occasionally affect multiple ones.

 The thoracic and lumbar dermatomes are the ones most commonly effected. Serious complications can occur when the dermatomes of the face are affected.

This can include vision loss and cranial palsies.

 The initial HZ rash usually presents as an erythematous rash of small raised papules. After 3 to 4 days, the papules progress to pustules or blisters, and after 10 days, the lesions typically crust or scab over and no longer considered infectious.

In addition to rash, pain is the most common symptom of HZ. Prodromal pain, or pain that occurs before the rash begins, is reported by approximately 75% of patients and may occur in the days to weeks before the rash is visible.

 The pain can be constant or intermittent with touch and has been described as a burning, throbbing, or stabbing sensation.

 Mild cases can be treated with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or both in combination. Moderate to severe pain may require treatment with opioid pain relievers. Other, less common symptoms of HZ include headache, fatigue, fever, and malaise. These symptoms are seen in less than 20% of patients.

 Patients with these symptoms can benefit from an OTC NSAID or acetaminophen. 

As an integral part of the clinical team, pharmacists can counsel patients with a confirmed diagnosis about OTC and prescription medications for the treatment of HZ, the progression of the disease, and self-monitoring for complications. See 

for a list of recommended self-care options for HZ.

 Note that these recommendations should be made after the diagnosis is confirmed, not in place of a referral for medical attention, to ensure that the standard of care is followed.

Another emerging role for pharmacists is identification and treatment of shingles in the community pharmacy setting. Some state practice acts allow pharmacists to prescribe treatment for ailments like herpes zoster through collaborative drug therapy agreements (CDTAs) or collaborative practice agreements. Pharmacists collaborate with physicians to prescribe medication as allowed in an agreed-on protocol. For HZ, these protocols often include treatment of only uncomplicated shingles cases, requiring referral for any cases in which the rash has become more severe with further complications.

 In cases meeting CDTA treatment criteria, the pharmacist is authorized to prescribe valacyclovir, famciclovir, or acyclovir, ensuring the patient has quick access to initiating antiviral therapy. 

Patient monitoring is critical after an episode of HZ because 10% to 15% of patients will develop PHN. Risk factors for PHN include older age, greater rash severity, and severe acute pain.

 Pharmacists can aid in patient monitoring by following up with the patient to confirm that no new lesions are forming, old lesions are crusting or scabbing, pain is stable or resolving, and other symptoms have resolved or are relieved by the recommended treatment. If new lesions are forming, a new fever has developed, or pain is becoming more severe, the patient should be referred for immediate treatment.

Whether triaging and referring the patient for treatment, prescribing antivirals per CDTA protocol, counseling on newly prescribed medication, recommending OTC self-care options, or aiding the patient in self-monitoring the progression of shingles, pharmacists can play a key role in the care of patients with HZ.

KIMBERLY MCKEIRNAN, PHARMD, BCACP, is a clinical assistant professor in the department of pharmacotherapy at the Washington State University College of Pharmacy and Pharmaceutical Sciences.

Shingles (herpes zoster) clinical overview. CDC website. cdc.gov/shingles/hcp/clinical-overview.html. Updated February 21, 2018. Accessed July 14, 2018.

Shingles (herpes zoster) overview. CDC website. cdc.gov/shingles/about/overview.html. Updated June 15, 2018. Accessed July 14, 2018.

Mahamud A, Marin M, Nickell SP, Shoemaker T, Zhang JX, Bialek SR. Herpes zoster-related deaths in the United States: validity of death certificates and mortality rates, 1979-2007. 

. 2012;55(7):960-966. doi: 10.1093/cid/cis575.

Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster. Recommendations of the Advisory Committee on Immunization Practices (ACIP). 

Knapp KK, Paavola FG, Maine LL, Sorofman B, Politzer RM. Availability of primary care providers and pharmacists in the United States. 

Honesty/ethics in professions. Gallup website. gallup.com/poll/1654/honesty-ethics-professions.aspx. Accessed January 9, 2017.

DeArment A. Pharmacists are face of health care in community. 

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Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster

Gnann JW Jr, Whitley RJ. Clinical practice. Herpes zoster

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Kost RG, Straus SE. Postherpetic neuralgia--pathogenesis, treatment, and prevention. 

Straus SE, Ostrove JM, InchauspéG, et al. NIH conference. Varicella-zoster virus infections. Biology, natural history, treatment, and prevention. 

Shaikh S, Tah CN. Evaluation and management of herpes zoster ophthalmicus. American Family Physician website. https://www.aafp.org/afp/2002/1101/p1723.html. Published November 2002.

Clinical community pharmacist. Washington State Pharmacy Association website. wsparx.site-ym.com/?CCP. Accessed May 23, 2016.

Jung BF, Johnson RW, Griffin DR, Dworkin RH. Risk factors for postherpetic neuralgia in patients with herpes zoster. 

Articles

Herpes Zoster Vaccines

Herpes zoster, also known as zoster or shingles, is caused by the reactivation of the varicella zoster virus. After an individual has been exposed to the varicella virus through chickenpox or via vaccination, the virus remains dormant in the dorsal root ganglia.

A Pharmacist's Guide to Identifying the Signs and Symptoms of Herpes Zoster

Herpes zoster, commonly known as shingles, is characterized by a painful, itchy rash and blisters, often resulting in permanent neuropathic pain (postherpetic neuralgia) that can be difficult to manage.

 It is caused by a reactivation of dormant varicella zoster virus, the same virus that causes chickenpox, in response to immune system compromise.

 Approximately 1 million cases of herpes zoster are diagnosed in the United States each year.

 As age increases, the prevalence of herpes zoster increases in adults. In those aged 50 to 59 years, the incidence ranges from 5 to 11 cases per 1000 population, depending on age.

 Postherpetic neuralgia, which may persist after the rash disappears, occurs in approximately 10% to 13% of cases.

Herpes Zoster Vaccine: Background and Trial Data

In 2006, the FDA approved zoster vaccine live (ZVL) (Zostavax) for use in immunocompetent adults 50 years and older for the prevention of herpes zoster and its complications.

 Because vaccine efficacy has not been studied long term in those patients aged 50 to 59 years, the CDC and the Advisory Committee on Immunization Practices (ACIP) recommend the use of ZVL in immunocompetent adults 60 years and older.

 Study results have demonstrated that ZVL efficacy wanes 5 years after the vaccination in those patients 60 years and older.

 Therefore, ACIP recommends waiting until patients are age 60 to administer ZVL to provide protection from herpes zoster when it is needed most.

 ZVL is administered as a single subcutaneous injection.

Several clinical studies have demonstrated efficacy for both ZVL and zoster vaccine recombinant, adjuvanted. Findings from the ZEST study demonstrated 69.8% efficacy rates for ZVL in preventing herpes zoster in patients aged 50 to 59 years, with a median follow-up of 1.3 years.

 Results from the SPS trial showed a 64% efficacy rate in patients aged 60 to 69 years and a 38% efficacy rate in those 70 years and older, suggesting a drop-off in efficacy with advanced age.

 Waning of immunity has also been noted with ZVL since the time of vaccination.

 Study data have shown efficacy rates of less than 35% by 6 years post vaccination.

 The longest study of ZVL demonstrated that estimates of effectiveness were no longer statistically significant after 9 to 11 years.

In a phase 3 clinical trial, ZVL demonstrated efficacy against postherpetic neuralgia in 65.7% of cases in participants aged 60 to 69 years and 66.8% in those 70 years and older, with a median follow-up of 3.1 years.

ZVL was the only option available for the prevention of herpes zoster until October 2017, when the FDA approved zoster vaccine recombinant, adjuvanted (Shingrix).

 Containing recombinant glycoprotein E in combination with an adjuvant, zoster vaccine recombinant, adjuvanted, is a viral subunit vaccine that increases the body’s immune response.

 It is indicated for the prevention of herpes zoster in adults 50 years and older, and it is administered as a series of 2 intramuscular injections given 2 to 6 months apart.

 ACIP recommends the zoster vaccine recombinant, adjuvanted, for adults over the age of 50, even if they have already received ZVL.

 Additionally, ACIP has expressed a preference for the zoster vaccine recombinant, adjuvanted, over ZVL (

Efficacy rates of zoster vaccine recombinant, adjuvanted, were evaluated in the phase 3 ZOE-50 trial.

 Findings indicated that zoster vaccine recombinant, adjuvanted, demonstrated 96.6% efficacy rates in patients aged 50 to 59 years and 97.4% in those aged 60 to 69 years during a median follow-up period of 3.2 years.

 Investigators pooled data from this trial with the ZOE-70 trial and found an efficacy rate of 91.3% in those 70 years and older.

Median follow-up in ZOE-70 was 3.7 years.

 At a follow-up of 1 year, vaccine efficacy was 97.6% and remained at 84.7% or higher at 3 years.

Zoster vaccine recombinant, adjuvanted, has also demonstrated efficacy in the prevention of postherpetic neuralgia.

 The efficacy rate was 91.2% in participants 50 years and older and 88.8% in those 70 years and older.

There are several important differences between the 2 herpes zoster vaccines that are worth exploring in more detail (

Zoster vaccine recombinant, adjuvanted, has clinical advantages over ZVL, in part because it is produced using recombinant DNA technology and is not likely to cause disease. In contrast, varicella-type rashes were reported in rare instances with ZVL in clinical trials.

 Additionally, cases of herpes zoster have been reported in immunocompetent patients, and life-threatening or fatal complications have been reported in immunocompromised patients following ZVL administration.

 Zoster vaccine recombinant, adjuvanted, contains an adjuvant for a stronger and more persistent immune response.

 Clinical trial results have demonstrated improved and longer-lasting efficacy compared with ZVL, and studies are under way to evaluate safety in those who are immunocompromised.

ZVL may be administered to patients 60 years and older.

 Some patients may prefer a 1-dose option to a 2-dose series for ZVL.

 It is important to remind patients 60 years and older that zoster vaccine recombinant, adjuvanted, is preferred by the CDC.

 However, ZVL may be used if a patient requests immediate vaccination if the zoster vaccine recombinant, adjuvanted, is not available at the time of the vaccine or if the patient is allergic.

ZVL is a live, attenuated vaccine and is contraindicated in those with immunosuppression because of conditions or therapies. These may include primary or acquired immunodeficiency states, AIDS, and other clinical manifestations of infection with HIV or leukemia, lymphoma, or other malignancies affecting the bone marrow or lymphatic system.

 Vaccinations should be deferred for at least 4 weeks after immunosuppressive therapy has been discontinued.

 However, ZVL may be administered to those taking a low-dose immunosuppressive therapy (eg, less than 14 days of corticosteroid use, less than 20 mg daily of prednisone or its equivalent, or a topical or inhaled corticosteroid).

ZVL is also contraindicated in patients with a history of anaphylactic or anaphylactoid reactions to gelatin, neomycin, or any other component of the vaccine.

 ZVL should not be administered to women who are pregnant or may become pregnant, and women should wait at least 4 weeks after the vaccination to become pregnant.

The CDC recommends administering ZVL at the same time as other vaccines, such as the pneumococcal vaccine and other inactivated vaccines.

 Injection site reactions (pain, redness, and swelling) have been reported in 63.6% of patients receiving ZVL in the ZEST study and 48% in the SPS trial. However, only 0.9% reported symptoms as grade 3 or adverse effects that limited daily activity.

The CDC/ACIP recommends 2 doses of zoster vaccine recombinant, adjuvanted, 2 to 6 months apart in patients 50 years and older for the prevention of herpes zoster.

 The series does not need to be restarted if more than 6 months have elapsed since the first dose, but there are no studies to evaluate these alternative scenarios. Individuals may be at greater risk of developing herpes zoster if there is a longer interval between doses.

 Zoster vaccine recombinant, adjuvanted, should be administered regardless of a patient’s history of herpes zoster, varicella, or a previous ZVL dose.

 It is also advisable to administer zoster vaccine recombinant, adjuvanted, at least 2 months after a dose of ZVL.

Like ZVL, zoster vaccine recombinant, adjuvanted, may be administered to those taking a low-dose immunosuppressive therapy (eg, less than 14 days of corticosteroid use, less than 20 mg daily of prednisone or its equivalent, or a topical or inhaled corticosteroid), anticipating immunosuppression, or recovering from an immunocompromising illness.

Zoster vaccine recombinant, adjuvanted, should not be given to patients currently experiencing an episode of herpes zoster.

 There is no specific waiting period, but the zoster rash should be clear before administering the vaccine.

 Also, individuals with a history of severe allergic reaction to the vaccine or any component of the vaccine should not receive it.

 Those who are known to be seronegative for varicella should not receive zoster vaccine recombinant, adjuvanted.

 Consider delaying zoster vaccine recombinant, adjuvanted, in patients who are pregnant or breast-feeding, as the vaccine has not been evaluated in these populations or in those who are moderately or severely ill.

Zoster vaccine recombinant, adjuvanted, may be administered with other vaccines, including influenza and pneumococcal vaccines.

 The safety of concomitant administration of 2 adjuvanted vaccines, such as ZVL and influenza virus vaccine, surface antigen, inactivated, and adjuvanted with MF59C.1 (Fluad), has not been evaluated.

The most commonly reported adverse effects with zoster vaccine recombinant, adjuvanted, administration in clinical trials included pain (78%), swelling (25.9%), and redness (38.1%) at the injection site.

 Tiredness, muscle pain, headache, shivering, fever, stomach pain, and nausea were also reported.

 Approximately 1 of 6 patients reported grade 3 adverse effects.

Zoster vaccine recombinant, adjuvanted, represents an advancement in the prevention of herpes zoster and its complications. It provides a greater and longer-lasting immune response for better protection and is preferred by ACIP over ZVL. Advise patients that both doses of zoster vaccine recombinant, adjuvanted, must be administered to receive the full benefit of the vaccine, even if they have received ZVL in the past. Also, it is important to set up reminders and speak with patients when they return to the pharmacy for refills. Advise patients that there may be may injection site pain and redness, but these symptoms generally dissipate after a few days and typically do not get worse with the second dose of the vaccine.

APRIL M. HOPPER, PHARMD, is manager of the Rite Aid Drug Information Center in Pittsburgh, Pennsylvania.

Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. 

. 2018;67(3):103-108. doi: 10.15585/mmwr.mm6703a5.

Zostavax (Zoster Vaccine Live) [prescribing information]. Whitehouse Station, NJ: Merck & Co Inc; 2018. merck.com/product/usa/pi_circulars/z/zostavax/zostavax_pipdf. Accessed July 26, 2018.

Zoster vaccine: CDC answers your questions. Immunization Action Coalition website. immunize.org/catg.d/p2025.pdf. Accessed July 3, 2018.

Shingles vaccine: FAQs. Therapeutic Research Center website. trchealthcare.com. Published 2017.

Zoster Vaccine - Recombinant, Adjuvanted (Shingrix) [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2017. gsksource.com/shingrix. Accessed July 3, 2018.

Vaccines and preventable diseases: shingles vaccination. CDC website. cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html. Updated June 13, 2018. Accessed July 18, 2018.

Herpes Zoster Vaccination: Recent Advancements and Recommendations

Pharmacists are now core members of the vaccination community, playing a role in vaccine accessibility, opportunity, identification, and safety. This has become more evident with the unprecedented uptake of the new recombinant, adjuvanted zoster vaccine (RZV, Shingrix). Pharmacists can take advantage of their unique position to promote important aspects of their patient’s health care by exhibiting a proper understanding of when to administer the vaccine to appropriate patients, and, just as important, when not

Patients visit community pharmacies as many as 35 times per year, according to estimates.

 Although many patients will visit their pharmacist significantly fewer times than this, there is no shortage of opportunities for practitioners to engage in conversations about vaccinations. To be successful, however, pharmacists must be aware of the recommended indications for each vaccine and should form the habit of having these critical conversations with patients.

Vaccinations may occupy the minds of parents during back-to-school season for their children, but adults may not be thinking about protecting themselves. As parents and patients 50 years and older arrive at the pharmacy to ensure their child’s vaccines are up-to-date, pharmacists should ask whether they have considered getting vaccinated for herpes zoster. As with all vaccines, education regarding the disease is critical in the decision-making process for patients.

Back-to-school conversations are not the only opportunities to have conversations about vaccines with patients. The fall and early winter bring another critical opportunity: flu season.

Most of pharmacy vaccination volume is related to influenza.

 Patients seeking vaccination for influenza already demonstrate a recognition of the importance of immunizations. These patients may be excellent candidates for conversations regarding other vaccines, including RZV, for which they are eligible.

Some adults may be familiar with multiple vaccinations in a single visit for their children. However, multiple vaccinations may be a foreign idea when it comes to their own health. It is safe to receive most adult vaccines during the same visit, and the CDC offers resources to help educate patients about multiple vaccinations. The 1 exception pertains to a patient’s receiving the adjuvanted influenza vaccine (Fluad). Because RZV is also adjuvanted, it cannot be administered at the same time as the adjuvanted influenza vaccine.

When pharmacists are having conversations about immunization, simply handing over information may not be enough. If a vaccine is indicated for a patient, the individual is at some level of risk for contracting the condition, and delaying a vaccination can put an unnecessary risk of infection on the patient.

There has been recent media attention surrounding patients who feel uncomfortable with multiple immunizations, and some patients will spread vaccinations across multiple visits. Because there is no documented benefit to the multiple-visit approach and there is significant risk associated with the practice, proper education can help patients make decisions that are in the best interest of their overall health.

Contraindications and Reasons to Delay RZV

There are, however, some circumstances in which pharmacists should delay administration of RZV, including the following

The patient has an active shingles infection.

The patient has another active acute infection (signified by a temperature over 101.3°F).

The patient received zoster vaccine live (ZVL; Zostavax) in the past 8 weeks.

The patient is pregnant or breast-feeding.

In some situations, RZV may be contraindicated for a patient entirely. Patients known to be seronegative for the varicella zoster virus may be advised against RZV. Despite this contraindication, there is no requirement to screen patients for the varicella zoster virus prior to vaccination. Most adults have

Another reason RZV may be contraindicated is a known hypersensitivity to the vaccine. In this circumstance, the patient may be a good candidate for ZVL. RZV does not have any cross-sensitivity with ZVL. This remains the primary situation in which ZVL would be indicated. ZVL may also be recommended to avoid delaying the vaccination for patients who are unable to access RZV because of a current short supply of the vaccine.

Pharmacists play a critical role in the accessibility of vaccinations. By identifying vaccination opportunities and providing education about vaccines, pharmacists are helping patients avoid significant conditions that could lead to long-term adverse health consequences. Pharmacists must also identify circumstances in which it is unsafe to administer vaccines to certain patients and provide education on any adverse events that may occur after receiving a vaccination. This is particularly important when it comes to RZV, as this vaccine is reputed to have more severe adverse effects than most other routine vaccines.

ERIC ROATH, PHARMD, MBA, is a clinical care coordinator for SpartanNash.

Moose J, Branham A. Pharmacists as influencers of patient adherence. 

. pharmacytimes.com/publications/directions-in-pharmacy/2014/august2014/pharmacists-as-influencers-of-patient-adherence-. Published August 2014. Accessed July 17, 2018.

Burson RC, Buttenheim AM, Armstrong A, Feemster KA. Community pharmacies as sites of adult vaccination: a systematic review. 

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Pharmacists are now core members of the vaccination community, playing a role in vaccine accessibility, opportunity, identification, and safety.

Seizing Patient Education Opportunities and Recognizing Precautions for Herpes Zoster Vaccination 

Prior to vaccines, immunity to a disease was acquired solely through contracting the illness.

 However, sickness brought an elevated risk of death.

 After immunizations were created and modernized, several diseases were virtually eradicated, including measles, diphtheria, mumps, smallpox, rubella, polio, and tetanus.

 At the heart of the modern vaccination world are pharmacists who play a vital role in the health of their patients by recommending and administering appropriate immunizations.

Study results have shown that pharmacy-based vaccination service rates have increased, with programs becoming widely available in 97% of counties in the United States during the time of the study and offering a convenient option for patients to protect themselves from a preventable disease.

There are many strategies pharmacists can follow to engage patients in discussions about immunizations to further increase vaccination rates within communities.

When pharmacists are knowledgeable about current immunization recommendations, they can strong endorsements to patients regarding appropriate vaccinations. The authority on immunization recommendations in the United States is the CDC’s Advisory Committee on Immunization Practices, consisting of a group of 15 health experts who determine the official immunization schedules.

 These recommendations are updated and reissued annually and are organized according to many patient-specific factors, such as age and disease states.

 Staying current on this information can reinforce a pharmacist’s knowledge and help to ensure that proper recommendations are made to patients.

Patients who visit community pharmacies are prime candidates for immunizations. Following the most recent vaccine recommendations, pharmacists can screen patients by age, disease state, and vaccination history during the dispensing process to determine appropriate recommendations for patients when they arrive at the pharmacy. Since the recombinant, adjuvanted zoster vaccine (RZV; Shingrix) was approved by the FDA in October 2017, pharmacists have been able to use current information to recommend the immunization in patients who are immunocompetent and 50 years and older.

 Additionally, the CDC offers quizzes to help patients learn about vaccinations, specifically which vaccines are recommended for them and their families.

Pharmacists accessing statewide immunization databases can help to limit unnecessary vaccines by confirming vaccination history. A vaccine history printed from the database and given to the patient can serve as a personal record, reinforce a current recommendation, and even act as a reminder of future, scheduled vaccines. Because RZV is administered in 2 doses, a personal record can help a patient remember to get the second vaccination in the series. Patients may even come to the pharmacy requesting a specific vaccination. Examining the statewide database and recommending companion vaccines can be a helpful way to ensure that a patient who is ready and willing to receive a vaccine at the time catches up on other vaccines they may not know they are due to receive.

Patients can exhibit a hesitancy toward receiving proper immunizations. Some avoid vaccinations because of a shortage of information, a perception of low priority, lack of accessibility, operational obstacles, and fear of immunizations.

 Identifying the reason why a vaccination has not been completed and tailoring the recommendations accordingly to educate the patient can lead to successful engagement between the pharmacist and the patient.

Many patients consider getting vaccinated a low priority because they fail to see the benefit of receiving immunizations. They may not have any external reinforcement during their everyday routines to remind themselves to get vaccinated.

 Some patients may not realize the importance of preventing illness, believing vaccination is not necessary because they are in good health and are not at risk of developing the conditions that immunizations prevent.

Educational gaps can also contribute to not getting vaccinated. Some patients do not know that most pharmacies provide a range of vaccinations without an appointment. Between 2006 and 2010, the percentage of countries with pharmacy-based immunization services increased from 36% to 97% worldwide.

 Because of the availability of pharmacy-driven immunizations, an additional 6.2 million influenza vaccines and 3.5 million pneumococcal vaccines are given annually.

The cost of vaccinations and missing immunization records in pharmacies can contribute to operational obstacles that dissuade patients from being immunized. Patients may not be aware of affordable immunization options, or even free public vaccination programs, that may offer a less expensive alternative to treating the disease that the vaccine is designed to prevent.

 This can be an important discussion to have with patients, some of whom may be hesitant to spend the money.

When making recommendations, it is beneficial for pharmacists to address any hesitancy a patient may have regarding a vaccine. Determining what is preventing patients from getting vaccinated and discussing their fears and uncertainties can make them feel more comfortable with a recommendation. It is also helpful to address unfounded myths that may be hindering a necessary vaccine.  

Pharmacists can use different strategies to engage with patients about vaccination opportunities to further increase immunization rates. Reminders, knowledgeable technicians, outreach programs, and marketing approaches can be useful tools for pharmacists to consider.

Developing a vaccine series completion reminder is an important step in ensuring proper vaccine administration. RZV is administered as a 2-shot series, with the second shot given 2 to 6 months after the first.

 Results from studies have shown that patients are more likely to be given the recommended immunizations after receiving a reminder.

 Pharmacists can ensure that patients receive the second shot in the recommended timeframe by providing reminders in person and through phone calls and text messages.

Pharmacists can also improve patient engagement by recruiting technicians to aid in the immunization process and identify individuals who may be eligible for a vaccine. Often during a community pharmacy visit, a patient will spend ample time with a technician, who may have more time than a pharmacist to do a screening on specific vaccinations. In certain states, technicians are also beginning to administer immunizations, creating engagement with patients that are more seamless and efficient.

 Although technicians can begin the patient identification process and administer vaccines in certain states, it is important to remember that only a pharmacist should be evaluating patients for vaccine appropriateness, making strong recommendations for required vaccines, and providing counseling.

Marketing techniques can also increase rates of immunization. Using posters or other visual aids around pharmacies helps promote vaccinations. Pharmacies can also add information about available immunizations to medication information when a patient visits the pharmacy. Grocery stores could implement overhead announcements to inform shoppers of vaccines that are available.

Pharmacists can advocate for vaccines outside the traditional pharmacy setting in health fairs and shot clinics. The latter is especially beneficial during influenza season. A pharmacy team can immunize hundreds of people within hours by traveling to a site and providing immunizations for a set amount of time, increasing the availability of vaccines to individuals who may not have a scheduled appointment with their provider or do not routinely visit a pharmacy. Pharmacists can work with local health departments and other associations to promote immunizations for high-risk populations. They may also provide education through seminars and brochures to spread information about the importance of vaccinations. For example, the Vaccine Information Statements from the CDC are a very informative and appropriate reference tool.

 They include information about specific vaccines and the diseases they target. They also cover common adverse effects associated with vaccines and provide references for more information.

Of course, it is just as important to have proper stock of the vaccines. Keeping an adequate inventory of vaccines in the pharmacy is critical to ensuring that patients get their needed immunizations. A patient cannot get an immunization if the recommended product is not available. Proper ordering protocols should be in place for the pharmacy team when ordering and stocking immunizations.

Pharmacists can better engage patients by taking active, informed roles as immunizers and practitioners. Communicating vaccine schedules and making strong recommendations for necessary vaccines to patients is a vital aspect of the role of a pharmacist. Outreach efforts like marketing and creating clinics outside a traditional pharmacy setting also contribute to this goal. Patients may feel hesitant to get immunized, but having a discussion addressing specific barriers to immunization can be helpful in improving a patient’s receptiveness regarding immunizations. Pharmacists can make a significant difference in the lives of patients by encouraging immunizations, and using known strategies to better engage patients is an excellent way to do so.

NATHAN SPANN, PHARMD, is a pharmacist with Albertsons/Sav-on Pharmacy in Boise, Idaho.

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WSU, Albertsons create first U.S. program allowing pharmacy technicians to administer immunizations. Washington State University website. news.wsu.edu/2017/04/18/pharmacy-technicians-to-immunize. Published April 18, 2017. Accessed July 5, 2018.

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Herpes Zoster (August 2018)

A Pharmacist's Guide to Identifying the Signs and Symptoms of Herpes Zoster

Herpes Zoster Vaccination: Recent Advancements and Recommendations

Seizing Patient Education Opportunities and Recognizing Precautions for Herpes Zoster Vaccination

Patient Engagement Strategies for Immunization in a Community Pharmacy Setting