Shingles Doesn’t Care: Re-Engaging Older Patients to Get Vaccinated
Since the FDA authorized emergency use of COVID-19 vaccines—and recently granted full approval to the Pfizer-BioNTech COVID-19 vaccine1—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 2019.2 During those 6 months, vaccinations against shingles declined by 43% among this population.2
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.3 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.3
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.4
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.6 Addressing factors that drive shingles vaccine hesitancy may improve rates for this recommended vaccination.
WHY RECEIVE A SHINGLES VACCINE?
Almost 1 of 3 US residents will develop shingles (ie, herpes zoster infection) during their lifetimes.7 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.5 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.5,7,8 Although there is no cure for shingles, administration of the vaccine is very effective in preventing infection and infectious complications.5
ABOUT THE SHINGRIX VACCINE
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.5,9,10
Shingrix is administered in 2 doses given 2 to 6 months apart.5 The Table details who should receive the vaccine.5,11
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.12 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.12
Adverse events (AEs) associated with Shingrix overlap with those of COVID-19 infection and include body aches and fever.11 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.11 Shingrix AEs normally resolve within 72 hours after vaccination.11
ADDRESSING SHINGLES VACCINE HESITANCY
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.5
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.5 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.5
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.5,11 As of November 18, 2020, Zostavax no longer is available for use in the United States.8 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.8 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.13
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.14 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.11 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.11
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.11
Alexandra Hanretty, PharmD, is a clinical pharmacy specialist in infectious diseases at Cooper University Healthcare in Camden, New Jersey.
Meghan Mitchell, PharmD, BCIDP, 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