Low use of herpes zoster vaccine raises concerns

Take-home:

Ophthalmologists in support of routine vaccinations for herpes zoster (shingles) can take steps to offer their older patients more protection against the ocular complications of the disease.

By Nancy Groves; Reviewed by Thomas Liesegang, MD

Jacksonville, FL-Despite the availability of the herpes zoster (shingles) vaccine, rates of vaccination remain relatively low.

However, increasing vaccination rates for the virus may be an uphill battle, according to those on the ophthalmic frontlines who see patients with the ocular complications of this disease.

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Thomas Liesegang, MD, is an advocate for more widespread vaccinations among the elderly, while acknowledging the arguments against it.

Acute Herpes Zoster “dendrites” during an acute episode of zoster. These plague-like lesions should be distinguished from finer dendrites of herpes simplex.

“I encourage all patients over the age of 50 to get the vaccine,” said Dr. Liesegang, MD, professor of ophthalmology, Mayo Clinic, Jacksonville, FL.

The herpes zoster (shingles) vaccine was approved by the FDA in 2006, yet only 20% of adults aged more than 60 years have received it.

Acute Herpes Zoster Keratouveitis with acute corneal edema, folds in Descemet’s membrane, and intraocular inflammation related to the zoster virus or the immune and vascular response to the zoster recurrence. (Images courtesy of Thomas Liesegang, MD)

The vaccine is 60% to 70% effective at preventing zoster, which can have serious complications, such as post-herpetic neuralgia, he said. This persistent pain is a significant burden to patients and is also associated with a high risk of suicide. The lifetime risk of developing herpes zoster is about 30%, and while for many the disease will be mild, it can be severe and debilitating.

Risk increases with age

Herpes zoster is responsible for an estimated $1.1 billion a year in health-care utilization and costs, Dr. Liesegang noted. Since most cases occur in the elderly, these costs are largely paid for by government programs, such as Medicare.

Herpes zoster increases with age because of a natural decline in the immune response. Although it is difficult to gather data since it is not a reportable disease in most countries-including the United States-there has been a trend toward increased incidence in this country not only in the elderly, but in all age groups, Dr. Liesegang said.

Acute involvement of periocular tissue and the eye from acute herpes zoster. This elderly female patient demonstrates swelling, acute and dried vesicles, crusting, and skin disruption as well as ocular involvement from acute herpes zoster.

One reason for the potentially worrisome change in incidence is, paradoxically, the success of the genetically similar but lower potency varicella vaccine at reducing the incidence of childhood chicken pox. Because exposure to the varicella virus is now far less likely than before the vaccine was approved in 1995-grandparents are no longer exposed to it by their grandchildren, for instance-the natural decline of the immune response theoretically will occur more rapidly.

However, the increase in zoster cases since the varicella vaccine was introduced is not dramatic, and the association is as yet unclear, Dr. Liesegang said.

Reasons for low vaccination rates

The zoster vaccine was originally recommended for individuals age 60 and over, but the FDA lowered the recommended age to 50 and older in 2011. However, the Centers for Disease Control and Prevention, which issues vaccination guidelines, does not presently recommend its use in individuals aged 50 to 59.

Only one other country, the United Kingdom, recommends regular vaccinations of its elderly citizens. Other countries have not yet determined that the zoster vaccine is cost effective for routine recommendation in their medical-economic environment, Dr. Liesegang said.

The low rate of vaccinations in primary-care settings may be a factor in the failure to decrease the incidence of zoster, but these clinicians are an audience that would need to be won over for the vaccination rate to increase.

There are many reasons why primary-care practitioners (PCPs) vaccinate relatively few patients, and one may be that they don’t consider herpes zoster to be a “bad disease,” Dr. Liesegang said. They typically refer complicated cases to a specialist, and since they see only milder cases, they consider herpes zoster to be a nuisance but nothing severe.

Concerns about the efficacy of the zoster vaccine, which is lower than the nearly 100% effectiveness of many childhood vaccines, as well as lack of demand from patients, also contribute to clinicians’ reluctance to routinely recommend the vaccine. Further, as of now, the vaccine is available most commonly as a frozen product and must be thawed before usage, a delivery system that clinicians may find inconvenient or cumbersome.

Yet another factor behind the low vaccination rates could be the cost, about $200 per vaccine. Though the vaccine is covered by Medicare, it falls under Part D rather than Part B, and more paperwork is involved. The vaccine may not be covered under the private insurance policies of some older adults not yet eligible for Medicare, and they may not want to pay these out-of-pocket expenses.

Concerns also present about the long-term effectiveness of the vaccine. In follow-up studies, efficacy has been maintained up to 7 years, but some physicians may feel data are insufficient to warrant vaccinations for patients who are in their 50s and who may have many years ahead of them.

“It is too early to determine if the zoster vaccine will need to be periodically repeated as a booster, adding to the long-term national health-care costs,” Dr. Liesegang said. “We await the results of the ongoing long-term studies.”

Role of ophthalmologists

Though PCPs have not enthusiastically adopted the herpes zoster vaccine, many infectious disease specialists and ophthalmologists-particularly, corneal disease specialists-have a different perspective. They see the severe cases that their colleagues do not, as well as the ocular, neurological, and other complications.

“We’re more attuned to the complications of zoster than most other physicians,” Dr. Liesegang said. “The physicians who are responsible for vaccinations are just not as concerned about the disease as ophthalmologists.”

Ophthalmologists who support routine vaccinations have several options. One is to urge their patients to talk to their PCPs, Dr. Liesegang said. If asked, most practices should be able to provide the vaccine.

As an alternative, in some communities, pharmacies now deliver the herpes zoster vaccine just as they offer seasonal flu shots, although patients may need to ask around to find a location.

“In the future, . . . pharmacies are going to be a much more common way of getting the vaccine, because they can see a large number of patients just coming in for the vaccine and can deliver it more efficiently,” Dr. Liesegang said.

Thomas Liesegang, MD

E: tliesegang@mayo.edu

Dr. Liesegang did not report any financial disclosures.