Shingles vaccine: the uptake

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Many Australians are missing out on the chance to be vaccinated against shingles – and one group says pharmacists could help

While a new, more efficacious non-live vaccine against the shingles/herpes zoster has been registered, it is not yet available in Australia.

Currently only around a third of 70-year-olds have had the free vaccination against the disease, warn Sanjay Jayasinghe, Sarah Sheridan and Kristine Macartney in this month’s Australian Prescriber.

Professor Macartney, Director of the National Centre for Immunisation Research and Surveillance says people aged 85 and above have a 50% chance of developing shingles.

“Most older Australians have had chickenpox at some point in their life, and shingles, also known as herpes zoster, is caused by a reactivation of the chickenpox virus in the body, usually many years later,” explains Macartney.

“Someone with shingles experiences a rash, often with pain which can develop into long-lasting, difficult to treat nerve pain,” she says. “The vaccine reduces the risk of this long-term pain.”

The figure of around a third of 70-year-olds having received the vaccine come from Australian Immunisation Register records over the first 17 months since the live vaccine began to be offered through the National Immunisation Program, to adults aged 70, and 71-79 in a five-year catch-up program.

Uptake was only 34% in 70-year-olds and 26% in 71-79 year-olds; it was higher among Indigenous Australians, though this varied across jurisdictions.

The authors note that almost all adults in Australia have been infected with the varicella zoster virus, putting them at risk of developing shingles.

“Pain accompanies herpes zoster in about 80% of patients aged over 50 years, and varies from burning to lancinating pain, sometimes with paraesthesia, anaesthesia or allodynia,” they observe.

“Antiviral therapy (valaciclovir or famciclovir) given within 72 hours of rash onset can help resolve acute pain and accelerate the healing of skin lesions. However, it is thought to have little or no effect on the likelihood of developing postherpetic neuralgia.

“Postherpetic neuralgia is problematic because it can be refractory to treatment with analgesics, neuroleptics and other drugs, and can last for months and even years.

“In older adults it often interferes substantially with activities of daily living and can have a very negative impact on overall well‑being.”

They cite the Shingles Prevention Study which showed efficacy of the live vaccine against herpes zoster was 51%, and against postherpetic neuralgia was 67%, in three years of follow-up.

The authors also look at the new herpes zoster recombinant subunit adjuvanted vaccine (HZ/su, Shingrix).

“It is not a live vaccine and requires a two-dose schedule with approximately 2–6 months between doses,” they write.

“The vaccine was registered in Australia in 2017 for people aged 50 years and above. However, it is not yet available for use. There is reportedly a limited global supply.”

“In 2018, an application by the manufacturer to include the HZ/su vaccine on the National Immunisation Program was unsuccessful due to uncertainty regarding cost-effectiveness.

“This vaccine is registered and used in some other countries, including the USA where the Centres for Disease Control and Prevention recommend it in preference to the live attenuated vaccine.

“The recombinant vaccine is more efficacious and more reactogenic than the live vaccine. In clinical trials, it provided 97% protection against herpes zoster for 50–59 year olds and 91% for those aged over 70 years.

“Similar levels of protection were observed against postherpetic neuralgia over more than three years.

“Overall in those aged over 70 years, more people vaccinated with the recombinant vaccine than with placebo reported adverse events that prevented normal everyday activity in the week following vaccination (grade 3 injection-site reactions: 8.5% vs 0.2%, and grade 3 systemic reactions: 6% vs 2%).

“Monitoring during the first eight months of its use in the USA has found the vaccine’s safety profile to be consistent with pre-licensure trials.

“Importantly, the recombinant vaccine can potentially be used in immunocompromised people.”

Though the article did not reference pharmacists specifically, pharmacists are able to administer vaccines against shingles in international jurisdictions such as New Zealand and parts of Canada.

National President Associate of the Pharmaceutical Society of Australia, Professor Chris Freeman, said in response to the article that the authors rightly note that “the uptake of Zostavax recorded on the Australian Immunisation Register is low and it is strongly recommended that GPs offer the vaccine to eligible patients and ensure administration is reported on the Australian Immunisation Register”.

“Pharmacists definitely have a role in identifying eligible patients for the shingles vaccine, and we would suggest equally have a role in vaccinating appropriate individuals to improve the uptake of this vaccine.

“Reducing unnecessary impediments to vaccination, including the shingles vaccine should look at expanding the number of health professionals that can administer this vaccine on the National Immunisation Program.”

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