0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Articles |

Barriers to the Use of Herpes Zoster Vaccine

Laura P. Hurley, MD, MPH; Megan C. Lindley, MPH; Rafael Harpaz, MD, MPH; Shannon Stokley, MPH; Matthew F. Daley, MD; Lori A. Crane, PhD, MPH; Fran Dong, MS; Brenda L. Beaty, MSPH; Litjen Tan, PhD, MS; Christine Babbel, MSPH; L. Miriam Dickinson, PhD; and Allison Kempe, MD, MPH
[+] Article and Author Information

From Denver Health, Children's Outcomes Research Program and The Children's Hospital of Denver, and Colorado School of Public Health and Colorado Health Outcomes Program, University of Colorado Denver, Denver, Colorado; National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and American Medical Association, Chicago, Illinois.


Acknowledgment: The authors thank Laura Seewald, BA, for aiding in the preparation of the manuscript. They also thank all pediatricians and family medicine physicians in the networks for participating and responding to the survey.

Grant Support: By the CDC (CDC SIP 5 U48 DP000054-03).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M09-2541.

Reproducible Research Statement:Study protocol: Available from Dr. Hurley (address below). Statistical code and data set: Certain portions of the analytic data set are available to approved individuals through written agreements with Dr. Hurley and the Centers for Disease Control and Prevention.

Requests for Single Reprints: Laura P. Hurley, MD, MPH, Wellington Webb Center for Primary Care, Denver Health, 301 West 6th Avenue, MC 3251, Denver, CO 80204.

Current Author Addresses: Dr. Hurley: Wellington Webb Center for Primary Care, Denver Health, 301 West 6th Avenue, MC 3251, Denver, CO 80204.

Ms. Lindley and Ms. Stokley: National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road NE, Mailstop E-52, Atlanta, GA 30333.

Dr. Harpaz: Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop A-47, Atlanta, GA 30333.

Dr. Daley: Institute for Health Research Kaiser Permanente—Colorado, 10065 East Harvard Avenue, #300, Denver, CO 80231.

Dr. Crane: Colorado School of Public Health, 13001 East 17th Place, B119, Building 500, Room E3343a, Aurora, CO 80045.

Ms. Dong, Ms. Beaty, and Drs. Dickinson and Kempe: Colorado Health Outcomes Research Program, 12477 East 19th Avenue, F443, Aurora, CO 80045.

Dr. Tan: American Medical Association, 515 North State Street, Chicago, IL 60610-4320.

Ms. Babbel: Children's Outcomes Research Program, 12477 East 19th Avenue, F443, Aurora, CO 80045.

Author Contributions: Conception and design: L.P. Hurley, M.C. Lindley, R. Harpaz, S. Stokley, M.F. Daley, L.A. Crane, L. Tan, C. Babbel, A. Kempe.

Analysis and interpretation of the data: L.P. Hurley, M.C. Lindley, R. Harpaz, M.F. Daley, L.A. Crane, F. Dong, B.L. Beaty, L. Tan, C. Babbel, L.M. Dickinson, A. Kempe.

Drafting of the article: L.P. Hurley, A. Kempe.

Critical revision of the article for important intellectual content: M.C. Lindley, R. Harpaz, S. Stokley, M.F. Daley, L.A. Crane, L. Tan, C. Babbel, A. Kempe.

Final approval of the article: M.C. Lindley, R. Harpaz, S. Stokley, M.F. Daley, L.A. Crane, B.L. Beaty, L. Tan, A. Kempe.

Statistical expertise: F. Dong, B.L. Beaty, L.M. Dickinson.

Obtaining of funding: L.A. Crane, A. Kempe.

Administrative, technical, or logistic support: R. Harpaz, C. Babbel, A. Kempe.

Collection and assembly of data: L.A. Crane, C. Babbel, A. Kempe.


Ann Intern Med. 2010;152(9):555-560. doi:10.7326/0003-4819-152-9-201005040-00005
Text Size: A A A

Background: The herpes zoster vaccine is the most expensive vaccine recommended for older adults and the first vaccine to be reimbursed through Medicare Part D. Early uptake has been 2% to 7% nationally.

Objective: To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians.

Design: Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model.

Setting: National survey conducted from July to September 2008.

Participants: General internists and family medicine physicians.

Measurements: Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination.

Results: Response rates were 72% in both specialties (301 general internists and 297 family medicine physicians). Physicians in both specialties reported similar methods for delivering vaccine, which included stocking and administering the vaccine in their offices (49%), referring patients to a pharmacy to purchase the vaccine and bring it back to the office for administration (36%), and referring patients to a pharmacy for vaccine administration (33%). Eighty-eight percent of providers recommend herpes zoster vaccine and 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines. For physicians in both specialties, the most frequently reported barriers to vaccination were financial. Only 45% of respondents knew that herpes zoster vaccine is reimbursed through Medicare Part D. Of respondents who began administering herpes zoster vaccine in their office, 12% stopped because of cost and reimbursement issues.

Limitations: Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers.

Conclusion: Physicians are making efforts to provide herpes zoster vaccine but are hampered by barriers, particularly financial ones. Efforts to facilitate the financing of herpes zoster vaccine could help increase its use.

Primary Funding Source: Centers for Disease Control and Prevention.

Figures

Grahic Jump Location
Figure.
Provider strength of recommendation for herpes zoster vaccine compared with other vaccines.
Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
No Title
Posted on May 12, 2010
Harry W. Daniell
UC Davis
Conflict of Interest: None Declared

To the The Editor:

The publication by Hurley et al (1) and the related editorial by Donahue and Belongia (2) do not acknowledge all factors which have limited the use of herpes zoster vaccine.

As a general internist, many of my patients have wanted to compare the benefits which they could expect to receive from the vaccine with the associated inconvenience and cost of its administration.

My response, derived largely from the publication by Oxman et al (3), included observations that the vaccine was 30% less effective in patients over age 70 than those ages 60-69, and in this older age group prevented less than 50% of cases of herpes zoster, but that the infection when present was often less severe in this age group and less frequently followed by post-herpetic neuralgia. They are also told that immune responses to vaccines generally are less vigorous with increasing age, that no studies documenting benefit from the herpes vaccine in patients over age 80 had been published, and that the reported incidence of herpes zoster in patients over age 75 was approximately 1% per year, suggesting a life-time incidence of less than 10% in many of them.

In order to more accurately define the potential benefits of herpes zoster vaccine in older age groups, stratification of the patients studied by Oxman et al into 5 year age groups, with appropriate age group analysis of their results, would aid patients and their physicians in better resulting at an appropriate recommendation for its use.

References

1. Hurley L, Lindley M, Harpaz R, Stokley S, Daley M, Craine L, et al. Barriers to the Use of Herpes Zoster Vaccine. Ann Intern Med 2010;152:555-60. [PMID: 20439573]

2. Donahue J, Belongia E. The Looming Rash of Herpes Zoster and the Challenge of Adult Immunization. Ann Intern Med 2010;152:609- 11.[PMID:20439578]

3. Oxman MN, Levin MJ, Johnson GR, Schmader KE, Straus SE, Gelb LD, et al. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med 2005;352:2271-84. [PMID:15930418]

Conflict of Interest:

None declared

Barriers to the Use of Herpes Zoster Vaccine
Posted on May 19, 2010
Subhash C. Arya
Sant Parmanand Hospital, Delhi, India
Conflict of Interest: None Declared

To the Editor

Financial barriers towards acceptance of Herpes zoster vaccine (1) are universal and could be minimized through linkage of such vaccinations with community festivals and family celebrations.

During national festivals like Christmas and New Year, every individual would spare available resources for celebrations. There is disproportionate exchange of gifts and present among relatives, business colleagues and friends. Money is also spared annually while celebrating birthdays, wedding anniversary, Mother's Day and Valentine's Day and several other important events. Periodically but regularly the local supermarkets and whole sale commercial organizations would offer attractive discounts, and festival incentives to public. The increased sale of consumer goods within a short span of time implies exorbitant profit for commercial organizations.

The manufacturers of Herpes zoster vaccines could be stimulated to embark upon an identical strategy. They could offer attractive bargains during national festivals and other frequently celebrated moments. Commercial establishments would rely on competent market researchers and ensure success on their prospective commercial ventures on such occasions. A well planned strategy for vaccine gifts should benefit prospective recipients of Herpes zoster vaccine and tone down the existing financial barriers (1).

References

1. Hurley LP, Lindley MC, Harpaz R, et al. Barriers to the use of Herpes Zoster vaccine. Annals of Internal Medicine 2010; 152:555-560

Conflict of Interest:

None declared

Barriers with regard to herpes zoster vaccination
Posted on May 26, 2010
Wim Opstelten
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlan
Conflict of Interest: None Declared

To the Editor - Hurley et al. demonstrated that the major barriers for physicians to use the herpes zoster (HZ) vaccine are the cost concerns for their patients and their worries about freezer storage of the vaccine (1). This may have resulted in a low vaccine uptake. With respect to these findings, we would like to make some comments based on a prospective questionnaire study in The Netherlands (2). In that primary care study, we assessed the willingness of elderly patients to accept a free offer of HZ vaccination simultaneously with the yearly influenza vaccination. For this study, the participating primary care physicians were free of charge equipped with adequate storage facilities. In all, only 39% of the invited patients accepted the HZ vaccination, whereas the compliance with the flu vaccination amounted 76%. The major determinants of non-compliance with the HZ vaccination were perceived lack of recommendation by the physician, unwillingness to comply with the physician's advice, and the perception of low risk of contracting HZ. These results demonstrate that taking away the barriers to use the HZ vaccine as reported by Hurley, may not lead to the desirable HZ vaccination rate. To increase the acceptance of HZ vaccination, more information for both patients and physicians about the impact of HZ in elderly people and the vaccine's effectiveness and cost- effectiveness will be indispensable. Furthermore, in Europe a refrigerator-stable HZ vaccine has been registered for which storage between 2o and 8o Celsius suffices. This new development may end the necessity of freezer storage (3).

References

1. Hurley LP, Lindley MC, Harpaz R, Stokley S, Daley MF, Crane LA, et al. Barriers to the use of herpes zoster vaccine. Ann Intern Med. 2010;152:555-60. [PMID: 20439573]

2. Opstelten W, van Essen GA, Hak E. Determinants of non-compliance with herpes zoster vaccination in the community-dwelling elderly. Vaccine. 2009;27:192-6. [PMID: 18996427]

3. Gilderman LI, Lawless JF, Nolen TM, Sterling T, Rutledge RZ, Fernsler DA, et al. A double-blind, randomized, controlled, multicenter safety and immunogenicity study of a refrigerator-stable formulation of Zostavax. Clin Vaccine Immunol. 2008;15:314-9. [PMID: 18077611]

Conflict of Interest:

None declared

Re:Barriers with regard to herpes zoster vaccination
Posted on June 7, 2010
Laura Hurley
No Affiliation
Conflict of Interest: None Declared

We thank Dr. Opstelten for his comments and agree that solving the financial and freezer storage barriers we discovered would not remove all barriers to herpes zoster (HZ) vaccine uptake in the U.S. However, there are a few important distinctions between our study (1) and Dr. Opstelten's (2) that make their results problematic to directly compare. First, Dr. Opstelten's study (1) was conducted in the Netherlands, and, at the time of his survey, HZ vaccine was not recommended in the Netherlands; therefore physicians and patients were likely not familiar with the vaccine. Our study (1) was conducted in the U.S. at a time when HZ vaccine had been recommended for almost two years. Second, there are major differences in the healthcare systems and financing of care in the Netherlands and the U.S. that may markedly affect responses of their populations. Third, the Opstelten study (2) presents the patient perspective whereas our study is from the provider perspective. Although we did not find perceived lack of serious sequelae from HZ and postherpetic neuralgia to be a major barrier to administering HZ vaccine to providers, it is possible that patients in the U.S could perceive it as a larger barrier. The 2007 National Immunization Survey (NIS)-Adult, which provides some insight into the patient perspective of HZ vaccine in the U.S., found that 77.8% of respondents who had not yet received HZ vaccine would accept it (in the hypothetical) if recommended by their doctor (3). It would be interesting to repeat a study similar to Dr. Opstelten's in the U.S. where patients would be faced with option of receiving free HZ vaccine rather that theorizing what they might do if offered it as in the NIS-Adult survey.

We agree with Dr. Opstelten's greater awareness of HZ vaccine among patients may lead to greater acceptance of the vaccine. U.S. patients are likely to be less aware of the HZ vaccine than other routinely recommended vaccines because the manufacturer has experienced supply constraints and, as a result, the vaccine has not been promoted very actively in the U.S. Dr. Opstelten also highlights that refrigerator-stable HZ vaccine (4) has been registered in Europe, another crucial issue. Aside from HZ vaccine, the other varicella-containing vaccines have been available in international markets in refrigerator-stable formulations (5). Hopefully, these vaccines will become available in the U.S. since the requirement for freezer storage is an important barrier to all vaccine programs.

References

1. Hurley LP, Lindley MC, Harpaz R, Stokley S, Daley MF, Crane LA, et al. Barriers to the use of herpes zoster vaccine. Ann Intern Med. 2010;152:555-60. [PMID: 20439573]

2. Opstelten W, van Essen GA, Hak E. Determinants of non-compliance with herpes zoster vaccination in the community-dwelling elderly. Vaccine. 2009;27:192-6. [PMID: 18996427]

3. Lu P., Euler G., Jumaan A., Harpaz R. Herpes zoster vaccination among adults aged 60 years or older in the United States, 2007: Uptake of the first new vaccine to target seniors_ Vaccine. 2009. 27;882-887. [PMID: 19071175]

4. Gilderman LI, Lawless JF, Nolen TM, Sterling T, Rutledge RZ, Fernsler DA, et al. A double-blind, randomized, controlled, multicenter safety and immunogenicity study of a refrigerator-stable formulation of Zostavax. Clin Vaccine Immunol. 2008;15:314-9. [PMID: 18077611]

5. Kreth HW, et al., Sixteen years of global experience with the first refrigerator-stable varicella vaccine (Varilrix). BioDrugs.2008;22:387-402. [PMID: 18998756]

Conflict of Interest:

None declared

Submit a Comment

Summary for Patients

Barriers to the Use of a Vaccine to Prevent Shingles

The summary below is from the full report titled “Barriers to the Use of Herpes Zoster Vaccine.” It is in the 4 May 2010 issue of Annals of Internal Medicine (volume 152, pages 555-560). The authors are L.P. Hurley, M.C. Lindley, R. Harpaz, S. Stokley, M.F. Daley, L.A. Crane, F. Dong, B.L. Beaty, L. Tan, C. Babbel, L.M. Dickinson, and A. Kempe.

Read More...

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)