8/29/2016. Herpes Zoster (Shingles) Everything you needed to know about Shingles, and the Shingles Vaccine

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1 Everything you needed to know about Shingles, and the Shingles Vaccine Margaret (Peg) O Donnell, DNP, FNP, ANP, B-C, FAANP Senior Nurse Practitioner, South Nassau Communities Hospital Herpes Zoster (Shingles) It is Painful it can be debilitating, and it is Preventable!! SHINGLES A reactivation of the chicken pox virus in a specific dermatome Objectives Audience will understand the pathogenesis of Shingles (Herpes Zoster), from childhood to adulthood. Audience will review the CDC recommendations for the Shingles vaccine, and will discuss the advantages and disadvantages of vaccination utilization. Audience will identify barriers to the utilization of Shingles Vaccine. Participants will discuss implementation strategies which improve vaccination rates 1

2 FACTS ABOUT SHINGLES (Herpes Zoster) 99% of persons older than 50 have been exposed to the chicken pox virus sometime in their life, and they are at risk for getting Shingles Due to waning t-cell mediated immunity, the risk of getting Herpes Zoster is greater as you age, and there is a greater chance of getting post-herpetic neuralgia (pain after the rash is gone). There are about a million cases of shingles a year in America The life cycle of Herpes Zoster 2

3 Natural Course of the Disease Prodrome: pain/pruritus, tingling, unilateral. Precedes eruption by 4-5 days. Eruptive phase: does not cross the midline Starts with red, swollen plagues that spread throughout the dermatome Vesicles arise in clusters, then rupture before forming a crust which falls off between 2-3 weeks Thoracic distribution Complications of Shingles Post herpetic neuralgia Ocular involvement with facial zoster Meningoencephalitis Cutaneous dissemination Super-infection of skin lesions Hepatitis/pneumonitis Peripheral motor weakness/ segmental myelitis Cranial nerve syndromes, particularly ophthalmic and facial (Ramsay Hunt Syndrome). Corneal ulceration Guillian-Barre Syndrome e 3

4 Post Herpetic Neuralgia The impact of post herpetic neuralgia on quality of life has been compared to congestive heart failure, major depression, and severe diabetes. Occurs in 50% of patients who develop shingles over the age of 70. Allodynia, hyperpathia and lancinating pain. Requires multimodality pain management. Why it is so painful FACTS ABOUT THE SHINGLES VACCINE (AKA: Herpes Zoster vaccine Zostavax ): Reduces the incidence of disease by 51.3% Reduces the incidence of Post-herpetic neuralgia by 66.5% Reduces the burden of illness due to Shingles by 61.1% 4

5 CDC recommendations The Centers for Disease Control/Advisory Committee for immunization Practices (CDC/ACIP), recommends Shingles vaccine to be given as a one time time dose for adults >60. The FDA has approved it s use for greater than 50 years of age. It is a live virus, therefore, patients must have an intact immune system to receive the vaccine. Get it while you are healthy!! Despite the safety and efficacy of this vaccine, only 24% of eligible persons take advantage of The Shingles vaccine. Contraindications Persons with blood cancers; lymphoma, leukemia, multiple myeloma Persons on chemotherapy for solid tumors, however, patients MAY receive the vaccine 2-4 weeks before starting chemotherapy. Persons on immune-modulating agents for RA, Lupus, MS, and other auto-immune diseases. However, patient MAY receive the vaccine 2-4 weeks before starting medications. Persons allergic to neomycin. May give to persons older than 80 years of age, however, its efficacy decreases as a person ages. Best to receive Other Considerations Patients who have received the Varicella vaccine: no information. Patients who are younger than 50 years of age. HIV patients, and other immunocompromised patients 5

6 Research study: Purpose This survey study was conducted to assess and evaluate Nurse Practitioners experiences with the herpes zoster vaccine, and to assist in identifying any entity that restraint or obstructs the provision of the CDC recommended HSV by Nurse Practitioners. Participants Study participants included New York State primary care nurse practitioners who are members of the Nurse Practitioner Association of New York State. NPs who are actively practicing with adults greater than 50 years of age. Pediatric and specialty nurse practitioners were excluded from this study, as they do not generally administer HSV. Methods This descriptive, cross-sectional survey design study used a Likert scale survey to quantitatively measure nurse practitioner s practice patterns and experiences with the Herpes zoster vaccine. Nurse practitioners, were sent an invitation which provided a link which directed volunteer participants to the anonymous webbased questionnaire via Qualtrix. 6

7 Findings The three major barriers identified: up front cost (46%), cost concerns for patients (39%) and reimbursement issues (29%). Knowledge of reimbursement: some (32%), little (40%), and none (18%), 49% were much more likely to administer vaccine if it were covered by Medicare part B. Identified barriers to the Utilization of Herpes Zoster Vaccine from physician studies: Patient barriers: Lack of provider recommendation Provider barriers: The up-front costs of purchasing the vaccine Cost concerns for patients Concerns about safety of the vaccine Concerns about the effectiveness of the vaccine Freezer storage patient The need to have patients pick up zoster vaccine at a pharmacy Low incidence of herpes zoster and post herpetic neuralgia Lack of serious sequelae of herpes zoster and post herpetic neuralgia More pressing medical issues taking precedence over this vaccine Concerns that I will accidently administering this vaccine to an immunocompromised Margaret O Donnell Stony Brook University Implications The results of this study inform the need for innovative strategies to be implemented by the providers, and support the need for a multi-layered, systematic foundation for change.. There are many gaps that need to be closed in order to improve adult vaccination rates in our country, and Nurse Practitioners are poised to assist on all levels. Education, policy change. Develop a comprehensive adult immunization program in America. 7

8 Surprising information about coverage: After the age of 60, most commercial insurances are paying for the vaccine. Catch the sweet spot, between the ages of 60-65, before Medicare kicks in, is the best time to receive vaccine. For those older than 65, Medicare part D (Pharmacy benefit), covers much of vaccination costs. However, not everyone has part D coverage, and there is a co-pay. The Shingles vaccine is easily obtained through pharmacies, however, in NYS, a provider prescription is necessary. This is not so for flu and pneumonia shots. Implementation Strategies ` 1. Standing orders 2. Protocols 3. Assessing vaccination status at each visit 4. Assessing insurance coverage for vaccination 5. offer vaccination options such as pharmacies References Cohen JI. Herpes Zoster. N Engl J Med. 2013; 369(18): /NEJMc Doan HQ, Ung B, Ramirez-Fort MK, Khan F, & Tyring SK. Zostavax : a subcutaneous vaccine for the prevention of herpes zoster. Expert Opin Biol Ther. 2013;(10), doi: / Centers for Disease Control/ Advisory Committee for Immunization Practices Working Group. Summary Report April, Overbeck KJ, Cohen JS. Prevention of Herpes Zoster and Post-Herpetic Neuralgia in Older Adults American Osteopathic Association Healthwatch. December, Schmader KE, Oxman MN, Levin MJ, Johnson G, Zhang JH, Betts R. Shingles Prevention Study Persistence of the efficacy of zoster vaccine in the shingles prevention study and the short-term persistence sub study. Clin Infect Dis,55(10), doi: /cid/cis638 Johnson BH, Palmer L, Gatwood J, Lenhart G, Kawai K, & Acosta CJ. Annual incidence rates of herpes zoster remain common among an immunocompetent Population in the United States. BMC Infect Dis. 2015; Elkin Z, Cohen EJ, Goldberg JD, Gillespie C, Li X, Jung J,et al. Studying physician knowledge, attitudes, and practices regarding the herpes zoster vaccine to address perceived barriers to vaccination. Cornea. 2013; 32(7), Doi: /ICO.0b013e a 8

9 References Harpaz R, Ortega-Sanchez IR, Seward JF, Advisory Committee on Immunization Practices Centers for Disease Control, & Prevention. Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, Recommendation Report 57 (RR-5). Gannon M, Qaseem A, Snooks Q, Snow V. Improving Adult Immunization Practices. Am J Public Health. 2012; 102(7): e46 e52. Published online 2012 July. Doi: /AJPH PMCID: PMC347] Johnson DR, Nichol KL, & Lipczynski K. Barriers to adult immunization. Am J Med. 2008;121(7 Suppl 2), S28-35.doi: /j.amjmed Campos-Outcalt D, Jeffcott-Pera M, Carter-Smith P, Schoof BK, & Young H. Vaccines provided by family physicians. Ann Fam Med.2010; 8(6), doi: /afm Hurley LP, Harpaz R, Daley MF, Crane LA, Beaty BL, Barrow J, Kempe A. National survey of primary care physicians regarding herpes zoster and the herpes zoster vaccine. J Infect Dis. 2008;197 Supplement, S doi: / Hurley LP, Bridges CB, Harpaz R, Allison MA, O Leary ST, Crane LA, Kempe A. U.S. physicians perspective of adult vaccine delivery. Ann Interrn Med.2010; 160(3), 161. doi: /M Yawn BP, Saddier P, Wollan PC, St Sauver JL, Kurland MJ, & Sy LS.A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction. Mayo Clinic Proceedings. 2007; 82(11), Pellissier JM, Brisson M, & Levin MJ. Evaluation of the costeffectiveness in the United States of a vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. Vaccine. 2007; 25(49), doi: Simberkoff MS, Arbeit RD, Johnson GR, Oxman MN, Boardman KD, Williams, H.M. Shingles Prevention Study, G. Safety of herpes zoster vaccine in the Shingles prevention study: a randomized trial. Ann Intern Med. 2010;152(9), doi: / Refereneces Bridges CB, Hurley LP, Williams WW, Ramakrishnan A, Dean AK, & Groom AV. Meeting the Challenges of Immunizing Adults. Vaccine Supplemental ; 33 D114-D120. Doi: /j.vaccine Auerbach DI. Will the NP Workforce Grow in the Future? New Forecasts and Implications for Healthcare Delivery. Medical Care. 2012;Vol. 50, No. 7, pp Shuler PA, Davis JE. The Shuler nurse practitioner practice model: a theoretical framework for nurse practitioner clinicians, educators, and researchers, Part 1. JAANP, 1993a. 5(1), pp Shuler, P. A., & Davis, J. E. The Shuler Nurse Practitioner Practice Model: clinical application, Part 2. JAANP 1993b. 5(2), pp Freed GL, Clark SJ, Cowan AE, & Coleman MS. Primary care physician perspectives on providing adult vaccines. Vaccine. 2013;29(9), doi: /j.vaccine High KP. Overcoming barriers to adult immunization. Journal American Osteopathic Association. 2009;(6 Suppl 2), S Lu PJ, Euler G, Harpaz R. Herpes zoster vaccination among adults aged 60 years and older, in the U.S. Am J of Prev Med. 2008; 40(2), e1-6. doi: /j.amepre Learning; References Jung JJ, Elkin ZP, Li X, Goldberg JD, Edell AR, Cohen MN, Cohen EJ. Increasing use of the vaccine against zoster through recommendation and administration by ophthalmologists at a city hospital. AJO. 2014; 155(5), Doi: /j.ajo Poland GA, Shefer AM, McCauley M, Webster PS, Whitley-Williams PN, Peter G. National Vaccine Advisory Committee. Standards for adult immunization practices. Am J Prev Med. 2014; 25(2), Trust for America s Health.Adult Immunizations: Shots to Save Lives. Robert Wood Johnson Foundation, Issue Briefs 13; 2010 Tan LJ. The Continuing Challenge of Adult Immunizations: Impact of the Affordable Care Act. Public Policy Aging Report. 2014;Volume 22, No. 4 doi: /j.vaccine Hurley LP, Lindley MC, Harpaz R, Stokley S, Daley MF, Crane LA,Kempe, A. Barriers to the use of herpes zoster vaccine. Ann Intern Med.2014; 152(9), doi: / Shi L,Singh D. Delivering Health Care in America, A Systems Approach. Burlington, MA: Jones and Bartlett 9