Article

Studying Physician Knowledge, Attitudes, and Practices Regarding the Herpes Zoster Vaccine to Address Perceived Barriers to Vaccination

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Purpose: To increase usage of the herpes zoster (HZ) vaccine at an academic medical center by studying physicians' knowledge, attitudes, practices, and perceived barriers and analyze the findings by practice setting. Methods: A cross-sectional Internet-based survey administered to all 266 general internal medicine physicians in 4 clinical settings at an academic medical center between October 6 and December 12, 2011. Outcomes measures included knowledge questions regarding the disease and vaccine recommendations, Likert-type items about physician attitudes and practices, and questions about barriers and proposed interventions to improve utilization. Results: Response rate was 33.5% (89 of 266). Responders did not answer all questions. Only 66% (42 of 64) responded that HZ vaccination was an important clinical priority, and 48% (38 of 79) reported that less than 10% of their patients received the HZ vaccine. 95% responded that the influenza (61 of 64) and 92% that the pneumococcal (59 of 64) vaccines were important. Approximately 53% (42 of 79) and 51% (40 of 78) reported that more than 75% of their patients received these vaccines, respectively. Top barrier to vaccination was cost to patients (51 of 66; 77%). Lack of awareness of national recommendations (46 of 65, 71%) varied by setting. Physicians' preferred interventions included nurse-initiated prompting about vaccination (36 of 75, 48%) and chart reminders (34 of 74, 46%). Conclusions: Not only increased knowledge but also a change in attitudes and practice are needed to enhance implementation of national recommendations. To improve use of this vaccine, physicians including ophthalmologists need to recommend it more strongly.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... In comparison, RZV, FDA-approved in 2017, is a recombinant, adjuvanted vaccine that utilizes a glycoprotein E antigen and an adjuvant system (AS01B) to enhance the immune response. RZV shows superior efficacy (56.9% for the first dose, and 70.1% for the second) and is recommended for adults aged ≥50 years [15,16], with reported efficacy against HZ and PHN at 91.3% and 88.8%, respectively [17,18]. ...
... The data were collected through a self-administered questionnaire (Appendix), which was developed following a comprehensive review of related articles and consultation with an expert in the field [18][19][20]. The questionnaire was crafted in Arabic and distributed online to the targeted population via a link shared by trained data collectors. ...
Article
Full-text available
Abstract Introduction Herpes zoster (HZ) is caused by the reactivation of the varicella-zoster virus (VZV) and can lead to complications such as postherpetic neuralgia. Although vaccines are available to prevent HZ, the level of concern about HZ and its vaccines in our region remains unknown. This study assessed the knowledge, attitudes, and practices regarding HZ and the HZ vaccines among adults aged ≥50 years in Jazan, Saudi Arabia. Methods A cross-sectional study was conducted using a questionnaire distributed to adults aged ≥50 years and data were collected on demographics, knowledge of HZ and its vaccines, attitudes, and practices. Multiple logistic regression examined factors associated with knowledge levels. Results Of 295 participants, 58% and 67.5% had low knowledge of HZ and its vaccines, respectively. Knowledge of HZ significantly differed by age, education, and occupation. Only 50% knew HZ affects nerves and skin and 28.8% knew HZ can be transmitted between individuals. Knowledge of the vaccine significantly differed by gender and information source. Conclusions This population has substantial knowledge gaps regarding HZ and vaccination. Targeted educational initiatives are needed to promote greater awareness of HZ immunization, especially for higher-risk groups like older adults and females.
... In comparison, RZV, FDA-approved in 2017, is a recombinant, adjuvanted vaccine that utilizes a glycoprotein E antigen and an adjuvant system (AS01B) to enhance the immune response. RZV shows superior efficacy (56.9% for the first dose, and 70.1% for the second) and is recommended for adults aged ≥50 years [15,16], with reported efficacy against HZ and PHN at 91.3% and 88.8%, respectively [17,18]. ...
... The data were collected through a self-administered questionnaire (Appendix), which was developed following a comprehensive review of related articles and consultation with an expert in the field [18][19][20]. The questionnaire was crafted in Arabic and distributed online to the targeted population via a link shared by trained data collectors. ...
Article
Full-text available
Introduction Herpes zoster (HZ) is caused by the reactivation of the varicella-zoster virus (VZV) and can lead to complications such as postherpetic neuralgia. Although vaccines are available to prevent HZ, the level of concern about HZ and its vaccines in our region remains unknown. This study assessed the knowledge, attitudes, and practices regarding HZ and the HZ vaccines among adults aged ≥50 years in Jazan, Saudi Arabia. Methods A cross-sectional study was conducted using a questionnaire distributed to adults aged ≥50 years and data were collected on demographics, knowledge of HZ and its vaccines, attitudes, and practices. Multiple logistic regression examined factors associated with knowledge levels. Results Of 295 participants, 58% and 67.5% had low knowledge of HZ and its vaccines, respectively. Knowledge of HZ significantly differed by age, education, and occupation. Only 50% knew HZ affects nerves and skin and 28.8% knew HZ can be transmitted between individuals. Knowledge of the vaccine significantly differed by gender and information source. Conclusions This population has substantial knowledge gaps regarding HZ and vaccination. Targeted educational initiatives are needed to promote greater awareness of HZ immunization, especially for higher-risk groups like older adults and females.
... Another study revealed that attitudes towards the HZ vaccine were generally positive; however, due to a lack of knowledge, poor practices were observed [11]. One more study concluded that not only increased knowledge but also a change in attitude and practice is needed to enhance the implementation of national recommendations [12]. Another study showed that HZ vaccination rates remain relatively low when compared with rates of influenza and pneumonia vaccination [13]. ...
... The first section (1-9) included questions on demographic data (gender, nationality, age, marital status, qualification and classification level, disease history, and history of chickenpox infection). The second section (10)(11)(12)(13)(14)(15)(16)(17)(18) included six questions that were related to knowledge about chicken pox, shingles and their risk factors. Questions 13, 14 and 15 were related to the fear of getting chickenpox and shingles, the fear of getting the disease from others and the fear of no cure. ...
Article
Full-text available
Background Herpes zoster (HZ) is a viral disease, which is more common among the elderly and immunodeficient individuals, among which approximately 22% of cases might progress to post-herpetic neuralgia (PHN). Hence, this study aimed to assess the knowledge, attitude and practice (KAP) towards HZ and its vaccination among primary health care physicians in Makkah, Saudi Arabia, 2023. Methodology This analytical cross-sectional study used an online pre-validated questionnaire and was conducted from July to August 2023. The target population included physicians working in primary healthcare (PHC) daily clinics in Makkah. Results A total of 153 participants were included in the current study. Of which 90 (58.8%) were females and 120 (78.4%) participants had chicken pox history. Around 123 (80.4%) had previously heard about shingles. The most reported source of information was physicians (63%) followed by the Internet (12.2%). Risk factors for shingles were found to be immunodeficiency (95.1%) and age (78%). Most (88.2%) participants had previously heard about the shingles vaccine and 99 (64.7%) reported that the shingles vaccine is needed even if the patient had chicken pox in the past. Most participants (82.4%) knew that the vaccine should be given to adults aged more than 50 years. About 69 (45.1%) thought that they were extremely likely to get the shingles vaccine if the doctor recommended it. Barriers to shingles vaccination among study participants included participant's perception that they were not at risk of getting shingles (33%) and concerns about vaccines’ side effects (27.5%). The average knowledge score about shingles was found to be 9.51 ± 3.14 and the average knowledge score about shingles vaccine was found to be 5.43 ± 1.46. Gender was significantly associated with knowledge score about the vaccine (p-value= 0.028) where females had higher knowledge scores about shingles vaccine as compared to males. Qualification level and current Saudi Commission for Health Specialties (SCFHS) classification were found to be significantly associated with knowledge scores about shingles (p-value = 0.002 and 0.003, respectively). Conclusion A good level of KAP about shingles and its vaccine was found among the study participants. However, few knowledge gaps in methods of protection were assessed. Female gender, married participants and higher SCFHS qualification level were positively associated with higher levels of knowledge and awareness as compared to other groups.
... Common barriers to vaccination include lack of physician knowledge and lack of strong clinical recommendations from physicians. 25,26 The purpose of this study was to determine the effectiveness of RZV for preventing HZO in real-world practice through a large-scale cohort study using administrative claims data. By focusing on the ocular benefits of vaccination, ophthalmologists could play a bigger role in the public health sphere by championing vaccination efforts to prevent a debilitating eye disease. ...
... 35,36 Barriers to ZVL vaccination in the United States included high cost, insurance coverage, and the absence of strong recommendations from general practioners. 25,26 Even with increased HZ education and coverage of the vaccine in insured patients over the age of 50, primary care physicians did not prioritize the HZ vaccine as much as the influenza and pneumococcal vaccines. 34 RZV shows greater efficacy compared to ZVL, so improving vaccination coverage is an important public health issue. ...
Article
Purpose: To examine the effectiveness of the recombinant zoster vaccine for preventing herpes zoster ophthalmicus in the general US population. Design: Retrospective, observational cohort study. Participants: Individuals enrolled in the OptumLabs® Data Warehouse (OLDW) (OptumLabs, Cambridge, MA) who were age-eligible for herpes zoster vaccination (≥50 years old) from 2018 through 2019. OLDW is a longitudinal, de-identified administrative claims and electronic health record database of patients in the United States with commercial insurance, Medicare Part D or Medicare Advantage METHODS: Patients were required to have ≥365 days of continuous enrollment to be eligible. Those with a diagnosis code of herpes zoster or an immunocompromising condition within one year prior to study inclusion were excluded. Vaccination with the recombinant zoster vaccine was ascertained by CPT codes, and herpes zoster ophthalmicus was ascertained by ICD-10 codes. Cox proportional hazards regression models were used to estimate the hazard ratio of HZO associated with RZV, and inverse-probability weighting was used to control for confounding. Vaccine effectiveness was calculated from hazard ratios. Main outcome(s) and measure(s): Incidence of herpes zoster ophthalmicus in vaccinated vs. unvaccinated person-time and vaccine effectiveness were assessed. Results: From January 1, 2018 to December 31, 2019 a total of 4 842 579 individuals were included in this study. 177 289 (3.7%) received two valid doses of RZV. The incidence rate of herpes zoster ophthalmicus was 25.5 (95% CI: 17.4, 35.8) cases per 100 000 person-years in the vaccinated group compared to 76.7 (95% CI: 74.7, 78.7) in the unvaccinated group. The overall adjusted effectiveness of RZV against herpes zoster ophthalmicus was 89.1% (95% CI: 82.9, 93.0). Conclusions: The effectiveness of RZV against herpes zoster ophthalmicus in individuals ages 50 years old and above is high in a real-world setting. However, the low vaccination rate in this study highlights the public health need to increase herpes zoster vaccination. Ophthalmologists can play an important role in recommending vaccination to eligible patients.
... Although previous studies have reported on perceptions, practices, and barriers to adult vaccination among primary care physicians [16][17][18][19][20][21][22], obstetricians/gynecologists (OB/GYN) [23][24][25][26][27][28], and pharmacists [29][30][31][32], the present study also assessed perceptions, practices, and barriers faced by clinicians and pharmacists, but in the context of implementing the individual components of the Standards. ...
... Among clinicians and pharmacists who did not perform the individual components of the Standards, we identified several systems-and provider-level barriers, similar to barriers reported previously [9,11,[14][15][16]19,[21][22][23]26,28,39]. In this study, the most common reported barrier was that providers did not consider vaccination within the scope of their practice. ...
Article
Full-text available
Background: The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians' (physicians, physician assistants, nurse practitioners) and pharmacists' reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients' attitudes toward vaccines were evaluated. Methods: Data from non-probability-based Internet panel surveys of U.S. clinicians (n = 1714) and pharmacists (n = 261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated. Results: High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians' and 38.4% pharmacists' submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS. Conclusion: Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers' reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.
... Pharmacies are convenient and accessible, with expanded hours of operation, and most physicians agree it is helpful for pharmacists to have a role in vaccinating adults. 7,9 Thus, collaborations between clinicians and pharmacists are important for increasing vaccination coverage. 48 Ensuring effective communication regarding patients' vaccination, including recording vaccinations in the IIS, is critical to the success of such partnerships. ...
... Providers often cite concern regarding payment structure and vaccine affordability as the main barriers to stocking vaccines and providing vaccination services. 7,11,12,20,40,41,[53][54][55] One study found that more than one third of primary care physicians reported not recommending vaccines to adult patients because they thought the patient's insurance would not cover vaccination or the patient could be vaccinated more affordably elsewhere. 11 Pharmacies have well-established payment and billing systems, but states' laws differ regarding which vaccines pharmacists can provide with or without a physician order. ...
Article
Full-text available
Introduction: Despite the proven effectiveness of immunization in preventing morbidity and mortality, adult vaccines remain underutilized. The objective of this study was to describe clinicians' and pharmacists' self-reported implementation of the Standards for Adult Immunization Practice ("the Standards"; i.e., routine assessment, recommendation, and administration/referral for needed vaccines, and documentation of administered vaccines, including in immunization information systems). Methods: Two Internet panel surveys (one among clinicians and one among pharmacists) were conducted during February-March 2017 and asked respondents about their practice's implementation of the Standards. T-tests assessed associations between clinician medical specialty, vaccine type, and each component of the Standards (March-August 2017). Results: Implementation of the Standards varied substantially by vaccine and provider type. For example, >80.0% of providers, including obstetrician/gynecologists and subspecialists, assessed for and recommended influenza vaccine. However, 24.3% of obstetrician/gynecologists and 48.9% of subspecialists did not stock influenza vaccine for administration. Although zoster vaccine was recommended by >89.0% of primary care providers, <58.0% stocked the vaccine; by contrast, 91.6% of pharmacists stocked zoster vaccine. Vaccine needs assessments, recommendations, and stocking/referrals also varied by provider type for pneumococcal; tetanus, diphtheria, acellular pertussis; tetanus diphtheria; human papillomavirus; and hepatitis B vaccines. Conclusions: This report highlights gaps in access to vaccines recommended for adults across the spectrum of provider specialties. Greater implementation of the Standards by all providers could improve adult vaccination rates in the U.S. by reducing missed opportunities to recommend vaccinations and either vaccinate or refer patients to vaccine providers.
... 18,19 The previously published baseline survey results show that only 66% of general internal medicine (GIM) physicians responded that HZ vaccination was an important clinical priority, and 48% reported that less than 10% of their patients received the HZ vaccine. 22 The top barrier to vaccination was cost to patients; and lack of awareness of national recommendations varied by provider setting. ...
... As in the baseline survey, significant differences in physician attitudes and practices remained among the 4 different provider sites in the follow up survey. 22 BG and Vol were more likely to report cost as a barrier to vaccination, and BG, without the vaccine on formulary, expressed greater difficulties with ordering and administering the vaccine. As a result, BG physicians were more likely to respond that less than 10% of their patients received the HZ vaccine. ...
Article
Full-text available
Objective: In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers. Methods: General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey. Results: Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey. Conclusions: Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.
... Studies of vaccine assessment, recommendation, and administration are available for primary care settings [10][11][12][13][14][15][16][17]. However, studies on implementation of the Standards in alternative vaccination settings, such as pharmacies or subspecialist clinics, are limited [18][19][20]. ...
Article
The revised Standards for Adult Immunization Practice (“Standards”), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists. Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices.
... Increasing vaccination rates against zoster has been a priority at NYU Langone Health since 2011 when we introduced interventions, including education, increased availability at our pharmacy, and electronic medical record reminders and alerts. We conducted surveys of our primary care doctors regarding their knowledge, attitudes, and practices before and 1 year after these interventions [45,46]. We have recently completed a 5-year follow-up survey of our expanded general internal medicine physicians in diverse practice settings (Cornea 2018 accepted for publication). ...
Article
Full-text available
Purpose of Review In this review, we will discuss herpes zoster, a common, serious, and potentially vision and life-threatening preventable disease. We will also review the two available zoster vaccines and discuss the current Food and Drug Administration (FDA) approvals and Center for Disease Control (CDC) recommendations regarding herpes zoster vaccination. Recent Findings The incidence of herpes zoster is increasing, the age of onset is decreasing, and more complications are being reported. The zoster vaccine live (ZVL), which contains a live attenuated virus, has been CDC recommended for immunocompetent adults age 60 years and older since 2008, and FDA approved for immunocompetent adults age 50 years and older since 2011. Under-usage of this vaccine remains a problem. The recombinant zoster vaccine (RZV), which contains a viral antigen in a novel adjuvant, was approved by the FDA in October 2017 for adults age 50 years and older. In January 2018, the CDC recommended this vaccine as preferred for immunocompetent adults age 50 years and older, including those who have received the zoster vaccine live in the past. Summary Now that there are two approved and recommended vaccines against zoster, including a new one requiring a two-shot series that appears more effective, it should be a high priority for physicians, including primary care doctors, ophthalmologists, and dermatologists, as well as other health care professionals, to increase vaccination rates of adults age 50 years and older against zoster and prevent this painful and potentially devastating disease.
... The current rate of immunizations for older adults does not meet the goals for immunization rates set out in Healthy People 2020. Known factors that decrease rates are lack of patient knowledge, fear, gender, and ethnic disparities, poor access to health services, perceived high costs to the patient, the tendency of providers to focus on acute and chronic health problems rather than health promotion and disease prevention, lack of continuity and follow-up to manage immunization regimens, lack of consistent and adequate payment to providers of adult vaccines, and lack of up-to-date knowledge among providers [10][11][12][13]. Known interventions aimed at improving adherence rates include a process to enhance access to vaccination services (e.g., expanded access in health care settings, reduced client out-of-pocket costs), use of provideror system-based interventions (e.g., standing orders, provider reminder systems, provider assessment and feedback), public service announcements related to getting vaccinated or news articles or reports noting shortages of vaccines, and interventions to increase patient demand for vaccination (e.g., patient reminders, patient education, the media). ...
Article
Full-text available
The current rate of immunizations for older adults does not meet the immunization goals for Healthy People 2020. Using a Social Ecological Model and Social Cognitive Theory, the purpose of this study was to disseminate and implement the Immunization Champions, Advocates and Mentors Program (ICAMP) into a variety of health care settings. This study used a single group pre-/post-test design. Champions were recruited nationally. Five geographically diverse face-to-face meetings were held to train health care providers to be ICAMP immunization champions. Dissemination and implementation of ICAMP was evaluated using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model. Participants were surveyed at baseline for descriptive information and were asked to gather immunization rates for at least one particular vaccine and provide follow-up data on progress toward goal achievement. A total of 212 champions from 82 settings participated in ICAMP. The majority were nurses (111/212, 52%). With regard to reach, we obtained 212 applications from individuals in a variety of settings interested in becoming champions. With regard to effectiveness, the majority of the champions (n = 178/212, 84%) used ICAMP material, 88% (n = 186/212) made changes related to immunization processes within their setting, and all reported that immunization practices improved. The majority used the toolkit materials up through 60 days following ICAMP. Sustained use of materials after the 60-day follow-up was less evident. ICAMP was implemented as intended and was effective in changing processes around immunizations. Ongoing work is needed to determine whether ICAMP improves immunization rates.
... As all the evidence identifies provider recommendation as the principal reason for adults to become vaccinated [1], this implies that if few providers are convinced of the importance of adult vaccination the uptake will remain low. Numerous studies show that many primary-care physicians do not consider vaccination of older adults a high priority [81][82][83][84][85]. ...
Article
Full-text available
Objectives Populations are aging worldwide. This paper summarizes some of the challenges and opportunities due to the increasing burden of infectious diseases in an aging population. Results Older adults typically suffer elevated morbidity from infectious disease, leading to increased demand for healthcare resources and higher healthcare costs. Preventive medicine, including vaccination can potentially play a major role in preserving the health and independence of older adults. However, this potential of widespread vaccination is rarely realized. Here, we give a brief overview of the problem, discuss concrete obstacles and the potential for expanded vaccination programs to promote healthy aging. Conclusion The increasing healthcare burden of infectious diseases expected in aging populations could, to a large extent, be reduced by achieving higher vaccination coverage among older adults. Vaccination can thus contribute to healthy aging, alongside healthy diet and physical exercise. The available evidence indicates that dedicated programs can achieve substantial improvements in vaccination coverage among older adults, but more research is required to assess the generalizability of the results achieved by specific interventions (see Additional file 1). Electronic supplementary material The online version of this article (10.1007/s41999-018-0040-8) contains supplementary material, which is available to authorized users.
... Finally, in previous studies focused on adult immunization rates, physicians have reported that having nurses or other staff members take a more active role in the immunization process, such as patient assessment, is helpful and improves practice workflow. [91][92][93] We found 4 out of 5 identified studies that reported including a heightened level of nurse involvement component in interventions supported and improved immunization rates among children as well, 34,48,82,88,94 contributing to increasing coverage up to 95% over 18 months in one instance. 48 Offering providers incentives such as bonuses and enhanced fee for service have also resulted in modest improvements in up-to-date rates. ...
Article
Full-text available
Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested interventional strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising interventional models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents’ and providers’ needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.
... However, for many people 65 years of age and older, zoster vaccine is a Medicare Part D benefit for which the copayment required for the vaccine can vary substantially based on the plan held by the patient. Health care providers may overestimate financial barriers to HZ immunization, with cost being the top reported barrier, 22 and recent evidence shows that more than $50 out-of-pocket costs are an inflection point for reduced patient acceptance of the zoster vaccine. 23 If licensed, HZ/su vaccine would presumably involve a copayment for each of its 2 doses. ...
... The vaccine cost is high and is not covered by the National Immunization Program in Korea so far. Most study participants were concerned about the cost and were uncertain about the effectiveness of the HZ vaccine, which is consistent with findings from other studies [11,12]. Our findings were also comparable with previous studies of physician attitudes toward the human papillary virus vaccine, which is a relatively new and expensive vaccine, like the HZ vaccine. ...
Article
Full-text available
This survey investigated Korean physician attitudes toward the herpes zoster (HZ) vaccine. A total of 400 physicians answered a self-reported questionnaire. Most physicians knew that HZ poses a significant socioeconomic burden and had good knowledge about HZ and its vaccine. Physicians who did not recommend HZ vaccine were concerned about costs (90.7%, 78/86) and doubted the effectiveness of the vaccine (58.1%, 50/86). Patient demand had a profound effect on physicians decisions; 84.9% (73/86) of them who said not recommending HZ vaccine reported that they would provide the vaccine upon patient request. In conclusion, educational initiatives should be targeted toward both physicians and patients.
Article
Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].
Article
Background: There is wide variation among physicians in the level of knowledge regarding vaccines and vaccination. We sought to compare the level of vaccine knowledge between qualified specialists and postgraduate residents. Methods: A questionnaire designed ad hoc by a consensus group was circulated to the Directors of 51 geriatrics internship programs in Italy. It investigated demographics, information sources, knowledge about influenza, pneumonococcal and herpes zoster vaccines and target groups. The proportion of correct responders was compared between residents and qualified specialists, and between best (top quartile) and worst (bottom quartile) performers. Results: A total of 459 questionnaires were analyzed; 245 (53%) were females; 253 (55%) were qualified specialists, 206 (45%) were residents. Mean age was 40.3 (SD: 12.8) years, almost 60% worked in acute care wards. On average, 33% of patients asked for information about vaccination. Residents answered significantly better on 7 out of 18 questions, and numerically albeit non-statistically higher correct response rates on a further 8 questions. There were significantly more men among the poor performers (p < 0.001), and significantly more residents among the best performers (p < 0.001). Overall, the rates of correct answers were low, with >50% of correct responses achieved on only 5 out of 18 questions (27.8%); for 2 questions, <20% responded correctly. Conclusions: Postgraduate residents in training have an overall better level of knowledge of vaccines, vaccination indications and practices than qualified specialists. This study provides avenues to develop targeted interventions to ensure health care providers are up to date and providing accurate information to patients.
Article
Background and purpose: Despite demonstrated efficacy, the utilization of herpes zoster vaccine (HZV), recommended by the Centers for Disease Control (CDC) for all immunocompetent adults aged above 60 years, is low (31%). The aim of this study was to identify nurse practitioner (NP) barriers to HZV administration and then to use these results to develop and evaluate the outcomes of an educational program. Methods: This study used a two-phase design. In Phase I, barriers that obstruct the provision of HZV were identified and NPs were surveyed to determine current HZV practice. The second phase used a quasiexperimental pretest-posttest design to evaluate the impact of the constructed program. Conclusions: In Phase I, NYS Primary Care NPs with practice years ranging from 1 to 24, who reported working in practice sites that ranged from 1 to 20 providers, possessed limited knowledge of the vaccine, especially, the financial aspects of the vaccination such as up-front cost (46%), cost to patients (39%), and reimbursement (29%), resulting in fewer provider recommendations. In Phase II, a paired-samples t test revealed a statistically significant difference between pretest scores (mean = 3.4, SD = 1.2) and posttest scores (mean = 4.7, SD = 1.3) on the knowledge survey, t (37) = -7.1, p < .0, demonstrating NPs' improved understanding of HZV. Implications for practice: Nurse practitioners will increase compliance with the CDC recommendations for HZV administration.
Article
Purpose: To investigate the knowledge, attitudes, and practice patterns of primary care physicians regarding administration of the herpes zoster (HZ) vaccine at NYU Langone Health (NYULH). Methods: A cross-sectional online survey was distributed from January to March 2017 to all physicians in the Division of General Internal Medicine and Clinical Innovation at NYULH across 5 different practice settings. Results: The response rate was 26% (138 of 530). Of the surveyed physicians, 76% (100/132) agreed that the HZ vaccine was an important clinical priority, compared with 93% and 94% for influenza and pneumococcal vaccination, respectively (P < 0.001). Only 35% (47/132) strongly agreed that it was important, compared with 68% (90/132) and 74% (98/132) who strongly agreed that pneumococcal and influenza vaccines, respectively, were important. Respondents estimated that 43% of their immunocompetent patients aged 60 or older received the HZ vaccine, whereas only 11% of patients aged 50 to 59 received the HZ vaccine (P < 0.001). The rate of HZ vaccination was lower in public hospitals (26%) than in the NYULH faculty group practice (46%) (P = 0.007). A greater percent (67% and 72%) of their patients have received influenza and pneumococcal vaccines, respectively (P < 0.001). Almost all doctors (99%, 131/132) consider the Centers for Disease Control and Prevention recommendations important in determining vaccination practices. Conclusions: HZ vaccination rates remain relatively low compared with rates of influenza and pneumonia vaccination. The recommendation for vaccination against zoster by the Centers for Disease Control and Prevention for individuals aged 50 years and older and stronger recommendations by primary care physicians for administration of zoster vaccines are needed to increase HZ vaccination rates.
Article
Herpes zoster (HZ) is caused by reactivation of latent varicella zoster virus (VZV) in people who have had chicken pox, usually resulting in a painful, unilateral, dermatomal, vesicular rash. Herpes zoster ophthalmicus occurs when the first division of cranial nerve V is involved. HZ is common, with approximately 1 million new cases per year in the United States, and occurs in 1 in 3 persons. Although the rate of HZ increases with age, over half of all cases occur under the age of 60 years. Complications of herpes zoster ophthalmicus include eye disease, postherpetic neuralgia (PHN), and strokes. VZV has also been found in temporal arteritis biopsies. There is growing evidence that HZ is followed by chronic active VZV infection contributing to these complications. In view of this, and the efficacy of suppressive antiviral treatment in reducing recurrent herpes simplex keratitis, a randomized controlled trial of suppressive valacyclovir to reduce new or worsening anterior segment disease and/or PHN is needed. The zoster vaccine (ZV) is safe and effective in reducing the burden of illness, severity of PHN, and incidence of HZ. It is Centers for Disease Control and Prevention recommended for persons aged 60 years and above without impaired cellular immunity, and Food and Drug Administration approved for those aged 50 and older. It is most effective in preventing HZ in recipients in their 50s. Because of underusage of the ZV, it has not impacted the epidemiology of the disease. Barriers to its use include cost, variable reimbursement, frozen storage, and lack of a strong recommendation by doctors.
Article
Herpes zoster ophthalmicus (HZO) is a common, vision and potentially life-threatening disease caused by the reactivation of the varicella-zoster virus (VZV) in the distribution of the first division of cranial nerve V. Although the rate of herpes zoster increases with age, over half of the people with zoster in general, including HZO, are under age 60. In addition, over 90% of people with zoster are immunocompetent, even though the disease is more common and severe in immunocompromised patients. The incidence of zoster is increasing worldwide for unknown reasons. The epidemiology has not yet been impacted by the zoster vaccine (ZV). The lack of a strong recommendation by physicians for this vaccine is a major barrier to its use. An unresolved dilemma regards the optimum timing for this vaccine. In the USA, the current recommendation by the Centers for Disease Control and Prevention (CDC) is for eligible people age 60 and older, despite its greater efficacy in reducing the incidence of disease and Food and Drug Administration (FDA) approval for age 50-59. Although there is a consensus regarding use of acute high-dose oral antiviral treatment to reduce ocular complications, there is limited evidence for prolonged treatment. The rationale for a proposed randomised controlled trial (RCT) of suppressive antiviral treatment to reduce chronic eye disease and postherpetic neuralgia (PHN) includes evidence that zoster is followed by chronic active VZV infection and similarities between HZO and herpes simplex virus (HSV) eye infection, where this treatment is effective and is the standard of care. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Article
Full-text available
Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.
Article
The live, attenuated shingles (herpes zoster) vaccine Zostavax(®) is approved in the EU for use in the prevention of herpes zoster and postherpetic neuralgia in adults aged ≥50 years. In adults aged ≥60 years, zoster vaccine reduced the burden of illness associated with herpes zoster, with reductions in the incidence of postherpetic neuralgia and herpes zoster, according to the results of the Shingles Prevention Study. Results of subsequent Short- and Long-Term Persistence Substudies indicate that the efficacy of zoster vaccine is maintained in the longer term, albeit with a gradual decline over time. In the Zostavax Efficacy and Safety Trial, zoster vaccine reduced the incidence of herpes zoster in adults aged 50-59 years. Findings of these studies are supported by the results of large, retrospective, cohort studies. Zoster vaccine was generally well tolerated, with injection-site adverse events being the most commonly reported adverse events. In conclusion, zoster vaccine provides an important opportunity to reduce the burden of illness associated with herpes zoster by reducing the incidence of herpes zoster and postherpetic neuralgia.
Article
Full-text available
Herpes zoster (HZ) adversely affects individuals aged 50-59, but vaccine efficacy has not been assessed in this population. This study was designed to determine the efficacy, safety, and tolerability of zoster vaccine for preventing HZ in persons aged 50-59 years. This was a randomized, double-blind, placebo-controlled study of 22 439 subjects aged 50-59 years conducted in North America and Europe. Subjects were given 1 dose of licensed zoster vaccine (ZV) (Zostavax; Merck) and followed for occurrence of HZ for ≥1 year (mean, 1.3 years) postvaccination until accrual of ≥96 confirmed HZ cases (as determined by testing lesions swabs for varicella zoster virus DNA by polymerase chain reaction). Subjects were followed for all adverse events (AEs) from day 1 to day 42 postvaccination and for serious AEs (SAEs) through day 182 postvaccination. The ZV reduced the incidence of HZ (30 cases in vaccine group, 1.99/1000 person-years vs 99 cases in placebo group, 6.57/1000 person-years). Vaccine efficacy for preventing HZ was 69.8% (95% confidence interval, 54.1-80.6). AEs were reported by 72.8% of subjects in the ZV group and 41.5% in the placebo group, with the difference primarily due to higher rates of injection-site AEs and headache. The proportion of subjects reporting SAEs occurring within 42 days postvaccination (ZV, 0.6%; placebo, 0.5%) and 182 days postvaccination (ZV, 2.1%; placebo, 1.9%) was similar between groups. In subjects aged 50-59 years, the ZV significantly reduced the incidence of HZ and was well tolerated. NCT00534248.
Article
Full-text available
The incidence of herpes zoster in the United States has been estimated to be > or =1 million cases annually, with a higher rate in adults older than 60 years. The morbidity of the disease, including postherpetic neuralgia, imposes significant effects on quality of life. We analyzed reports of herpes zoster in the Veterans Affairs (VA) population because these patients are older and could provide a reflection of disease trends in the aging US population. These data will provide a baseline for future analyses of the incidence of herpes zoster after the introduction of the herpes zoster vaccine in late 2007. To evaluate the trend in the annual incidence of herpes zoster for fiscal year 2000 (beginning October 1999) through fiscal year 2007 (through September 2007), we derived incidence rates using the Veterans Health Administration Decision Support System reports of herpes zoster by International Classification of Diseases, Ninth Revision codes from 2000 through 2007 and the corresponding denominator data for all veterans in care. These rates were validated by review of medical records of patients with diagnoses of herpes zoster at the Atlanta VA Medical Center. The annual incidence of herpes zoster increased from 3.10 episodes per 1000 veterans in 2000 to 5.22 in 2007 (R(2)=0.9743; P<.001). This increasing rate was seen in both men and women but only in groups older than 40 years. The increasing incidence of herpes zoster in our veteran population and its effect on the quality of life of the veterans validate the need for improved rates of vaccination in this population.
Article
Full-text available
Despite wide promulgation, clinical practice guidelines have had limited effect on changing physician behavior. Little is known about the process and factors involved in changing physician practices in response to guidelines. To review barriers to physician adherence to clinical practice guidelines. We searched the MEDLINE, Educational Resources Information Center (ERIC), and HealthSTAR databases (January 1966 to January 1998); bibliographies; textbooks on health behavior or public health; and references supplied by experts to find English-language article titles that describe barriers to guideline adherence. Of 5658 articles initially identified, we selected 76 published studies describing at least 1 barrier to adherence to clinical practice guidelines, practice parameters, clinical policies, or national consensus statements. One investigator screened titles to identify candidate articles, then 2 investigators independently reviewed the texts to exclude articles that did not match the criteria. Differences were resolved by consensus with a third investigator. Two investigators organized barriers to adherence into a framework according to their effect on physician knowledge, attitudes, or behavior. This organization was validated by 3 additional investigators. The 76 articles included 120 different surveys investigating 293 potential barriers to physician guideline adherence, including awareness (n = 46), familiarity(n = 31), agreement (n = 33), self-efficacy (n = 19), outcome expectancy (n = 8), ability to overcome the inertia of previous practice (n = 14), and absence of external barriers to perform recommendations (n = 34). The majority of surveys (70 [58%] of 120) examined only 1 type of barrier. Studies on improving physician guideline adherence may not be generalizable, since barriers in one setting may not be present in another. Our review offers a differential diagnosis for why physicians do not follow practice guidelines, as well as a rational approach toward improving guideline adherence and a framework for future research.
Article
Full-text available
The incidence and severity of herpes zoster and postherpetic neuralgia increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV). We tested the hypothesis that vaccination against VZV would decrease the incidence, severity, or both of herpes zoster and postherpetic neuralgia among older adults. We enrolled 38,546 adults 60 years of age or older in a randomized, double-blind, placebo-controlled trial of an investigational live attenuated Oka/Merck VZV vaccine ("zoster vaccine"). Herpes zoster was diagnosed according to clinical and laboratory criteria. The pain and discomfort associated with herpes zoster were measured repeatedly for six months. The primary end point was the burden of illness due to herpes zoster, a measure affected by the incidence, severity, and duration of the associated pain and discomfort. The secondary end point was the incidence of postherpetic neuralgia. More than 95 percent of the subjects continued in the study to its completion, with a median of 3.12 years of surveillance for herpes zoster. A total of 957 confirmed cases of herpes zoster (315 among vaccine recipients and 642 among placebo recipients) and 107 cases of postherpetic neuralgia (27 among vaccine recipients and 80 among placebo recipients) were included in the efficacy analysis. The use of the zoster vaccine reduced the burden of illness due to herpes zoster by 61.1 percent (P<0.001), reduced the incidence of postherpetic neuralgia by 66.5 percent (P<0.001), and reduced the incidence of herpes zoster by 51.3 percent (P<0.001). Reactions at the injection site were more frequent among vaccine recipients but were generally mild. The zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.
Article
Full-text available
Immunization is one of the most effective and cost-effective prevention measures available. As a result of universal vaccination of children, polio has been eliminated in the United States and much of the world, measles and rubella are no longer endemic diseases in the United States, and most of the other vaccine-preventable diseases of childhood are at or near record lows. A recent review of clinical preventive services by Partnership for Prevention gave childhood immunization a perfect score of 10, based on clinically preventable burden and cost-effectiveness.
Article
Full-text available
A clinical trial has shown that a live-attenuated varicella-zoster virus vaccine is effective against herpes zoster (HZ) and post-herpetic neuralgia (PHN). The aim of this study was to examine the cost-effectiveness of vaccination against HZ and PHN in Canada. A cohort model was developed to estimate the burden of HZ and the cost-effectiveness of HZ vaccination, using Canadian population-based data. Different ages at vaccination were examined and probabilistic sensitivity analysis was performed. The economic evaluation was conducted from the ministry of health perspective and 5% discounting was used for costs and benefits. In Canada (population = 30 million), we estimate that each year there are 130,000 new cases of HZ, 17,000 cases of PHN and 20 deaths. Most of the pain and suffering is borne by adults over the age of 60 years and is due to PHN. Vaccinating 65-year-olds (HZ efficacy = 63%, PHN efficacy = 67%, no waning, cost/course = 150)isestimatedtocost150) is estimated to cost 33,000 per QALY-gained (90% CrI: 19,000-63,000). Assuming the cost per course of HZ vaccination is 150,probabilisticsensitivityanalysissuggestthatvaccinatingbetween65and75yearsofagewilllikelyyieldcosteffectivenessratiosbelow150, probabilistic sensitivity analysis suggest that vaccinating between 65 and 75 years of age will likely yield cost-effectiveness ratios below 40,000 per Quality-Adjusted Life-Year (QALY) gained, while vaccinating adults older than 75 years will yield ratios less than $70,000 per QALY-gained. These results are most sensitive to the duration of vaccine protection and the cost of vaccination. In conclusion, results suggest that vaccinating adults between the ages of 65 and 75 years is likely to be cost-effective and thus to be a judicious use of scarce health care resources.
Article
Immunizations are recommended throughout life to prevent infectious diseases and their sequelae. Adult coverage, however, remains low for most routinely recommended vaccines and well below Healthy People 2020 targets. In October 2011, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2012. Apart from influenza vaccination, which is now recommended for all adults, other adult vaccines target different populations based on age, certain medical conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications. To assess adult (≥19 years) vaccination coverage for select vaccines, CDC analyzed data from the 2010 National Health Interview Survey (NHIS). This report summarizes the results of that analysis for pneumococcal, hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines, as well as tetanus antigen-containing vaccines (including tetanus, diphtheria, and acellular pertussis vaccine [Tdap]), by selected characteristics (age, vaccination target group status, and race/ethnicity). Influenza vaccination coverage estimates for the 2010-11 influenza season have been published separately. Compared with results of the 2009 NHIS survey, increases in coverage were observed only for Tdap vaccination for persons aged 19-64 years (1.6 percentage point increase to 8.2%), zoster vaccination among persons aged ≥60 years (4.4 percentage point increase to 14.4%), and ≥1 dose HPV vaccination in women aged 19-26 years (3.6 percentage point increase to 20.7%); coverage for the other vaccines was unchanged at <70%. These data indicate only limited recent improvements in vaccination coverage among adults in the United States. Substantial increases are needed to reduce the occurrence of vaccine-preventable diseases among adults.
Article
Purpose: To increase the vaccination rate and identify barriers to administration of the vaccine against herpes zoster by having ophthalmologists screen and provide the vaccine. Design: Prospective interventional cohort study. Methods: Setting: Academic City Hospital, Bellevue Hospital. Participants: A total of 100 eligible patients based on recommended Centers for Disease Control (CDC) criteria and ability to speak English and Spanish who received the herpes zoster vaccine were compared with 66 patients who declined the vaccine. Interventions: The vaccine was administered after written informed consent was obtained to complete a screening questionnaire evaluating the participants' eligibility and interest in receiving the vaccine. Main outcome measures: Barriers to administration of the vaccine were evaluated. Results: A total of 170 consenting patients, including 100 patients who were vaccinated, 66 patients who declined vaccination, and 4 patients who were ineligible, were analyzed. The proportion of subjects who would consider receiving the vaccine if recommended by a doctor among those who received the shingles vaccine, 98.0% (95% CI: 95%-100%), was significantly greater than the proportion in the group that declined, 74.2% (95% CI: 64%-85%) (P ≤ .0001). The most common reason that patients declined the vaccine was wanting to speak with their primary care physician, 46.9% (95% CI: 33%-61%). Conclusions: Ophthalmologists can screen, educate, and prescribe the vaccine against herpes zoster in order to increase utilization of this vaccine. Nonfinancial or access barriers of this vaccine among underserved eligible patients include absence of recommendation by their primary care doctor.
Article
The objective of this study was to determine current practices and opinions among cornea specialists for treating and preventing recurrences of herpes zoster ophthalmicus (HZO). In November 2010, a survey of 15 questions was distributed to The Cornea Society listserv. Questions identified respondents' treatment practices for recurrent HZO and opinions regarding prolonged antiviral prophylaxis and zoster vaccine. Of 100 respondents, the majority were cornea specialists (83 of 98, 85%). Eighty-seven percent (84 of 97) reported treating recurrent or chronic cases of HZO in the last year. The most common choice of treatment in the posed recurrent HZO clinical scenario was a combination of oral antiviral and topical corticosteroid (63 of 100, 63%), although significant variability existed in the duration of oral antiviral administration. Fifty-four respondents (56%) believed that prolonged acyclovir prophylaxis could reduce recurrent signs of HZO; 28% (27 of 98) believed that recurrences of HZO could be reduced after the period of acyclovir administration. For patients with a history of HZO, most respondents reported not recommending the adult zoster vaccine (63 of 98, 64%), but 46% (43 of 94) believed that the vaccine could reduce recurrent signs or did not know. Many cornea specialists are managing recurrent or chronic cases of HZO, but there is variability in the use of topical corticosteroids and antivirals. Additionally, no consensus exists on the efficacy of prolonged antiviral therapy or the adult zoster vaccine to reduce chronic or recurrent disease. These results demonstrate the need for further systematic study of treatment and prophylaxis for recurrent and chronic HZO.
Article
The estimation of herpes zoster (HZ) vaccine efficacy by time since vaccination and age at vaccination is crucial to assess the effectiveness and cost-effectiveness of HZ vaccination. Published estimates for the duration of protection from the vaccine diverge substantially, although based on data from the same trial for a follow-up period of 5 years. Different models were used to obtain these estimates, but it is unclear which of these models is most appropriate (if any). Only one study estimated vaccine efficacy by age at vaccination and time since vaccination combined. Recently, data became available from the same trial for a follow-up period of 7 years. We aim to elaborate on estimating HZ vaccine efficacy (1) by estimating it as a function of time since vaccination and age at vaccination, (2) by comparing the fits of a range of models, and (3) by fitting these models on data for a follow-up period of 5 and 7 years. Although the models' fit to data are very comparable, they differ substantially in how they estimate vaccine efficacy to change as a function of time since vaccination and age at vaccination. An accurate estimation of HZ vaccine efficacy by time since vaccination and age at vaccination is hampered by the lack of insight in the biological processes underlying HZ vaccine protection, and by the fact that such data are currently not available in sufficient detail. Uncertainty about the choice of model to estimate this important parameter should be acknowledged in cost-effectiveness analyses.
Article
Less than half of adults for whom seasonal influenza vaccine is recommended receive the vaccine. Little is known about physician willingness to collaborate with community vaccinators to improve delivery of vaccine. To assess among general internists and family medicine physicians: (1) seasonal influenza vaccination practices, (2) willingness to collaborate with community vaccinators, (3) barriers to collaboration, and (4) characteristics associated with unwillingness to refer patients to community sites for vaccination. Mail and Internet-based survey. National survey conducted during July-October 2009. General internists and family medicine physicians. Survey responses on vaccination practices, willingness to collaborate to deliver vaccine and barriers to collaboration. Response rates were 78% (337/432 general internists) and 70% (298/424 family medicine physicians). Ninety-eight percent of physicians reported giving influenza vaccine in their practice during the 2008-2009 season. Most physicians reported willingness to refer certain patients to other community vaccinators such as public clinics or pharmacies (79%); to collaborate with public health entities in holding community vaccination clinics (76%); and set up vaccination clinics with other practices (69%). The most frequently reported barriers to collaboration included concerns about record transfer (24%) and the time and effort collaboration would take (21%). Reporting loss of income (RR 1.40, 95% CI 1.03-1.89) and losing opportunities to provide important medical services to patients with chronic medical conditions (RR 1.77, 95% CI 1.25-2.78) were associated with unwillingness to refer patients outside of the practice for vaccination. Surveyed physicians may not be representative of all physicians. The majority of physicians report willingness to collaborate with other community vaccinators to increase influenza vaccination rates although some will need assurance that collaboration will be financially feasible and will not compromise care. Successful collaboration will require reliable record transfer and must not be time consuming.
Article
To study the clinical course of herpes zoster ophthalmicus (HZO) and to compare the demographics, treatments, and outcomes in patients aged <60 years versus patients aged ≥60 years at the time of diagnosis. Retrospective chart review of all 112 patients presenting for management of HZO from January 1, 2008 to December 31, 2008. A total of 112 patients (58 aged <60 years and 54 aged >60 years) at the time of HZO onset. Anterior segment complications, treatments, and surgical procedures were documented at 3 months, 6 months, and 1 year, and then annually for the remainder of the follow-up period. Intraocular pressure, inflammation, steroid use, surgical procedures, anterior segment complications, post-herpetic neuralgia, and delayed herpes zoster pseudodendrites. Equal numbers of patients were affected with HZO in the younger and older age groups (51.8%, n = 58 vs. 48.2%, n = 54, respectively, P = 0.69). The most common decade of HZO onset was between 50 and 59 years. Younger patients were more likely to be healthy compared with older patients (P = 0.05). Delayed herpes zoster pseudodendrites were more common in the younger patients (36.7% vs. 16.7%, P = 0.03). The mean number of flares per patient-years was significantly higher in the younger patients (z test, P = 0.024). Post-herpetic neuralgia, neurotrophic keratopathy, and secondary infectious keratitis were more frequent in the older patients (P = 0.05). Prevalence of corneal perforation, corneal thinning, cataract formation, and glaucoma was similar between the 2 groups. Most patients in both groups (84.2% of younger patients and 89.5% of older patients) were taking topical steroids 3 years after referral for HZO. Herpes zoster ophthalmicus affects individuals aged younger than and older than 60 years in similar numbers, with the most common decade of onset between age 50 and 59 years. Younger patients had more episodes of delayed pseudodendritiform keratitis and flares of inflammation compared with older patients, who had more problems related to neurotrophic keratopathy. The author(s) have no proprietary or commercial interest in any materials discussed in this article.
Article
Shingles (herpes zoster [HZ]) is a localized, generally painful and debilitating disease that occurs most frequently among older adults. It is caused by reactivation of varicella-zoster virus. HZ causes substantial morbidity, especially among older adults. The vaccine to prevent HZ was approved by Food and Drug Administration and recommended by the Advisory Committee for Immunization Practices for people aged ≥60 years in 2006 (these recommendations were published in 2008). To examine HZ vaccination among people aged ≥60 years in the U.S. in 2008. Data from the 2008 National Health Interview Survey among people aged ≥60 years were analyzed in 2010. Multivariable logistic regression and predictive marginal analyses were conducted to identify factors independently associated with HZ vaccination. Potential missed opportunities also were assessed. By 2008, only 6.7% (95% CI=5.9%, 7.6%) of adults aged ≥60 years reported having had HZ vaccination. The level of HZ vaccination coverage was lower (4.7%) among people aged 60-64 years compared to people aged 65-74 years (7.4%); 75-84 years (7.6%); and ≥85 years (8.2%). Coverage was statistically higher for non-Hispanic whites (7.6%) compared with non-Hispanic blacks (2.5%) and Hispanics (2.1%). Among people aged ≥60 years who reported never receiving HZ vaccination, 95.1% reported at least one missed opportunity to be vaccinated. People more likely to report ever having been vaccinated were older, female, non-Hispanic white, married, more educated, and reporting received influenza vaccination in the past year. By 2008, HZ vaccination coverage was 6.7%. The coverage level was low among all groups, but it was lowest among minority groups. Increased efforts are needed to remove barriers and to enable HZ vaccination among all adults aged ≥60 years.
Article
Approximately 1 million episodes of herpes zoster occur annually in the United States. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions. To evaluate risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings. A retrospective cohort study from January 1, 2007, through December 31, 2009, of individuals enrolled in the Kaiser Permanente Southern California health plan. Participants were immunocompetent community-dwelling adults aged 60 years or older. The 75,761 members in the vaccinated cohort were age matched (1:3) to 227,283 unvaccinated members. Incidence of herpes zoster. Herpes zoster vaccine recipients were more likely to be white, women, with more outpatient visits, and fewer chronic diseases. The number of herpes zoster cases among vaccinated individuals was 828 in 130,415 person-years (6.4 per 1000 person-years; 95% confidence interval [CI], 5.9-6.8), and for unvaccinated individuals it was 4606 in 355,659 person-years (13.0 per 1000 person-years; 95% CI, 12.6-13.3). In adjusted analysis, vaccination was associated with a reduced risk of herpes zoster (hazard ratio [HR], 0.45; 95% CI, 0.42-0.48); this reduction occurred in all age strata and among individuals with chronic diseases. Risk of herpes zoster differed by vaccination status to a greater magnitude than the risk of unrelated acute medical conditions, suggesting results for herpes zoster were not due to bias. Ophthalmic herpes zoster (HR, 0.37; 95% CI, 0.23-0.61) and hospitalizations coded as herpes zoster (HR, 0.35; 95% CI, 0.24-0.51) were less likely among vaccine recipients. Among immunocompetent community-dwelling adults aged 60 years or older, receipt of the herpes zoster vaccine was associated with a lower incidence of herpes zoster. The risk was reduced among all age strata and among individuals with chronic diseases.
Article
To present population-based estimates of herpes zoster (HZ) recurrence rates among adults. To identify recurrent cases of HZ, we reviewed the medical records (through December 31, 2007) of all Olmsted County, Minnesota, residents aged 22 years or older who had an incident case of HZ between January 1, 1996, and December 31, 2001. Kaplan-Meier curves and Cox regression models were used to describe recurrences by age, immune status, and presence of prolonged pain at the time of the incident HZ episode. Of the 1669 persons with a medically documented episode of HZ, 95 had 105 recurrences (8 persons with >1 recurrence) by December 31, 2007, an average follow-up of 7.3 years. The Kaplan-Meier estimate of the recurrence rate at 8 years was 6.2%. With a maximum follow-up of 12 years, the time between HZ episodes in the same person varied from 96 days to 10 years. Recurrences were significantly more likely in persons with zoster-associated pain of 30 days or longer at the initial episode (hazard ratio, 2.80; 95% confidence interval, 1.84-4.27; P<.001) and in immunocompromised individuals (hazard ratio, 2.35; 95% confidence interval, 1.35-4.08; P=.006). Women and anyone aged 50 years or older at the index episode also had a greater likelihood of recurrence. Rates of HZ recurrence appear to be comparable to rates of first HZ occurrence in immunocompetent individuals, suggesting that recurrence is sufficiently common to warrant investigation of vaccine prevention in this group.
Article
Recently, several new vaccines have been recommended for adults. Little is known regarding the immunization purchase and stocking practices of adult primary care physicians. To determine the proportion of family practice and internal medicine physicians who routinely stock specific adult vaccines and their rationale for those decisions, we conducted a cross-sectional survey in 2009 of a national random sample of 993 family physicians (FPs) and 997 general internists (IMs) in the US. Of the 1109 respondents, 886 reported that they provide primary care to adults aged 19-64 years and 96% of these physicians stock at least one vaccine recommended for adults. Of those, 2% plan to stop and 12% plan to increase vaccine purchases; the rest plan to maintain status quo. Of the respondents, 27% (31% FPs vs 20% IMs) stocked all adult vaccines. We conclude that many primary care physicians who provide care to adults do not stock all recommended immunizations. Efforts to improve adult immunization rates must address this fundamental issue.
Article
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. To assess current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination among general internists and family medicine physicians. Mail and Internet-based survey, designed through an iterative process and conceptually based on the Health Belief Model. National survey conducted from July to September 2008. General internists and family medicine physicians. Survey responses on current vaccination practices, knowledge and practice regarding reimbursement, and barriers to vaccination. 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. Survey results represent reported but not observed practice. Surveyed providers may not be representative of all providers. 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. Centers for Disease Control and Prevention.
Article
As part of a series of studies on vaccine acceptance, we assessed determinants of compliance of the community-dwelling elderly with herpes zoster (HZ) vaccination in an existing influenza vaccination program. General practitioners (GPs) sent out a questionnaire to 1778 patients aged > or =65 years, and offered them free HZ vaccination simultaneously with the yearly influenza vaccination. In all, 690 patients (39%) were vaccinated against HZ; 1349 patients (76%) accepted influenza vaccination. Determinants of non-compliance with HZ vaccination were perceived lack of recommendation by the GP, unwillingness to comply with the doctor's advice, perception of low risk of contracting HZ, perception of short pain duration of HZ, and the opinion that vaccinations weaken one's natural defenses. The same determinants were associated with non-compliance with both vaccinations, but objections in general towards vaccination, a high education and difficulties to visit GPs were also important. Uptake of HZ vaccination was rather low and more data on (cost-)effectiveness might encourage GPs to offer HZ vaccination to their patients.
Article
In the past 50 years we have made substantial progress in understanding the biology of disease and in devising new ways to prevent or treat it. However, there has been a substantial lag in applying what we know to actual patient care. In this article, based on his Shattuck Lecture, Claude Lenfant outlines the magnitude of the problem of translating research knowledge into clinical practice and offers suggestions for closing this gap.
Article
Dr Hope-Simpson presents a study of all cases of herpes zoster occurring in his general practice during a sixteen-year period. The rate was 3·4 per thousand per annum, rising with age, and the distribution of lesions reflected that of the varicella rash. It was found that severity increased with age, but that the condition did not occur in epidemics, and that there was no characteristic seasonal variation. A low prevalence of varicella was usually associated with a high incidence of zoster. Dr Hope-Simpson suggests that herpes zoster is a spontaneous manifestation of varicella infection. Following the primary infection (chickenpox), virus becomes latent in the sensory ganglia, where it can be reactivated from time to time (herpes zoster). Herpes zoster then represents an adaptation enabling varicella virus to survive for long periods, even without a continuous supply of persons susceptible to chickenpox.
Article
To assess immunization practices and attitudes of U.S. primary care physicians regarding adult influenza and pneumococcal immunizations. Mailed survey of primary care internists and family physicians across the United States; four follow-up contacts by mail and telephone. Bivariate and multivariate analyses assessed immunization practices and attitudes and differences by physician characteristics. Three hundred and sixteen of 668 eligible physicians responded (50 refused, response rate of 266 = 40%); 220 provided adult vaccinations. More than 64% indicated they routinely vaccinated patients >/=65 years and those <65 years with chronic disease indications with both influenza and pneumococcal vaccine. Reported barriers for influenza vaccination included vaccine safety concerns by patients (58%), urgent concerns dominating visits (43%), and inadequate reimbursement (26%). Reported barriers for pneumococcal vaccination included urgent concerns during office visits (44%), no patient immunization history (36%), patient concerns about vaccine safety (31%), and inadequate reimbursement (25%). Many physicians indicated willingness to try tracking systems (72%), chart reminders (55%), patient reminders (53%), standing orders (36%), external lists of unimmunized patients for pneumococcal vaccination (74%), external patient reminders (70%), and office training of physicians (36%) or staff (46%). While most physicians favored adult vaccinations, practical barriers to vaccination exist. Most physicians would adopt evidence-based strategies to improve immunization delivery.
Article
Few recent studies have reported data on the incidence of herpes zoster (HZ) in U.S. general clinical practice. To estimate the age- and sex-specific incidence of HZ among U.S. health plan enrollees. Data for the years 2000 to 2001 were obtained from the Medstat MarketScan database, containing health insurance enrollment and claims data from over 4 million U.S. individuals. Incident HZ cases were identified through HZ diagnosis codes on health care claims. The burden of HZ among high-risk individuals with recent care for cancer, HIV, or transplantation was examined in sub-analyses. Overall incidence rates were age- and sex-adjusted to the 2000 U.S. population. MarketScan U.S. health plan enrollees of all ages. We identified 9,152 incident cases of HZ (3.2 per 1,000 person-years) (95% confidence interval [CI], 3.1 to 3.2 per 1,000). Annual HZ rates per 1,000 person-years were higher among females (3.8) than males (2.6) (P<.0001). HZ rates rose sharply with age, and were highest among individuals over age 80 (10.9 per 1,000 person-years) (95% CI, 10.2 to 11.6). The incidence of HZ per 1,000 person-years among patients with evidence of recent care for transplantation, HIV infection, or cancer (10.3) was greater than for individuals without recent care for these conditions (3.0) (P<.0001). The overall incidence of HZ reported in the present study was found to be similar to rates observed in U.S. analyses conducted 10 to 20 years earlier, after age- and sex-standardizing estimates from all studies to the 2000 U.S. population. The higher rate of HZ in females compared with males contrasts with prior U.S. studies.
Article
The Shingles Prevention Study showed that a varicella-zoster virus (VZV) vaccine administered to adults 60 years of age or older reduced the incidence of herpes zoster from 11.12 to 5.42 cases per 1000 person-years. Median follow-up was 3.1 years, and relative risk reduction was 51.3% (95% CI, 44.2% to 57.6%). To assess the extent to which clinical and cost variables influence the cost-effectiveness of VZV vaccination for preventing herpes zoster in immunocompetent older adults. Decision theoretical model. English-language data published to March 2006 identified from MEDLINE on herpes zoster rates, vaccine effectiveness, quality of life, medical resource use, and unit costs. Target Population: Immunocompetent adults 60 years of age or older with a history of VZV infection. Time Horizon: Lifetime. Perspective: U.S. societal. Interventions: Varicella-zoster virus vaccination versus no vaccination. Outcome Measures: Incremental quality-adjusted survival and cost per quality-adjusted life-year (QALY) gained. Results of Base-Case Analysis: By reducing incidence and severity of herpes zoster, vaccination can increase quality-adjusted survival by 0.6 day compared with no vaccination. One scenario in which vaccination costs less than 100,000 dollars per QALY gained is when 1) the unit cost of vaccination is less than 200 dollars, 2) the age at vaccination is less than 70 years, and 3) the duration of vaccine efficacy is more than 30 years. Results of Sensitivity Analysis: Vaccination would be more cost-effective in "younger" older adults (age 60 to 64 years) than in "older" older adults (age > or =80 years). Longer life expectancy and a higher level of vaccine efficacy offset a lower risk for herpes zoster in the younger group. Other factors influencing cost-effectiveness include quality-of-life adjustments for acute zoster, unit cost of the vaccine, risk for herpes zoster, and duration of vaccine efficacy. The effectiveness of VZV vaccination remains uncertain beyond the median 3.1-year duration of follow-up in the Shingles Prevention Study. Varicella-zoster virus vaccination to prevent herpes zoster in older adults would increase QALYs compared with no vaccination. Resolution of uncertainties about the average quality-of-life effects of acute zoster and the duration of vaccine efficacy is needed to better determine the cost-effectiveness of zoster vaccination in older adults.
Article
To establish accurate, up-to-date, baseline epidemiological data for herpes zoster (HZ) before the introduction of the recently licensed HZ vaccine. Using data from January 1, 1996, to October 15, 2005, we conducted a population-based study of adult residents (Greater than or equal to 22 years) of Olmsted County, MN, to determine (by medical record review) the incidence of HZ and the rate of HZ-related complications. Incidence rates were determined by age and sex and adjusted to the US population. A total of 1669 adult residents with a confirmed diagnosis of HZ were identified between January 1, 1996, and December 31, 2001. Most (92%) of these patients were immunocompetent and 60% were women. When adjusted to the US adult population, the incidence of HZ was 3.6 per 1000 person-years (95% confidence interval, 3.4-3.7), with a temporal increase from 3.2 to 4.1 per 1000 person-years from 1996 to 2001. The incidence of HZ and the rate of HZ-associated complications increased with age, with 68% of cases occurring in those aged 50 years and older. Postherpetic neuralgia occurred in 18% of adult patients with HZ and in 33% of those aged 79 years and older. Overall, 10% of all patients with HZ experienced 1 or more nonpain complications. Our population-based data suggest that HZ primarily affects immunocompetent adults older than 50 years; 1 in 4 experiences some type of HZ-related complication.
Article
The incidence and morbidity of herpes zoster (HZ) and HZ ophthalmicus (HZO), and the potential impact of varicella vaccine on their epidemiology. Herpes zoster affects 20% to 30% of the population at some point in their lifetime; approximately 10% to 20% of these individuals will have HZO. The peer-reviewed literature published from 1865 to the present was reviewed. Herpes zoster is the second clinical manifestation of varicella-zoster virus (VZV). The incidence and severity of HZ increase with advancing age. Varicella-zoster virus-specific cell-mediated immunity, which keeps latent VZV in check and is boosted by periodic reexposure to VZV, is an important mechanism in preventing VZV reactivation as zoster. Thus, widespread varicella vaccination may change the epidemiology of HZ. Herpes zoster ophthalmicus occurs when HZ presents in the ophthalmic division of the fifth cranial nerve. Ocular involvement occurs in approximately 50% of HZ patients without the use of antiviral therapy. There is a long list of complications from HZ, including those that involve the optic nerve and retina in HZO, but the most frequent and debilitating complication of HZ regardless of dermatomal distribution is postherpetic neuralgia (PHN), a neuropathic pain syndrome that persists or develops after the zoster rash has resolved. The main risk factor for PHN is advancing age; other risk factors include severe acute zoster pain and rash, a painful prodrome, and ocular involvement. Many cases of HZ, HZO, and PHN can be prevented with the zoster vaccine. Vaccination is key to preventing HZ, HZO, and PHN, but strategies for both varicella and HZ vaccines will need to be evaluated and adjusted periodically as changes in the epidemiology of these VZV diseases become more evident.
Article
Our aim was to provide a better understanding of why many adults fail to receive recommended immunizations. Consumers (N = 2,002) and healthcare providers (N = 200) completed structured telephone interviews concerning their attitudes and knowledge about adult vaccines and factors affecting their vaccination decisions. Self-reported immunization rates for tetanus, influenza, and pneumococcal vaccines (which were emphasized in the surveys) were lower than goal rates set by national guidelines. Among the most common reasons consumers gave for not receiving immunizations were lack of physician recommendations and mistaken assumptions (e.g., healthy people do not need immunizations). Healthcare providers tended to cite concerns such as side effects, fear of needles, and lack of insurance coverage as reasons consumers forego vaccination. Providers also cited practice issues, such as lack of an effective reminder system, as barriers to increasing adult immunization rates. We conclude that a better understanding of why adults do not get vaccinated is important for efforts to increase immunization rates in this broad age group.
Hulstaert F, et al..
  • Bilcke
Clinical research to clinical practicelost in translation N Engl J Med.
  • Lenfant