Impact of Provider Nudges on Herpes Zoster Vaccine Series Completion during the COVID-19 Pandemic in the United States

Objectives: To determine the impact of a pharmacy-based, clinical decision support (CDS) tool on herpes zoster (HZ) vaccine series completion during the initial months of the COVID-19 pandemic across the US. Method(s): In partnership with Kroger Health, a pharmacy CDS tool alerted staff of patients due for their second HZ vaccine dose, which had been accompanied previously by a timed text message. Once operations changed due to COVID-19, the system limited outreach to only patients visiting the pharmacy. Primary outcomes included the proportion of patients receiving both doses within a Kroger-owned pharmacy (n=2,293) and the number of days between doses, both within and across two 32-week periods before and after the pandemic hit the US. Generalized estimating equation-based (GEE) logistic and linear regression models determined differences in completion rates and time to completion. Result(s): During the observation period, 38,937 adults received at least one HZ vaccine dose, with 77.2% receiving both doses. Patients engaged by the CDS tool achieved 80.5% dose completion, versus 65.4% of those not intervened (p<0.0001), which was lower than in the period immediately before the pandemic (85.8%, p<0.0001). The dosing window averaged 119.4 days (SD: 26.91), which was the longest timeframe between doses since the HZ vaccine was launched and nearly one month longer than before the pandemic (93.0 days [SD: 28.02], p<0.0001). The odds of dose completion increased in areas of higher health literacy (OR: 1.01;95% CI: 1.007-1.014), but decreased in areas of higher poverty (OR: 0.992;95% CI: 0.988-0.995). Time to completion was slightly shorter (B=-0.04, p<0.05) in areas of higher health literacy. Conclusion(s): Despite changes in clinical processes, a nationwide community pharmacy was successful in completing HZ vaccine dose series for adults during the pandemic, suggesting that processes in community pharmacies can protect staff while remaining committed to providing preventive health services during public health crises.Copyright © 2023

Retrospective review of vaccination status in patients with newly diagnosed chronic lymphocytic leukaemia

Introduction: Patients with chronic lymphocytic leukaemia (CLL) are at increased risk of infection. CLL is associated with a secondary immunodeficiency and impaired response to vaccination. Recent British Society of Haematology guidelines recommend that patients with CLL should receive vaccination against pneumococcal infection at diagnosis, an annual influenza vaccine and COVID-19 vaccination. Patients aged 70-79 years should also receive the Shingrix vaccine. Patients with CLL should not receive live vaccines. In response to this guideline, a letter detailing vaccination requirements was created for patients to give to their general practitioner (GP). The local process for vaccination referral has since changed. Previously, vaccination requirements were communicated to the GP via letter. There is now a dedicated Vaccination Hub to which clinicians can directly refer patients for appropriate vaccinations. Aim(s): The aim of this project was to assess vaccination referral and vaccination status in patients with newly diagnosed CLL. Method(s): All new diagnoses of CLL from 2021 to 2022 were identified by review of the Haematology Multi-Disciplinary Team meeting electronic registration forms. Electronic patient records were reviewed to determine vaccination referral completion and vaccination status. Result(s): A total of 29 patients were identified as new diagnoses of CLL. Seventeen patients were diagnosed in 2021 and 12 in 2022. Sixty-nine percent of the patients were male and the average age was 70.9 years. Vaccination was discussed with 11 patients (38%) and 10 patients (34%) were referred for vaccination. Eleven patients (38%) had never received a pneumococcal vaccine. Nine patients (31%) had previously received the vaccine but not within the past 5 years. Five patients (17%) patients had received one dose of Pneumovax 23 following referral. No patients had received the initial Prevenar 13 vaccine. Twelve patients (41%) had not received an influenza vaccine. Of those who had received the vaccine, the majority (70%) had received this routinely. Similarly, 71% of patients had received the COVID-19 vaccine routinely as opposed to three patients who received this postreferral. Of those who were eligible, 50% had received the Shingrix vaccine. Conclusion/Discussion: Local rates of vaccination in patients with CLL are low. Numbers were too small to allow for comparison between the methods of referral. Of those referred, not all received the appropriate vaccinations. Further work is therefore required to improve both the number and completion of the referrals. Future steps will include local teaching on vaccinations in CLL and the referral pathway.

Herpes zoster – Part 3: Prevention of herpes zoster and post-herpetic neuralgia

Vaccination recommendations for the prevention of herpes zoster (HZ) aim to reactivate specific cell-mediated immunity towards the varicella/zoster virus. This specific immunity naturally declines with age but there are many factors that can accelerate this decline, including, most recently, the immune response induced by SARS-CoV-2. Two vaccines are available to date. A live attenuated vaccine (Zostavax®) licensed in 2006 and more recently a recombinant vaccine (Shingrix®). We present data on the efficacy of these two vaccines as well as on the relevant precautions and safety of use. © 2023 Elsevier Masson SAS Les recommandations vaccinales en matière de prévention du zona ont pour objectif de réactiver l'immunité à médiation cellulaire spécifique contre le virus varicelle-zona. Cette immunité spécifique décline naturellement avec l'âge mais nombreux sont les facteurs qui peuvent accélérer ce déclin dont récemment la réponse immunitaire induite par le SARS-CoV-2. Deux vaccins sont disponibles à ce jour : un vaccin vivant atténué (Zostavax®) homologué en 2006 et plus récemment un vaccin recombinant (Shingrix®). Nous présentons des données d'efficacité de ces deux vaccins ainsi que celles concernant leurs précautions d'emploi et la sécurité de leur utilisation. © 2023 Elsevier Masson SAS

No Safety Concerns Observed When the Adjuvanted Recombinant Zoster Vaccine (Rzv) and the Covid-19 Mrna-1273 Booster Were Co-Administered in >=50-Year-Olds

Intro: The US CDC recommends that COVID-19 vaccines may be coadministered with other age-appropriate vaccines. There is limited data assessing outcomes, including reactogenicity, on such co-administration. For the first time, we present interim safety data of RZV administered concomitantly or sequentially with an mRNA-1273 booster vaccine. Method(s): In this phase 3, randomized, open-label, multi-center study (NCT05047770), adults aged >=50 years were randomized 1:1 to receive the first RZV dose with mRNA-1273 booster (50 mug) at day 1 and the second RZV dose at week (W)8 (Co-Administration group [Co-Ad]), or mRNA-1273 at day 1, the first RZV dose at W2 and the second RZV dose at W10 (Sequential group [Seq]). Descriptive analyses of solicited/unsolicited adverse events (AEs) with onset within 7/30 days post-mRNA-1273 or first RZV dose, and of serious AEs/potential immune-mediated diseases/AEs of special interest (SAEs/pIMDs/AESIs) reported until database freeze are reviewed. Finding(s): The exposed set comprised 267 (Co-Ad) and 272 (Seq) participants. In each group, most solicited AEs were mild/moderate in intensity and each with <=2.5 days median duration, the most frequent were injection site pain, myalgia, and fatigue. Unsolicited (vaccines-related) AEs were reported by 25.0% (2.9%) of participants post-mRNA-1273 in Seq, 25.2% (0.8%) post-RZV in Seq, and 37.1% (3.7%) in Co-Ad. SAEs/pIMDs/AESIs were reported for 6/1/2 participants in Co-Ad and 5/1/3 in Seq. In Seq, one SAE/AESI (pulmonary embolism) and one pIMD/AESI (cutaneous vasculitis) occurred 2 and 9 days postmRNA-1273 (before RZV administration), respectively, and were considered mRNA-1273-related by investigators. In Co-Ad, one AESI (chronic hepatitis) occurred 35 days post-second RZV dose, considered vaccines-related by Sponsor. No fatalities occurred. Conclusion(s): No safety concerns were identified. The frequency/severity/type of AEs were comparable between groups and consistent with the known safety profile of each vaccine, whether RZV and mRNA-1273 booster were administered concomitantly or sequentially. Co-administration may enhance vaccine coverage rates. Funding(s): GSKCopyright © 2023

Le zona – Partie 3 : la prévention du zona et des névralgies post-zostériennes

Résumé Les recommandations vaccinales en matière de prévention du zona ont pour objectif de réactiver l'immunité à médiation cellulaire spécifique contre le virus varicelle-zona. Cette immunité spécifique décline naturellement avec l'âge mais nombreux sont les facteurs qui peuvent accélérer ce déclin dont récemment la réponse immunitaire induite par le SARS-CoV-2. Deux vaccins sont disponibles à ce jour : un vaccin vivant atténué (Zostavax®) homologué en 2006 et plus récemment un vaccin recombinant (Shingrix®). Nous présentons des données d'efficacité de ces deux vaccins ainsi que celles concernant leurs précautions d'emploi et la sécurité de leur utilisation. Summary Vaccination recommendations for the prevention of herpes zoster (HZ) aim to reactivate specific cell-mediated immunity towards the varicella/zoster virus. This specific immunity naturally declines with age but there are many factors that can accelerate this decline, including, most recently, the immune response induced by SARS-CoV-2. Two vaccines are available to date. A live attenuated vaccine (Zostavax®) licensed in 2006 and more recently a recombinant vaccine (Shingrix®). We present data on the efficacy of these two vaccines as well as on the relevant precautions and safety of use.

Vaccines for the prevention of infections in adults with haematological malignancies

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To assess the benefits and adverse effects of vaccines for the prevention of infections in adults with haematological malignancies.Copyright © 2023 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Adult Vaccination

Adult vaccination rates are low in the United States, despite clear benefits for reducing morbidity and mortality. Vaccine science is evolving rapidly, and family physicians must maintain familiarity with the most recent guidelines. The recommended adult immunization schedule is updated annually by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. All eligible patients should receive SARS-CoV-2 vaccines according to the current guidelines. Adults without contraindications should also receive an annual influenza vaccine. Hepatitis A vaccine is recommended for adults with specific risk factors. All pregnant patients, adults younger than 60 years, and those 60 years and older who have risk factors should receive a hepatitis B vaccine. A 15- or 20-valent pneumococcal conjugate vaccine is recommended for all patients who are 65 years and older. Patients who receive 15-valent pneumococcal conjugate vaccine should receive a dose of 23-valent pneumococcal polysaccharide vaccine one year later. Adults 19 to 64 years of age should receive a pneumococcal vaccination if they have medical risk factors. A single dose of measles, mumps, and rubella vaccine is recommended for adults without presumptive immunity, and additional doses are recommended for patients with HIV and postdelivery for pregnant patients who are not immune to rubella. A tetanus and diphtheria toxoids booster is recommended every 10 years. For pregnant patients and those in close contact with young infants, a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine should be administered. The human papillomavirus vaccine is recommended for all people through 26 years of age. Herpes zoster vaccine is indicated for all adults 50 years and older.Copyright © 2022 American Academy of Family Physicians.

Impact of COVID-19 pandemic on recommended vaccine uptake in a single-practice primary care COPD cohort in the UK

Introduction: Immunisation against vaccine-preventable disease is a critical aspect of COPD care. UK recommendations are annual influenza vaccination, pneumococcal vaccine (as a single-dose) and shingles vaccine if aged >=70 years. Aims and objectives: This retrospective study aimed to determine/characterise influenza, pneumococcal and shingles vaccination status in a single-practice primary care COPD cohort during the COVID-19 pandemic. SARSCoV-2 aspects were also evaluated. Method(s): All registered patients with COPD were identified via ICD-10 codes. Extracted data included COPD parameters and comorbidities. Vaccine-specific details were identified using SNOMED codes. Result(s): Records identified 378 patients with COPD;mean age 71 years (range 29-98). Mean % predicted FEV1 was 66.7%;49.2% reported a score of >=3 on the MRC Breathlessness Scale. Pneumococcal vaccination was reported for 83.1%. Shingles vaccine uptake in eligible patients was 64.3%. Influenza vaccine uptake (for 2021/22) was 87.8% (89.3% in those >=65 years)- higher than in prior influenza seasons;2018/19 (77.7%),2019/20 (77.1%) and 2020/21 (83.1%)-indicating a relative increase during the pandemic;6% in 20/21 and 12.7% in 21/22 versus 18/19 and 19/20 respectively. COPD severity, comorbidities and gender did not influence vaccine uptake. SARSCov-2 vaccine uptake for dose 1 and 2 was 97.4% and 93.4% for a booster dose. From January-December 2021, 22 patients (5.6%;range 52-98 years) had confirmed SARS-Cov-2 infection (all of whom were immunized). Conclusion(s): Uptake of recommended vaccines in COPD patients was high;seasonal influenza vaccine uptake showed a trend increase during the COVID-19 pandemic.

Recombinant zoster vaccine (RZV) second-dose series completion in adults aged 50-64 years in the United States.

In 2018, CDC recommended a highly efficacious adjuvanted recombinant zoster vaccine (RZV) as a 2-dose series for prevention of herpes zoster (HZ) for immunocompetent persons age ≥ 50 years, with the 2nd dose recommended 2-6 months after the 1st dose. We estimated second-dose RZV series completion in the U.S. among 50-64-year-olds using two administrative databases. Second-dose RZV series completion was ∼70% within 6-months and 80% within 12-months of first dose. Among those who received only 1 RZV dose with at least 12 months of follow-up time, 96% had a missed opportunity for a second-dose vaccination, defined as a provider or pharmacy visit, among whom 36% had a visit for influenza or pneumococcal vaccination within 2-12 months of their first-dose of RZV. We found that RZV series completion rates in 50-64-year-olds was high. Availability of RZV at pharmacies has potentially helped increase series completion, but missed opportunities remain.

Willingness to accept herpes zoster vaccines and the influencing factors in China.

BACKGROUND: Herpes zoster increases the burden on the elderly in an aging society. Although an effective vaccine licensed by China Food and Drug Administration in 2019 was introduced into the market in June 2020, the willingness and influencing factors of herpes zoster vaccines in Chinese adults ≥ 50-years-old during coronavirus disease-2019 pandemic are yet to be elucidated. METHODS: An online questionnaire survey was conducted using a simple random sampling method in October 2021 for viewers of the broadcast program. A binary logistic regression and multiple response analysis were conducted for herpes zoster vaccine and vaccination willingness. Pareto's graphs were plotted to present the multiple-choice questions of influencing factors. RESULTS: A total of 3838 eligible participants were included in this study. Among them, 43.02% intended to be vaccinated, including 10.34% self-reported about receiving at least one shot of shingles vaccine, 30.22% declined, and 26.76% were hesitant. This population comprised a large proportion of middle-aged and older people (≥ 50-years-old) who have not experienced an episode of herpes zoster (54.98%) or are unaware of the virus (33.22%). The strongest determinants of vaccine hesitancy among older people were education background of Master's degree or above compared to senior high or equivalent and below, personal monthly income < 3000 RMB compared to 3000-5999 RMB, and living in a rural area. CONCLUSIONS: The willingness to get shingles vaccines can be improved further. Professional education and credible recommendation might prompt the elderly to improve their willingness and reassure them of the safety and efficacy of the vaccine. Also, accessibility and affordability should also be improved in the future.

Risk of herpes zoster ophthalmicus following COVID-19 vaccination in a large US claims database

Purpose : To determine whether there is an increased risk of herpes zoster ophthalmicus (HZO) following COVID-19 vaccination. Methods : Retrospective observational study utilizing OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de- identified administrative claims and electronic health record data. A cohort study design and a self-controlled design were both utilized to investigate HZO following vaccination, defined by an ICD-10 diagnosis code within 30 days after vaccine administration (or up to the second dose if a second dose was administered), plus a new prescription or dose escalation of antivirals within 5 days of HZO diagnosis. Using a cohort design, COVID-19 vaccinated individuals from 12/11/2020- 6/30/2021 were compared to two influenza-vaccinated cohorts: a pre-pandemic group (1/1/2018-12/13/2019) and an early pandemic group (3/1/2020-11/1/2020). Cox proportional hazard models were used to identify unadjusted and adjusted hazard ratios for HZO. Using a self-controlled design, the incidence rate ratio comparing the risk of HZO in the risk intervals following COVID-19 vaccination to a control interval 60 to 90 days prior to the first dose was estimated using conditional Poisson regression. Results : Among 3,567,715 patients in the COVID-19 vaccinated cohort, there were 60 post-vaccine HZO cases. Patients vaccinated against COVID-19 were not at increased risk of HZO compared to pre-pandemic influenza vaccinated patients (N= 5,101,709;HR= 0.84;95% CI: 0.61-1.16;p= 0.29) and early pandemic influenza vaccinated patients (N= 4,060,412;HR= 0.93;95% CI: 0.64-1.34;p= 0.69) after adjustment for demographics, comorbidities, zoster vaccine, and medication use. Additionally, HZO cases post-COVID-19 vaccination were less likely to be prescribed ophthalmic steroids compared to cases following pre-pandemic and early pandemic influenza vaccination (18.3% vs 29.6% vs 41.4%, respectively). In the self-controlled design, patients were not at increased risk of HZO after COVID-19 vaccination compared to their control interval (IRR= 0.74;95% CI: 0.49-1.12;p= 0.15). Conclusions : There is not an increased risk of HZO following COVID-19 vaccination. These results provide reassurance for the safety of the COVID-19 vaccine from an ophthalmic standpoint.

Review: Vaccine Guidelines for Older Adults

Vaccines are important for everyone, but they’re critical for adults older than 65 years.

Unboxing herpes zoster ophthalmicus and the recombinant shingles vaccine

Reactivation of the varicella zoster virus as herpes zoster (shingles) typically affects the peripheral nerves, resulting in a painful rash, most often on the torso. However, it can also manifest ophthalmologically, affecting the ophthalmic division of the trigeminal nerve. This manifestation is associated with a particularly high level of morbidity and may result in blindness. A new recombinant shingles herpes zoster vaccine protects patients against this virus and post-infection sequelae, improving medical and psychosocial outcomes. © 2021 Medicine Today Pty Ltd. All rights reserved.

ITS NOT AN ALLERGIC REACTION TO THE COVID VACCINE: HERPES ZOSTER FOLLOWING COVID MRNA VACCINE

CASE: A 72 year old male presented to the outpatient clinic with a “vaccine reaction” after he developed a left arm rash following his Moderna COVID-19 booster. He had received the Moderna vaccines in March & April with the only side effect being arm soreness. On 10/30/2021, he received his booster in his lateral left upper arm. Three days later, he reported arm soreness that progressed in intensity by day 6 and developed a rash. Patient had no prior history of shingles and had received the SHINGRIX vaccine. Medical history was remarkable for subtotal colectomy with ileostomy 2/2 to Crohn's disease, stage III CKD, hypertension, HLD, amputations of the right big toe and left metatarsal 2/2 to osteomyelitis. Home medications included daily allopurinol 100mg, amlodipine 5mg, mesalamine 1,000 mg and octreotide 200 mcg/mL injection 0.5mL SQ BID. Presenting vital signs were normal. A physical exam revealed vesicles on an erythematous base in a C5 dermatome distribution. Incidentally, there was a concentration of vesicles located at the Moderna Booster vaccine site. Rash collected in groups of vesicles on the anterior forearm. Due to delay in presentation and stage III CKD, antivirals were not prescribed. Patient was prescribed Gabapentin 300mg nightly for pain and instructed to continue OTC Tylenol. After several weeks the rash resolved and pain subsided. IMPACT/DISCUSSION: Approximately 4% of patients with a history of Varicella develop a recurrent episode later in life with people who are immunosuppressed most affected. Possible triggers of zoster (HZ) include external reexposure to the virus, acute or chronic diseases such as malignancies or infections (i.e COVID-19), medications and stress. As of 12/5/21, the Vaccine Adverse Event Report System (VAERS) reported shingles in 1200 patients after receiving Pfizer vaccine, 1201 Moderna, and 1203 in Janssen vaccine recipients. While these reports are unable to be validated, it is important for clinicians to recognize the suggested relationship. Hypotheses of why our patient developed shingles include: 1) the immune activation from the vaccine activated dormant varicella, 2) the patient being older & immunocompromised puts him at a higher risk of developing HZ in general, and 3) the vaccine triggers a transient lymphopenia similar to being infected with COVID-19 and lymphopenia causes reactivation. As we continue to reach higher percentages of individuals receiving vaccines, we likely will continue to encounter cases such as described. CONCLUSION: It is important for clinicians to be aware of HZ reaction post COVID vaccination and to have this in their differential when a patient complains of a “reaction” to the vaccine. We regret that the patient being mis-triaged as an “allergic reaction” led to the patient being evaluated outside of the possible window of acute treatment of HZ. By describing this case we hope clinicians will be more aware of this relationship and prevent delay to treatment or misdiagnosis.

COVID-19 VACCINE HESITANCY REMAINS HIGH IN INFLAMMATORY BOWEL DISEASE PATIENTS

Introduction Despite the global impact of the COVID-19 pandemic, vaccine hesitancy remains common in the general public. Adults who were on immunosuppressive medications were among the earlier groups recommended by the Centers for Disease Control and Prevention to receive the COVID-19 vaccine. It is unclear whether similar vaccine hesitancy is seen in patients with inflammatory bowel disease (IBD), especially those who are on immunosuppressive medications. We sought to examine rate of vaccine hesitancy in patients with IBD as well as associated demographic and socioeconomic risk factors. Methods We performed a retrospective chart review in November 2021 of 1383 patients with IBD seen at University of Maryland Medical Center, a tertiary referral medical center, between November 2020 and October 2021. Data obtained from patients' charts included demographics;disease characteristics including disease phenotype, number of years since diagnosis, number of IBD-related surgeries;and IBD therapy including biologics, thiopurines or methotrexate, corticosteroids, and mesalamine. Information on COVID vaccination and routinely recommended vaccines were also collected which included annual influenza vaccine, Prevnar/ Pneumovax, and Shingrix. Those with no recorded COVID-19 vaccine were contacted by nurses for updated vaccine status. Results 72% (990/1383) of patients in this cohort were on a biologic, 17% (232/1383) were on corticosteroids, and 16% (224/1383) were on thiopurine or methotrexate, indicating a cohort of patients with moderate to severe disease phenotype. Fifty-seven percent (792/1383) of patients received either the Pfizer, Moderna, or Johnson & Johnson vaccine. In a multivariate regression analysis, COVID vaccination was found to be positively associated with a number of factors including older age (p-value= 4.92e-4), female sex (p=1.61e-3), Asian and Caucasian races (p=9.13e-3, 6.47e-06), number of years since diagnosis (p=2.73e-2), number of clinic visits in the past 12 months (p= 2.66e-10), and biologic use (p=4.41e-4). This remained the case while controlling for IBD disease type;marital status;insurance (Commercial vs Medicaid vs Medicare);and tobacco, alcohol, and substance use history. Patients who received other routinely recommended vaccines (influenza, Prevnar/Pneumovax, Shingrix) were not more likely to receive COVID- 19 vaccine. Discussion Although majority of patients in this cohort were on an immunosuppressive medication, COVID-19 vaccination rate is only recorded to be at 57%. Number of clinic visits, presumably more education and conversation with healthcare providers, had a positive impact on COVID-19 vaccination. In this cohort, younger adults, males, and African Americans were less likely to receive COVID-19 vaccine. Healthcare providers need to recognize these potential risk factors for COVID-19 vaccine hesitancy.

Improving Adult Immunization Rates Within Racial and Ethnic Minority Communities

Part 1: Quality Improvement, Recommended Vaccines, and Reducing Vaccine Disparities SUPPLEMENT SPONSOR: AMERICAN ACADEMY OF FAMILY PHYSICIANS This project is funded by a grant from the Centers for Disease Control and Prevention (CDC) National Center for Immunization and Respiratory Diseases.