What Is the Pharmacist's Continued Role in Preventing Herpes Zoster?

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Community pharmacists have become an integral part of the fight to prevent herpes zoster (shingles). Since the FDA approval of the zoster vaccine live (ZVL, Zostavax) in 2006, community pharmacists have helped immunize several thousand eligible patients.¹

The CDC reports that rates of zoster immunization have increased by 16.2% from 2010 to 2015, and pharmacists have played a key role in this improvement. In October 2017, the FDA announced the approval of zoster vaccine recombinant (HZ/su, Shingrix), which gives pharmacists an updated vaccine to assist in the reduction of herpes zoster in their patients.² Armed with an understanding of herpes zoster immunization updates, community pharmacists can better engage their pharmacy teams and patients in the opportunity to improve immunization rates to further reduce disease incidence.

According to the CDC, herpes zoster, a reactivation of latent varicella-zoster virus (VZV), affects 1 in 3 individuals in their lifetime. Individuals who either developed or were exposed to VZV are at risk for developing herpes zoster, which includes 99.5% of the US population over 40 years of age. The exact mechanism by which VZV is reactivated is unknown; however, it is likely attributed to a decline in immunity. As such, the risk of developing herpes zoster increases with age, with half of cases occurring over the age of 60. Additional at-risk groups include those who are immunocompromised, individuals with specific cancers or HIV, those who have undergone bone marrow or organ transplants, and those who are taking immunosuppressive medications.³

Declining immunity as a natural result of aging increases not only the prevalence of herpes zoster but also the likelihood of developing severe associated long-term complications for patients who do develop the disease. Severity of postherpetic neuralgia (PHN) and ocular effects demonstrates an age-related relationship. With almost 13% of herpes zoster cases in individuals over 60 years resulting in PHN, the long-term impact of herpes zoster can be life-altering for many.³

Immunization plays a key role in reducing the development of herpes zoster altogether and also in reducing disease severity and long-term complications in those who develop herpes zoster despite vaccination. To date, ZVL has been the mainstay of prevention; however, advancements in the recently released HZ/su vaccine offer promising improvements. Trial data demonstrated an overall reduction in herpes zoster of 97.2% for all patients older than 50 years and a 91.3% reduction in patients older than 70 years—a major improvement to the overall 51% reduction seen with ZVL.^4,5

Unlike its live attenuated predecessor, HZ/su is a recombinant adjuvanted vaccine.⁴ As a result, HZ/su may not necessarily exclude individuals based solely on contraindication to receiving live vaccines. Other major differences include the refrigerated, not frozen, storage requirement and intramuscular administration. HZ/su is a 2-dose series that requires administration at 0 and 2 to 6 months, in comparison with the single-dose ZVL. Both vaccines need to be reconstituted; however, HZ/su is supplied with an adjuvant for reconstitution rather than a sterile diluent. Unlike ZVL, which needs to be discarded if not used within 30 minutes after reconstitution, HV/su is stable for 6 hours when refrigerated.^4,5

HZ/su is indicated for the prevention of herpes zoster in patients 50 years and older and is also recommended for administration to this age group by the Accreditation Council of Immunization Practices (ACIP).^6,7 This is a notable change from the ACIP recommendations for the ZVL vaccine that, despite the FDA- approved labeling for patients 50 years and older, never received approval for the 50- to 59-year-old population based on reported duration of immunity.

The HZ/su vaccine boasts increased longevity, an attribute that ZVL lacks. ZVL has demonstrated declining efficacy within the first 3 to 5 years after vaccination, while HZ/su has demonstrated sustained immunity in patients who were followed for up to 4 years.^4,7 Those vaccinated early (prior to age 60) with ZVL may be underprotected, as vaccine-induced immunity wanes while they enter decades of life that present the highest risk for devel- oping herpes zoster. New ACIP recommendations indicate an HZ/su series in patients who have previously received ZVL and that HZ/su is now preferable to ZVL for the prevention of herpes zoster and related complications.⁷

Community pharmacists are in a unique position to identify and target the expanded group of patients who now fall under the ACIP recommendations to receive HZ/su. The Pharmacists’ Patient Care Process, a 5-step process developed by the Joint Commission of Pharmacy Practitioners, is a model that engages pharmacists to collect and assess information to establish patient needs, make a plan/recommendation, implement/administer, and follow up.⁸

Collecting and assessing are the first steps to identifying any needed immunization for a patient, and pharmacists are making this a part of daily practice for HZ/su. A thorough assessment includes review of patient-specific factors such as age, health conditions, occupation, travel and lifestyle, and knowledge of current immunization schedules.^8,9 With age being the most prev- alent indicator for patients needing ZVL, assessing patients for HZ/su is simple. Patients falling into the age group of 50 years or older can be easily recognized during the prescription verification process or while verifying date of birth upon prescription pickup.

The accessibility of community pharmacists offers expanded opportunities for conversations about needed immunizations during patient encounters.¹⁰ Pharmacists can leverage prescription counseling sessions and self-care consults to initiate discussion about recommended immunizations. In addition, pharmacists can use opportunities to educate and recommend specific immunizations to groups of patients in their local communities through health fairs, presentations, and “brown bag” events. Review of vaccine status and further recommendations should also be a mainstay of medication therapy management sessions, including comprehensive medication reviews.

Talking to patients about gaps in their immunization status can sometimes be challenging; however, as health care providers, pharmacists have the responsibility to voice recommendations. The use of “personal selling” techniques has demonstrated impact on immunization rates.¹¹ In this scenario, the pharmacist initiates patient conversations, effectively questions, and actively listens to decipher unmet patient needs, and presents the recommended service persuasively to bridge common goals.

Similarly, a pharmacist can make a “CASE” for a particular patient: Corroborate, About me, Science, and Explain.⁸ Discussing personal experiences, including those with friends and family members, regarding vaccine-preventable disease can help validate the pharmacist’s recommendations.^8-14 Probing patients about their hesitation or concerns with a specific vaccine can provide a starting point for education. Pharmacists can then tailor an evidence-based recommendation that specifically addresses the needs of the patient. For example, some patients may not have received ZVL because of concerns with the almost 50% possibility that they would still develop a case of herpes zoster even after being immunized. Recognizing these concerns, a pharmacist can incorporate key points regarding the vast improvements with HZ/ su in terms of efficacy and duration of response. Most important, pharmacists should focus on specifically recommending identified immunizations, rather than asking patients whether they would like it or suggesting it might be beneficial.^8,12

Pharmacists are the central force in immunizing patients; however, pharmacy team members play an integral role in the process. Successful implementation of immunization programs relies on well-trained technicians. Pharmacy technicians can be involved in the assessment of patient immunization status, highlighting opportunities for pharmacists to intervene.^15,16 Education for technicians should include the ability to review patient profiles for immunization history within the pharmacy dispensing system, as well as the use of immunization registries, where available.⁸ Team members can also be educated about key identifiers for specific vaccines and refer patients who fit these criteria to the pharmacist. For example, technicians should be able to recognize all adults over 50 years as potential candidates for the HZ/su vaccine and refer them to a discussion with the pharmacist.

Effective communication practices by the pharmacy team, including technician staff, are another key component of successful immunization programs. Daily technician communication practices have a substantial impact on referral relationships, the ability to relay billing and third-party information, verification of patient-received vaccines, and immunization-related documentation within the patient’s chart.¹⁶ Pharmacists have the responsibility to ensure team members are well adapted to speaking with both patients and providers. In addition, barriers exist for access to patient immunization histories because of inconsistent reporting and communication among health care professionals.¹⁵ For this reason, pharmacy practice is beginning to include more staff education on reporting to immunization registry programs and sharing immunization histories with a patient’s network of providers.

Knowledge of vaccine-related inventory and how to source product is another important technician role. Patients cannot be immunized without product on hand, so technicians are being trained (where states allow) about where to look for specific vaccines and how to reorder when they are out of stock.

In some areas, technicians are taking a more active role in immunization programs, including vaccine delivery. In December 2016, Albertsons Companies produced the first technician immunizer in Idaho through an innovative program.¹⁷ While the opportunity to administer immunizations is not widely available yet, technicians can become trained and/or certified in other areas (where states allow)—eg, cardiopulmonary resuscitation—to further support their role.¹⁶

Pharmacists in the community are well positioned to continue to positively affect immunization trends, particularly with the addition of HZ/su to the vaccine repertoire. Staying up-to-date with current recommendations, engaging patients in discussion about gaps in immunization history, and working together with health care team members will continue to keep pharmacists as premier providers for immunization health.

Caitlin Malone, PHarmD, is the residency program director and experiential coordinator for the Jewel-Osco market of Albertsons Companies. She earned a bachelor’s degree from the University of Illinois in Urbana-Champaign and a PharmD from the University of Illinois at Chicago College of Pharmacy in 2010. She completed a PGY1 community practice residency with Jewel-Osco in 2011. Prior to her current role, she held several positions, including pharmacy manager, primary residency preceptor, wellness pharmacist, and clinical point person.

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