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  • It has been estimated that 50% of all individuals living to age 85 will ultimately develop herpes zoster and that the risk of recurrence is approximately 5%.
  • Although incidence of herpes zoster is relatively in younger individuals, it increases dramatically in the fifth decade of life as a result of cellular immunosuppression brought on by advancing age.
  • Complications of herpes zoster can occur during or after the acute phase. PHN is the most common complication of herpes zoster. Ophthalmic zoster is also common and can lead to sight-threatening complications such as keratitis, iritis, and retinitis. Cutaneous sequelae include bacterial superinfection, and sometimes scarring or disfigurement. Visceral complications, such as pneumonitis and hepatitis, are seen in immunocompromised and immunosuppressed patients.
  • Patients with PHN may also have one or more physical or psychological comorbidities, which can interfere with social and functional activities of daily living, thereby adversely impacting their quality of life.
  • Initial papules quickly become grouped vesicles that pustulate and subsequently scab. Again, the involved area usually heals (except for residual pigmentation) in 2 to 4 weeks (about a month).
  • Elderly gentleman admitted with facial cellulitis secondary to herpes zoster involvement of the second and perhaps also the third branch of the trigeminal nerve. He initially noted a soreness under his dentures days before the facial rash erupted.
  • Current Management Strategies for Herpes Zoster
  • Antivirals, such as acyclovir, famciclovir, and valacyclovir, are the most widely used therapy for acute herpes zoster. Antiviral therapy reduces the severity and duration of herpes zoster and the duration of PHN, but does not prevent PHN in all patients. Their efficacy when administered beyond 72 hours of rash onset is unknown because all controlled studies have initiated treatment within 3 day of rash onset. Corticosteroids, when administered in combination with antivirals, reduce acute pain associated with herpes zoster but do not prevent PHN. Steroid use has an unfavorable risk-benefit ratio, especially in individuals with diabetes, renal insufficiencies, and hypertension.
  • Several pharmacologic agents are used for the management of PHN, including gabapentin, pregabalin, lidocaine patch 5%, tricyclic antidepressants, and opioid analgesics. None of these treatments for PHN is effective in all patients, a substantial percentage of patients are refractory to therapy, and most treatments have side effects that can cause some patients to discontinue treatment. Thus, the limitations of currently available treatments for PHN make the prevention of PHN by vaccination a beneficial strategy.
  • The Shingles Prevention Study was a large, randomized, double-blind, placebo-controlled efficacy trial designed to determine whether the zoster vaccine could decrease the incidence and/or severity of herpes zoster and decrease the incidence of PHN. More than 38,000 adults ≥60 years of age enrolled in the study and were followed for up to 5 years after enrollment. To ensure optimal reporting of cases of herpes zoster, subjects were told to immediately notify the site if herpes zoster was suspected. In addition, subjects received a call each month from an automated telephone response system to inquire about signs and symptoms of herpes zoster.
  • Overall, the vaccine significantly reduced herpes zoster burden of illness by 61.1%; vaccine efficacy was higher in the 60-69 age group than in the 70 and older group. Although the effect of zoster vaccine on the incidence of herpes zoster was less among older subjects than among younger subjects, the effect of the vaccine on the severity of illness was greatest among older subjects, so that the burden of illness, the primary end point of the study, was maintained at 55.4%.
  • Patient Barriers to Vaccination While it is important for physicians and clinical staff to implement procedures to improve vaccination rates, they must understand patient beliefs and attitudes that may impede incorporating vaccination into everyday clinical practice. Barriers faced by patients for whom vaccination may be appropriate tend to fall into three categories: First, patients may not possess the necessary knowledge about immunizations, lacking awareness of vaccine-preventable diseases, the potential threats these diseases pose, and the availability of a vaccine. Patients also have fears about vaccine safety and may not possess information about vaccine risks and benefits. Finally, logistical problems may limit access to immunization, including complicated vaccination schedules, inconvenient clinic hours and wait times, transportation problems, and the overall costs involved in receiving a vaccine. 1 The CDC noted that some adults erroneously believe that the vaccines they received as children offer lifelong protection against disease. While this may be true for some vaccines, adults may not have received all appropriate vaccinations because some of these vaccines may not have been available when they were children. It is also important to inform adult patients that immunity to some diseases may also wane over time. 2 Taking into account patient beliefs and attitudes will assist in meaningful communication between physicians and patients regarding the need for monitoring and providing necessary vaccinations. References: 1. Burns IT, Zimmerman RK. Immunization barriers and solutions. J Fam Pract. 2005;54:S58 – S62 . 2. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm. Accessed August 19, 2007.
  • Standards for Adult Immunization Practices 1 The Standards for Adult Immunization Practices were first developed in 1990 as a large collaborative effort led by the National Vaccine Advisory Committee (NVAC) to encourage best practices. They have recently been revised to reflect major changes in the healthcare system during the last decade. Primary care healthcare professionals are encouraged to include vaccinations as part of their routine care of adults. Barriers such as physical examinations or extra visits to administer vaccines should be minimized. The patient’s vaccination status can be ascertained by reviewing vaccination history as well as assessing medical and lifestyle risk factors, occupation, and potential contraindications to vaccination. The healthcare professional should discuss with the patient the risks and benefits of vaccination and the diseases vaccinations prevent and should provide educational material if available. Office protocols help define appropriate procedures for administering vaccines. Office personnel should be properly trained to manage vaccination procedures and should be vaccinated as recommended. Strategies to improve vaccination rates might include reminder/recall systems. Vaccination providers can work with other healthcare professionals and the community to help meet the needs of the population served. Reference: 1. Poland GA, Shefer AM, McCauley M, Webster PS, Whitley-Williams PN, Peter G, and the National Vaccine Advisory Committee. Standards for adult immunization practices. Am J Prev Med . 2003;25:144–150. Key Point: Standards to help achieve best adult immunization practices have been defined.

Transcript

  • 1. Embassy Suites Raleigh-Durham/Research Triangle Cary, North Carolina June 21, 2008 Symposia Series 2 2008
  • 2. Strategies for Preventing Herpes Zoster and Postherpetic Neuralgia: Are Your Patients Adequately Protected? Kevin P. High, MD, MSc Chief, Section on Infectious Diseases Professor of Medicine Sections on Infectious Diseases, Hematology/Oncology, and Molecular Medicine Co-Director, Molecular Medicine Graduate Program Wake Forest University School of Medicine Winston-Salem, North Carolina
  • 3. Faculty Disclosure
    • Dr High: advisory board/speakers bureau: Merck & Co., Inc.; research grants: ViroPharma Inc.
  • 4. Do you routinely recommend and administer the herpes zoster vaccine to your patients who are ≥60 years of age?
    • Yes
    • No
    Use your keypad to vote now! KEY QUESTION ? 0
  • 5. Learning Objectives
    • Discuss the natural history and public health burden of herpes zoster and postherpetic neuralgia (PHN)
    • Review the benefits and limitations of current treatment options for herpes zoster and PHN
    • Evaluate clinical trial data on the efficacy and safety of herpes zoster vaccination
  • 6. Low Adult Immunization Rates
    • Only 2% of adults ≥60 years of age received herpes zoster vaccination in its first year of availability (2006)
    • Only 2% of adults aged 18 to 64 years reported receiving Tdap
      • 44% of adults >65 years of age reported receiving tetanus vaccination in the previous decade
    • Only 10% of women aged 18 to 26 years reported receiving at least 1 dose of the 3-dose human papillomavirus (HPV) vaccine course
    CDC and National Foundation for Infectious Diseases news conference, January 23, 2008. Anne Schuchat, MD, Assistant Surgeon General, United States Public Health Service; Director, National Center for Immunization and Respiratory Diseases, CDC. Michael N. Oxman, MD, Professor, University of California, San Francisco; Staff Physician, Infectious Disease Section, VA Medical Center, San Diego. Kristin Nichol, MD, MPH, Chief of Medicine, Minneapolis VA Medical Center; Professor of Medicine and Vice Chair, Department of Medicine, University of Minnesota.
  • 7. Natural History, Epidemiology, and Health Burden of Herpes Zoster and PHN
  • 8. Natural History of Herpes Zoster VZV = varicella-zoster virus Adapted from Kost RG, Straus SE. N Engl J Med. 1996;355:32-42; Hope-Simpson RE. Proc R Soc Med . 1965;58:9-20. Age VZV T Cells Varicella Herpes Zoster Zoster Threshold Varicella Exposure Silent Reactivation?
  • 9. Case Study
  • 10. Case Study 1
    • A 61-year-old woman was recently diagnosed with cancer in her left breast and underwent port placement for chemotherapy. Several days later she developed burning, itching, and severe pain on her left chest (near the port site), arm, and back
    • A few days later, she developed a vesicular rash
    • She was unable to sleep because of excruciating discomfort
    • She cannot tolerate even contact with clothing to the affected area
  • 11. Herpes Zoster Rash Photo provided courtesy of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital.
  • 12. What factors in this patient’s history may have predisposed her to the development of herpes zoster?
    • Impaired cell immunity due to advancing age, diseases, or immunosuppressive therapy
    • Psychological stress
    • Physical trauma
    • All of the above
    • None of the above
    Use your keypad to vote now! ? DECISION POINT 0
  • 13. Risk of Herpes Zoster
    • Lifetime risk of herpes zoster is estimated to be 1 in 5 individuals 1
    • 50% of individuals living until 90 years of age will develop herpes zoster 2
    • Risk factors for herpes zoster include
      • Advancing age 1-3 (reduced VZV-specific cell-mediated immunity [CMI])
      • Global reduction in CMI
        • HIV/AIDS 1,2
        • Hematologic and neoplastic malignancy 1,2
        • Bone marrow and organ transplants 1,4
        • Immunosuppressive therapy 1,2
      • Psychological stress 5
      • Physical trauma 5
    1 Gnann JW Jr, Whitley RJ. N Engl J Med. 2002;347:340-346; 2 Johnson RW, Whitton TL. Expert Opin Pharmacother . 2004;5:551-559; 3 Levin MJ et al. J Infect Diseases . 2008;197:825-835; 4 Kawasaki H et al. J Pediatr . 1996;128:353-356; 5 Thomas SL, Hall JA. Lancet Infect Dis . 2004;4:26-33.
  • 14. Incidence of Herpes Zoster Increases With Age Donahue JG et al. Arch Intern Med . 1995;155:1605-1609; Oxman MN et al. N Engl J Med. 2005;352:2271-2284. Estimated 1 million cases in the United States annually, which will likely increase as population ages Rate Per 100,000 Person-Years Age (Years) 1629 876 640 318 194 184 90 54 39 121 1118 1122 495 307 262 201 0 500 1000 1500 2000 0-14 15-24 25-34 35-44 45-54 55-64 65-74 ≥ 75 Women Men
  • 15. Complications of Herpes Zoster Gnann JW Jr, Whitley RJ. N Engl J Med . 2002;347:340-346; Arvin AM. Clin Microbiol Rev . 1996;9:361-381; Moriuchi K, Rodriguez W. Pediatr Infect Dis J . 2000;19:648-653. Neurologic Ophthalmic
    • PHN
    • Motor neuropathy
    • Cranial palsy
    • Encephalitis
    • Transverse myelitis
    • Postzoster stroke syndromes
    • Stromal keratitis
    • Iritis
    • Retinitis
    • Visual impairment
    • Episcleritis
    • Keratopathy
    Cutaneous Visceral
    • Bacterial superinfection
    • Scarring
    • Disfigurement
    • Pneumonitis
    • Hepatitis
    • Encephalitis
  • 16. Postherpetic Neuralgia
    • Chronic neuropathic pain that persists or develops after herpes zoster rash has healed 1
      • Recent definitions include pain 90-120 days after rash onset 1-3
    • Clinical features of PHN include 2
      • Constant aching and burning, intermittent lancinating or stabbing pain, allodynia, hyperpathia
    • Risk factors include 3
      • Advancing age, severity of acute pain and rash, painful prodrome, and number of affected dermatomes
    • Frequency and severity increase with advancing age 4
    1 Oxman MN et al. N Engl J Med. 2005;352:2271-2284; 2 Wood MJ, Easterbrook P. Shingles, scourge of the elderly. In: Sacks SL et al, eds. Clinical Management of Herpes Viruses . Amsterdam: IOS Press; 1995:193-209; 3 Jung BF. Neurology . 2004;62:1545-1551; 4 Levin MJ et al. J Infect Dis . 2008;197:825-835.
  • 17. Impact of PHN on Quality of Life in Older Adults Schmader KE. Clin J Pain . 2002;18:350-354; Chidiac C et al. Clin Infect Dis . 2001;33:62-69; Lydick E et al. Qual Life Res . 1995; 4:41-45; Katz J et al. Clin Infect Dis . 2004;39:342-348; Coplan PM et al. J Pain . 2004;5:344-356. Physical Functional
    • Diminished energy
    • Anorexia
    • Weight loss
    • Physical inactivity
    • Impaired sleep
    • Interference with basic activities of   daily living including
      • Dressing
      • Bathing
      • Eating
      • Mobility
    Psychological Social
    • Depression
    • Anxiety
    • Difficulty concentrating
    • Decreased social gatherings
    • Change in social role
  • 18. Diagnosis of Herpes Zoster
  • 19. Acute Herpes Zoster: Clinical Manifestations
    • Prodrome of dermatomal pain ≥ 2-5 days
    • Rash characteristics
      • Initially maculopapular, then vesicular with an erythematous base
      • Unilateral, although can slightly overlap midline
      • Usually involves 1 or 2 dermatomes
      • May be associated with pain or other abnormal sensations
      • Evolves over 7-10 days, healing over next 2-4 weeks
    • Reactivation may involve pain without rash (zoster sine herpete)
    Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246-275.
  • 20. Acute Herpes Zoster Rash Order of rash progression Vesicles Pustular lesions Lesions crust over Resolution of rash Photo and slide courtesy of John W Gnann, Jr, MD.
  • 21. Herpes Zoster Rash Photo provided courtesy of Dr. Kenneth Schmader, Associate Professor of Medicine – Geriatrics, Duke University School of Medicine.
  • 22. Trigeminal Zoster Photo provided courtesy of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital.
  • 23. Pitfalls in Diagnosis
    • Prodrome of acute pain and paresthesias may be mistaken for other painful conditions 1
      • Migraine, glaucoma, myocardial infarction, pleurisy, duodenal ulcer, cholecystitis, appendicitis, and biliary or renal colic
    • Rash can appear similar to other rashes
      • Zosteriform herpes simplex is the most frequent error in diagnosis 2
        • Can be linear, but heals more rapidly, is likely to have less pain, and may recur in same area 2
        • If indicated, only reliable way to distinguish between the two is with laboratory testing (PCR, culture, DFA) 2,3
      • Occasional confusion with contact dermatitis
    DFA = direct immunofluorescence assay; PCR = polymerase chain reaction. 1 Oxman MN. Clinical manifestations of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246-275; 2 R űbben A et al. Br J Dermatol . 1997;137: 256-261; 3 Gershon AA et al. Varicella-zoster virus. In: Murray PR et al, eds. Manual of Clinical Microbiology . 6th ed. Washington, DC: ASM Press; 1995:884-894.
  • 24. Recurrent Herpes Simplex Photo provided courtesy of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital.
  • 25. Contact Dermatitis Reprinted with permission from DermNet. Available at: http://dermnet.com. Accessed February 4, 2008.
  • 26. Treatment Strategies for Herpes Zoster and PHN
  • 27. Case Study 1 (cont’d)
    • The patient was started on
      • V alacyclovir 1000 mg 3 times per day for 7 days
      • Oxycodone 10 mg/acetaminophen 650 mg every 4-6 hours as needed
      • Gabapentin 300 mg, titrated up to 300 mg tid over the next 2 weeks
      • Silver sulfadiazine cream applied 1-2 times per day, and diphenhydramine 25 mg every 6 hours as needed for itching
  • 28. Antiviral therapy administered within 72 hours of rash onset can reliably prevent PHN
    • True
    • False
    • Unsure
    Use your keypad to vote now! ? DECISION POINT 2
  • 29. Pharmacologic Management of Herpes Zoster: Antivirals
    • Most widely used treatment
    • Nucleoside analogs block viral replication 1 and promote rash healing 2
    • 3 agents available
      • Acyclovir 3 : 800 mg 5x per day, 7-10 days
      • Famciclovir 4 : 500 mg q8h, 7 days
      • Valacyclovir 5 : 1000 mg 3x per day, 7 days
    • Shown to accelerate rash healing and resolution of acute pain (days 1-30) 1
      • Effective when administered within 72 hours of rash onset; efficacy beyond 72 hours is unknown 1,6
    • Do not reliably prevent PHN 1,6
    1 Kost RG, Straus SE. N Engl J Med. 1996;335:32-42; 2 Gnann JW Jr, Whitley RJ. N Engl J Med. 2002;347:340-346; 3 Zovirax [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2004; 4 Famvir [package insert]. East H an o ver, NJ: Novartis Pharmaceuticals; 2002; 5 Valtrex [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2005; 6 Mounsey AL et al. Am Fam Physician. 2005;72:1075-1080.
  • 30. Management Strategies: Acute Herpes Zoster CNS = central nervous system; NSAIDs = nonsteroidal anti-inflammatory drugs. Physicians’ Desk Reference. 62th ed. Montvale, NJ: Thomson PDR; 2008; Montes LF et al. Cutis. 1986;38:363-365; Kalibala S et al. AIDS Action. 1990;10:2-3. Treatment Whom to Treat Limitations Oral antivirals Patients with zoster rash Use within 72 hours of rash onset IV acyclovir Selective use in immunosuppressed patients or those with CNS disease May use after 72 hours in immunosuppressed patients Oral corticosteroids Adjunctive therapy for patients with moderate to severe pain (controversial) Side effects: use with caution in patients with underlying illnesses Aspirin, NSAIDs, antihistamines, calamine, silver sulfadiazine Patients with minor pain or itching May not provide adequate pain relief Opioids, opioid-like drugs Patients with moderate to severe pain Significant side effects, potential for addiction
  • 31. Case Study 1 (cont’d)
    • The patient’s rash resolved about 1 month after initial onset, but she is still experiencing discomfort in the same area. She returns to the clinic several times over the course of the next 6 months, during which time gabapentin was titrated up slowly to 2400 mg per day in divided doses and opioid medication was discontinued, as she no longer required it
    • She presents again 7 months after rash onset because her pain has increased. She ran out of gabapentin 2 weeks ago
  • 32. Treatments for PHN: Pain Response and Adverse Event Profiles Gabapentin, pregabalin, lidocaine patch 5%, and topical capsaicin are approved by the Food and Drug Administration (FDA) for the treatment of PHN. 1 Rowbotham M et al. JAMA. 1998;280:1837-1842; 2 Dworkin RH et al. Neurology. 2003;60:1274-1283; 3 Pappagallo M, Haldey EJ. CNS Drugs . 2003; 17:771-780; 4 Watson CPN, Babul N. Neurology . 1998;50:1837-1841; 5 Raja SN et al. Neurology. 2002;59:1015-1021; 6 Davies PS, Galer BS. Drugs . 2004;64:937-947. Medication Pain Response and Adverse Event Profile Gabapentin, pregabalin 1,2 33% reduction in pain with gabapentin; 63% of patients receiving pregabalin experience clinically significant pain reduction Adverse events include somnolence, dizziness, and peripheral edema Tricyclic antidepressants 3 47% to 67% of patients report at least moderate pain relief Adverse events include sedation, confusion, urinary retention, dry mouth, postural hypotension, and arrhythmia Opioid analgesics 4,5 38% to 58% of patients report pain relief Adverse events include constipation, nausea, loss of appetite, dizziness, and drowsiness Lidocaine patch 5% 6 60% efficacy (ie, at least moderate pain relief) No systemic adverse events, but local reactions include erythema and skin rash Capsaicin cream Moderate pain relief but often with intolerable burning
  • 33. Limitations of PHN Treatments
    • PHN is difficult to treat
      • Therapy does not work for every patient
      • Effect of therapy is often modest
    • Therapy must be individualized
      • Introduce and modify treatments sequentially to determine their efficacy and tolerability
        • Titrate dose so benefits exceed side effects
        • Introduce treatments separately
    Adapted from Kost RG, Straus SE. N Engl J Med. 1996;335;32-42. Comorbid illness, the risk of drug interactions, and side effects must be considered when treating elderly patients with PHN
  • 34. Case Vignette
  • 35. Reducing the Incidence and Severity of Herpes Zoster and PHN With Herpes Zoster Vaccination
  • 36. Herpes Zoster Vaccination Age VZV T cells Varicella Zoster Threshold Varicella Exposure Silent Reactivation? Zoster Vaccination Adapted from Kost RG, Straus SE. N Engl J Med. 1996;355:32-42; Hope-Simpson RE. Proc R Soc Med . 1965;58:9-20. Herpes Zoster
  • 37. Shingles Prevention Study
    • A VA Cooperative Study to determine whether zoster vaccine decreased the incidence and/or severity of herpes zoster and PHN
    • Randomized, double-blind, placebo-controlled
    • 22 US sites (VA and university medical centers)
    • Enrolled 38,546 adults ≥60 years of age
      • 46% ≥70 years of age (>6.6% ≥80 years of age)
    • Study end points
      • Reduction in burden of illness (composite of incidence, severity, and duration of herpes zoster)
      • Incidence of herpes zoster and PHN
    VA = Department of Veterans Affairs. Oxman MN et al. N Engl J Med. 2005;352:2271-2284.
  • 38. Herpes zoster vaccination reduces the burden of illness associated with zoster by…
    • ~31%
    • ~41%
    • ~61%
    • 100%
    Use your keypad to vote now! KEY QUESTION ? 3
  • 39. Vaccine Efficacy for Herpes Zoster CI = confidence interval Oxman MN et al. N Engl J Med. 2005;352:2271-2284. 0 1 2 3 4 5 6 7 8 9 All 60-69  70 Herpes Zoster Burden of Illness Vaccine Placebo P <.001 Age (Years) Burden of Illness Efficacy (95% CI) 61.1% (51.1 - 69.1) 65.5% (51.5-75.5) 55.4% (39.9-66.9)
  • 40. Herpes Zoster Vaccination Reduces Incidence of Herpes Zoster and PHN Oxman MN et al. N Engl J Med. 2005;352:2271-2284. 6.0 Herpes Zoster Years of Follow-Up Years of Follow-Up 1.0 PHN Years of Follow-Up Years of Follow-Up 5 0.7 Placebo Zoster Vaccine Cumulative Incidence (%) 0 1 2 3 4 5.5 5.0 4.5 4.0 3.5 3.0 0.5 1.5 1.0 0.0 2.5 2.0 P <.001 Placebo Cumulative incidence (%) 0 1 2 3 4 5 0.9 0.8 0.6 0.5 0.4 0.3 0.2 0.1 0.0 P <.001 51% 66.5% Zoster Vaccine
  • 41. CDC Recommends Herpes Zoster Vaccination in Adults
    • October 2007 — CDC includes zoster vaccine in adult immunization schedule for adults ≥60 years of age
    • May 15, 2008 — For the prevention of herpes zoster, the CDC recommends that the zoster vaccine be given to all persons ≥60 years of age who have no contraindications including 1 :
      • Patients who have had a previous episode of herpes zoster
      • Patients with chronic medical conditions
    1. Centers for Disease Control and Prevention. MMWR (early release). 2008;57:1-30.
  • 42. Contraindications to Herpes Zoster Vaccine ZOSTAVAX [package insert]. Whitehouse Station, NJ: Merck & Co., Inc.; 2006.
    • History of anaphylactic/anaphylactoid reaction to neomycin
    • Serious current illness (or T ≥38.5°C)
    • History of immunodeficiency states including
      • Leukemia, lymphomas, or other malignant neoplasms affecting the bone marrow or lymphatic system
      • AIDS or other clinical manifestations of infection with HIV
    • Immunosuppressive therapy, including high-dose corticosteroids
    • Active untreated tuberculosis
    • Known or suspected pregnancy
    • Please see full CDC recommendations at: http://www.cdc.gov/mmwr/pdf/rr/rr57e0515.pdf
  • 43. Barriers to Vaccination
    • Patient-related issues
      • Lack of knowledge about immunizations
      • Fear of needles
      • Vaccine access
      • Vaccine coverage
    • Physician-related issues
      • Missed opportunities to vaccinate
      • Unfamiliar with vaccination guidelines
      • Lack of insight as to the importance of vaccination
    Adapted from Burns IT, Zimmerman RK. J Fam Pract. 2005;54:S58 - S62.
  • 44. Strategies to Improve Vaccination Rates
    • Communicate effectively with patients
      • Provide education and information about risks and benefits of vaccination
        • http://www.cdc.gov/vaccines/pubs/vis/vis-facts.htm
    • Develop office protocols
      • Assess each patient’s vaccination status
      • Administer and document vaccinations properly
      • Implement strategies to improve vaccination rates
        • eg, patient reminders
    • Facilitate patient access to recommended vaccinations
      • Identify and minimize office barriers
      • If needed, refer patients to other facilities offering vaccines
        • Health centers, travel clinics, infectious disease specialists
    Poland GA et al; and the National Vaccine Advisory Committee. Am J Prev Med . 2003;25:144 -150.
  • 45. Case Study
  • 46. Case Study 2
    • A 72-year-old man with a history of chronic obstructive pulmonary disease, coronary artery disease, and mild renal insufficiency arrives at the clinic for his yearly flu shot
    • Medical history includes a history of herpes zoster (V-1 dermatome with ocular involvement and 18 months of PHN) 9 years ago
    • Medications: inhaled corticosteroids, beta agonist, ASA, and ACE inhibitor
    • Because of his prior severe case of shingles, the patient has read about the herpes zoster vaccine and wants to receive it today
    ACE = angiotensin-converting enzyme; ASA = aspirin.
  • 47. Does this patient meet the criteria to receive the herpes zoster vaccine, and can it be given with his flu shot?
    • Yes, he should receive it, but should not get it at the same time as his flu shot
    • Yes, he should receive it, and can get the flu shot at the same time
    • No, he does not meet criteria to receive the zoster vaccine because his medications include inhaled corticosteroids
    • Unsure
    Use your keypad to vote now! ? DECISION POINT 0
  • 48.
    • Corticosteroids: Patients ≥60 years of age receiving a dose equivalent to 20 mg/d prednisone for >2 weeks should not receive the zoster vaccine for at least 1 month after discontinuation of such therapy
      • Topical (eg, skin, nasal, inhaled), intra-articular, bursal, or tendon injections are not considered sufficiently immunosuppressive to raise vaccine safety concerns
    • Immunosuppressive therapy not considered sufficiently immunosuppressive to raise vaccine safety concerns includes:
      • Methotrexate (≤0.4 mg/kg/week)
      • Azathioprine (≤3.0 mg/kg/d)
      • 6-Mercaptopurine (≤1.5 mg/kg/d)
    Centers for Disease Control and Prevention. MMWR (early release). 2008;57:1-30. CDC Recommendations: Immunocompromised Patients
  • 49. CDC Recommendations: Herpes Zoster Vaccine and Inactivated Vaccines Can Be Administered Concomitantly
    • Immunogenicity of zoster and influenza vaccines is not compromised when the 2 are administered simultaneously 1
    • Zoster and influenza vaccines given concomitantly are generally well tolerated in older adults 2
    • Simultaneous administration of inactivated vaccines should not result in an impaired immune response or an increased rate of adverse events 1
      • Therefore, the zoster vaccine can be administered with other indicated vaccines within the same visit (eg, Td, Tdap, PPV)
    1. Centers for Disease Control and Prevention. MMWR (early release). 2008;57:1-30; 2. Kerzner B et al. J Am Geriatr Soc . 2007;55:1499-1507.
  • 50. Case Study
  • 51. Case Study 3
    • A 61-year-old woman, born and raised in Cary, North Carolina, arrives at the clinic for routine follow ­ up
    • Active problems: hypertension, type 2 diabetes
    • Social history: investment banker, unmarried, no   children
    • Medical history: no prior herpes zoster; claims she has never had chickenpox
  • 52. Which of the following is a true statement concerning this patient?
    • She should not receive the herpes zoster vaccine
    • She should not receive the herpes zoster vaccine until she receives 2 doses of the varicella vaccine
    • She should have varicella titers taken first and, if positive, may receive the herpes zoster vaccine
    • She may receive the herpes zoster vaccine today
    Use your keypad to vote now! ? DECISION POINT 0
  • 53. Should the Herpes Zoster Vaccine Be Given to Patients With Unknown Chickenpox History?
    • VZV seropositivity rate among Americans ≥60 years of age is >99% 1
      • Most patients who do not recall history of chickenpox are VZV seropositive
      • Serologic testing was not an entry requirement for the Shingles Prevention Study
    • Data have shown herpes zoster vaccination to be safe in VZV-seronegative patients 2
    • VZV serologic testing is not recommended prior to receiving herpes zoster vaccine
    1 Kilgore PE et al. J Med Virol . 2003;70(suppl 1):S111-S118. 2 Macaladad N et al. Vaccine. 2007;25:2139-2144.
  • 54. Q & A
  • 55. PCE Takeaways
  • 56. PCE Takeaways
    • Incidence and severity of herpes zoster increase with advancing age to produce substantial negative effects on quality of life
    • Antiviral therapy may reduce the incidence and severity of acute herpes zoster, but does not reliably prevent PHN
    • Herpes zoster vaccination offers a safe and highly effective method of reducing the public healthcare burden of herpes zoster and its complications
            • continued
  • 57. PCE Takeaways
    • The CDC recommends vaccination of all persons ≥60 years of age with no contraindications, including those with a history of herpes zoster or chronic medical conditions
    • The CDC has included the herpes zoster vaccine in the 2007-2008 Recommended Adult Immunization Schedule
  • 58. Do you now plan to routinely recommend and administer the herpes zoster vaccine to your patients who are ≥ 60 years of age?
    • Yes
    • No
    Use your keypad to vote now! KEY QUESTION ? 0
  • 59. Lunch Don’t forget to complete your CME/CE evaluation form and return it to the registration desk at the end of our program
  • 60. Embassy Suites Raleigh-Durham/Research Triangle Cary, North Carolina June 21, 2008 Symposia Series 2 2008