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Feature Article

Herpes zoster: improving protection in older people

JOHN C.B. LITT, ANTHONY L. CUNNINGHAM
OPEN ACCESS

Contraindications to the live attenuated HZ vaccine, including specific immunocompromising conditions, are listed in Box 3.1,10 Comprehensive information on the safe doses of immunosuppressive ­therapy and timing restrictions for administering HZ vaccine in patients taking these medications are provided in the NCIRS fact sheets on HZ and the HZ vaccine.10,40 In addition, it is suggested that all healthcare providers use the prevaccination checklist, a screening tool that highlights the various contraindications to the live attenuated HZ vaccine (https://beta.health.gov.au/search/pre-vaccination).41 

HZ vaccination in a patient with past HZ who has recently taken a course of corticosteroid is discussed in the case study in Box 4.42,43 

Improving protection against herpes zoster

Increasing vaccine uptake

Since the HZ vaccine was launched on the Australian NIP in November 2016, its uptake has been strong in the 70- to 79-year-old age group, with estimated ­vaccine ­coverage levels now above 60% of the target group (personal communication, Jim Malamatinas, 5 December 2018). ­This ­estimate is based on doses of HZ vaccine delivered to GP practices and is not a formal estimate of coverage. The latter should be available in the next few months. Nevertheless, a significant proportion of the target group remain unvaccinated.

Several factors have been shown to affect the uptake of the HZ vaccine. One of the most important influences in patients ­having HZ vaccination is a recommendation from their GP. Some tips on discussing HZ vaccine with older patients appear on page 31 of this Supplement.

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Patient concerns and beliefs that may decrease HZ vaccine uptake include:

  • Concerns about:44-49
    –  the vaccine’s efficacy
    –  adverse effects from, and allergic reaction to, the vaccine
  • beliefs that:44-46,48,50
    –  there is no need for vaccine as they rarely get sick
    –  they already have good immunity to HZ
    –  they are at low risk of getting HZ
    –  vaccines weaken the immune system and natural immunity is more important
    –  the vaccine can cause HZ.

Difficulty in attending their GP and their GP not discussing the HZ vaccine have also been shown to reduce patients’ HZ vaccine uptake.44,46,49,51,52

The following factors have been shown to increase the uptake of HZ vaccine:44-54

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  • GP recommending to have the vaccine
  • older age
  • female sex
  • higher level of education
  • friends or relatives affected by HZ or PHN
  • belief that HZ can be severe
  • higher awareness about HZ and the HZ vaccine
  • regular user of influenza or pneumococcal vaccines
  • having a regular GP
  • availability of the vaccine.

A number of other factors, including the presence of chronic disease, such as diabetes, being a smoker, infrequent GP attendance and patient health status, have shown mixed or unclear effects on vaccine uptake.46,55-59

Improved zoster vaccines

The declining efficacy of live attenuated HZ vaccine with age, especially in those over the age of 70 years, has left a sub­stantial unmet medical need in this growing ­population. Furthermore, this vaccine is contra­indicated in severely immuno­compromised patients, in whom HZ is common and often severe. 

A new recombinant herpes zoster ­subunit vaccine HZ/su is available in the US and is also licensed in Canada, Europe and Japan. The new vaccine has been registered by the TGA but is not yet available in Australia (see the case study in Box 5).60,61 

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Associate Professor Litt is a Public Health Physician and Associate Professor in the Discipline of General Practice, Flinders University, Adelaide, SA. Professor Cunningham is Executive Director of the Westmead Institute for Medical Research and Professor of Research Medicine at The University of Sydney, Sydney, NSW.