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Shingles: the forgotten vaccine during the COVID-19 pandemic

Catherine Heffernan looks at how the pandemic has diverted focus from other vital vaccination programmes

In recent weeks, you’d be forgiven for thinking that there was only one vaccination programme for adults in the UK, the COVID-19 vaccine. Whilst the 2020/21 ‘flu season has just ended with improved uptake rates on the previous season, the same cannot be said for the shingles vaccine or the pneumococcal (PPV23) vaccine. In England uptake rates of the shingles vaccine have plummeted from 61.8% of 70 year olds vaccinated in 2013/14 to 26.5% in 2019/20.1

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The eligibility criteria changed after 2017/18 (individuals become eligible on their 70th birthday rather than on 1st September) so we should be cautious in doing direct comparison to the earlier years but nevertheless, COVID-19 has impacted upon the delivery of this vaccine, particularly as it was not prioritised like other vaccination programmes to be delivered during lockdown April 20202 and wasn’t reinstated until July 2020.3 About one in four people will develop shingles during their lifetime. The shingles vaccine is given for direct protection, protecting the most vulnerable from pneumonia and severe disease. Moreover, the vaccine is not a seasonal vaccine and while it is commonly given with the ‘flu vaccine, like the PPV23 vaccine, it can be given throughout the year.

What is shingles?

Shingles, also known as herpes zoster, is a painful, sometimes debilitating condition. It results from a reactivation of latent varicella zoster (chickenpox) virus. Following initial infection, the virus lies dormant in the nervous tissue but can reappear when re-activated as shingles. The incidence and severity of shingles increases with age, roughly doubling every decade after the age of 50.4 The estimated life-time risk is between 25% and 35%.5 Individuals over the age of 70 are more likely to develop complications including bacterial skin infections. Post herpetic neuralgia (PHN) is the most common, an extremely painful condition which causes persistent neuropathic pain for 3 to 6 months after rash onset and sometimes longer.6 Older age is associated with greater risk of developing PHN. In the UK, 10% of those aged 50 years with shingles will develop PHN rising to 20% at age 80.7, 8 Available treatments are ineffective.9 The costs of treating PHN are estimated to be between £341-£397 per PHN episode with a primary care cost of £103 per patient per shingles episode.10 The over 70s account for 77% of the annual burden of shingles on healthcare.11

The shingles vaccine

The shingles vaccine has been found to be effective in preventing shingles12 and can reduce the incidence of PHN by 67% and shingles by 51% in the over 60s.13 The shingles vaccine offers direct protection to the patient by boosting their pre-existing VZV immunity and preventing reactivation of latent virus. The vaccine offers no herd protection therefore other factors such as social mixing and household size do not affect risk of disease. It is a live viral vaccine and is contraindicated for immunosuppressed individuals. It is essential to assess the eligibility of individuals prior to offering the shingles vaccine and ensure that those who can benefit are not excluded.

Shingles Vaccination Programme

The shingles vaccination programme began on 1 September 2013. The aim of the programme was to offer routine shingles (herpes zoster) vaccination to all 70 year olds each year, with a catch-up programme for older cohorts each year until 2020/21 to capture individuals born up to 1 September 1942 (i.e. aged 71 to 79 years on 1 September 2013 at the programme launch). The choice of target age groups was based on cost-effectiveness analysis incorporating the age-specific incidence of herpes zoster and postherpetic neuralgia, the decline in vaccine efficacy with age, and the estimated duration of vaccine-induced protection.14

Since the introduction of the programme, there has been a big decrease in consultations for shingles and PHN. There was an estimated 35% decline in herpes zoster incidence amongst the routine cohort and a 33% drop in catch-up cohort across the first three years of the programme, equivalent to 17 000 fewer zoster consultations among the 5·5 million individuals eligible for vaccination.15 A 50% decline was seen in PHN incidence amongst the three routine cohorts across the first three years of the vaccination programme with a 38% decline in the catch-up cohort.

In September 2013 the programme launched with a routine cohort of 70-year olds and a catch-up up cohort of 79 year olds. As the years progressed, an additional cohort was added each year and in 2020/21 all ages between 70 and 79 are eligible.16 They will remain eligible to receive shingles vaccine at their GP surgery up to their 80th birthday. It is good practice to continue to offer the catch-up cohorts the shingles vaccine to prevent increased susceptibility to shingles amongst these cohorts. Shingles vaccination is part of essential services of GP contract since 2019/20 and can be offered to throughout the year, although it is commonly given with the influenza vaccine.

Improving uptake

There is variation in uptake of shingles vaccine linked to deprivation, geography, ethnicity and accessibility. In relation to determinants of compliance, a European study found that non-compliance with HZ vaccination was linked to a 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 defences.17

These reasons are similar to vaccine hesitancy in other programmes like COVID-19 vaccines. Health care professionals are continually cited in the literature as being the most trusted advisors of vaccinations so taking the time to speak with eligible patients about the vaccine before their vaccination appointment or at another primary care appointment will encourage vaccine acceptance.

Prior to 2020/21, shingles vaccination used to be offered opportunistically. However, it has always been good practice to operate a patient invite/reminder (call/recall) system in relation to shingles vaccine. In London, a shingles summer campaign was run each year prior to the COVID-19 pandemic. As surgeries were relatively quiet, it was an ideal way to promote and improve uptake of the vaccine. Different approach was used each year from providing practices with packs of promotional materials to have a ‘shingles awareness’ week to having a party to celebrate NHS turning 70.18 Patients aged 70 years were invited to have their shingles vaccination and enjoy tea and cakes – courtesy of Waitrose and the practices – to celebrate the NHS birthday.

In other years, coffee mornings were used. For many practices, the number of patients eligible for shingles was small so a coffee morning was a fun way to cover much of the eligible cohort in a single go. Practices could order a coffee morning kit from a central email and organise a shingles clinic. Throughout the endeavours, the running mantra was ‘if you invite them, they will come.’

The focus is now on getting eligible people vaccinated with their two doses of COVID-19 but we shouldn’t forget the other adult vaccinations. They have been introduced for a reason; they reduce mortality and morbidity by protecting the vulnerable either from infection, progression to severe disease or both. Shingles cannot always be prevented but the vaccine reduces the chance of developing it.

Dr Catherine Heffernan, Consultant in Public Health


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