Few receive the shingles vaccine because of cost to doctors

by Michael Smith

It’s a classic good-news, bad-news story.

The vaccine against shingles, already shown to be effective, is both safe and well-tolerated, researchers found after following more than 38,000 participants in the randomized trial that led to the 2006 approval of the vaccine.

On the other hand, few people are getting the vaccine, and for a variety of reasons — including its cost — researchers noted in a separate study. Both analyses appear in the May 4 issue of the Annals of Internal Medicine.

The findings highlight the lack of a comprehensive approach to adult vaccination in the U.S., according to James Donahue, DVM, PhD, and Edward Belongia, MD, both of the Marshfield Clinic Research Foundation in Marshfield, Wis.

In an editorial accompanying the two studies, they argued that such a broad approach should address vaccine financing and delivery, coverage levels, surveillance of vaccine-preventable diseases, vaccine safety, and logistical barriers.

The vaccine against herpes zoster and postherpetic neuralgia was shown to be effective in large randomized placebo-controlled trial, but its long-term safety had not been studied, according to Michael Simberkoff, MD, of Veterans Affairs New York Harbor Healthcare System in New York City, and colleagues.

So the researchers followed 38,546 adults ages 60 or older during the clinical trial of the vaccine from November 1998 to September 2001, then followed them for an average of 3.4 years through April 2004. The analysis included 6,616 who participated in an adverse events substudy.

The study looked at serious adverse events and rashes in all participants and injection-site events in the substudy participants during the first 42 days after inoculation.

After that, all participants were monitored for vaccination-related, serious adverse events and deaths, and inpatient care was monitored in substudy participants.

They found:

* Serious adverse events after inoculation were rare and evenly distributed between vaccine and placebo recipients — 255 vaccine recipients and 254 placebo recipients reported such an event.
* In the substudy, local site reactions were seen in almost half of the vaccine recipients — 1,604 or 48% — compared with 539 or 16% of those who got placebo.
* After inoculation, herpes zoster occurred in seven vaccine recipients and 24 participants who got placebo.
* Rates of inpatient care or death did not differ between vaccine and placebo recipients over an average of 3.39 years of follow-up.

Simberkoff and colleagues cautioned that adverse events substudy was not randomized. As well, they noted, not all reported serious adverse events were confirmed with medical data.

Although the vaccine was approved in 2006 and recommended in 2008 by the Advisory Committee on Immunization Practices for all adults over 60, the use of the vaccine has been limited, according to Laura Hurley, MD, of Wellington Webb Center for Primary Care in Denver, and colleagues.

To find out why, the researchers surveyed nearly 600 internists and family medicine physicians. They found:

* More general internists than family medicine physicians thought that more than half of their patients were eligible for the vaccine — 39% versus 13%, a difference that was significant at P<0.001.
* In both specialties, 49% of doctors stocked and administered the vaccine in their offices, while 36% sent patients to a pharmacy to buy the vaccine and bring it back to the office for administration, and 34% referred patients to a pharmacy for the shot.
* While 88% said they recommend the vaccine, only 41% strongly recommend it, compared with more than 90% who strongly recommend influenza and pneumococcal vaccines.
* The most frequently reported barriers to vaccination were financial: The vaccine costs about $200 and only 45% of respondents knew that the vaccination is reimbursed through Medicare Part D.
* Of respondents who began giving the vaccine, 12% said they stopped because of cost and reimbursement issues.

Hurley and colleagues cautioned that the survey relies on reported — but not observed — practice. As well, they said, those who answered the survey may not be representative of all healthcare providers.

The cost of the vaccine is “significant,” said Len Horovitz, MD, of Lenox Hill Hospital in New York City, who was not involved in either study.

“But the cost of treating postherpetic neuralgia is far more,” he told MedPage Today in an e-mail.

Michael Smith is a MedPage Today North American Correspondent.

Originally published in MedPage Today. Visit MedPageToday.com for more vaccine news.

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  • family practitioner

    Our wonderful CMS system provides coverage for this vaccine butthrough medicare part D, making it different than other vaccines; this allows various part D providers to cover it whichever way they prefer. Some allow the doctor to do it, some want they pharmacist to do it, some want the patient to pick it up at the pharmacy and bring it to the doctor’s office, some require prior auth, some don’t. It is a mess. And if I screw it up, the patient may be stuck with the bill and then I have an angry patient, or I have to eat the cost.

    Here are 2 simple suggestions:
    1. cover the shingles vaccine like other vaccines, ie pneumovax, which means in the doctors office without prior auth
    2. require insurance to cover the cost of the vaccine and the administration.

    Not too complicated is it?

  • dgh

    Probably best off getting it at the health department. I needed to get the tDAP (dTAP?, whatever the adult version is) before I started med school and my physician just didn’t have it. He looked at getting a vial for me, but it was again like 200 bucks and he doubted he’d ever be able to use the other 3-4 doses. In his defense we was an internist specializing in geriatrics (which I didn’t know when I made my first appointment, I just saw he was a MD within walking distance of my house, he took me as a pt anyways) and not too many elderly actually needed the vaccine.

    However the health department hooked me up for 10 or 15 bucks (I forget). I was also able to get my titers for 10 bucks a pop (needed a whole lot to please the med school as I couldn’t find my Hep A/B or MMR records.

  • stargirl65

    I have many patients ask about the shot. I explain it’s covered on Part D. I don’t carry it (could not carry the large overhead) and send them to the pharmacy. Many had to pay $200 cash. Some get it covered by their Part D.

    Some are not Medicare age but the insurance companies cover the exact COST of the medicine. I’m not looking to get rich off giving Zostavax, but I would like to make a little profit to cover my acquisition time and costs, storage costs, and management of the shots.

  • ninguem

    stargirl how dare you think about making money

  • mamadoc

    We stock if but right now there’s problems with the supplies and we aren’t getting our orders. As mentioned above, Medicare part D remibursement is all over the place, and those of us in the real world don’t have staff with the time to figure out who’s got what coverage. Most of our private insurers are covering the cost and you can also charge for the injection. We ask the PATIENTS to check with their part D or other insurance–after all, they’re the ones with the time and motivation. If they then choose to receive the vaccine, they sign an agreement that they will pay for their vaccine if the insurance company doesn’t or pay for it completely, and that means the injection charge as well. We don’t bother having them bring the vaccine from the pharmacy since we have two pharmacies with pharmacists trained to inject, and the stuff has to be used immediately after it thaws (which takes no time at all) and it’s just too much hassle for the patient to transport and us to give timely once they bring it in. It’s not about getting rich from the vaccine, it’s about not getting stuck holding the bag for an expensive medicine we’ll never be paid for. Most of us have pretty thin margins and no room for a hit like that.

  • http://kevinmd.com dkdmd

    This study vaccinated 19,270 people. The vaccinated group reported 7 cases of shingles vs 24 in the placebo group. Wholesale cost for treated group (total)=$2,967,580. That equates to $174,563.52 cost for the each of 17 people who didn’t get shingles. Merck’s own studies don’t show anywhere near this kind of improvement. Economically, who really benefits with this vaccine?? Hint-Merck. Not the people who paid for it.

  • Cheryl

    I do wish the study indicated better results, but, having watched my father suffer with post herpetic neuralgia around his left eye for the 20 years before he died, I paid
    for my shot – about $240( 200 for vaccine, which was said to be the cost, plus $40 for injection). About the cost of 2 new tires — … it wasn’t covered at all by my ( fairly comprehensive) insurance. As I had had a shingles outbreak already ( w/o pain, really) apparently I was in a lower risk category but didn’t know it. It is being recommended for folks over 60. I’s not the best comparison – but I still get a tetanus booster ( much cheaper OC) even tho’ my likelihood of getting tetanus is close to 0. It’s that little threat of having extraordinary pain – and the opportunity to preclude it – that makes it worthwhile. I think that we will get to a point where it will be covered.

  • bvseth

    Many military hospitals and clinics carry the vaccine for military and their dependents. However, our family internist said not to get it because it is not effective, and shingles does not recur. After researching the vaccine online, I know he is wrong on both counts. Why aren’t doctors more informed about this vaccine? My mother and grandmother suffered from shingles over a long period of time. I know how painful it can be.

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