|The PAFP Foundation provides family medicine representation in statewide public health efforts and supplies members with even more high-quality (and in many cases, free) CME through the PAFP Foundation.
Public Health Information and CME in Keystone Physician
Family Physicians Need to Vaccinate against Herpes Zoster
By Donald B. Middleton, MD
Professor, Dept. Family Medicine
Vice President for Residency Education
UPMC St. Margaret
Unlike other vaccines Zostavax is the only vaccine given to prevent something you already have in your body. The vaccine serves to remind our lymphocytic protection system that we are already infected. No wonder it does not work 100%! But it does prevent a great deal of suffering, reducing the incidence of shingles and the severity and incidence of postherpetic neuralgia by about 65%. Patients who develop shingles even after being vaccinated generally have milder disease and have a lower rate of developing postherpetic neuralgia. The complicated relationship of our immune systems to herpes zoster infection makes the fact that the vaccine works at all miraculous. Other vaccines like HPV do not help once one is infected.
A 48% response rate preventing shingles of any severity (most studies show about 55% response rate) is not too bad. We are discovering that many vaccines don't work as well as we wish they did. For example, the protection from Tdap may last only a few years. Flu vaccine was about 60% effective this year (I got the flu [documented by PCR] even after being vaccinated). MMR must be repeated and even then may not be totally effective. So what if Zostavax doesn't work 100% of the time? Management of a case of shingles in an older patient already on medication or dealing with some chronic illness is not easy. Do we not want to protect some of the people if we can?
The duration of protection from the vaccine is not yet determined because it has not been out long enough to know. So far it seems to be working extremely well. Studies have proven 4-5 years of protection at minimum. Given the low recurrence rate of shingles itself, I would suspect that the vaccine will provide protection for closer to 20 years (personal opinion).
Two major studies have shown that the vaccine is cost effective: not vaccinating individuals leads to more economic damage than vaccinating them. All insurers in the state of Pennsylvania, as far as I know, pay for Zostavax for patients age 60 through 64 years. Some insurers pay for Zostavax at age 50 and above (including UPMC Health Plan). Medicare pays for all patients age 65 and over through part D, the pharmacy benefit. If a doctor cannot make money giving a Zostavax, I don't see a problem with giving the patient a prescription and a handout on shingles and telling the patient to go to the pharmacy to get Zostavax. You don't even have to spend any time doing it. Often I just walk out of the exam room and ask my nurse to give Mrs. X a handout on shingles and a prescription for a Zostavax vaccine to get at her pharmacy. Just because the vaccine is given by the pharmacist does not mean that the patient will lose loyalty to the doctor. It’s like any other prescription or consultation.
I now have four senior citizens in my practice who complain about their postherpetic neuralgia on virtually every visit to the office despite the fact that it has been years since they were affected. They were affected before Zostavax was available. I wish that I had had it for them.
The way I read the shingles vaccine study, the number needed to vaccinate (NNV) is given for a time period, not for the entire life span. If you include the lifetime of the patients, the NNV drops. Besides the NNV concept is sometimes not useful. A quote from page 978 of Plotkin’s book, Vaccines, 6 edition, 2013: “Administration of zoster vaccine to 1 million people in the target population will prevent approximately 70,000 cases of HZ, 20,000 cases of PHN, 250,000 visits to a medical office, 350,000 prescriptions, 8700 emergency department visits, 8000 hospitalizations, and $71-89,000,000 in medical costs.” Why wouldn’t family doctors want to give or prescribe this super vaccine whenever they can?
Top Tips From The PAFP Foundation Two Big March CME Conference
The Valley Forge CME conference in March got rave reviews for top-notch CME. Read the entire conference wrap-up newsletter at www.pafp.com. Top tips:
- What makes people so desperate to smoke? Nicotine gets past all the sensory input right to the limbic system which generates the focus, emotion and memory for addiction.
- 2012 new addition to USPSTF HIV testing guidelines? Routine one-time screening for patients 15-64.
- OA: order weight-bearing films to get the true picture.
- Medical Home Transition project meets MOC part IV requirements!
The Residency Program & Community Health Center Collaboratives meet March 7 in Valley Forge. Read the entire wrap-up newsletter at www.pafp.com. Top tips:
- Use evidence-based dosages of depression meds. Inappropriate dosing and duration are the most common cause for failure to respond.
- Know the updated CRC screening guidelines. Offer the full menu of options for screening.
- Best way to prevent progression of prediabetes: 5-10% weight loss.
- Decrease diabetes A1c by 1% to decrease complications by 21% - lots bang for your buck!
- LDL management approach from NIH: detection, eval, tx.
Coming Soon: 'Ask, Advice, Refer' Free Training And Technical Assistance
The "ask, advice, refer" (AAR) dinner training held March 7 was archived and will be available soon to all PAFP members. After you watch Dr. Leone’s excellent presentation (attendees commented how it really changed their approach to smoking cessation), watch the AAR video and then connect with PA cAARds for free technical assistance. You may also use the PAFP Foundation’s data management system to track patients with diabetes who smoke so you can track your progress.
Meanwhile, watch Dr. Weida’s CME lecture on the latest smoking cessation interventions.
Check it out at www.pafp.com/smoke.
Tips from April’s Medical Home Transition Advisory Committee meeting:
- DPW’s "ops memo" lets MA patients with special health care needs remain with their pediatrician during trial visits with a family physician. You, as the adult provider, bill as a consultant.
- Working with a pediatrician on transition? Ask for a one-to-two-page "transition note" and all immunization records.
- Check these videos from the Peal Center, particularly "Moving from Pediatric to Adult Providers."
Free, In-Practice Training on Breastfeeding, Pediatric Obesity Now Available!
EPIC® Breastfeeding Education, Support and Training (BEST): Statewide, one to two hours. Contact Program Director Amy Wishner MSN, RN at firstname.lastname@example.org.
EPIC® Pediatric Obesity: Southeast and southwest regions, one and 1/2 hours. Contact Program Director Dottie Schell, BS, RN, CLC at email@example.com.
Seeking Trainers: Receive training and materials plus an honorarium. Program arrangements are made by PA-AAP program staff. Seeking participating practices: A presenter will come to your practice. CME/CEUs are available. The free lecture includes resources and is designed for the entire office team.
If You Work in Health Care, You Have No Excuse...
If you work in health care, you have no excuse not to be vaccinated! You can make influenza vaccination mandatory for all workers at your practice – it’s a great way to increase rates. But there are other ways. Successful interventions include peer-to-peer education, improving access and providing alternatives to needles. Other ideas include vaccinating workers at their desks if they say they’re too busy, or making employees actively refuse to be vaccinated and discussing with them why they won’t be immunized.
Vaccinated or not, don’t forget about hand washing, respiratory hygiene and cough etiquette. Read this health care worker vaccination article!