Shingles is a Nightmare! ACP Quality Connect Shingles is a Nightmare! A Webinar with Dr. Steven R. Peskin Friday, March 24, 2017 12 -1 PM EST

I Raise the Rates: Initiative to Raise the Adult Immunization Rates in Primary Care An ACP Quality Connect Program

Acknowledgements Support for this program has been from Pfizer, Inc.

ACP Quality Connect Mission To create and sustain a learning community of empowered physicians and other health care professionals, patients and caregivers, to improve health, care delivery and outcomes. Create QI network of internists and other physicians and their health care teams Partner with state chapters and health care systems Highlight patient engagement as part of health care team Add value and joy to clinicians in everyday practice

Adult Vaccination Rates = POOR! Data: NFS 2014, NHIS 2013 Vaccine [Population] Influenza Early 2013-14 Early 2014-15 Influenza [Early Season 2014– 2015] – All Adults 39.0% 39.7% [All] 18 – 49 years 31.4% 30.6% [All] 50 – 64 years 39.1% 43.7% > 65 years 61.8% 61.3% HCW [19 – 64 years] 62.9% Not asked PPS23 & PCV13 Rate 2012 Rate 2013 High risk 19 – 49 years 20.0% 21.2% 59.9% 59.7% Tetanus [19 – 49 years, received past 10 years] 64.2% Tetanus/Pertussis [19+, received in past 8 yrs] 14.3% 17.2% Shingles [Zoster] age 60+ 20.1% 24.2% Hepatitis B Vaccine [High risk 19 – 49 years] 35.3% 32.6% HPV Vaccine [women 19 – 26 years] 34.5% 36.9% http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2014.htm#place http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6305a4.htm

Disparities and Adult Vaccination Rates = EVEN WORSE! Data: NIS-Flu and BRFSS Vaccine [Population] 2013 -2014 Rate Influenza [> 18 years] All Adults 42.2% Hispanic 33.1% White 45.4% Black 35.6% Asian 43.6% Pneumococcal [>65 years] 59.7% 39.2% 63.6% 48.7% 45.3% Vaccine [Population] 2013-14 Rate Zoster [>60 years] All Adults 24.2% Hispanic 9.5% White 27.4% Black 10.7% Asian 22.6% Tdap [>19 years] 17.2% 10.2% 19.7% 12.6% 15.5% Again – no need to go into the data – just use one - pneumococcal perhaps to show disparities

I Raise the Rates Approaches Increased adult immunizations Training and practice coaching Communications Campaign Performance measure feedback

Improvement Tools Champion Training Performance Monitor and Learning Platform Practice Coaching Calls Webinars Focus on Topics Important to Practices (costs, team- based approaches, referral tools, recommendation) PDSA Library Resident Training Modules

Champion Role and Responsibilities Lead your practice setting in QI project aimed at increasing immunization rates among your patience Engage peers in promoting the importance of immunizations Teach colleagues about strategies that can promote immunizations Promote immunizations in your organization or community Become future coaches and QI leaders

Medconcert: Performance Monitoring Dashboard View your performance based on vaccine measure and against established benchmarks and peer comparators.

Medconcert: Patient Population Management/Outliers View your patient population and your patient outliers to see where gaps may be.

Medconcert: Improvement Tools Access to improvement tools and educational resources for patients and staff. Resources specific to each vaccine measure and focusing on the adult immunization practice standards.

This Approach Can Make a Difference   Baseline (%) Follow-up (%) Improvement (%) Herpes Zoster (shingles) Vaccination 51.92 66.18 14.26 High Risk Pneumococcal Vaccination 69.13 92.65 23.52 Influenza Immunization 79.34 97.64 18.3 Influenza Vaccination Coverage Among Healthcare Personnel 75 100 25 Pneumococcal Vaccination Status for Older Adults 96.12 99.01 2.89 Tdap Vaccination 76.56 91.23 14.67

And You Can Make a Profit Decision points: Which vaccines to stock Storage and handling Purchasing method Optimal coding Standing orders/team-based care Vaccine MCR Margin Non-MCR Margin Estimated Net Profit 9/12-8/13 influenza 29.07 20.61 13,106.16 PPSV23 38.70 21.54 1,794.06 Tdap 49.05 30.45 11,985.90 Zostavax 20.54 123.24 HPV4 50.00 600.00 PCV13 35.52 14.89 50.41 Other Vax: 20.00 est 100.00 TOTAL: $27,759.77

I Raise the Rates State Partners Louisiana Florida Arkansas NJ CDC-funded National Adult Immunization Campaign: Georgia and Illinois Disparities Project: Alabama, Louisiana, Georgia and Illinois

What You Need to Know About Shingles and the Shingles Vaccine What is Shingles Risk of Shingles Vaccination

SHINGLES MY NIGHTMARE!

What is Shingles? Shingles, also known as zoster or herpes zoster, is a painful skin rash caused by the varicella zoster virus, the same virus that causes chickenpox. If you’ve had chickenpox, you are at risk of getting shingles. One out of every three people 60 years old or older will get shingles. One out of six people older than 60 years who get shingles will have severe pain. The pain can last for months or even years. The most common complication of shingles is severe pain where the shingles rash was. This pain can be debilitating. There is no treatment or cure from this pain. As people get older, they are more likely to develop long-term pain as a complication of shingles and the pain is likely to be more severe. Shingles may also lead to serious complications involving the eye. Very rarely, shingles can also lead to pneumonia, hearing problems, blindness, brain inflammation (encephalitis), or death.

Risk of Shingles Almost 1 out of every 3 people in the United States will develop shingles, also known as zoster or herpes zoster, in their lifetime. Anyone who has recovered from chickenpox may develop shingles; even children can get shingles. However the risk of shingles increases as you get older. About half of all cases occur in men and women 60 years old or older. Some people have a greater risk of getting shingles. This includes people who have medical conditions that keep their immune systems from working properly, such as certain cancers like leukemia and lymphoma, and human immunodeficiency virus (HIV), and receive immunosuppressive drugs, such as steroids and drugs that are given after organ transplantation. People who develop shingles typically have only one episode in their lifetime. However, a person can have a second or even a third episode.

Protect Yourself Against Shingles Adults 60 years old or older should talk to their healthcare professional about getting a one-time dose of the shingles vaccine. The shingles vaccine can reduce your risk of shingles and the long term pain it can cause. Persons who have already had shingles or who have a chronic medical condition can receive the shingles vaccine. In a clinical trial involving thousands of adults 60 years old or older, the vaccine reduced the risk of shingles by about half. Even if the shingles vaccine doesn’t prevent you from getting shingles, it can still reduce the chance of having long- term pain. Talk with your healthcare professional for more information and to find out if the shingles vaccine is right for you.

The shingles vaccine is a safe way to protect your health. Vaccines are tested and monitored. The shingles vaccine went through years of testing before being licensed by the Food and Drug Administration (FDA) in 2006. The Centers for Disease Control and Prevention (CDC) and FDA continue to monitor vaccines after they are licensed. Vaccine side effects are usually mild and temporary. In most cases, shingles vaccine causes no serious side effects. Some people experience mild reactions that last up to a few days, such as headache or redness, soreness, swelling, or itching where the shot was given. Vaccines are safe for most people. The shingles vaccine is safe for you unless you are pregnant, have a weakened immune system, or have allergies to certain components of the vaccine. It is safe for people taking most prescription medications to get this vaccine, but ask your healthcare professional if you have any questions.

Vaccination Shingles is a painful rash that usually develops on one side of the body, often the face or torso. The rash forms blisters that typically scab over in 7 to 10 days and clears up within 2 to 4 weeks. For some people the pain can last for months or even years after the rash goes away. This long- lasting pain is called post-herpetic neuralgia (PHN), and it is the most common complication of shingles. Your risk of shingles and PHN increases as you get older. Shingles vaccine has been used since 2006. Zostavax® is the only shingles vaccine currently approved for use in the United States. This vaccine reduces the risk of developing shingles by 51% and PHN by 67%. It is given in one dose as a shot, and can be given in a doctor’s office or pharmacy.

Who Should Get Shingles Vaccine? People 60 years of age or older should get shingles vaccine. They should get the vaccine whether or not they recall having had chickenpox, which is caused by the same virus as shingles. Studies show that more than 99% of Americans aged 40 and older have had chickenpox, even if they don't remember getting the disease. There is no maximum age for getting shingles vaccine. Even if you have had shingles, you can still receive shingles vaccine to help prevent future occurrences of the disease. There is no specific length of time you must wait after having shingles before receiving shingles vaccine, but generally you should make sure the shingles rash has disappeared before getting vaccinated. The decision on when to get vaccinated should be made with your healthcare provider. Shingles vaccine is approved by the Food and Drug Administration for people aged 50 years and older. However, CDC does not have a recommendation for routine use of shingles vaccine in people 50 through 59 years old. Protection from shingles vaccine lasts about 5 years, so adults vaccinated before they are 60 years old might not be protected later in life when the risk for shingles and its complications are greatest. Adults 50 through 59 years who have questions about shingles vaccine should discuss the risks and benefits with a healthcare provider. Talk with your healthcare provider if you have questions about shingles vaccine. Shingles vaccine is available in doctor’s offices and pharmacies. To find doctor’s offices or pharmacies near you that offer the vaccine, visit Zostavax or HealthMap Vaccine Finder.

Who Should Not Get Shingles Vaccine? A person who has ever had a life-threatening or severe allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine. Tell your doctor if you have any severe allergies. A person who has a weakened immune system because of: HIV/AIDS or another disease that affects the immune system, treatment with drugs that affect the immune system, such as steroids, cancer treatment such as radiation or chemotherapy, or cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma. Women who are or might be pregnant. Women should not become pregnant until at least 4 weeks after getting shingles vaccine. Someone with a minor acute illness, such as a cold, may be vaccinated. But anyone with a moderate or severe acute illness should usually wait until they recover before getting the vaccine. This includes anyone with a temperature of 101.3°F or higher. This information was taken directly from the Shingles Vaccine Information Statement (VIS) dated 10/06/2009.

What Are the Types of Shingles Vaccine? Zostavax® is only shingles vaccine currently approved for use in the United States. It is given in one dose as a shot, and can be given in a doctor’s office or pharmacy.

How Well Does Shingles Vaccine Work? Zostavax®, the shingles vaccine, reduced the risk of shingles by 51% and the risk of post-herpetic neuralgia by 67% based on a large study of more than 38,000 adults aged 60 years or older. Protection from shingles vaccine lasts about 5 years. While the vaccine was most effective in people 60 through 69 years old, it also provides some protection for people 70 years old and older. Adults vaccinated before age 60 years might not be protected later in life when the risk for shingles and its complications are greatest.

What Are the Possible Side Effects of Shingles Vaccine? A vaccine, like any medicine, could possibly cause serious problems, such as severe allergic reactions. However, the risk of a vaccine causing serious harm, or death, is extremely small. No serious problems have been identified with shingles vaccine. Mild side effects of shingles vaccine: Redness, soreness, swelling, or itching at the site of the injection (about 1 person in 3). Headache (about 1 person in 70).

What Are the Possible Side Effects of Shingles Vaccine? (continued) It is safe to be around infants and young children, pregnant women, or people with weakened immune systems after you get the shingles vaccine. There is no documentation of a person getting chickenpox from someone who has received the shingles vaccine (which contains varicella zoster virus). Some people who get the shingles vaccine will develop a chickenpox-like rash near the place where they were vaccinated. As a precaution, this rash should be covered until it disappears. Like all vaccines, shingles vaccine is being closely monitored for unusual or severe problems by CDC and FDA. Signs of a severe allergic reaction can include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness, and weakness. These would start a few minutes to a few hours after the vaccination. If you have a severe allergic reaction or other emergency that can’t wait, call 9-1-1 or get the person to the nearest hospital. Otherwise, call your doctor. Afterward, the reaction should be reported to the Vaccine Adverse Event Reporting System (VAERS). Your doctor might file this report, or you can do it yourself through the VAERS website, or by calling 1- 800-822-7967. The shingles vaccine does not contain thimerosal (a preservative containing mercury).

How Can I Pay For Shingles Vaccine? Medicare Medicare Part D plans cover the shingles vaccine, but  there may be a cost to you depending on your plan. There may be a copay for the  vaccine, or you may need to pay in full then get reimbursed for a certain  amount. Medicare Part B does not cover the shingles vaccine. Medicaid Medicaid may or may not cover the vaccine. Contact your insurer to find out. Private health insurance Most private health insurance plans cover the vaccine for people 60 years of age or older. Some plans cover the vaccine for people 50 through 59 years of age. Vaccine assistance programs Some pharmaceutical companies provide vaccines to eligible adults who cannot afford them.