Studying Physician Knowledge, Attitudes, and Practices Regarding the Herpes Zoster Vaccine to Address Perceived Barriers to Vaccination

Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists

Recombinant zoster vaccine has been recommended by the US Advisory Committee on Immunization Practices (ACIP) for the prevention of herpes zoster (HZ) in immunocompetent adults aged at least 50 years since 2018. In January 2022, this was extended to immunodeficient/immunosuppressed adults aged at least 19 years. Key study objectives were to assess specialists' knowledge of the ACIP HZ vaccination recommendations, their attitudes toward HZ vaccination, and HZ vaccination practices/barriers. This cross-sectional, web-based survey (conducted in March 2022) included US dermatologists, gastroenterologists, infectious disease specialists, oncologists, and rheumatologists who treat patients with psoriasis, inflammatory bowel disease, human immunodeficiency syndrome, solid tumors/hematological malignancies, and rheumatoid arthritis, respectively. Although most of the 613 specialists correctly identified the ACIP HZ vaccination recommendations for adults aged at least 50 years (84%) and immunodeficient/immunosuppressed adults aged at least 19 years (67%), only 29% knew that recombinant zoster vaccine is recommended for individuals who have previously received zoster vaccine live, and only 18% knew all current ACIP recommendations. For patients with the diseases listed, 84% of specialists thought that HZ is a serious risk, 75% that HZ vaccination is extremely/very important, and 69% were extremely/very likely to recommend HZ vaccination. Only 36% administer vaccines themselves, mainly because patients receive vaccinations from others. Barriers to vaccination included more urgent/acute issues, insufficient time, and lack of patient motivation/willingness. Full knowledge of the ACIP HZ vaccination recommendations among the surveyed specialists was low. There may be a need to educate specialists to improve adherence to these recommendations. [Figure: see text].

The Knowledge, Attitude and Practice Among Makkah Physicians Towards Herpes Zoster Vaccination, Saudi Arabia, 2023

Background Herpes zoster (HZ) is a viral disease, which is more common among the elderly and immunodeficient individuals, among which approximately 22% of cases might progress to post-herpetic neuralgia (PHN). Hence, this study aimed to assess the knowledge, attitude and practice (KAP) towards HZ and its vaccination among primary health care physicians in Makkah, Saudi Arabia, 2023. Methodology This analytical cross-sectional study used an online pre-validated questionnaire and was conducted from July to August 2023. The target population included physicians working in primary healthcare (PHC) daily clinics in Makkah. Results A total of 153 participants were included in the current study. Of which 90 (58.8%) were females and 120 (78.4%) participants had chicken pox history. Around 123 (80.4%) had previously heard about shingles. The most reported source of information was physicians (63%) followed by the Internet (12.2%). Risk factors for shingles were found to be immunodeficiency (95.1%) and age (78%). Most (88.2%) participants had previously heard about the shingles vaccine and 99 (64.7%) reported that the shingles vaccine is needed even if the patient had chicken pox in the past. Most participants (82.4%) knew that the vaccine should be given to adults aged more than 50 years. About 69 (45.1%) thought that they were extremely likely to get the shingles vaccine if the doctor recommended it. Barriers to shingles vaccination among study participants included participant's perception that they were not at risk of getting shingles (33%) and concerns about vaccines' side effects (27.5%). The average knowledge score about shingles was found to be 9.51 ± 3.14 and the average knowledge score about shingles vaccine was found to be 5.43 ± 1.46. Gender was significantly associated with knowledge score about the vaccine (p-value= 0.028) where females had higher knowledge scores about shingles vaccine as compared to males. Qualification level and current Saudi Commission for Health Specialties (SCFHS) classification were found to be significantly associated with knowledge scores about shingles (p-value = 0.002 and 0.003, respectively). Conclusion A good level of KAP about shingles and its vaccine was found among the study participants. However, few knowledge gaps in methods of protection were assessed. Female gender, married participants and higher SCFHS qualification level were positively associated with higher levels of knowledge and awareness as compared to other groups.

Effectiveness of the Recombinant Zoster Vaccine for Herpes Zoster Ophthalmicus in the United States

PURPOSE

To examine the effectiveness of the recombinant zoster vaccine (RZV) for preventing herpes zoster ophthalmicus (HZO) in the general United States population.

DESIGN

Retrospective, observational cohort study.

PARTICIPANTS

Individuals enrolled in the OptumLabs Data Warehouse (OLDW; OptumLabs, Cambridge, MA) who were age eligible for herpes zoster (HZ) vaccination (≥50 years of age) from 2018 through 2019. The OLDW is a longitudinal, de-identified administrative claims and electronic health record database of patients in the United States with commercial insurance, Medicare Part D, or Medicare Advantage METHODS: Patients were required to have 365 days or more of continuous enrollment to be eligible. Those with a diagnosis code of HZ or an immunocompromising condition within 1 year before study inclusion were excluded. Vaccination with the RZV was ascertained by Current Procedural Terminology codes, and HZO was ascertained by International Classification of Diseases, Tenth Revision, codes. Cox proportional hazards regression models were used to estimate the hazard ratio of HZO associated with RZV, and inverse-probability weighting was used to control for confounding. Vaccine effectiveness was calculated from hazard ratios.

MAIN OUTCOME MEASURES

Incidence of HZO in vaccinated versus unvaccinated person-times and vaccine effectiveness were assessed.

RESULTS

From January 1, 2018, through December 31, 2019, a total of 4 842 579 individuals were included in this study. One hundred seventy-seven thousand two hundred eighty-nine (3.7%) received 2 valid doses of RZV. The incidence rate of HZO was 25.5 cases (95% confidence interval [CI], 17.4-35.8 cases) per 100 000 person-years in the vaccinated group compared with 76.7 cases (95% CI, 74.7-78.7 cases) in the unvaccinated group. The overall adjusted effectiveness of RZV against HZO was 89.1% (95% CI, 82.9%-93.0%).

CONCLUSIONS

The effectiveness of RZV against HZO in individuals 50 years of age and older is high in a clinical setting. However, the low vaccination rate in this study highlights the public health need to increase HZV use. Ophthalmologists can play an important role in recommending vaccination to eligible patients.

Implementation of the Standards for adult immunization practice: A survey of U.S. Health care providers

The revised Standards for Adult Immunization Practice ("Standards"), published in 2014, recommend routine vaccination assessment, strong provider recommendation, vaccine administration or referral, and documentation of vaccines administered into immunization information systems (IIS). We assessed clinician and pharmacist implementation of the Standards in the United States from 2016 to 2018. Participating clinicians (family and internal medicine physicians, obstetricians-gynecologists, specialty physicians, physician assistants, and nurse practitioners) and pharmacists responded using an internet panel survey. Weighted proportion of clinicians and pharmacists reporting full implementation of each component of the Standards were calculated. Adjusted prevalence ratio (APR) estimates of practice characteristics associated with self-reported implementation of the Standards are also presented. Across all medical specialties, the percentages of clinicians and pharmacists implementing the vaccine assessment and recommendation components of the Standards were >80.0%. However, due to low IIS documentation, full implementation of the Standards was low overall, ranging from 30.4% for specialty medicine to 45.8% in family medicine clinicians. The presence of an immunization champion (APR, 1.40 [95% confidence interval {CI}, 1.26 to 1.54]), use of standing orders (APR, 1.41 [95% CI, 1.27 to 1.57]), and use of a patient reminder-recall system (APR, 1.39 [95% CI, 1.26 to 1.54]) were positively associated with adherence to the Standards by clinicians. Similar results were observed for pharmacists. Nonetheless, vaccination improvement strategies, i.e., having standing orders in place, empowering an immunization champion, and using patient recall-reminder systems were underutilized in clinical settings; full implementation of the Standards was inconsistent across all health care provider practices.

Knowledge about vaccines and vaccination in older people: Results of a national survey by the Italian Society for Gerontology & Geriatrics

BACKGROUND

There is wide variation among physicians in the level of knowledge regarding vaccines and vaccination. We sought to compare the level of vaccine knowledge between qualified specialists and postgraduate residents.

METHODS

A questionnaire designed ad hoc by a consensus group was circulated to the Directors of 51 geriatrics internship programs in Italy. It investigated demographics, information sources, knowledge about influenza, pneumonococcal and herpes zoster vaccines and target groups. The proportion of correct responders was compared between residents and qualified specialists, and between best (top quartile) and worst (bottom quartile) performers.

RESULTS

A total of 459 questionnaires were analyzed; 245 (53%) were females; 253 (55%) were qualified specialists, 206 (45%) were residents. Mean age was 40.3 (SD: 12.8) years, almost 60% worked in acute care wards. On average, 33% of patients asked for information about vaccination. Residents answered significantly better on 7 out of 18 questions, and numerically albeit non-statistically higher correct response rates on a further 8 questions. There were significantly more men among the poor performers (p < 0.001), and significantly more residents among the best performers (p < 0.001). Overall, the rates of correct answers were low, with >50% of correct responses achieved on only 5 out of 18 questions (27.8%); for 2 questions, <20% responded correctly.

CONCLUSIONS

Postgraduate residents in training have an overall better level of knowledge of vaccines, vaccination indications and practices than qualified specialists. This study provides avenues to develop targeted interventions to ensure health care providers are up to date and providing accurate information to patients.

Dissemination and implementation of the ICAMP

The current rate of immunizations for older adults does not meet the immunization goals for Healthy People 2020. Using a Social Ecological Model and Social Cognitive Theory, the purpose of this study was to disseminate and implement the Immunization Champions, Advocates and Mentors Program (ICAMP) into a variety of health care settings. This study used a single group pre-/post-test design. Champions were recruited nationally. Five geographically diverse face-to-face meetings were held to train health care providers to be ICAMP immunization champions. Dissemination and implementation of ICAMP was evaluated using the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model. Participants were surveyed at baseline for descriptive information and were asked to gather immunization rates for at least one particular vaccine and provide follow-up data on progress toward goal achievement. A total of 212 champions from 82 settings participated in ICAMP. The majority were nurses (111/212, 52%). With regard to reach, we obtained 212 applications from individuals in a variety of settings interested in becoming champions. With regard to effectiveness, the majority of the champions (n = 178/212, 84%) used ICAMP material, 88% (n = 186/212) made changes related to immunization processes within their setting, and all reported that immunization practices improved. The majority used the toolkit materials up through 60 days following ICAMP. Sustained use of materials after the 60-day follow-up was less evident. ICAMP was implemented as intended and was effective in changing processes around immunizations. Ongoing work is needed to determine whether ICAMP improves immunization rates.

U.S. clinicians' and pharmacists' reported barriers to implementation of the Standards for Adult Immunization Practice

BACKGROUND

The Standards for Adult Immunization Practice (Standards), revised in 2014, emphasize that adult-care providers assess vaccination status of adult patients at every visit, recommend vaccination, administer needed vaccines or refer to a vaccinating provider, and document vaccinations administered in state/local immunization information systems (IIS). Providers report numerous systems- and provider-level barriers to vaccinating adults, such as billing, payment issues, lower prioritization of vaccines due to competing demands, and lack of information about the use and utility of IIS. Barriers to vaccination result in missed opportunities to vaccinate adults and contribute to low vaccination coverage. Clinicians' (physicians, physician assistants, nurse practitioners) and pharmacists' reported barriers to assessment, recommendation, administration, referral, and documentation, provider vaccination practices, and perceptions regarding their adult patients' attitudes toward vaccines were evaluated.

METHODS

Data from non-probability-based Internet panel surveys of U.S. clinicians (n = 1714) and pharmacists (n = 261) conducted in February-March 2017 were analyzed using SUDAAN. Weighted proportion of reported barriers to assessment, recommendation, administration, referral, and documentation in IIS were calculated.

RESULTS

High percentages (70.0%-97.4%) of clinicians and pharmacists reported they routinely assessed, recommended, administered, and/or referred adults for vaccination. Among those who administered vaccines, 31.6% clinicians' and 38.4% pharmacists' submitted records to IIS. Reported barriers included: (a) assessment barriers: vaccination of adults is not within their scope of practice, inadequate reimbursement for vaccinations; (b) administration barriers: lack of staff to manage/administer vaccines, absence of necessary vaccine storage and handling equipment and provisions; and (c) documentation barriers: unaware if state/city has IIS that includes adults or not sure how their electronic system would link to IIS.

CONCLUSION

Although many clinicians and pharmacists reported implementing most of the individual components of the Standards, with the exception of IIS use, there are discrepancies in providers' reported actual practices and their beliefs/perceptions, and barriers to vaccinating adults remain.

Clinicians' and Pharmacists' Reported Implementation of Vaccination Practices for Adults

INTRODUCTION

Despite the proven effectiveness of immunization in preventing morbidity and mortality, adult vaccines remain underutilized. The objective of this study was to describe clinicians' and pharmacists' self-reported implementation of the Standards for Adult Immunization Practice ("the Standards"; i.e., routine assessment, recommendation, and administration/referral for needed vaccines, and documentation of administered vaccines, including in immunization information systems).

METHODS

Two Internet panel surveys (one among clinicians and one among pharmacists) were conducted during February-March 2017 and asked respondents about their practice's implementation of the Standards. T-tests assessed associations between clinician medical specialty, vaccine type, and each component of the Standards (March-August 2017).

RESULTS

Implementation of the Standards varied substantially by vaccine and provider type. For example, >80.0% of providers, including obstetrician/gynecologists and subspecialists, assessed for and recommended influenza vaccine. However, 24.3% of obstetrician/gynecologists and 48.9% of subspecialists did not stock influenza vaccine for administration. Although zoster vaccine was recommended by >89.0% of primary care providers, <58.0% stocked the vaccine; by contrast, 91.6% of pharmacists stocked zoster vaccine. Vaccine needs assessments, recommendations, and stocking/referrals also varied by provider type for pneumococcal; tetanus, diphtheria, acellular pertussis; tetanus diphtheria; human papillomavirus; and hepatitis B vaccines.

CONCLUSIONS

This report highlights gaps in access to vaccines recommended for adults across the spectrum of provider specialties. Greater implementation of the Standards by all providers could improve adult vaccination rates in the U.S. by reducing missed opportunities to recommend vaccinations and either vaccinate or refer patients to vaccine providers.

Evaluating Physician Attitudes and Practices Regarding Herpes Zoster Vaccination

PURPOSE

To investigate the knowledge, attitudes, and practice patterns of primary care physicians regarding administration of the herpes zoster (HZ) vaccine at NYU Langone Health (NYULH).

METHODS

A cross-sectional online survey was distributed from January to March 2017 to all physicians in the Division of General Internal Medicine and Clinical Innovation at NYULH across 5 different practice settings.

RESULTS

The response rate was 26% (138 of 530). Of the surveyed physicians, 76% (100/132) agreed that the HZ vaccine was an important clinical priority, compared with 93% and 94% for influenza and pneumococcal vaccination, respectively (P < 0.001). Only 35% (47/132) strongly agreed that it was important, compared with 68% (90/132) and 74% (98/132) who strongly agreed that pneumococcal and influenza vaccines, respectively, were important. Respondents estimated that 43% of their immunocompetent patients aged 60 or older received the HZ vaccine, whereas only 11% of patients aged 50 to 59 received the HZ vaccine (P < 0.001). The rate of HZ vaccination was lower in public hospitals (26%) than in the NYULH faculty group practice (46%) (P = 0.007). A greater percent (67% and 72%) of their patients have received influenza and pneumococcal vaccines, respectively (P < 0.001). Almost all doctors (99%, 131/132) consider the Centers for Disease Control and Prevention recommendations important in determining vaccination practices.

CONCLUSIONS

HZ vaccination rates remain relatively low compared with rates of influenza and pneumonia vaccination. The recommendation for vaccination against zoster by the Centers for Disease Control and Prevention for individuals aged 50 years and older and stronger recommendations by primary care physicians for administration of zoster vaccines are needed to increase HZ vaccination rates.

Vaccination programs for older adults in an era of demographic change

OBJECTIVES

Populations are aging worldwide. This paper summarizes some of the challenges and opportunities due to the increasing burden of infectious diseases in an aging population.

RESULTS

Older adults typically suffer elevated morbidity from infectious disease, leading to increased demand for healthcare resources and higher healthcare costs. Preventive medicine, including vaccination can potentially play a major role in preserving the health and independence of older adults. However, this potential of widespread vaccination is rarely realized. Here, we give a brief overview of the problem, discuss concrete obstacles and the potential for expanded vaccination programs to promote healthy aging.

CONCLUSION

The increasing healthcare burden of infectious diseases expected in aging populations could, to a large extent, be reduced by achieving higher vaccination coverage among older adults. Vaccination can thus contribute to healthy aging, alongside healthy diet and physical exercise. The available evidence indicates that dedicated programs can achieve substantial improvements in vaccination coverage among older adults, but more research is required to assess the generalizability of the results achieved by specific interventions (see Additional file 1).

Interventions to increase pediatric vaccine uptake: An overview of recent findings

Although much is known about factors contributing to variation in pediatric immunization uptake, there is a need for synthesis of effective vaccine promotion strategies. With growing public health concern on how to best sustain high pediatric immunization rates, and improve where the rates are suboptimal, this review offers evidence gathered from several studies on the achievement of these goals. We identified and analyzed reported findings on childhood (primarily ≤ 7 years) immunization outcomes from tested intervention strategies that focused on parents, guardians, and caregivers, as well as providers, clinics/practices, and communities. The findings suggest that targeted and tailored interventions offer substantial possibilities, especially in a combined manner. We describe promising intervention models that have been operationalized with success and provide evidence for scalability across contexts. Moreover, they are sensitive to parents' and providers' needs, are feasibly integrated in daily clinical practice, and account for broader community concerns and issues.

Improving adherence to national recommendations for zoster vaccination through simple interventions

OBJECTIVE

In 2011, 15.8% of eligible patients in the United States were vaccinated against herpes zoster (HZ). To increase the usage of the HZ vaccine by studying physicians' knowledge, attitudes, practices, and perceived obstacles after interventions to overcome barriers.

METHODS

General internal medicine physicians were surveyed with a cross-sectional internet survey from October to December 2011 before interventions to increase the use of the HZ vaccine and 1 year later. Interventions included education, increasing availability at the medical center pharmacy, and electronic medical record reminders. Outcome measures included changes in knowledge, attitudes, and practices, and perceived barriers. McNemar chi-square tests were used to compare the changes from the baseline survey for physicians who completed the follow-up survey.

RESULTS

Response rate for the baseline study was 33.5% (89/266) and for the follow-up was 29.8% (75/252). Fifty-five completed both surveys. There was a decrease from 57% at baseline to 40% at follow-up in the proportion of physicians who reported that less than 10% of their patients were vaccinated. They were more likely to know the HZ annual incidence (30% baseline; 70% follow-up; P=0.02), and report having educational information for physicians (7% baseline; 27% follow-up; P=0.003). The top helpful intervention was nursing administration of the vaccine. Average monthly HZ vaccine usage in the affiliated outpatient pharmacy increased in 10 months between surveys by 156% compared with the 3 months before the baseline survey.

CONCLUSIONS

Interventions implemented during the study led to an increase in physicians' basic knowledge of the HZ vaccine and an increase in usage at the affiliated pharmacy.

Physician Attitudes toward the Herpes Zoster Vaccination in South Korea

This survey investigated Korean physician attitudes toward the herpes zoster (HZ) vaccine. A total of 400 physicians answered a self-reported questionnaire. Most physicians knew that HZ poses a significant socioeconomic burden and had good knowledge about HZ and its vaccine. Physicians who did not recommend HZ vaccine were concerned about costs (90.7%, 78/86) and doubted the effectiveness of the vaccine (58.1%, 50/86). Patient demand had a profound effect on physicians decisions; 84.9% (73/86) of them who said not recommending HZ vaccine reported that they would provide the vaccine upon patient request. In conclusion, educational initiatives should be targeted toward both physicians and patients.