Primary care physicians’ experience with zoster vaccine live (ZVL) and awareness and attitudes regarding the new recombinant zoster vaccine (RZV)

Abstract

Background: The Advisory Committee on Immunization Practices (ACIP) has routinely recommended zoster vaccine live (ZVL) for adults ≥60 since 2008; only 33% of eligible adults received it by 2016. A recombinant zoster vaccine (RZV) was licensed in 2017 and ACIP recommended in January 2018. Our objectives were to assess among primary care physicians 1) practices and attitudes regarding ZVL and 2) awareness of RZV. Methods: We administered an Internet and mail survey from July to September 2016 to national networks of 953 primary care physicians. Results: Response rate was 65% (603/923). Ninety-three % of physicians recommended ZVL to adults ≥60, but fewer recommended it to adults ≥60 with a prior history of zoster (88%), adults >85 (62%) and adults ≥60 on low-dose methotrexate (42%). Several physicians recommended ZVL in ways that are not recommended by ACIP including to adults 50–59 (50%), adults ≥60 with HIV (33%), and adults ≥60 on high dose prednisone (≥20mg/day) (27%). Nineteen percent of physicians stocked and administered ZVL and did not refer patients elsewhere for vaccination, 37% did not stock and only referred patients to receive it, and 44% both stocked/administered and referred elsewhere. Twenty-three % (n=115) of physicians who had ever administered ZVL in the office (n=490) had stopped, citing primarily financial issues (90%). Only 5% were ‘very aware’ of RZV. Conclusions: Physicians report not recommending ZVL to certain ACIP-recommended groups, but report recommending it to some groups for which the vaccine should be avoided. Implementation of recommendations for RZV will need to consider financial barriers and the complex patchwork of office-based and pharmacy delivery ZVL has encountered.

Surveillance of Vaccination Coverage Among Adult Populations —United States, 2018

“…Although the Healthy People 2020 target was achieved, approximately 65% of adults recommended to receive this vaccine remain unprotected. Barriers that might have constrained overall herpes zoster vaccination uptake include shortages of herpes zoster vaccines (e.g., there was a ZVL shortage in 2011 and a RZV shortage in 2018) as well as financial and logistic challenges ( 44 , 45 ). The high cost for providers to purchase a supply and high out-of-pocket costs for patients are well-documented barriers ( 46 , 47 ).…”

Advancing regulatory science and assessment of FDA REMS programs: A mixed-methods evaluation examining physician survey response

“…Eight weeks has also been the standard used in physician surveying to rapidly investigate emerging vaccine policy-relevant policy making by the Centers for Disease Control and Prevention. 19,[47][48][49][50] The simulation findings also show the value of graphing response curves over time to visually monitor study progress and assess potential for respondent bias. This is akin to tracking patient accrual rates into a clinical trial over time to assess screening yield and generalizability of the study population.…”

Shared Clinical Decision-Making Recommendations for Adult Immunization: What Do Physicians Think?

“…Decision aids are a central component of SDM but do not presently exist for the relevant adult vaccinations. Multiple previous surveys have demonstrated substantial physician knowledge gaps about specific adult vaccines [9][10][11][12] ; decision aids could bridge this gap and reduce the time needed for discussion. In our study, substantial numbers of physicians reported needing additional guidance on what SDM means and how to explain it to patients as well as not knowing how to implement SDM, corresponding to previous literature demonstrating lack of self-efficacy or familiarity with SDM as major barriers to implementation of such recommendations.…”

“…Our data highlight the challenges SDM recommendations for adult vaccination pose for primary care physicians given the increasing expectations for SDM for multiple clinical decisions, the complexity of the patients they are seeing, and the limited time they have for primary care visits. Given the fact that physicians' knowledge about changing vaccine recommendations, insurance coverage for vaccines with different types of recommendations, and the risks and benefits for patient subgroups is likely to be limited based on previous data from national surveys, [9][10][11][12] the development of decision support tools for specific vaccine decisions will be important in guiding SDM vaccine discussions. Our data also emphasize the need for decision software to be aligned with SDM recommendations; if not aligned, such systems may default to either routine recommendations or indicate a vaccine is not recommended.…”

“…8 The use of the category "shared clinical decision-making" (abbreviated as SDM) by ACIP in their recommendations for adult vaccines is new, while at the same time SDM is a term that has been used in the context of many other types of decisions in adult care in recent years. Previous literature has identified substantial physician knowledge gaps about the benefits and risks of specific adult vaccines [9][10][11][12] as well as lack of familiarity with SDM 13 in general which may pose barriers to implementation of SDM for adult vaccination. Therefore, we sought to assess among nationally representative samples of general internal medicine providers (GIMs) and family physicians (FPs) (1) attitudes about and experience with ACIP SDM recommendations for vaccination; (2) knowledge of insurance reimbursement for vaccines with SDM recommendations; (3) how SDM recommendations are being incorporated into vaccine forecasting software (automated process for determining the recommended vaccinations needed for an individual) in electronic health records (EHRs); and (4) provider and practice characteristics associated with reporting not knowing how to implement SDM as intended by ACIP.…”