Long-Term Care Survey Alert

Published on Fri Jul 25, 2008 PDF

Contraindications exist, as does a challenge to administering the vaccine.

Not only is shingles a painful, sometimes debilitating condition, but facilities that aren't preparing to offer elderly residents the shingles vaccination may end up with potentially avoidable negative outcomes down the line. The question is, should your facility be offering it, and if it does, what are the safety precautions and practical realities of doing so?

The Centers for Disease Control & Prevention recently recommended that people 60 years of age and older, including those in nursing homes, receive the single-dose vaccination, Zostavax.

The vaccine helps prevent shingles, a painful skin rash caused by Varicella Zoster, the same virus that causes chickenpox. Shingles only occurs in people who've had Varicella Zoster, which lies dormant in the nerve roots. Shingles outbreaks tend to occur more commonly in people with suppressed immunity due to cancer, corticosteroid therapy or HIV. But shingles attacks also occur more often as people get older and their immune systems naturally become less effective.

The vaccine prevented shingles in about half of people 60 years of age and older and also reduced the pain associated with shingles, according to a CDC fact sheet.

"The vaccine is administered to a population that is immune to the [chickenpox] virus," says the CDC's Rafael Harpaz, MD, considering that almost all persons 60 years of age and older had chickenpox. "The shingles vaccine boosts the immunity acquired after [having] chickenpox," he tells Eli. Medicare Part D will pay for the virus, adds Harpaz.

According to the CDC fact sheet, a person should not get shingles vaccine who has:

• Ever experienced a life-threatening allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine.

• A weakened immune system because of the following:

• 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;

• a history of cancer affecting the bone marrow or lymphatic system, such as leukemia or lymphoma.

• Active, untreated tubercu- losis.

You can vaccinate someone with a minor illness, such as a cold, says the CDC. But wait to vaccinate a resident with moderate or severe illness, including a fever of 101.3 F. or higher, until he recovers.

Be Prepared to Address This Concern

Staff may ask whether residents who are vaccinated could potentially spread varicella to unvaccinated staff or unvaccinated, immunocompromised nursing home residents. But the risk, based on the CDC's experience, is "very low," says Harpaz.

In 10 years of the varicella vaccination program (the shingles vaccine contains the same virus as the varicella vaccination only with a higher titer), there were only five documented instances of vaccine virus transmission, he says. "Therefore, the risk, if any, is extremely low or negligible," particularly if the vaccine recipient doesn't develop a rash.

In addition, no varicella-like rashes were documented during any clinical zoster (shingles) vaccine trials, according to the CDC's Advisory Committee on Immunization Practices (ACIP). And no evidence indicated that vaccine recipients transmit vaccine virus to their contacts, the ACIP stated in its recommendations for the vaccine.

Nursing home staff should, however, have evidence of chickenpox immunity (a history of the disease or vaccination), which should provide protection if a resident develops a vaccine rash, Harpaz says.

Staff should know their immunity status for chickenpox for another reason, adds infection control expert James Marx, RN, MS, CIC: Those who lack immunity can catch primary chickenpox from a resident who develops shingles.

Given that the shingles vaccination has to be stored frozen -- and discarded within 30 minutes of thawing -- nursing homes have a challenge on their hands in giving it to residents, says Marx, principal, BroadStreet Solutions in San Diego. To store the frozen vaccine would require monitoring the freezer for adequate temperature control, which most facilities aren't prepared to do, he says.

An alternative: The facility could take residents to a pharmacy or health department to receive the shingles vaccination, he suggests. Or a resident could receive it when he goes to his physician's office for care, Marx adds.