Background/Purpose:

Vaccination against herpes zoster (shingles) can reduce the frequency of infection, the severity of shingles should it occur, and the frequency of post-herpetic neuralgia. As active biologic therapy is currently considered a contraindication to vaccination against shingles with a live virus zoster vaccine (LVZV), provider awareness of this situation may promote vaccination rates in eligible patients for whom biologic therapy is contemplated. Factors such as determining vaccine cost may limit point-of-care (POC) vaccination in eligible patients.

Methods:

In patients with a coded diagnosis of rheumatoid arthritis (RA) chart documentation assessed how frequently LVZV was addressed prior to initiation of biologic therapy. Following an educational intervention, a reminder and documentation system was implemented using a sheet given to all patients at the time of clinic intake, including a decision tree for providers to determine the need for vaccination based on age, prior vaccine status, diagnosis, and potential contraindications. A senior rheumatology fellow reviewed all charts. Pre-intervention consecutive charts from patients attending the rheumatology outpatient clinics in 2016 from 5/1 thru 5/31 were retrospectively reviewed. Inclusion criteria were patients coded with RA, age >50 years, and on biologic therapy. Exclusion criteria included patients already on biologics prior to established care in our clinic, or contraindication to LVZV per CDC guidelines. The post-intervention study prospectively reviewed charts on the same eligible consecutive patients seen in 2017 from 5/10 thru 5/26.

Results:

Of 168 consecutive charts retrospectively reviewed pre-intervention, only 76 met eligibility criteria. In 0 charts was there provider documentation about the need for vaccination. Although nursing and/or medication documentation noted LVZV was appropriately given in 19%, there was no provider documentation as to why or if it actually was given. The percentage of vaccinated patients being seen solely by attendings were slightly higher compared to those seen by fellows.

All patients representing the 116 consecutive charts, which were reviewed post-intervention, were screened with the reminder sheet: only 16 met eligibility criteria for LVZV. Only 2 of the eligible patients received LVZV or a prescription for it accompanied by documentation by the provider in the record that the vaccine was given. 8 of the eligible patients were given a prescription for LVZV vaccination (4 seen by attendings, 4 by fellows), but there has been no documentation of the provider subsequently receiving confirmation that patients so prescribed actually received the vaccine. 6 of the eligible patients already had received LVZV previously as recorded in the clinic reminder sheet, but in only 4 patients was subsequent chart documentation found.

Conclusion:

In eligible RA patients the documentation of completed LVZV remains low. The majority of eligible patients required a prescription for vaccination after POC, but there has been no confirmation that any received it. Efforts at increasing vaccination rates should be directed at providing a system to report back successful receipt of vaccination post-visit.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improved-provider-awareness-and-delivery-of-zoster-vaccination-in-patients-with-rheumatoid-arthritis-contemplating-biologic-therapy-need-to-target-eligible-patients-prescribed-for-vaccination-post-cl/