Shingrix shortage: Advice for physicians

With demand for the newer shingles vaccine, known as Shingrix, far outstripping the pace at which the manufacturer can supply it, shortages will likely continue throughout 2019, predicts the CDC. 

“GlaxoSmithKline [GSK] are running their vaccine plants as much as they can, to produce more but it’s just not enough,” says Julio Viola, PharmD, the director of centralized pharmacy services at Northwell Health Systems, which operate in the New York metro area. 

One reason for the shortage, Viola explains, is that while CDC guidelines recommended that the older shingles vaccine, Zoster vaccine live (ZVL, Zostavax), be administered to people aged 60 and above, the CDC guidelines for Shingrix (whose full name is recombinant zoster vaccine, or RZV, Shingrix) recommend it for people aged 50 and above. GSK was not prepared for the increase in the pool of eligible patients that actually wanted to receive the vaccine, he says.

Another reason for the shortage is the exceptional efficacy of the new vaccine, which has been in use since 2017. “It’s efficacy in preventing shingles is 96-97% in the group between 50 and 69, and it’s 91% effective in people 70 and older,” explains Dennis Gingrich, MD, a professor of family and community medicine at Penn State College of Medicine in Hershey, Pennsylvania. Gingrich notes that the older vaccine, in use since 2006, only reduced the occurrence of herpes zoster by about 50%.

Safety concerns play a role too, says Gingrich. Zostavax was a live vaccine and thus had the potential for somewhat more adverse effects than the newer recombinant vaccine, explains Gingrich.  “Adverse reactions in trials for the new vaccine have been less than 0.01%,” he says.
The new vaccine should be given in two doses, with the second dose administered sometime in the period two to six months after the first, according to the CDC.

How to handle the shortage

There are a few steps physicians can take to make sure their practices

Establish a standing order with the manufacturer for monthly deliveries: Doing so can guarantee your practice will have a regular Shingrix supply, even if it’s not enough for every patient who wants it, says Viola.

Set aside a second dose for each patient who receives a first dose of the vaccine:  “That way, you complete the process for each person and no one is hanging out there [without the full course of treatment],” says Viola.  Gingrich agrees; his office does reserve a second dose for each patient who receives a first one.

Triage who gets Shingrix first: “Prioritize older patients who are immunocompromised over healthy individuals,” says Viola, explaining that they are at greatest risk for the disease.  Gingrich concurs. “We identify and address the needs of the most at-risk patients as well as trying to respond to patient requests,” Gingrich says.

The old vaccine is still an option: A physician can offer the old vaccine to patients, and assure them that the newer vaccine becomes available they can be re-immunized with it, says Viola. That approach has been approved by the CDC, he notes.
Gingrich’s practice has opted not to offer its patients the older vaccine, but instead to wait and administer the newer vaccine as it becomes available.

“The Advisory Committee on Immunization Practices recommends that the new recombinant vaccine still be given to patients who have previously received Zostavax.” says Gingrich.

Establish a call list: Invite patients to put their names down for notification from you when you have Shingrix available, suggests Viola. When they get the first dose, book their appointment for the second, and remind them to come in for that final injection, he says.
Advise patients to check certain websites and to be persistent: GSK offers patients a Shingrix locator, although the information at the site is often out of date as supplies go quickly. Patients can also call your office and local pharmacies for up-to-the-minute notifications of vaccine availability.

Putting this vaccine in context
Gingrich encourages all healthcare providers to educate patients about the enormous value offered by vaccines.

“Vaccines are among the most safe, cost effective ways to keep people healthy. We, as healthcare practitioners, need to remind the public of that fact on every occasion that we can.”

He also notes that physicians must often try to persuade patients to do what’s best for them.  This is not true with Shingrix, he says: “They are asking for it before I can get the suggestion out of my mouth.”