Correspondence

Introduction of Shingrix® vaccine for the whole programme and expansion of eligible cohorts letter

Published 4 July 2023

Applies to England

To:

• NHS England regions:
  • directors of commissioning
  • directors of public health and primary care
  • heads of public health commissioning
  • heads of primary care
  • public health commissioning teams
• Integrated care boards:
  • clinical leaders
  • accountable officers
• GPs
• Local medical committees
• Local authorities:
  • chief executives
  • directors of public health

cc.

• Chief pharmacists of NHS trusts
• NHS trusts and foundation trusts
• Clinical immunologists
• Rheumatologists
• Oncologists

Dear Colleagues,

This letter provides information about forthcoming changes to the NHS shingles vaccination programme.

From 1 September 2023, all newly eligible individuals will be offered 2 doses of the non-live shingles vaccine Shingrix® instead of Zostavax®. In addition to this, the eligibility for the immunocompromised and immunocompetent cohorts will change to allow individuals to be protected at an earlier age. This is based on recommendations from the Joint Committee on Vaccination and Immunisation (JCVI).

Although shingles can occur at any age, the risk and severity of shingles and its complications increases with age and is high in individuals who are immunosuppressed. It is important to ensure that those at greatest risk are vaccinated at an earlier age and this forms the basis of the JCVI recommendations.

This letter is aimed at health professionals who are responsible for commissioning and operationally delivering the national NHS shingles vaccination programme. We encourage you to share this guidance with all those involved in delivering the programme in your area.

Key points about the changes to the programme

Change of vaccine

• Shingrix® will replace Zostavax® for the whole shingles programme
• Shingrix® will require a 2-dose schedule for all cohorts. The dosing interval will differ for immunocompromised and immunocompetent patients
• Shingrix® should be offered to all people reaching eligible age on or after 1 September 2023. Those cohorts previously eligible for Zostavax® who are under 80 years of age, should continue to be offered Zostavax® until central stocks deplete (via ImmForm), after which they should be offered Shingrix®
• individuals who have received Zostavax® previously should not be revaccinated with Shingrix®
• Shingrix® can be administered alongside other vaccines. Please refer to the Shingles Green Book chapter for more information
• in 2018, it was agreed that patients could be immunised with shingles vaccine at any point in the year as soon as they reach eligible age. Shingles vaccination should continue to be offered year-round

Changes to eligibility

Immunocompromised cohort

Since September 2021, Shingrix® has been available to immunocompromised individuals aged 70 to 79 years, who are contraindicated to receive Zostavax®, as part of the NHS shingles vaccination programme.

The forthcoming change from 1 September 2023 will expand the eligibility to all immunocompromised individuals aged 50 years and over (with no upper age limit).

Immunocompromised individuals who have already received 2 doses of Shingrix® do not need re-vaccination.

Immunocompromised individuals represent the highest priority for vaccination given their risk of severe disease, and therefore the programme aims to catch up all immunocompromised individuals aged 50 years and over in the first year of the programme implementation.

The second dose should be given 8 weeks to 6 months after the first dose for this cohort, in line with the Summary of Product Characteristics (SmPC).

Immunocompetent cohort

The eligible age for immunocompetent individuals will change from 70 to 60 years of age for the routine cohort, in a phased implementation over a 10 year period.

The routine offer will move from 70 to 60 years of age in 2 stages over a 10 year period as follows:

During stage 1 (1 September 2023 to 31 August 2028)

Shingrix® will be offered to those turning 70 and 65 years on or after 1 September 2023.

Zostavax® will be offered to persons aged between 70 to 79 that were eligible for the vaccination programme before 1 September 2023. Once all stocks of Zostavax® are exhausted, these individuals can be offered Shingrix® if they have not previously been given a shingles vaccine.

During stage 2 (1 September 2028 to 31 August 2033)

Shingrix® will be offered to those turning 65 and 60 years of age.

From 1 September 2033 and thereafter, Shingrix® will be offered routinely at age 60 years.

Those who have been previously eligible ( in stages 1 and 2) will remain eligible until their 80th birthday.

Summary table of implementation stages for immunocompetent patients

Implementation stages	Delivery period	Eligible for first dose
Stage 1 (5 year duration)	1 September 2023 to 31 August 2028	Those who reach age 65 or 70 years during this period should be called in on or after their 65th or 70th birthday [footnote 1]
Stage 2 (5 year duration)	1 September 2028 to 31 August 2033	Those who reach age 60 or 65 years during this period should be called in on or after their 60th or 65th birthday [footnote 1]
Ongoing routine offer	1 September 2033 onwards	Those turning 60 years of age should be called in on or after their 60th birthday [footnote 1]

Immunocompetent individuals remain eligible until their 80th birthday (as is currently the case). However, where an individual has turned 80 years of age following their first dose of Shingrix®, a second dose should be provided before the individual’s 81st birthday to complete the course.

For immunocompetent individuals the second dose can be given 6 to 12 months after the first dose.

Information provided in the annexes of this letter:

Annexe A: detailed information and guidance for healthcare professionals

Annexe B: vaccine coverage data collection

Annexe C: supporting programme resources

For any operational queries, please contact your NHS England Regional Public Health Commissioning Team. For clinical queries or queries about supporting programme resources, please email immunisation@ukhsa.gov.uk.

The annual shingles vaccine coverage data for the 8th year of the programme in England (financial year 2021 to 2022) shows that cumulative vaccine coverage for each birth cohort continues to increase each year. This latest data suggests recovery of the programme in 2021 to 2022 after the programme was impacted by the COVID-19 pandemic in the year prior.

Results assessing the impact of shingles vaccination in the 5 years after the introduction of the programme in England showed large reductions in both GP consultations and hospitalisations for herpes zoster and post-herpetic neuralgia. Therefore, it is important to continue to offer the shingles vaccine to all eligible patients, particularly in regions with lower coverage and those impacted by the COVID-19 pandemic.

We would like to take this opportunity to thank everyone involved in commissioning and operationally delivering the national NHS shingles vaccination programme.

Yours sincerely,

Deborah Tomalin, Director of Public Health Commissioning and Operations, NHS England

Dr Mary Ramsay CBE, Director of Public Health Programmes (including immunisation), UK Health Security Agency

Annexe A: information and guidance for healthcare professionals

The recommendations of the Joint Committee on Vaccination and Immunisation (JCVI)

In February 2019, based on impact and cost effectiveness modelling, the JCVI recommended that the national shingles immunisation programme be changed such that Shingrix® is offered to immunocompetent individuals routinely at 60 years of age, and to immunocompromised individuals aged 50 years old and over.

JCVI further advised a catch-up of 60 to 70 year olds that should be implemented in stages, starting with vaccination of those turning 65 and 70 years old for 5 years, then moving to vaccination of those turning 60 and 65 years old for 5 years, following which time vaccination could then be routinely offered to those turning 60 years old. The advice was based on the high efficacy, safety, and immunogenicity of Shingrix® observed in clinical trials. Evidence suggests that Shingrix® provides a substantially longer duration of protection from shingles than Zostavax®.

Timing and eligibility

The changes to the programme should be implemented from 1 September 2023 including the offer of Shingrix® to all newly eligible cohorts and the change to eligibility.

For the immunocompromised, the earliest eligible age will move down to 50 years and the eligible cohort will include all those aged 50 years and over (that is, for the immunocompromised cohort there is no upper age limit).

For the immunocompetent, the change to the eligible age will be implemented in a phased manner, in 2 5-year stages.

During stage 1 (1 September 2023 to 31 August 2028) Shingrix® will be offered to those turning 70 and 65 years on or after 1 September 2023. Individuals will remain eligible until their 80th birthday. Anyone aged 65 to 69 before 1 September 2023 will not be eligible for shingles vaccination until they turn 70 years of age.

Zostavax® will be offered to persons aged between 70 to 79 that were eligible for the vaccination programme before 1 September 2023. Once all stocks of Zostavax® are exhausted, these individuals can be offered Shingrix® if they have not previously been given a shingles vaccine.

During stage 2 (1 September 2028 to 31 August 2033) Shingrix® will be offered to those turning 65 and 60 years of age. From 1 September 2033 and thereafter, Shingrix® will be offered routinely at age 60 years. Those who have been previously eligible ( in stages 1 and 2) will remain eligible until their 80th birthday. This is set out in the Immunocompetent patients – timeline for the phased implementation of the change to eligible age table.

Vaccine supply

Shingrix® will be available to order online via the ImmForm website. See the ImmForm helpsheet for information on registering for an ImmForm account.

Ordering controls may be in place to enable the UK Health Security Agency ( UKHSA) to balance incoming supply with demand. Details on ordering will be available on ImmForm and in Vaccine Update in due course. Please make sure that local stocks of vaccine are rotated in fridges so that wastage is minimised. It is recommended that practices hold no more than 2 weeks’ worth of stock. Locally held stocks of Shingrix® ordered via ImmForm for the previous shingles immunocompromised programme can be used for eligible cohorts in the expanded programme.

Zostavax® will remain available through ImmForm until central stocks deplete. Zostavax® can continue to be offered to those cohorts previously eligible for Zostavax® who are under 80 years of age, after which time they should receive Shingrix®.

Funding and service arrangements

All routine NHS-funded vaccinations and immunisations are an essential service under the GP Contract. From the 1 September 2023, the Shingles vaccination programme will be expanded and move to a 2-dose Shingrix® vaccine, as set out in the letter above.

Practices will be required to undertake call/recall for patients in the immunocompetent and immunocompromised cohorts as they become eligible for the programme from September 2023, and catch-up call/recall for the newly eligible immunocompromised patients aged 50 to 69 years in the first year of the revised programme.

Practices will need to administer Shingrix® (2-dose schedule) to patients in both the immunocompromised and immunocompetent cohort who become eligible from 1 September 2023. For those in the immunocompromised cohort the second dose is to be administered 8 weeks to 6 months after the first dose, and for those in the immunocompetent cohort the second dose is to be administered between 6 to 12 months after the first dose. Practices will need to administer Zostavax® (1-dose schedule) to patients in the immunocompetent cohort who were eligible prior to 1 September 2023 until stocks deplete ( the current routine 70 to 79 year cohort eligible on or before 31 August 2023).

Practices will receive a payment of £10.06 per dose administered.

Accurate and timely recording of all vaccines given, and good management of all associated documentation, is essential as per the standards set out in the GMS Regulations and Statement of Financial Entitlement (SFE).

Shingrix® can be administered alongside other vaccines, which may increase opportunities to make an opportunistic offer. Unlike influenza vaccination, shingles vaccination is not seasonal and should be offered year-round. Please refer to the Shingles Green Book chapter for more information.

Patient Group Directions (PGDs)

An updated Shingrix® PGD template will be produced by UKHSA for NHS England areas to authorise for their commissioned services. This will be available from the PGD collection on GOV.UK.

Information and guidance for healthcare practitioners

Detailed clinical guidance on shingles and shingles vaccination is contained in chapter 28a of Immunisation Against Infectious Disease (the Green Book).

Healthcare practitioner information and guidance to support the Shingrix® programme including e-learning and a training slide set will be available on the Shingles vaccination guidance for healthcare practitioners webpage.

Leaflets, posters, record card, postcard, stickers and resources

Updated patient information materials will be available on the Shingles vaccination programme webpage to order from the Health Publications website.

See Annexe C for further details on health practitioner guidance and patient facing resources to support the change.

Consent

Guidance on informed consent can be found in chapter 2 of the Green Book.

Reporting suspected adverse reactions

Health professionals and those vaccinated are asked to report suspected adverse reactions through the online Yellow Card scheme, by downloading the Yellow Card app or by calling the Yellow Card scheme on 0800 731 6789 9am – 5pm Monday to Friday.

Annexe B: vaccine coverage data collection

Dose one and dose 2 coverage of the Shingrix® vaccination will be collected. GP practice-level shingles vaccine coverage will be based on data automatically uploaded via participating GP IT suppliers to the ImmForm website (a website used by the UKHSA and NHS to collect data on vaccine coverage and provide vaccine ordering facilities for the NHS) on a monthly basis for the first 12 months where after it will be a quarterly collection.

From September 2023 data will be collected on the following:

For the immunocompromised cohort

Denominator:

The number of individuals aged 50 years old and over (no upper age limit) registered at a GP practice who have a SNOMED code that indicates their immunocompromised status.

Numerator:

The number of individuals aged 50 years old and over (no upper age limit) registered at a GP practice who have a SNOMED code that indicates their immunocompromised status and have the following SNOMED codes:

(a) 39756611000001109, 39655511000001105, 38737511000001105 or 38736811000001106 (indicating receipt of first dose of Shingrix®)

(b) 1326111000000107 (indicating receipt of second dose of Shingrix®).

For the immunocompetent cohort

Denominator:

The number of individuals aged 65 to 79 years old registered at a GP practice.

Numerator:

The number of individuals aged 65 to 79 years old registered at a GP practice.

And have the following SNOMED codes:

(a) 39756611000001109, 39655511000001105, 38737511000001105 or 38736811000001106 (indicating receipt of first dose of Shingrix®)

(b) 1326111000000107 (indicating receipt of second dose of Shingrix®)

Plus

The number of individuals aged 80 years old registered at a GP practice who have the following SNOMED codes:

(a) 39756611000001109, 39655511000001105, 38737511000001105 or 38736811000001106 (indicating receipt of first dose of Shingrix®) when aged 79

(b) 1326111000000107 (indicating receipt of second dose of Shingrix®) when aged 80.

The existing Zostavax® vaccine coverage collection will continue for those aged 71 to 79 years of age as it is still offered to those age groups while stock deplete.

The data will be validated and analysed by UKHSA to check data completeness, identify and query any anomalous results and describe epidemiological trends.

Annual reports of shingles vaccine uptake are available on GOV.UK.

Annexe C: supporting national shingles programme resources

Health professional guidance

Shingles vaccination: guidance for healthcare professionals

Shingles slide set

Shingles programme landscape poster

Shingles vaccination: eligibility poster

Patient facing resources

Shingles vaccination checklist

Guide to shingles vaccine leaflet

Shingles birthday reminder invitation postcard (2 versions)

Shingles vaccination poster

Shingles vaccination record card

Shingles stickers

Shingles social media cards

All patient facing resources and the health professional posters can be ordered free of charge from Health Publications or downloaded from the shingles vaccination programme collection on GOV.UK.

All users need to register to receive deliveries. If you register as a health professional, you can order 500 to 1,000 copies on the website. For larger quantities, please call 0300 123 1002.

1. Those that become eligible but do not take up the vaccine offer immediately remain eligible until their 80th birthday. Individuals who were eligible for Zostavax® should continue to receive Zostavax® until central stocks deplete (via ImmForm), after which time they should receive Shingrix®. The 80th birthday upper age cut off remains in place for the immunocompetent cohort regardless of vaccine offered. ↩ ↩² ↩³