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Vaccine update: issue 328, May 2022, Shingrix® special edition

Published 11 May 2022

Applies to England

Shingles vaccination

Despite the recent developments in vaccine literacy in our population, many people still associate vaccinations with infants or young children. There is less awareness of the life course of vaccination and the importance of vaccination in older adults other than flu.

Awareness of pneumococcal and shingles vaccinations in adults on social media revealed that the key barriers to vaccination among people living in deprived areas include a lack of awareness that they could be vaccinated against pneumococcal disease or shingles (herpes zoster) and knowledge about these vaccines more generally.

In an online survey 56% of older adults eligible for routine vaccines in the most deprived areas didn’t know they needed the vaccination against pneumococcal disease and 69% didn’t know about shingles. 46% had never heard of the former, while 55% hadn’t heard of the latter.

Building awareness in these groups is essential to improving uptake. Most people have heard of chickenpox caused by varicella zoster virus.

We have outbreaks of chickenpox across the country. Whilst you cannot catch shingles from chickenpox, you can contract chickenpox from someone who has shingles, if you have not had chickenpox before.

Shingrix® vaccine

Shingrix® is good news for people who have a weakened immune system.

In June Joint Committee on Vaccination and Immunisation’s (JCVI’s) meeting, held on 22 June 2021 the committee noted a decrease in the number of children getting vaccinations occurring across all ages, as well as ‘very large decreases’ among the elderly for shingles vaccination.

More than 10% less older people had been jabbed against shingles between April and June 2020 compared to the previous year.

Since 1 September 2021 non-live Shingrix® vaccine has been available to all individuals eligible for shingles vaccination under the existing NHS shingles (herpes zoster) immunisation programme but who are clinically contraindicated to receive live Zostavax vaccine due to their immunocompromised health status.

In line with the current requirements of the shingles programme, the shingles vaccine should be offered via a proactive call to those becoming eligible at 70 years old and will be offered opportunistically or if requested for those over 70 years until the age of 80.

The introduction of the inactivated shingles vaccine follows the recommendation made by JCVI, at its February 2018 meeting, that Shingrix® should be offered to all immunocompromised people for whom Zostavax® is contraindicated but who are eligible for vaccination under the current programme, so that they can gain a similar level of protection to those who are not immunocompromised.

The Committee noted that vaccination in this group was particularly important, due to the higher incidence of herpes zoster. This advice was consistent with the original recommendation for vaccination of all adults aged 70 to 79 years with herpes zoster vaccine.

Key points about the change to the programme

Since last August, Shingrix® has been available to be ordered online via the ImmForm website for those who are eligible for shingles vaccination but are clinically contraindicated to receive the live vaccine Zostavax® due to their immunocompromised status. Shingrix® should be used for those who are eligible from 1 September 2021.

Shingrix® requires a 2-dose schedule, with the second dose administered from 2 months following the first dose.

It is important that Shingrix® is given only to those who are clinically contraindicated for Zostavax® due to their immunocompromised status in order to have sufficient supply for those who need to receive it.

GPs should continue to offer Zostavax® to eligible patients who are not contraindicated.

Any individual who reaches their 80th birthday is no longer eligible for a shingles vaccination due to the reducing efficacy of the Zostavax® vaccine as age increases. This reflects the 2010 recommendation made by JCVI. However, where an individual has turned 80 years of age following their first dose of Shingrix®, a second dose should be provided to complete the 2-dose schedule for Shingrix®.

Further detailed information and guidance for healthcare professionals relating to this change is set out in below.

Details on ImmForm vaccine coverage data collection are set out below.

For the 2019 to 2020 shingles immunisation programme, overall, 26.5% of those that turned 70 and 25.8% of those that turned 78 during 2019 to 2020 (from 1 April 2019 to 31 March 2020) were vaccinated by the end of June 2020. Compared to 2018 to 2019, vaccine coverage decreased by 5.4 percentage points for 70-year olds and decreased by 7.1 percentage points for 78-year olds during this period.

Ongoing efforts are therefore needed to identify and vaccinate all eligible individuals who have missed out to ensure a continuing reduction in the number of cases of this debilitating and painful condition. We encourage providers to take every opportunity to offer shingles vaccination to eligible patients throughout the year to help to protect as many older people as possible from this potentially devastating illness.

We are grateful for your continued support of the shingles immunisation programme. Every vaccination given is another step closer to reducing the burden of this unpleasant condition in older adults.

Information and guidance for healthcare professionals

Guidance and training

The Shingles (herpes zoster) chapter 28a has been updated. This guidance is based on advice from the JCVI, the UK’s independent advisory committee of immunisation experts.

The Green Book chapter 11 immunisation schedule has now been revised and published.

Healthcare professionals’ information and guidance for the shingles vaccination programme has been updated to include the offer of Shingrix® for eligible patients.

A training slide set is available on the shingles vaccination programme webpage.

Information resources for healthcare professions to give to eligible individuals or to use in vaccination settings are available to order or download.

Timing of vaccination

Since 1 September 2021, GPs should be offering the non-live shingles vaccine Shingrix® to all those who are eligible for shingles vaccination but for whom Zostavax® is clinically contraindicated due to their immunocompromised status.

Shingrix® requires a 2-dose schedule, with the second dose administered from 2 months (and ideally within 6 months) following the first dose. Those who present more than 6 months after the first dose can receive a single completing dose at any stage in line with the Green Book advice.

Shingrix® can be administered alongside flu and the pneumococcal polysaccharide (PPV) vaccines.

As is the case for Zostavax®, patients can be offered shingles vaccination (with a suitable product) opportunistically at any point in the year as they are or become of eligible age (on or after their 70th birthday).

As for Zostavax®, any individual who reaches their 80th birthday is no longer eligible for a shingles vaccination.

However, where an individual has turned 80 years of age following their first dose of Shingrix®, a second dose should be provided to complete the 2-dose schedule.

Patient Group Directions

A Shingrix® vaccine patient group direction (PGD) has been produced for NHS England and NHS Improvement Areas to adopt and authorise for their commissioned services.

This PGD template is to support the administration of Shingrix® vaccine for immunocompromised individuals in accordance with the national shingles immunisation programme. It is valid from 1 September 2021 to 31 August 2023.

Practitioners must not use these PGD templates until they have been authorised in Section 2. This is a legal requirement (see Human Medicines Regulations 2012). Practitioners should follow local policy or procedures to access authorised PGD documents.

This PGD template should be used with reference to current national guidance, the Green Book, and Summary of Product Characteristics for the vaccine.

Vaccine supply

Since August 2021, Shingrix® has been available to order online via the ImmForm website for individuals for whom Zostavax® is clinically contraindicated.

See the ImmForm helpsheet for information on registering for an ImmForm account.

Ordering controls are in place to enable UK Health Security Agency (UKHSA) to balance incoming supply with demand. Details of ordering controls are available on ImmForm. Please make sure that stocks of shingles vaccine are rotated in fridges so that wastage is minimised. It is recommended that practices hold no more than 2 weeks’ worth of stock.

Identifying eligible patients

GPs should offer the non-live shingles vaccine Shingrix® to all those who are eligible for shingles vaccination but are clinically contraindicated to receive the live vaccine Zostavax® due to their immunocompromised status.

The section on contraindications for Zostavax® in the Shingles (herpes zoster) Green Book chapter has been updated following a review by an Expert Working Group and was published on 23 August 2021.

Where GPs undertake searches for eligible patients, search criteria should be adjusted wherever possible to ensure patients eligible for vaccination but for whom Zostavax® is contraindicated are included for vaccination with Shingrix® from September 2021 and are invited for their second dose in good time.

In relation to the introduction of Shingrix®, we suggest GPs can search their systems for any eligible patients aged 70 to 79 years who have not received Zostavax and have:

• a code for contra-indicated for shingles vaccine (Herpes zoster vaccination contraindicated (situation) – 868531000000103)

or

• another code for immunosuppression (as used to identify those eligible for flu or coronavirus (COVID-19) vaccination).

These patients can then be contacted or, for those outside of the call/recall cohort, flagged for opportunistic vaccination with Shingrix® when they present at the surgery for another purpose, or request vaccination, at a later date.

At the time of presentation for vaccination the patient’s immunosuppressed status should be checked against the new Green Book chapter in case there has been a change and they are now indicated for Zostavax®.

SNOMED codes for immunosuppression

A list of SNOMED codes to assist with identifying patients who are indicated for Shingrix® vaccine is available on GOV.UK.

SNOMED codes for administration of Shingrix® vaccine

SNOMED codes and GP IT systems will be updated to allow the recording of the 2 doses of Shingrix® in electronic health records since September 2021. The recommended SNOMED codes for recording administration of Shingrix® vaccine doses in electronic patient records are as follows:

	SNOMED ConceptID	SNOMED DescriptionID
Shingrix® vaccine 1st dose	1326101000000100	Administration of first dose of vaccine product containing only Human alphaherpesvirus 3 antigen for shingles (procedure)
Shingrix® vaccine 2nd dose	1326111000000107	Administration of second dose of vaccine product containing only Human alphaherpesvirus 3 antigen for shingles (procedure)

Funding and service arrangements

From 1 April 2021, the provision of vaccination and immunisation services became an essential service for all routine NHS-funded vaccinations, as first set out in February 2020’s ‘Update to the GP contract agreement 2020/21-2023/24’ and as communicated in the letter ‘Update on vaccination and immunisation changes for 2021 to 2022’. The letter includes the expectation of the introduction of this alternative vaccine for those who are unsuitable for vaccination with Zostavax®. Practices will be able to administer Shingrix® under the General Medical Services (GMS) contract as it becomes available. All payment details are set out in the Statement of Financial Entitlements from 1 April 2021.

The shingles routine and catch-up programme requires a call for vaccination for patients at becoming eligible at 70 years of age, and vaccination opportunistically, or if requested, until the age of 80 years. This applies for both Zostavax® and Shingrix® vaccines.

MHRA Black Triangle Scheme

Shingrix® is part of the Medicines and Healthcare products Regulatory Agency’s (MHRA) Black Triangle Scheme for new medicines and vaccines to allow rapid identification of new safety information.

Healthcare professionals are asked to report all suspected adverse reactions via the Yellow Card Scheme.

Vaccine coverage data collection

Dose 1 and dose 2 coverage of the Shingrix® vaccination will be collected as part of the shingles immunisation programme. 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 UKHSA and NHS to collect data on vaccine coverage and provide vaccine ordering facilities for the NHS) on a quarterly basis.

2021 to 2022 data will be collected on the following:

Denominator

The number of individuals aged 70 to 79 (inclusive) years old registered at a GP practice who have a SNOMED code that they are clinically contraindicated to receive the live vaccine Zostavax® due to their immunocompromised status.

Numerator

The number of individuals aged 70 to 79 (inclusive) years old registered at a GP practice who have a SNOMED code that they are clinically contraindicated to receive the live vaccine Zostavax® due to their immunocompromised status and have the following SNOMED codes:

• 1326101000000105 (indicating receipt of first dose of Shingrix®)
• 1326111000000107 (indicating receipt of second dose of Shingrix®)

The number of individuals aged 80 years old registered at a GP practice who have a SNOMED code that they are clinically contraindicated to receive the live vaccine Zostavax® due to their immunocompromised status and have the following SNOMED codes:

• 1326101000000105 (indicating receipt of first dose of Shingrix®) when aged 79
• 1326111000000107 (indicating receipt of second dose of Shingrix®) when aged 80

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

What you can do to maximise uptake

Boost awareness by using the posters and banners in your practice and on your websites

Have copies of the leaflets available to give to eligible people and their families. Encourage people to discuss the shingles vaccination and remind them that it is offered to them to reduce the burden of shingles.

Check older adults are up to date

When adults visit the GP practice, receptionists, practice nurses and GPs can use this opportunity to check whether they’re up to date and offer them an appointment for any missing vaccinations. Sounds simple, but making sure everyone is doing their bit to check status can really make the difference in getting coverage rates high.

Check your IT system flags when people have missed out

Check with your IT supplier that your system is configured correctly to flag patients with outstanding vaccinations. For those using EMIS, videos on how to do this for shingles are available. Similar advice for TPP/SystmOne practices will be available shortly.

Use the shingles vaccination checklist

This checklist has been developed to help immunisation practitioners plan their immunisation programme. This checklist is available for download only.

Use the web banners (female banner and male banner) and promote awareness of the shingles vaccination on your practice website and in your communications to patients in the eligible age group.

Herpes zoster (shingles) immunisation programme 2019 to 2020: evaluation reports

The routine and catch-up shingles vaccination programme offers the shingles vaccine to those turning 70 or 78 years old in any given year; they remain eligible until their 80th birthday. This is the annual, and fourth quarterly, shingles report of the financial year 2019 to 2020 based on current eligibility criteria, evaluating those eligible for the shingles vaccine from 1 April 2019 to 31 March 2020, assessed at the end of June 2020. Results from this report are comparable to figures from the 2018 to 2019 annual report but are not comparable to earlier annual reports, which were based on a different methodology and eligibility criteria. Cumulative shingles vaccine coverage for all earlier routine cohorts (offered at 70 and now aged 71 to 76 years) continues to increase year-on-year through opportunistic vaccination.

Cumulative shingles vaccine coverage at the end of June 2020, for cohorts first offered shingles vaccine prior to the financial year 2019 to 2020, was highest among 76 year olds (76.7%) and lowest among 71 (48.2%) and 77 (48.0%) year olds – half of whom need to wait until their 78th birthday to become eligible for the vaccine as part of the final catch-up cohort.

Order shingles vaccination programme resources

These resources are available free to order or download:

• shingles vaccination leaflet
• Shingrix® vaccination flyer for people with a weakened immune system
• shingles age wheel poster
• shingles ‘Who’s eligible for shingles vaccination?’ poster
• shingles invitation postcard
• social media graphics (female banner and male banner)
• shingles vaccination checklist (download only)