Federal officials have recommended a new vaccine that is more effective than an earlier version at protecting older adults against the painful rash called shingles. But persuading many adults to get this and other recommended vaccines continues to be an uphill battle, physicians and vaccine experts say.
"I'm healthy, I'll get that when I'm older," is what adult patients often tell Dr. Michael Munger when he brings up an annual flu shot or a tetanus-diphtheria booster or the new shingles vaccine. Sometimes they put him off by questioning a vaccine's effectiveness.
"This is not the case with childhood vaccines," said Munger, a family physician in Overland Park, Kan., who is president of the American Academy of Family Physicians. "As parents, we want to make sure our kids are protected. But as adults, we act as if we're invincible."
The new schedule for adult vaccines for people age 19 and older was published in February following a recommendation last October by the federal Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices and subsequent approval by the director of the CDC. The most significant change was to recommend the shingles vaccine that was approved by the Food and Drug Administration last fall, over an older version of the vaccine.
The new vaccine, Shingrix, should be given in two doses between two and six months apart to adults who are at least 50 years old. The older vaccine, Zostavax, can still be given to adults who are 60 or older, but Shingrix is preferred, according to the CDC. In clinical trials, Shingrix was 96.6 percent effective in adults ages 50 to 59, while Zostavax was 70 percent effective. The differences were even more marked with age: Effectiveness in adults 70 and older was 91.3 percent for Shingrix, compared with 38 percent for Zostavax. Shingrix also provided longer-lasting protection than Zostavax, whose effectiveness waned after the first year.
The guidelines suggest that people who already had the Zostavax shot be revaccinated with Shingrix.
The two-shot series of Shingrix costs about $280, while Zostavax runs $213.
"What's remarkable [about the new vaccine] is that the high level of immunity persists even in the very old," said Dr. Anne Louise Oaklander, a neurologist who is an expert on shingles. "It's pretty hard to get the immune system of older people excited about anything."
Shingles is caused by the same varicella-zoster virus that causes chickenpox. The virus can re-emerge decades after someone recovers from chickenpox, often causing a painful rash that may burn or itch for weeks before it subsides. About 1 in 3 Americans will get shingles during their lifetime; there are roughly 1 million cases every year. People are more likely to develop shingles as they age, as well as develop complications like postherpetic neuralgia, which can cause severe, long-standing pain after the shingles rash has disappeared. In rare cases, shingles can lead to blindness, hearing loss or death.
Although shingles vaccination rates have inched upward in recent years, only a third of adults who were 60 or older received the Zostavax vaccine in 2016.
In contrast, by the time children are 3 years old, typically more than 80 percent of kids, and frequently more than 90 percent, have received their recommended vaccines.
What gives? Cost can be a big deterrent for adult vaccines. The federal Vaccines for Children program helps parents whose kids are eligible for Medicaid or are uninsured cover the cost of vaccines up to age 19.
Adults with private insurance who get vaccines recommended by the CDC also are sheltered from high costs because the shots must be covered by most commercial plans without charging consumers anything out-of-pocket, under a provision of the Affordable Care Act. Patients, however, should confirm their coverage before requesting the new shingles vaccine, because insurers typically add new vaccines gradually to their formularies after they have been added to the recommended list, and consumers may need to wait a little while for coverage.
But vaccine coverage under the Medicare program for people age 65 and older is much less comprehensive. Vaccines to prevent influenza and pneumonia are covered without a copayment under Medicare Part B, which covers outpatient care.
Other vaccines, including the shingles vaccine, are typically covered under Part D drug plans, which may leave some beneficiaries on the hook for all or part of the cost of the two-shot series.
That can pose a significant problem for patients. "Not every Medicare beneficiary elects Part D, and even if you do, some have deductibles and copayments," said Dr. William Schaffner, an infectious-diseases specialist at Vanderbilt University School of Medicine.
Even if adults want to get recommended vaccines, they sometimes lose track of which they have received and when. Pediatricians routinely report the vaccines they provide to state or city vaccination registries that electronically collect and consolidate the information. But the registries are not widely used for adults, who are more likely to get vaccines at various locations, such as a pharmacy or at work, for example.
"I'm always asking patients, 'Did you get all the doses in the series?' 'Where did you get them?'" said Dr. Laura Riley, vice chair of obstetrics at Boston's Massachusetts General Hospital who is a member of the Advisory Committee on Immunization Practices. "It can be very challenging to track."