Graduate students in JHSPH’s Vaccine Policy Issues class examine current national and international policy issues across the spectrum of vaccine work. As a part of the course, students selected topics for analysis. Selected entries will appear in a series on the IVAC blog. This is the first in the series.

Guest post by Sally Ann Iverson, DVM, MPH

By the time you’ve reached your golden years, diseases you experienced in your childhood have likely been reduced to distant memories of unpleasantness. However, chickenpox is one childhood disease that should not be forgotten. Long after the painful pox have cleared, the virus remains dormant in your nerves waiting for an opportunity to wreak havoc on your adult life in the form of shingles. 

Shingles occurs when the Varicella zoster virus reactivates and causes a painful and sometimes debilitating rash. Although it’s unknown exactly what causes the virus to reactivate, it’s thought to be associated with a weakened immune system and older age. The majority of the US population is susceptible to shingles, as 90% of Americans have experienced chickenpox by the age of 15. Almost one out of every three of these people will go on to develop shingles, resulting in about one million cases every year. About half of these cases occur in men and women over 60 years of age.

Electron micrograph of Varicella zoster

Electron micrograph of Varicella zoster virus, responsible for shingles and chicken pox. Photo courtesy of CDC Public Health Image Library.

You may ask, “What’s so terrible about a rash?” Imagine tingling, burning, and stabbing sensations as the virus dances along your nerves and blisters your skin. People who have experienced shingles have described it as “the demon’s hand” and women have declared it more painful than childbirth. About 20% of the people who experience shingles will suffer from permanent damage to the nervous system, a condition known as post-herpetic neuralgia, that can persist for months or even years after the rash has resolved.

Given the nightmare that shingles is capable of producing, you may be relieved to learn that there is a vaccine for adults that can cut your risk of shingles in half. You may also expect that people would be lining up around the corner to receive this vaccine, especially since the US Advisory Committee on Immunization Practices (ACIP) has made formal recommendations that all adults over 60 should receive the shingles vaccine. Yet surprisingly, only 10% of people in the recommended age group have been vaccinated for shingles.

Although there are many reasons for underutilization of the vaccine, multiple studies have found one factor that seems to be a root cause: money. The herpes-zoster vaccine is the most expensive vaccine recommended for older adults. At around $160-$200, it cost four times as much as the pneumococcal vaccine and ten to twenty times as much as the flu vaccine. It’s also the only routinely recommended vaccine for older adults not covered under Medicare part B; instead, shingles vaccine has been relegated to coverage under Medicare part D prescription drug plan.

The distinction between “part B” and “part D” vaccines is substantial, and affects the 93% of the US population over 65 that is currently covered by Medicare. For vaccines covered under Medicare part B, such as the flu and pneumococcal vaccines, a patient can go to his or her doctor to get vaccinated. The doctor will then bill Medicare and will be fully reimbursed for the cost of the vaccine. However, the process is much more complicated for a vaccine covered under part D. Doctors cannot bill Medicare directly for the cost of the vaccine, so they must either require the patient to pay the full price of the vaccine upfront (and later submit for reimbursement to Medicare), or they will ask the patient to go and purchase the vaccine from a pharmacy, and bring it back to the office to be vaccinated. This later scenario is highly discouraged by the CDC, as the vaccine must be kept at specific temperatures that may be violated during transport from the pharmacy.

This complex system is confusing, inefficient, and expensive for both patients and doctors. Patients may be required to pay initial high costs out of pocket, as well as any co-pays that remain after reimbursement. Doctors are less than enthusiastic about regularly stocking and administering the vaccine due to the complicated process associated with current Medicare coverage. Additionally, financial loopholes in the current system may result in physicians covering up to 25% of the cost of the vaccine, which is more than the full cost of any other vaccine they would be administering!

Transferring coverage of the shingles vaccine to Medicare part B would greatly reduce the burden to patients, and would pave the way for the breakdown of other barriers to vaccination. Surveys of physicians have found that a simpler system would encourage more doctors to regularly stock the vaccine, resulting in improved access for patients. We can also expect that more people will be motivated to receive a vaccine that is affordable and easy to obtain.

On the whole, vaccines have proven themselves as one of the most cost-effective preventative health interventions we have available, and the CDC has also endorsed the shingles vaccine as a cost-saving health intervention. By allocating Medicare resources to preventative measures such as shingles vaccine, we have the opportunity to avert higher healthcare costs later on.

Shingles is a disease not soon forgotten by those who experience its wrath, and it should not be forgotten by our healthcare system either. The inclusion of the shingles vaccine under Medicare part D has been the first step in addressing this debilitating disease, but it is not good enough. Our healthcare system can do a better job and reach more than 10% of the target population. It’s time to dig the shingles vaccine out from under all the paperwork, and slate it for coverage under Medicare part B.

Dr. Sally Ann Iverson recently graduated from the Johns Hopkins Bloomberg School of Public Health with a Master of Public Health degree and a certificate in vaccine science and policy. She will begin a fellowship as a veterinarian at the Plum Island Animal Disease Center this July.