Is free adult shingles vaccination on the horizon?

There have been a number of changes to the childhood vaccination programme this year. Chickenpox and RSV vaccination have been added to the schedule and are discussed elsewhere in this publication. But what about adult vaccination?

In February, the National Immunisation Advisory Committee (NIAC) issued new recommendations in relation to herpes zoster (HZ) vaccination for adults. The guidance recommends the recombinant zoster vaccine (RZV) for
all adults aged 65 years and older.

Furthermore, the vaccine is recommended for adults aged 50 years and older with primary or acquired cellular and combined immune deficiencies resulting in lymphopaenia (<1,000 lymphocytes/µl) or functional lymphocyte disorder. This cohort includes people living with HIV who are severely immunosuppressed (CD4 count <200 cells/µl). Vaccination is also recommended for people who have received haematopoietic stem cell (all recipients aged ≥18 years) or solid organ (recipients aged ≥50 years) transplants, and those with immune mediated inflammatory disorders who are/have/will be receiving immunosuppressive therapy.

NIAC also recommends that immunisation with RZV is considered for patients aged 18-49 years and older with immunocompromising conditions, particularly solid organ transplant recipients, those with haematological malignancies, and those with advanced or untreated HIV (CD4 count <200 cells/µl). Vaccination should be considered in consultation with the patient’s treating hospital specialist.

Commenting on the recommendations, NIAC said: “There are important ethical considerations surrounding HZ vaccination. In Ireland RZV is available to buy privately, but only to those who are informed and can afford it, perpetuating healthcare disparities. The vaccine’s high cost further exacerbates this issue. The introduction of a targeted, national HZ vaccination programme has the potential to address these inequities by making the vaccine accessible to all those most at risk of HZ and its complications.”

However, in a health technology assessment (HTA) published in July, HIQA concluded that, while the vaccine is safe and effective, adding it to the routine immunisation schedule for adults would not be an efficient use of HSE resources, at the current vaccine price.

At a cost of €151 per vial (dose), the incremental cost-effectiveness ratios (ICERs) ranged from €127,825 per quality-adjusted life year (QALY) for vaccination of those turning 80 years old, to €979,815 per QALY for those turning 50 years old. Based on the assumptions in the model, the vaccine cost would need to be less than €30 per dose for HZ vaccination at 75 and 80 years old to be cost-effective, assuming a willingness to pay threshold of €45,000 per QALY.

The estimated five-year incremental budget impact of adult HZ  vaccination programme with 50 per cent uptake ranged from €15.1 million for vaccination of 85-year-olds to €53.3 million with vaccination of 65 year-olds (one year age group only).

HIQA estimated that, if everyone aged 65 and over was offered the vaccine as recommended by NIAC and 50 per cent availed of it, the five-year budget impact would be €218 million. The five-year incremental budget for eligible immunocompromised persons, as recommended by NIAC, was estimated at €56.2 million.

HIQA said, while free adult HZ vaccination would improve equity of access to this vaccine, “the use of resources in this way may create inequity in other areas of the healthcare system”.

At the current cost, it seems unlikely that the vaccine will be made available free of charge to adults.