Is increasing use of the herpes zoster vaccine stemming the tide of emergency department (ED) visits for older Americans with shingles?

A recent study published in JAMA Dermatology couldn’t prove causation, but study authors suggested that likely was a factor. The Beth Israel Deaconess Medical Center–led study sought to determine the effect of vaccination on ED utilization for herpes zoster (HZ), looking at utilization trends and costs.

To do that, researchers pulled data from the Nationwide Emergency Department Sample, looking for trends over time in the number of visits and costs for treatment of HZ in EDs in the United States. Over the time period pinpointed, January 1, 2006 through December 31, 2013, shingles cases were identified using validated International Classification of Diseases, Ninth Revision-Clinical Modification diagnosis codes. At the same time, patients were grouped by age and vaccine recommendation status:

• Age younger than 20 years (varicella vaccine recommended);
• Age 20 to 59 years (no vaccine recommended); and
• Age 60 years or older (HZ vaccine recommended).

With the focus of the study determining population-based incidence rates of HZ-related ED visits, charge for ED services, and total charges, 1,350,957 ED visits for HZ were identified between 2006 and 2013, representing 0.13% of all U.S. visits seeking emergency care. Patients were slightly more likely to be male, with a mean age of 54 years.

Results indicate that the percentage of HZ-related ED visits increased from 0.13% to 0.14% (8.3%) during the study period. What was notable, according to the researchers, is that patients aged 20 to 59 years, with an increase of 22.8%, were the primary drivers of the escalation.

At the same time, ED visits related to shingles decreased for patients aged younger than 20 years and older than 60 years, from 0.03% to 0.02% (-39.6%) and from 0.28% to 0.25% (-10.9%), respectively. “A live-attenuated vaccine for HZ has been available in the U.S. since 2006,” according to the article. “The vaccine reduces the likelihood of developing HZ by 51.3% in individuals aged 60 years or older, and vaccinated individuals who develop HZ usually have less severe disease. In 2008, the Advisory Committee on Immunization Practices (ACIP) recommended live zoster vaccine for the prevention of HZ and its complications among adults aged 60 years or older. Vaccination rates in this population increased from 6.7% in 2008 to 24.2% in 2013.”

Looking at all age groups, the study team reports overall costs increases from 2006 to 2013. The overall total adjusted costs for HZ-related ED visits jumped up from $92.83 million to $202.47 million, while mean costs also showed sharp increases—from $763 to $1262.

“The number of ED visits and total cost associated with HZ increased between 2006 and 2013,” the researchers conclude. “Greater use was driven by an increased number of visits by patients aged 20 to 59 years, but populations recommended for vaccination (<20 and ≥60 years) demonstrated decreased ED utilization. Per-visit and total costs increased across all age groups. Vaccination may be associated with a reduction of ED utilization. Further research is required to confirm these results and examine the drivers of increased ED costs.”