Letters

Abstract

Today I had the pleasure of reading the article, “Lessons Learned from an Old Acquaintance,” written by Dr. B (Dec. 2006, p. 6). As a nursing home administrator, I must say there is very little “positive” reading material related to LTC. The simple idea that somebody as important as a doctor, or a nurse, would follow an individual patient/resident's progress through multiple living situations, speaks volumes about their compassion. Dr. B just happens to be one of the finest men I know. He actually regularly demonstrates that he cares about people, patients, family members, and friends alike. My mother was blessed with being a resident in a nursing home where Dr. B served as both her physician and as the medical director. If Dr. B says it is so, it is so. Guaranteed! —Rick Scollon, R.N., MS, CNHA, administrator, Oregon Manor, Ltd., Oregon, Wis. Thank you for your report on release of the new adult zoster vaccine, Zostavax (Dec. 2006, p. 26). CARING'S headline states that a “Study Confirms Benefits of Vaccine” in preventing postherpetic neuralgia (PHN). However, our long-term care group has decided not to recommend facility-wide vaccination for now. We reason that the window of exposure among nursing home residents is small, the incidence of PHN is low, and there are effective treatments for PHN that make mass prevention less compelling. Patients admitted to a nursing home do not survive long enough to benefit from many interventions recommended for general populations. Will nursing home patients live long enough to benefit from the zoster vaccine? As acknowledged in the article, the zoster vaccination recommendation is based on a large, well-designed study conducted by M.N. Oxman et al (N. Engl. J. Med. 2005;352:2271–84); however, the study included only healthy community-dwelling persons as subjects. Ninety-six percent of this group was alive at the end of the study, which lasted a median of 3.12 years. By contrast, according to the Centers for Disease Control and Prevention's 1999 National Nursing Home Survey, the median survival of long-stay nursing home residents is less than 2 years (http://www.elderweb.com/home/node/2771, accessed Dec. 30, 2006). Thus, the study patients' window of exposure to PHN was significantly longer than that of a typical nursing home population. In addition, our nursing home medical group collectively could not recall a single case of PHN among our patients in the preceding 5 years. We concluded from this data and from our own anecdotal observations that most nursing home patients will die before they activate zoster, experience PHN, or reap any benefit from this new vaccine. We also calculated the number-needed-to-treat from Dr. Oxman's results. He reported in his study a PHN incidence of 1.38 per 1000 patient-years in the placebo group and a “66.5%” relative reduction to 0.46 per 1000 in the vaccination group. The absolute rate reduction was therefore 0.92, corresponding to an NNT of 1080 to prevent 1 PHN case. Thus, to avoid this single statistical case of PHN, all 100 residents would need to be vaccinated in each of 10.8 average-size nursing facilities. The small absolute benefit of vaccination did not seem to us worth the cost ($162,000 per PHN case avoided) or effort of a facility-wide immunization program. Finally, as mentioned in the December article, cyclovir drugs are probably efficacious in attenuating PHN among the handful of zoster cases that we actually do see each year (http://www.clinicalevidence.com/ceweb/conditions/ind/0905/0905.jsp, accessed Dec. 30, 2006 [password required]). Other drugs available for PHN include gabapentin, which the FDA has approved specifically for the PHN indication, possibly duloxetine (not FDA-approved for PHN), as well as opioid or non-opioid analgesics. Our nursing home medical group has opted to defer for now recommending facility-wide use of adult zoster vaccine. We have decided to vaccinate on a case-by-case basis only those residents over age 60 with a prognosis for survival over 3 years. What is really needed is a study conducted among nursing home patients—an idea for AMDA's research network? —D. MacLean, M.D., CMD, Medical Director, Long-term Care Section, Department of Health &Social Services, Delaware Hospital for Chronically Ill, Smyrna, Del.