Shingles: What is it and how vaccinations may help
Dan Onion, MD, MPH
Mt. Vernon/Vienna Health Officer
Several townspeople have asked my opinion about the new herpes zoster immunization now available, so here goes!
Herpes zoster or shingles is a fairly common disease (in my full time practice of primary care, I'd see 8-10 cases a year) caused by the recrudescence of the herpes varicella/chickenpox virus years after typical childhood chickenpox with fever, painful rash and pustules. The name shingles comes from Latin and French words for belt, or girdle, from the appearance of the skin rash on the torso. Since the introduction of childhood chickenpox vaccination in the mid 1990s, many fewer children now get it. But that leaves nearly everyone born before then with the potential to develop shingles later in their lives and especially if they become immunocompromised with immunosuppressant medications like steroids or anti-cancer drugs, or from diabetes, cancer itself, or other serious illness.
Strangely, the chickenpox virus hides in the body's sensory nerves, and can much later cause a recurrence of the chickenpox-like rash with pain/itching, redness and pustules confined to the anatomic distribution of the nerve in which it had been lurking undetected and innocuously for many years. So it manifests as a day or two of pain or itching and then a relatively unimpressive rash in a patch of body skin, often the trunk or an arm, or even and dangerously the face when an eye is involved. It is almost always on one side of the body, not symmetrical. The duration of the rash is usually several weeks, worst in the first and then gradually healing; it is shortened by antiviral antibiotics if given within the first 2-3 days. However, in about 5-10% of people, the pain persists despite the rash healing, a condition called post-herpetic neuralgia. This can be devastating; these poor people have skin hypersensitivity in the now-healed skin, so even the touch of clothing causes severe pain and suffering. I had an older patient once who had had shingles on her right chest wall; she took to wearing a small dishpan under her clothes, over the neuralgic skin patch, to prevent spasms of pain caused from clothing bumping it. Her pain lasted years and never went completely away.
If adults weren't immunized as children and never had chickenpox, they can still catch it from children or even from someone with an active case of shingles. Those cases are much more serious than in children, with fatalities from viral pneumonia. There is no evidence for immunizing these adults protectively with the childhood or zoster vaccines helps.
So most people over age 30, who have had chickenpox (the vast majority), can develop shingles at any time, most commonly over age 50, with a further higher incidence progressively with aging. To prevent shingles and the rarer incidence of severe post-herpetic neuralgia, two vaccines have been developed:
1) Zostavax in the early 2000s, a live attenuated Herpes varicella virus (like less virulent cow-pox virus vaccination was used to prevent small pox). It is given in a single shot, costing about $200, over age 60 and prevents over 50% of new shingles cases and 60% of post herpetic neuralgia over the first 3 years. Thereafter that efficacy diminishes gradually over time.
2) Shingrix just recently; contains inert pieces ("recombinant subunits" produced in test tubes) of the varicella virus. It requires two shots, a month apart, costing $300, and has many more side effects of local redness, swelling and pain as well more frequent systemic fever reactions, than Zostavax. But it appears to be moderately more effective over the first 3 years studied, especially in people over age 70. And studies have shown benefit even starting at age 50. We don't know how long the protection provided by this new vaccine will last or whether it is effective in people after they have had a first episode of shingles, unlike Zostavax, which clearly does.
There are many unanswered questions here:
1) Should I get one of these vaccinations?
Answer: Yes, maybe, if you have had known chicken pox and/or are older than 30 and immunocompromised, or over 50-60.
2) Which should I get and when?
Answer: Harder question, but probably depends on your age; get one of the two vaccines by age 69-70, when your immune system is still intact, because that is when your likelihood of developing shingles later starts to rise dramatically. The new vaccine might be better if you are immunocompromised by medication-treated diabetes or other conditions since it is effective from age 50 on.
3) What if I've already had shingles once; can I get it again and if so would the vaccines help?
Answer: Yes, you can get it again, although the episode of shingles you had jazzes up your immunity for at least a year. So get one vaccine or the other about a year after your shingles to prevent more episodes.
4) Should I get a booster shot of one or the other after some years go by?
Answer: So far, research has not shown that benefit for either vaccine, probably because you've gotten older and the vaccine is less effective in people over 70-75.
5) Is it worth it?
Answer: It depends on your attitude about the odds. Since the major complication worth preventing, post herpetic neuralgia, is fairly rare, about 200 people would have to be immunized with either of these vaccines to prevent one such bad case over the first 3 years post vaccination. That's a lot of money and immunization site pain and soreness for the other 199, and #200 never knows he was the lucky one.
6) So how do I sort all this out? What would you do?
Answer: I had chicken pox as a child, memorably! So I know I've got the little buggers hiding in my pain-sensing nerves. I got a Zostavax shot 15 years ago at age 60. I may leave it at that, despite, my being on steroids for another problem, though that may impair my immunity beyond normal. Tough call, but two shots of Shingrix with some likely local pain and suffering, especially with the 2nd one, dissuade me for now. And the effectiveness of a booster with either vaccine is unclear. If I did decide to go ahead, I would choose Shingrix because it clearly is more effective in older people despite no data past the 3-year mark yet.
A good but dense summary of all these issues with medical references can be found at: http://www.rxfiles.ca/rxfiles/uploads/documents/Shingrix_QandA.pdf