Thursday, February 21, 2019

Should you get a shingles shot?

If you had chicken pox as a child, you are at risk of getting shingles.
Most of us old enough to drive had the chicken pox when we were children. A vaccine was first licensed in the U.S. in 1995 and the number of cases of chicken pox peaked in the early 2000’s and have declined steadily since. For most kids, chicken pox was a mild illness, and when I was a child we would have “chicken pox parties” when a case appeared in our neighborhood to get it over with. The virus, however, is sneaky. After recovery, the virus would often go into a dormant resting phase, living in nerve roots near the spine. Our immune system generally kept it from reactivating. As we age, our immune system becomes less robust and can let the virus emerge from its resting phase. Because the virus’s home is at the root of the nerve, it spreads along the course of the nerve. When it does so, we experience pain along the nerve, then a red rash and finally blisters that often form ulcers and eventually heal. This is what we call shingles, known medically as herpes zoster. Shingles is a VERY unpleasant illness. The patient suffers some combination of intense itching and pain for weeks. If the affected nerve is one that serves the face, the eye can be involved and permanent vision impairment can occur. Rarely it can cause deafness if the hearing nerve is involved. The blisters can get a secondary bacterial infection. Rarely, meningitis can occur. Worst of all, since it is affects so many people, 10-20% of shingles victims can develop “post-herpetic neuralgia.” This is intense pain that lasts long after the rash is cleared, often for years, and potentially for life.
OK; shingles is nasty. What can we do to prevent it? First, vaccinate your children. No chicken pox, no later shingles – hopefully 40-50 years from now, shingles will be of historical interest only. For those of us who had chicken pox – and that includes MOST of us 30+ - we must consider getting vaccinated against shingles. If you are 100% sure you never had chicken pox, you can rest easy, but since it was such a mild illness in childhood, it is easy to forget having it. There is a blood test that can tell if you indeed are one of the fortunate few who escaped (and are then at risk of getting chicken pox as an adult – a worse illness!). I ordered the test on about a dozen patients who were sure they had not had chicken pox, and 100% were wrong – they had evidence of having had it.
The first vaccine to prevent shingles was a live attenuated vaccine introduced in 2006, called Zostavax. Live attenuated vaccines use a weakened form of a virus to stimulate our immune system to fight off the real thing. This vaccine was given as a single subcutaneous (under the skin) shot and was very well-tolerated with minimal side effects. The cost is about $160. After being marketed for 10 years, with over 34 million doses used, there were some 23,500 reports of adverse effects, 93% of which were mild. Sounds good – but…unfortunately the vaccine was not as effective as hoped. In the first year after getting the vaccine, the rate of getting shingles was reduced by about 2/3 but by year 7, the protection was less than 50% and by year 11 the reduction in shingles cases was only 38%. The vaccine also proved even less effective in the oldest old, those over 80, who were at greatest risk for both shingles and post-herpetic neuralgia. Also, since the vaccine used a live virus, it could not be used in people with very weak immune systems, such as those on chemotherapy.
Enter the newest contender: Shingrix. This vaccine combines a protein from the virus coat and a naturally-derived “adjuvant,” a non-specific irritant that really juices up the body’s immune system to react to the virus protein. Because there is no live virus in the vaccine, it can be given to patients with compromised immune systems. This vaccine must be given into the muscle and requires two doses, two to six months apart. It is much more effective than Zostavax, giving 97% protection after 3 years, and seems almost as effective in those over 70 as in younger people. What’s the catch? Shingrix has a lot more side-effects than Zostavax. To date, some 84% of people vaccinated reported at least some ill effects, with 17% grading them as severe, compared with 3% of those who got the placebo. Most of these were local soreness and redness, and this generally lasts 2-5 days, though a number of people also felt generally achy and had a fever. The cost for the 2-dose series is about $300, and is covered under Medicare part D plans.
Bottom line: if you or someone close had shingles and you really do not want to get it (and yes, you can get it again), the best way to prevent it is with Shingrix. Try to time it so you can give yourself a few days of R+R and some Tylenol for a few days – do not get it the Friday before a big wedding or competing in the club championship.
Also, since even Shingrix is not 100% effective, it is important to know the signs and symptoms - a painful rash along a very local band of skin anywhere on your body - and it is critical to call your doctor immediately if you see any blisters. There are effective medicines to shorten the course of shingles, but they must be given within 72 hours of the first blister to be most effective. If you note this type of rash late Friday night, you do not need to call the doctor at midnight but do call Saturday morning and do not wait until Monday – and insist on either being seen or treated. With a good description, and perhaps a “selfie” sent as backup, I am comfortable treating shingles over the phone.

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