A Vaccine as an Option to Keep Shingles at Bay

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A Vaccine as an Option to Keep Shingles at Bay

By JANE E. BRODY

Bill Alkofer for The New York Times

Merritt Clapp- was misdiagnosed three times before the third doctor

finally concluded that she was suffering from shingles.

Maybe you haven’t heard anything about the shingles vaccine. Or maybe you

have, but decided against getting it for any of a number of reasons like

these:

It is approved for people 60 and older, and you are 45.

Your insurance does not cover it, and it costs $165 to $300.

It protects just half of those vaccinated, and you would just as soon take

your chances.

No one yet knows how long the benefits will last.

No one yet knows about delayed side effects.

You do not know anything about shingles, so how common or bad can it be?

Before dismissing the vaccine entirely, you may want to consider Merritt

Clapp-’s recent encounter with shingles. Although at 39 she is much

younger than the typical shingles patient, her experience with confusing

symptoms and a twice-missed diagnosis occurs at all ages. This is her story:

“My shingles case began with the periodic sensation that bugs were crawling

in my hair. Three weeks later, I developed a headache that was one-sided but

unlike a migraine. The pain was so bad I couldn’t go to work. That evening,

I discovered a raised and very tender ridge on my scalp.

“Unable to sleep and in terrible pain, I went to the local emergency room.

The doctor there gave me an intravenous painkiller, tested me for meningitis

or encephalitis, and concluded that I had a migraine and infected hair

follicle.

“The terrible head pain grew, as did the sensitivity of the rash, and at 3 a

m. The next day, my husband drove me to a major hospital. The doctor

cursorily looked at the blistering rash and treated me for a migraine. He

had no explanation for the rash.

“After another horrible night and day of pain and a growing rash, my husband

drove me to Urgent Care, where a nurse immediately suspected shingles, and

the doctor concluded ‘shingles’ in 30 seconds. I got acyclovir for the virus

and Vicodin for pain. I slept a lot, and my eye swelled. When the blisters

scabbed over, I returned to work, but I was so tired and my eye was so

sensitive to light that I had to cut short my workdays.”

Mrs. Clapp-, an urban planner from St. , said that after her

experience she encouraged her mother, who is 71, to get the shingles vaccine

But that decision is not always simple.

Shingles, or herpes zoster, can afflict anyone who has had chickenpox. Both

are caused by the varicella-zoster virus. It is not known whether shingles

can develop in people who received the chickenpox vaccine, which contains a

live attenuated form of the virus.

This virus never leaves the body. It lies dormant for years in nerve roots

near the spinal cord and can be reactivated as a shingles infection at any

time, especially in people whose immune system is weakened by advanced age,

extreme stress, a disease like cancer or AIDS or medications like

chemotherapy, steroids and drugs used to prevent organ rejection.

Sometimes, a physical stress like cold or sunburn can bring on an attack.

Reactivated, the virus migrates down the nerve until it reaches the skin,

where it causes vague symptoms of irritation, pain, numbness, itching or

tingling, followed in two or three days by a painful, blistering rash on one

side of the face, head or body. Untreated, the rash lasts two to four weeks.

The pain can be severe and may be accompanied by headache, fever, chills and

an upset stomach. In rare cases, it can lead to pneumonia, hearing loss,

blindness, encephalitis and, rarer still, death.

After the rash clears, about one patient in five develops post-herpetic

neuralgia, or PHN, a debilitating pain that does not always respond to

treatment and can be devastating to ordinary life for months or even years.

Treatment with the antiviral drug acyclovir is best administered as early as

possible, preferably within 72 hours of the first sign of a rash, to shorten

the course of the disease and prevent the severe symptoms that Mrs.

Clapp experienced. Antiviral drugs, if taken early, can reduce the

severity of subsequent post-herpetic neuralgia, but starting antivirals

after PHN develops is of no help.

About one million cases of shingles a year occur in the United States, and

the risk of it and of PHN increases with age. Half of 85-year-olds will have

had shingles and, as people age, shingles-associated nerve pain increases in

frequency and severity.

Debilitating nerve pain occurs in nearly a third of people with shingles who

are 60 or older, and about 12 percent of older people who have shingles have

pain that lasts three months or longer. The pain of PHN, which is difficult

to treat, has been described as burning, throbbing, aching, stabbing or

shooting. Even clothing touching the skin or a cool breeze can cause

excruciating pain.

The shingles vaccine, Zostavax by Merck, was licensed in May 2006 after a

study of more than 38,500 men and women 60 and older showed that it

prevented about half of cases of shingles and reduced the risk of PHN by

two-thirds.

The vaccine, given in a single dose by injection, contains the same

attenuated virus as the chickenpox vaccine, but is 14 times as potent. The

side effects have been minimal, usually redness, soreness, swelling or

itching at the injection site and, rarely, headaches. Based on the study,

the researchers estimated that the vaccine could prevent 250,000 cases of

shingles a year and significantly reduce its severity and complications in

another 250,000 people. The vaccine is most effective in people 60 to 69,

and less so with advancing age.

The vaccine is approved for use in people 60 and older who have had

chickenpox. The Advisory Committee on Immunization Practices for the Centers

for Disease Control and Prevention recommended that it be given to people

who have had shingles, though the chances of another attack are low. Some

insurers will not pay to immunize patients who have had shingles.

For Medicare beneficiaries, the cost is covered only for those with Medicare

Part D, the drug benefit, and only if the vaccine is in the formulary of

their chosen plan.

Coverage for Zostavax by independent insurers is spotty, though appeals are

possible. Many older people who would benefit most from it are unable or

unwilling to pay for it. The manufacturer’s price is about $150. The

patients’ cost is often $300, although some public health services offer it

for about $165. Doctors have to buy the vaccine for their patients.

Because people in their 50s account for one in every seven cases of shingles

some physicians administer the vaccine “off label” to those younger than 60

even though its safety and effectiveness in younger people are not known.

Also unknown is whether the vaccine is safe to administer to people whose

immune systems are already weakened.

Follow-up studies are under way to determine how long the vaccine remains

effective. If immunity wanes, a booster shot may be necessary.

Until the unknowns are resolved, the vaccine is not recommended for those

with immune systems weakened by disease or drug treatment, women who are

pregnant or might be pregnant and people with active untreated tuberculosis.

Nor should the vaccine be given to anyone who has had a life-threatening

allergic reaction to gelatin or the antibiotic neomycin.

Federal health officials urge vaccine recipients to help them monitor

reactions by reporting unusual symptoms like high fever or behavior changes

or allergic reactions like difficulty breathing, rapid heart beat, dizziness

hives or wheezing to their doctors and asking the doctors to file a Vaccine

Adverse Event Report. Patients can file reports themselves through www.vaers

hhs.gov or by calling (800) 822-7967.

Updated from an article that appeared in The New York Times on Oct. 2, 2007.

Shingles Vaccine for the Middle-Aged and Very Old

By IRENE M. WIELAWSKI

The Centers for Disease Control and Prevention strongly recommends routine

vaccination of people 60 and older to get shingles shots, noting that

surveys showed Zostavax — licensed in 2006 — to be greatly underutilized.

About 4 percent of an estimated 50 million candidates for the vaccine have

received it, according to government surveys.

In the meantime, studies are under way to support use of Zostavax in people

50 and older, since shingles incidence climbs sharply after age 50. Current

studies show that the vaccine is most effective in people under 70,

preventing shingles in 64 percent of this group. Effectiveness drops to 41

percent for those 70 to 79 years old, and to 18 percent for people 80 and

older, according to the C.D.C. But the vaccine’s effectiveness in preventing

a painful aftermath of shingles called postherpetic neuralgia remains high

in the very elderly, supporting use of vaccine in this age group.

Merck, the sole maker of the shingles vaccine, is currently working to

increase production of Zostavax amid a supply shortage that has required

some people to delay vaccination. Cost, too, may deter some people from

shingles vaccination. Merck charges health care providers $161.50 per dose

of Zostavax, and physician administration fees and other charges can boost

charges to consumers as high as $300.

Private insurance coverage is uneven, and coverage by Medicare, the government

insurance for people 65 and older, is under Part D — the prescription drug part

of the plan. This makes reimbursement more complicated and costly than for other

adult vaccines like influenza and pneumonia shots, which are covered under Part

B, eliminating most physician fees.