Do I need the shingles vaccine? A doctor explains

What if there was an infection that can cause permanent nerve damage and pain? What if the virus could affect the eye and cause blindness or affect the brain and cause meningitis?  What if the burning rash attacks almost half of all Americans sometime in their life?  If you knew there was a vaccine which could protect you from that malady, would you get the shot?   The disease is called shingles or herpes zoster and despite a successful vaccine being available only five (5) percent of eligible adults have been inoculated.  Have you?

When we were children most of us got the chicken pox infection, also called “varicella.”  This is caused by the varicella-zoster virus and results in a short illness with a rash and fever. Most children recover without difficulty, and often enjoy a brief respite from school. The interesting thing is that we never get rid of the virus.  It hides in the bodies of nerve cells next to our spine or face.  We live our whole lives never feeling that dormant infection.

Sometimes, as we get older, that same virus can burst out of the nerve in which it has been sleeping.  At age 30 healthy persons have a 1 in a 1000 chance each year of the chicken pox virus awakening.  By age 65, it happens to more than 1 in a 100 each year.    If we become ill, in almost any form, there is a further increase in the chance of the painful droplets breaking out on our skin. This is because of weakness in our immune system. If we live to be 85, more than half of us will get shingles.

As the virus has been hiding in a nerve, the rash will follow the length of that nerve.   If the nerve is on a leg, shingles will be a red band with little bubbles (also known as vesicles or pox), along the leg.  On the chest or arm the rash will follow the nerve like a stripe.  If it affects the nerve that crosses the front of the eye, it can cause painful, scarring injury to the front of the eye (cornea).  Because each nerve covers only half the body, the clue to a shingles rash is that it stops exactly at the middle of the body and affects only one half.

There are several stages of a zoster attack.  First, before there is any rash, there is numbness, burning or sharp pain.  It can be confusing to have an intense pain without any obvious injury.   Early shingles pain over the left chest is often confused with a heart attack.  Then a day or two later little clear fluid filled bubbles appear. They gradually form a continuous stripe rapping around half the body.  Usually, the rash never leaves this one area.  Rarely, in patients with severe immune problems like leukemia, lupus or HIV, the virus can spread over the body like a severe case of chicken pox.

As long as there are fluid filled bubbles the patient is contagious.  However, they are not contagious for shingles.  You cannot catch shingles.  They are contagious for chicken pox.  If a patient with shingles encounters someone who has never had chicken pox, then they can give that person chicken pox.  Eventually the bubbles dry up.  However, because the infection has burst out of the nerve there may be extended or even permanent pain in the nerve.  In some individuals this can be incapacitating or require long term pain medicine. This is known as post-herpetic neuralgia.

Obviously, herpes zoster is a condition which none of us ever wishes to acquire.  One way to protect ourselves is to never get chicken pox.  For children, who can be protected by the chicken pox vaccine this is a reasonable approach.  However, for most of us adults who had chicken pox when we were young, this is an impossible solution.  In fact some scientists believe that adults who had the chicken pox infection as children can be protected from getting shingles by occasionally being exposed to a child with an active chicken pox infection. Therefore, as more children are vaccinated for chicken pox there may be an increase in shingles.  Fortunately, there are alternatives.

The best solution is the shingles vaccine.  Manufactured and sold as Zostavax, the vaccine is recommended by the CDC for use by healthy people 60 years or older. The ACIP recommends it for anyone 60 or more who has previously had shingles, had any chronic medical condition or lives in a long term care facility.  Zostavax decreases the chance of getting shingles by 50% and decreases the chance of permanent pain if you do get the rash by 70%.   Zostavax is a single shallow subcutaneous injection and is not repeated.  This is a live vaccine, so cannot be given to someone who already has a suppressed immune system.  The main side effect is irritation at the injection site and a 2% chance of a flu like syndrome.  Zostavax cannot be used to treat an active shingles infection.

If you do get shingles, contact your doctor immediately.  Oral antiviral medicines started within the first 72 hours of the breakout, reduce the chance of nerve damage and pain.  These medicines also decrease the severity and length of a zoster attack.  Many doctors also put patients with a shingles attack on steroids because this may also prevent post-herpetic neuralgia.  This is somewhat controversial, because of the potential side effects of steroids.  If there is involvement in or next to the eye, it is vital to see an ophthalmologist immediately.

Shingles, herpes zoster, is a self-limited painful rash that can cause permanent injury.  It can make anyone’s life a little harder, especially if they are already dealing with other medical problems.  If you are over 60, talk to your doctor about being vaccinated.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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  • NormRx

    The price varies widely for this vaccine. Shop around and check with your insurance company, they may require you to receive this vaccine from a network pharmacy. If you are in the VA system, receive it there.

  • Peter Elias

    I am constantly amazed at the use of relative risk information rather than absolute risk or NNT/NNH. Reducing an event from 4 in 100,000 to 2 in 100,000 is a 50% reduction. So is reducing the incidence from 4 in 10 to 2 in 10. Relative risk information is useless.

    One needs to treat 175-231 (depending on study) patients with Zostavax to prevent a case of shingles, and ~ 1000 patients to prevent a case of PHN.
    Don’t tell patients you can reduce their risk of PHN by 70% if they get shingles. Tell them that for every 1000 people who get the vaccine, 1 will have prevented PHN.

    • NormRx

      Your are absolutely right Peter. The same can be said about cholesterol drugs and my favorite is cancer risk with circumcision. I am pulling these figures out of my head but I believe the cancer risk for circumcised males is 2/100.000 and for uncircumcised males it is 4/100,000. So you have a 50% reduction in cancer risk if you are circumcised. No mention is made of the morbidity and mortality associated with circumcision. I recently read a blog by a physician that post at this site and he was talking to the mother about circumcising her son. She absolutely wanted her son circumcised, when he asked her why, she replied that “a circumcised penis taste better.? Can you just imagine what a physician would say/do if a similar question was asked of a father who wanted his daughter to have a cliterectomy or some other form of genital mutilation and the father answered in the same manner. The cops would be called.

  • davemills555

    I don’t know if Medicare covers this but I have found that most pharmacies require full payment up front and tell you to go fight with your insurance company for reimbursement. Also, in my area, you’ll be hard pressed to find a pharmacy that has the shingles vaccine in stock because of the special handling requirements. The vaccine usually requires a handling fee on top of the cost of the vaccine because it must be kept in a special storage environment. That fee is expensive! When I call my insurance company, each customer agent gives me a completely different answer each time I call. They are being vague on purpose. None of them will say that the shingles vaccine is covered. I get the feeling that if I pay for it myself ($250 to $300), I’ll be stuck in spite of my “full coverage” prescription plan. I’ve given up. I’ll take my chances and hope I don’t get shingles. One thing I know for sure, the treatment for shingles is much more costly than the vaccine. My doc says getting shingles could require a hospital stay of several days. My doc says the treatment meds and the pain meds for shingles far exceeds the cost of the vaccine. The vaccine may not be covered by my plan, but the treatment and hospital stay is fully covered. I guess my insurance would rather pay for the treatment instead of the vaccine. Penny wise, pound foolish! Welcome to short sighted American style health care.

  • MissMeg

    Grandma got the shingles and was in immense pain several years ago. Our phone conversations were short because the pain was too much for her. She said it felt like someone was “turning a knife in her.” In desperation, I searched the internet and found positive information about a product developed by a man with a pharmaceutical background. Made from certain medicinal plant oils, this product could supposedly send the shingles virus back into dormancy. Cost was about $20 for a small bottle at the time, not much to lose if the product proved to be “snake oil,” which to my mind was quite possible. Turns out, it was worth every penny and more. Grandma rubbed it on the affected area and the soles of her feet as recommended. In a short time the pain was relieved. She never had a recurrence. Grandma was pleased and her doctor was impressed.
    Yes, I know. Sounds like an absurd sales pitch from some ignorant internet-user who thinks they can cure a dreadful disease that actually requires a vaccine to eradicate.

    A word to the wise: Answers sometimes come from unlikely places. Be willing to look.

  • Leeann

    My healthy, 38 year old coworker has been told that an outbreak on her forehead is shingles. I also am healthy and even younger than she. I noticed the 1 in 1,000 statistics. Shouldn’t I just get the vaccine and not run the risk?