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Shingles and the vaccine

What is shingles?

Shingles or herpes zoster is a painful rash that is caused by the reactivation of the chicken pox virus (varicella).   When you get chicken pox, the virus does not leave your body.  Instead it hides in your nervous system (sensory ganglia) and is suppressed from becoming active by your immune system.  When your immunity falls, the virus can blossom and the shingles rash can develops.

The incidence of shingles increases with age because the innate immune system weakens the older one becomes.  10-20% of people will develop shingles at some point in their life.  The incidence increases dramatically after age 50 years, and some studies show that over 50% of people who reach 85 years old will develop shingles.

Even though it is covered by Medicare Part D, only 20% of eligible patients actually get vaccinated.

Shingles is painful

Two main problems occur with shingles.  First is the immediate or acute pain.  The pain can be very severe and has been likened to passing a kidney stone or giving birth.  The rash can also leave scars in the involved skin.

The second problem is long lasting pain that continues after 1-3 months (the definition varies in different studies).  This is called “postherpetic neuralgia” which translates to “nerve pain after shingles.”  It can be severe and last months to years.

The acute pain and pain of postherpetic neuralgia is usually treated with medications like gabapentin (Neurontin) that work on nerve pain.  However, the pain can be relentless and debilitating and sometimes does not respond to treatment.

The shingles vaccine

In 2006, a vaccine was approved to prevent shingles and its sequelae such as postherpetic neuralgia.  It is an attenuated live vaccine.  This means that the vaccine virus is alive, but is changed so that it does not cause the unwanted effects of the natural chicken pox virus.  The vaccine is recommended for all people over 60 years old including those who have had shingles in the past.  Since it is a live vaccine, it should not be given to pregnant women or those who are actively trying to get pregnant within a month of receiving the vaccine.  It should also not be given to immunocompromised people (those with poor immune systems).  These may include patients undergoing chemotherapy, those with chronic lymphoma, and HIV patients with T-cell counts less than 200.

How well does the vaccine work?

In 2011, a paper was published to answer this question.  The authors combined the data of only very high quality studies.  38,546 patients over 60 years old were included in the study.   The authors found that the vaccine lowered the incidence of shingles, but did not reduce the overall incidence of postherpetic neuralgia.  This means that the rate of postherpetic neuralgia was essentially the same between those who developed shingles despite receiving the vaccine and those who did not receive the vaccine.  However, since fewer people developed shingles after receiving the vaccine, the number of people who actually developed postherpetic neuralgia was less.    The authors note that there were very few serious side effects and concluded that the vaccine was safe.

The study did not look at pain levels to see if the pain with either acute shingles or post herpetic neuralgia was less in vaccinated patients.  In a 2015 study from Minnesota of patients over 60 years old, there was no difference in the severity of pain or duration of pain between vaccinated and unvaccinated patients who developed shingles.  However, at GoldinSkin, we occasionally see patients who have developed shingles despite having had the vaccine.  We think that the pain level and degree of rash is less than in those patients we see who have not received the vaccine.  This is our subjective view and we have not formally studied this question.

 

How long does the vaccine last?

The answer to this is not well studied, but the vaccine may lose its effect after 7-10 years.  Studies are currently underway to determine if a booster vaccine should be given at 10 years.  This is not the recommendation at the current time.

 

Vaccination after having shingles

Patients often ask us if they should get the shingles vaccine if they just recovered from shingles.  The FDA recommends the vaccine despite a prior history of shingles.  However, we usually advise patients that the vaccine is not necessary.  The vaccine boosts the immune system to fight the chicken pox virus and prevent future episodes of shingles.  When you have shingles, your immune system is exposed to live chicken pox virus and you essential undergo a natural vaccination. Although not proven, the natural or wild type chicken pox virus is probably more effective at stimulating the immune system than the vaccine virus, so vaccination after having had shingles does not make sense to us.

Harry M. Goldin, M.D.

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