Imagine awaking to stabbing chest pain, extreme fatigue and a sick feeling, and a bizarre rash wrapping around half of your chest. Fearing a looming heart attack you seek immediate medical attention, only to be diagnosed with shingles. This may sound like an uncommon scenario, but it is far from it, and contrary to the feeling of relief many feel at diagnosis, shingles can be debilitating. According to the Centers for Disease Control and Prevention (CDC), 99.5% of adults over 40 have the shingles virus lying dormant inside of them just waiting to strike, and 1 in 3 people will develop an active shingles infection in their lifetime. Worse, one individual can reactivate shingles up to three times unless vaccinated. Yet still there are many misconceptions about the disease, and even following all current guidelines, shingles infection can’t always be avoided. Given the vulnerability of our population to shingles re-activation, increased education about shingles and support for the vaccine from medical professionals, especially in higher risk groups, are necessary to reduce the rate of shingles infection.
According to the Centers for Disease Control and Prevention (CDC), 99.5% of adults over 40 have the shingles virus lying dormant inside of them just waiting to strike, and 1 in 3 people will develop an active shingles infection in their lifetime.
The frequency of shingles infection in the American population relates primarily to the pathology of the virus. Shingles is caused by herpes zoster, the same virus that causes the chicken pox many of us experienced as children. In all individuals who have been affected by chicken pox, the opportunistic virus remains dormant in the nerves until it can reactivate, resulting in shingles infection. The NIH National Institute of Neurological Disorders and Stroke explains on their website that during initial herpes zoster infection, some virus particles travel to the nervous system, where they eventually reactivate and travel outward to the skin to begin shingles infection later in life. Even those who received the chickenpox vaccine show some likelihood of developing a milder shingles infection, given that the live attenuated vaccine utilizes a weakened virus that can still carry out the viral life cycle. Shingles is most common in individuals over the age of 60 and the risk of shingles is significantly greater among those suffering from immunodeficiency or taking immunosuppressants. Generally presenting as severe localized pain which mimics a heart attack or migraine, accompanied by a rash across one side of the chest, the infection is treated by a course of antivirals and plenty of rest. Around 1 million cases are diagnosed annually, with a small percentage resulting in post-herpetic neuralgia, a debilitating condition in which searing pain can persist for weeks or months following treatment.
However, there is an apparent solution: a shingles vaccine is currently available for eligible patients that can significantly reduce the probability of developing the disease.
However, there is an apparent solution: a shingles vaccine is currently available for eligible patients that can significantly reduce the probability of developing the disease. The vaccine, which has been approved for individuals over the age of 50 and is strongly encouraged for anyone over 60, can reduce the risk of shingles by 51% and the risk of post-herpetic neuralgia by 67% as specified by the CDC. Effectiveness was nearly twice as high in younger subjects (60s) than in patients over 70. Unfortunately, the CDC identifies a loss of effectiveness within five years of vaccination. Those vaccinated too young will see diminished efficacy by the time they reach the most susceptible age. A newer vaccine, described in the article “Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults” published in the New England Journal of Medicine in April, has shown 97% effectiveness in Phase III trials, though it has yet to be approved by the FDA for widespread use. This vaccine, a recombinant subunit vaccine, in contrast to the current live attenuated vaccine, is equally as effective in all age groups ranging from 50s to 70s. However, it is not yet known if the same decrease in efficacy over five years can be expected, as the average length of patient monitoring was just 3.2 years. In addition, the new vaccine has been associated with higher rates of adverse systemic reaction, which demands further research.
A major hurdle in shingles vaccination is the limitation on eligibility for the vaccine.
A major hurdle in shingles vaccination is the limitation on eligibility for the vaccine. Not only is the vaccine not approved for adults under the age of fifty who can still develop the disease, but those often most vulnerable to shingles reactivation, patients with compromised immune systems or undergoing chemotherapy, are not eligible. Here is yet another way in which the vaccine being currently developed is potentially superior: as a recombinant subunit vaccine, it may not present the same risks of infectivity as a live attenuated vaccine to patients with compromised immunity. Provided the issue of adverse systemic reaction is resolved, this vaccine could be a highly effective shingles preventative for a more diverse group of individuals.
The promising data on this vaccine makes clear that shingles could become a disease of the past, and makes it ever more important that we pursue new avenues to treat and prevent shingles.
The promising data on this vaccine makes clear that shingles could become a disease of the past, and makes it ever more important that we pursue new avenues to treat and prevent shingles. Even the current vaccine could decrease the prevalence of shingles by half in the elderly population, but it is not being used to the best of its reach. The CDC states that in 2010 only 14% of Americans over the age of 60 received the shingles vaccine despite the fact that the odds of developing shingles in that age group are extremely high. Increased use of the shingles vaccine could not only reduce the number of Americans diagnosed with shingles, but could help facilitate additional research into better vaccination protocol. The real key to progressing in the fight against shingles is education, as lack of awareness prevents patients from receiving the vaccination. With the help of companies like shingles vaccine producer Merck, whose shingles commercials can be seen on national television, the general population is becoming more aware of their risk and the options before them. If this trend continues, by the time my generation reaches high-risk age, shingles may be all but eradicated. At the very least all those involved with public health should shift their view of shingles as an inconvenience to a real health concern which can be addressed, for the sake of our aging population.
Centers for Disease Control and Prevention (2014). Shingles. Retrieved from http://www.cdc.gov/shingles/index.html
Lal, Himal et al. (2015). Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults. New England Journal of Medicine, 372, 2087-2096.
National Institute of Neurological Disorders and Stroke (2015). Shingles Information Page. Retrieved from http://www.ninds.nih.gov/disorders/shingles/shingles.htm