Lingering Questions And Answers About The Shingles Vaccine

In case you missed our earlier post and Radio Boston segment on the shingles vaccine, here's the CliffsNotes version:

Whether to get the shingles vaccine is a complex personal decision, and here are some points to consider as you make it: Your risk of shingles  -- a painful, blistery rash -- rises dramatically as you age. The vaccine, Zostavax, is about 51% effective at preventing shingles but far more effective at preventing a potentially life-ruining complication, a chronic pain condition called postherpetic neuralgia. The vaccine is approved for age 50 and up, and it is generally covered by health insurance if you're over 60, but coverage for younger people gets spotty, and Zostavax is not cheap, costing up to $200 or so. And preliminary studies suggest that the vaccine's protection wears off somewhat after a few years.

Left scratching your head? Join the club. I've decided to get the vaccine out of sheer terror — I've just heard too many horror stories, and the post brought more in the comments section. But because shingles is not generally contagious, your decision does not affect others, so you'll hear no preaching from me about whether you should get it. I do, however, want to add a few points of information in response to readers' very good questions:

Q: What about children who have had the chicken pox vaccine? Will they be able to contract shingles in the future? I've asked a couple of physicians, and they did not know the answer. 

A: According to the CDC: The short answer is yes, but the risk is a small fraction of the risk following chickenpox itself. In case you wish to know more, chickenpox can be mild and unrecognized during infancy or in utero, or following vaccination (the vaccine does not prevent all infections). So kids may get the vaccine and also (often unknowingly) be infected with the natural virus. Also, the weakened virus used to formulate the varicella vaccine can in fact cause shingles. But the risk for all of these seems low and rates of shingles in children and adolescents seem to be declining.

Q: What are the risks for someone who never got chicken pox as a child?  Should I get the chicken pox vaccine (in my mid thirties) or wait and get the shingles one?

A: Also according to the CDC, well over 99% of adults have been infected with the chickenpox virus, including persons who do not recall the illness, and if you were born before 1980 you need not get the chickenpox vaccine but can instead wait to get the shingles vaccine (exception: guidelines for health care workers are more stringent). Persons who wish to be reassured can ask their physician about lab testing to confirm that they have evidence of chickenpox infection. It's all more complex than this, but that may be more than you want to read.

A couple of somewhat biting comments also raise good points. (Sigh. Must you pollute your good thoughts with trollishness?)

One begins "Unbelievably naive reporting on the efficacy of said vaccine. Wow:)." Gee, thanks, friend, I didn't know it was naive to quote the country's premier government health authority on efficacy. But you do make a good point, which is that early data suggest that the vaccine's protection drops very significantly with time. Here is the site for Zostavax on the European Medicines Agency website, and if you go to page 21 of the product information here you'll find this early data suggesting that the protection drops, very roughly, by half: (HZ refers to herpes zoster, or shingles; PHN is postherpetic neuralgia, the longer lasting complication; and BOI is "Burden of Illness.")

The Long-term Persistence Substudy (LTPS): Following completion of the STPS, the LTPS evaluated the duration of protection against HZ, PHN and HZ BOI in a total of 6,867 subjects previously vaccinated with ZOSTAVAX in the SPS. The mean age at enrollment into the LTPS was 74.5 years. A concurrent placebo control was not available in the LTPS; data from prior placebo recipients were used to estimate vaccine efficacy.

The LTPS analyses for vaccine efficacy are based on data collected primarily from Year 7 through Year 10 following vaccination in the SPS. The median follow-up during the LTPS was ~3.9 years (range is one week to 4.75 years). There were 263 evaluable HZ cases reported among 261 patients [10.3/1000 person- years] during the LTPS. The estimated vaccine efficacy during the LTPS follow-up period was 21% (95% CI: [11 to 30%]) for HZ incidence, 35% (95% CI: [9 to 56%]) for PHN incidence and 37% (95% CI: [27 to 46%]) for HZ BOI.

And finally, a commenter who called me simplistic (Hey, have you been talking to my husband?) writes: "What's scary is that we MAY be turning a simple childhood illness into an epidemic of adult onset of shingles." The comment links to a 2006 journal article connecting the rise in shingles to the drop in cases of childhood chicken pox thanks to the vaccine.

Indeed, when I spoke to Dr. Anne Louise Oaklander of Massachusetts General Hospital, she confirmed that the near-universal chickenpox vaccine is thought to be contributing to a rise in shingles. Part of the impetus for developing the shingles vaccine, she said, came from projections of a spike in shingles because of the childhood vaccine. The thinking: When children have chicken pox and adults are exposed to them, the exposure boosts the adults' immunity to the virus that causes both. Now, with the vast majority of children immunized, the adults get much less exposure, and less of a boost.

"Epidemiologists long ago made the observation that women on average come down with shingles several years after men," she said, "and it was figured out that the likeliest reason was that the majority of people looking after kids with chicken pox were women. And when adults are exposed to kids with chicken pox, or grandparents with shingles, it reboosts their immunity."