Lingering Questions And Answers About The Shingles Vaccine

Shingles (Wikimedia Commons)

A case of shingles (Wikimedia Commons)

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? Continue reading

The Scariest Reason To Get The Shingles Vaccine

Shingles rash on the chest of a 90-year-old man (Courtesy of Merck)

Shingles rash on the chest of a 90-year-old man (Courtesy of Merck)

First came several hours of blackest end-of-vacation stress. Not over anything truly serious, just garden-variety panic, as in, “We forgot the wallet and we’re late for the plane but just took the wrong exit for the airport.” It brewed inside me for hours amid my self-recriminations on the endless flight home.

Then, as we were finally filing off the plane, I felt a prolonged itchiness on the left side of my torso. Discreetly peeking under my shirt, I found a cluster of red pinpoints, sprinkled in a strip near my navel. “Oh, hell, not this too,” I thought. “Maybe it’s shingles from all that stress. I knew I should have gotten that shot.”

Shingles, in case you’ve missed all the vaccine ads on TV and in drugstores lately, is an often excruciating, blistery rash caused by the reactivation of the chicken pox virus that lies long dormant near your spine after your childhood chicken pox. It hits about a million Americans a year. The TV ads have a horror-movie ring, warning that the virus “may already be inside you.” A tough-looking firefighter tells you it was the worst burning sensation he ever encountered, and “it is bad.”

Think of it as ‘Extended Release’ shingles. Or as the closest thing to the trials of Job for an unlucky few.

Ha. I scoff at those ads. I’m not scared of shingles. Sure, I’ve heard the pain compared to third-degree burns and medieval torture, and very rare complications can cause blindness or affect the brain. But it generally lasts no more than several weeks, and that’s just not a frightening enough prospect to energize me to get an extra vaccine. Especially one that can cost me $185 even at a Costco pharmacy (which I know because I just called.)

No, the reason my heart dropped when I saw my rash — and the reason I am now going to pay out of pocket for the vaccine because my health insurance covers it only for those over 60 — is an affliction even less familiar to most people than shingles. It is called postherpetic neuralgia. Think of it as “Extended Release” shingles. Or as the closest thing to the trials of Job for an unlucky few.

We have a family friend whose epic case poisoned his life for years, but at my request, Dr. Anne Louise Oaklander, a Massachusetts General Hospital neuropathologist and researcher, refreshed my fear. Her postherpetic neuralgia patients, she said, “tell me that every day is spoiled, and that they are in chronic pain,” sometimes for years — pain so bad that it can lead to depression and job loss and isolation. In rare cases, even suicide.

“Shingles is no fun,” she said, and its rare complications can be serious, “but it passes,” and “the reason to get the vaccine is to avoid postherpetic neuralgia,” which affects 10 to 20 percent of people 60 and above who get shingles. Rates rise rapidly with age.

On the fence

At age 52, I’ve been on the fence for a while about getting Zostavax, the shingles vaccine. Though the FDA approved it in 2006 for virtually everyone over 50, Zostavax has been slow to catch on, hindered by supply shortages and other challenges. More on that later. But Merck, which makes Zostavax, says the pace is picking up.

“We shipped a lot more vaccine in 2012 than in 2011, almost double the amount,” said Dr. Eddy Bresnitz, the executive medical director for adult vaccines at Merck.

Should you, too, get on that bandwagon? The answer is a deeply personal decision — ideally, in consultation with your doctor, of course. It’s even more personal than most vaccine decisions, because shingles is not generally infectious, so you don’t have to factor in good citizenship.

Rather, your choice may hinge more than anything else on your age, your money, and what you fear, or don’t. Continue reading

Q&A: Putting The Shingles Vaccine On Your Medical To-Do List At 50

Ouch. A case of shingles, also known as herpes zoster

I’m terrified of shingles. My grandmother described the pain as the most excruciating of her life, far worse than childbirth. A family friend not only had shingles but a hideous after-effect called post-herpetic neuralgia, which I would translate as “endless torture,” or perhaps “hell on earth” — months and months of unbearable agony. (Read the basics on shingles here.)

So when the news broke late last week that the FDA had lowered the cut-off for shingles vaccine approval to age 50 and above — the previous cut-off had been 60 — I wondered how quickly the new federal guidelines would translate into actual vaccines at our doctors’ offices. Since it was first approved in 2006, the shingles vaccine — called Zostavax and made by Merck — has brought a mix of headlines: some laments that seniors were not taking full advantage of it, other complaints that shortages made the supplies spotty, and that insurance coverage was spotty as well.

I spoke this morning with Dr. Ben Kruskal, director of infection control at Harvard Vanguard Medical Associates, and an expert on vaccines. My takeaway: Wait a few weeks for the dust of the new approval to settle and health insurers to decide about coverage. But then it’s worth putting the shingles vaccine on your medical to-do list if you’re over 50 — and even then, it may be a few more months until the supply catches up with your demand.

Dr. Ben Kruskal

Our conversation, lightly paraphrased:

Q: Why has the recommended cut-off just dropped from age 60 to age 50?

A: Clinical trials have now demonstrated that the vaccine’s benefits extend down to age 50, so that has changed the recommendations of the CDC vaccine panel. It’s not that anyone thought it wouldn’t be beneficial to younger people, but companies seeking licensure try to pick a group in which there’s a very clear and dramatic effect, and it’s very clear that shingles is much more common in older people. All along there has been the thought that they probably would push it younger, and that’s where we are now. There will undoubtedly be some age at which it’s not worth doing, but at this point the cut-off is 50.

Q: How are you translating this for your patients? Will you move immediately to suggesting the vaccine for patients between 50 and 60?

A: Before we make a widespread recommendation, we want to wait and be able to tell our patients whether health insurers will pay for it or not. It’s likely they will. In general, the health insurers follow the CDC vaccine recommendations, though with expensive vaccines like this — Zostavax costs about $200 — there are starting to be some holes in that patchwork.

Q: Do they pay for it now for 60 and above?

A: Most do. All the major payers that we work with do cover it. The complication comes for Medicare patients:  It’s not that it’s not covered, but it’s covered under Medicare Part D, which makes the payment for the vaccines very complicated instead of being straightforward. The patient has to take the prescription for the vaccine from the doctor to the pharmacy, and then bring the vaccine — which has to be kept frozen — back to the office to have it administered.

Q: That sounds stupid. Is there a movement to change that?

A: As far as I know, there isn’t. But I’ve heard of at least one company springing up that is trying to handle all the paperwork and make it possible for doctors’ offices to just stock the vaccine and get reimbursed for it.

Q: So what should fiftyish people do at this point? Continue reading