What to know about reporting on shingles

By Liz Seegert

You probably have heard of shingles, a condition caused by reactivation of the chicken pox virus in older age. But without experiencing it, it may be difficult to imagine just how painful it can be or how serious a threat the complications that accompany this disease may pose for the older population.

About a million new cases of shingles, also known as herpes zoster, or varicella-zoster virus (VZV), are diagnosed in the United States every year, according to the CDC. Anyone who has ever had chickenpox is susceptible. Once a person is infected with this virus, it remains in their body for life. It stays inactive in many but certain triggers, such as a weakened immune system, can cause it to spring back to life.

It’s most common in 60- to 80-year-olds – about 10 per 1,000 people in this age bracket will get it, says the CDC. By the time people reach age 80, about half of all Americans will have had it. According to the National Institutes of Health (NIH). Among the estimated one million cases each year, between one and four percent of sufferers are hospitalized for complications.

Risk of developing shingles rises after age 50; approximately one-third of those who develop shingles also develop serious complications. Risk of complications increases after age 60. And while there’s a vaccine that’s been proven effective in older adults, many are skipping it, as reported in this New York Times article. That is not wise since complications can range from lingering pain to stroke and heart problems.

Initial shingles symptoms include a painful rash developing on one side of the face or body. The rash forms blisters that typically scab over in seven to 10 days and clear within two to four weeks, according to the NIH. In rare cases (usually people with a weakened immune system), the rash is more widespread and look similar to a chickenpox rash. In addition to the rash, it there can be burning, shooting pain, tingling and itching.

The early signs of shingles usually develop in three stages: severe pain or tingling, possibly itchy rash, and blisters that look like chickenpox. While most people experience short-term symptoms, shingles can be more serious for some, including greater risk of heart attack or stroke, as The Washington Post recently reported.

As this article in Today’s Geriatric Medicine points out, the increased incidence of the disease in older adults may be due to lower cellular immune function. Additional risk factors include being female, having suppressed immune function from psychological stress or other diseases (such as HIV or cancer) and medical treatments (such as chemotherapy). As a person’s immunity to the varicella zoster virus begins to decline at the cellular level at older ages, the VZV virus can travel back up the nerve roots, where it remains dormant for decades and eventually reach the skin. According to the CDC:

• 95 percent of adults are at risk for the disease.
• Risk rises after age 50; risk of complications increases after age 60.
• More than one-third of adults who get the disease will develop serious complications.
• Prompt treatment is essential to control acute symptoms.
• In addition to rash and blisters, symptoms can include skin that is sensitive to touch; mild itching to strong pain; flu-like symptoms such as chills, fever, upset stomach, or a headache.

Complications

The most common complication of shingles is pain from a condition known a post-herpetic neuralgia (PHN). People with PHN have severe pain in the areas where they had the shingles rash, even after the rash clears up. In most patients, the pain usually clears in a few weeks or months, but some people can have pain from PHN for years. Persistent pain from shingles is a common symptom in people over 60; one out of six will experience severe pain. Long-term and more severe pain from shingles become more common as people age. Some people never fully recover from the chronic pain and are at risk for depression and social isolation.

Shingles can also increase the short-term risk of heart attack and stroke in older adults, according to this study by researchers at the Mayo Clinic. According to the NIH:

• Outbreaks that start on the face or eyes can lead to vision or hearing problems. Permanent blindness can result if the cornea of the eye is affected.
• Bacterial infection of the open sores can lead to scarring. In a very small number of cases, bacteria can cause more serious conditions, including toxic shock syndrome and necrotizing fasciitis, a severe infection that destroys the soft tissue under the skin.
• The burning waves of pain, loss of sleep and interference with even basic life activities can cause serious depression.
• In patients with immune deficiency, the rash can be much more extensive than usual and pneumonia can be a complication. These cases are more serious, but are rarely fatal.
• Shingles can also lead to pneumonia, brain inflammation (encephalitis), or death, although this is very rare.

Photo: NIAID via Flickr

Treatment

Zostavax, first approved in 2006, is the only shingles vaccine currently approved for use in the United States. The vaccine reduces the risk of developing shingles by 51percent and PHN by 67 percent based on a large study of more than 38,000 adults aged 60 years or older. Protection from shingles vaccine lasts about five years. It is given in one injected dose and can be administered in a doctor’s office or pharmacy.

The CDC recommends that everyone over age 60 years received the shingles vaccine whether or not they recall having had chickenpox. That’s because nearly everyone in the United States age 40 and older had chicken pox as a child. (Studies show that more than 99 percent of Americans age 40 and older have had chickenpox, even if they don’t remember getting the disease.) There is no maximum age for receiving the shingles vaccine, which has been shown to reduce the risk of contracting shingles by 51 percent and the risk of post-herpetic neuralgia by 67 percent.

Zostavax is made with a weakened form of the herpes zoster virus. While it reduces the risk of shingles, it still hasn’t caught on, as this Philly.com article noted. Maybe that is because the reduction shrinks with age, making the vaccine less effective in older people more likely to get the disease. The risk is reduced by 70 percent for people in their 50s but only 38 percent of people over 70. “Moreover, the protection fades to almost nothing eight years after vaccination, a Kaiser Permanente study found,” the story said.

Meanwhile, GlaxoSmithKline is seeking FDA approval for its drug, Shingrix, for people over age 50. It could be a possible billion-dollar-a-year blockbuster.

Who pays?

This can be a little confusing:

• Medicare Part D plans cover the shingles vaccine, but there may be a cost to the consumer, depending on their plan. However, not every older adult has a Part D plan and may have to pay out of pocket for this vaccine.
• Medicare Part B does not cover the shingles vaccine
• Medicaid may or may not cover the vaccine. Contact your insurer to find out.
• Most private health insurance plans cover the vaccine for people 60 years of age or older. Some plans cover the vaccine for people ages 50 through 59

The good news is that shingles itself is not contagious. But others can catch chickenpox from someone with shingles. So it’s best to avoid close contact.

Story ideas:

• What’s the prevalence of shingles among older adults in your community? How many older adults are hospitalized each year due to complications?
• What are health providers, hospitals, or clinics doing to increase vaccination rates
• Does your city offer it for free or low-cost as a public health measure?
• What’s stopping people from getting vaccinated?

Resources

• This article from the New England Journal of Medicine on preventing shingles and complications in older adults.
• This article from The Gerontologist (November 2016), detailing the prevalence of shingles among older adults in the U.S. (email Todd Kluss, Communications Manager, GSA, for access to full article).

Sources

• American Chronic Pain Association: 800-533-3231, ACPA@theacpa.org.
• National Shingles Foundation: 212-222-3390, www.vzvfoundation.org.
• National Foundation for Infectious Diseases (NFID), Bethesda, MD. Joanna Colbourne, director, Communications & Public Outreach, 301-656-0003.
• Merck Vaccine Patient Assistance Program (manufactures Zostavax) (800) 293-3881.
• James Steckelberg, MD: consultant, Division of Infectious Diseases and a professor of medicine, Mayo Medical School, Rochester MN. Contact through media relations: 507-284-5005. If the request is not urgent, you may also email your request to newsbureau@mayo.edu.
• Bruce Hirsch, MD: Infectious disease specialist and assistant investigator in patient-oriented research at the Feinstein Institute for Medical Research; also an assistant professor of medicine at Hofstra Northwell School of Medicine; 516-562-4280; bhirsch@northwell.edu.
• George Pasvankas, M.D.: anesthesiologist and pain management physician at University of California, San Francisco, Pain Management Center; 415-885-PAIN (7246).