Shingles vaccine .. Pros and Cons

Maybe you haven't heard anything about the shingles vaccine. Or maybe you have, but decided against getting it for any of a number of reasons like these:

- Although it has been approved by the U.S. Food and Drug Administration and by the European Commission for people 60 and older, you are only 45.

- It protects just half of those vaccinated, and you would just as soon take your chances.

- No one yet knows how long the benefits will last.

- No one yet knows about delayed side effects.

- You do not know anything about shingles, so how common or bad can it be?

- Your insurance does not cover it.

Before dismissing the vaccine entirely, you may want to consider Merritt ClappSmith's recent encounter with shingles. Although at 39 she is much younger than the typical shingles patient, her experience with confusing symptoms and a twice-missed diagnosis occurs at all ages. This is her story:

"My shingles case began with the periodic sensation that bugs were crawling in my hair. Three weeks later, I developed a headache that was one-sided but unlike a migraine. The pain was so bad I couldn't go to work. That evening, I discovered a raised and very tender ridge on my scalp.

"Unable to sleep and in terrible pain, I went to the local emergency room. The doctor there gave me an intravenous painkiller, tested me for meningitis or encephalitis, and concluded that I had a migraine and infected hair follicle.

"The terrible head pain grew, as did the sensitivity of the rash, and at 3 a.m. the next day, my husband drove me to a major hospital. The doctor cursorily looked at the blistering rash and treated me for a migraine. He had no explanation for the rash.

"After another horrible night and day of pain and a growing rash, my husband drove me to Urgent Care, where a nurse immediately suspected shingles, and the doctor concluded 'shingles' in 30 seconds. I got acyclovir for the virus and Vicodin for pain. I slept a lot, and my eye swelled. When the blisters scabbed over, I returned to work, but I was so tired and my eye was so sensitive to light that I had to cut short my workdays."

ClappSmith, an urban planner from St. Paul, Minnesota, said that after her experience she encouraged her mother, who is 71, to get the shingles vaccine. But that decision is not always simple.

Shingles, or herpes zoster, can afflict anyone who has had chickenpox. Both are caused by the varicella zoster virus. It is not known whether shingles can develop in people who received the chickenpox vaccine, which contains a live attenuated form of the virus.

This virus never leaves the body. It lies dormant for years in nerve roots near the spinal cord and can be reactivated as a shingles infection at any time, especially in people whose immune system is weakened by advanced age, extreme stress, a disease like cancer or AIDS or medications like chemotherapy, steroids and drugs used to prevent organ rejection. Sometimes, a physical stress like cold or sunburn can bring on an attack.

Reactivated, the virus migrates down the nerve until it reaches the skin, where it causes vague symptoms of irritation, pain, numbness, itching or tingling, followed in two or three days by a painful, blistering rash on one side of the face, head or body. Untreated, the rash lasts two to four weeks.

The pain can be severe and may be accompanied by headache, fever, chills and an upset stomach. In rare cases, it can lead to pneumonia, hearing loss, blindness, encephalitis and, rarer still, death.

After the rash clears, about one patient in five develops post-herpetic neuralgia, or PHN, a debilitating pain that does not always respond to treatment and can be devastating to ordinary life for months or even years.

Treatment with the antiviral drug acyclovir is best administered as early as possible, preferably within 72 hours of the first sign of a rash, to shorten the course of the disease and prevent the severe symptoms that ClappSmith experienced. Anti-viral drugs, if taken early, can reduce the severity of subsequent post-herpetic neuralgia, but starting anti-virals after PHN develops is of no help.

About one million cases of shingles a year occur in the United States, and the risk of it and of PHN increases with age. Half of 85-year-olds will have had shingles and, as people age, shingles-associated nerve pain increases in frequency and severity.

Debilitating nerve pain occurs in nearly a third of people with shingles who are 60 or older, and about 12 percent of older people who have shingles have pain that lasts three months or longer. The pain of PHN, which is difficult to treat, has been described as burning, throbbing, aching, stabbing or shooting. Even clothing touching the skin or a cool breeze can cause excruciating pain.

The shingles vaccine, Zostavax by Merck, was licensed in May 2006 in the United States after a study of more than 38,500 men and women 60 and older showed that it prevented about half of cases of shingles and reduced the risk of PHN by two-thirds.

"Among vaccine recipients who did get shingles, the episodes generally were far milder than they otherwise would have been," said Dr. Stephen Straus, an infectious disease specialist at the National Institute of Allergy and Infectious Diseases.

The vaccine, given in a single dose by injection, contains the same attenuated virus as the chickenpox vaccine, but is 14 times as potent.

The side effects have been minimal, usually redness, soreness, swelling or itching at the injection site and, rarely, headaches.

Based on the study, the researchers estimated that the vaccine could prevent 250,000 cases of shingles a year in the United States and significantly reduce its severity and complications in another 250,000 people. The vaccine is most effective in people 60 to 69, and less so with advancing age.

The vaccine is approved for use in people 60 and older who have had chickenpox. The Advisory Committee on Immunization Practices for the Centers for Disease Control and Prevention recommended that it be given to people who have had shingles, though the chances of another attack are low. The manufacturer's price for the vaccine is about $150. The patients' cost in the United States is often $300.

Because people in their 50s account for one in every seven cases of shingles, some physicians administer the vaccine "off label" to those younger than 60, even though its safety and effectiveness in younger people are not known. Also unknown is whether the vaccine is safe to administer to people whose immune systems are already weakened.

Follow-up studies are under way to determine how long the vaccine remains effective. If immunity wanes, a booster shot may be necessary.

Until the unknowns are resolved, the vaccine is not recommended for those with immune systems weakened by disease or drug treatment, women who are pregnant or might be pregnant and people with active untreated tuberculosis. Nor should the vaccine be given to anyone who has had a life-threatening allergic reaction to gelatin or the antibiotic neomycin.