Wednesday, February 6, 2013
Shingles is a common disorder. It's caused by the reactivation of the chicken pox virus, varicella zoster virus, which remains dormant in one's nerves after infection with chicken pox. Anyone who has had chicken pox is at risk.
Shingles is an unpleasant illness. It causes prodromal nerve irritation, followed by the appearance of a blistering rash that follows the distribution of a nerve root. The rash can be painful and itchy, and can be the source of subsequent bacterial infection. In some cases, cranial nerves, including nerves that supply the eye and ear, may be affected and this may lead to loss of vision or hearing.
The most unpleasant complication of shingles is the occurrence of "post-herpetic neuralgia," defined as pain in the distribution of the shingles rash (or affected nerve root), which persists for more than three months after the shingles goes away. This may occur in 10 to 20% of cases. Early treatment with antiviral therapy may reduce the risk of post-herpetic neuralgia.
One's risk of developing shingles, and post-herpetic neuralgia as a complication, increases with age. Immune deficiency, such as infection with HIV/AIDS or treatment with cancer chemotherapeutic drugs, also increases one's susceptibility to shingles. It is uncertain how the use of the chicken pox vaccine, now standard in children, will affect their adult risk of shingles compared with those who are unvaccinated.
A vaccine for shingles, Zostavax, was FDA approved in 2006. In 2008 the CDC recommended that persons over the age of 60 receive the vaccine. This recommendation is based on the relatively higher prevalence of shingles and its related complication in this age bracket. However, the shingles vaccine is also effective in healthy adults ages 50-59. At this time the CDC has not recommended routine vaccination of this age group, which is likely related to lower disease incidence (about 4.6% annually in 50-year-olds, compared with 7% annually in 60-year-olds, ,and 9 to 11% in 70 and 80-year-olds).
Here are some common questions that patients ask me about the shingles vaccine.
1. If I have already had shingles should I get a vaccine?
The shingles vaccine has not been tested in those who have already had shingles once. It is speculated that having the condition increases one's immunity and helps prevent future recurrences. However, there is some research indicating that those who have already been afflicted may continue to be at significant risk for recurrence. Therefore, it may be reasonable for this population to be vaccinated.
2. What are the most common side effects related to the shingles vaccine?
According to the CDC, redness, pain, itching, and swelling at the site of the vaccine may occur in 1 out of 3 who receives the vaccine. Headache may occur in 1 out of 70. More serious allergic reactions to the vaccine components including fever, difficulty breathing and throat swelling, are infrequent.
3. Will it be safe for me to be around babies, pregnant women, and those with immune compromise after I have had the shingles vaccine?
Yes, although it is a live attenuated virus vaccine, there have been no described cases of the chicken pox virus being transmitted in this manner from a person inoculated with Zostavax to a person who is not immune.
4. In what population is the shingles vaccine contraindicated?
Although shingles is more common in those with immune compromise, the shingles vaccine is contraindicated in this population, which includes patients with HIV/AIDS, patients on cancer chemotherapy, patients on drugs that affect their immune system (such as oral steroids), and pregnant women. There are case reports describing disseminated shingles resulting from the vaccine in patients with established immune deficiency.
5. I'm not sure if I had chicken pox, Should I have a shingles vaccine?
Persons who are unsure of whether or not they have had chicken pox should have blood work done to determine their immunity. If there is no evidence of previous exposure then a chicken pox vaccine (Varicella) should be administered in those who are eligible, not a Zostavax.
6. After 60, how often does one need a shingles vaccine?
Currently a single vaccine at or after age 60 is recommended. The shingles vaccine is also FDA approved for patients ages 50-59 years. However, given the lower disease prevalence and risk in this population the cost and health-benefit is not as well established and at this time the CDC does not specifically recommend it. It remains uncertain how long the immunity conferred by a single shingles vaccine will last.
7. What is the cost of a shingles vaccine?
A shingles vaccine costs approximately $200. Many health insurance plans, including Medicare Part D and private insurers, cover the immunization after (but not before) age 60.
For more information go online here and here.
Juliet K. Mavromatis, MD, FACP, is a primary care physician in Atlanta, Ga. Previous to her primary care practice, she served on the general internal medicine faculty of Emory University, where she practiced clinical medicine and taught internal medicine residents for 12 years, and led initiatives to improve the quality of care for patients with diabetes. This work fostered an interest in innovative models of primary care delivery. Her blog, DrDialogue, acts as a conversation about health topics for patients and health professionals. This post originally appeared there.
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Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
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Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
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Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
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Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
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The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.