Gettysburg Medical News
The Clinical View
by P.E. Hoffsten, MD
20 June 2007

SHINGLES VACCINE – TO DO OR NOT TO DO

            There is the story of the funny little man who got on the bus each morning, read his morning paper, and then very carefully tore it into tiny pieces and threw them out the window as he was on his way to work.  Other regular riders on this bus trip observed this over and over.  Finally one of them could stand it no longer.  A fellow rider had to ask him what he was doing and why he tore this newspaper up and threw it out the window each morning.  The little man replied with a very straight face that it was because he didn’t want the wild elephants disturbing traffic on his way to work. The inquiring person was very puzzled and commented that there were no wild elephants in this city and none for 10,000 miles.  The man then replied, “See!  It really does keep wild elephants off the streets”.

            The little man may have been absolutely crazy but believe it or not, we all do things that are just about as rational as he was doing.  Specifically, we go through all kinds of preventive measures using copper bracelets and magnets and various over-the-counter products such as echinacea.  They have no more demonstrated effectiveness than throwing the newspaper out the window as the little man did.  And so our preventive measures are often believed to be effective just like the little man’s.  The basic tenant that allows our preventive measures to be believable is that we never know what does not happen to us.  If we are in an automobile accident, we know it.  If we get pneumonia, we know it.  If somebody gets shingles, they know it.  But few people pay attention to our daily blessings of not having had an automobile accident or not having had a case of pneumonia or not having shingles.

            Thus presents the dilemma of whether or not to use a vaccine to prevent something such as shingles.  First, we might not ever get shingles that we are trying to prevent anyway. Second, the vaccine may or may not be effective and so shingles may come even if the vaccine is used.

            As an example, I grew up in the polio era where a significant number of people my age wound up paralyzed due to a viral disease called polio.  I grew up thinking about how I didn’t want to have that happen to me and hoped that it didn’t.  I was fortunate.  Today, middle school and high school students don’t give a thought to polio because they were vaccinated and the disease is virtually eradicated from the United States.  This is an example where vaccination works very, very well.  But those vaccinated children today have no appreciation for not having polio.

            So with all that preface and gibberish, what are of the considerations regarding shingles?  The statistics show that one person in four will get shingles during their lifetime.  The older the person becomes, the more likely they are to have shingles as the incidence per thousand population goes up with age.  Of those individuals that develop shingles, about one in four will be left with a very painful residual nerve damage called post-herpetic neuralgia that really doesn’t have a known predictably effective treatment.  Those that have experienced a bad case of shingles would offer almost any price to have prevented it.  Shingles begins as a vague band of irritation on one side of the body.  This can last 3-4 days and then a rash breaks out over this area.  The rash breaks down into an area of crusts that can last a month with severe burning pain.  Medication started early can decrease the discomfort of shingles.  But make no mistake!!  It is best to never get shingles to begin with.

            The shingle vaccine (Zostavax) costs around $150.00 to $200.00 per shot.  The likelihood of getting shingles with this vaccination is cut in half.  As an additional benefit, the likelihood of having the severe nerve pain that may come after shingles is cut by two-thirds.  Thus, the vaccine does not completely stop the shingles or its sequelae but it does quite significantly reduce the likelihood that the person will develop this problem.

            To make the situation even more complicated, it is known that the vaccine becomes less effective as the vaccinated population ages.  Thus for those person’s 80-years-of-age or older, there was only an 18% decrease of incidence of shingles in that group.  That compares to a 61% decrease for those individuals under age 60.  Weighed against this however, is the fact that shingles in the older age group is much more severe and painful than it tends to be in the younger group.  This presents a complex consideration of less effective vaccine but an even greater need to cut back the likelihood of developing shingles.

            Fortunately, the vaccine seems to be safe.  Side effects and complications are not expected. 

            Thus there appears that there will be 4 groups of people to consider. There will be one group who won’t get the shot, will never get shingles and will never know what they didn’t get.  The second group that will not get the shot, will get shingles and dearly wish that they had gotten the injection.  The third group of people will get the shot, never get shingles, but never really know what they didn’t get.  The last group is going to be very disappointed.  There will be some people who will get the shot, they will shingles anyway, and be really disappointed.  But even in this group, the expectation is that the shot will attenuate and decrease the severity of whatever shingles occurs.

            There are health policy groups that work with insurance companies and governmental agencies.  It is the responsibility of these groups to determine whether a given medical practice is worth the money spent for it.  Present analyses indicate that the Zostavax shot is probably a good investment considering the grief that it will stop for those it helps.  Like I said above, the people that get the shot are going to have to be happy with not knowing what they never got.