Herpes zoster, or shingles, is caused by the reactivation of the latent varicella-zoster virus (VZV) within the sensory ganglia. The term shingles comes from the Latin word cingulum, which means belt or girdle, and refers to the characteristic rash that commonly appears as a band or belt on the trunk of patients with active
infection.1 What causes the virus to emerge from latency is not completely understood, but waning cell-mediated
immunity is linked directly to the reactivation. 2 This theory is the basis of research that led to the development of this vaccine.
Shingles affects people in all age groups. Anyone who has had chickenpox or received the chickenpox vaccine is susceptible to developing shingles. In immunocompetent people, an agerelated decrease in immunity reactivates the infection. Both genders are affected equally by the virus. Approximately 300,000 to 600,000 cases are reported each year in the United States.3 Pain is the most common symptom of shingles and may precede the rash during a prodromal stage. The rash manifests as grouped vesicles or bullae that may weep and then crust over in 3 to 4 days.
Shingles is usually limited to one dermatome; the thoracic and lumbar dermatomes are the most commonly
involved sites.2 Serious eye complications can occur if VZV is reactivated along the ophthalmic branch of the trigeminal nerve. Patients with eye involvement should be evaluated by an ophthalmologist.
The most common complication of shingles is postherpetic neuralgia (PHN). This manifests as mild to
severe pain that may last for months after the primary infection resolves. Approximately 10% to 15% of patients who experience shingles also experience PHN. Half of these patients are aged 60 years or older.1 PHN usually improves over time, but some patients may experience pain or a burning sensation for an indefinite period, leading to insomnia, depression, weight loss, and an inability to perform activities of daily living.
THE SHINGLES VACCINE
Zoster vaccine live is approved for the prevention of shingles in adults aged 60 years or older. The vaccine boosts immunity against VZV and reduces pain and complications in patients who may develop shingles after receiving the vaccine. Studies show the vaccine reduces the chance of VZV reactivation by 51% and decreases the ncidence of PHN by 67%.4 Seroconversion occurs in approximately 6 weeks.
THE WHO, WHEN, AND HOW OF ADMINISTRATION
The vaccine is approved for all adults aged 60 years or older. However, the shingles vaccine is not to be used to treat an active infection or residual PHN. Administering the vaccine to patients who have already had shingles has not been studied, but there are no known adverse effects.
Contraindications to the vaccine include hypersensitivity to the vaccine's ingredients, namely an allergy to gelatin or the antibiotic neomycin; primary or acquired immunodeficiencies; active untreated tuberculosis; pregnancy; and active high-dose corticosteroid therapy. A patient who has had documented contact dermatitis to neomycin can be vaccinated. If patients are on a short course of high-dose corticosteroids, one month should separate the administration of the last steroid dose and the vaccine. If the patient has received blood or plasma transfusion or immune globulin, wait at least 5 months before administering the shingles vaccine. This includes VZV immune globulin as well.5
The vaccine is administered in one dose, subcutaneously in the lateral upper arm, if possible. It should not be given intravenously. The patient may have redness or swelling at the injection site. And like all medications, serious allergic reactions may occur. Patients must be educated about possible adverse reactions and what to do, should they occur.
THE BOTTOM LINE
The shingles vaccine has been shown to be effective in lowering the occurrence of shingles, lessening the pain of an infection and the possibility of PHN. It is approved for patients aged 60 years and older, with just a few contraindications. JAAPA
For information that can be photocopied and handed to patients, please see the next section.
REFERENCES 1. Albrecht MA. Patient information: Herpes zoster (shingles). UpToDate Patient Information Web site. http://patients.uptodate.com/topic.asp?file=inf_immu/9349. Accessed June 13, 2007.
2. Albrecht MA. Clinical features of varicella-zoster virus infection: Herpes zoster. UpToDate Web site. http://uptodateonline.com/utd/content/topic.do?topicKey=viral_in/ 16889&type=A&selectedTitle=1~60 Accessed June 12, 2007.
3. Schmader K, George LK, Burchett BM, et al. Racial differences in the occurrence of herpes zoster. J Infect Dis. 1995;171(3):701-704.
4. Oxman MN, Levin MJ, Johnson GR, et al; Shingles Prevention Study Group. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005; 352(22):2271-2284.
5. Zoster vaccine: Drug information. UpToDate Web site. http://uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/98583&type=A&selectedTitle=2~4. Accessed June 12, 2007.
Patient Information
Should I get the shingles vaccine?
WHAT IS SHINGLES?
Shingles is a disease caused by the same virus that causes chickenpox. It is also known as herpes zoster. After chickenpox is healed, the virus that caused the infection stays dormant, or sleeping, in the cells of the nervous system. Scientists don't know what makes this virus wake up; but when it does, it can cause a painful rash. Changes in the body that occur with age allow the virus to wake up and become active. Scientists believe this is how the virus is able to cause an infection again.
HOW DO I KNOW IF I HAVE SHINGLES?
Shingles usually appears as a rash that forms a band on only one side of your body. A few days before the rash appears, you may feel unusual sensations like a burning feeling or tingling in the area where the rash is about to develop. The rash appears as blisters. The surface of the blisters may break open, and fluid will drain from them. The blisters form a crust a few days later.
Pain is the main symptom. The pain can be very severe. You may have a fever or feel chills. You may have a eadache. You may have an upset stomach. If the shingles rash appears on your face, it can cause serious eye problems. You should see an eye doctor if the rash appears around your eyes or on the tip of your nose.
Shingles is not likely to cause death. The main complication is that you may continue to have pain after the rash is gone. This is called postherpetic neuralgia (PHN). About 10% to 15% of patients who get shingles will have PHN. Half of the people who get PHN are aged 60 years or older. This pain can be mild or it can be severe. PHN results from an injury to the nerves caused by shingles. After the injury, these nerves do not feel sensations in a normal way. You may feel an unpleasant burning sensation that can last for a few months. PHN usually improves with time, but in some people the burning sensation may not go away at all.
HOW WOULD I GET SHINGLES?
It is not possible to “catch” shingles from someone who has it. Only people who have had chickenpox or received the chickenpox vaccine can develop shingles. However, you can get chickenpox if you touch the blisters on someone with shingles before a crust forms on the blisters. One of every five people who have had chickenpox will get shingles.
WHAT IS THE SHINGLES VACCINE?
This is a new vaccine that increases the body's ability to keep the virus dormant. It is for people aged 60 years and older. The vaccine is given as an injection (shot) in the muscles of your upper arm. The vaccine is not a treatment for shingles, and it will not help someone who already has PHN.
WHY SHOULD I GET THE SHINGLES VACCINE?
The vaccine can reduce the pain that shingles causes. The vaccine also can make PHN less severe for those people who develop this problem. However, scientists have not been able to prove that the vaccine will prevent shingles in all patients.
WHO SHOULD GET THE SHINGLES VACCINE?
If you are at least 60 years old, you should get the shingles vaccine, even if you have already had shingles. You may have redness, slight swelling, or feel soreness where the vaccine was injected in your arm. No serious problems have been reported with getting this vaccine. However, like any medication, this vaccine can cause an allergic reaction. Any reaction or high fever should be immediately reported to your PA or doctor.
WHO SHOULD NOT GET THE SHINGLES VACCINE?
This vaccine is not for everyone. You should not get the vaccine if you have an allergy to gelatin or to the antibiotic neomycin.
If you have a weakened immune system because you have HIV/AIDS; cancer, such as leukemia or lymphoma; or any other disease that weakens your immune system, you should not get the shingles vaccine. If you are taking high-dose corticosteroids, you should not get the shingles vaccine. If you are pregnant, you should not get this vaccine. If you have active, untreated tuberculosis, you also should not get this vaccine.
It is possible to give the chickenpox virus to someone who hasn't had it after you get the vaccine. You should avoid contact with pregnant women and people who have a weakened immune system due to cancer therapy or HIV/AIDS for 6 weeks after receiving the vaccine. You should talk to your PA or doctor if any special people in your life may be at risk.
WHAT SHOULD I DO NEXT?
Talk to your PA or doctor. He or she can help you decide if you should get the shingles vaccine. Your PA or doctor will be able to answer your questions about how the vaccine might affect your health risks, allergies, and other medical conditions. JAAPA
Katie Iverson is the department editor for When the Patient Asks and practices at the Emergency Treatment Center, University of Iowa Hospitals and Clinics, Iowa City. She has indicated no relationships to disclose relating to the content of this article.