What's the Straight Dope on Shingles Vaccination?

Factual Questions
141

Virtually everyone who’s been infected is carrying the virus (typically in a dormant state).

Chickenpox infection for those in the “target group” was extremely common (even if someone had a mild case and didn’t realize they were infected) so best to figure you are carrying the virus.

Yes, the CDC estimates 1 in 3 Americans will get shingles.

Yes.

Yes. It’s called post-herpetic neuralgia and occurs in approximately 10% of victims.

Yes. It’s quite possible that those who do come down with shingles after vaccination will have milder cases.

Immunity is generally weaker over time.

Haven’t heard that one.

Some people (evidently a small minority) have reported a chickenpox-like rash near the vaccination site. This is NOT the same as shingles. Other “unpleasant side effects” are the usual injection-related pain, soreness and/or redness for a few days at the vaccination site.

If money is really tight and insurance won’t cover the shot, you could roll the dice, skip the shot and figure you’ll either dodge shingles or like most people have an unpleasant but relatively short-term outbreak. I’ve heard enough horror stories about severe outbreaks and long-lasting post-outbreak pain to have wanted to give myself the best possible chance of avoiding the whole mess through vaccination.

So far, so good (though having an NSA microchip implanted along with the vaccine makes me uneasy at times).

142

Sorry, somehow hit the submit too early, and then took too long to finish. :frowning:

Assuming that to be mostly correct (or at least in line with what we know now) I can see two courses of action:

A) Get the vaccination.
Downside: This will cost about $200 (if your insurance doesn’t cover it) and has the usual small level of unpleasant side effects all vaccinations seem to have. (Minor shingles outbreak, some pain, etc.)
Benefit:
If you are in the group that doesn’t have and won’t contract the chickenpox virus, none at all.
If you are in the 70+% of those who were never going to have an outbreak of shingles regardless, none at all.
If you are in the unlucky 15% who will still get shingles despite the vaccination, none at all? Or does it reduce it even if it doesn’t prevent the disease entirely?
If you are in the lucky 15% the vaccination keeps you from having the shingles outbreak you otherwise would have had.

Basically, if looks to me like this choice has you pay $200 and undergo a minor risk from the vaccination in return for a 15% chance of escaping what could be a really, really painful outbreak of shingles.

B) Don’t get the vaccination. Instead learn what you can so you’ll be aware of what the first signs of a shingles outbreak feel like and, if you are in the 30% or so who gets one, immediately get the vaccination at that point. Is that just the same vaccination? If so, I assume it doesn’t give you as much relief as having had it before hand? Or, maybe it does? Since the immunity hasn’t had a chance to start wearing off as it might have if the vaccination had occurred, say, 3.5 years earlier?
So it looks like with this method, 70% will suffer no bad effects at all, 15% will suffer a hopefully reduced case of shingles that they would have suffered even if they’d gotten the vaccination, and the last 15% whill have that hopefully reduced case of shingles that the vaccination would have completely spared them.
So, preemptively getting the vaccination is like making a bet that a 15% chance of saving you some pain is worth $200 to you right now? Is that what it comes down to?

I’m genuinely undecided about this. It’s not that I’m reflexively anti-vaccination or anything. In fact, I just got a TDAP two months ago. And went through some significant arm pain for ten days, but tetanus isn’t something I will gamble with. But I dunno if this bet seems worth it to me.
What do you say? Am I thinking about this reasonably?

143

I too have never heard that getting the vaccine within 24 hours of getting shingles provides protection. Can you provide a citation for that?

More importantly, I think your chances of recognizing a shingles outbreak within 24 hours are close to zero. According to what I’ve read, the early symptoms of shingles is a headache and flu-like symptoms. Tingling and skin pain develops later, and the rash develops after that. How are you going to distinguish the early symptoms from the flu or similar mild diseases? Also, are you confident that even if you do recognize it within 24 hours, which seems fairly impossible without prior experience, you are going to be able to get a same day appointment with your doctor in the few hours remaining, to get the shot? What if you’re traveling when it happens or it’s on a weekend? This seems like a terrible plan to me.

As I mentioned above, I just got the shingles vaccine about a week ago. I did develop a rash around the injection site, that lasted for about 3 days and was mildly painful for the first day. It was nothing worse than a mild sunburn. Compared to the reported symptoms of shingles, it was a no-brainer decision.

The only legitimate issue I see that you’ve raised is the cost. Do you have health insurance at all? Why do you think your insurance won’t pay for it?

–Mark

144

You would think that at 77 I would have heard about everything, but apparently not. I had no idea that the shingles vaccine could be so expensive. On my current insurance (through my retirement plan) there has never been any charge for ANY injection, including Shingles. I think I now understand better how poor health insurance is (or can be) in the US.

If you guys ever get a chance, look into an HMO policy (mine is Kaiser).

Bob

145

I did it at almost exactly your age. It didn’t exist when I was at the normal age to get it, and then my sister came down with shingles that landed her in the ER. Mom couldn’t remember whether I’d had chickenpox as a kid because I was kind of a delicate flower with sensitive skin and had all sorts of other rashes (trivia note: I had a pediatric dermatologist named Dr. Spot!)

After a chat with my doctor, he did a blood titer test, and I showed no immunity to chickenpox, so I went ahead and got the vaccine. Better safe than sorry in my book.

ETA: my boss, who was one whole day older than me, got chickenpox in her 30s. She was miserable and spent 3 weeks off work soaking in oatmeal baths and popping steroids. You do NOT want to get chickenpox as an adult.

146

For those who are doubting whether it’s worth it to get the jab, here’s my description of what it was like having shingles: http://boards.straightdope.com/sdmb/showpost.php?p=17812003&postcount=22

Any chance at all of preventing that from happening to you is worth the money.

I have a co-worker who had it on his face. He’s lost 75% of the vision in his right eye, and after 18 months still has a severe burning itch in the eyelid. Now and then he comes in with the eyelid all scratched up and bloody. Those are the nights when the socks or gloves that he puts on his hands while he sleeps have come off. Everyone tells me that he was a happy laid back guy before this happened to him. He is barely tolerable now, although I do fight to be as kind as possible in response to his harshly abrasive presence.

Get. the. vaccine.

147

Not really, I was just told it by the receptionist at my GPs office. I’ll see if I can find something.

Oh, we have insurance, through my husband’s job. But if all plans are supposed to cover vaccinations, it must be one of those grandfathered plans. :frowning: Because I’m absolutely sure – I called the plan info line directly to ask, and also had my pharmacy check. At my physical a couple of months ago, my doctor gave me scripts to get the TDAP, pneumonia, shingles and flu vaccinations. There was no coverage at all for any of them, and they’d come to just about $500 for the lot. Oh, and my husband will likely need the same set, of course, he’s do for his checkup next month.

A thousand bucks at once is really painful, so we’re looking at choices – what to get at once (the TDAP), what can wait a month or so (flu/pneumonia, maybe?), and what we’re not sure about (the shingles one.)

148

Another factor to throw into the mix is that shingles rates are increasing.

My WAG is that such is the result of adults having less exposure to kids with chickenpox, which functioned as an environmental booster. This decreased exposure began even before widespread use of the chickenpox vaccine as a consequence of adult children (and thus grandkids) more commonly living away from grandparents and thus not exposing them when they got the disease, but is much more dramatic now as many parents in their 50s and below, to 30s, had natural disease but have never since been exposed to natural disease, as their kids were vaccinated.

Some experts conclude that childhood immunization has nothing to do with the increase in adult shingles rates (since it had begun to rise before childhood chickenpox immunizations began) but whatever the reason the risk is increasing, including in those under 50.

Unless you know you have been exposed to natural disease as an adult,and more hitting 60 have not than ever before, I’d think holding off is not a great idea.

149

The CDC does not concur with the idea that vaccination has helped drive up shingles incidence.

“CDC is monitoring the effects of varicella vaccination on the epidemiology of herpes zoster in the United States. Studies indicate that overall rates of herpes zoster appear to be increasing, however, introduction of the varicella vaccine does not seem to be affecting this increase. Although uncommon in children, the rate of herpes zoster in United States children has been declining since the routine varicella vaccination program began. Perhaps because vaccinated children are less likely to become infected with wild-type chickenpox virus, which is more likely to reactivate as shingles compared to attenuated vaccine virus.”

Moreover:

*"Each year, more than 3.5 million cases of varicella, 9,000 hospitalizations, and 100 deaths are prevented by varicella vaccination in the United States.

Varicella incidence, based on national passive surveillance data published in 2012, declined 79% during 2000-2010 in 31 states that met CDC’s criteria for adequate and consistent reporting. From this same data source, incidence declined 72% during 2006-2010, after a routine second dose of varicella vaccine was recommended. Varicella incidence from 2 active surveillance sites declined 98% during 1995-2010…
Varicella hospitalizations declined 93% in 2012 versus the pre-vaccine period; during the 2-dose varicella vaccination period (2006-2012), hospitalizations declined38%
Varicella deaths declined by 87% during 2008 to 2011 as compared to 1990 to 1994 based on data from the National Center for Health Statistics (NCHS). In children and adolescents less than 20 years of age, varicella deaths declined by 99% during 2008 to 2011 as compared with 1990 to 1994.
Varicella incidence among HIV-infected children declined 63% during 2000-2007 compared to 1989-1999.
Varicella vaccination provides indirect benefits to people who are not eligible for vaccination. Varicella incidence among infants, a group not eligible for varicella vaccination, declined by 90% from 1995 to 2008."*

One would expect that over time, shingles rates will decline markedly because there will be far fewer people carrying the virus into late adulthood.

150

Yes Jack, I am aware. In this case I respectfully disagree with the conclusion.

Not sure why you are quoting those varicella numbers when the issue was the impact on shingles. Yes the two dose chickenpox immunization schedule has decreased complications due to primary chickenpox disease. Before the immunization about 100 people died across the whole country each year from primary chickenpox infection and the number is now near zero.

And no question in my mind that those who are vaccinated as children will be at much less risk of shingles as adults. Long term shingles rates will decrease as the result of universal childhood immunization against chickenpox. Skeptical as I was at its introduction (believing that most of the benefit on morbidity and mortality could be gained with giving it only to those who did have natural disease by age ten, since almost all of the mortality and morbidity was in age groups older than that) I have become convinced.

The observation is that shingles rates among those who had natural disease is increasing. This increase began, very slightly in the early 90s, before the chickenpox vaccine was introduced in 1996. And a study looking only at shingles rates of those over 65 (old enough that they likely did have adult exposure to chickenpox in their kids) shows that the increase has been fairly steady in that population.

Certainly the fact that the increase began before the vaccine falsifies lack of adult exposure as a sole factor. It does not however rule it out as a significant contributing factor. Changing patterns of exposure of grandparents to grandchildren, increased numbers of individuals surviving on immunosuppressives, and other factors no doubt contribute as well.

Concluding however that lack of versus repeated adult exposure has no contribution to shingles rates is just not justified. Historically it was observed that pediatricians and others who have more exposure to natural chickenpox get shingles less frequently and less severely. Case control studies, such as this one demonstrated that adult exposure to natural disease lowered rates as well.

Again, however, the point is a simple one. Not to attack childhood immunization against chickenpox, but to point out that whatever the cause shingles is more frequent now than it has been, and unless adults who are advised to get the shingles vaccine actually do get it in decent numbers probably will become more frequent.

It’s approved for those over 50. IMHO a 50 year old has had no adult exposure to chickenpox may want to consider not waiting until they are 60 to get vaccinated. Just MHO.

151

To expand on the defects in your WAG about shingles incidence (courtesy of the CDC):

*"Some scientists have suggested that exposure to varicella disease may boost a person’s immunity to VZV and reduce the risk for VZV reactivation as zoster. Some studies have shown reduced risk for zoster in adults who are exposed to varicella, but other studies have not shown this effect.[6-10]

In the years following implementation of the childhood varicella vaccination program in the United States in 1996, rates of varicella in children fell dramatically. This led some scientists to speculate that increases in zoster in adults were the result of widespread vaccination of children against varicella, because adults have fewer opportunities to be exposed to varicella disease in children. However, this seems increasingly unlikely.

A recent CDC study, using Medicare data from 1992 to 2010, found that among adults aged 65 years or older, zoster rates were increasing even before the varicella vaccine was introduced in the United States.[1] Moreover, zoster rates didn’t accelerate after the routine varicella vaccination program began.

We also examined whether there was a link between state varicella vaccination coverage and zoster rates. Zoster rates did not accelerate as states increased varicella vaccination coverage. In fact, zoster incidence was the same in states with consistently high vaccination coverage as it was in states with lower vaccination coverage.

Our study adds to a growing body of evidence showing that the increase in zoster rates is not a result of childhood varicella vaccination.[1,2,4,11]"*

There is a recent study which suggested a temporary link between chickenpox vaccination and increased shingles incidence in one limited age group. But it also found that re-exposure to chickenpox enhanced adults’ immunity for a much shorter period than previously believed (thus, the “booster” effect has been overstated).

*"A new model developed by the scientists also confounds previous findings on the length of time re-exposure chickenpox boosts immunity to shingles. The effect was thought to last for up to 20 years, but results of the current modeling study show it only lasts for two. The new model is the first based on real immunological and virological data from individuals.

“We were surprised to find that re-exposure to chickenpox is beneficial for so few years and also that the most pronounced effect of vaccination on increasing cases of shingles is in younger adults,” says lead author Dr Benson Ogunjimi.

“Our findings should allay some fears about implementing childhood chickenpox vaccination,” he says."*

And while there are some respectable voices in medicine that have concerns about the vaccine supposedly increasing shingles rates, this meme is also a favorite of antivaxers, as seen here.*

*the main researcher quoted, Gary Goldman, has an interesting history, as does his sometime collaborator, Neil Z. Miller (who talks to extraterrestrials in his spare time when he is not excreting new antivax books).

152

I keep going back and forth on the varicella vaccine/shingles increase theory. I used to be all gung ho about it, because it’s so elegant and beautiful and logical. But then I realized it was repeated an awful lot in antivaxx circles, and knowing their track record for accuracy, I began to doubt it. Then that study came out that showed rates were increasing before vaccination, and I figured that pretty much put it to rest.

But it’s still such a pretty theory. Added to it is the information that shingles is something like 4 times as likely in White elders than in Black elders, and Black grandparents spend a lot more time around their grandkids, and now I just don’t know what to think.

At the end of the day though, it doesn’t matter. Chicken pox vaccination isn’t going anywhere. When the majority of kids is getting vaccinated, it doesn’t make any sense to not vaccinate your kid in the hopes that they catch chicken pox young and can go be a booster for Grandma. It’s just increasing the risk he won’t get it until his teens, because there aren’t many kids to catch it from anymore.

153

Agreed that at the end of the day it does not matter. And the recent study cited by Jack is interesting.

That said the fact that anti-vaxxers say something does not automatically mean that what is said is incorrect.

I suspect anti-vaxxers are against the new MenB vaccines being widely routinely used for all college students. Does that mean that therefore the opposite must be true? In fact in this case the AAP and the CDC agree that despite the advertising campaign heavily promoting it the vaccine actually should only be used for very specific indications and not as widely as the commercials would suggest.

The anti-vaxxers would claim that the vaccine makers’ commercials in this case make the vaccine seem much more effective than it is and the disease much more common than it is. Some colleges have responded to the marketing campaign by requiring the vaccine. Anti-vaxxers are usually wrong. Almost always. Almost. But something is not false just because an anti-vaxxer says it. As the AAP notes

The concerns about increasing shingles rates did not originate with anti-vaxxers but within the medical community and before the vaccine was recommended for universal use. It may turn out that the increase we’ve seen in shingles since then is coincidental and completely from other unidentified causes. In any case the benefits to the individuals getting the vaccine and longer term to society as a whole outweigh the hypothetical and unproven cost. The recent study cited above does reassure that likely the increase is due to other unidentified factors.

End of day remains: rates of shingles are rising, for whatever reason. Getting protected makes even more sense than it used to.

154

I figured there was a chance you’d jump on the mention of antivaxers largely to the exclusion of other points raised (in spite of my taking pains to mention that some sober analysts also had concerns about vaccination possibly having an association with shingles incidence). The fact that antivaxers fervently espouse this very tenuous connection should be enough to make physicians very cautious about promoting it without a careful examination of all the evidence, which mostly refutes it.

Incidentally, I don’t doubt that many pediatricians have revved-up immune systems (for good or ill) because of their frequent exposure to sick kiddies (that was one of the myriad reasons I was not interested in going into pediatrics). Whether re-exposure to chickenpox accounts for a reported lower shingles incidence in that group (and not exposure to other pathogens or unrelated factors) is questionable.**

*the odds are overwhelming that whatever meme antivaxers are flogging is grossly exaggerated, unproven or an outright fabrication (which is most common).
**if this theory was correct, one would expect that shingles rates are markedly increasing in pediatricians due to lack of virus-shedding “booster” children, and I haven’t heard of that occurring. :slight_smile:

155

Y’see Jack, I had “espoused” it first, back in the '90s, as the decision to recommend the vaccine universally was being made. At the time many of us were concerned that shingles rates would rise as a result of this vaccine, and again, most of the morbidity and mortality benefits would be gained at a fraction of the cost and none of that potential risk by having given it only to children who had reached ten without catching natural disease. We worried that we’d see a rise and since then we’ve seen a rise, including in younger adults. Now maybe it’s just coincidental and the CDC is convinced so.

Our side lost the argument then though and we all came on board, including my having own younger two of four children who had not yet had natural disease immunized. The worst case would have been getting enough kids immunized that a sizable number of those who did not vaccinate avoided getting it in childhood due to decreased exposure but enough not immunized that they were still at risk of catching it later, not vaccinated at age 10. Once the decision to go universal was made it was important for us all to do our best to get everyone vaccinated.

Responding to your silly aside, I, like most pediatricians of my age cohort and above, of course have been exposed to chickenpox as an adult on myriad occasions, both professionally and more intimately caring for two older children who had it. And being good patients the odds are most of us will do the shingles vaccine when we hit 60. So while it would be an interesting experiment to see if pediatricians who have not had any adult exposure to primary chickenpox still have lower than average rates of shingles as they age, even without the shingles vaccine, the experiment will likely not occur.

I do not believe that the cause of promoting immunizations justifies knee jerk response rejecting any statement on the basis that an anti-vaxxer says it or even using that as part of the argument against it. The newer study you cited was OTOH good. A bit more convincing to me than the CDC’s argument alone.

It seems to me that you are overly and needlessly defensive. Dude, the point of my post was to promote getting the shingles vaccine because the risk is going up!

156

Actually, you’re the one who brought up purported pediatrician resistance to shingles based on repeated exposure to chickenpox. I merely pointed out that even if pediatricians had lower shingles rates, there are multiple potential explanations. And if your theory was correct, evidence should indicate that incidence rates in your profession have recently been jumping because your exposure to “booster” children has dropped substantially. That doesn’t require an “experiment” to prove, just a demonstration that shingles is now considerably more common among pediatricians. I have not seen any such evidence.

Again (since you apparently missed it the first time): if a physician (or any rational human being) finds himself promoting a meme popular among antivaxers, it is incumbent on that person to make sure that he’s considered all the evidence (rather than promoting a position that is extremely likely to be dead wrong).

The CDC’s “argument” is similarly based on epidemiologic evidence, hard as that may be to swallow for someone who has believed differently since the '90s and is now “going along” with what professionals in this field have determined to be the best course of action.

Good for you. I regret your unnecessarily having a tizzy because your theory as to why shingles incidence is rising has been shown to contain multiple flaws.