Dr. Stephen Tyring discusses the safety and efficacy of the shingles vaccine, including the dermatologist’s role in the public health effort to prevent reemergence of the virus.
Steven K. Tyring, MD, PhD is a board-certified dermatologist at Houston Skin Associates, Houston, Texas
“Vaccines have been around for a couple hundred years, since the advent of the smallpox vaccine, but usually the vaccines are to prevent something that a person doesn’t already have,” said Stephen K. Tyring, MD, PhD, who presented “Zoster Vaccination” as part of the panel “Herpes Zoster: Controversies and Conundrums in Treatment and Prevention” at the 2022 American Academy of Dermatology (AAD) Annual Meeting.
“[Almost] all of us who grew up in the 20th century have the chickenpox virus, or at least the DNA sitting in the nerve root, the dorsal root ganglion.”
As a result, roughly 30% of people who had chickenpox are likely to get shingles in their lifetime, said Dr. Tyring.
“And so this vaccine is doing something that most vaccines don’t do and that is preventing a reemergence of a virus. And of course, there is another vaccine that prevents chickenpox. Now, since about 1996, when it was approved and beginning in the early 21st century when it was more widely used, the chickenpox vaccine has been highly effective.”
Although chickenpox itself has become rare with the wide-spread use of the vaccine, shingles is still a possibility for those who had chickenpox prior to its availability, said Dr. Tyring.
“The first shingles vaccine was … a live attenuated version that … was based upon a concentrated version of the chickenpox vaccine given to people that had chickenpox as children.”
The now-defunct vaccine lowered the risk of having shingles by about 50% and post herpetic neuralgia by two-thirds, said Dr. Tyring.
“So it was a success, but it wasn’t quite as successful as a vaccine that prevents a disease in first place.”
Today the live attenuated vaccine has been replaced by a recombinant vaccine, which provides more significant protection from shingles.
“So the discussion now is …should people get the new recombinant vaccine?”
According to Dr. Tyring, the answer is a resounding yes.
“Over the past 30 years of doing shingles studies, I’ve seen that the devastating consequences, many people saying it’s the worst pain they’ve had in their life.”
Patients say the pain is worse than surgery. It’s more painful than bullet wounds or childbirth without anesthesia, said Dr. Tyring.
“The reason it’s more painful is not only the intensity but the duration because the pain of post herpetic neuralgia can last months or even years and be the worst thing that can happen to a senior citizen…”
The CDC recommends that healthy individuals over the age of 50 receive the vaccine, said Dr. Tyring. However, despite studies that have demonstrated the safety and efficacy of the recombinant shingles vaccine vs placebo, vaccination rates remain low. Study authors point out the need for a public health effort to address this issue.1
“The vaccine in the studies was much more effective and, in fact, up to 97% more effective against the placebo.”
Over the course of 4 years, study participants showed a continued high rate of protection (over 90%), said Dr. Tyring.
Furthermore, “The FDA last year approved [the recombinant vaccine] for people over 18 if they were immunocompromised… so now a person with profound immunosuppression due to AIDS, or cancer, or organ transplantation… can get the vaccine via their insurance, or if they’re over 18 via the Medicare or other government insurance. They don’t have to wait to they’re 50.”
This is important because those who are immunocompromised are likely to get shingles in their younger years, said Dr. Tyring. What’s more is it’s safe.
“It’s just as safe for them as it is for those of us who are not severely immunocompromised, so I not only tell my patients if they’re over 50 and/or are over 18 and immunocompromised to get it, I [also] say everybody in my family and my wife’s family have gotten the vaccine and we’re very happy we did. So I highly recommend it.”
Generating Patient Awareness
Prevention, of course, is the best medicine. To help minimize shingles rates and/or intensity, there are two key questions dermatologists should pay particular attention to on new patient questionnaires, said Dr. Tyring:
1. Have you had shingles?
2. Have you had the shingles vaccine?
Answers may require a pointed conversation with patients because dermatologists don’t generally have the vaccine available in the office, said Dr. Tyring.
“…almost all pharmacies carry [the vaccine] and the pharmacists in most pharmacies are willing to give the vaccine so there’s absolutely no reason.”
Still other patients may wonder if they need the new vaccine since they received the old one, said Dr. Tyring.
“The studies showed that there is absolutely no more side effects if you’ve previously received the old recombinant vaccine, and the efficacy is the same. …the old vaccine is probably worn off by now because nobody has gotten it the past few years. The new vaccine is indicated for those who have and who have not received the vaccine and definitely indicated for those who remember chickenpox as well as those who do not.”
5 Shingles Vaccine FAQs
1. Who is at risk for getting shingles?
If you had chickenpox, you are at risk for shingles. But some may be at more risk than others, said Dr. Tyring.
“Assuming you had chickenpox, the biggest risk for getting shingles other than immune status is family history.”
2. What if someone doesn’t remember having chickenpox? Do they need to be vaccinated?
“Many people come in with shingles and say ‘my diagnosis isn’t correct’ because I never had chickenpox and shingles is always something that comes back after a person has had chickenpox.”
There are many possible reasons for someone believing they didn’t have chickenpox, from a mild case that wasn’t diagnosed to simply not remembering it, said Dr. Tyring.
“We can pretty well assure that anybody over 50, whether they remember chickenpox or not, has had the virus and therefore we don’t test them. We just say get the vaccine. I’m one of the people over 50 that doesn’t remember having chickenpox but, of course, my blood test showed I had it.”
3. If you still have a low chance of getting shingles despite receiving the vaccine, what’s the benefit?
Although there are some vaccinated individuals who will still get shingles, the benefits include mild symptoms and a lower risk for post herpetic neuralgia, said Dr. Tyring.
“So you win either way: Either you’re not going to get shingles or you’re going to get a really mild case that probably isn’t going to be very significant.”
4. What if I’ve already had shingles? Should I still get the vaccine?
“Well, there’s no data to say you should or shouldn’t but certainly, to put it on one side of perspective, people who get shingles once don’t usually get it again, if they’re otherwise relatively healthy. But the lifetime risk of a second case of shingles (assuming you had the first) is about 5%.”
5. Can I get the vaccine before age 50?
“You’re dealing with the shades of grey when you’re not profoundly immunocompromised. But a lot of people who’ve seen their siblings, parents, or others suffer from it, and they’re not 50 yet, will pay for it out of pocket. If I had had a relative who had suffered from shingles, I would have done that. But I didn’t have a relative… I just didn’t want to be first my family, so I got the vaccine.”
Reference:
- Sun Y, Kim E, Kong CL, Arnold BF, Porco TC, Acharya NR. Effectiveness of the Recombinant Zoster Vaccine in Adults Aged 50 and Older in the United States: A Claims-Based Cohort Study. Clin Infect Dis. 2021 Sep 15;73(6):949-956. doi: 10.1093/cid/ciab121. PMID: 33580245; PMCID: PMC8442779.