There are approximately one million cases of herpes zoster (HZ) every year in the US. HZ is the re-emergence of latent childhood varicella-zoster in the form of a painful outbreak of vesicles that track along a peripheral dermatome. Shingles, the term commonly used to refer to an HZ outbreak, is a word whose root comes from the Latin word cingula, meaning girdle or waist, a common location for HZ.
The frequency of HZ is greater in the elderly, with approximately 75% of 75 year olds having had a case of HZ. Along with this greater frequency with age is the greater per-case frequency of that most dreaded complication, post-herpetic neuralgia (PHN). PHN often results in poorly controlled allodynia in the dermatome of the HZ and can significantly reduce a person’s quality of life. I personally recall an elderly patient of mine who became housebound after developing PHN, as she was no longer able to wear a blouse that touched the affected area.
There is a vaccine to reduce the incidence of both HZ and PHN, the zoster vaccine. It is indicated for all immunocompetent individuals 60 years and older but the uptake of this vaccination in the US population has been low. In a retrospective study of vaccine use and effectiveness, Langan et.al. selected a random 5% sample of Medicare beneficiaries from 2007 through 2009 and found that only 3.9% had been vaccinated. In comparing the incidence of HZ and PHN in those vaccinated vs those not vaccinated, it was found that HZ occurred in 5.4/1000 patient-years in the vaccinated population vs 10.0/1000 patient-years in the unvaccinated group. The overall incidence of PHN within 30 days of HZ was 0.22 vs 0.65 (AHR of 0.38). So, not only does the vaccine reduce the incidence of HZ outbreaks, it also lessens the risk of PHN if shingles develops in a vaccinated individual.
Zoster vaccine is a covered benefit for PHC members ages 60 and over. What with the high incidence of HZ and the potentially devastating effects of PHN, vaccination should be considered for your patients in this age group. By the way, zoster at any age, but certainly among the younger age groups should trigger an HIV test.
Marshall Kubota, MD
Langan SM et.al. “Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: A cohort study.” PLoS Med 2013 Apr 9; 10:e1001420. (http://dx.doi.org/10.1371/journal.pmed.1001420)