These two Web sites from the Centers for Disease Control and
Prevention can answer a lot of questions about the virus and its
prevention:
www.cdc.gov/shingles/index.html
www.cdc.gov/vaccines/vpd-vac/shingles/default.htm
And this very comprehensive report, issued by a C.D.C. advisory committee two years ago, goes into even more detail :
www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
www.cdc.gov/shingles/index.html
www.cdc.gov/vaccines/vpd-vac/shingles/default.htm
And this very comprehensive report, issued by a C.D.C. advisory committee two years ago, goes into even more detail :
www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm
Shingles
A Vaccine as an Option to Keep Shingles at Bay
By Jane E. Brody
NY Times Article : October 10, 2008
Although at 39 she is much younger than the typical shingles patient, her experience with confusing symptoms and a twice-missed diagnosis occurs at all ages. This is her story:
“My shingles case began with the periodic sensation that bugs were crawling in my hair. Three weeks later, I developed a headache that was one-sided but unlike a migraine. The pain was so bad I couldn’t go to work. That evening, I discovered a raised and very tender ridge on my scalp.
“Unable to sleep and in terrible pain, I went to the local emergency room. The doctor there gave me an intravenous painkiller, tested me for meningitis or encephalitis, and concluded that I had a migraine and infected hair follicle.
“The terrible head pain grew, as did the sensitivity of the rash, and at 3 a.m. the next day, my husband drove me to a major hospital. The doctor cursorily looked at the blistering rash and treated me for a migraine. He had no explanation for the rash.
“After another horrible night and day of pain and a growing rash, my husband drove me to Urgent Care, where a nurse immediately suspected shingles, and the doctor concluded ‘shingles’ in 30 seconds. I got acyclovir for the virus and Vicodin for pain. I slept a lot, and my eye swelled. When the blisters scabbed over, I returned to work, but I was so tired and my eye was so sensitive to light that I had to cut short my workdays.”
Mrs. Clapp-Smith, an urban planner from St. Paul, said that after her experience she encouraged her mother, who is 71, to get the shingles vaccine. But that decision is not always simple.
Shingles, or herpes zoster, can afflict anyone who has had chickenpox. Both are caused by the varicella-zoster virus. It is not known whether shingles can develop in people who received the chickenpox vaccine, which contains a live attenuated form of the virus.
This virus never leaves the body. It lies dormant for years in nerve roots near the spinal cord and can be reactivated as a shingles infection at any time, especially in people whose immune system is weakened by advanced age, extreme stress, a disease like cancer or AIDS or medications like chemotherapy, steroids and drugs used to prevent organ rejection.
Sometimes, a physical stress like cold or sunburn can bring on an attack.
Reactivated, the virus migrates down the nerve until it reaches the skin, where it causes vague symptoms of irritation, pain, numbness, itching or tingling, followed in two or three days by a painful, blistering rash on one side of the face, head or body. Untreated, the rash lasts two to four weeks.
The pain can be severe and may be accompanied by headache, fever, chills and an upset stomach. In rare cases, it can lead to pneumonia, hearing loss, blindness, encephalitis and, rarer still, death.
After the rash clears, about one patient in five develops post-herpetic neuralgia, or PHN, a debilitating pain that does not always respond to treatment and can be devastating to ordinary life for months or even years. [Frequency of PHN : 1 month after onset of shingles is 9 - 14.3% and at 3 months is about 5%. At 1 year, 3% continue to have severe pain.]
Treatment with one of the antiviral drugs [Famvir/famciclovir, Valtrex/valacyclovir or Zovirax/acyclovir] is best administered as early as possible, preferably within 72 hours of the first sign of a rash, to shorten the course of the disease and prevent the severe symptoms that Mrs. ClappSmith experienced. Antiviral drugs, if taken early, can reduce the severity of subsequent post-herpetic neuralgia, but starting antivirals after PHN develops is of no help. [They are taken for 7 days.]
About one million cases of shingles a year occur in the United States, and the risk of it and of PHN increases with age. Half of 85-year-olds will have had shingles and, as people age, shingles-associated nerve pain increases in frequency and severity.
Debilitating nerve pain occurs in nearly a third of people with shingles who are 60 or older, and about 12 percent of older people who have shingles have pain that lasts three months or longer. The pain of PHN, which is difficult to treat, has been described as burning, throbbing, aching, stabbing or shooting. Even clothing touching the skin or a cool breeze can cause excruciating pain.
2018 update:
The shingles vaccine, SHINGRIX is now available. It is a recombinant vaccine. It is NOT a live virus, hence can be administered to the immuno-compromised patient. It is 90% effective. The vaccination requires TWO visits to administer the series. Initial shot followed two to six months later for the second shot. It is an intramuscular shot given in the deltoid muscle of the upper arm. Patients can anticipate some discomfort in the area for 2-3 days after the shot. There may be some pain, redness and swelling at the site. In addition some patients may experience muscle aches, fatigue, headache, low grade fever and gastrointestinal symptoms.
This is now the recommended vaccine and is indicated for adults over the age of 50. We are no longer using the Zostervax and people who received this can and should get the new Shingrix.
Exploring Why a Virus Reactivates to Cause Shingles
By Irene M. Wielawski
NY Times Article : October 19, 2008
Dr. Jeffrey I. Cohen directs the medical virology section of the clinical infectious diseases laboratory at the National Institute of Allergy and Infectious Diseases, in Bethesda, Md. His research focuses on the molecular genetics of human herpes viruses, among them the varicella-zoster virus that causes chickenpox (varicella) in children and that later in life can reactivate to cause shingles (zoster). Scientists are studying this phenomenon of reactivation in hopes of developing methods to prevent it.
Q: What is varicella-zoster virus, and how does it make people sick?
A: The varicella-zoster virus has been around for thousands of years. It is the virus that causes chickenpox and, later in life, can cause shingles. Varicella-zoster is highly infectious, entering through the respiratory tract and spreading throughout the body. Pre-vaccine, just about everyone born and raised in the United States was infected during childhood and developed the chickenpox rash as well as the fever associated with it.
The virus also infects the nervous system, entering clusters of nerve cells called ganglia that are located along the spinal cord and in the head. After a child recovers from chickenpox, the virus remains in a dormant state in these cells. Later in life, the virus can reactivate, causing shingles, which is a very different illness than chickenpox.
Q: We commonly think of chickenpox as a one-time illness that confers lifelong immunity. How does varicella-zoster virus manage to survive the body’s immune response and hide in nerve cells?
A: It is not entirely clear how the virus is able to maintain the dormancy or latency in nerve cells. It is very clear, however, that when the virus infects a nerve cell it acts differently than when it infects other cells in the body. In the nerve cells, the virus usually stops replicating and makes only a few viral proteins so as not to kill the cell. In this way, it establishes a latent infection or dormancy in the nerve cells of the body. It does not kill the infected cell the way it kills infected skin cells, for example.
From a molecular standpoint, it is not clear why it acts differently in nerve cells; this is something we and other scientists are working on. Other viruses like poliovirus and the common cold virus don’t survive long-term in the body. The body is able to clear them during the course of the initial illness. We think that the varicella-zoster virus adapts within nerve cells in a way that enables it to escape complete destruction by the immune system.
Q: Does the virus hide in cellular tissue other than nerve cells?
A: No. During chickenpox, the virus affects many cells in the body. Obviously it infects skin cells, but it also kills the infected skin cells over the course of the illness. That’s what causes the chickenpox rash. You have dead and dying cells, which cause a vesicle or blister, and the blister fills up with material from the dead cell.
Varicella-zoster virus also can infect the liver and lung cells during chickenpox. Children can have a mild form of hepatitis from the virus, and also a mild form of pneumonia. It definitely does not establish latency in either the liver or the lungs. The virus only remains latent in the nervous system cells.
Q: Can one get chickenpox again from this remaining virus?
A: It is very rare for anyone to get chickenpox again, but you can get shingles if the virus in one of these infected nerve cell clusters reactivates.
Q: How is it that chickenpox and shingles are so different, despite being caused by the same virus?
A: During chickenpox you have widespread infection of cells throughout the body, and you get a rash all over the body. In shingles, the virus is reactivating from one cluster of nerves. So you have a rash only in the area of the body where these nerves are responsible for sensation. Most cases of shingles occur on the chest or face.
Some scientists believe that shingles is most likely to occur at the site where people had the most severe chickenpox. The idea is that more nerve cells in that area got seeded with virus and therefore are more likely to be sites of viral reactivation.
The other difference is that there usually is a lot of pain associated with the shingles rash, whereas the chickenpox rash is associated with itching. Also, the older you are when you get shingles, the more likely you are to develop pain that persists after the rash has resolved. This is a complication of shingles known as postherpetic neuralgia. It can last for years and be very debilitating.
Everyone who has had chickenpox is at risk for shingles because they have varicella-zoster virus in their nerve cells. Children now vaccinated against chickenpox also have varicella in their bodies because the vaccine uses live virus. But based on studies in children with impaired immune systems, it’s believed that those vaccinated against chickenpox will be less likely to develop shingles later in life than those who had chickenpox as children.
Q: Is there any way to intervene to prevent both chickenpox and shingles?
A: Viruses typically use molecules on the surface of cells called receptors to get inside the cells. The receptor acts as a sort of doorway for the virus. We are trying to identify the receptors for varicella-zoster virus because if you can block the receptor you can block the virus from entering the cell.
We recently identified a molecule that is important for the entry of varicella-zoster virus into cells. In studying it, we were able to show that if you use antibody to the molecule you can reduce the ability of the virus to get into the cell. Also, if you reduce the amount of this molecule in the cell, you can reduce the cell’s vulnerability to varicella-zoster virus.
It’s possible, though, that varicella uses different receptors, depending on the type of cell it is trying to get into. From studies of other viruses, we know that they may use one type of receptor to get into a nerve cell and a different type of receptor to get into a white blood cell. We don’t yet know the mechanism of varicella-zoster virus but we suspect that it is using more than one receptor.
Q: How is varicella-zoster virus able to escape detection by the immune system once it enters a nerve cell?
A: It’s clear that when the virus infects cells, it somewhat alters the immune recognition molecules on the surface of the cell, making it more difficult for the immune system to recognize these virus-infected cells and attack them. Another question we’re working on is what viral genes enable varicella-zoster virus to establish latency in nerve cells. We’ve taken a couple of approaches to studying this in the laboratory. One is to delete or knock out individual viral genes, then test the altered virus in animal models. We’ve found in these experiments that the absence of some genes impairs the virus’s ability to establish latency.
Q: Why does the virus reactivate only in some people?
A: The human immune system produces both antibodies to a particular virus and also, at the cellular level, lymphocytes or T-cells that defend against the virus. We think that the cellular or T-lymphocyte response is most important in preventing reactivation of varicella-zoster virus and consequent shingles.
Older people, who are the most likely to get shingles, usually have adequate levels of antibody to the varicella-zoster virus but tend to have reduced levels of cellular immunity. But reactivation probably has additional triggers — differences in individuals’ genes or environmental factors, possibly — that cause the virus to reactivate, because only about 30 percent of people will get shingles in their lifetime. At the present time, we just don’t know what these triggers are.
Q: If you’ve had shingles, can you get them again?
A: Yes, you can get shingles a second time. Of the 20 percent of people who get shingles in their lifetime, some will get it again. Probably, this has to do with how much time has elapsed between episodes. The first bout of shingles boosts your immune response and particularly your cellular immune response — your T-cells — but that response declines over time, leaving you susceptible to a second case of shingles.
Q: When you are talk about older people, what age range do you mean?
A: Shingles is much more common in people older than 50, and the incidence increases the older they get. People in their 70s and 80s are also much more likely to get the postherpetic neuralgia complication. It’s possible to get shingles earlier than 50; if you had chickenpox in infancy you might get shingles as a young adult. It’s thought that your immune system was not sufficiently mature at the time of chickenpox to develop the full cellular immunity response that prevents varicella-zoster virus from reactivating.
Q: You mentioned that varicella-zoster virus has been around for thousands of years. Has it changed much over that time in the way that other viruses — H.I.V., for example — change or mutate?
A: There’s no evidence that varicella-zoster has gotten more or less potent over the years, and we also know that it changes at a much, much lower rate than H.I.V. The H.I.V. makes a lot of mistakes when it replicates or divides; varicella-zoster virus is much less error prone in replication. This makes it much easier to develop an effective vaccine, compared to trying to make a vaccine against a virus like H.I.V. that mutates very, very rapidly. The vaccines we have for chickenpox and shingles work partly because the virus cannot escape the immune system’s response to the vaccine, whereas with H.I.V. that’s much more likely to occur. It also makes varicella-zoster virus infections easier to treat because if you develop an antiviral medication, the virus is less likely to become resistant. With H.I.V., it is common to have virus that resists treatment.
Treatment for an Acute Shingles Attack
The treatment goals for an acute attack of herpes zoster include:
- Reduce pain
- Reduce discomfort
- Hasten healing of blisters
- Prevent the disease from spreading
Home Remedies for Shingles
Applied Cold. Cold compresses soaked in Burrow's solution (an OTC remedy) and cool baths may help relieve the blisters. It is important not to break blisters as this can cause infection. Experts advise against warm treatments, which can intensify itching. Patients should wear loose clothing and use clean loose gauze coverings over the affected areas.
Itch Relief. In general, to prevent or reduce itching, home treatments are similar to those used for chickenpox. Patients can try antihistamines, (particularly Benadryl), oatmeal baths, and calamine lotion.
Over-the-Counter Pain Relievers. For an acute shingles attack, patients may take over-the-counter pain relievers:
- Children should take acetaminophen. (Shingles is very rare in children.)
- Adults may take aspirin or other nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil). Such remedies, however, are not very effective for postherpetic neuralgia.
Nucleoside Analogues.
The best class of drugs developed against varicella-zoster are those known as nucleoside, or guanosine, analogues, which are able to block viral reproduction. None of these drugs can actually destroy the virus and cure the disease, but they can significantly reduce the severity of the attack, hasten healing, and reduce the duration. There is some evidence that early treatment with these drugs can reduce the risk for postherpetic herpes.
These anti-viral drugs are usually taken for 7 days. Ideally they should be started within 72 hours of the onset of infection. The earlier they are given the more effective these drugs are, but they can be helpful even if treatment is started after 3 days. Combinations of antiviral therapy with other drugs, such as tricyclic antidepressants or anticonvulsant drugs, are under investigation
Acyclovir (Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex) are approved for shingles. Acyclovir is the oldest, most studied of these drugs, but either famciclovir (Famvir) or valacyclovir (Valtrex), which are both metabolized into acyclovir, are now preferred to treat herpes zoster in most patients. They relieve symptoms better than acyclovir and require fewer daily doses (typically three) than the five doses needed with acyclovir.
Because herpes zoster tends to resolve fairly quickly in young adults, these drugs are generally reserved for patients at greatest risk for complications or persistent pain. They include:
- Elderly people
- Those with infections that threaten the eye
- Patients who are HIV positive or immunocompromised in other ways
- Patients whose infection covers a larger-than-average surface area of the skin
- Those with very severe pain
Possible side effects of nucleoside analogues include rash, headache, fatigue, tremor, nausea and vomiting. Seizures are a very rare side effect. Patients with AIDS or other diseases that compromise the immune system are at increased risk for kidney damage and blood clots. Patients with suppressed immune systems are also more likely to have viral resistance to these drugs. These drugs are safe to take during pregnancy.
Foscarnet. Foscarnet (Foscavir) is a powerful antiviral drug known as a pyrophosphate analogue. It is used in cases of VZV strains that have become resistant to acyclovir and similar drugs. Administered intravenously, the drug can have toxic effects. It can impair kidney function (which is reversible) and cause seizures. Fever, nausea, and vomiting are common side effects. It can also cause ulcers on genital organs. As with other drugs, it does not cure shingles.
Brivudin. Brivudin (Helpin, Zostex) is another anti-viral drug, but it is not available in the U.S. It needs to be taken only once a day.
Oral Corticosteroids
Oral corticosteroids, including prednisolone or prednisone, are powerful anti-inflammatory medications. They have some benefit for reducing pain and accelerating healing in acute attacks when used with acyclovir. (They are not recommended without acyclovir.) They also may be helpful for improving symptoms of Bell's palsy and Ramsay Hunt syndrome. Corticosteroids do not appear to prevent a further shingles attack or reduce the risk for PHN. Side effects of corticosteroids can be severe, and patients should take oral steroids at as low a dose and for as short a time as possible. (Injected or intravenous steroids, however, may offer specific relief for PHN without significant side effects.)
Epidural Blocks
Epidural blocks are injections of local anesthetics and steroids outside the tough membrane surrounding the spinal cord (the dura matter). The injected drugs block the nerves and may offer relief from acute herpes zoster pain for some people. A 2006 study found that a single epidural injection helps slightly to relieve shingles pain for a month, but the effect does not last any longer. The injection does not help prevent postherpetic neuralgia.
In-Depth From A.D.A.M. Treatment for Postherpetic Neuralgia
Postherpetic neuralgia (PHN) is difficult to treat. Once PHN develops, a patient may need a multidisciplinary approach that involves a pain specialist, psychiatrist, primary care physician, and other health care providers.
In 2004, the American Academy of Neurology (AAN) issued treatment guidelines for postherpetic neuralgia based on an extensive review of published studies. The AAN recommends:
- Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, maprotiline)
- Anticonvulsants (gabapentin and pregabalin)
- Lidocaine skin patches
- Opioids (oxycodone, methadone, morphine)
Topical Pain Relievers. Creams, patches, or gels containing various substances can provide some pain relief.
- Lidocaine and Other Anesthetic Patches. A patch that contains the anesthetic lidocaine (Lidoderm) is approved specifically for postherpetic neuralgia (PHN). One to four patches can be applied over the course of 24 hours. Another patch (EMLA) contains both lidocaine and prilocaine, a second anesthetic. The most common side effects are skin redness or rash.
- Capsaicin (Zostrix) is prepared from the active ingredient in hot chili peppers. An ointment form has been approved for postherpetic neuralgia. Its benefits are limited, however. A patch form that uses a higher than standard dose may work better. In one study, it reduced pain by 33% in nearly half of patients. Capsaicin should not be used until the blisters have completely dried out and are falling off the skin. Capsaicin ointment should be handled using a glove, and applied to affected areas three or four times daily. The patient will usually experience a burning sensation when the drug is first applied, but this sensation diminishes with use. It may take up to 6 weeks for the patient to experience its full effect, and about a third of patients cannot tolerate the burning sensation.
- Topical Aspirin. Topical aspirin, known chemically as triethanolamine salicylate (Aspercreme), may bring relief.
- Menthol-Containing Preparations. Topical drugs containing menthol, such as high-strength Flexall 454, may be helpful.
Ethyl chloride (Chloroethane) and fluori-methane are chemicals that cool the blood vessels in the skin. Sprays that contain these chemicals are not anesthetics, but are used to inactivate the sensitive areas. To use the spray, the patient must be in a comfortable position. The spray bottle is held upside-down, about 12 - 18 inches from the targeted area, and the face must be covered if the spray is being used near the head.
Tricyclic Antidepressants
Tricyclic antidepressants relieve pain in up to two-thirds of patients. These drugs not only relieve depression, which can be common in PHN sufferers, but certain tricyclics specifically block sodium channels, which play a role in causing pain in PHN. Nortriptyline (Pamelor, Aventyl), amitriptyline (Elavil, Endep), and desipramine (Norpramin) are standard drugs.
According to one study, two-thirds of patients obtain pain relief if they take tricyclics within 3 months to a year after a herpes zoster attack. The drugs are less successful when taken after that. It may take several weeks for the drugs to become fully effective. They do not work as well in patients who experience burning pain or allodynia (pain that occurs with normally non-painful stimulus, such as a light touch or wind).
Unfortunately, tricyclics have side effects that are particularly severe in the elderly, who are also more likely to have PHN. Desipramine and nortriptyline have fewer side effects than amitriptyline and are preferred for older patients. Side effects include dry mouth, blurred vision, constipation, dizziness, difficulty urinating, disturbances in heart rhythms, and an abrupt drop in blood pressure when standing up.
Anticonvulsant (Anti-Seizure) Drugs
Certain anticonvulsant drugs have effects that block over-excitation of nerve cells and may be helpful for PHN patient. (Anticonvulsant drugs are also known as anti-seizure drugs.)
Gabapentin.
Gabapentin (Neurontin) was the first anticonvulsant drug approved for PHN. Studies suggest significant pain relief in patients with PHN and reduction in the use of opioids. Many patients also report improved quality of life, including better sleep. Gabapentin is also showing promise in combination with valacyclovir for reducing pain from an acute herpes zoster attack.
Side effects include skin rashes, increased risk for infection, headache, dizziness, sleepiness, swelling, and upset stomach. Some people experience visual disturbances, ringing in the ears, agitation, or odd movements when drug levels are at their peak. These side effects may limit their value in older people who are at risk of falling. In general, however gabapentin is safer than tricyclic antidepressants for elderly patients.
Pregabalin.
Pregabalin (Lyrica) is similar to gabapentin. Like gabapentin, side effects can include sleepiness and dizziness
Other Anticonvulsant Drugs.
The AAN guidelines found insufficient evidence to recommend carbamazepine (Tegretol).
Opioids and Opioid-like Drugs
Opioids.
Patients with severe pain that does not respond to tricyclic antidepressants may need powerful painkilling opioid drugs. They may be taken by mouth or delivered through a skin patch. Oxycodone is the standard opioid for PHN. Morphine is also used. Methadone (Dolophine) may also be helpful. A 2005 study found that morphine worked best when combined with the anticonvulsant gabapentin. Constipation, drowsiness, and dry mouth are common side effects of opioids.
Tramadol.
Tramadol (Ultram) is a pain reliever that has been used as an alternative to opioids. It has opioid-like properties but is not as addictive. (Dependence and abuse have been reported, however.) It can cause nausea but not severe gastrointestinal problems, as NSAIDs can. Studies suggest it might be very helpful for PHN patients, particularly those with heart problems or other conditions that restrict tricyclic antidepressants.
Other Medical Treatments
Intrathecal Corticosteroid Injections. Epidural (also called intrathecal) injections of corticosteroids are administered within the the tough membrane surrounding the spinal cord. The corticosteroids are sometimes combined with anesthetics. Some older studies indicated that these injections may relieve PHN pain, but this treatment is still under investigation and is not common medical practice. A 2006 study reported that epidural injections may provide slight temporary relief for acute shingles attacks, but they do not prevent PHN.
Antiviral Drugs. Researchers are investigating whether treatment with antiviral drugs may help reduce the pain associated with postherpetic neuralgia. A small 2006 study suggested that a 2-week course of therapy with intravenous acyclovir, followed by 1-month treatment with oral valacyclovir, may help relieve pain.
Surgery. Certain surgical techniques in the brain or spinal cord attempt to block nerve centers associated with postherpetic neuralgia. These methods carry risk for permanent damage, however, and should be used only as a last resort when all other methods have failed and the pain is intolerable. Most studies indicate that surgery does not relieve PHN pain.
Psychologic Approaches
Stress Reduction Techniques. A number of relaxation and stress-reduction techniques may be helpful for managing chronic pain. They include meditation, deep breathing exercises, biofeedback, and muscle relaxation. Such techniques may apply to those with severe pain from acute infection and from persistent long-term postherpetic neuralgia.
Behavioral Cognitive Therapy. Behavioral cognitive therapy is showing benefit in enhancing patients' beliefs in their own abilities for dealing with pain. Using specific tasks and self-observation, patients gradually shift their fixed ideas that they are helpless against the pain that dominates their lives to the perception that it is a manageable experience. The skill of the therapist is very important to its success.
Alternative Remedies
Many people with chronic pain such as PHN turn to alternative treatments for relief. Aside from hypnosis, little evidence indicates that these treatments work for PHN. Remedies include:
- Hypnosis
- Topical use of diluted apple cider vinegar
- Acupuncture
- Colostrum (a pre-milk fluid produced by mammals)
- Pantothenic acid (Vitamin B5)
Painful Shingles Can Strike More Than Once
By Melinda Beck : WSJ Article : February 22, 2011
Having shingles can be a miserable experience. Now, to make matters worse, the long-held notion that people can only get shingles once in their lives appears to be false, according to a study in the journal Mayo Clinic Proceedings this month.
It's estimated that 1 in 3 Americans will get shingles at some point, with one million new cases reported a year in the U.S. It typically starts with itching, tingling or numbness, then develops into a painful rash that blisters. It often hits people who are elderly or already suffering from another illness or trauma, and the residual nerve pain can last for months.
The incidence rate has been rising around the world, in all age groups, though it isn't clear why, says Rafael Harpaz, a medical epidemiologist in the Centers for Disease Control and Prevention's division of viral diseases. More than half of cases occur in people over age 60, when the risk of complications also rises steeply. Women are slightly more likely to contract shingles than men.
Shingles 101
The CDC has urged all Americans age 50 and older to get the shingles vaccine—whether they've had shingles or not.
Shingles is caused by the Varicella zoster virus, or VZV, the same virus that causes chicken pox, and it only strikes people who have had chicken pox in the past. Like other herpes viruses, VZV never fully leaves peoples' bodies. It can lie dormant for decades in the nerve roots in the spinal column, until it suddenly replicates and travels down the nerves to cause shingles. This frequently creates a striped rash that follows the pattern of nerves on the back or chest.
Exactly what prompts the virus to wake up is unknown, but it seems to occur when the immune system, which has kept it in check for years, becomes weakened due to age, illness or treatments such as chemotherapy. Emotional stress can cause recurrences of other herpes viruses, and the CDC is investigating whether it can spark shingles as well.
For the new study on shingles recurrence, researchers at the Olmsted Medical Center in Rochester, Minn., examined medical records of nearly 1,700 patients who had a documented case of shingles between 1996 and 2001. They found that more than 5% of them were treated for a second episode within an average of eight years—about the same rate as would typically experience a first case.
That a recurrence is so common is more of a surprise to virologists and other scientists than primary-care physicians, who have seen it in their practices, says Barbara Yawn, director of research at the Olmsted center and the study's lead author. "I've gotten calls and emails from some saying, 'Thank you. Now they will believe us.'"
The Olmsted researchers found the people most likely to have a recurrence were patients whose pain had lasted more than 30 days with their first shingles episode.
It's possible that some subgroups of the virus are more prone to recurrence, says Dr. Yawn. In their next study, her team is monitoring new episodes of shingles and the CDC will analyze samples of those that recur to look for genetic patterns. The earlier studies were funded in part by Merck and the National Institutes of Health, while the new study is funded by the CDC.
Some shingles cases are mild, causing only a minor rash. But some patients develop sharp, stabbing nerve pain that can make the affected area extremely sensitive. "Sometimes people say they can't stand to have anything touch the rash area, even clothes," Dr. Yawn says.
In some cases, the nerve pain is the only symptom for days. Patients have been hospitalized with what was thought to be heart disease or appendicitis until the telltale shingles rash appeared. "Sometimes the rash never develops—that really confuses doctors," says the CDC's Dr. Harpaz.
Nerve pain that lingers for more than a month is called postherpetic neuralgia, or PHN, and it can last for years in some patients. While antiviral medications can shorten the duration and severity of shingles episodes, PHN is harder to treat. Some patients get limited relief from opiates, antiseizure medications and antidepressants, but many elderly people can't tolerate the side effects.
In rare cases, shingles has other serious consequences. Blisters can become infected. A rash on the face can spread shingles into eyes, which can lead to loss of vision, sometimes permanent. A rash around the ear can cause a complication known as Ramsey Hunt syndrome, which can include deafness and weakness of the facial muscles.
A big unknown is whether people who got the chicken-pox vaccine as children will be susceptible to shingles in later years or protected from it—or even vulnerable to full-blown chicken pox if their immunity has weakened. Since the chicken-pox vaccine was only approved in 1996, it will be several decades before the first generation of Americans to be widely vaccinated reaches the typical shingles years.
"It's quite plausible that rates will come down dramatically as those kids become older adults," says Dr. Harpaz, though he notes that some people who got the chicken-pox vaccine may unknowingly harbor the actual virus because the vaccine doesn't prevent 100% of cases, and some people may have had a mild, unnoticeable case before they were vaccinated.
The new shingles vaccine, known as Shingrix, doesn't eliminate all cases. It is about 90% effective in people over the age of 50. The cases that do occur in vaccinated people tend to be milder.
If it's possible to get shingles more than once, why does a vaccine work at all? Unlike most vaccines, which prime a person's immune system to ward off a virus the first time it invades, the vaccine boosts the immune system's ability to keep the preexisting herpes infection in check, even though it never fully disappears.
By Melinda Beck : WSJ Article : February 22, 2011
Having shingles can be a miserable experience. Now, to make matters worse, the long-held notion that people can only get shingles once in their lives appears to be false, according to a study in the journal Mayo Clinic Proceedings this month.
It's estimated that 1 in 3 Americans will get shingles at some point, with one million new cases reported a year in the U.S. It typically starts with itching, tingling or numbness, then develops into a painful rash that blisters. It often hits people who are elderly or already suffering from another illness or trauma, and the residual nerve pain can last for months.
The incidence rate has been rising around the world, in all age groups, though it isn't clear why, says Rafael Harpaz, a medical epidemiologist in the Centers for Disease Control and Prevention's division of viral diseases. More than half of cases occur in people over age 60, when the risk of complications also rises steeply. Women are slightly more likely to contract shingles than men.
Shingles 101
- 1 in 3 Americans will have it in their lifetimes.
- There are one million new cases a year.
- It only strikes people who have had chicken pox
- Risks and complications rise with age.
- Symptoms include blistery rash, nerve pain.
- Can cause vision and hearing damage.
- Vaccine cuts risk by about half.
The CDC has urged all Americans age 50 and older to get the shingles vaccine—whether they've had shingles or not.
Shingles is caused by the Varicella zoster virus, or VZV, the same virus that causes chicken pox, and it only strikes people who have had chicken pox in the past. Like other herpes viruses, VZV never fully leaves peoples' bodies. It can lie dormant for decades in the nerve roots in the spinal column, until it suddenly replicates and travels down the nerves to cause shingles. This frequently creates a striped rash that follows the pattern of nerves on the back or chest.
Exactly what prompts the virus to wake up is unknown, but it seems to occur when the immune system, which has kept it in check for years, becomes weakened due to age, illness or treatments such as chemotherapy. Emotional stress can cause recurrences of other herpes viruses, and the CDC is investigating whether it can spark shingles as well.
For the new study on shingles recurrence, researchers at the Olmsted Medical Center in Rochester, Minn., examined medical records of nearly 1,700 patients who had a documented case of shingles between 1996 and 2001. They found that more than 5% of them were treated for a second episode within an average of eight years—about the same rate as would typically experience a first case.
That a recurrence is so common is more of a surprise to virologists and other scientists than primary-care physicians, who have seen it in their practices, says Barbara Yawn, director of research at the Olmsted center and the study's lead author. "I've gotten calls and emails from some saying, 'Thank you. Now they will believe us.'"
The Olmsted researchers found the people most likely to have a recurrence were patients whose pain had lasted more than 30 days with their first shingles episode.
It's possible that some subgroups of the virus are more prone to recurrence, says Dr. Yawn. In their next study, her team is monitoring new episodes of shingles and the CDC will analyze samples of those that recur to look for genetic patterns. The earlier studies were funded in part by Merck and the National Institutes of Health, while the new study is funded by the CDC.
Some shingles cases are mild, causing only a minor rash. But some patients develop sharp, stabbing nerve pain that can make the affected area extremely sensitive. "Sometimes people say they can't stand to have anything touch the rash area, even clothes," Dr. Yawn says.
In some cases, the nerve pain is the only symptom for days. Patients have been hospitalized with what was thought to be heart disease or appendicitis until the telltale shingles rash appeared. "Sometimes the rash never develops—that really confuses doctors," says the CDC's Dr. Harpaz.
Nerve pain that lingers for more than a month is called postherpetic neuralgia, or PHN, and it can last for years in some patients. While antiviral medications can shorten the duration and severity of shingles episodes, PHN is harder to treat. Some patients get limited relief from opiates, antiseizure medications and antidepressants, but many elderly people can't tolerate the side effects.
In rare cases, shingles has other serious consequences. Blisters can become infected. A rash on the face can spread shingles into eyes, which can lead to loss of vision, sometimes permanent. A rash around the ear can cause a complication known as Ramsey Hunt syndrome, which can include deafness and weakness of the facial muscles.
A big unknown is whether people who got the chicken-pox vaccine as children will be susceptible to shingles in later years or protected from it—or even vulnerable to full-blown chicken pox if their immunity has weakened. Since the chicken-pox vaccine was only approved in 1996, it will be several decades before the first generation of Americans to be widely vaccinated reaches the typical shingles years.
"It's quite plausible that rates will come down dramatically as those kids become older adults," says Dr. Harpaz, though he notes that some people who got the chicken-pox vaccine may unknowingly harbor the actual virus because the vaccine doesn't prevent 100% of cases, and some people may have had a mild, unnoticeable case before they were vaccinated.
The new shingles vaccine, known as Shingrix, doesn't eliminate all cases. It is about 90% effective in people over the age of 50. The cases that do occur in vaccinated people tend to be milder.
If it's possible to get shingles more than once, why does a vaccine work at all? Unlike most vaccines, which prime a person's immune system to ward off a virus the first time it invades, the vaccine boosts the immune system's ability to keep the preexisting herpes infection in check, even though it never fully disappears.
