Shingles myths persist, putting the lives of the elderly at risk

Health minister Mark Butler endorsed the Pharmaceutical Benefit Advisory Committee’s recommendation to fund Shingrix on the National Immunisation Programme (NIP), though details about exactly when the change will be implemented remain unclear.

Minister Butler made the announcement at the Communicable Diseases and Immunisation Conference in Perth in June.

The future of Zostavax, which is currently the only shingles vaccination listed on the NIP, is also unclear, though there has been suspicion that it will be jettisoned when Shingrix officially joins the NIP.

The recently endorsed PBAC recommendation is for Shingrix to be provided to Aboriginal and Torres Strait Islanders who are at least 50, and other people at age 70—as well as those over 18 who have had or will receive a haemopoietic stem cell transplantation, or a solid organ transplant and are on immunosuppressants, or who have an active haematological malignancy or advanced or untreated HIV with CD4 counts < 250/ µL or those with a higher CD4 count unable to be established on effective anti-retroviral therapy.

About one in three Australians will develop shingles at some point in their lifetime, says consultant geriatrician and Associate Professor Michael Woodward, from Austin Hospital in Melbourne.

“There are about 560 cases of herpes zoster or shingles per 100,000 population per year in all age groups, but this increases by more than two-fold to nearly 1200 cases per 100,000 in those over the age of 50,” Associate Professor Woodward says.

About one quarter of those cases are in the ophthalmic branch, which increases the risk of complications such as hearing and vision loss and neurological complications.

Myth busting

Myth #1 ‘Shingles only has sensory side effects.’

Associate Professor Woodward says one of the biggest myths is that shingles only has sensory side effects. This is untrue; it can also affect motor function.

“We don’t notice that paralysis of motor nerves occurs in people who get it in intercostal dermatomes because there’s very few muscles there, but if it occurs in say, a limb or an arm dermatome or facial dermatome, it can cause quite significant and often not completely resolving paralysis. A person can end up with a degree of weakness in that muscle group for months or even years,” he explains.

Myth #2 ‘Shingles is a ‘mild disease.’’

“About 30% of people who have shingles go on to develop post-herpetic neuralgia, which is defined as neuropathic pain persisting for more than three months after an outbreak of shingles in the person. It can be very severe. In fact, it’s rated as above limb fractures in terms of severity of pain—about the same level of pain as occurs in childbirth,” Associate Professor Woodward says.

Additionally, shingles increases the risk of stroke.

Myth #3 ‘The childhood chickenpox vaccine protects against shingles.’

Unfortunately, there’s a gap of about 40 years between the oldest children who have had chickenpox vaccination and the adults who have an increased risk of developing shingles, so it is highly unlikely to offer protection, Associate Professor Woodword says.

Myth #4 ‘You can catch shingles from somebody who has got chickenpox.’

“You can only catch chickenpox from somebody who’s got chickenpox— and your chance of catching chickenpox is low because 97% of the Australian population have already had it,” he says.

Myth #5 ‘You can’t get shingles if you have a good immune system.”

It is true that a waning immune system, or immunosenescence, is a risk factor but “a very large number of people with otherwise normal immunity are still at risk of developing shingles,” he says.

Myth #6 ‘You can only get shingles once.’

Associate Professor Woodward says this is not true. Approximately 6% of people who’ve had it once will get it again.

“So, shingles is not just a sensory problem. It’s not just a rash. It’s not caused by being near somebody with chickenpox,” Associate Professor Woodward says.

Given the serious consequences, Associate Professor Woodward says vaccination is crucial.

Currently, Zostavax is funded people over the age of 70, with a catch up up to the age of 79.

“We now recommend the vaccine even down to the age of 50 because that’s when your risk of developing shingles becomes exponentially greater,” Associate Professor Woodward says.

However, the PBAC did not recommend funding Shingrix (or Zostavax) for most non-indigenous Australians under the age of 70, stating that the cost effectiveness was too uncertain in that group.

What are the differences between the two vaccines?

While Zostavax is a single injection, Shingrix involves two primary doses, usually given two to six months apart. However for those who are immunodeficient, immunosuppressed or likely to become immunosuppressed due to disease or therapy, the two doses can be given one to two months apart.

However there are bigger differences, especially regarding efficacy and duration of protection.

“Zostavax is slightly more effective at preventing post herpetic neuralgia (PHN) than shingles, so those who do get shingles despite vaccination are less likely to develop PHN. Shingrix prevents against shingles ‘full stop’,” Associate Professor Woodward says.

He says Zostavax has a lower efficacy than Shingrix, at about 60% effective compared to 90% efficacy for Shingrix, even for those under 80. Shingrix also seems to provide protection for around 9-10 years, possibly more, while the Zostavax’s protection wanes after a few years.

There are other important differences between them too. Zostavax is a live attenuated vaccination and may not be suitable for people with compromised immunity – around 5% of the population, he estimates.

“We do not recommend the live attenuated vaccine in those who have immunosuppression, for instance more than 20 milligrams of prednisone or more, daily, over a two week period or longer, or several of the very immunosuppressant drugs such as cyclosporine mycophenolate. And we also don’t recommend it for those who have haematological and other diseases that cause immunosuppression. So, conditions like certain lymphomas and leukaemias. So immunosuppression is both a reason for being worried about shingles but also a reason for not giving the live attenuated vaccine.”

However, the side effects with Shingrix may be higher. There are more reports of localised pain, redness and swelling which he believes are associated with the adjuvant. He says there are also more reported systemic effects including fever and fatigue.

He says around 79% of people over the age of 50 will develop a local pain which is significant after their first dose of Shingrix and it’s probably a similar percentage after their second dose of vaccine –which is recommended two to six months after the first dose.

Around 40% will develop redness and about 20-30% will develop swelling.

“These are usually not of the most severe grade, grade three,” he says. “Grade three reactions are very rare, but they do occur. And indeed, there’s a slightly greater risk of systemic reactions, such as a fever and headache and fatigue after Shingrix, so there is a price, if you like, to be paid for this much greater, much longer lasting protection.”

He believes that price is worth paying because more and more people are working into their 70’s these days, or are looking after grandchildren, or leading active lives and they simply can’t afford to be out of action for weeks – especially from something that is easily prevented.

Recommended resources:

• Australian Immunisation Handbook Shingles (herpes zoster) vaccine | Australian Government Department of Health and Aged Care
• NCIRS Factsheet Zoster vaccines – Frequently asked questions
• Valuing Vaccines Report Dec 2021