New vaccines for older Americans

Those of us who had chickenpox when we were young (or in my case when I was in medical school – but that’s another story) figured we were pretty much done with those itchy blisters. But the chickenpox virus, known in medical terms as the varicella zoster virus or VZV, is a tricky actor.

Like its cousin, the herpes simplex virus that causes cold sores and genital herpes, VZV never really goes away. Once the initial infection is over, the clever virus travels down the fibers of sensory nerves – the nerves that send messages to our brains telling us that “it” hurts or “it” itches or “it” feels nice – and sets up residence in the body of the nerve, close to the spinal cord or brain. There it happily remains dormant, kept that way, we assume, by our immune system.

But our immune system weakens as we get older, or when we receive chemotherapy for cancer or when we have HIV/AIDS. And then VZV can wake up and suddenly we have shingles. The virus travels from its hideout in the nerve cell body back the way it came to the skin area served by that particular nerve root. The skin in that area begins to itch and hurt, and the pain can be severe.

Up to a week after the first symptoms, a rash appears. It starts as small red spots, and then turns into small, fluid-filled blisters just like chickenpox. Unlike chickenpox, the rash is confined to one discrete band-like area of the skin (usually in the trunk area or on the face) and is on one side of the body only.

Did I mention it hurts? The pain can be mild or like an itchy sensation. Or it can be intense, with the lightest touch or even a breeze leading to agony.

Usually within two to four weeks, the rash begins to heal. But in about 20 percent of patients the pain doesn’t go away. That’s because VZV, when it activates, can cause damage to the nerve in which it resides. And damaged nerves don’t work right. They fire off and send pain messages to the brain even when there’s nothing obvious causing the pain. The pain is sharp, lancinating, burning. In short, it’s darned uncomfortable and can have a profound effect on a person’s daily life. This is called post herpetic neuralgia (PHN).

Shingles itself goes away. But PHN can last for months, even years. Older antidepressants, known as tricyclic antidepressants can help with the pain, as can anticonvulsants, in particular a drug called Neurontin. Physicians use these drugs “off label” to treat PHN, because even though they are not approved by the FDA for PHN, the medical literature supports their use. Another new anticonvulsant, Lyrica, is FDA approved for use in treating the pain of PHN.

Even better news for those of us who are aging is the FDA approval of a new vaccine meant to prevent shingles in the first place. Called Zostavax, the vaccine is a stronger version of the chickenpox vaccine now regularly given to children. The FDA has approved the vaccine for adults 60 years of age or older, since 50 percent of shingles cases occur in this age group. And PHN occurs in only 10 percent of shingles sufferers younger than 60, but increases to 40 percent of those with shingles who are older than 60.

The vaccine prevents shingles 50 percent of the time. Studies show it also decreases the severity of shingles. And even better, it decreased the incidence of PHN by 67 percent. Since shingles affects about 500,000 people every year, this vaccine can have a major effect on older Americans’ wellbeing.

A committee of the federal Centers for Disease Control will decide in October whether Zostavax should be one of the recommended vaccines given to older Americans, along with the pneumonia and flu vaccines. It remains to be seen how Medicare, the major insurer for older Americans, will cover the cost of this vaccine, which will be about $150.