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Shingles vaccination proposed

Millions of people in their seventies could be vaccinated against shingles, according to several newspapers. The news is based on a recommendation from the government’s independent committee on immunisation. It says there may be benefits in vaccinating the elderly against the virus that causes the painful skin condition.

The DailyTelegraph says a vaccination programme could be in place by late 2010 if it is proven to be cost-effective.

What is the basis for these current reports?

News coverage has been based on a short statement released by the Joint Committee on Vaccination and Immunisation (JCVI). The JCVI is an independent expert advisory committee that gives advice to the government on matters relating to prevention of communicable diseases through immunisation. Any advice given to government is based on a systematic review of the medical evidence on a subject.

The recent JCVI statement concerns the potential for a programme to vaccinate the elderly against herpes zoster, the painful condition also known as shingles. Their guidance is based on a review of medical, epidemiological and economic evidence plus a review of the available safety and efficacy data on herpes zoster vaccination.

This was not a full statement on the matter, which the JVCI will release soon. However, it states that a universal herpes zoster vaccination programme should be introduced for adults aged 70 to 79, “provided that a licensed vaccine is available at a cost effective price”.

What is shingles?

Shingles, or herpes zoster, is a painful skin rash that is caused by a reactivation of the varicella zoster virus (VZV) that causes chickenpox. Anyone who has had chickenpox could develop shingles, although it is more common in people over 60 years of age.

The initial symptoms of shingles include oversensitivity and a burning sensation in the affected area followed by the development of a rash of small raised spots that soon turn to fluid-filled blisters. After about a week, the blisters dry to form scabs that eventually fall off. The rash, which usually only affects one side of the body, can be very painful and debilitating. During a bout of shingles, pain and sensitivity mean many people cannot even bear the feeling of clothes touching the affected skin. The pain of shingles may last long after the rash has disappeared, sometimes for months or years. The lingering pain from shingles is known as postherpetic neuralgia.

Why do shingles affect some people?

Chickenpox is an infectious disease usually affecting children, although it can be caught by any person of any age if they have never had the disease. It is extremely common in children aged between two and eight years. The illness is spread by droplets in sneezes and coughs from an infected person, leading to a characteristic itchy skin rash with itchy skin blisters. Symptoms vary from child to child, but generally, they are mild and disappear in seven to ten days. Rarely, some children can develop further complications.

Following a chickenpox infection, a person’s body will make antibodies, making them immune to further new chickenpox infections for the rest of their life. However, the virus remains dormant in the nerve cells and can be reactivated years or decades after the primary infection. When it reactivates, it causes an outbreak of shingles, usually following the route of a nerve supply to the skin.

The risk of shingles increases with age, and while it unclear what triggers a reactivation of infection, it is thought to be due to compromised immunity. Possible reasons for a weakened immune system can be the use of certain medications, illness, malnutrition or because of the natural decline in immunity that can accompany increasing age.

How is shingles currently managed?

Most treatments aim to ease symptoms. As pain is a common feature of shingles. painkillers may be prescribed. Some people are prescribed antidepressants that can also help with pain.

Another possible treatment is the use of antiviral medicines that, while unable to cure shingles, can limit the severity of infection by helping to limit the replication of viral particles in the body. Antivirals are most effective if taken within 72 hours of the rash appearing. Antiviral drugs are often prescribed to people aged 50 years or above, those that have a weakened immune system or people with severe infection.

Is shingles contagious?

A person with shingles cannot spread shingles to other people. However, the varicella zoster virus is present in the fluid-filled blisters of a shingles rash, meaning that exposure to people with shingles can lead to chickenpox in people that have not already caught the virus or been vaccinated against it.  While chickenpox is often a mild illness in childhood  in adults it can be more severe. Certain groups, including pregnant women, are also at a heightened risk of complications from chickenpox infection.

A person who has had chickenpox is at no risk of catching shingles from someone with shingles or chickenpox again because of the lifelong immunity provided by their own chickenpox infection.

If possible, a person with an outbreak of shingles should avoid contact with anyone who has not had chickenpox themselves, particularly pregnant women and newborn babies.

How will the vaccination work and will it be safe?

The vaccine will prevent shingles but cannot treat shingles or postherpetic neuralgia if they have already developed. The JCVI has reviewed the efficacy and safety data on available vaccines and has recommended that a programme be initiated. The vaccine will be made of a weakened chickenpox virus that will stimulate an immune response to make the body immune to future infection.

According to the Centers for Disease Control and Prevention, there has never been a case of transmission of chickenpox virus from a person who has received the shingles vaccine. However, some people who receive the vaccination may develop a “chickenpox-like rash” near the site of their injection, so as a precaution the area should be kept covered. As the vaccine is a live vaccine it will not be given to people who have severely compromised immune systems (due to illness or immune suppressive medication) or to pregnant women.

Research described by the US Food and Drug Administration (a study of 38,000 people) showed that vaccination reduced the occurrence of shingles by 50%. Research on people aged over 70 has also shown that in those people who were vaccinated, but still developed shingles, the incidence of postherpetic neuralgia was reduced.

What will happen now?

The JCVI will release a full statement and recommendations to government about the scope of a universal vaccination programme in this country. They have advised that a programme be initiated if “a licensed vaccine is available at a cost effective price”. The JCVI statement also suggests that any such vaccination will only be available for people aged 70 to 79 years old.

The Guardian has reported that some campaigners want the vaccine to be offered to people from the age of 60 years, when the risk of shingles rises sharply. However, it is important to remember that the JCVI has considered a range of studies assessing the effectiveness and safety of the vaccine and have come to their judgement by following this systematic analysis of evidence. There may explanations justifying this decision in the full statement that is due to be released.

Links to the headlines

Shingles jab for elderly. Daily Express, January 31 2010

Shingles vaccine hope for elderly. BBC News, January 31 2010

Shingles vaccine proposed for all those in their 70s. Daily Mail, January 30 2010

Row over age limit for shingles vaccination. The Guardian, January 30 2010

Further reading

Department of Health statement: Shingles vaccine moves a step closer.

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