Why do many neglect shingles shots?

Cost, lack of promotion by doctors, ignorance are factors

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Shingles is the stealth bomber of adult diseases.

It starts with chickenpox, the childhood malady that comes with a fever, sore throat and a body-blanketing rash.

Once the chickenpox disappears, though, the virus that causes it doesn't. Instead, this version of the herpes virus hides in your nerves, and in about 20 percent of all older adults who had chickenpox as children it will emerge again as shingles.

Shingles also has a rash, usually on the face or torso, accompanied by a pain that some people say is the worst they have ever been through.

Some shingles facts

Name of virus: Herpes varicella zoster virus (it is known as varicella when it causes chickenpox; zoster when it causes shingles).

How it works: The virus causes chickenpox in children, then hides in the nervous system and can emerge in adults as their immune systems weaken.

Incidence: Affects 20 percent of people over age 60 who had chickenpox as children.

Symptoms: A rash on one side of the body, accompanied by stinging pain. Sometimes infects the eyes.

Treatment: The shingles vaccine, Zostavax, can be taken to prevent the disease or lessen its symptoms if it occurs, but will not work once the person is infected. After an infection, pain medications are prescribed.

Side effects: About 30 percent of patients have pain lasting more than 90 days after an infection. Some patients also suffer eye damage, including damage to the nerves in the cornea.

Availability of vaccine: Zostavax, made by Merck & Co. Inc., is on two-to-three-month back order nationally, but is available at some locations locally, including Rite Aid pharmacies, Walgreens Take Care clinics and the Allegheny County Health Department immunization clinic in Oakland. It is not available at MedExpress and UPMC Urgent Care clinics.

Cost: Retail cost is $220 at Walgreens and Rite Aid, and is $164 at the county health department clinic, 3441 Forbes Ave., Oakland. Many insurance plans cover all or part of the cost. Medicare covers the vaccine under the Part D drug benefit program, requiring a co-payment.

Contraindications: People with weakened immune systems, such as cancer patients, should not get the vaccine. Women who are pregnant or planning to become pregnant, and people taking high steroid doses, also should avoid it.

People who get the vaccine should temporarily avoid pregnant women and young children who have not been vaccinated against chickenpox, as well as people with weakened immune systems.

"Not many people know about the pain that can be associated with shingles," said Paul Kinchington, a researcher at UPMC's Eye Center who has spent much of his career studying the disease. "It is a potentially excruciating, long-term pain that can be completely refractory to pain treatment.

"A lot of people will blow shingles off and say it's not a problem -- but they haven't had it."

There is a way to prevent the disease or at least blunt its impact -- yet very few people are taking advantage of it.

A vaccine known as Zostavax can prevent half the cases or cut the severity of the illness in others, but even though it has been available for five years, only 7 to 10 percent of eligible patients are getting the inoculation.

There seem to be at least three reasons for that, experts said -- cost, lack of promotion by doctors and ignorance on the part of patients.

Even though more and more health insurance plans are covering the vaccine, the out-of-pocket cost for one dose is $200 to $300 (in this region, both Walgreens Take Care Clinics and Rite-Aid pharmacies carry the vaccine for $220).

And for those with Medicare, it is the only adult vaccine that falls under the Part D drug benefit plan, which means most people will have some out-of-pocket cost. A Highmark spokesman said its Medicare supplementary plans typically require a $40 co-pay, for instance.

Eddy Bresnitz, medical director for adult vaccines for Merck & Co. Inc., which makes Zostavax at a list price of about $160, said cost may be an issue for some older patients.

"I think when most adults think about vaccines, they think about the influenza vaccine, and in many cases they get that for nothing. And even where there is a cost, it's maybe $25 at a local pharmacy. When they compare it to that, $160 seems like a lot.

"But then," Dr. Bresnitz quickly added, "when you say this vaccine has a higher cost, I say, compared to what? If you compare it to the cost of treating a case of shingles, it's a whole lot lower."

UPMC's Dr. Kinchington said there is a legitimate reason for the higher cost, because the shingles virus, which is used to make the vaccine, is very difficult to grow in laboratory cultures, and the shingles vaccine has to be 14 times more concentrated than the chickenpox varicella vaccine, which is made from the same virus.

Jason Spangler, chief medical officer of Partnership for Prevention, a Washington, D.C., group advocating better preventive medical care, says his organization believes Medicare should cover the full cost of the shingles vaccine, just as it does for the flu and pneumonia vaccines.

Under the health care reform act, Congress has asked the Government Accountability Office to consider whether the shingles vaccine should be shifted into Medicare Part B, which would provide full coverage. A recommendation is expected this summer.

The second reason not many people are getting the vaccine is that many of their doctors aren't promoting it.

It's not that they don't see its value -- it's just that preventive measures often come low on the list at a busy family practice office, said Rafael Harpaz, a medical epidemiologist at the Centers for Disease Control and Prevention.

"Doctors who take care of seniors have so much in terms of acute care and chronic care management to do that prevention is not as much a part of their thinking as with pediatricians, who are dealing with a generally healthy population and are trying to keep them that way," Dr. Harpaz said.

Finally, older patients may be reluctant to get the shot because they don't know much about shingles and associate vaccines with children.

"If you asked people on the street what shingles was, they might not know," Dr. Spangler said, "whereas if you asked them about pneumonia or the flu, they'd know about those."

Still, the doctors said, it's important that people start learning more about shingles because the number of cases -- now estimated at 1 million to 3 million per year -- is bound to surge as the baby boomers age.

Shingles also has some serious side effects that go beyond the initial infection.

In about 20-30 percent of all shingles patients, Dr. Kinchington said, the pain will last far beyond the disappearance of the rash, and sometimes will stay with them the rest of their lives.

In some cases, people will get a condition known as allodynia, in which even a gentle breeze or the touch of a shirt or blouse on the affected area will cause agonizing pain.

The other threat is eye damage, he said.

Not only can shingles cause eye pain directly, but it can temporarily cloud the cornea, and in rare cases can attack the retina and cause blindness.

In some people, after the eye pain goes away, they will be left with no sensation at all in their corneas, which means they can permanently damage them when they do such things as put in eye drops or contact lenses.

While the shingles vaccine is now recommended for those 60 and older, there is mounting evidence that younger people can get shingles -- sometimes more than once.

A study sponsored by Merck last year showed that the vaccine cut the incidence of shingles in people aged 50 to 59 by nearly 70 percent. The company has asked the federal Food and Drug Administration to consider lowering the recommended age for the vaccine to 50.

And research by Minnesota physician Barbara Yawn showed that in one group of adult shingles patients, about 6 percent of them experienced a repeat episode within eight years. More than 30 percent of those patients were under age 50, she added.

Dr. Yawn knows what that can mean from personal experience.

At 33, she got shingles herself, including a rare side effect called Ramsay Hunt syndrome, which caused ear pain and some palsy.

She had to stay home from her busy medical practice during the infection because she felt so sick.

"Even my physician partners did not realize how uncomfortable and miserable I was. One of them even came to my house to see why I wasn't at work. Once he got a look at me, he said, 'Oh, now I understand. You should definitely stay home.' "

Mark Roth: mroth@post-gazette.com or 412-263-1130.


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