Beth Longware Duff

Individuals who have experienced the painful and often debilitating condition known as shingles (herpes zoster, or HZ) would like to think that it’s a 1-and-done infection. Unfortunately, although a reoccurrence of shingles is not common, it can and does happen due to the innate nature of the varicella zoster virus (

VZV does not discriminate by age. The virus is at the root of both the childhood infection known as chickenpox (varicella) and the adult infection 

. Both chickenpox and shingles are characterized by a blistering red rash. Other shared symptoms include fever, fatigue, and headache.

Once the primary infection (chickenpox) resolves, VZV moves into the dorsal root ganglia where it remains dormant for decades. It can then 

 as HZ and possibly cause serious complications like postherpetic neuralgia (

, an estimated 1 million cases of HZ occur annually in the United States. Although the incidence rate in the general population is about 4 cases per 1000 individuals, it increases to about 1 case per 100 individuals among people who are 60 years and older.

Recurrent shingles — that is, any occurrence of shingles that happens after the initial case — is basically another reactivation of the VZV that’s already in the body. As long as VZV is present, there’s always a chance of relapse and another episode of shingles. Risk factors for recurrent shingles are primarily linked to the overall condition of an individual’s immune system. Immunocompromised people are particularly prone to relapse.

Other risk factors include age (attributable to weaker immune systems), gender (women account for 60% of all recurrent shingles cases), high anxiety and stress levels, certain immunosuppressive therapies, cancer, autoimmune diseases like HIV/AIDS and lupus, and chronic diseases like diabetes, hypertension, and chronic obstructive pulmonary disease.

The time period between an initial case of shingles and a reoccurrence can vary, but researchers have identified a 4- to 8-year window as most likely. A 

 conducted in Minnesota reported that during an average of 7 years of follow-up, HZ recurrences were as common as HZ incident occurrences in the studied population, when matching for age, sex, and immune status.

“Our high HZ recurrence rates suggest that zoster vaccination should be offered in people who have had an HZ episode to prevent potential recurrences,” the study’s authors concluded.

Shingrix, the shingles vaccine that was introduced in the United States in 2017, is the first line of defense against shingles and its complications. As individuals age, their immune systems decline, increasing their risk of developing shingles. Shingrix works by helping the immune system defend against shingles.

Two doses of Shingrix administered 2 to 6 months apart have been proven to be more than 90% effective at preventing HZ and PHN. The vaccine offers continued protection for at least 4 years.

Shingrix is recommended by the CDC’s Advisory Committee on Immunization Practices for use in immunocompetent adults 50 years and older. It can be administered to a patient with shingles once the rash has healed to protect against future reoccurrences and related complications.

1. CDC. Shingles (Herpes Zoster). Updated October 5, 2020. Accessed June 30, 2021. 

https://www.cdc.gov/shingles/hcp/clinical-overview.html

2. Yawn BP, Wollan PC, Kurland MJ, Sauver JL, et al. Herpes zoster recurrences more frequent than previously reported. 

Articles

Here’s what to know about recurrent shingles and risk factors. 

Recurrent Shingles: Herpes Zoster Can Strike More Than Once	

Although COVID-19 vaccines and vaccination rates have received a lot of attention recently, it’s worth noting that there are numerous other vaccines recommended by the CDC in its 

. However, the agency reports that coverage among US adults remains low across the board. There is 1 bright spot: the vaccination rate for 

 (HZ), also known as shingles, has surpassed its Healthy People 2020 goal.

 from its most recent annual National Health Interview Survey (

), a continuous, cross-sectional national household survey of the civilian population. The objective of the NHIS is to monitor the health of Americans and to provide estimates of health indicators, health care use and access, and health-related behaviors.

NHIS data were collected from more than 25,000 adults between 2010 and 2018 to determine if they had received the following vaccines: influenza, pneumococcal, HZ, tetanus and diphtheria, acellular pertussis, hepatitis A, hepatitis B, and/or human papillomavirus (HPV) vaccines.

Coverage was found to be low in all age groups, and there were racial and ethnic differences that revealed lower coverage for most vaccinations among non-White compared with non-Hispanic White adults.

Additionally, the authors of the report noted that vaccination coverage estimates for 3 out of 4of the vaccines (influenza, pneumococcal, and hepatitis B) did not meet their respective 

 target levels. “Herpes zoster vaccination coverage in 2018 was 4.5 percentage points above the Healthy People 2020 target of 30%,” they added.

HZ vaccination coverage among adults aged ≥50 and ≥60 years in 2018 was 24.1% and 34.5%, respectively, similar to the estimates for 2017. White adults had higher coverage (28.0% and 38.6%, respectively) compared with Black (12.4% and 18.8%), Hispanic (12.2% and 19.5%), and Asian (19.6% and 29.1%) adults.

, the only HZ vaccine available in the United States, is approved by the FDA for the prevention of shingles in immunocompetent adults aged 50 and older. The 2-dose series was proven in clinical trials to be up to 90% effective at preventing shingles, and a recent 

 confirmed that Shingrix is safe and effective even for frail individuals.

Overall, the NHIS report concluded that routine vaccination is an essential preventive care service for all individuals that should not be delayed because of the COVID-19 pandemic.

“The adult immunization schedule, updated annually, provides current recommendations for vaccinating adults and a resource for persons who provide health care services for adults in various settings,” the report stated.

The report also noted that awareness among the general population of the need for vaccines for adults is low and that adult patients rely on provider recommendations for vaccination.

“Many of the long-established public health actions to increase vaccination coverage among adults can be used for both routine vaccinations and for a COVID-19 vaccine,” its authors advised. “It is important to assess the vaccination status of all patients at each visit to avoid missed opportunities for vaccination and ensure timely vaccine catch-up.”

The report adds that all vaccines that are due or overdue should be administered according to the recommended CDC immunization schedules, unless a specific contraindication exists, to provide protection as soon as possible and minimize the number of health care visits needed to complete vaccination.

Lu PJ, Hung MC, Srivastav A, Grohskopf LA, et al. Surveillance of vaccination coverage among adult populations––United States, 2018. 

http://dx.doi.org/10.15585/mmwr.ss7003a1external icon

Rates for other vaccinations remain low in the United States.

Shingles Vaccination Rate Surpasses US Target Goal

Herpes zoster, also commonly known as shingles, is a viral infection that occurs when the dormant varicella-zoster virus (VZV) reactivates in the body after causing an earlier case of chickenpox. Once a person recovers from chickenpox, VZV travels deep into nerve tissues and remains dormant for decades. When it reawakens, it travels back up the same nerve to the skin where it reemerges as shingles.

Any individual that has had chickenpox can develop shingles unless they have been vaccinated against it, which greatly decreases their risk. Approximately 60% of all shingles cases occur in people over the age of 60.

 is a painful and blistering raised rash that erupts most often along one side of the torso, waist, chest, neck, or back. Other sites include around an 

Shingles on the scalp is particularly tricky to treat because the skin there is very sensitive. Simple pressure from washing or brushing the hair can result in broken and bleeding blisters.

Besides pain, shingles on the scalp can cause headaches and weakness on one side of the face that makes it appear to droop. It can also cause hair loss from combing or scratching, or even permanent baldness from cicatricial alopecia, which destroys the hair follicles that generate hair growth and replaces them with scar tissue.

When diagnosing shingles on the scalp, one of the first steps a health care provider takes is to examine the appearance and feel of the rash. They also ask about other symptoms the patient is experiencing.

Symptoms associated with shingles include itching, burning, redness, or tingling in the area of the rash; mild to severe pain in the affected area; fever, chills, nausea, headache, sensitivity to light, and fatigue. A course of antivirals should be started as soon as possible to shorten the length of the infection and help prevent serious complications.

During the acute eruptive phase of shingles of the scalp, the blisters form and then break. A dry crust then forms on the skin. The focus should be on managing the 

 and itching while preventing permanent damage to the scalp.

Recommendations include applying cold compresses to the affected area to numb the pain and using calamine or menthol lotion to lessen itching. Use gentle, unscented shampoos and warm water to wash the hair, and avoid scrubbing the scalp. Don’t use hair spray and styling products for the duration of the rash, which could last 3 to 5 weeks.

, the only shingles vaccine available in the United States, is the one way to protect against shingles and postherpetic neuralgia (

), the most common complication from shingles. The vaccine is recommended for healthy adults age 50 and older. It is administered in 2 shots given 2 to 6 months apart.

“Two doses of Shingrix are more than 90% effective at preventing shingles and PHN. Protection stays above 85% for at least the first 4 years after you get vaccinated,” notes the CDC on its website.

Pay special attention to prevent permanent hair loss.

Managing Shingles on the Scalp	

Since the beginning of the COVID-19 era, rumors and misinformation about the virus have circulated worldwide. One of the most recent examples of this involved a study conducted in Israel that reported a potential link between the BNT162b2 mRNA (Pfizer-BioNTech) vaccine and a reactivation of the herpes zoster (HZ) virus, or 

Unfortunately, the data was often misunderstood and misconstrued by some mainstream and social media outlets, resulting in disinformation that was disseminated over multiple news cycles.

Specifically, the ongoing observational study that began in December 2020 at 2 medical centers in Israel monitors post-vaccination adverse events in patients with autoimmune inflammatory rheumatic diseases (AIIRD). In April 2021, the authors of the case series reported in 

 that of the 590 participants (491 with AIIRD and 99 controls), HZ reactivation following COVID-19 vaccination occurred in just 6 patients (1.2%) with stable AIIRD, compared with none in the control group.

All of the infected patients were women ranging in age from 36 to 61 years. All were on immunosuppressant drugs due to their autoimmune disorders, and none had received the chickenpox or 

. With 1 exception, their shingles cases were mild and resolved with antiviral medications.

"Our report does not establish any causality or definite link but draws the attention to a possible association between mRNA COVID-19 vaccine and herpes zoster," Dr Victoria Furer , lead author and rheumatologist at the Tel Aviv Medical Center, confirmed for the 

Media outlets picked up the story, but unfortunately 

 inaccurately. False and misleading headlines proclaimed that herpes infections that were not part of the Israeli study—including herpes simplex associated with oral and genital herpes infections observed in sexually transmitted diseases—could be linked to the Pfizer-BioNTech vaccine.

Meanwhile, no reports of an increase in shingles cases after COVID-19 vaccination have been reported in the United States, according to William Schaffner, MD, professor of medicine at Vanderbilt University Medical Center.

"We have been emphasizing the vaccination of older adults," Schaffner, who is also a spokesperson for the Infectious Diseases Society of America, told the AP. "That's the very population in which shingles is the most common, and so you would expect some cases of shingles to occur after vaccination ... because it's going to occur anyway."

Pharmacists can play an important role in answering their patients’ questions and encouraging them to get vaccinated against both COVID-19 and shingles. In early 2021, the American Pharmacists Association (APhA) announced its support for the CDC’s efforts to build the American public’s confidence in the COVID-19 vaccines.

“Pharmacists are already on the front lines, playing a major role in vaccinating Americans against COVID-19,” said Scott Knoer, MS, PharmD, FASHP, and executive vice president and CEO of APHA in a prepared 

 “This project will build on the trust that people already have in their pharmacists to provide education about the vaccines, and thoughtfully and comprehensively address patient concerns. Pharmacists will be a critical partner in ensuring that this pandemic is brought under control as quickly as possible.”

With all the misinterpretations associated with her study, Furer boiled the confusion down to 1 salient point during an interview with the 

 "We should not scare people,” she said. “The overall message is to get vaccinated. It is just important to be aware."

1. Furer V, Zisman D, Kibari A, et al. Herpes zoster following BNT162b2 mRNA Covid-19 vaccination in patients with autoimmune inflammatory rheumatic disease: a case series. 

https://doi.org/10.1093/rheumatology/keab345

2. Not Real News: A look at what didn’t happen this week. Associated Press. Updated April 27, 2021. Accessed June 1, 2021. 

https://apnews.com/article/ap-fact-check-israel-media-arthritis-social-media-1261d8c91eb855754edb14fb36afe8bf

3. Fact Check-Study does not show COVID-19 link to genital herpes. 

 Updated April 22, 2021. Accessed June 1, 2021. 

https://www.reuters.com/article/factcheck-covid-herpes/fact-check-study-does-not-show-covid-19-link-to-genital-herpes-idUSL1N2MF1XR

4. American Pharmacists Association Collaborates with CDC to Build the Public’s Confidence in COVID-19 Vaccines. Press Release. American Pharmacists Association; March 29, 2021. Accessed June 1, 2021. 

https://pharmacist.com/APhA-Press-Releases/american-pharmacists-association-collaborates-with-cdc-to-build-the-publics-confidence-in-covid-19-vaccines

5. Jaffe-Hoffman M. New vaccine side effect? In Israel, six people develop herpes zoster. 

 Updated April 19, 2021. Accessed June 1, 2021. 

https://www.jpost.com/health-science/new-vaccine-side-effect-in-israel-six-people-develop-herpes-zoster-665632

Mainstream news outlets and social media misinterpreted Israeli study findings.