Beth Longware Duff

Decades after the introduction of the chickenpox vaccine and 14 years after the first shingles vaccine was approved in the United States, it’s time to take stock of where the country is in respect to shingles infections. The bad news is infection rates are up; the good news is there is an effective shingles vaccine that holds promise for the future.

First, some background on the subject from Jeffrey I. Cohen, MD, chief, Laboratory of Infectious Diseases at the National Institutes of Health (NIH). Shingles (herpes zoster, or HZ) is caused by a reactivation of the varicella zoster virus (

) that causes chickenpox. “During chickenpox, the virus spreads in the blood and infects the nerves. Those nerves are seeded with virus, meaning the virus is there and stays in those nerve cells for the life of the person,” explained Cohen. “It can reactivate at a later time from the nerves, causing shingles.”

This is the scenario that plays out for approximately 1 in 3 Americans, accounting for an estimated 1 million cases of shingles annually. According to the 

, although the shingles infection rate among older adults has plateaued in recent years, the rates among younger and middle aged adults have been gradually increasing over a long period of time.

 revealed that although chickenpox and shingles vaccines may be reducing HZ-related emergency room visits for children and patients over the age of 60, the numbers are up for patients between 20 and 60 years of age.

The reasons for the overall rise in rates are unclear. Prior to the introduction of the varicella vaccine in 1996, there was speculation in the medical community that the number of shingles cases would increase based on the theory that exposure to chickenpox boosts an individual’s immunity to VZV and reduces the risk that it will reactivate as shingles. That is, as more children received the varicella vaccine and the number of chickenpox cases declined, shingles cases in adults would rise.

However, 2 subsequent CDC studies found that the shingles rates began increasing in the US before the chickenpox vaccine was introduced and did not increase faster afterwards. Additionally, there have been similar increases in shingles rates in countries that do not have routine chickenpox vaccination programs.

One important question remains unanswered: Will shingles eventually just disappear once generations of people have been vaccinated against chickenpox? “Epidemiologists are predicting that it will go away, or at least become very rare in the US,” said neurologist Anne Louise Oaklander, MD, PhD, and director of the Nerve Unit at Massachusetts General Hospital. “We hope that with the new vaccination this will become of historical interest only. But it’s very much with us right now.”

Recent data from the CDC revealed that the 

 is increasing in the US, currently almost 35% and surpassing the agency’s Healthy People 2020 target of 30%.

Shingrix is now the only shingles vaccine since Merck 

 earlier this year that it was removing Zostavax from the US. market. Approved by the FDA in 2017 for use in people 50 years and older, Shingrix is administered in a 2-dose series and has proven to be 

 at preventing shingles in clinical trials across all age groups tested.

1. CDC. Shingles (Herpes Zoster). Page last reviewed: August 14, 2019. Accessed September 3, 2020. 

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

2. What Are Trends in Emergency Department Utilization, Costs for Shingles? News Release. 

 June 21, 2017. Accessed September 3, 2020. 

https://media.jamanetwork.com/news-item/trends-emergency-department-utilization-costs-shingles/

Articles

Decades after the introduction of the chickenpox vaccine and 14 years after the first shingles vaccine was approved in the United States, it’s time to take stock of where the country is in respect to shingles infections

US Shingles Update: Cases Up, but Vaccination Rates Increasing

 for developing herpes zoster (HZ) range from age and gender to race and overall general health. These factors may also contribute to a longer shingles infection period and the likelihood of 

Journal of the American Academy of Dermatology

 concluded that many chronic inflammatory skin diseases (CISD) may also lead to an increased risk for HZ and subsequent hospitalization.

The study’s authors—Raj Chovatiya, MD, PhD, and Jonathan I. Silverberg, MD, PhD—analyzed data from the 2002 to 2012 Nationwide Inpatient Sample, which provides a representative cohort of hospitalizations in the United States. They concluded that hospitalization for shingles was significantly associated with several CISDs, including atopic dermatitis (AD), and that there was a greater length of stay for those patients

“Nearly one in three people in the US will develop herpes zoster in their lifetime, with approximately 1 million cases annually and a 3% hospitalization rate,” the authors wrote in the study. “Patients with chronic inflammatory skin diseases have potential risk factors for HZ, including long-term use of systematic immunosuppressants and immune dysregulation in the skin and periphery.”

The authors also reported that HZ hospitalization was associated with the female sex and extensive use of corticosteroids, and inversely associated with an increased number of chronic conditions and early adult age. They concluded that additional studies are needed to establish CISD-specific vaccination guidelines, particularly for individuals who are younger than the age recommended for HZ vaccination.

AD is the most common, chronic, and severe type of eczema, a non-contagious group of dermatologic conditions that cause red, irritated, itchy and/or inflamed skin. Statistics from the 

indicate that AD affects 18 million people in the US, with nearly 40% suffering from a moderate or severe form of the disease. It is more common in adult females than males, and multiracial and white adults tend to have the highest prevalence of AD.

 can be mistaken for other skin conditions that are similar in appearance and share symptoms like itching, burning, and stinging, but emerging patterns differ. For example, the shingles rash first appears as small raised dots in a band along one side of the body, often on the torso. The eczema rash, on the other hand, can emerge anywhere on the body, including arms and legs.

Two other important differences that set the shingles rash apart from other rashes are that shingles is typically much more painful, and it clears up within a few weeks. By comparison, eczema is a chronic condition that can stretch from childhood to adulthood.

 in the US was discontinued by Merck in July 2020, 

 is the only vaccine to prevent shingles. The recombinant zoster vaccine was licensed by the FDA in 2017 and is recommended by the CDC for adults age 50 years and older.

Shingrix’s efficacy in preventing shingles has been reported to be as high as 97% in individuals 70 and older, and its efficacy for the prevention of the shingles complication 

Chovatiya R, Silverberg JI. Association of herpes zoster and chronic inflammatory skin disease in US inpatients. 

Journal of the American Academy of Dermatology.

Study suggests higher hospitalization rate for some skin diseases.

Chronic Inflammatory Skin Diseases and Shingles Risk

Virtually every person born prior to 1980 in the United States was infected with the highly contagious varicella zoster virus (VZV) before an effective vaccine was available. The virus causes varicella (chickenpox) and then settles into the dorsal root ganglia, where it remains dormant for decades before 

 as herpes zoster (shingles). Consequently, almost every adult American is at risk for developing the painful condition.

There are various factors, however, that increase an individual’s risk for shingles. Some are related to a decline in VZV-specific immunity, but there are other reasons as well, including:

 The chances of developing herpes zoster and associated complications, including 

, increase considerably after the age of 50. This is due to a normal decline in a person’s immune system that occurs throughout the aging process. The risk of shingles continues to increase with each passing decade. For example, whereas about 1 in 3 Americans experience shingles during their lifetime, that ratio rises to 1 in 2 among people age 80 and older.

 are more likely to develop shingles than men, with pregnant and menopausal women being most vulnerable. Although the exact reason for this is not known, it’s thought to be related to normal hormonal changes that occur during the aforementioned periods in a women’s life, which affect the immune response.

 Shingles is more common in people of non-Hispanic white ancestry than in those of African American ancestry. According to the CDC, herpes zoster is at least 50% less common in Blacks than in whites. One 

 concluded that elderly Blacks were up to 75% less likely to develop herpes zoster than elderly whites.

 Certain medical conditions and medications that suppress an individual’s immune system can make them more susceptible to shingles. For example, patients with 

 (particularly leukemia and lymphoma) or HIV, as well as bone marrow and solid organ transplant recipients are at greater risk. Immunosuppressive medications like steroids, chemotherapy, and those related to organ transplants also increase an individual’s chances of developing shingles. People with suppressed or compromised immune systems are also more likely to develop a form of shingles called 

Vaccination is the best way to reduce the chances of developing shingles. 

 is currently the only shingles vaccine distributed in the United States.

Approved by the FDA in 2017 for people age 50 and over, Shingrix is a nonliving vaccine made of a virus component. It is administered in 2 doses given 2 to 6 months apart.

Shingrix offers protection against shingles for more than 5 years and has proven to be over 90% effective across all target age groups. It has also been shown to reduce the length and severity of the infection, and lower the risk of complications.

Zostavax, the first available shingles vaccine, was 

 from distribution in the United States by Merck in July 2020. The CDC 

 that patients who have previously received Zostavax should subsequently receive Shingrix. Providers are advised to consider the patient’s age and time since receipt of Zostavax to determine when to vaccinate with Shingrix, although the minimum interval should be 8 weeks.

Schmader K, George LK, Burchett BM, Hamilton JD, Pieper CF. Race and stress incidence of herpes zoster in older adults. 

Journal of the American Geriatrics Society.

CDC. Frequently Asked Questions About Shingrix. Page last reviewed March 26, 2018. Accessed August 10, 2020. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/faqs.html#:~:text=Frequently%20Asked%20Questions%20About%20Shingrix,-Related%20Pages&text=Shingrix%20is%20the%20preferred%20shingles,dose%20as%20soon%20as%20possible.

Age, gender, race, and general health make the list of potential risk factors for shingles. 

Risk Factors for Developing Shingles

More senior Americans than ever before are reporting that they’ve been vaccinated against shingles, according to newly published 

National Center for Health Statistics. Although the shingles vaccination rate is now almost 35% nationally, there are racial, economic, and educational disparities among those receiving the vaccine.

The National Health Interview Survey focused on the 10 years between 2008 and 2018. During that time, the national shingles vaccination rate among adults aged 60 and older rose from 6.7% in 2008 to 34.5% in 2016, and then remained constant through 2018. Rates for adults aged 70 and over were even higher, ranging from 7.8% in 2008 to 37.8% in 2016, which also held constant through 2018. The higher rates surpassed the CDC’s 

Other key findings of the survey include:

By 2018, women and men were equally as likely to have received a shingles vaccine. Their vaccination rates were 35.4% and 33.5%, respectively.

The vaccination rate of 38.6% for non-Hispanic white adults was about twice that of non-Hispanic Black (18.8%) and Hispanic (19.5%) adults.

Vaccination rates increased with family income, ranging from 20.4% among poor adults to 38.4% among adults in higher income brackets.

The rate also increased with educational attainment. Adults with less than a high school diploma had a rate of 21.2%; adults with more than a high school diploma or GED had a rate of 39.9%.

Geographically, the vaccination rate of those surveyed ranged from a high of 42.8% in the West North Central region of the United States to a low of 26.3% in the East South Central region.

“While there has been a shingles vaccine [Zostavax] available since 2006, a new vaccine [Shingrix] was introduced in late 2017, and uptake in the market may have occurred differentially in 2018,” noted the authors of the report.

They also found that the discontinuation of Zostavax in the United States—

 by Merck in May with an effective date of July 1, 2020—may further alter shingles vaccination patterns in the future. Additionally, the 2017 

 by the CDC’s Advisory Committee on Immunization Practices (ACIP), which expanded shingles vaccination to adults aged 50 and over, may also impact future vaccination rates.

Supply shortages of Shingrix developed shortly after its introduction in the US market, but 

recently reported that the COVID-19 pandemic led to a drop-off in vaccinations, allowing GlaxoSmithKline (GSK) to catch up on production of its shingles vaccine.

A company spokesman reported that GSK has produced “without interruption” during the pandemic. As a result, Shingrix is no longer listed on the CDC’s shortages list, and GSK assured its customers that it has supplies “available to meet demand across all distribution channels.”

Terlizzi EP, Black LI. Shingles vaccination among adults aged 60 and over: United States, 2018. 

https://www.cdc.gov/nchs/data/databriefs/db370-h.pdf

Sagonowsky E. GSK’s Shingrix supply recovers thanks to drop in vaccinations, uninterrupted production. 

 Published July 9, 2020. Accessed August 10, 2020. https://www.fiercepharma.com/pharma/gsk-s-shingrix-supply-recovers-due-to-drop-vaccinations-uninterrupted-production

The report showed that the vaccination rate has quintupled over the last decade.

Author | Beth Longware Duff

Articles

US Shingles Update: Cases Up, but Vaccination Rates Increasing

Chronic Inflammatory Skin Diseases and Shingles Risk

Risk Factors for Developing Shingles

Shingles Vaccinations on the Rise in United States