Alice Goodman

November 27, 2013

NEW ORLEANS — Although most adults 40 years and older are at risk for herpes zoster infection, also known as shingles, uptake of the vaccine (Zostavax) to prevent infection is disappointing, researchers say.

"The risk of herpes zoster is increasing faster than the aging population," said Elizabeth Cohen, MD, from the NYU Langone Medical Center in New York City.

One manifestation of shingles is herpes zoster ophthalmicus — a painful condition with ocular complications that affects 25% of all people infected, she explained.

"Ophthalmologists and other physicians should encourage patients older than 40 to get vaccinated. As renowned bioethicist Arthur Caplan said, 'We have a moral obligation to do the right thing to change behavior'," she said.

Dr. Cohen reviewed the epidemiology of shingles and discussed the underuse of the vaccine here at the American Academy of Ophthalmology (AAO) 2013 Annual Meeting.

More than 90% of the people born in the United States who are older than 40 have had chicken pox. The virus lingers in the body and can be reactivated as shingles many years later.

The risk for reactivation is increasing in the United States and globally, Dr. Cohen explained. The risk goes up after age 40 and rises sharply at age 50. One in 3 people older than 50 will develop shingles, as will 50% of those who live to age 85. Shingles is not necessarily an older person's disease; more than 50% are younger than 60 years at onset, and the mean age of onset is 52 years.

 
Only 69% of the physicians said that the shingles vaccine was important, whereas 94% said the flu vaccine was important.
 

It is not clear why the risk has increased by almost 70% in the past 15 years. "The increase in infection is greater than the increase of the aging population," she said. For unknown reasons, shingles occurs in more women than men.

The risk for postherpetic neuralgia, a painful complication of shingles, also increases with age. In fact, 80% of cases occur in people older than 50 years. Postherpetic neuralgia increases morbidity and quadruples 1-year medical costs, Dr. Cohen noted.

Herpes zoster ophthalmicus increases the risk for stroke 4.5 times within 1 year of diagnosis, and shingles increases the risk for cancer 9-fold in the first year after diagnosis, she reported.

The vaccine was originally approved for patients older than 60, but it is now encouraged for those 50 and older who are not immunocompromised or on immunosuppressant treatment, do not have anaphylactic allergy to gelatin and neomycin, and are not pregnant.

"It is better to get the vaccine in your 50s and 60s, but it is never too late to get it," Dr. Cohen said. Information about the vaccine is available on the Web site of the Centers for Disease Control and Prevention.

The vaccine reportedly reduces the overall burden of disease by 61%, decreases the incidence of shingles by 51%, and lowers the incidence of postherpetic neuralgia by 66%.

Unfortunately, only 15% of people older than 50 are vaccinated, according to the Centers for Disease Control.

Barriers to Vaccination

Barriers to implementing the vaccine include its high cost, a complex reimbursement process, the need for frozen storage, and availability. In addition, studies have indicated that the lack of a strong recommendation by a physician could be the biggest barrier, Dr. Cohen said.

Dr. Cohen and her team surveyed primary care physicians and consenting patients at the Bellevue Eye Clinic in Washington. Only 69% of the physicians said that the shingles vaccine was important, whereas 94% said the flu vaccine was important.

A second part of the survey compared 100 patients who were vaccinated with 66 eligible patients who chose not to be vaccinated. The demographic characteristics of the 2 groups were similar. The most common reason for refusing the vaccine was wanting to speak to their primary care physician first.

"We need to encourage doctors to recommend the vaccine. Ophthalmologists with a strong relationship with their patients are more likely to recommend it," she stated. In addition to prevention, treating herpes zoster ophthalmicus minimizes complications.

The Zoster Eye Disease Study (ZEDS) is currently enrolling 1050 patients with herpes onset within the previous 6 months, Dr. Cohen reported. The study will evaluate whether prolonged suppression with valacyclovir will reduce complications, including chronic ocular disease and postherpetic neuralgia. Patients will be randomized to 1 year of treatment with valacyclovir 1000 mg/day or placebo. Follow-up will be 18 months.

"More than 1 million cases of shingles occur in the United States each year, and herpes zoster ophthalmicus represents nearly 25% of all cases of shingles," said Kathryn Colby, MD, director of the AAO cornea program.

"Ophthalmologists need to accurately diagnose herpes zoster and recognize the general symptoms of shingles. Timely treatment is critical to minimize complications, protect vision, and reduce nerve pain that can cause patient suffering," said Dr. Colby, who is a cornea surgeon at Massachusetts General Hospital and practices at the Massachusetts Eye and Ear Infirmary in Boston.

"Ophthalmologists can play an important role in ensuring that vulnerable patients are vaccinated," she noted.

"Dr. Cohen's presentation highlights the renewed interest in herpes zoster infection, both in the eye and elsewhere," said Elmer Tu, MD, from the Department of Ophthalmology and Visual Science at the University of Illinois Eye and Ear Infirmary in Chicago. "This interest is due to the increased vaccination of children over the last nearly 20 years and the more recent introduction of a vaccine for adults over the age of 50."

Dr. Tu noted that shingles is also increasing in those 20 to 50 years of age, but neither the pediatric nor adult version of the vaccine is indicated for this cohort.

"Now that we have additional interventions that have the potential to reduce the recurrence of herpes zoster infection, we are forced to re-examine not only the costs and benefits of vaccination, but the rationale and efficacy of our current treatment regimens," he explained.

"Because of the uncommon but potentially devastating effects of herpes zoster on the eye, the ophthalmologist plays a vital role in educating patients about the benefits of herpes zoster vaccination," he said.

As Dr. Cohen pointed out, "support for a nationwide study on the appropriate treatment of patients with active disease is needed to establish guidelines for the care of this potentially blinding disease," Dr. Tu noted.

Dr. Cohen reports financial support from Merck for the study. Dr. Colby reports financial support from Novartis. Dr. Tu reports financial relationships with Bausch + Lomb.

American Academy of Ophthalmology (AAO) 2013 Annual Meeting. Presented November 16, 2013.

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