An interview with Dr. Jay Keystone, Travel Health Director at the Medisys Preventive Health Clinic in Toronto, and Dr. Vivien Brown, VP Medical Affairs, Medisys Corporate Health
Important Note: Due to high levels of demand for the Shingrix vaccine, suppliers have recently implemented order limits. It is anticipated that Shingrix vaccine order limits and shipping delays will continue in the near term. Currently the Shingrix vaccine is widely unavailable and on back order throughout Canada. It has become increasingly challenging to keep an ample supply at Medisys clinics. Contact your local Medisys clinic to determine whether Shingrix vaccine doses are available in your area.
Q: What is shingles?
Shingles is a painful, blistering skin rash caused by the varicella-zoster virus, the same virus that causes chickenpox. The varicella-zoster virus remains dormant and inactive in certain nerves in the body from childhood. With stress and an aging immune system, this virus becomes stimulated once again and is reactivated. About 20 per cent of those with the shingles rash will go on to suffer from chronic nerve pain in the area of the skin affected. This pain can be severe and is often debilitating for months or even years. This complication of chronic nerve pain is called post herpetic neuralgia (PHN).
Q: Can anyone get shingles?
The lifetime risk of getting shingles is about 30 per cent. Anyone who’s had the chickenpox is at risk of getting shingles. Shingles is commonly associated with individuals who are 50 years and older. Most shingles sufferers in Canada are over the age of 60. However, people in their 20s, 30s and 40s can and do get shingles as well.
Q: Can you prevent shingles?
Yes. Shingles is a vaccine-preventable disease. No vaccine is 100% effective in preventing disease; however the shingles vaccine will significantly reduce your risk of shingles. In studies, compared with placebo, the newer immunization, Shingrix significantly reduced the risk of developing shingles by 90-97% in subjects 50 years and older. Moreover, similar to the flu vaccine, vaccination will significantly reduce the severity of the disease and the risk of nerve pain if the disease is contracted. Zostavax, the first vaccine, decreases risk by about 50-60 per cent overall, decreasing in older people, but about two thirds of patients in all ages groups are protected from PHN with Zostavax.
Q: If you’ve had shingles can you get it again?
Yes. Shingles can come back a second or, rarely, a third time. However, getting shingles more than once is uncommon. There is limited data on the use of Shingrix in patients who have had shingles before. Our current Canadian guideline does endorse receiving the Zostavax vaccine about 1 year after a shingles episode, to decrease the risk of a second episode.
Q: Who should receive the Shingrix vaccine?
Those who are 50 years and older should consider being vaccinated to prevent shingles. Both vaccines are recommended and approved by Health Canada for individuals 50 years and older. There are some studies that suggest that stress may precipitate shingles. Risk factors include a family history, especially with multiple relatives, non-insulin dependent diabetes mellitus, and those with autoimmune rheumatic diseases such as rheumatoid arthritis and systemic lupus. All of these groups have a significantly increased risk of shingles, particularly family history. Also, although off label, there are some studies suggesting that individuals under 50 who are immunocompromised should be immunized with Shingrix. Immunizing individuals under the age of 50 is an "off label" use of the vaccine; it is important to consult a qualified health professional for a personalized recommendation.
Q: If you have NEVER had chickenpox, should you still get the shingles vaccine?
If you’ve never had chickenpox you do NOT need the shingles vaccine. Instead, you should be vaccinated against chickenpox two doses of Varivax one month apart). Note that before the advent of the chickenpox vaccine about 90% of children under the age of 12 were exposed to the virus that causes chickenpox (varicella-zoster virus). The chickenpox vaccine has reduced the prevalence of chickenpox significantly.
Q: What is the difference between Zostavax and Shingrix?
Both Zostavax and Shingrix are vaccines used to help prevent the occurrence of shingles. There are several differences between the two vaccines, most importantly, in clinical studies Shingrix has shown greater effectiveness at preventing shingles in individuals over 50 years of age relative to Zostavax. Zostavax is a subcutaneous, one-time injection while Shingrix is an intramuscular (IM) injection requiring two injections, with the second dose given 2 to 6 months after the first. Shingrix is a recombinant, non-live vaccine, while Zostavax is a live, attenuated vaccine. Live virus vaccines aren't recommended in immunocompromised patients. Despite Shingrix being more effective relative to Zostavax, it requires two shots spaced over a period of 2 to 6 months, whereas Zostavax requires only one shot. Some individuals may opt for Zostavax because of the convenience of not having to return for a second shot.
Q: If you have already received a Zostavax injection, can you get a Shingrix injection?
While Shingrix has been shown to be more effective at preventing shingles relative to Zostavax, especially in older patients, we DO NOT YET have Canadian guidelines for revaccination. That said, the US national immunization committee (ACIP) has recommended Shingrix for those who have received Zostavax. This ACIP recommendation is based on the fact that within 5 years post vaccination, Zostavax prevents shingles by only 40% and, by 10 years reduces post herpetic neuralgia by only 35%.
Revaccination is a personal decision for you to discuss with your doctor. At Medisys preventive health clinics, we carry both the Shingrix vaccination and the Zostavax vaccination. While we recommend our patients get vaccinated, the choice of the vaccine depends on several factors. Shingrix is more effective, but requires 2 doses and has greater side effects. The effectiveness of Zostavax significantly decreases with age, though the decrease in PHN remains significant. Zostavax will also decrease the severity of an episode of shingles, should you be affected, after vaccination. This process, called attenuation, really means that the value of the vaccine (like influenza vaccine) is measured not just by how many cases are avoided, but also by how severe the cases are that develop after vaccination.
Q: Who should NOT get the Shingrix vaccine or Zostavax and what are the side effects?
Shingrix is a recombinant, non-live vaccine and thus, theoretically, it can be given to individuals who are immune compromised (live vaccines like Zostavax are not recommended in immune compromised individuals). Individuals allergic to any ingredients in the Shingrix vaccine should not get the vaccine. The most common side effects of Shingrix are pain, redness, and swelling at the injection site, muscle pain, tiredness, headache, shivering, fever, and upset stomach, which are related to the immune system responding to the vaccine. Based on available data, the majority of reactions to the vaccine were transient and mild to moderate in intensity, lasting less than three days. However, there were some patients that did report significant symptoms for a few days following vaccination, and did miss work with headache, fever, chills and generalized malaise or significant fatigue. If you choose to be vaccinated, it may be advisable to schedule the injection so as to avoid interference with important events or travel, as the risk of side effects differ per individual and can be unpredictable. Zostavax is a live virus and is not recommended in immune compromised individuals or pregnant women. The side effect profile for Zostavax is minimal with minor injection site reaction like redness and soreness. After 10 years on the market, there have been no unexpected issues associated with Zostavax.
Q: What is the cost of the vaccine?
The Shingrix vaccination costs $350 and the Zostavax vaccination costs $225. Some health benefit plans may cover the cost of the shingles vaccination in part or in full. Consult your plan administrator to inquire.
Q: Where can you get the Shingrix vaccination?
You can get the Shingrix vaccination or Zostavax at many family doctors’ offices, provided they have stock of the vaccine. There is a widespread shortage of the new Shingrix vaccine across Canada. Contact your local Medisys Preventive Health Clinic at 1 800 361-3493 or email us at firstname.lastname@example.org to determine whether or not your preferred shingles vaccine is in stock.
At Medisys, we practice personalized medicine, reviewing your history, your risk, your age and your best choice before making recommendations.
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