Vaccinate all patients over 50 years for herpes zoster
WAILEA, Hawaii — Ophthalmologists are more likely to see herpes zoster over herpes simplex, Jay S. Pepose, MD, PhD, said at Hawaiian Eye 2018.
The only real treatment for post-herpetic neuralgia (PHN) is to prevent it and this is where the vaccine becomes important, he said.
A controversy existed because the American Academy of Ophthalmology and the American Dermatologic Society recommended that patients over 50 years be vaccinated for shingles but the CDC recommendation was 60 years and above, Pepose said.
Now all recommendations are in line.
In October, the FDA indicated all healthy adults over 50 years be vaccinated and Shingrix (GSK) was selected as the preferred vaccine.
There are 1 million new cases of herpes zoster annually in the U.S. vs. 35,000 new cases of herpes simplex keratitis, Pepose said, along with 100,000 new cases of zoster ophthalmicus.
One in two people over 70 years will get shingles in their lifetime, he said.
The risk of stroke increases by 30% within 1 year of zoster and 4.5 times following herpes zoster ophthalmicus, Pepose said.
“This is thought to be related to varicella zoster virus (VZV) traveling down the afferent sensory fibers of the trigeminal nerve to internal carotid and its intracranial branches,” he said.
There are common misconceptions about shingles, he added.
It was thought that the vaccine could perhaps curb immunity in older patients.
“It turns out the incidence of zoster was increasing with age even before the production of the vaccine,” Pepose said.
The vast majority of zoster patients are healthy, he said. The mean age of onset for shingles is 52 years.
The ocular disease usually occurs weeks after.
“Although zoster is more severe in immunocompromised individuals, 92% of zoster patients are healthy,” he said.
The risk of PHN increases with age. PHN is associated with depression and is the leading cause of suicide in chronic pain patients over 70 years.
“Both varicella and varicella vaccine establish an immune response and lifelong neuronal latency, but changes in cell-mediated immunity lead to reactivation,” Pepose said.
He added that only 24% of eligible patients aged 60 years or older have been vaccinated.
“All patients over age 50 years should be vaccinated. I think you’ll have to be cautious with this in first quarter as the reimbursement is going through for the insurance company,” he said.
Zoster trials are ongoing.
“In those who currently have zoster, I wouldn’t vaccinate after it clears but wait a year and then vaccinate. I don’t think there is any evidence that proves the vaccine causes reactivation,” he concluded. – by Abigail Sutton
Pepose JS. The shingles vaccine and zoster ophthalmicus. Presented at: Hawaiian Eye; Jan. 13-19, 2018; Wailea, Hawaii.
Disclosure: Pepose reports no relevant financial disclosures.