A 69-year-old man living in a long-term care facility and recently diagnosed with metastatic lung cancer complained of numbness, itching, and pain in his lower right chest; the nursing staff attributed the discomfort to his recent diagnosis. The level of pain continued to increase, with the patient describing it as “like someone is sticking a knife in me and twisting it.” Subsequently, the patient developed a low-grade fever, headache, and generalized malaise for 1 to 2 days. Within 7 days, blister-like vesicles began to appear in clusters on the patient’s right chest. A diagnosis of shingles (also called herpes zoster) was determined, and the patient was started on antiviral medications to decrease the symptoms and course of the viral infection. Many older adults, such as this patient, who have the varicella zoster virus (VZV) living in their nerve roots are at risk for an outbreak of shingles whenever their cellular immunity becomes compromised.
The Centers for Disease Control and Prevention (CDC) has approved and recommends a new vaccine to prevent herpes zoster in older adults. The vaccine, Zostavax® (zoster vaccine live), manufactured by Merck, is recommended to protect against shingles in adults 60 and older. It is estimated that the lifetime incidence of herpes zoster is 10% to 20% in the general population but is up to 50% in individuals living to age 85 (CDC, 2008). The increase in risk with age is thought to result from an age-related decline in cell-mediated immune function (“Zoster Vaccine Live,” 2007). The vaccine, when implemented, is expected to avert a predicted increase in shingles cases as Baby Boomers begin reaching the ages most affected by the disease.
Sequence of Illness
Shingles is caused by the VZV, the same virus identified in chickenpox, the clinical manifestation of the primary VZV infection. During the course of chickenpox, the infectious virus is present in large amounts in the classic pox or blister-like vesicles; from there, the virus travels to the endings of sensory nerves in the skin, proceeds up the sensory nerves to the dorsal root and to the cranial sensory ganglia where the nerve cell bodies are clustered, and then establishes a lifelong residence (i.e., latent infection) in the sensory neurons (Oxman, 2009).
The latent VZV eventually reactivates (awakens), most likely from a single sensory neuron, to cause herpes zoster. As described by Oxman (2009), the virus multiplies and spreads within the ganglion, infecting many additional neurons and supporting cells, which results in intense inflammation and neuronal necrosis. The viral path proceeds from the sensory ganglion back down the nerve to the skin. The rash of herpes zoster is characterized by a unilateral vesicular eruption within a dermatome, which is representative of the dermatome innervated by the ganglion in which the latent virus is reactivated. The dermatomes most commonly affected are those of the abdomen, thorax, and ophthalmic branch of the trigeminal nerve.
Typically, herpes zoster begins with severe unilateral pain that has been described as stabbing or throbbing and persists for several days in the area where the skin lesions will eventually appear. The prodromal pain of herpes zoster has been compared to the pain experienced from appendicitis, biliary or renal colic, cholecystitis, duodenal ulcers, glaucoma, myocardial infarction, and pleurisy. The diagnosis and treatment of herpes zoster is virtually impossible until the classic vesicular dermatomal rash appears, which frequently prolongs the patient’s pain and suffering. Other prodromal symptoms include fever, headache, chills, and upset stomach. The rash of vesicles and pustules are usually present for 7 to 10 days, but the dry, flat, adherent crusts may last 2 to 3 weeks. Healing (reepithelialization) is normally complete within 4 weeks of rash onset. However, pain, which reaches its maximum intensity early in the second week, can continue after the rash has resolved, resulting in a debilitating complication known as postherpetic neuralgia (PHN) (Oxman, 2009).
PHN has been described as the worst pain one could ever experience, although the manifestations vary from patient to patient (Oxman, 2009). As cited by Zussman and Young (2008), at least 40% of patients older than 60 and 75% older than 70 developed PHN following an episode of herpes zoster. In comparison, multiple studies have shown that children and adolescents have either no risk or an extremely low risk of developing the condition (Zussman & Young, 2008).
According to Sampathkumar, Drage, and Martin (2009), “it is not uncommon for the pain of PHN to interfere with sleep and recreational activities and to be associated with clinical depression” (p. 278). PHN pain is attributed to sensory nerve damage and is often intermittent and not associated with external stimuli. Cutaneous scarring is responsible for the lack of normal sensitivity of the skin to touch and associated with increased pain. This sensory loss and hypersensitivity is a phenomenon called allodynia, where light touch or the brush of clothing is sometimes perceived as being painful (Sampathkumar et al., 2009).
Treatment and management of pain associated with PHN can be complicated in older adults, where each individual may have different sets of risk and adverse effects from medications. An excellent source for clinical practice is Dubinsky, Kabbani, El-Chami, Boutwell, and Ali’s (2004) guideline, which appears on the Agency for Healthcare Research and Quality’s National Guideline Clearinghouse website: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=5989&nbr=3947. The guideline recognizes tricyclic antidepressant agents, gabapentin (Neurontin®), pre-gabalin (Lyrica®), opioid drugs, and topical lidocaine patches as being effective in the treatment of PHN.
Age and Herpes Zoster
It has been estimated that 1 million or more cases of shingles occur each year in the United States (Oxman et al., 2005). The literature supports that more than 90% of adults in the United States have serologic evidence of prior VZV infection; consequently, the latent virus is present in virtually every older adult who was raised in the continental United States. It can therefore be concluded that every older adult in the country is at risk of developing herpes zoster. It has been estimated that half of the people who live to age 85 will get shingles (Cadogan, 2010).
Zussman and Young (2008) discussed the findings of an epidemiological study of older adults in a multicenter population survey of adults 65 and older; the results substantiate that the risk of developing herpes zoster increased by an odds ratio of 1:2 for every 5-year increase in age after 65. This increase in incidence with aging is due to a progressive decline in the body’s immunity to the VZV associated with aging. In addition, the U.S. Census Bureau (2004) estimated that 49 million people in the United States were 60 and older, a number expected to double by the year 2030.
The CDC (2008) recommends beginning treatment and controlling the acute symptoms with antiviral medication within 72 hours of development of the rash, thus reducing the pain and length of an outbreak. Antiviral medications include acyclovir (Zovirax®), famciclovir (Famvir®), and valacyclovir (Valtrex®). Topical agents such as antibiotic agents, medicated lotions, or astringent soaks may be used to relieve the pain and itching associated with the blisters. Pain medications such as analgesic or opioid agents may also be prescribed for shingles or PHN (CDC, 2008).
The Shingles Vaccine
The Shingles Prevention Study (SPS), a cooperative study, was the primary landmark study, conducted by the U.S. Department of Veterans Affairs, to determine whether vaccination with a live attenuated vaccine would decrease the incidence, severity, or both of herpes zoster and PHN in adults 60 and older (Oxman et al., 2005). The study was a randomized, double-blind, placebo-controlled trial that found that use of the zoster vaccine reduced the burden of illness due to herpes zoster by 61.1%; the incidence of PHN was lowered by 66.5%, and the incidence of herpes zoster was reduced by 51.3% (Oxman et al., 2005). On the basis of the results of this landmark study, the U.S. Food and Drug Administration approved the zoster vaccine for use in adults 60 and older for the prevention of herpes zoster (CDC, 2006). The zoster vaccine research added a powerful new weapon against shingles and the suffering caused in older adults.
Zostavax is a one-time vaccination for use in adults 60 and older to prevent shingles. The shingles vaccine is made from a weakened form of the VZV. Zostavax should be administered subcutaneously in the upper arm; however, this single-dose vaccine is not to be used as a treatment for shingles or PHN. The vaccine has been tested in approximately 20,000 adults 60 and older. The most common side effects in people who received the vaccine are redness, soreness, swelling, or itching at the injection site, and headache. Researchers suggest the shingles vaccine is effective for at least 6 years, but it may last much longer. Currently, further research is underway to determine exactly how long the vaccine protects against shingles (CDC, 2009).
Contraindications for the shingles vaccine include a life-threatening allergic reaction to gelatin or the antibiotic neomycin and severe allergy to any component of the vaccine. Individuals with a weakened immune system as a result of leukemia, lymphoma, or bone cancer and people with HIV/AIDS who have T cell counts below 200 are not candidates for vaccination. Furthermore, individuals being treated with drugs that affect the immune system (including high-dose steroids) and women who are or might be pregnant should not receive the vaccine (CDC, 2009).
According to the CDC (2009), individuals who have already had shingles should receive the shingles vaccine to help prevent future occurrences of the disease. The time frame between having the disease and immunization should be determined by the health care provider and based on the individual’s specific circumstances. The literature does support waiting at least until the shingles rash has disappeared before administering the vaccine (CDC, 2009).
Educating Patients and Health Care Providers
Health care has moved from an emphasis on illness to an emphasis on wellness and prevention, including the shift from acute care services to preventive and community-based services such as ambulatory care. Health care providers, especially nurses, are essential in the dissemination of knowledge to improve health outcomes associated with the shingles virus in older adults. At the local level, community-based health education programs can reduce disparities by increasing exposure of the proportion of the population to health information and disease prevention programs.
Vaccines have been one of the best health options, paying for themselves many times over in preventing sickness and early death. Traditionally, vaccines have targeted communicable diseases; hence, getting immunized has had a social purpose. Shingles is less contagious and lethal than influenza, measles, and other diseases prevented by vaccines; therefore, older adults may need more health education to understand the benefits of the shingles vaccine.
Understanding vaccination coverage from Medicare and private insurance, and how low-income adults without insurance can get coverage, are essential components of a successful immunization plan. To accomplish these goals, health care providers must play an active role in educating their patients to know how and when insurance pays for the vaccine. Merck charges approximately $161.50 for a single dosage of the vaccine (CDC, 2008). Physician administration fees and other charges can bring the price for consumers up to $300 for the one-dose vaccine. Medicare medical coverage (Part B) currently covers the influenza, pneumococcal, and hepatitis B vaccines, but it is up to each individual Medicare Part D prescription plan to decide the amount paid for the shingles vaccine. Starting in 2008, Congress required that all Medicare Part D prescription drug plans, which are administered by private contractors, include all commercially available vaccines not covered by Part B (CDC, 2008). Additionally, Part D participants may have to meet a plan’s requirement for deductibles or copayments, and coverage may vary depending on what stage of prescription drug coverage (e.g., initial coverage period, gap, catastrophic coverage) they are in (CDC, 2008).
It is important to discuss the three ways providers can be reimbursed for providing vaccines to older adults with Part D prescription drug coverage, as outlined by the CDC (2008):
- An in-network provider can charge the Part D plan for the vaccine and administration.
- An out-of-network physician can bill the beneficiary, who must seek reimbursement from the Part D plan, or the physician can use a new Medicare Internet portal device that offers web-assisted electronic physician billing to Part D plans.
- A specialty pharmacy can send the vaccine to a physician’s office, and the pharmacy can then bill the Part D plan for the vaccine and the physician can bill Part D for the administration fee.
Other available sources for reimbursement include private insurance plans, which may also cover the vaccine for beneficiaries ages 60 to 64 who are not enrolled in Medicare. For low-income adults without insurance, Merck offers a vaccine assistance program that can be accessed by telephone (1-800-293-3881) or Internet ( http://www.merckhelps.com).
Logistical problems have also arisen with the vaccine; Zostavax must be stored at a temperature of 5º F (−15º C) when it is transported and stored. In addition, the vaccine should be diluted just prior to administration and discarded if unused within a half-hour of preparation. Not all health care providers who see adult patients have access to freezers capable of maintaining this temperature. For offices without a free-standing freezer, Merck encourages health care providers to refer appropriate patients to a pharmacy participating in the Merck Adult Vaccination Program, which allows the pharmacist to provide the vaccines (CDC, 2008). Merck is currently working to develop a refrigerator-stable version (4º C) of the vaccine.
Recently, the CDC (2010) added the herpes zoster vaccine immunization for all adults 60 and older to the Recommended Adult Immunization Schedule, so there is much anticipation that this will increase health care provider awareness and administration of the vaccine. The CDC offers satellite “Immunization Updates” four times per year; these updates address storage and handling concerns and other questions health care provides might have.
The CDC is an important resource available to providers, as they continue to conduct surveillance and measure immunization coverage, work to minimize barriers to access, monitor vaccine use and impact, and track adverse events related to the current herpes zoster vaccine (CDC, 2008).
In answering the question of why older adults should receive the shingles vaccine, the SPS study findings establish that the herpes zoster vaccine is safe and effective for the prevention of herpes zoster and PHN in older adults. Health care education can empower providers and the public with knowledge related to cost issues, barriers to immunization, and the vaccination schedule. Prevention can be accomplished; however, it will take a concerted effort from public health professionals, community partnerships, and the mass media to educate the public. Nurses play an integral part in patient education to reduce missed opportunities for vaccination, which will thus reduce the overall burden of herpes zoster in the aging U.S. population.
- Cadogan, M.P. (2010). Herpes zoster in older adults. Journal of Gerontological Nursing, 36(3), 10–14. doi:10.3928/00989134-20100218-01 [CrossRef]
- Centers for Disease Control and Prevention. (2006, October). CDC’s advisory committee recommends “shingles” vaccination. Retrieved from http://www.cdc.gov/media/pressrel/r061026.htm
- Centers for Disease Control and Prevention. (2008). CDC seeks to protect older adults with shingles vaccine message. Retrieved from http://www.cdc.gov/vaccines/vpd-vac/shingles/downloads/shingles-vac-msg-2008.pdf
- Centers for Disease Control and Prevention. (2009). Vaccines and preventable diseases: Herpes zoster vaccine (shingles) Q&A. Retrieved from http://www.cdc.gov/vaccines/vpd-vac/shingles/vac-faqs.htm
- Centers for Disease Control and Prevention. (2010). Recommended adult immunization schedule: United States 2010. Retrieved from http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-schedule.pdf
- Dubinsky, R.M., Kabbani, H., El-Chami, Z., Boutwell, C. & Ali, H. (2004). Practice parameter: Treatment of postherpetic neuralgia: An evidence-based report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 28, 959–965.
- Oxman, M.N. (2009). Herpes zoster pathogenesis and cell-mediated immunity and immunosenescence. Journal of the American Osteopathic Association, 109(Suppl. 2). Retrieved from http://www.jaoa.org/cgi/reprint/109/6_suppl_2/S13
- Oxman, M.N., Levin, M.J., Johnson, G.R., Schmader, K.E., Straus, S.E. & Gelb, L.D. et al. (2005). A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. New England Journal of Medicine, 352, 2271–2284. doi:10.1056/NEJMoa051016 [CrossRef]
- Sampathkumar, P., Drage, L.A. & Martin, D.P. (2009). Herpes zoster (shingles) and postherpetic neuralgia. Mayo Clinic Proceedings, 84, 274–280. doi:10.4065/84.3.274 [CrossRef]
- U.S. Census Bureau. (2004). Projected population of the United States, by age and sex: 2000 to 2050. Retrieved from http://www.census.gov/ipc/www/usinterimproj/
- Zoster vaccine live (Oka/Merck): Profile report. (2007). Drugs and Therapy Perspectives, 23(2), 5–6.
- Zussman, J. & Young, L. (2008). Zoster vaccine live for the prevention of shingles in the elderly patient. Clinical Interventions in Aging, 3, 241–250.