Underused, Shingles Vaccine Beset with Problems

Shingles on the waist, above the eye, and forehead, CDC.

If you talk with people who have had shingles, many will tell you that it took a terrible toll on them and that they wish that they could forget about the entire experience. Some can’t. “Freddy” had shingles three years ago, when he was 61. A decorated Vietnam veteran, he told me that nothing prepared him for the incredible pain, headaches, fever, nausea, and numbness that he had from shingles. Freddy had a painful rash on his left side and fluid filled blisters. His entire left side was affected and he says that he still has numbness. He went to work, but was miserable, and immediately went to bed when he got home. His doctor told him that his symptoms were “classic” signs and symptoms.

In 2006, the shingles vaccine was approved and recommended for people age 60 whose immune system was good. However, the uptake for the vaccine is just 10 percent. If this was the case with uptake of childhood vaccines, people would be in an uproar.

Shingles is caused by the same virus that causes chicken pox, the varicella- or herpes-zoster virus. Once you have chicken pox, the virus remains in your body in a dormant state for the rest of your life. The risk for shingles rises with age.

• The Shingles Prevention Study found that the vaccine reduced the odds of getting shingles and postherpetic neuralgia (pain along a nerve three months after symptoms begin) by 51 percent;

• A subsequent study showed a 55 percent reduction in getting shingles;

• The shingles vaccine is covered under Medicare Part D; however copays vary widely, depending on your plan;

• About one in three individuals will get shingles in their lifetime;

• Those individuals who get vaccinated and get shingles will have a less severe case, have decreased likelihood of loss of work, and lower treatment costs;

• In one study, African Americans got vaccinated less and the risk for shingles was lower; however, researchers maintain that the burden is still considerable and urge all groups to get the vaccine;

• Because the vaccine was only licensed recently, the duration of its effectiveness remains unclear and is under study.

• The Advisory Committee for Immunization Practices recommends that people age 60 and over get the vaccine. However, most people don’t know about it, doctors don’t recommend it, and pharmacies often don’t carry it because of storage issues. It is also one of the costliest vaccines available: costing as much as 20 times what the flu vaccine costs, and 4 times as much as the pneumonia vaccine.

Freddy says that he would have definitely gotten the vaccine, but he knew nothing about it. That says something: Freddy works as an analyst for a health agency in the mid-Atlantic.

“This vaccine is a perfect storm,” says Rafael Harpaz, MD, MPH, epidemiologist with the Centers for Disease Control and Prevention, Immunization Services, National Center for Immunization and Respiratory Diseases, Atlanta GA. “It is one of the most expensive vaccines, there are big supply shortages, the manufacturer [Merck] does not promote it, and doctors don’t tell patients about it because it is difficult to get. Added to that are reimbursement issues: it may be unaffordable or require cumbersome paperwork for people to get their money back.”

In New York, one patient told me that she went to several chain drugstores: all told her that they never carry it and her doctor had no idea where to find the vaccine. Finally, a pharmacist at an independent pharmacy told her that the vaccine was on order and that they would have it in four months. That was not all. She’d get a prescription from her doctor, have to pick up the vaccine dose, and have the doctor give her the shot. The pharmacy warned her to check with her health plan on the cost so that she would be sure that she wanted it. She gave up.

Harpaz pointed out that adult vaccines are “an extremely tough sell.” It took decades to get the pneumonia vaccine up front and it took doctors demonstrating that preventing pneumonia was cost effective and pushing it aggressively as a way to stop unnecessary hospitalizations. The pneumonia vaccine is part of Medicare Part B.

Shingles vaccines may not be promoted very much unless more data comes out that demonstrates adverse effects on employee work performance (days out of work, in pain, and discomfort) or high treatment costs linked for people who don’t get vaccinated.

The shingles vaccine is covered under Medicare Part D, but that doesn’t mean it is affordable. Out of pocket expenses for the vaccine are all over the map, very much dependent on who negotiates what contracts with whom.  The Government Accounting Office is exploring ways to make these vaccines more accessible and simplifying payment and reimbursement.