Connecting the Dots: Chicken Pox, Varicella Vaccine and Shingles
Jan 08, 2013

DrZibnersToday’s guest post from Dr. Lara Zibners addresses a follow-up question we received on our Vaccinate Your Baby Facebook page in response to a previous post about the varicella (chicken pox) vaccine.

 “How likely is it that my older 2 kids (who got wild pox and weren’t vaccinated) will get shingles later?” 

Boy, do I love a follow-up question! It means someone out there actually took the time to read my words, contemplate their meaning, and push the issue further. So let’s take the question in parts A & B: (A) what is the risk of developing shingles over one’s lifetime? and (B) is the risk different if an individual has “wild-type” chicken pox versus the varicella vaccine?
First off, let’s start by stating one unarguable fact: shingles sucks. Sorry, there’s no other way to describe it. Burning pain followed by nasty little blisters which are confined to what we call a “dermatome.” A dermatome is an area of the skin that is supplied by a single spinal nerve. In other words, the area of the spine called “T4” (for thoracic nerve #4) provides sensation to the nipple line and “T10” is the level of the belly button. Does that make sense? It may help if I tell you that as a first year medical student I dressed up as “Dermatome Man” by spray painting a sweat suit in stripes of pink, yellow and blue and writing the corresponding dermatome in each area. If that doesn’t help, then it just confirmed for you that I’m a dork. Fine. Moving on.
herpeszosterWhen a body encounters the varicella virus, either via wild-type chicken pox infection or the vaccine, the virus can basically go for a long snooze in one of these spinal nerves. If it wakes up, it causes shingles, also known as herpes zoster. Complications include zoster of the eyes (causing scarring), infection of the blisters, or infection of other organs of the body including the brain, liver or lungs. As if zoster itself wasn’t miserable enough. What’s even worse is that some people go on to develop a condition called “post herpetic neuralgia.” This is where the blisters have gone away (in about 1-2 weeks) but the burning painful sensation remains, in some cases for years. The pain can be so terrible and debilitating that it has even driven some poor souls to suicide. If that isn’t the definition of “sucks,” I don’t know what is.
So now to the heart of the question. What is the risk that a child will develop shingles at some point in his life? The answer partly depends on how long he lives. As we age, along with our knees and eyesight, our immune systems begin to show signs of wear and tear. This means a greater chance that the varicella zoster can “wake up.” About 50% of people over the age of 85 will have had an episode of shingles. Other people at risk include those with abnormal immune systems, such as children on chemotherapy for cancer.
But there is some good news. Lots of good news, actually. First and foremost is that while scientists are still researching this exact question, it appears that the risk of shingles may be lower for people who have received the varicella vaccine as opposed to having suffered through “wild-type” chicken pox. Of course, that news is only good if your child had the vaccine, isn’t it? Well, don’t lose hope. Because there is more good news. In the form of another vaccine.
Yep, it is now part of our routine immunization recommendations for adults 60 years and older to receive a dose of the zoster vaccine. The zoster vaccine is basically a ramped up version of the varicella vaccine, with at least 14 times the concentration of the live-attenuated virus. That’s enough to wake up the immune system memory and keep that sleeping varicella quiet. While the vaccine isn’t perfect, resulting in about a 50% decrease in the risk of shingles, it is very good at preventing the complications. In a study of over 38,000 adults, there was a significant decrease in duration and severity of the disease and almost a 70% decrease in the risk of post-herpetic neuralgia.
So there you have it. There is an argument that ongoing lifetime exposure to children with “natural” chicken pox will prevent shingles. And that we’ve tinkered with this system by immunizing against varicella in the first place. Which is technically true. Repeated exposure will keep the old immune system more awake and charged up, better prepared to beat down that pesky varicella. But the vaccine does the same thing. And vaccinating against both means a lower risk of severe complications from chicken pox and a much lower risk of severe complications from zoster. Which is worth celebrating, eh?
For more information on the zoster vaccine and shingles, check out these links.
In addition to being painful, there are instances when shingles can have a severe impact on people.  This video from PKIDs on the Shot By Shot gallery is just one more reason you’ll want to do what you can to avoid getting shingles.  [youtube=]

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14 responses to “Connecting the Dots: Chicken Pox, Varicella Vaccine and Shingles”

  1. Leigh Smith says:

    When our daughter got the flu vaccination this fall, I actually had a nurse mention off-hand that some parents have “concerns” about the varicella vaccine, so this is a timely article/answer. Thank you, Dr. Zibners (and Christine). I also have a question. You write that the routine immunization recommendation is “for adults 60 years and older to receive a dose of the zoster vaccine.” I’m curious (and maybe this is answered elsewhere; I’ve never read about it) … Why is the vaccine not recommended for younger adults–say those of us who were children in the ’70s and ’80s, prior to availability of the varicella vaccine? Is it assumed that through parenthood and/or daily life we’ll have enough exposure to the wild-type pox to wake up our systems, up until about age 60, when immunity is assumed to significantly wane?

  2. Tsu Dho Nimh says:

    QUESTION: If I have already had chickenpox and a couple of mild rounds of shingles … would the zoster vaccine do any good?

  3. Ken says:

    I had a serious case of shingles about five years ago (I was 52 at the time). Am I protected against another serious outbreak? Do you recommend I get the shingles vaccine when I turn 60?

  4. Lauren @ the VEC says:

    To learn more about shingles and the shingles vaccine, the Vaccine Education Center at The Children’s Hospital of Philadelphia has a Question and Answer sheet titled,
    “Shingles: What you should know”:

  5. Lara Zibners says:

    These are awesome questions!! To start with, the reason shingles is more common in older folks is that at some point our immune systems start to show signs of aging, allowing VZV to “wake up” and present as shingles. While the vaccine would work in younger adults, and is approved down to age 50, to make sure we have enough to cover those at greatest risk, routine use isn’t recommended until a little later. The zoster vaccine can be given to those who have had either the varicella vaccine or those with a history of “wild-type” disease AND even for someone with a prior episode of shingles. The idea is that as we get older, the complications of shingles become even more common, so we really do benefit from the additional boost to our immunity.
    Keep ’em coming…

  6. lilady says:

    Just to add to Dr. Zibner’s post above. The original FDA approval stipulated that the zoster vaccine would be given to people age 60 and above. The FDA then approved the vaccine for those age 50 and above, March 2011.
    The ACIP however, declined to recommend the vaccine for that age group…for a variety of reasons, including vaccine shortages. Once those manufacturing issues are resolved, I suspect that the ACIP will again review their recommendations. Right now, the vaccine can be prescribed for younger people (“off label” use)…doctor’s call.

  7. dingo199 says:

    Tsu Dho Nimh :
    QUESTION: If I have already had chickenpox and a couple of mild rounds of shingles … would the zoster vaccine do any good?

    It would likely as not stop you getting further episodes.

  8. Nathan says:

    The research really doesn’t support the vaccine having a meaningful impact on reducing further episodes of shingles if you have already had one outbreak of shingles.
    The risk of herpes zoster recurrence following a recent initial episode is fairly low among immunocompetent adults, regardless of vaccination status. Such a low risk suggests that one should evaluate the necessity of immediately vaccinating immunocompetent patients who had a recent herpes zoster episode.”
    It’s a bit of a controversial question.
    “The US Food and Drug Administration currently views shingles recurrence as “unlikely” and recommends against immunizing individuals with a “diagnosis or verification of a history of chickenpox or shingles by a healthcare provider.”
    In contrast, the CDC recommends vaccination of all individuals aged 60 years and older, including those who have experienced an episode of shingles.
    Dr. Oxman sees no conflict between the positions adopted by the 2 agencies.
    “This is not the same as giving the vaccine twice,” Dr. Oxman explained with respect to the CDC’s stand. “The recommendation is for a dose of vaccine irrespective of a history of shingles.”
    “The reason for this is that the diagnosis and memory of having shingles are not reliable: You wouldn’t want to tell someone not to bother with the vaccine because they’ve had shingles, and then develop a case associated with long-term pain,” Dr. Oxman added, noting that the vaccine comes at the right price (free) and there is no reason to believe that revaccination is linked to any adverse events.
    Further studies are needed to determine the vaccine’s efficacy for preventing recurrence in patients with a confirmed history of shingles, as well as the duration of that effect.”

  9. Vaxine Skeptic says:

    How was this determined? Is there a study or two that can be linked to? The varicella vaccine has been in use since 1995. What groups were compared to come up with this claim?
    “First and foremost is that while scientists are still researching this exact question, it appears that the risk of shingles may be lower for people who have received the varicella vaccine as opposed to having suffered through “wild-type” chicken pox. Of course, that news is only good if your child had the vaccine, isn’t it? Well, don’t lose hope. Because there is more good news. In the form of another vaccine.”

  10. Nathan says:

    Since most shingles occurs in the elderly, and the vaccine has only been in the US for about 15 years or so, it’s too early to tell the full impact on shingles incidence. But studies on immunocompromised kids (who have a greater overall incidence of shingles) as well as epidemiologic studies on vaccinated children show a decreased incidence of shingles in the vaccinated.
    “Conclusions: In children with leukemia who receive the live attenuated varicella vaccine, the subsequent incidence of zoster is lower than in children who have natural varicella infections.”
    “The incidence of zoster in the vaccinated children group was slightly less than that in the group that had experienced natural varicella.”
    “Conclusions: In the early post-varicella vaccination period, incidence rates of medically attended herpes zoster did not increase for the overall population and decreased moderately for children 9 years and younger, the age group targeted for varicella vaccination.”

  11. Dr Zibners, what if you had only one vaccine for chicken pox, instead of two, and then got wild chicken pox. Where do you think immunity to shingles figures in with that kind of scenario?

  12. Tsu Dho Nimh says:

    OK – thanks to the links y’all dug up, it looks like recurrence is low and the issue is still being discussed.
    “Vaccination appeared to have little effect on the likelihood of developing a second case of shingles. Among the 1036 vaccinated individuals, the rate was 19 cases per 10,000 adults compared with 24 cases per 10,000 adults among the 5180 unvaccinated individuals ” With the usual “we need a larger study” comments.
    I’m going to get the vaccine anyway, because I’ve had repeated outbreaks (always on the same dermatome) and although it’s mild compared to some experiences, it’s a PITA.

  13. We would not desire to risk our skin for possible damage as it will beat the function of using a skin whitening item.

  14. mathews z7 says:

    Great article. I wilpl bbe facing many of these issues as well..

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