How to reduce, prevent herpes zoster

New York-The statistics concerning herpes zoster (HZ)-also known as shingles-are startling, said Elisabeth Cohen, MD.

The risk of herpes zoster increases significantly in people born in the United States who are 40 years and older, and rises sharply after age 50 (mean, 52 years). HZ will also develop in one in three people during their lifetimes, noted Dr. Cohen, professor of ophthalmology, New York University (NYU) School of Medicine.

Of patients who live to more than 85 years, half will develop HZ, she said. Older patients are at a greater risk of severe post-herpetic neuralgia and complications requiring hospitalization. Interestingly, the annual incidence of increase in cases of HZ from 1996 to 2007 was almost 70%, which far exceeds the increase in the aging population and does not seem related to introduction of the varicella vaccine for chickenpox.

Dr. Cohen described the newly associated complications of HZ infection:

• HZ ophthalmicus (HZO) increased the risk of stroke by 4.5 times within 1 year of infection despite treatment.

• Varicella zoster vasculopathy (VZV) causes stroke secondary to chronic viral infection of the large and small cerebral arteries.

• VZV has been associated with temporal arteritis.

Patients with HZ also have an increased risk of cancer development, especially lymphoid malignancies, within 1 year of the HZ diagnosis.

“The HZ vaccine-recommended by the U.S. Centers for Disease Control and Prevention since 2006 for patients 60 years and older who are not immunocompromised-reduces the overall burden of disease by 60% and reduces the incidence of HZ by about 50%,” she said. “(The vaccine) was approved by the FDA in 2011 for patients aged 50 and older, . . . (for) patients (in this age group), the efficacy is almost 70%.

“I strongly recommend this vaccine for patients in (their) 50s,” she continued.

Despite the benefits, the vaccine is underutilized, with only about 15% of patients aged more than 60 years having received it.

“The barriers to use of the vaccine include cost, complex and partial reimbursement, requirement for frozen storage, lack of availability (although this has been resolved), and lack of recommendation by physicians,” Dr. Cohen said.

Interventions at NYU to increase the use of the vaccine included physician and patient education, increased vaccine supplies, and issuance of health reminders and alerts. Thse actions have resulted in an increase in the number of immunizations and prescribed physicians, but resistance by physicians to the zoster vaccine compared with the flu vaccine (in favor of vaccine, 66% versus 97%, respectively).

In addition to the interventions based on knowledge, attitudes, and practice in implementing evidence-based recommendations, Dr. Cohen also emphasized the importance of a moral obligation to do the right thing to change behavior.

The Zoster Eye Disease Study has been proposed to the National Eye Institutes to test if suppressive valacyclovir can reduce HZO complications.

Information about contraindications to the zoster vaccine is available at www.cdc.gov.vaccines.

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