Friday, January 14, 2011
The Shingles (Herpes Zoster) Vaccine Really Works But Many Older Folks Don’t Receive It - They Should
A new study was reported in JAMA January 12, 2011. Kaiser Permanente, Southern California and Centers for Disease Control and Prevention investigators evaluated 75,761 Kaiser members who had no underlying immunological disorder and who had been vaccinated between January, 2007 and December 2009. These were compared to a control group of 227,283 age matched members who had not been vaccinated.
Among the unvaccinated individuals, this study showed that, as anticipated, shingles incidence goes up with age from - 60-64 years of age (9.7 infections per 1000 person years) to over age 80 (17.3 per 1000 person years).
Vaccination reduced the frequency by about 50% from a total of 13.0 per 1000 person years to 6.4 per 1000 person years. This halving of incidence was found at all age intervals, indicating that the vaccine works as well in the very elderly as in “younger” individuals. The incidence of zoster was steady over time. For example, at one year, slightly more that 1% of the unvaccinated individuals had developed zoster compared to less that 0.05% in the vaccinated group; at two years the numbers were about 2 ½ % and 1%, respectively. During the time of patient follow-up, this can be stated as one case of herpes zoster was prevented with each 71 vaccinated. However, since the follow up was only about 1 ½ years for most individuals and since it is estimated that beginning at age 60 a person has a 20% lifetime risk of zoster, it is my presumption that it actually takes many fewer individuals vaccinated to prevent one episode of zoster over the rest of one’s life.
Not part of this study, the original Merck investigation demonstrated that many older people do not respond well to the vaccine with increases in antibody production. This finding is consistent with many others that those over 60 years of age respond much less well than do those who are younger. This raises the question as to whether it would be useful to measure antibody production after vaccination to determine who has and who has not responded well. Perhaps those who do not should get a second vaccination. This is an important issue for all vaccines in older people. The same occurs with influenza vaccine which is why, this year, the dose for older people was doubled. But perhaps there are other approaches as well to improving the response rates for those at increased risk in their older years who respond less well to vaccines.
The study makes clear that this vaccine is effective, including for those over 80 years of age where the incidence is the highest. Given the implications of herpes zoster in immediate and longer term suffering and the attendant costs, I believe this is a vaccine that essentially everyone over the age of 60 (other than immunocompromised individuals) should receive. Insurance should pay for it just as with the influenza vaccine.
Even if paid for out of pocket, it is worth it. Patients need to ask for it and doctors need to encourage it.
Praise for Dr Schimpff
The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.
-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).