Issue 47 / 9 December 2013

HERPES zoster is on the rise in Australia, but research from the US suggests the national varicella immunisation program is not the cause.

Professor Raina MacIntyre, head of the School of Public Health and Community Medicine at the University of NSW, told MJA InSight that the increased incidence of herpes zoster (HZ) in Australia mirrored that in the US.

“Yes, we’ve been seeing the same trend over the last couple of decades, but the increase was apparent before the varicella vaccine was introduced”, Professor MacIntyre said.

She was responding to US research in the Annals of Internal Medicine which found the age-specific incidence of HZ had begun to increase in adults aged older than 65 years before the childhood varicella vaccination program was implemented. (1)

Using US Medicare data from 1992 to 2010, the research included more than 2.8 million patients older than 65 years. The researchers found 281 317 cases of HZ, with age- and sex-standardised HZ incidence increasing by 39% from 10.0 per 1000 person-years in 1992 to 13.9 per 1000 person-years in 2010.

The researchers found no evidence of a statistically significant change in the rate of increase after introduction of the varicella vaccination program for US children in 1996.

“Introduction and widespread use of the vaccine did not seem to affect this increase”, the authors concluded. “This information is reassuring for countries considering universal varicella vaccination.”

In Australia, the lifetime risk of shingles is estimated to be 20%–30%, with about half of people who live to 85 years likely to develop it, according to the National Centre for Immunisation Research and Surveillance (NCIRS). (2)

A monovalent varicella vaccine has been available in Australia since 2001 and was added to the schedule for all children at age 18 months in 2005, with a catch-up available for Year 7 students. It was replaced by the quadrivalent measles, mumps, rubella, varicella vaccine in July this year. (3)

Professor MacIntyre told MJA InSight that the burden of HZ was large, “arguably greater than the burden of varicella”.

She said that although the US research was reassuring, the study had its limitations.

“The authors only looked at patients over the age of 65 and many of them may already have a high level of HZ.”

According to the NCIRS, more than 97% of the Australian population has antibodies to varicella zoster virus by age 30 years, and most cases of shingles occur in immunocompetent adults older than 50 years.

“More research needs to be done in the 20‒64 years age group”, Professor MacIntyre said.

The increased incidence of HZ could be attributable to an increase in immunosuppression in the community, caused by factors such as more effective drugs used in the treatment of cancer, she said.

Professor Heath Kelly, from the Victorian Infectious Diseases Reference Laboratory, said the increased incidence in HZ in Australia “remains unexplained”.

“There is now a growing consensus that zoster is increasing in the US and this appears also to be true in Australia”, he told MJA InSight.

“What is less clear is the role of the varicella vaccine in this. Studies in all countries that have introduced the varicella vaccine confirm that its introduction has been associated with a significant decrease in cases of chickenpox.

“However, to infer a causal link between an increase in zoster and the varicella vaccine is more difficult because the link, if it exists, is indirect”, Professor Kelly said.

An HZ vaccine was recommended by the Pharmaceutical Benefits Advisory Committee (PBAC) in 2008 for patients aged over 60 years but the recommendation lapsed because of supply problems. The PBAC is expected to seek new submissions before its March 2014 meeting to have the HZ vaccine listed on the National Immunisation Program.

 

1. Annals Intern Med 2013; 159: 739-745
2. National Centre for Immunisation Research & Surveillance 2009; Zoster vaccine for Australian adults: information for immunisation providers
3. Department of Health, Victoria 2013; History of vaccine introduction

13 thoughts on “Shingles on the rise

  1. Jules Black says:

    We were taught in medical school in the 1960’s that the natural immunity from a chickenpox attack rendered one immune to Shingles.

    Not so??

  2. Huw R Davies says:

    Not so. Shingles is the recurrence of a dormant HZV infection in a specific dermatome. It’s not a new infection. It can be passed on to non-immunised individuals http://www.cdc.gov/shingles/hcp/clinical-overview.html

  3. James Taylor says:

    I have noted its greater frequency in my age group; I had it in the left L1 dermatome; I wonder if taking prednislone for asthma and eczzema was an important contributing factor.  The two problems (eczema and shingles) seemed to potentiate each other.

     

  4. Alisdair Barnes says:

    Anecdotally in my own practice I seem to be seeing more recurrent herpes type 2 (genital herpes) – usually on buttock area – in older women. Are others seeing this and is this evidence of some related mechanism (and therefore again not due to the vaccine)?

  5. Ray Hendle says:

    I attribute the essential cause of this rise to the increase in life expetency.

    Hence there is an increase in senile dementia.

    Who cares, at least initially, for these aged mums and dads?

    What lowers the immune system?

    Answer those questions and you’ll be on track.

    I (and my wife) have experienced this firsthand.

  6. William Darvall says:

    How on earth could the recent varicella immunization program affect the recent increased onset of shingles in later life? They are totally unrelated, as you “infect” yourself with shingles! Shingles may cause varicella in contacts without immunity, but varicella cannot cause shingles in contacts.

  7. David Gordon says:

    Varicella vaccination of children would reduce the amount of chickenpox in the community so there would be less exposure to chickenpox in those who had previously been exposed, so less “natural boosting” of immunity. Boosting of immunity would seem to be important as we get older, and would be the basis of the vaccine also being effective in reducing the risk of zoster.

    Increased zoster may also be a result of improved diagnostic testing and reporting

     

  8. Ruth Armstrong says:

    Re William Darvall: Thank you for your question.
    As explained in the background of the research article this story is discussing http://annals.org/article.aspx?articleid=1784289, the thinking has been that older people’s immunity to varicella is boosted by contact with children with chickenpox. As children are immunised and the incidence of chickenpox decreases, this could leave older people more vulnerable to reactivation of the virus as herpes zoster.

    Dr Ruth Armstrong, Medical Editor, MJA InSight

  9. Dr Margaret E Taylor says:

    It may be due to increasing frequency of zinc deficiency. As most of us don’t eat a lot of oysters, the main source of zinc is red meat which has about twice as much as the white meats.These days people are eating more white meat in the mistaken belief that it is healthier, but it is also cheaper. Also so many are on PPIs which reduce stomach acid and therefore the absorption of minerals (and increase the incidence of pneumonia and osteoporosis). The best evidence for the benefit of multivitamins and minerals is that they reduce the incidence of infections. eg Barringer Ann Intern Med. 2003 Mar 4;138(5):365-71. Infections over 1 year were 73% on placebo and 43% on supplements especially in the diabetics (93% vs 17%). A basic one  with at least 10mg of zinc is a good cheap investment in pevention of shingles, respiratory and other infections.

  10. Sue Ieraci says:

    If older people have waning immunity due to lack of repeated exposure (still theoretical, as I understand it), is it time to test the elderly for chickenpox immunity and offer vaccine boosters? Has anyone documented this phenomenon? By what mechanism would re-exposure to varicella prevent the outbreak of zoster?

  11. Denise Allen says:

    I have shingles at the moment. I just thought I had a persistent stiff neck (right side) for about a week….then got the other symptons around my right ear ….shooting pain, very tender sore scalp and about half a dozen individual lesions that looked more like pimples and a swollen lymph node which scared the life out of me. I had had a very stressful 6 weeks with a family illness then the last ten days of those 6 weeks extremely stressful. I was given Tramadol that made me vomit all day to the point I had to take myself to the hospital late at night to get a little white tablet to put under my tongue….it worked. Have not taken anything since. My lesions are healing, my scalp is no longer sore and tender but my neck is still quite sore. Dreadful experience all round.

  12. David De Leacy says:

    I am somewhat bemused that there is so much surprise that viral reactivation disorders are increasing as the mean age our developed world population inevitably trends upwards? As an analogy, the increased prevalence and incidence of neuro-degenerative dementia in the world is happily recognised as an untoward consequence of the vastly improved health outcomes from the 20th century from all public health measures (personal and global) leading to significant increase in longevity by the late 20th century cohort of citizens. (e.g. Baby boomers etc)   

    Immune-senescence is a very well recognised and described condition within immunology. One could surmise that this condition is due to tired and unrepaired telomeres with an associated happen-chance loss of important T cell, B cell, NK cell subsets that eventually renders the host susceptable to the ravages of diseases such as viral reactivation disorders (shinges, EBV in lymphomas) and other cancers. Indeed the loss or diminution of our normal immune surveillance mechanisms (innate and adaptive) eventually renders all of us susceptible to overwhelming infections and death.

    As my physician tutor of many years ago opined as a diagnosis of last resort: “It’s JPFROG young man” Just plain f…..g running out of gas!

  13. Warren Anderson says:

    I would caution against using assumptions in this area when we certainly don’t have all the data as I do believe that the increase warrants additional research.  If we use plain data we can see that there may be an issue that needs significant investigation.  If you look at the reported cases of VZ in Western Australia from 2009 to 2014 you will see an alarming increase.  2009 had 541 reported cases with a rate of 24.2 per 100000 whilst in 2014 it was 1317 cases at a rate of 53.2 per 100000.  That is an increase of over 150% in 5 years which by far outstrips the pace at which our population is ageing (ABS predicts population growth of 3.5% annually of 65+ years).  Now we could say that maybe our reporting has improved in terms of VZ cases in Australia in the last 5 years but there is no evidence of this and the increase is that startling that it warrants us not glossing over the facts. In Australia we also know that whilst there has been a decrease in stroke deaths there has been an increase in stroke rates and there is an increase in Cranial Nerve Neauralgia/Neorpathies all which VZ reactivation plays a significant role in contributing to.  A recent study of 100000 patients in the UK with CN damage showed that the most significant cause was from stroke and 2nd most common was VZV. The most concerning observation that I have made (which I acknowledge is not based on any data) is the amount of young people that are getting shingles and the article above clearly states that this is the area that needs more investigation.  I totally agree.  The data surely shows that something is happening and whether this is due to the immunisation programs or not needs far more investigation.

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