Shingles: The Disease and the Vaccine
It started as joint pain
I wasn’t even 51 when I had the unpleasurable experience of shingles. Shingles is caused by varicella zoster virus (VZV), which also causes chicken pox. VZV is a type of herpes virus.
I had been camping in the summer on the Eastern part of the US. It was very hot and humid. The last day my left hip and groin were bothering me. I figured I had just lifted something badly and strained a muscle or ligament. The ride home was quite unpleasant, and I kept shifting position trying to get comfortable. I was tired and grouchy, and my left groin was getting more sore. By the time we got home, all I wanted to do was take some ibuprofen and lay down. I thought my exhaustion and grouchiness was just from not sleeping well in a tent for 3 days and spending so much time out in the heat.
The next day wasn’t any better. My groin was hurting even more, and I was very tired. I kept looking in the mirror to see if there was anything obvious, like a tick bite, or if there was swelling. Swelling was definitely visible now in my groin and lower pelvis on the left side. I didn’t seen anything that looked like a bull’s eye or any bug bites, so I was pretty sure this wasn’t related to a tick bite or other insect bite. I took more ibuprofen and thought I had certainly pulled something.
The following day, I was again looking in the mirror to see if things were getting worse. I wasn’t feeling any better and had slept very poorly. Now, I had a rash on my inner thigh and still had the swelling, and I was just getting more and more uncomfortable. It was time to call the doctor.
Sure enough, the nurse practitioner listened to my symptoms, took one look at the rash, and said she wanted to confer with the physician. This took literally less than 3 minutes. The physician needed about 20 seconds to confirm that I had shingles. Neither the nurse practitioner or the physician came close enough to touch me. It was clear that they wanted to avoid any contact with this contagious rash. I left with a prescription for valacyclovir.
Valacyclovir (brand name Valtrex) is an antiviral medication. It does not cure the infection, but it can limit the replication of the virus and shorten the duration of the outbreak. Valacyclovir is also used to treat other types of herpes virus infections, such the ones that cause cold sores or genital herpes (herpes simplex viruses), which also cause skin lesions. It is sometimes also used to limit chicken pox infection by VZV. The medicine does not cure the infection in any of these cases. It only limits the frequency of occurrences of re-activation of the virus or the duration of the active period of the viral infection.
For me, valacyclovir helped the rash go away pretty quickly in about 2 weeks, but I still had a stinging and burning sensation on my inner thigh for months. Even now 2 years later, I get the occasional stinging sensation in that area of my leg. It is not excruciating, but I find myself rubbing the area over and over to alleviate the weird feeling.
From chicken pox to shingles
When I was a child, there wasn’t a vaccine. Children were exposed at school or in play groups so that they could get chicken pox and be immune. The idea was that chicken pox was safer to have as a child than as an adult. My case was very mild; I think I had ~4 pox. This is still generally true. Adults typically get more severe cases than most children do. Anyone who has had chicken pox is at risk of getting shingles.
In the US today, most children are vaccinated against chicken pox. The vaccine used in children is called a live virus vaccine, which means that it has a modified version of VZV that is not as infectious or able to cause symptomatic disease. This type of weakened virus that is used for vaccination is called an attenuated virus. Those who had chicken pox as a child can get shingles. People with active shingles can spread the virus to anyone who has not been vaccinated with the chicken pox vaccine or has not had chicken pox. Those people won’t get shingles, they will get chicken pox.
Chicken pox happens when the virus first infects a person. The infection is systemic, but the main symptoms are itchy blisters and fever. The itchy blisters pop and then scab. These skin lesions are highly contagious, and the infection is spread by contact (directly by touching the lesion or indirectly, for example, by sharing a towel) or through the air by coughing or sneezing. The sores eventually heal and the active infection resolves, but the virus is not gone. Instead, the virus enters the nervous system and the viral genome remains in the sensory nerves as a latent virus, which means it is no longer replicating and being released. It is dormant.
Children receiving the live attenuated virus vaccine could have the attenuated virus persist in a latent form in their sensory nerves; but this is very uncommon, because the virus is weakened.
In people who have had chicken pox, the latent virus may get regularly re-activated. Alternatively, stress or other triggers can cause the virus to re-activate. In a young person, the immune system reacts to this re-activated virus so quickly and effectively, no symptoms occur. In an older person (over 50 years old) or a person with a compromised immune system, the immune system cannot effectively combat the re-activated virus. This is how shingles happens.
When the virus re-activates, the virus replicates in the sensory nerves and then is released from the nerves to infect the skin causing a blistery, painful rash. Because the virus replicates and is released from the nerve, the nerve becomes injured and needs to recover after the active infection stops. Sometimes the nerve does not recover properly, which can lead to a condition called postherpetic neuralgia (PHN). PHN is common if shingles is not quickly diagnosed and treated with antiviral medication. The faint occasional stinging sensation that I have even 2 years after having shingles is PHN.
There are 2 shingles vaccines available in the US. The latest one is called Shingrix; the earlier one is called Zostavax. Neither vaccine cures the infection, but they can reduce the length of time that the virus remains re-activated, thus reduce the amount of the nerve damage, decrease the time that the skin lesions take to resolve, and limit PHN.
Shingrix is a called a “recombinant vaccine” and has 2 components: One is a protein (glycoprotein E) from the virus and the other is a set of immune-boosting molecules (ASO1b). Such immune-boosting components in vaccines are called adjuvants. Because Shingrix has this adjuvant component, the discomfort associated with the vaccine is greater than that caused by Zostavax, but Shingrix is more effective. Effective immunization with Shingrix requires 2 doses of the vaccine. Shingrix is the vaccine recommended by the CDC, because it has a higher rate of successful long-lasting immunization than Zostavax.
Zostavax is a live virus vaccine like the vaccine used for children, but Zostavax has a higher amount of the attenuated virus than the vaccine used in children. People who have received the Zostavax vaccine can get the Shingrix vaccine.
Although the initial recommendations were for people over age 60 to receive the shingles vaccine, the Center for Disease Control is now recommending the Shingrix vaccine for people over 50. I wish my doctor had offered the vaccine to me when I had my 50-year-old physical.
The first dose of Shingrix
I had to wait until the shingles rash was fully resolved before I could get the vaccine. Even then, it was difficult to find a location with any. When I finally found it at my local pharmacy, I had to argue with my insurance company to have it covered. The pharmacy was considered “out of network.” None of the in-network pharmacies, my doctor’s office, or urgent care centers had any of the vaccine. Given the full price, I was glad that I argued. I subsequently found out that I could use an online search tool to find where Shingrix was available. Once I had a list of where it was available near me, I could check which location was considered an in-network provider and make an appointment.
The pharmacist warned me that I might feel like I had the flu, get chills, and find that my arm at the site of the injection was painful. She wasn’t kidding!
I got the vaccine around 4PM. Within a few hours of receiving the vaccine, I started to ache. My arm where I had been injected hurt, but what really bothered me were the body aches, especially in my back. Around 10PM, I went to bed and tried to sleep. I was up every hour or so to use the bathroom, and I just couldn’t get comfortable enough to fall asleep.
By 2AM, I gave up trying to sleep and took some ibuprofen. I didn’t want to interfere with my body’s immune response to the vaccine, but the discomfort was too much. I finally slept for a few hours. When I woke, I still felt awful and was running a fever. After taking a shower, I felt exhausted and had to lie down for a few hours, not really sleeping but not really fully awake either.
After getting up for the second time the day after getting the shot, I took some more ibuprofen. By the evening, the aches and fever had subsided. But my arm was painful, amazingly hot to the touch, and had a patch of red far larger than where the site of the injection was. Even the second day after the shot, the redness, heat, and pain in my arm were not any better. It took nearly 5 days for the redness and soreness in my arm to fully go away.
These redness, heat, and pain are classic signs of an immune response, as is fever and tiredness. These were all signs that the vaccine was working. My body mounted an immune response. This version of the shingles vaccine causes such an extreme reaction, because it contains the special additive, the adjuvant, to help stimulates T cells. It is the T cell response that declines as we get older.
The second dose of Shingrix
I had the first dose in September. I had to wait at least three months to get the second dose and not longer than six months. I got the second dose in December. I used the Shingrix location finder to find a CVS with the vaccine and made an appointment at the Minute Clinic. It only took a few minutes to get the vaccine.
Even though the doctor warned me that the second dose could be more painful than the first, I did not find that my arm was nearly as sore as with the first dose. I also did not have the flu-like symptoms. I was a bit tired for about 1 day after getting the shot, and my arm was sore for about 4 days. Compared with the first dose, I didn’t wait to take ibuprofen this time. I took some within a couple of hours of getting the shot. Whether this made the difference or whether my body just reacted differently to the second dose, I can’t know.
Regardless, I am happy that I am now protected and won’t be getting shingles again. A weekend of discomfort and a sore arm are worth preventing a repeat of the pain of shingles.
K. Dooling, Shingrix Update: Common Shingrix Reactions — Which Can Be Prevented? Medscape (01 February 2019) https://www.medscape.com/viewarticle/907686.
New Shingles Vaccine Fact Sheet for Adults. Center for Disease Control and Prevention. (accessed 19 August 2019) https://www.cdc.gov/shingles/fact-sheets/shingles-factsheet-adults.html
Chickenpox (Varicella) Vaccine Safety. Center for Disease Control and Prevention. (accessed 19 August 2019) https://www.cdc.gov/vaccinesafety/vaccines/varicella-vaccine.html
Slideshow: A Visual Guide to Shingles. WebMD (accessed 19 August 2019) https://www.webmd.com/skin-problems-and-treatments/shingles/ss/slideshow-shingles-pictures