There are plenty of illnesses that we still don’t know how to prevent. But there are some that we’ve figured out how to sidestep pretty easily with just a vaccine. One of those is shingles, a painful, blistering skin rash that typically appears later in life.
About one in three people in the United States will get shingles in their lifetime, according to estimates from the Centers for Disease Control and Prevention (CDC). The risk of developing it increases as we age. Yet, only about 35% of adults have been vaccinated against herpes zoster (the official name for shingles), according to the latest data. For something so common—and painful—that’s a pretty low rate. There are a lot of reasons why this is the case...not all of them great. If you haven’t been vaccinated yet or are on the fence, we’ve got all the info you need to know about this shot.
Why Shingles Is Worth Avoiding
Let’s back up real quick here—we can’t talk about the shingles vaccine without talking about why shingles is something people generally want to avoid if they can.
Shingles is a reactivation of the varicella zoster virus, which is the virus that causes chickenpox. “Once you’re infected, the virus remains dormant in nerve cells,” says Amesh Adalja, M.D., a senior scholar at the Johns Hopkins University Center for Health Security in Baltimore. It can stay in your cells, never bothering you, for decades, until it decides to reactivate. “When the virus reactivates, you don’t get chickenpox, but a different type of syndrome called shingles. It causes a rash that can be very painful,” Dr. Adalja says.
The shingles rash appears as a stripe along one side of the body or one side of the face, and typically causes pain, itching, or tingling before the skin symptoms shows up. It can also cause fever, headache, chills, and an upset stomach. The rash typically takes two to four weeks to fully clear.
Generally, the older you get, the more at risk you are of developing shingles and of experiencing complications, says Subhashis Mitra, M.D., director of the infectious diseases fellowship program at Michigan State University in East Lansing. He explains that as we get older, our immunity begins to wane, which increases the chance the virus can pop back up. “Similarly, people who are immunocompromised for whatever reason, are at increased risk,” he adds.
For some people, shingles can have a lasting impact. About 10% to 18% of people with shingles will end up with a complication called postherpetic neuralgia (PHN), which causes long-term nerve pain. It can last for months or years, says Rachel M. Bartash, M.D., infectious disease specialist at Montefiore Health System and assistant professor of infectious diseases at the Albert Einstein College of Medicine. The risk of developing PHN also increases with age, Dr. Bartash says.
Because the human immune system is so complex and unpredictable, it’s hard to say why some people may get shingles and others never do. It’s also impossible to predict if someone will get it or not. Also, getting shingles once doesn’t make you immune—you can always get it again.
The Facts About the Shingles Vaccine
The shingles vaccine works by preventing a reactivation of the virus, says Dr. Adalja. But like most vaccines, it’s not 100% protective. “But those who do get shingles despite being vaccinated are more likely to have less severe cases and not complicated by postherpetic neuralgia.”
Zostavax, the first shingles vaccine, became available in 2006. A second vaccine, Shingrix, hit the market in 2017. As of July 2020, Zostavax is no longer produced (though the CDC says remaining inventory can still be safely used until it expires), and Shingrix will be the sole approved and recommended shingles vaccine in the U.S. Shingrix comes in two doses and is recommended for adults 50 and older.
Why the change up? The primary problem with Zostavax was that it was a live-attenuated vaccine, which means it uses a live, but weakened, form of the virus. So you couldn’t give it to immunocompromised or pregnant patients, says Dr. Mitra. By contrast, Shingrix is a recombinant vaccine, which means it’s made with just one specific piece of the virus. “You can give Shingrix to a larger range of patients,” including some who are immunocompromised, says Dr. Bartash.
Studies also show that Shingrix is more effective at preventing both shingles and postherpetic neuralgia compared to Zostavax, Dr. Bartash adds. In fact, Shingrix has been shown to be 97% effective in preventing shingles in adults 50 to 69 years old and 91% effective in adults 70 years and older. Shingrix is 91% effective and 89% effective, respectively, at preventing PHN in those age groups, according to the CDC fact sheet on the vaccine. In comparison, the CDC says Zostavax only reduced the risk of shingles by 51% and the risk of postherpetic neuralgia by 67% in adults aged 60 years or older.
The Reasons Vaccination Rates Are So Low
So back to the million-dollar question: If there’s vaccine that can significantly reduce the risk of getting shingles, why aren’t more people getting it?
“Adult vaccination rates are always lower than childhood vaccination rates,” says Dr. Adalja. Experts think that one of the big reasons is because vaccinations are often required to attend public school. Adults don’t have a similar driving force to get recommended vaccinations.
Here are some of the other factors influencing adult vaccination rates, and shingles vaccination rates in particular:
It’s pretty common for people to skip medical care because of cost. Vaccination is no different. The shingles vaccine in particular isn’t cheap—it costs around $168 per dose. But the price you pay will vary depending on your insurance (if you have it) and what it covers. Since the vaccine is strongly recommended, some insurance companies may cover it, but there are still quite a few that will not, Dr. Mitra says. It is not covered by Medicare Part A and B, for example, but it is covered under Medicare Part D. This can be a huge barrier for people who may want to prevent shingles but don't want to or simply can’t spend the money on it.
Whenever multiple doses of a vaccine are required, compliance goes down, Dr. Mitra says. “Even if we can convince people to get the first dose, if they have to come back after a few months, that is always a challenge,” he says. “If a person is otherwise healthy and usually only comes in for a yearly checkup, and now they have to come back in between, some people may not like that or understand why,” Dr. Mitra explains. Additional doctor’s appointments also cost more money, which can be a barrier for lower-income people.
The whole “two different vaccines” thing has also probably caused some confusion, interfering with vaccination rates, says Dr. Adalja. In fact, Dr. Mitra says that patients always used to ask about which shingles vaccine they should get. Fortunately, that is soon going to be a moot point since there’s just one, highly effective option.
As it often goes with healthcare, a lot of people can’t see a reason to shell out cash upfront for something that may or may not ever happen to them. “When people see a clear benefit, it’s much easier to convince them [to get vaccinated],” Dr. Mitra says. “Experience is a big thing. If someone had shingles, they may bring up the topic. Some people ask about it because they saw what it was like when their father had it,” she adds. “The difficult sell is the 50-year-old who has never had it or seen anyone else have it.”
The Bottom Line on Shingles
While personal views and experience play a huge part in adult vaccination rates, Dr. Mitra notes that usually, vaccination rates see a natural increase over time. For example, while the current vaccination rate for shingles is not optimal, it has been increasing since the first vaccine became available in 2006—definitely a positive, Dr. Mitra says. Doctors are hopeful that, over time, vaccination rates will continue to rise, especially now that there’s an even more effective option available.
Dr. Bartash says that ultimately, she wants to encourage all adults to get vaccinated against shingles if they can. “I know with everything going on right now, people are hesitant to engage with routine general medical care,” she says. “But preventing things we can prevent is important.”