Addressing Shingles Risk in Adults Ages 50 to 55

Announcer:
You’re listening to VacciNation on ReachMD. Here’s your host, Dr. Alexandria May.

Dr. May:
This is VacciNation on ReachMD, and I'm Dr. Alexandria May. Here with me today to assess the risk of shingles in adults 50 to 55 is Dr. William Schaffner. He's a Professor of Preventative Medicine and Health Policy as well as a Professor in the Division of Infectious Diseases at the Vanderbilt University School of Medicine in Nashville. Dr. Schaffner, welcome to the program.

Dr. Schaffner:
Good to be with you, Dr. May.

Dr. May:
Now, we often associate shingles with older adults, but incidence begins rising in the early 50s. So, Dr. Schaffner, what's happening immunologically at this stage that makes adults 50 to 55 more vulnerable?

Dr. Schaffner:
Yeah, Dr. May, we all know that shingles is a recrudescent varicella-zoster virus, right? We acquire the infection, get chicken pox, and we recover, but the virus doesn't leave us. It hibernates inside us, and at some point in the future, it can reactivate over a neural segment of the body. It's our cell-mediated immunity that we think largely keeps the bear in the cave, if you will. As we get older, this cell-mediated immunity—our entire immune defense system—begins to become less effective. And at some point, the virus can recrudesce, causing shingles.

We generally think as doctors that this affects people age 65 and older, and it is true the older you are, your risk is increased. In fact, increasing age is the dominant risk factor for shingles. But what we fail to appreciate is that this change begins to occur in the 50s, so this coincides quite appropriately with the CDC's recommendation to vaccinate universally starting at age 50. So that's a good idea to keep in mind.

Dr. May:
And beyond age-related immune decline, how do common comorbidities like diabetes, cardiovascular disease, and autoimmune disorders amplify shingles risk and complications in this population?

Dr. Schaffner:
So as it is with many other infections, as you add comorbidities along with your increasing age, you increase your risk of getting shingles, and these comorbidities may themselves be immune suppressors. The comorbidities are also important in that they sometimes enhance your capacity to get more severe disease.

Diabetes is a classic example. We all know that people with diabetes have an enhanced proclivity for infection, and also in the current environment with increasing age, there are more immune-compromised patients out there, whether because of their disease or because they are being treated with immune suppressants. Once again, the risk goes up. You'd like to anticipate that by vaccinating them before that happens.

Dr. May:
That makes sense. And for patients in their early 50s who are still in peak working and caregiving years, how does shingles affect quality of life and chronic disease stability?

Dr. Schaffner:
Yeah, well, shingles fortunately does not have a high mortality. However, it has a high morbidity when it occurs. You know, even acute shingles can be very serious. It's one thing to have the shingles on your trunk. It's another to have it on your face where it can actually hazard your vision. And so acute shingles is not something any of us would want to have.

The second thing is it can bollocks up diabetes control, right? It can involve glycemic control. So we need to think about routine shingles vaccination. I say routine universal shingles vaccination, meaning to integrate that into all the other parameters we use to assess the completeness of our chronic care that we give our patients. In addition to everything else we do to make sure our, for example, diabetic patients are well cared for, we need to add a box to make sure that they've been vaccinated. So we need to integrate vaccination into everything we do regarding the chronic care of our patients.

Dr. May:
For those just tuning in, you're listening to VacciNation on ReachMD. I'm Dr. Alexandria May, and I'm speaking with Dr. William Schaffner about how shingles begins to disproportionately affect adults in their early 50s.

So, Dr. Schaffner, now that we've discussed risk and complications, let's shift to prevention. The CDC currently recommends two doses of the recombinant zoster vaccine starting at age 50. Based on that, can you tell us why it's so important to vaccinate these patients right at the threshold age?

Dr. Schaffner:
Well, we've just been talking about why that's important because it’s right at that time of age-related immune suppression. People acquire chronic underlying medical conditions, including various reasons for immunosuppression, and this gradually increases during that decade between age 50 and age 60. Now, bear in mind that if we vaccinate, then your patients will be protected later on. This is a splendid vaccine. It has a long period of time where it remains very effective. There are currently no recommendations for revaccination. We don't have to because the studies show that protection really persists for a very long period of time.

And then I have to mention one other very practical reason. Starting at age 65, this vaccine's payment is covered under Medicare, but it's under Part D. Part D is the prescription drug benefit, and there are many physicians in their offices who don't like to deal with Part D just because of the administrative entanglements. So not only is it scientifically and medically appropriate to start at age 50, but I would remind you that between age 50 and through age 64, the vaccine will be covered by the individual's regular medical insurance. That's something that you could do right in your office.

It's a very important reason, but you have to get your mind off 65 and start at age 50. And when I give grand rounds to general internists, I always look right at them and say, what I mean by routine universal vaccination is the next time you're in your office and the very next patient that comes in who's older than age 50, that patient should not leave without having received the first dose of shingles vaccine. And that's true of the next patient and the next patient who is over age 50 until you've vaccinated everyone in your practice for whom the vaccine is recommended. It's a new way of assertive thinking. Universal routine vaccination means just that—everybody in your practice who's eligible.

Dr. May:
Absolutely. And you mentioned a lot on the provider level of what providers can do, making sure they see every patient and vaccinate them every time as they're indicated. And I can see clearly the efficacy that you've spoken to, but despite those clear recommendations, vaccination uptake at exactly age 50 still remains inconsistent.

What practical strategies can help clinicians close that gap in routine practice?

Dr. Schaffner:
Well, I think we're starting with this conversation and perhaps getting everyone to think age 50 rather than age 65 and then trying to introduce that to your other caregivers—the nurses, physicians assistants, and nurse practitioners with whom you work. So we can all start thinking about that. And indeed, if you have electronic prompts in your office, upgrade those prompts. So they start at age 50 and not at age 65.

Dr. May:
Absolutely. I love the electronic medical record prompts for that so that it's always in front of you every time, even if it's something that you're not thinking of immediately.

Finally, Dr. Schaffner, as we think about preventative care in midlife, how should shingles vaccination be positioned in conversations with patients aged 50 to 55?

Dr. Schaffner:
Well, you know, the recommendation is that we discuss the immunization history of every patient at virtually every encounter, and there are certain vaccines that are appropriate for adults, particularly older adults, and we need to integrate that into our routine care. So we do that to make sure all of our patients are up to date with their immunizations. Shingles is very easy—50 and over, universal routine—so that's one of the easiest ones to remember and to get integrated into our daily practice. And as I said, if you vaccinate between age 60 through age 64, you can stock that vaccine in your practice. You can administer it; if that doesn't work for you, make sure you have a good link with the pharmacists in your community. They're part of the immunization neighborhood, and you can direct your patients to them because they'll be able to vaccinate your patient. The goal is to get the patient vaccinated.

Dr. May:
With those counseling strategies in mind, I want to thank my guest, Dr. William Schaffner, for joining me to discuss the importance of shingles vaccination for patients in their early 50s. Dr. Schaffner, it was great speaking with you today.

Dr. Schaffner:
Dr. May, it was a pleasure, and let's remember: shingles, bad. Shingles vaccine, good.

Announcer:
You’ve been listening to VacciNation on ReachMD. To access this and other episodes in our series, visit VacciNation on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!