In a recent Vaccine Education Center Parent Pack personal story, Nancy Greeley, an otherwise healthy adult who developed shingles, wrote:

I assumed my symptoms would be getting better in a week — they were not. Even with early diagnosis and [antiviral] medication, the pain was bad. I went through about five weeks of intense pain, and it finally was gone after seven weeks. It hurt inside me wherever something touched me. Moving hurt. Sitting in a chair hurt. Going to bed hurt. Wearing a bra was not an option. The pain caused severe exhaustion.

She continued, “It hurts with aching, burning, and shooting pains at different times,” describing how the pain made it difficult to sleep or even think clearly.

Why healthcare provider recommendations matter

When she developed shingles, this patient was long overdue for a shingles vaccine. Considering the World Health Organization’s (WHO’s) “Three Cs of Vaccine Hesitancy,” we can try to understand why she had not been vaccinated:

  • Did she delay vaccination because of lack of confidence in the vaccine? Not at all.
  • Did she lack convenient access to affordable care? Nope.
  • Was she complacent? Yep! She wrote, “My only reason for not getting it? I just didn’t get around to it (although I get sick leave at work that would have covered the time it took to get it).”

Complacency is defined as satisfaction with the current situation, especially when accompanied by a lack of awareness of actual dangers. Imagine if at either a well care or acute care visit, this patient’s healthcare provider had said, “Today, I have a vaccine that is routinely recommended for you. It prevents shingles — an extremely painful skin condition … like a burn that keeps growing. The pain can last for months or even years.” It is likely that she would have gotten vaccinated.

While it may seem time consuming to get parents to understand that their 12-year-old will be susceptible to certain cancers about 20 years from now if they decline the HPV vaccine, it should be easier to get adults motivated to avoid pain, especially potentially chronic pain like postherpetic neuralgia (PHN). PHN occurs in 10% to 18% of people who develop shingles.

In fact, with this in mind, shingles vaccine seems like it could take so little clinical conversation that it would be ideal to have a standing order in place. Standing orders are written protocols that allow qualified healthcare professionals to vaccinate patients meeting certain criteria based on prior approval by an authorized practitioner. For a template with standing orders for administering the shingles vaccine to adults, go to Immunize.org’s list of standing order templates or the PDF version.

Shingles vaccine history

It was 14 years ago, on June 6, 2008, when the U.S. Centers for Disease Control and Prevention (CDC) published the original zoster vaccination recommendation “for all persons aged >60 years who have no contraindications, including persons who report a previous episode of zoster or who have chronic medical conditions.” The only available zoster vaccine at that time was Zostavax®, a live attenuated vaccine. This vaccine was, in essence, a 14-fold higher dose than the chickenpox vaccine, and while it worked, it wasn’t perfect; vaccine recipients had a 51% reduced chance of developing shingles and a 67% lower chance of experiencing PHN. This vaccine is no longer available in the U.S. because a better option is now available.

In October 2017, the Food and Drug Administration (FDA) licensed the second shingles vaccine, Shingrix®. This recombinant vaccine includes a single surface protein from the virus and adjuvants that greatly improved response rates — protecting more than 9 of every 10 recipients from developing shingles or PHN. Additionally, because the vaccine does not contain live varicella virus, it is safe for immunocompromised adults.

The Advisory Committee on Immunization Practices (ACIP) has recommended Shingrix for two groups:

Importantly, even if a patient in one of the above categories previously received the Zostavax vaccine or had a prior episode of shingles, they are still recommended to receive Shingrix.

Age as an important risk factor for shingles

Because of advances in public health and medicine (and cosmesis), we often hear that “60 is the new 40.” But you can’t fool the immune system, so even adults who are working all week and hiking on the weekends should not be complacent about on-time shingles vaccination.

A study based in a general practice population over a span of 26 years (1947-1972) showed increasing rates of zoster infection:

  •   0.8 per 1,000 in children ages 0 to 9 years
  • ~2.0 per 1,000 in adults during their 20s to 40s
  •   5.6 per 1,000 in adults during their 50s
  • 11.0 per 1,000 in people 80 or older

This increased risk over the lifespan is likely due to waning immunity against varicella zoster virus, specifically a loss in cell mediated immunity over time.

With this in mind, remind your zoster vaccine-eligible patients that a good reason to take the time to get vaccinated while they’re feeling fine is that if they develop shingles, it will set them back and keep them from doing what they need or want to do, possibly for weeks or months. As Nancy Greeley lamented in her personal story, “imagine…how foolish I felt realizing that I could have avoided this whole episode.”

Shingles resources

Vaccine Education Center

Immunize.org

Vaccine Handbook App

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Materials in this section are updated as new information and vaccines become available. The Vaccine Education Center staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family's personal health. You should not use it to replace any relationship with a physician or other qualified healthcare professional. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult your physician or, in serious cases, seek immediate assistance from emergency personnel.