Shingles, Nasty and Dangerous

For Tony Trask, getting sunburnt was nothing new. So when a brief trip to the local swimming pool in December 2007 left the Sydneysider with a nasty sunburn on his forehead, he thought it was a bit unusual. He mentioned the ‘sunburn’ to his doctor later that day when having a regular check-up, and was prescribed a topical cream. But by the next day, the sunburn had turned into little blisters around his right eye, he had a searing headache and was in severe pain.

Six days later and still in pain, Trask was sitting in his doctor’s office, shocked as he was informed that he had a viral disease called shingles, also known as herpes zoster.

It occurs when a virus called varicella zoster, which causes chicken pox, reactivates. Though Trask had suffered chicken pox as a child, he didn’t know the virus that caused it had been lurking in the nerve endings of his spinal cord ever since, dormant, waiting to catch his immune system off guard before pouncing again. Or, that for some patients, while the rashes and blisters fade, the tingling and burning from what is called postherpetic neuralgia (nerve pain) can last with little respite.

With the blisters now surrounding his right eye and his vision affected, Trask was given a referral to see an eye specialist. He was perturbed to learn that other than taking a strong dose of anti-viral tablets over eight days, the shingles just had to run its course. Trask recalls: “Most of the time I just lay in bed trying not to move too much to ease the pain.”

Most shingles outbreaks
last no more than three to five weeks but some patients are at greater risk of developing life-threatening complications, including those who are undergoing treatment for cancer.

Research released in December 2015 found that a severe case of shingles can raise the risk for stroke and heart attack. A team of researchers headed by Dr Caroline Minassian at the London School of Hygiene and Tropical Medicine in England researched more than 67,000 US Medicare patients who had shingles and suffered either a stroke or a heart attack within a year.

In the Public Library of Science journal PLOS Medicine, researchers reported a 2.4-fold increase in the ischaemic stroke rate and a 1.7-fold increased heart attack rate. The greatest increase was in the first week following shingles diagnosis. After six months, risk levels return to normal.

Researchers suggested two possible reasons: the virus causes fatty build-ups in the arteries to break off and cause a stroke or a heart attack; or the stress caused by the pain sends blood pressure up, again resulting in a stroke or a heart attack.

Further research into shingles at the Mayo Clinic in Minnesota that was also reported in December 2015 showed that adults with asthma appeared to have a 70 per cent greater risk of developing shingles, compared with those without asthma.

There is no cure for shingles. Its name comes from the Latin and French words for ‘girdle’ because it often appears at waist level, partly circling the body. Professor Raina MacIntyre, who heads the School of Public Health and Community Medicine at the University of NSW in Sydney, explains that after a bout of chicken pox, the virus can stay latent in the nerve roots for decades, and then reactivate to cause shingles. This is why the disease occurs in the distribution of nerves. The blisters are only one of many symptoms and are caused by direct viral effects in the skin. Other symptoms may include numbness or tingling, itching and fatigue, headaches, high fever, a sensitivity to light and excruciating nerve pain that can leave you sleepless, unable to work or carry out daily activities.

“As we get older, the immune system starts to decline,” MacIntrye explains. “This is called immunosenescence, and starts at about age 50. As the immune system begins to decline, there is a corresponding increase in the risk of shingles.”

Shingles is technically contagious, says MacIntrye, as it’s the same virus that causes chicken pox, however much less so. The virus can be passed on by direct contact with fluid from shingles blisters, until they dry up and form a crust. Exposure to shingles can also cause chicken pox in those people who have not been exposed to the childhood disease.

Timo Vesikari, a professor of virology at the University of Tampere in Finland, and director of the institution’s vaccine research centre, says most people will have only one shingles outbreak in their lifetime because it serves as a reminder for the immune system to become vigilant again. Still, depending on how old you are when the first outbreak occurs, it is possible to have a second one and maybe even a third.

With average life expectancies increasing, and with the baby boomer generation well into shingles territory, doctors expect to see more cases. Says Vesikari: “Think of it this way – if we all lived for 200 years, then everyone would develop shingles at some point.”

Given that one in three adults over the age of 50 will develop the disease, it’s best to prevent an outbreak in the first place. “For this you have to get a vaccine,” says Vesikari.

If you have not been vaccinated, then you need to act quickly, at the first sign of shingles symptoms, as the anti-viral medication is best used within 72 hours of an outbreak. This is especially important if you are hoping to mitigate the very distressing post-infection pain that can often occur.

Right now there is one vaccine on the market. Called Zostavax, it has been approved in over 60 countries, including Australia, New Zealand, Malaysia, Hong Kong, Singapore and the Philippines and, according to Immunise Australia, has been found to reduce the chance of an outbreak overall by 59.5 per cent. But with ingredients such as live chicken pox virus, it is difficult to produce in large quantities. The result is that a single shot costs about US$120, which is too costly for many governments to subsidise. But there are exceptions. Australia, for example, will add Zostavax to its Immunisation Register on November 1, 2016, for people aged 70, with a catch-up group for those aged 71 to 79.

Experts still don’t know how long each vaccination will remain effective, but five years is thought to be the limit. So, if you do get vaccinated in your 50s or early 60s, it’s important to talk to your doctor about if and when to get a second vaccination. If you have had shingles, there’s no point in getting vaccinated as your immune system has already been jump-started by the disease.

Soon the question of when to be vaccinated (or re-vaccinated) may no longer be of concern; in the near future – maybe early next year – a new vaccine is expected to make it to market, one that Vesikari also worked on. Tentatively called Shingrix, experts are excited because throughout every research phase, it has proved at least 90 per cent effective in adults 50 and older. The research trials, which took place in a number of countries, involved more than 16,000 patients aged 50 and older, with some well into their 80s.

Unlike Zostavax, Shingrix does not contain any live virus, instead combining an easily replicated protein found in the virus with an adjuvant, or chemical substance, that helps the body’s immune system wake up. Adjuvants are already used in vaccines to prevent a host of conditions, including hepatitis A and B, diphtheria and tetanus, but this is the first time one has been used in the battle against shingles.

The manufacturer of the vaccine, GlaxoSmithKline Inc., is expected to submit its findings to the US FDA for approval in the latter half of this year. Approval for the Australian, New Zealand and Asian markets is expected to follow within 18 months to two years.

If you have not been vaccinated, learn to recognise the early signs of shingles and call your doctor as soon as you suspect something’s wrong.

Francesca Napoli, an airline customer service agent, wishes she had done just that when she had an outbreak nine years ago. Aged 46 at the time, she woke one morning in January 2007 with a sharp pain in her left side. At first she attributed it to muscular pain and stress. But the pain didn’t subside. Over the next two days it worsened to the point where she could barely stand. When she visited her doctor, he examined the painful left side and noticed the red blisters Napoli had assumed was a heat rash. She had no idea there could be a connection between what she thought was muscular pain with the seemingly innocuous heat rash.

Her doctor diagnosed shingles and prescribed anti-viral medication and pain relief. Even with painkillers to take the edge off, the next four days were difficult. “The pain was excruciating,” says Napoli. “It was more intense than anything I’d ever experienced or have experienced since.”

Eight years later, 68-year-old Tony Trask looks back at that time and is amazed at the lengths he went to in order to find relief from the pain, including naturopathy and acupuncture. Fortunately, his eyes were not permanently affected. He still experiences a tingling sensation across his forehead, and bears scars there to prove it wasn’t a nightmare.

For others, with a new vaccine on the horizon that’s already being described as very promising by experts such as MacIntyre, shingles may no longer pose a problem. Assuming the vaccine passes all the safety checks, this will be a good news story.

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