Shingles hurt. A lot. And if not treated promptly and effectively, it can cause serious near and long-term problems. Doctors call shingles Herpes Zoster.
Herpes zoster (HZV) is a virus, the same Varicella virus that causes chicken pox. It is a different than the virus causing cold sores (Herpes simplex). Ninety-five percent of people over age 50 harbor the Varicella virus in their bodies, specifically in sensory nerve complexes called ganglia. Getting chicken pox is bad enough. But the virus can be reactivated to cause shingles. The chicken pox vaccine does not prevent you from getting shingles. If you are exposed to a relative or friend with active shingles infection and haven’t had chicken pox, you can develop chicken pox. But being exposed to a person with chicken pox does not increase your risk for a zoster recurrence. Care should be taken around people with shingles especially if you’ve never had chicken pox.
Who is at risk? People who have an impaired immune system from genetic deficiencies, cancer or its treatment, and other viruses such as the Human Immune Deficiency virus (HIV) are especially vulnerable. But shingles is seen in otherwise healthy individuals of all ages. Its incidence increases as we age. The lifetime risk of developing shingles is about 25% but increases to 50% or 1 in every two people 80 and older. This increase with age is thought to be due to the body’s natural breakdown of the immune system. Stress may be a contributing factor due to its triggering a complex cascade of events affecting immunity.
The reactivation of the virus can present with severe pain even before the eruption of blisters on the skin. The chest wall, abdomen, and face and scalp are frequent locations for these blisters. They erupt along the course of the nerves that give sensation to the skin. It may take as long as a month for the blisters to clear. Secondary bacterial infections can develop. Infrequently, shingles leads to serious complications involving the brain, eye, liver, and lungs.
Post-herpetic neuralgia is a perplexing complication that causes pain in the affected nerve after the blisters have cleared. It is thought to be due to damage to the nerve’s tissue by the virus. By definition, if pain lasts more than 90 days, it is called post-herpetic neuralgia. It can be severe and affect the quality of one’s life.
When blisters from the virus affect the face and scalp, it is important to seek medical care. The eye can be affected in up to 50% of cases when the nerve around the eye is involved. Loss of vision, although rare, is a potential complication. Because the virus reactivates in a specific sensory nerve, the blisters and the pain that precede it occur on one-side of the face or body. It is especially important to recognize the appearance of a blister on the tip of one’s nose. When this is seen, the risk for complications affecting the eye greatly increase. Doctor’s call this Hutchinson’s sign and a prompt consultation with an ophthalmologist is imperative.
The diagnosis of shingles is usually made by the presence of unexplained pain in the course of a sensory nerve and the eventual appearance of a typical rash comprised of raised blisters or vesicles. A diagnosis of shingles should be considered whenever unexplained and localized pain is experienced.
Diagnostic testing for zoster is available but usually employed only when an unusual presentation occurs. No test is 100% accurate. We have become familiar with ICAs (immunochromatographic assay) used in home-testing for Covid. In HZV, this test is good at identifying patients who are not infected (high specificity); it is much less accurate in identifying those who have the reinfection (low sensitivity). The gold standard for HZV testing is called the qPCR (quantitative polymerase chain reaction) test. Because it is quantitative, it may be used to predict the duration of a patient’s disease. It is very accurate in determining if a patient has active HZV.
If the eye is involved with HZV, antiviral drops are used to treat the eye’s surface. Treatment may require the use of drops up to 9 times per day for 2 weeks or longer. If the interior parts of the eye are affected, antiviral medications taken by mouth are added. These pills are prescribed when other parts of the body are involved with the virus and help to control the disease’s severity.
New treatments are in the research pipeline and some will be available soon. Some drugs (such as 6-thioguanine) currently approved for other diseases (leukemia) have been found to be more potent than currently available antivirals. For some complications affecting the eye, gene-editing therapy using new CRISPR technology shows promise. Omega-3 oils high in EPA (eicosapentaenoic) and DHA (docosahexanoic) acids have been found to reduce inflammation in peripheral nerves. Additionally, researchers are studying products produced by algae, fungi, essential oils such as Australian tea tree and eucalyptus oil and other botanicals to supplement available antivirals.
What can you do? Get the HZV vaccine. It is called Shingrix and is given in two doses between 2 and 6 months apart. It is a recombinant vaccine and does not contain live virus. Recombinant vaccines have been used in humans for over 35 years. Even if you have had shingles or received an older HZV vaccine such as Zostavax in the past, revaccination with Shingrix is recommended. In healthy adults between ages 50 and 69, it is 97% effective in preventing shingles. In older patients, it is 91% effective. The enhanced immunity from this vaccine has been shown to last at least 7 years. Other than a sore arm, the vaccine is safe and well-tolerated. If you have concerns about more serious, very rare side-effects, speak to your doctor.
Postherpetic neuralgia can be difficult to treat. Anti-epileptic drugs such as gabapentin (Neurontin) and gabalin (Lyrica) and tricyclic anti-depressants (Elavil) have been found to be effective in reducing pain and improving quality of life. The FDA recently approved a capsaicin skin patch called Qutenza. It is available by prescription. Opioids had been used in the past for pain relief but are less frequently prescribed today. Botox injections have been found to be helpful in some patients. Because postherpetic neuralgia can interfere with an elderly patient’s sleep and independent activity, these patients can require help from family and other caregivers. Referral to a pain specialist may be recommended.
Take away points? Ninety-five percent of people age 50 and older harbor the chicken pox virus that causes shingles. The virus can be reactivated at any time even in healthy individuals but especially the elderly. Although very few people die from HZV, it can cause serious complications involving other organs such as the eye. Shingles can lead to long-term pain called postherpetic neuralgia. Both the acute disease and its chronic complications can be treated with currently approved medications. More treatment options may soon be available. The single best thing you can do to prevent the heartache of shingles and its after- effects is to get the Shingrix vaccine.
Dr. J.C. Noreika is a retired eye surgeon. He is a graduate of Jefferson Medical College and teaches medical students at Wills Eye Hospital.
COVID UPDATES
It is time to accept that the presence of SARS-CoV-2, the virus that causes COVID-19, is the new normal. This virus will likely circulate globally for the foreseeable future, taking its place alongside other common respiratory viruses such as influenza. And it likely will require similar annual vaccines in consultation with the US Food and Drug Administration (FDA) Vaccines (JAMA. Published online May 2, 2022)
Anthony Fauci, MD noted that a variety of factors make COVID-19 different from polio and measles which are viruses that were previously eliminated in the US:
There are too many diverse variants of SARS-CoV-2
SARS-CoV-2 has animal reservoirs for the virus.
So, ultimately, to attain control, case counts need to be low enough that they are not disrupting society, overwhelming hospitals or creating fear. This will put SARS-CoV-2
in a similar place as other respiratory viruses like RSV and influenza.
Early national data from a study published in The Lancet Infectious Diseases suggest that one booster dose of vaccination offered substantial additional protection against the risk of symptomatic COVID-19. Although preliminary, this national data provides some reassurance that one booster vaccine dose is associated with considerable added protection against symptomatic disease when compared with no booster vaccine.
Dr. Fauci and the new COVID czar in the US both indicated we are exiting the pandemic phase of the pandemic in the US and entering endemicity (which will still take vigilance to manage as COVID cannot be eradicated). Part of this transition resulted from a large CDC seroprevalence study in the US published this week showing that almost 60% of adults and 75% of children 0-17 in the US have anti-nucleocapsid antibodies to SARS-CoV-2 indicating they had the disease along with an 83% COVID-19 vaccination rate (at least 1 dose) in those over 5 in the US.
The EU and the WHO also indicated this week (with the lowest death rate from COVID we have seen worldwide since spring 2020) that we can exit the emergency phase into endemic management. In the endemic phase, masks (fit/filtered) will be optional for those who want to wear and based on individual risk tolerance, not mandated for populations (especially since masks work best for individual protection per physical science studies)
A large trial found that the COVID-19 oral antiviral treatment Paxlovid was not effective at preventing coronavirus infection in people living with someone infected with the virus. However, Paxlovid continues to be @ 90% effective at preventing hospitalization or death in COVID patients at high risk of severe illness when taken for five days shortly after symptom onset.
Pfizer is testing three extra-small doses of its vaccine in children under 5 after two shots didn’t prove quite strong enough. Currently in the U.S., only children ages 5 or older can be vaccinated, using Pfizer’s vaccine — leaving 18 million younger tots unprotected
Moderna hopes to be the first to offer vaccinations for the youngest children. Last week, it filed with the Food and Drug Administration data it hopes will prove two of its low-dose shots work in children younger than 5.
Last month, Moderna announced that its new bivalent COVID-19 booster shot was more effective against all variants than the company’s currently available coronavirus vaccine. “We’re confident by the fall of this year we should have large amounts of a new booster vaccine that will protect against Omicron and other variants,” said Moderna’s Chief Medical Officer Paul Burton in an interview on CBS’s “Face the Nation.”
Measles cases jumped by 79% in the first two months of this year compared to 2021, after COVID-19 and lockdowns disrupted child vaccination campaigns around the world, according to data from UNICEF and the World Health Organization (WHO). Measles is a very contagious disease that can be particularly dangerous for young children and babies. It spreads more quickly than Ebola, flu or COVID-19. UNICEF executive director Catherine Russell described the immunization gaps combined with a return to social mixing in the wake of the pandemic as a “perfect storm”.
Scientists have found the coronavirus in 29 kinds of animals, including household pets, livestock, and wildlife, according to researchers’ latest tally. In most cases, humans infect animals, and animals don’t transmit the virus back to humans. But scientists have expressed concerns about recent research that shows some animals — such as mink and deer — appear to be able to spread the virus to humans. Scientists have identified the virus in a growing list of animals, according to the CDC, including cats, dogs, ferrets, gorillas, hamsters, hippos, hyenas, mice, otters, pigs, rabbits, and tigers. In many cases, humans spread the coronavirus to pets at home or to wildlife in zoos and sanctuaries.
A new study provides previously unknown answers about which hospitalized COVID-19 patients are most likely to need mechanical ventilation or to die. Researchers showed that vital signs and lab results at the time of hospital admission — not comorbidities and demographics — are the most accurate predictors of disease severity.
Greece and Italy lifted covid-19 restrictions over the weekend, nixing respective proof-of-vaccination requirements in two of the most popular destinations for Mediterranean vacations. Visitors flying to Greece from the United States previously had to show proof of vaccination, recovery from the disease or a negative test. Italy also eased restrictions in recent days, scrapping its passenger locator form as of Sunday, and dropping its Green Pass requirement — which demonstrates proof of vaccination, recovery from covid or a negative test result — for places such as restaurants and cinemas. The pass is still required for some settings, including hospitals.
The World Health Organization hasn’t given an official recommendation on a fourth dose, and “there isn’t any good evidence at this point of time” that it will be beneficial, said WHO chief scientist Soumya Swaminathan. “What we know from immunology is that if you give another booster, you will see a temporary increase in the neutralizing antibodies. But what we’ve also seen is that these neutralizing antibodies will wane quite rapidly,” Swaminathan told CNBC in an interview. The U.S. Food and Drug Administration has so far authorized a fourth shot only for those aged 50 and above, as well as those who are immunocompromised. And the U.S. Centers for Disease Control and Prevention was skeptical of the need for a fourth dose for healthy adults in the absence of a clearer public health strategy
(WSJ 5/4/22) The resiliency of the American consumer has been a hallmark of modern history. After events such as Hurricane Katrina in New Orleans or the attacks of 9/11, people have shown they will snap back to doing many of their favorite things, given time.
Live Nation, which owns Ticketmaster, said concert ticket sales were up 45% as of February 2022 compared with the same period in 2019, the last full prepandemic year.
Membership levels at gym chain Planet Fitness in January surpassed prepandemic levels following a stretch in which some 25% of the nation’s gyms closed
Over two million people traveled by plane each day on average between April 17 and 23, according to the Transportation Security Administration. That figure averaged about 2.4 million in 2019.
Attendance at college football games was robust last fall. Ohio, Michigan, Texas, South Carolina and Massachusetts all dropped mask requirements in schools late last year.
Chuck E. Cheese parent CEC Entertainment Inc. filed for bankruptcy protection back in June 2020. The company declined to provide sales figures, but said it has seen an increase in birthday party bookings and is returning to normal operations.
With people primping to go out in public, they are spending more on deodorant, teeth whiteners, razors and cosmetics,
In March, just 9% of doctors’ appointments were done through telehealth, according to Zocdoc. In May 2020, almost 30% had been.
Since January, visits to fitness chains and exercise studios like Pure Barre and CorePower Yoga, LLC have nearly doubled. Even hot yoga, with its deep breathing and mutual sweat exchange, is back.
Airlines, restaurants and child-care centers, which relied on government loans to stay afloat during Covid-19’s peak, can now hardly keep up with demand.
(WSJ 5/4/22) Some pandemic stars have taken a hit – From hoping that consumers had permanently shifted their behavior, the companies are now considering previously unthinkable changes.
Streaming service Netflix, now forced to compete with the return of live events, dinners out and kids’ birthday parties, posted its first subscriber loss in a decade in the most recent quarter. It expects to lose another two million global subscribers in the current period.
Peloton, losing money and saddled with excess equipment, is lowering the price of its stationary bikes
Hand sanitizer sales are down more than 50% year-to-date compared with a year ago, according to IRI data.
To block infections entirely, scientists want to deliver inoculations to the site where the virus first makes contact: the nose. . There are eight of these nasal vaccines in clinical development now and three in phase 3 clinical trials, where they are being tested in large groups of people. What could be most important about nasal vaccines is their ability to awaken a powerful bodily defender known as mucosal immunity, something largely untapped by the standard shots. The mucosal system relies on specialized cells and antibodies within the mucus-rich lining of the nose and other parts of our airways. These elements move fast and arrive first, stopping the virus, before it can create a deep infection.
The U.S. Food and Drug Administration is warning Americans to watch out for phony at-home, over-the-counter COVID-19 tests that look a lot like the real things. Two fakes the FDA knows of are counterfeit Flowflex COVID-19 test kits and iHealth Antigen Rapid Test Kits. The FDA has a list of authorized at-home OTC COVID-19 tests. It is not aware of any counterfeit tests distributed by federal government test distribution programs.
