Two years before Elisabeth J. Cohen, MD, joined NYU Langone Health’s Department of Ophthalmology in 2010, she suffered a bout of shingles, or herpes zoster, that left her vision permanently impaired. The disease ended her career as a distinguished cornea surgeon, but she remains at the forefront of medicine. Dr. Cohen has become an ardent advocate for more widespread vaccination against the disease—an intensely painful infection caused by localized reactivation of the virus that causes chicken pox. She is leading a multisite clinical trial, funded by a $15 million grant from the National Eye Institute, to evaluate new treatment protocols for the form of shingles that afflicted her. In November, Dr. Cohen was invited to deliver the George E. de Schweinitz Memorial Lecture, the nation’s oldest lecture in ophthalmology. Here, she shares some important information and insights about a disease that affects one in three Americans.
1. The Disease Is Common, and On the Rise
Shingles strikes when a weakened immune system allows the chicken pox virus to reawaken, travel down nerves, and attack a patch of skin. More than 1 million new cases are diagnosed each year in the U.S. Within the first three months of an episode, patients are at increased risk for stroke. “Shingles affects so many people because chicken pox is almost universal,” says Dr. Cohen. Vulnerability starts around age 40, when immunity to the virus starts to wane. Susceptibility increases with age, but the highest number of cases occur among people in their 50s. Although young people can get shingles, the number has declined since a vaccine for chicken pox became available in 1995. Over the past six decades, the incidence of shingles has increased fourfold across all age groups, but Dr. Cohen acknowledges that “no one knows why this is happening.”
2. A New Vaccine Is Highly Effective
The good news is that the Shingrix vaccine, approved by the U.S. Food and Drug Administration (FDA) in 2017, is 97 percent effective (and 90 percent effective for those over 70). The bad news is that data show that most eligible Americans have never been vaccinated. “Shingrix contains a viral protein, not a live virus, that is much more effective and safer than Zostavax®, the older vaccine,” explains Dr. Cohen. “There’s no doubt that people 50 and older should get both Shingrix injections, two months apart, even if they’ve previously received Zostavax®.” People who have had shingles should wait a year or so before getting vaccinated. Know, too, that about 15 percent of people have severe local arm pain, flu-like symptoms, or a combination of the two for a few days after each shot.
3. Research Holds Promise for Shingles of the Eye
Shingles causes painful blisters that can appear on any part of the body. In about 20 percent of cases, it attacks the eye, causing a dangerous condition called herpes zoster ophthalmicus, or HZO. While acute antiviral therapy can shorten the duration of the rash, it reduces eye complications by only 50 percent and does not prevent chronic pain. Dr. Cohen hypothesizes that because HZO bears similarities to herpes simplex eye disease, which is reduced by prolonged low dose antiviral therapy, good results might be achieved with similar treatment. The Zoster Eye Disease Study (ZEDS), supported by the National Eye Institute of the National Institutes of Health, tests whether valacyclovir, a drug approved for prolonged treatment of herpes simplex infections, is also effective in reducing complications of HZO. For more information about ZEDS, please email firstname.lastname@example.org.
4. Statin Drugs May Elevate Your Risk
Studies show that people who take cholesterol-lowering statin drugs are at higher risk for developing shingles. “A possible reason,” says Dr. Cohen, “is that statins may affect the immune system.” Because there are no shingles studies on people under 50 who take statins, Dr. Cohen recommends that people in this category consult their doctor about whether to get vaccinated. “If I were an internist or cardiologist treating a younger adult with high doses of statins,” notes Dr. Cohen, “I would think about recommending the Shingrix vaccine on a case-by-case basis, even though it is not FDA approved for people under 50.”
5. Time Is on Our Side
Data suggests that people vaccinated against chicken pox are less likely to get shingles because their nervous system is populated by a weaker form of the chicken pox virus. “It’s hard to eradicate a disease completely,” notes Dr. Cohen. “But we think shingles will be less of a problem in vaccinated populations.” Meanwhile, Dr. Cohen hopes that now that a more effective vaccine is available, more doctors will receive it themselves, putting them in a better position to urge patients to get vaccinated. “We need doctors to strongly recommend Shingrix to their 50-plus patients the way they do the flu vaccine,” she says.