Zostavax <50 yo

[rev ronin]

For those of you working in related fields, do you have any consumer demand for Zostavax for those younger than 50?  Yes, yes, it's not covered by insurance, but given how devastating shingles can be, and the trend towards earlier onset with the reduction of varicella in the community, one of my NP peers and I (we're both in our 40's) were talking about whether it would make sense to pay cash for it for ourselves before hitting age 50.

 

I called two of my local pharmacies, and they WILL NOT administer the vaccine to anyone younger than 50 or 60.  I realize that using Zostavax in a <50 YO is an off-label use, but I didn't expect finding someone to sell/administer it to us to be the biggest hurdle.

 

Anyone else thinking along these lines, or is it just me?

[Reality Check 2]

We have found that commercial insurance on those less than 60 is actually covering the Zostavax and in our office.

 

Our Medicare plans for those over 63-65 are not covering it if we give it in our office but will cover it at the pharmacy which makes zero sense.

 

Our pharmacists have not argued about giving it to those younger and sometimes our oncologists request it before chemo starts - they send us the patient to get all vaccinated before chemo.

 

I completely agree that folks need it.

 

I am working on women over 40 and Gardasil. That's a challenge too....

[rev ronin]

I am working on women over 40 and Gardasil. That's a challenge too....

Given that Gardasil doesn't make a difference (doesn't decrease cancer risk) once a person has been exposed to HPV, I can see the age 27 cutoff making sense: in the vast majority of cases, young adults will either have engaged in sufficiently risky behavior to have been exposed to HPV... or if they make it through to 27 without having done so, they're unlikely to be exposed in the future.  Now, when you put divorced people back into the dating scene after years in a reasonably monogamous relationship, however...

[Reality Check 2]

Given that Gardasil doesn't make a difference (doesn't decrease cancer risk) once a person has been exposed to HPV, I can see the age 27 cutoff making sense: in the vast majority of cases, young adults will either have engaged in sufficiently risky behavior to have been exposed to HPV... or if they make it through to 27 without having done so, they're unlikely to be exposed in the future.  Now, when you put divorced people back into the dating scene after years in a reasonably monogamous relationship, however...

And, that is exactly what I am working with. Newly single folks with or w/o hx of HPV.

Europe is doing Gardasil at older ages with some compelling information that I am looking at.

 

Hopefully help some folks

[Reality Check 2]

So, the CDC says that Zostavax immunity can wane in 5 yrs and those vaccinated "young" might not benefit fully.

 

Well, a 65 yr old who lives to 90 won't benefit fully either.

 

Is there going to be a 5-10 yr booster recommendation? Titers?

 

I believe in reducing post herpetic neuralgia but don't want to make empty promises.

[rev ronin]

I could care less about post-herpetic neuralgia... compared to not wanting shingles in the first place! :-)

[GetMeOuttaThisMess]

Since I'm a numbers guy, a study was done shortly after the release of the vaccine to determine the NNT to prevent one case of PHN that either severely impacted daily life or had the pt contemplating suicide. I don't remember the specific number but the cost to reduce one incidence of this scenario was >$500K ($300/inj. retail as I recall). Since incidence was greater the older the individual the recommendation was to give it to those >65 y/o. Bottom line, the vaccine is to prevent THESE occurrences as opposed to preventing shingles in general since the majority resolve just fine without significant morbidity. Speaking for myself, I never had to take anything for my limited outbreak but for everyone like me there is always a case of "it hurt really bad".

 

Now, how the manufacturer chooses to market the vaccine...

[rev ronin]

Now, how the manufacturer chooses to market the vaccine...

They can't market to <50 unless there's an FDA label for <50, so they'd first have to choose to study it in that population...

[GetMeOuttaThisMess]

Yep, last I looked it had been lowered to fifty but for me personally, I'll wait till my immune system starts to take a hit at 60 or later. That being said, it wouldn't surprise me to see Tdap and zoster go to booster dosing, especially Tdap.

[rev ronin]

The thing that's really changed my mind about getting it before 50 is the sheer number of cases I'm seeing in <50 YO's.  At least 1/3rd of the shingles cases we're seeing in my clinic are <50 and not immunocompromised in any way.

 

What I THINK that means is that the success of the varicella vaccine in young people has ended up greatly reducing the encounters of those of us who GOT varicella (as kids) are having with circulating varicella in the community, and thus leading to reduced retention of our immunologic memory.  No wild varicella means a de facto quicker drop off in our immunity.  But it'd really take a big study done over a long time to substantiate that, and I suspect by the time it was done, those of us in the donut hole (not old enough for Zostavax, too old to have received varcicella vaccine as kids) will have been substantially reduced by aging into the Zostavax labelled use.

[GetMeOuttaThisMess]

What I'd like to see is a subjective pain score controlled study in those with shingles who were/weren't vaccinated and/or had confirmed varicella before vaccine availability. IOW, does either scenario show a reduced pain score compared to the other. Also, long term, is there a reduction in PHN in either control group.

[hlj25950]

I'm 39. I had shingles this year as a 1st year PA student. Stress = shingles. I could/can not get anyone to give me a shingles vaccine. If it reduced my risk for 5 years, I'd definitely get a shot every 5 years. I hope that the manufacturers are looking into lowering the age of use. If any PA's want to do a research project, perhaps they should pitch this.

[AbeTheBabe]

I tried to get a Shingles shot before I started Humira for my Crohn's (I'm in my twenties) and no one would give it to me even though my gastroenterologist wrote me a prescription for it and I was willing to pay for it out of pocket. It's been about a year now and so far so good, but I still wish I was able to get it.

[GetMeOuttaThisMess]

I'm 39. I had shingles this year as a 1st year PA student. Stress = shingles. I could/can not get anyone to give me a shingles vaccine. If it reduced my risk for 5 years, I'd definitely get a shot every 5 years. I hope that the manufacturers are looking into lowering the age of use. If any PA's want to do a research project, perhaps they should pitch this.

Shingles equals shingles. Common association is that emotional/physical stress equals greater risk. I think this falls under a time honored association as opposed to actual causation since this would be difficult to prove/disprove. Personally, I think that there's probably something to it based on common observations. I know in my case a decade or so ago, everything was peachy at the time, including the mild thoracic outbreak itself. For those discussing early vaccination, remember the actual basis behind the vaccine. Shingles itself is self-limited and neuralgia can be treated successfully with different classes of meds. It was all about the PHN and marketing was based on the "prevent shingles" angle to ...wait for it...push sales at $300 a pop initially.

 

Darn. What's gotten into us? A civil discussion with trading of information?

[Reality Check 2]

My youngest shingles case was a 14 yr old. I cultured one of the blisters and did a varicella titer to be sure.

He was stressed out in school. No diseases and I couldn't find any to worry about - such as diabetes or Crohn's.

 

I see Rev's point about natural immunity versus immunization. Are we hitting the mark?

 

Ok, the when I was young story ---- our neighborhood had parties for chicken pox - "Hey Little Johnny has chicken pox - go play with him....". I had a mild case in second grade. I am approaching 50 - and knock wood - haven't been challenged with shingles and have autoimmune thyroid disease. 

 

One of my kids got chicken pox AFTER the vaccine. Just a tiny 5 spots that followed the 3 phase cycle and there was the promodal phase as well. No big deal. 

 

I have run into many immigrant adults who did not face varicella in their native country as children and are now not immune as adults. We have debated about giving them the actual Varicella vaccine or the Zoster vaccine. I am not in front of the data and can't recall precisely. The CDC contradicts itself page to page. I called an ID friend who didn't have solid answer either. So, at least one got Varicella vaccine and one got Zostavax. Not enough for a study.....

 

The 1% complication rate in kids really doesn't scare me. The adult cases with pneumonia and such is more scary. 

 

So, still not clear on what our future holds - boosters? Titers? Change the vaccine schedule? 

 

tdap is tough on the pertussis factor. Immunity can be 6-26 years - that's sure helpful. The titer costs over $300 - so cheaper to give a new vaccine. BUT, folks WITH vaccines within the 10 year and even 5 year marks are still testing positive for pertussis. Now what?

 

I, too, am enjoying the open and helpful conversation!!!