The New Vaccine Your Patients May Not Want

Dear Doctor: If I Never Had Chicken Pox, Do I Still Need The Shingles Vaccine?

DEAR DR. ROACH: I'm a 56-year-old male who never had the chicken pox. When the first of my children was born, I had blood tests done to see if I'd ever been exposed. I had not, so I received the chicken pox vaccine in case my children were to expose me. Twenty-five years later, many friends and colleagues have either received the shingles vaccine or have had a shingles outbreak. My question to you is: Since I've never had chicken pox, do I still need the shingles vaccine? -- D.S.S.

ANSWER: Yes, the shingles vaccine is still recommended. Shingles is a recurrence of the chicken pox virus. The vaccine you got was a live but weakened form of chicken pox. It has a lower risk of causing shingles than getting the actual chicken pox, but there is still a risk.

Shingles is so bad that the vaccine is absolutely worth it, in my opinion. Even people who have had the old, one-shot vaccine (Zostrix), as well as those who don't recall having had chicken pox, should get the new, two-dose vaccine (Shingrix), which is not a live virus. It's better to just get the vaccine than get blood testing done in people who don't recall getting chicken pox as a child.

DEAR DR. ROACH: I am a 77-year-old male who apparently suffered a case of food poisoning. I say apparently because no cause was ever discovered for the uncontrollable vomiting and diarrhea that lasted for a whole day, then reoccurred briefly the following morning.

A trip to the emergency room involved many tests, but nothing turned up except a troponin level well over 0.04 ng/mL, which prompted an angiogram that didn't reveal any problems with my heart. What else might have caused my high troponin level? -- Anon.

ANSWER: A troponin level is a standard blood test usually used to evaluate patients for heart attacks. However, newer, highly sensitive assays have proven that tiny levels of troponin may be detected in nearly everybody.

A level above 0.04 ng/mL is often used as the cutoff for the "normal" range, but depending on the assay and population studied, a few healthy people may have levels above this. People with heart attacks may have troponin levels in the hundreds or thousands. The higher the troponin level, the more muscle damage there is.

The fact that your coronary arteries show no blockages is very good news. Other types of heart damage may also cause a high troponin level, including inflammation of the heart (myocarditis) and heart failure. Also, critical illness can cause high troponin levels (at much higher levels than you may have had) in people who don't have heart blockages. (A median of 0.57 ng/mL was found in people with septic shock.)

I found a long list of reported causes of elevated troponin levels, but gastroenteritis was not on the list. I suspect your body was working so hard to fight off the infection without enough fluid that your heart needed more oxygen-carrying blood than it got, leading to tiny amounts of injury to the heart muscle despite normal heart arteries. You can lose a lot of fluid with vomiting and diarrhea, and people at age 77 don't have as much reserve as they did when they were younger.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.Cornell.Edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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Shingles Vaccine Highly Effective Over 4 Years

The two-dose recombinant zoster vaccine (RZV; Shingrix) remained highly effective at preventing shingles over a 4-year period in real-world settings, according to a prospective cohort study.

Over 4 years, the two-dose regimen was 76% effective (95% CI 75-78), with one dose of the vaccine just 64% effective over the same time period (95% CI 62-67), underscoring the need for people to get both doses, Nicola P. Klein, MD, PhD, of Kaiser Permanente Northern California in Oakland, and colleagues reported in the Annals of Internal Medicine.

"The study findings are reassuring in confirming that the recombinant zoster vaccine is highly effective for at least 4 years," Klein told MedPage Today in an email. "The study also reaffirms the importance of getting the second dose of vaccine to maximize protection against shingles, which can be a painful and potentially dangerous condition."

Klein noted that vaccine effectiveness was the same in patients who received the second vaccine dose later than the recommended interval of 2 to 6 months between doses. "One of the main messages is that everyone for whom the vaccine is recommended should get two doses, but not to panic if the second dose ended up being delayed beyond 6 months."

The study included about 2 million people over the age of 50 who had never received RZV. During the study period from 2018 through 2022, 38% received at least one vaccine dose and 29% received two doses of RZV. After both doses, vaccine effectiveness was 79% during the first year, 75% during the second year, and 73% during the third and fourth years.

Although vaccine effectiveness after one dose was 70% effective during the first year, effectiveness waned substantially after that to 45% during the second year, 48% during the third year, and 52% after the third year.

Effectiveness also varied by age. The vaccine was slightly more effective in people who were vaccinated when they were younger than 65 years of age (81%) versus those who were older (74%).

Notably, in people who received corticosteroids -- a group at significantly higher risk for shingles -- the vaccine exhibited lower but substantial effectiveness (65%). The authors pointed out the number of shingles cases per 100 recipients prevented by the vaccine was about the same in corticosteroid users and nonusers.

"Our analysis can give clinicians additional support for urging adults in the recommended categories -- over age 50 or immunocompromised -- to get vaccinated against herpes zoster," Klein said.

The study's estimates of vaccine effectiveness were lower than those observed in the ZOE-50 and the ZOE-70 clinical trials, the authors noted. ZOE-50 found that the vaccine was 97% effective in people ages 50 and older and ZOE-70 found that the vaccine was 90% effective in those 70 years of age or older. A long-term follow-up study of those trials concluded that vaccine effectiveness held steady for at least 7 years, but long-term effectiveness of the vaccine in real-world settings hasn't been extensively evaluated, the authors said.

The prospective cohort study gathered data from patients in four healthcare systems within the Vaccine Safety Datalink, a collaboration between the CDC and nine integrated healthcare systems. RZV was offered free of charge to most eligible patients. Researchers excluded those who received a diagnosis of shingles in the year before the study began. Among participants, 38% were 65 years of age or older, 53% were female, and 59% were white. The outcome was incident herpes zoster infection.

During the study follow-up over 45,000 cases of shingles were diagnosed and most (94%) were in unvaccinated participants. Unadjusted incidence of herpes zoster was 1.7 per 1,000 person-years in fully vaccinated people versus 6.7 per 1,000 person-years in unvaccinated people.

One of the potential limitations of the study was that a diagnosis of shingles required both a herpes zoster diagnosis ICD code and an antiviral prescription, rather than PCR testing. This may have lowered vaccine effectiveness estimates, researchers wrote. Also, patients with milder illness may have not sought care, potentially overestimating vaccine effectiveness.

Katherine Kahn is a staff writer at MedPage Today, covering the infectious diseases beat. She has been a medical writer for over 15 years.

Disclosures

The study was funded by the CDC.

Klein reported prior institutional funding from Sanofi Pasteur, Merck, Pfizer, Seqirus, and GSK. A co-author became an employee at Pfizer after completion of this study.

Primary Source

Annals of Internal Medicine

Source Reference: Zerbo O, et al "Effectiveness of recombinant zoster vaccine against herpes zoster in a real-world setting" Ann Intern Med 2024; DOI: 10.7326/M23-2023.

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Recombinant Zoster Vaccination In Older Adults Not Linked To Increased Gout Risk

Receiving recombinant zoster vaccination (RZV) does not pose a statistically significant increased risk for new-onset gout among adults aged at least 65 years in the United States (US), according to study results presented at the American College of Rheumatology (ACR) 2023 Annual Meeting, held from November 10 to 15, in San Diego, California. 

Researchers conducted a retrospective observational study sourcing real-world data from the Centers for Medicare and Medicaid Services Chronic Conditions Warehouse

Database. They reported on the risk for new-onset gout following RZV exposure among US adults aged at least 65 years. 

New-onset gout cases during the risk period (days 1-30 after vaccination) or control period (days 31-60 after vaccination) were identified by hospital or outpatient gout diagnoses, followed by prescriptions for allopurinol, colchicine, probenecid, or febuxostat within 3 months.

A total of 1309 patients with new-onset gout were identified; of these, 1074 patients (82%) received two RZV doses between 2018 and 2019. 

The majority of patients were men (61%), identified as White (87%), and were aged between 70 to 79 years (55%). 

Common comorbidities included chronic kidney disease (41%), diabetes mellitus (36%), and ischemic heart disease (33%). 

The majority of patients had no prior hospitalizations (87%) or emergency department visits (77%), and 9% received a concurrent influenza vaccine.

A total of 783 incidences of new-onset gout were observed after the first RZV dose and 526 cases after the second dose, which were distributed evenly between the risk and control windows. 

The risk ratio for developing gout, as estimated by conditional Poisson regression models, was 1.01 (95% CI, 0.90-1.12).

These findings were further validated through secondary and sensitivity analyses.

A temporal scan was conducted to identify clustering of gout cases following RZV vaccination. The study authors noted, "The temporal scan did not detect significant clustering of incident gout cases over the 60-day follow-up."

Disclosure: Multiple study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors' disclosures. 

Reference

dosReis S, Zhang C, Amill-Rosario A. Incident gout after recombinant zoster vaccination in adults aged ≥65 years in the USA. Abstract presented at: ACR 2023; November 10-15, 2023; San Diego, CA. Abstract 0232.

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