It's debatable if the fiduciary standard is 'higher' than suitability. But the better question might be, who's holding the bar?
Few take advantage of a new vaccine to prevent the painful condition
Last spring I struck up a casual conversation with a stranger and heard about how the debilitating pain of his wife's shingles infection had been overwhelming both of their lives for months. Though 1 had heard of shingles, I thought it was a nuisance rash that troubled a few overly sensitive seniors. When he bemoaned that they had not learned about the shingles vaccine in time to protect his wife, I made a mental note to look into getting vaccinated - then promptly forgot.
A few months later, I found myself with aching muscles and a stinging rash on the left side of my torso. I wrote it off to several days of hard work on a yard project. Though I eased off, the pain intensified. I could not rest. My breath came in painful gasps. It felt like hundreds of nails were being relentlessly driven into my side, and the rash raised into an angry, red relief map that read, "Welcome to the World of Shingles."
My doctor prescribed an antiviral medication to reduce the length and severity of the outbreak, along with pain medication and topical anesthetics that offered minimal relief. It took almost a month for my life to return to normal.
I'd been lucky. It's not uncommon for severe pain to last months or even years after the rash has cleared up. Though people under age 40 generally recover quicker, it can be a long-term ordeal in up to half of untreated victims 60 or older. Had the rash developed on my face near an eye or ear, it I could have led to vision or hearing damage.
And there is potentially other collateral damage. A study published in the January issue of Neurology found that having shin*gles can increase the risk for heart attack by 10%.
Until recently, there has been no defense against the shingles virus. Doctors can treat shingles with an antiviral medication up to 72 hours after a rash appears, but most victims don't seek treatment in time, leaving them with little relief. Almost six years ago a vaccine came on the market that, testing shows, can help 60% of thèse Vaccinated dodge the shingles bullet and reduce severity in others. But not many people are being vaccinated. The reasons are as complex as the shingles virus itself.
Tlckinq time bomb
Like anyone else who has ever had chickenpox, shingles had been a ticking time bomb in me. After individuals recover from chickenpox, the varicella zoster virus goes dormant, lurking in nerve cells, ready to reactivate as shingles under the right circumstances.
The reasons the zoster virus reactivates are not well understood, but it is usually associated with a decline in the immune response. The Centers for Disease Control and Prevention predict that one in every three people in the United States will develop shingles. There are about a million cases each year in this country.
The shingles vaccine is quite new, having been officially recommended for universal use June 6, 2008, under the trade name Zostavax. It contains the same live, but extremely mild, viral strain used in the chickenpox vaccine for children, but it is packed with about 14 times the amount. Tests show it takes that much more firepower to kickstart aging immune systems into action. Merck & Co., one of the largest pharmaceutical companies in the world, is the only maker of both chickenpox and shingles vaccines.
Dr. Jonathan Temte, a professor in the department of family medicine at the University of Wisconsin School of Medicine and Public Health, is also chair of the U.S. Advisory Committee on Immunization Practices, which examined the results of Merck's tests for the shingles vaccine. His committee recommends that everyone over 60 get vaccinated for shingles.
"We see shingles in every decade of life, even children" says Temte. "But if you are making a policy for a population, you look at the risk at various ages, and starting about age 60, we find a rapid increase in the risk for shingles."
With about half of all baby boomers now over 60, that adds up to a serious shingles boom. "For people who live to 85, about half will have at least one episode of shingles," Temte adds. "The older you are, the more likely you are to have lasting pain, and up to 25% of cases include vision problems."
The vaccine could cut those numbers. Temte says the tests concluded that the vaccine is about 60% effective in reducing cases of shingles and up to 65% effective in reducing the extended pain. Nonetheless, only about 16% of individuals 60 and over have gotten their shingles vaccine nationwide.
"It's a big concern how underutilized the shingles vaccine is," says Temte. He speculates that many physicians are not recommending it. "When it comes to being proactive for preventative measures for older adults, health care systems are not very good."
An expensive vaccine
Temte notes some people are hesitant to get the shingles vaccine because they are worried about side effects of vaccines in general.
But Temte says the risks are low. The Vaccine Safety Datalink searches hundreds of thousands of medical records comparing vaccine recipients to non-recipients once a vaccine is recommended.
"Most patients and even most physicians are unaware of the extensive system in existence to assure safety of vaccines," says Temte. "Because it is a live virus vaccine, one in 1,000 may get a brief rash around the injection site, and one in 100 might get a slight fever or feel some fatigue."
There are some people who should not get the vaccine, including those who've had a life-threatening or severe allergic reaction to gelatin, the antibiotic neomycin, or any other component of shingles vaccine. It is also not recommended for people with weakened immune systems or for women who are or might become pregnant.
The price may also be keeping vaccination rates low. At $219.99 for cash-paying walk-in customers at Walgreens, it's two to three times as expensive as most other adult vaccines, according to Dr. Christopher Crnich, assistant professor in the University of Wiscons in-Madison School of Medicine and Public Health.
All Medicare Part D plans cover the shingles vaccine, though some plans still call for partial payment out-of-pocket. Most private health insurance plans cover the vaccine for people 60 or older, and some cover it for people 50 to 59.
Some pharmaceutical companies provide vaccines to eligible adults who can't afford them. For information on the patient assistance program that includes Zostavax (shingles vaccine), see merck.com/merckhelps/vaccines/home.html.
"It's expensive," acknowledges Crnich. "But it's a one-time cost. Long-term followup shows it provides protection for up to seven years, and perhaps longer. Studies show it is cost effective. It's much less expensive than many other medications you may take, such as being treated for elevated blood pressure or cholesterol."
Crnich says the vaccine works particularly well for adults 50 to 70. "The shingles vaccine is more effective the younger you are when you receive the vaccine and decreases with age. Get it when you are reasonably healthy so you can mount an appropriate immune response to the vaccine.
'The shingles vaccine is more effective the younger you are when you receive [it]/ ^
-Dr. Christopher Crnich
Temte: 'Starting about age 60, wa find a rapid Increase In the risk for shingles.'