VARICELLA-ZOSTER: EPIDEMIOLOGY OF SHINGLES 1

Varicella-Zoster: Epidemiology of Shingles

Carissa A. Trapp

California State University Channel Islands

HLTH 301: Intro to Public Health Administration

Professor Kristen Linton

4 Dec 2020
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Varicella-Zoster: Epidemiology of Shingles

Varicella-zoster virus (VZV) is a secondary infection known as herpes zoster, or

commonly as shingles. The primary infection of varicella-zoster virus is varicella, universally
known as chickenpox (Arvin, 1996), named for the common pocked rash that covers the skin.
According to Arvin (1996), VZV, whose natural host is humans, is an alpha herpesvirus, which
is enveloped and “contains the linear, double-stranded DNA genome.” Outbreaks are most
common in temperate climates, primarily during late winter and spring. 90+% of children
contract varicella between the ages of 5 and 10 years, predominantly exposed at school. “Since
almost all children become infected, the annual incidence of varicella is equivalent to the birth
rate” (Arvin, 1996). Varicella is highly contagious as it is spread through “respiratory droplets or
vesicular fluid” (Arvin, 1996). Another component of its infectivity is a person is contagious 24-
48 hours before the exanthem appears.

Without the initial infection of VZV, humans are not susceptible to herpes zoster, the
shingles affliction. According to Arvin (1996), the secondary infection is due to the reactivation
of the virus, which resides dormant in the dorsal sensory ganglia of the spinal nerve. Herpes
zoster has not seasonal pattern, “indicating that disease results from the reactivation of latent
virus rather than new exposures to VZV” (Arvin, 1996). The primary symptoms of VZV
reactivation are a vesicular rash and extreme pain due to its present in the nerves. People who are
at risk of the reactivation of VZV are those whose innate immunity of T-cells diminish due to
advancing age, stress, immunosuppression, use of immunosuppressive drugs, and radiation in
cancer treatments (Carter, 2020). Shingles, an ailment often present in those with weakened
immune systems, is often the reason younger individuals are diagnosed with HIV. Furthermore,
“the mean age at onset of zoster… is 59.4 years, with 68% of cases occurring in those 50 years
and older” (Yawn & Gilden, 2013). Herpes zoster is a disease of the elderly and the
immunocompromised.

Vaccines are highly recommended in preventing both varicella and herpes zoster. The
vaccines Varivax and Varilrix, which were approved by the FDA for use in 1995, are an
“attenuated vaccine administered around the first year of age, and with a boost vaccination in
school age” (Freer & Pistello, 2018). The attenuated, meaning a weakened but live virus, is
especially successful at long-lasting immune protection for varicella, but is not recommended for
VARICELLA-ZOSTER: EPIDEMIOLOGY OF SHINGLES 3

immunosuppressed individuals. Because age is the predominant factor of reactivation of VZV, a

vaccine is also highly recommended for those ages 50 and up. Efficacy rates are 70% for 50-59
year olds, 64% for those between 60 and 69 years old, and only 38% for individuals older than
70 (Carter, 2020). Like the varicella vaccine, zoster vaccine live (Zostavax) is not recommended
for the immunocompromised. Another vaccine that contains the viral antigens and an adjuvant
shows higher efficacy rates. For people between the ages of 50 and 59 there is a 96% efficacy
rate, and “97% in persons between ages 60 and 69, and 91% in persons greater than 70 years of
age” (Carter, 2020). If a reactivation event happens, individuals are treated with the antiviral
acyclovir. However, these are only effective for active herpes zoster; they are not preventative.

Synthesis

All four studies are in concurrence in that varicella, the primary infection of the varicella-
zoster virus, is highly contagious and recommend the use of the live attenuated varicella vaccine
to protect against the varicella infection (Arvin, 1996; Carter, 2020; Freer & Pistello, 2018; &
Yawn & Gilden, 2013). The varicella vaccine, approved in the United States in 1995 by the FDA
has shown extensive success in decreasing the rate of chicken pox. The Arvin study (1996)
concluded that “herpes zoster occurs only in individuals who have had primary VZV infection.”
The science that early on in the vaccination program concluded that if inoculated VZV would not
have the opportunity take up residence in the dorsal sensory ganglia. However, as further
longitudinal studies were conducted, it was determined that a reactivation of VZV was in fact
possible (Carter, 2020; Freer & Pistello, 2018; & Yawn & Gilden, 2013). Yawn & Gilden (2013)
have determined that while zoster is still a global health issue after widespread use of VZV
attenuated vaccine. However, they point out that the vaccine has decreased the rates of zoster
reactivation.

In 1996, when the Arvin article was published, there was no vaccine available for the
secondary infection of herpes zoster. This establishes why it is important to utilize recent studies
for more current information. There are two common vaccines for herpes zoster used in present
day: the live attenuated vaccine and a subunit vaccine that introduces antigens to the hosts
immune system (Carter, 2020; Yawn & Gilden). There is consensus that the efficacy of the live
attenuated vaccine decreases with age. As of 2013, Yawn & Gilden point out, that the vaccine
had yet to affect “the epidemiology of zoster, because uptake has been low, reaching only 14.4%
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in the United States after licensure.” By 2020, Carter discusses the efficacy rates by age group of
the live attenuated zoster vaccine, commenting that “after the first year of vaccination with ZVL,
there is a dramatic decrease in efficacy, and 6 years post vaccine, the efficacy rates drops to
below 35%” (2020). Thus Carter suggests the recombinant zoster vaccine with the zoster antigen
as a more efficacious vaccine with rates above 90% for all age groups. Both Carter and Freer &
Pistello highlight the fact that the recombinant zoster vaccine is recommended for use for the
immunocompromised and immunodeficient populations, with a caveat that they have high
incidence of adverse reactions.. Freer & Pistello (2018) also discuss a heat-inactivated vaccine
that is similarly safe for usage for immunodespressed patients. However, it “stimulates lower and
less efficient immune response compared to the live attenuated vaccines” (Freer & Pistello,
2018). With three different available vaccine types, it is possible for most patients to receive the
immune support they need.

Health Belief Model

Prior to 1995 the perceived susceptibility of VZV was high. When one child was exposed
in a family/day care unit/etc. parents encouraged transmission as the perceived severity was that
the younger one was at infection, the less severe the sickness would be (Arvin, 1996). However,
it was recognized in the early 2000s that there were still severe outbreaks amongst school-aged
children. The perceived benefits of the vaccine were diminished. However, it was determined
that with a second-dose of vaccination before entering school, the efficacy of the vaccine could
improve (CDC, 2019). Today, 25 years after the approval of the live attenuated varicella vaccine
and the second-dose policy, the perceived susceptibility of contracting the primary infection is
low.

Similarly, because early literature discussed that inoculated individuals did not
experience the reactivation of herpes zoster, the perceived susceptibility of shingles was low
(Arvin, 1996). As longitudinal studies proved this to be less than true, it became abundantly clear
that it was necessary to help bolster the immune system’s T-cells to decrease chances of
reactivation (Carter, 2020). With the live-attenuated vaccine, it was important to communicate
that in immunocompetent individuals vaccination was unlikely to trigger the reactivation of the
latent VZV. Through awareness of available vaccines, rates of reactivation have decreased
(CDC, 2019).
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The perceived severity of herpes zoster is high. Older adults are aware of the fact that
shingles is a significantly painful ailment that can persist for months, sometimes years (Carter,
2020). Early on in the availability of the first shingles vaccine (live attenuated), there were
barriers to the rate of inoculation (Yawn & Gilden, 2013). Those barriers were due to cost,
freezer storage, and a lack of supply. The perceived benefits of the vaccine were high, as many
saw the benefits in reducing the risk of a reactivation of VZV. However, as the vaccine was
proven to be less efficacious, fewer people received the vaccine. Fortunately, with the
development of the recombinant zoster vaccine, and the high rates of efficacy, the rates of
vaccination for herpes zoster have increased (Carter, 2020; CDC, 2019).
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References

Arvin A. M. (1996). Varicella-zoster virus. Clinical microbiology reviews, 9(3), 361–381.

https://doi.org/10.1128/CMR.9.3.361-381.1996

Carter, T. M. (2020). Shingles: Not just a rash. The Journal for Nurse Practitioners, 16(2), 111-
115. https://doi.org/10.1016/j.nurpra.2019.10.013

Centers for Disease Control and Prevention. (2019, April 15). Varicella. https://www.cdc.gov/
vaccines/pubs/pinkbook/downloads/varicella.pdf

Freer, G., & Pistello, M. (2018). Varicella-zoster virus infection: natural history, clinical
manifestations, immunity and current and future vaccination strategies. The new
microbiologica, 41(2), 95–105. https://pubmed.ncbi.nlm.nih.gov/29498740/

Yawn, B. P., & Gilden, D. (2013). The global epidemiology of herpes zoster. Neurology, 81(10),
928–930. https://doi.org/10.1212/WNL.0b013e3182a3516e