Varicella zoster virus (VZV) is the virus that causes chicken pox, usually a relatively minor childhood illness. Unlike other viruses that are cleared from our bodies after infection, VZV stays in our sensory nerve cells forever. Over the subsequent decades our immunity to VZV wanes. When our immunity falls too low, VZV can reactivate and cause shingles. Shingles is a painful blistering rash along the distribution of one sensory nerve. The rash resolves in a few weeks, but in some older patients the effected patch of skin can remain painful for months or even permanently. This painful condition after shingles is called postherpetic neuralgia and it can be quite debilitating.
In 2006 a vaccine to prevent shingles, Zostavax, became available. It is recommended for everyone over 60 who has had chicken pox. It has been proven effective in preventing shingles, and therefore in preventing postherpetic neuralgia.
But is Zostavax safe? A large study in the current issue of Annals of Internal Medicine answered that question. The study randomized over 38,000 patients to receive Zostavax or a placebo injection. The side effects from Zostavax were not worse than from placebo. Most of the side effects (like most vaccines) involved inflammation at the site of injection.
So to summarize, Zostavax is safe, and it effectively prevents a very painful potentially disabling condition. Recall also that all children are now being vaccinated against chicken pox, so that in 60 years Zostavax will not even be necessary since a generation will have grown up uninfected with VZV.
In anything resembling a rational healthcare delivery system champagne corks would fly, the makers of Zostavax would get a pat on the back (and well-deserved profits) and we would all shift our attention to more pressing matters. Some patients would decide to buy Zostavax; some would not. Private or government charity programs would pay for the vaccine for indigent patients. Joy and health would reign.
But instead, there is gnashing of teeth and wringing of hands. Why? Because only about 7% of eligible patients have received the vaccine. It turns out Zostavax is the most expensive vaccine recommended for adults (about $200) and the first to be covered by Medicare part D, the Medicare drug “benefit”. That means pharmacists are paid to dispense it to patients, not doctors.
To sort out why more patients aren’t receiving Zostavax, another study in the same issue of Annals of Internal Medicine surveyed hundreds of primary care doctors about the barriers that might be preventing them from recommending and administering Zostavax to their patients. The results: the biggest barrier was financial. Many patients without coverage don’t want to pay for it, and doctors aren’t being paid by insurance companies to administer it.
This was such a staggeringly shocking finding, that it merited an editorial in the very same issue of Annals. That’s three articles about a vaccine that works as intended and is safe. The editorial opines that reimbursement should be revised to promote increased utilization of the vaccine. In other words, we should take more money from other people to assure that patients who don’t want to pay for their own Zostavax can get it for free.
Now don’t get me wrong, I’m all for charity care for indigent patients. (I volunteer at a clinic that serves indigent patients two afternoons a month.) But the vast majority of patients who aren’t getting Zostavax aren’t poor; they just have better things to do with $200.
What the editorial didn’t say is that you can’t do much better than a product or service in which the main barrier to obtaining more is the price. After all, that’s the only reason we don’t get twice as many clothes or cars or homes. If the price was lower, we would. If Zostavax was free, some other barrier to its use would necessarily arise, perhaps a lengthy wait, or a difficult to navigate bureaucracy, or rationing by some other means.
So perhaps each patient should shoulder the cost of his or her own Zostavax. We should also all donate a little time or money for those who truly can’t afford it. And some of us may rationally choose to accept the risk of shingles. Alternatively, we could riot in Athens until the EU pays to keep us all shingles-free.
Annals of Internal Medicine Summary for Patients: Safety of the Vaccine to Prevent Shingles
Annals of Internal Medicine article: Safety of Herpes Zoster Vaccine in the Shingles Prevention Study
Annals of Internal Medicine article: Barriers to the Use of Herpes Zoster Vaccine
Annals of Internal Medicine editorial: The Looming Rash of Herpes Zoster and the Challenge of Adult Immunization
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