Shingles: The Disease
Shingles, also known as herpes zoster, is a painful viral condition caused by the reactivation of the varicella-zoster virus (VZV), the same virus responsible for chickenpox. While anyone with a history of chickenpox is at risk of developing shingles, the likelihood increases with age and in those with weakened immune systems. The disease can lead to significant morbidity, including postherpetic neuralgia (PHN), a debilitating complication characterized by persistent nerve pain. Fortunately, effective vaccination exists, and nurses play a critical role in raising awareness, educating patients, and promoting vaccine acceptance.
Shingles occurs when the varicella-zoster virus, which remains dormant in the dorsal root ganglia after a person recovers from chickenpox, reactivates. This reactivation typically happens decades later, often due to age-related decline in cell-mediated immunity or immunosuppressive conditions. Upon reactivation, the virus travels along sensory nerves to the skin, causing a painful, blistering rash.
Prodromal phase: Patients often experience tingling, itching, or localized pain in a dermatomal distribution (typically on one side of the body, not crossing the midline), lasting several days before the rash appears.
Rash phase: A painful vesicular rash develops, usually resolving in 2 to 4 weeks. Common sites include the torso, face, or neck.
Postherpetic neuralgia (PHN): The most common complication, characterized by persistent pain for months or years after rash resolution. It affects about 10-20% of shingles patients, with higher incidence in older adults.
Other complications may include:
Herpes zoster ophthalmicus (eye involvement)
Bacterial superinfection of lesions
Neurological complications such as facial paralysis or encephalitis
Disseminated zoster in immunocompromised individuals
Epidemiology
Approximately 1 in 3 people in the U.S. will develop shingles sometime during their lifetime.
The risk rises sharply after age 50 and by age 70 the lifetime prevalence of shingles is about 15% increasing to more than 25% at age 90.
An estimated 1 million cases occur annually in the U.S.
Shingles: The Current Vaccine: Shingrix (Recombinant Zoster Vaccine, RZV)
Shingrix (GSK) is the currently available shingles vaccine, approved by the U.S. Food and Drug Administration (FDA) in 2017 and recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP). The previous live vaccine, Zostavax, is no longer available in the U.S. and was discontinued in late 2020.
Key Characteristics:
Type: Recombinant, adjuvanted, non-live vaccine
Dosing Schedule: Two intramuscular doses, 2–6 months apart
Indication: Adults aged 50 years and older, and adults 19 years and older who are immunocompromised due to disease, medication therapy, or asplenia
Efficacy:
Over 90% effective in preventing shingles and PHN in adults ages 50+
Maintains strong protection for at least seven years post-vaccination
Side Effects:
Common local and systemic reactions include pain at injection site, myalgia, fatigue, fever, and headache. These usually resolve in 2–3 days.
Serious adverse events are rare.
Contraindications and Precautions:
Severe allergic reaction to a dose or vaccine component
Should not be used for treating active shingles or PHN
Shingles: Role of Nurses in Vaccination Conversations
Nurses are often the first point of contact in primary care and community health settings and are ideally positioned to provide accurate information, correct misinformation, and influence patient attitudes toward shingles prevention. Their role includes identifying the patient’s perceptions and perspectives regarding vaccines and vaccination, providing accurate information, correcting misinformation and misinterpreted information, and improving vaccination acceptance and vaccination rates.
Educating About Shingles and Its Risks
Patients may underestimate the severity of shingles, especially if they are unaware of complications such as PHN. Nurses should:
Explain the pathophysiology of shingles in lay language
Emphasize the unpredictability and potential severity of the disease
Use storytelling or patient examples to make the consequences real
Communicating the Value of Vaccination
One of the biggest barriers to vaccine uptake is misunderstanding its benefits. Nurses should:
Highlight the high efficacy of Shingrix in preventing both shingles and PHN
Reinforce that vaccination is recommended even for those who have had shingles before
Explain that immunity to shingles from the older Zostavax vaccine wanes over time and that Shingrix offers improved protection
Addressing Vaccine Hesitancy
Nurses must be equipped to handle common concerns, including:
Fear of side effects: Explain that short-term discomfort is a sign the immune system is responding and is outweighed by long-term protection
Misinformation: Use evidence-based responses and patient-friendly resources
Cost concerns: Discuss insurance coverage, Medicare Part D, and assistance programs, as well as where they may be able to find the vaccine and use existing health coverage for payment. This discussion should also enable patients without health coverage to find vaccine that may be available through public health programs.
Tailoring Messaging to High-Risk Populations
Special attention should be paid to:
Adults over 50
Immunocompromised patients (e.g., those with cancer, HIV, or on immunosuppressive therapy)
Ethnic and racial minorities who may have lower vaccination rates
Individuals previously vaccinated with Zostavax may receive Shingrix. The ACIP recommends that 12 months separate a dose of Zostavax and Shingrix. However, since Zostavax was discontinued in 2020, the spacing of those vaccines should no longer be an issue.
Implementing Vaccine Reminders and Follow-Up
Given the two-dose schedule, nurses should:
Schedule the second dose before the patient leaves the clinic, emphasizing the need to receive that second dose within 2-6 months after the first dose. Delaying the second dose more than that 2-6 month interval may diminish the long-term effectiveness of the vaccine.
Use electronic health record (EHR) prompts and reminder calls.
If the patient EHR has bidirectional communication with the state’s immunization information system (immunization registry), ensure documented vaccine doses are pulled into the immunization information in that EHR.
Track missed appointments and conduct outreach
Integrating Vaccination into Routine Care
Nurses in primary care, geriatrics, and specialty clinics can:
Review vaccine history during annual wellness visits
Integrate shingles vaccination with other adult immunizations (e.g., influenza, pneumococcal) and discuss safety and efficacy when co-administering those vaccines
Collaborate with pharmacists and public health programs to broaden access
Supporting Interprofessional Collaboration
Nurses play a key role in team-based care:
Educate and update physicians, pharmacists, and care managers on CDC guidance.
Participate in community outreach events or workplace vaccination clinics.
Contribute to developing and implementing standing orders or protocols.
Conclusion
Shingles is a common and often debilitating disease, particularly in older adults and those with weakened immune systems. With the availability of the highly effective Shingrix vaccine, prevention is both achievable and essential. Nurses, as trusted health care providers and educators, are vital in translating this scientific advance into real-world health benefits. By offering evidence-based education, addressing patient concerns, and promoting vaccine accessibility, nurses can significantly reduce the burden of shingles in the communities they serve.
As health care systems continue to focus on preventive care, nurse-led efforts to improve adult immunization rates are indispensable. Through proactive engagement, advocacy, and personalized care, nurses can ensure that more patients are protected from the pain and complications of shingles—one conversation at a time.
References
Centers for Disease Control and Prevention (CDC). (2022). Shingles (Herpes Zoster). Retrieved from https://www.cdc.gov/shingles
Dooling, K. L., Guo, A., Patel, M., et al. (2018). Recommendations of the ACIP for Use of Herpes Zoster Vaccines. MMWR, 67(3), 103–108.
Levin, M. J., Oxman, M. N., et al. (2016). Safety and efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. NEJM, 372, 2087–2096.
Ruth Carrico, PhD, FNP-C, CIC, FSHEA, FNAP, FAAN, is an adjunct professor in the Division of Infectious Diseases at the University of Louisville School of Medicine and a board certified family nurse practitioner. She has worked in the field of infection prevention and control for more than 30 years and is also board certified in infection prevention and control. Her research and clinical practice focus on disease prevention in all settings where care is delivered and involves public health and care of vulnerable populations.
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