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Researchers hunt for weapons against shingles

Solution may be a souped-up chicken pox vaccine or behavioral intervention to boost the immune system.

By Victoria Stagg Elliott, amednews staff. Nov. 3, 2003.

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The search for therapies to prevent shingles among the elderly has honed in on two very different possible interventions -- tai chi and a strong dose of the chicken pox vaccine.

A study of 36 adults older than 60 found that 15 weeks of tai chi, a Chinese exercise program focused on body movement, increased cell-mediated immunity to the painful re-activation of the varicella virus. Results were published in the September/October issue of Psychosomatic Medicine.

"Ours is the first randomized, controlled study to demonstrate that behavior can have a positive effect on immunity that protects against shingles," said Michael Irwin, MD, lead author of the study and a professor at the University of California, Los Angeles, Neuropsychiatric Institute.

Meanwhile, a study in which 196 elderly individuals who had received varicella shots in previous research were given booster shots found that the vaccine could bolster immunity to shingles. The findings were presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy in Chicago in September.

The vaccine, which is similar to the one used in childhood but at a much larger dose, has by far generated the most interest. Several early studies have suggested that a version of the varicella vaccine can produce immunity in the cells, but it will be the long-running Shingles Prevention Study that is expected to finally answer the question at the end of 2004. That effort is a double-blind, placebo-controlled, multicenter trial involving more than 38,000 subjects organized by the U.S. Dept. of Veterans Affairs in conjunction with Merck & Co., the vaccine manufacturer, and the National Institute of Allergy and Infectious Diseases.

"When this experiment is analyzed, we'll know if it's time for doctors to start giving this vaccine," said Myron Levin, MD, professor of pediatrics at the University of Colorado, Denver and lead investigator of the Shingles Prevention Study there.

The search for preventive therapies has intensified because experts have speculated that the use of the varicella vaccine, while decreasing the incidence of chicken pox in children, may cause an increase in shingles in adults. Without the periodic boosters provided by exposure to sick kids, adults who came of age before the vaccine was available may have immune systems that are more likely to allow shingles to develop. The aging of the baby boomers also means that the population at high risk of shingles will soon be a lot larger.

Immunization infrastructure lacking

But even if the vaccine is found safe and effective, concerns exist about its delivery. The adult immunization infrastructure is far less developed than the one for children, and physicians struggle to get everyone their flu and pneumococcal vaccines.

"Internists have not done as good a job as the pediatricians have done in institutionalizing immunization in their practices, and to a certain extent it's because of the less-regular contact that many adults have with physicians," said Wendy Keitel, MD, associate professor at Baylor College of Medicine, Houston and lead investigator of Baylor's Shingles Prevention Study.

The question of when adults should get the shingles vaccine also remains to be settled. A study published last year in the New England Journal of Medicine suggested that immunity in kids may wane, and they may need booster shots. The Shingles Prevention Study is expected to determine only whether the vaccine will work. The issue of duration of protection will have to be answered later.

And if both methods prove successful, the question will be whether patients want a vaccine or tai chi.

"It is a lot easier to take a shot than to do tai chi, but we've also found that many older adults are not very interested in getting a vaccine to prevent shingles," Dr. Irwin said. "These mind-body interventions may have more health-promoting effects than just simply producing an increase in shingles immunity."

Maybe patients would want both.

"Tai chi may have the same effect against influenza, but you'd be nuts to count on something like that instead of influenza vaccine," said Michael Oxman, MD, national chair of the Shingles Prevention Study and one of the authors of the tai chi paper. "What I would want to do is get vaccinated and do tai chi, if it all pans out, and I still think that's a significant if."

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