Personal history with chickenpox, vaccines is key

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith,

A painful infectious disease that usually impacts people over 50 is showing up in younger adults. So today I'm talking about possible reasons for this with Dr. Jennifer Moffat. She's an associate professor of microbiology and immunology at Upstate, and she studies the Varicella zoster virus, which causes chickenpox and shingles.

Welcome to "The Informed Patient," Dr. Moffat. .

Jennifer Moffat, PhD: Well, thank you for the invitation, Amber. I'm delighted to be here today to talk to you about the virus, the diseases and how we can treat them and prevent them.

Host Amber Smith: Well, I'd like to start by asking you to tell us about the Varicella zoster virus. When and how was it discovered?

Jennifer Moffat, PhD: It was known to humanity for a long time. In fact, the word "shingles," which it causes, comes from a Roman word, "cingulum," for the belt. And so it was known as "the belt of fire." In fact, that is often found around people's waist and chest. So it's been with humans for a long time, but it was in the 1950s that we were able to culture it and grow it.

And that was done by Thomas Weller in England.

Host Amber Smith: So how is it similar to or different from other viruses? What distinguishes it?

Jennifer Moffat, PhD: What is really important about it is that it can infect us and stay in our bodies for life. It is "latent"; we say latent, meaning it's hidden in our nervous system for our whole life.

And this is a property of other viruses too, but Varicella zoster virus is also famous for being one of the most contagious viruses, especially in childhood. Chickenpox spreads rapidly right through a classroom, and shingles infections can trigger another outbreak of chickenpox in kids.

Host Amber Smith: So does it infect just humans, or other animals, too?

Jennifer Moffat, PhD: It is uniquely infecting humans. It cannot infect any other animal, but other animals have their own version. There's a monkey chickenpox, but it's not the same virus.

Host Amber Smith: And I understand it spreads easily from person to person. But is it airborne or is it on surfaces?

How does it spread?

Jennifer Moffat, PhD: It spreads through our breath droplets, our respiratory spread. So when a person has chickenpox, some of the virus is growing in their throat, and it can then spread through talking, playing and so on, in the air. And when a person has shingles, it was just recently discovered that the saliva contains the virus. Even though the rash may be on your back, it can spread through your respiratory droplets, but really it can also spread through the rash. And the blisters contain a lot of virus, so scratching it puts it on the fingers, but mainly it's spread through the air.

Host Amber Smith: How long have you been studying Varicella zoster virus? This has been your whole career, right?

Jennifer Moffat, PhD: Yes, 30 years ago, at this time of year, is when I started my postdoctoral fellowship (specialized training) to work on a new thing for me, which was this virus. I was at Stanford University Medical Center in the pediatric infectious diseases department.

It really set me off. I just took it and never let go. So I've been building up a lot of research years, 30 years now, and it's a small field, so I'm more and more considered one of the world experts.

Host Amber Smith: Well, let's talk, if we can, about how chickenpox is related to shingles. Can you describe both of the diseases, how they're contracted and how they are similar?

Jennifer Moffat, PhD: Yeah. Well, we all are familiar with chickenpox, mainly as a childhood disease. And its official disease name is varicella. So that's the first half of this virus's name. Varicella is chickenpox, and kids spread it, from one kid to the other, in families, classrooms and so on. And we were all familiar with the rashes and so on.

It wasn't known until the '50s, really, that shingles was the same virus that popped out in adults. And the other name for shingles is zoster. So the Varicella zoster virus is now known as the one that causes both. It's the same virus. So when a child is infected, from their playmates and siblings, the virus infects their nervous system immediately. So even before the rash pops up, during the incubation phase, the virus enters the nervous system, where it infects the nerves that are along the spine, the dorsal root ganglia. And it stays there forever. And our immune system then quiets things down. We get better when immune to the virus quite well during young adulthood.

And this immunity is important to keep the virus from popping back out. So in any situation where immunity dwindles either from medical reasons, health reasons or age, the virus says, "Ah, here's my chance." And it comes roaring back from the nerves out to the skin. And that can be mainly on the chest, the back and the face.

A third of shingles cases are on the face, and then that's the eyes, the ears, the mouth -- very sensitive areas, but it is the same virus. And you can't actually catch shingles. It comes from inside of us, So you can't catch it from another person who has shingles. If you've had chickenpox or been vaccinated against it, the only way you can get shingles is from the viruses already inside you.

Host Amber Smith: So if you, as a child, you never had chickenpox, then you shouldn't have a risk for shingles?

Jennifer Moffat, PhD: That's right. There is a risk, though, if you've never had chickenpox and never had a vaccine for it, and you've never encountered this virus, the older you are, if you do get it, the more dangerous it is. So chickenpox in kids used to put 10,000 kids a year in the hospital and killed even 100 kids a year, on average. That's all different now in the age of the vaccine, but adults who got it were very seriously ill, and more adults died than kids. So it's a good idea to get immunity to it with a vaccine as a child or get infected, which happens in a lot of countries.

Host Amber Smith: So a person who was vaccinated against chickenpox, should they also get a shingles vaccine when they reach the age for that?

Jennifer Moffat, PhD: Yeah. The chickenpox vaccine was one of the things I worked on 30 years ago, and it was approved in 1995. So the children who got it then are approaching 28, 29 years old.

They're not really old enough to worry about shingles, but when they are 50, they will definitely be eligible for the Shingrix vaccine or any new vaccine.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Jennifer Moffat. She's an associate professor of microbiology and immunology at Upstate, and she specializes in the study of the Varicella zoster virus, which causes chickenpox and shingles.

So why are there more cases appearing in people under 50 with shingles, people that are even in their 20s, 30s, 40s that are getting shingles? What is the current hypothesis for why that's happening?

Jennifer Moffat, PhD: Yeah, that is a great question, Amber, and we aren't sure, so we still have more questions than answers on this one, but what we know is, everywhere around the world, the cases and the incidence, we call it, the rate or the number of cases per population, is rising for shingles.

We don't know why, and it's not necessarily linked to just an aging population. That's one idea: "Oh, we're just all getting a bit older, so there's more shingles." Well, yes, we get more shingles when we're old, but that doesn't account for what we're seeing, which is people younger -- 20s, 30s, 40s and 50s -- are now getting shingles more often.

And what could that be about? A lot of thoughts. OK, so we know that if the immune system is weakened, the virus can pop out, so that might be something going on. Maybe overall, our immune systems aren't in great shape, but that can't explain all of this.

Maybe we're taking more medications like steroids or immunosuppressant drugs that raises the risk. Maybe people are less healthy, right? We have epidemics of other diseases. Maybe it's linked to that. But we've tried to rule all of these things out, and what we're left with is still scratching our heads and thinking, "What on earth is causing this? Is it just doctors diagnose it better now? We have better medical care, people go to the doctor more?" Those could all be parts of it.

But what we're leaning toward is almost a global change in our human/virus balance, and it could be something very subtle like air pollution or sunlight or temperature. We don't know. We're hopeful to solve it, but we can't say today why we see more virus.

Host Amber Smith: How is the disease different in a young person compared with someone over 50?

Jennifer Moffat, PhD: Luckily, young people have less serious outbreaks of shingles. When they get it, it's a lot less concerning. It doesn't last as long, it doesn't create such a large rash, and it will often heal just fine on its own.

However, that's not the case the older we are. The risks we're worried about are the virus comes out of nerves, and when it does that, it can really irritate the nerves, and it can then cause nerve damage and pain, long-lasting pain, from those nerves called postherpetic neuralgia, or PHN, devastating, painful, can last for years or more. And young people just rarely experience that lingering pain. So that's the major difference, the seriousness of it.

Host Amber Smith: Well, let's talk about what can be done to protect people from chickenpox and shingles. Are pediatricians still vaccinating children against chickenpox?

Is that still a recommended vaccine?

Jennifer Moffat, PhD: It is recommended. It is recommended by the CDC (Advisory) Committee on Immunization Practices, and it's also mandated by the state of New York. So the 1-year-old children will get their first dose, and then again, usually right around the start of school, between age 4 and 6. This has been fantastic to prevent outbreaks of chickenpox in the schools and day care.

So what we don't see anymore is this normal springtime wave of chickenpox. That is not happening. The whole epidemiology (occurrence) of this infection has changed due to vaccination.

Host Amber Smith: If there is someone who got through childhood without being vaccinated, is it too late to get the vaccine as an adult?

Jennifer Moffat, PhD: No, it's not. We screen all of our incoming staff at Upstate Hospital. At University Hospital, if you get a job here, you will be screened for your immunity to chickenpox. And every year we find adults who are not immune, and they get the vaccine in our employee health (department). And that is a good idea to protect them. The patients who have shingles could infect them and give them chickenpox.

Host Amber Smith: Well, what are the vaccination rates for shingles for people over age 50? I think that that's when they're recommended, 50 and up, right?

Jennifer Moffat, PhD: Yeah. The vaccine that's used in America right now is called Shingrix, and it is highly effective, 95% effective, at preventing shingles. Well, that's too bad because only 30% or so of people who are eligible have even gotten it. So that's not enough. We could do better.

And people are sick and tired of vaccines, right? Like, "Enough already. I've had all those shots." But Shingrix is one that you probably don't want to put off because once you turn 50, you're eligible, and it's a two-dose vaccine. It does hurt. People say the arm is real sore, but it's worth it because shingles is so much worse, and the lingering pain is no joke. And the virus, when it reactivates in their eyes, can be blinding, and that's terrible.

Host Amber Smith: So maybe just because lack of awareness, maybe people aren't aware about this. Any ideas why it's so low?

Jennifer Moffat, PhD: It's discussed in some friend groups. It comes up. I answer a lot of questions from my friends about it. But I don't think it's promoted well, and then I think people just put it off and avoid it. I can't tell you how many people say, "Oh, I knew I should have gotten my vaccine, and now I've got shingles." It will come up and sneak right up on you because after age 50, your chance of getting shingles goes up and up every year, and by the time you're 80, it's about 50-50 that you've had it already. That's a lot of cases. So, best get it when you're 50 or early 50s; your immune system is still pretty robust. You're going to make a great immune response. That vaccine will work even better. So don't put it off.

Host Amber Smith: And is that a one-time vaccine at age 50?

You don't have to repeat it later?

Jennifer Moffat, PhD: You do. It's a two-dose regimen, but you don't have to repeat it. It's one dose, and then you need the second dose two months to six months later.

Host Amber Smith: And then you're good for life.

Jennifer Moffat, PhD: Yes. Then you're very good. It's like a booster. So the Shingrix vaccine is interesting in that it's the only approved vaccine right now that's designed as a booster for people who are already immune, who already had chickenpox or the Varicella vaccine.

So the Shingrix is designed as a booster, so you really just need that one boost right in your 50s.

Host Amber Smith: Now if we're seeing this show up in people in their 20s and 30s and 40s, is there any thought to vaccinate these people at younger than 50?

Jennifer Moffat, PhD: Well, it comes up; we talk about this in the field all the time, and we're thinking, "Why don't we give people a booster at 30 and get them through to 50?"

And that just hasn't been studied. There hasn't been a clinical trial to study that question. But now that Shingrix is approved, some doctors are recommending to their patients, they're saying, "Hey, you have a particularly high risk for shingles. Let's give you the vaccine." And those are people with underlying health conditions that raise their risk of shingles. And if they have a really smart doctor, they will recommend that they get it as a younger person. But that isn't routine right now. But that could change, and it just requires more research.

Host Amber Smith: Well, let me make sure I understand. If a person becomes infected with shingles, they can't spread shingles to somebody else, or could they spread it to someone who's unvaccinated?

Jennifer Moffat, PhD: Well, if you think that through, a person who's unvaccinated and is exposed to someone with shingles either will get chickenpox from them because it's their first time getting the disease, or they won't get anything because they're immune.

So a person with shingles is contagious. The virus is being shed from their breath and from their rash, but they can't give anybody else shingles.

They just can't, because that virus came from inside of their nervous system. But they can definitely infect: Young kids who are under a year old could get chickenpox, and anyone whose immunity was weakened could be infected and get a type of chickenpox. So really, shingles isn't spreadable.

Host Amber Smith: Does it complicate if a person has another, say, neurologic disorder?

Does contracting shingles complicate that existing disease?

Jennifer Moffat, PhD: I don't know of particular examples of that, but I do know that shingles infections can cause neurological problems. It can infect the brain and cause encephalitis, which can be fatal and needs treatment immediately. It can cause weakness, paralysis, especially facial paralysis, hearing loss, it can attack the retina, cause blindness, cause sensory problems with taste and smell. It really does attack the nervous system, and that's one reason to get that Shingrix vaccine, is nobody wants a facial paralysis and blindness.

Host Amber Smith: Do you have any personal experience with shingles?

Jennifer Moffat, PhD: Well, regrettably, yes. It's ironic, isn't it, that I work on this virus, and I've actually had it twice.

As a young woman, I had a tooth infection, and the infection under my filling triggered shingles on the left side of my face, and it was so mysterious. I didn't know what was wrong at first, but eventually it was very clear that I had shingles from the tip of my nose into my ear, and that was very uncomfortable. I suffered a lot.

So it did heal, and everything seemed fine. And then again, during the COVID epidemic, I got my first COVID vaccine and then the second, and then I got shingles right after that. And it turns out, they found out now that there's a higher risk of shingles right after getting other vaccines.

So I got it again in that same place on my face, and it went into my ear and caused ear pain for a couple of years. So it was definitely worse the second time. I felt like a dummy. You know, (chuckles) here I am, I should have had my Shingrix shot, but, of course, I hadn't, and then I regretted that a lot.

Host Amber Smith: Well, the Shingrix, that wasn't available until when?

Jennifer Moffat, PhD: 2018.

Host Amber Smith: When you were in your 30s, it probably didn't exist, right?

Jennifer Moffat, PhD: It did not exist. No. But later, I was overdue for my Shingrix vaccine and regretted putting it off.

Host Amber Smith: Well, good advice then. Thank you.

Getting back to the virus itself, I'm curious about what is still being studied about it, and what more is left to learn?

Jennifer Moffat, PhD: Oh, well, (chuckles) I have a very busy laboratory here at Upstate, and my emphasis is on discovering and testing new antiviral drugs to treat shingles. Despite the vaccine, we still have a million cases a year of shingles, and people are desperate for treatment, something that you could either take a pill or spread on an ointment, but something to speed healing, reduce the risk of pain, heal the rash, all of those things.

So I have a lot of work to do with, companies and labs around the world who send me their compounds to test them, to see if we can stop some shingles right on the skin.

Host Amber Smith: Very interesting. Well, Dr. Moffat, thank you so much for making time to tell us about your work.

Jennifer Moffat, PhD: Oh, it's been my pleasure, Amber. I just think there's a lot of new discoveries still left to be done.

Host Amber Smith: My guest has been Dr. Jennifer Moffat, from the department of microbiology and immunology at Upstate.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

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