Herpes zoster (HZ) is estimated to affect more than one million Americans every year. Availability of a vaccine that decreases the incidence of HZ and its most painful sequela, postherpetic neuralgia (PHN), in patients ≥60 years enables clinicians to focus on prevention rather than on simply alleviating the HZ-associated pain, debilitating symptoms and emotional effects. This program is designed to increase awareness of the benefits of vaccination to reduce the burden of HZ and PHN, thereby improving the quality of patient care, reducing the costs to society, and enhancing public health. 

Herpes zoster (shingles) affects quality of life and jeopardizes independent living, particularly in the elderly population.¹ It is more common in individuals aged ≥50 years and is estimated to affect 1 million Americans annually.^2,3 The incidence and severity of herpes zoster and postherpetic neuralgia (PHN), its most common and painful sequela, increase with age.^4,5 Risk increases in those with medical conditions or who are receiving treatments that compromise the immune system.

Herpes zoster is caused by varicella zoster virus—the virus that causes chickenpox. Following recovery from chickenpox, the virus remains dormant, but may later reactivate to cause herpes zoster. Herpes zoster is diagnosed based on clinical and laboratory findings and is often confused with other diseases that have similar signs and symptoms. Prior to the rash, it is often difficult to diagnose. Diagnosis is partly based on the distribution of blisters and the characteristic pain—the main symptom—which may be severe.²

Until recently, treatment for herpes zoster was geared toward managing the pain and emotional effects. Availability of the herpes zoster vaccine for patients ≥60 years of age is likely to reduce the incidence, severity, duration, and burden of the disease, protect against PHN, and lower the cost of herpes zoster.⁶ Efficacy of the vaccine has been confirmed in the Shingles Prevention Study, a randomized, double-blind study of 38,546 adults ≥60 years of age.⁴

Although early diagnosis and intervention can reduce the severity and duration of herpes zoster and its associated pain and debilitation, the main focus should now be on prevention.^2,7  The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends that people ≥60 years of age, regardless of whether they have previously had herpes zoster, be vaccinated against it.⁸  

References

1.  Coplan PM, Schmader K, Nikas A, et al. Development of a measure of the burden of pain due to herpes zoster and postherpetic neuralgia for prevention trials: adaptation of the brief pain inventory. J Pain. 2004;5:344-356.

2.  National Institute of Allergy and Infectious Diseases. Shingles. Available at: www3.niaid.nih.gov/topics/shingles/Cause.htm  Accessed January 12, 2008.

3.  Centers for Disease Control and Prevention. National Immunization Program (NIP). Shingles (Herpes Zoster). Available at: www.cdc.gov/vaccines/vpd-vac/shingles/dis-faqs.htm  Accessed January 12, 2008.

4.  Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005;352:2271-2284.

5. Holodniy M. Prevention of shingles by varicella zoster virus vaccination. Expert Rev Vaccines. 2006;5:431-443.

6. Katz J, Cooper EM, Walther RR, et al. Acute pain in herpes zoster and its impact on health-related quality of life. Clin Infect Dis. 2004;39:342-348.

7. Wright WL. Diagnosis and treatment of herpes zoster: role of the nurse practitioner. J Am Acad Nurse Pract. 2003;15(suppl 12):10-15.

8. Centers for Disease Control and Prevention. CDC’s Advisory Committee Recommends “Shingles” Vaccination. Available at: www.cdc.gov/od/oc/media/pressrel/r061026.htm Accessed January 12, 2008.

This CME activity is intended for primary care physicians and geriatricians.

At the conclusion of this CME activity, participants should be better able to:

• Describe the prevalence, incidence, and potential complications of herpes zoster
• Identify the risk factors, presenting signs and symptoms, and diagnostic criteria for herpes zoster
• Summarize the quality-of-life issues that affect patients with herpes zoster and postherpic neuralgia (PHN)
• Discuss available treatments for the management of herpes zoster and PHN, and the potential benefits of the herpes zoster vaccine
• Apply practice strategies aimed at reducing the incidence, severity, duration, and burden of herpes zoster and PHN. 

Michael N. Oxman, MD
Professor of Medicine and Pathology
University of California, San Diego
Staff Physician (Infectious Disease)
VA San Diego Healthcare System
San Diego, California

Kenneth E. Schmader, MD
Chief
Division of Geriatrics
Duke University Medical Center
Director
Geriatric Research Education and Clinical Center
Durham VA Medical Center
Durham, North Carolina

CME Course Director
Ira M. Leviton, MD, FACP
Associate Professor of Clinical Medicine
Albert Einstein College of Medicine
Bronx, New York

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME). Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians and other health-care providers. 

Albert Einstein College of Medicine designates this educational activity for a maximum of 2.0 AMA PRA Category 1 credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

 There are no fees for participating and receiving CME credit for this activity.  During the period November 2008 through November 30, 2009, participants must:

• Register for the program where prompted
• Read the learning objectives and faculty disclosures
• Study all parts of the educational activity
• Complete the posttest by recording the best answer to each question in the answer key on the evaluation form
• Complete the evaluation form

A statement of credit will be issued only upon receipt of a completed activity evaluation form and a completed posttest with a score of 70% or better. If you submit your test materials online, you will receive your statement of credit immediately.  If you submit your test via fax or mail, your statement of credit will be mailed to you within 4 to 6 weeks of receipt.

Estimated time to complete the activity: 2 hours

For CME questions, please contact Albert Einstein College of Medicine at 718-920-6674 ext. 231.

The “Conflict of Interest Disclosure Policy” of Albert Einstein College of Medicine requires that faculty participating in any CME activity disclose to the audience any relationship(s) with a pharmaceutical or equipment company. Any presenter whose disclosed relationships prove to create a conflict of interest with regard to their contribution to the activity, or who refuses to provide all their conflict-of-interest information, will not be permitted to present.

Michael N. Oxman, MD, is National Chairman of VA Cooperative Study #403: “The Shingles Prevention Study” and its substudies, which has been supported, in part, by grants from Merck & Co., Inc., to the VA Cooperative Studies Program, the Veterans Medical Research Foundation, San Diego, and the VA Connecticut Research and Education Foundation.

Kenneth E. Schmader, MD, has received grant/research support from Merck and Co., Inc.  

Ira M. Leviton, MD, FACP, has served on advisory boards and is a member of the speakers' bureau for Astellas Pharmaceuticals, Cubist, Pfizer Inc., and Wyeth.

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. Albert Einstein College of Medicine, Haymarket Medical Education LP, and Merck & Co., Inc., do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of Albert Einstein College of Medicine, Haymarket Medical Education LP, and Merck & Co., Inc. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development.  The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of the patients' conditions, review of any applicable manufacturers' product information, and comparison with recommendations of recognized authorities.

The information in this program is provided to medical professionals for information purposes only.

The material contained herein is intended to be a faithful representation of the live presentations to the extent reasonable. The authors/presenters are exclusively responsible for the respective content.  Accordingly, no responsibility is assumed by Merck & Co., Inc., Haymarket Medical Education LP, or Scientia MedMedia LLC, for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise; or from any use of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without medically appropriate (1) evaluation of (a) their patients' conditions and (b) indications and possible contraindications, warnings, and adverse effects or dangers in use; (2) review of any applicable manufacturers' prescribing and other product information; (3) comparison with recommendations of recognized authorities; and (4) independent verification of diagnostic methods, therapeutic methods, results of research, and measurement of medical doses.