I don’t like to be preachy, but it bugs the everloving crap-ola out of me when people throw comments out there that are completely irrational and obviously untrue. This kind of thing tends to be followed with assertions that the [insert evil body of power here] is involved in a plot to undermine [insert way of life, liberties, food sources, etc. here]. I agree completely that there are dysfunctional and manipulative evil bodies of power out there. All I’m asking is that you vet your information before you start pointing the finger. The impetus for today’s blog is:
“It’s a real shame, there is a huge rise in Shingles and PHN as a result of the chicken pox vaccine. Since children aren’t getting the disease anymore, it’s striking adults in the form of shingles as hosts.
Has anyone else noticed this epidemic in their practice?”
What makes me most sad about this assertion is that the author probably believes it is true. She read that article, knowing what she knows. But she didn’t think about what she doesn’t know that she doesn’t know: she therefore couldn’t think about the implications or assertions of the article critically. Even worse, she passed along the information as though it is true.
I think that most people in the healthcare industry are interested in helping others. You wouldn’t put up with all the hurdles and logistics and pain of training if you weren’t on some level an idealist. (If you’re smart and more interested in making money, you go into tech or marketing–I just don’t buy that doctors go into the field for the $. There are too many other options that are easier ways to get rich. But that is another post.) What I want to talk about today is that one of the most difficult issues with being a healthcare provider is the information that we don’t know we don’t know.
There are a lot of things that I know that I know: how to drive a car, for example. There are a lot of things that I know that I don’t know: how to drive a rocket ship to the moon.
In medicine in particular, it seems to me that things get more and more and more complex. Going to graduate school and doing research on a subtype of 1 receptor involved in angiogenesis taught me that: I learned about it for over 2 years and still felt like I was scratching the surface.
We cannot possibly be aware of all that we don’t know we don’t know. This situation becomes, in my opinion, the source of malpractice— which I believe is mostly unintentional. I don’t know of any doctor, acupuncturist, chiropractor, etc. who said on their application “I want to hurt people.” The problem, at least in part, is in limiting the scope of one’s knowledge and disseminating information based only on what you know that you know. Unless we look it up, we will not learn. If we don’t learn, we get behind very quickly and then we pass out information to patients that is, frankly, incorrect and often hurtful. If we further base our care on that information, this is malpractice—causing harm to patients. The law (and my patients) doesn’t care when I graduated from medical school: it is part of my job description to keep up. Beyond what the law says, I feel that it is my moral and ethical obligation to double-check what I am doing. It is hubris to think that I know what I know simply because I learned about it 10 years ago. I want to learn about my blind side: what I don’t know that I don’t know.
So in an effort to try to explain herpes viruses, epidemics, and basic immunology, I constructed this response. Perhaps others will find it helpful. Maybe someone will correct me and show me what I don’t know that I don’t know. I welcome it. I’m still learning.
(By all means continue reading if you’re interested, but this is the immunology part and you might not be so into it.)
Varicella zoster virus (VZV,), one of the herpetic viruses and the virus that causes BOTH chicken pox and shingles, works like this. After it has caused chicken pox, it gets into the dorsal root ganglion (collection of nerve cell bodies) of the spinal cord and resides there dormant. When it is activated, usually by stress, it will irritate the nerves in that ganglion: first it causes burning pain along the dermatome served by that ganglion, and then the characteristic herpetic lesions appear on the skin. Post-herpetic neuralgia is very concerning–and can be quite debilitating–because the nerves from that ganglion(s) can become permanently irritated, resulting in chronic pain. Remember that the dorsal root is the sensory root: this is why patients have pain as a symptom rather than motor dysfunction and why the pain is most commonly along a cutaneous distribution rather than at a deeper level.
The article you are citing makes it sound as though NOT getting chicken pox increases your chances of getting shingles. Actually, GETTING chicken pox is a SURE way to increase your chances of getting shingles. The body cannot clear VZV: in EVERYONE the virus resides in the dorsal root ganglion. So if you had chicken pox as a child, you have the virus already in your system with the potential to develop shingles. If you have received a vaccine, you have acquired immunity (more on this below) to the VZV without the risk of shingles because you are able to preemptively ward off an attack of active VZV when exposed.
The fact that herpetic viruses are difficult/impossible for the body to clear is demonstrated in most, if not all, of the herpetic viruses (recent literature is demonstrating, for example, that herpes viruses may be a significant part of the etiology of Alzheimer’s–they are finding clusters of herpes in the areas of the beta amyloid plaques). You get cold sores over and over again, you get genital outbreaks over and over again, etc. because the body cannot clear herpes viruses. Viruses, by definition, live inside of other cells: they depend on cell mechanisms in order to replicate. Herpes viruses infect nerves, and the immune system is less adept at attacking the nerves in the spinal cord because it has the added issue of getting into the blood brain barrier. Further, the cells that are best suited to deal with viruses, the T killer or cytotoxic T cells, would be commanding the infected nerve cells to commit apoptosis (cell suicide). This would lead to permanent nerve damage: nerves are not able to repair themselves the way that other tissues can. When they are cut, sometimes they can reconstruct their “pathway” to the target tissues by following the sheath that formerly surrounded their axon, but when they are told to commit apoptosis, the entire cell, including the soma/cell “brain” dies. There is nothing left to follow the neurolemmic sheath. But I digress…
An epidemic is a situation in which the numbers (incidence) of a disease exceed expectations in a given period of time and in a particular population. Right now, nearly 1 in 3 adults will get shingles at some point in their lifetime. I am not sure how you arrived at the conclusion that this is an epidemic as these numbers have actually decreased in younger populations since the vaccine was introduced in 1995.
The vaccine was constructed not only as a way to prevent the severe cases of chicken pox from killing children–granted this is a minority, but it’s 100% for you if your child happens to be in that category and 100 out of 158,000 is not insignificant–but even more to prevent shingles and PHN. Since about 1 million people each year will get shingles, it doesn’t seem to me that this was an irrational reason to develop a vaccine. Merck is a drug company, yes. Drug companies do try to make money on drugs, yes. But it is not reasonable or accurate to say that Merck “created” this issue any more than Salk created polio.
Additionally, the article you cite states that vaccines provide only temporary immunity. This is patently false. Anytime you stimulate the adaptive immune system, T and B cells give you lifelong immunity. I’m not sure how the author thinks that establishing immunity happens, but the lab tests are based on looking for antigen-antibody interactions: you can’t have antibody-antigen interactions without stimulating the cells that make antibodies: the B cells. This absolutely means that the adaptive immune system has been stimulated.
We get booster vaccinations, like tetanus for example, because the immune system needs “reminders” to keep the levels of B and T cells HIGH in the system: the B and T cells are still there. They just need reminders to remain on higher alert—kind of like the “code orange” alert level in the airport. When we are chronically exposed to something, staph or strep for example, the body is constantly being stimulated to keep titers of B and T cells elevated to fight those infections. In the cases of pathogens that we see less frequently, the body does not waste energy maintaining a high number of those B and T cells. So statistically speaking, it is less likely that the antigen (the key) would interact in a meaningful way with the B or T cell designed to fit it (the lock).
The links in the article you cite actually link back to the same page and/or author in several instances. To me, this is not citation.
Here are some articles that are vetted and contain reliable information if you are interested.
All the best to you and your patient and I hope that this has been helpful.