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Why don’t we vaccinate against chickenpox?

A friend asked me the other day, “why don’t we vaccinate against chickenpox?”. It’s a fair question. Currently in the UK we vaccinate every child against measles, mumps, rubella, diphtheria, pertussis, meningitis, pneomococcal disease, and others. Chickenpox is usually a mild illness (I had it three times, shut up, that’s totally normal), but just like those other infections it can sometimes be very serious. A tiny proportion of people with chickenpox develop encephalitis or meningitis, and recently a young boy very sadly died.

So, why don’t we vaccinate? The answer isn’t straightforward, and to understand it properly you need to know a bit about chickenpox and shingles.

Chickenpox is caused by a virus called varicella zoster. The initial infection causes chickenpox, which involves the itchy spots, blisters and general poorly-ness that we all know. Generally the acute infection clears within a few days and the spots and blisters clear up within a week or two. But what about the virus? Sadly, it doesn’t leave the body when the rash does.

Instead, virus particles lie dormant in nerve ganglia, which are nerve roots found in or near to the spinal column. The virus sleeps happily there, doing absolutely no harm for many years, and kept in check by the immunity that we develop after fighting off the initial infection. Most people then go on to meet other people with chickenpox. Maybe your kids get it, or people you meet at work, or socially. However it happens, every time you encounter the virus your immune system gets a little refresher course in how to deal with it effectively, and those viruses sleeping in your nerve ganglia are effectively kept snoozing for a while longer.

But (oh, that but) eventually the viruses wake up. They multiply, as viruses do, and spread up the infected nerve until they reach the surface and cause symptoms. This new illness is called shingles (or sometimes herpes zoster); it mainly affects adults, and it ranges from mild irritation to debilitatingly painful. Every nerve ganglion serves a distinct area of our bodies, so the area served by the infected nerve develops a painful, itchy, blistery rash. That rash can cause chickenpox in people who have never been exposed, because it’s full of newly-hatched virus particles. Commonly the rash appears on the torso, but it can also affect the face, causing embarrassment as well as pain and discomfort. It an even affect the eyes, causing ophthalmic shingles. Usually people also feel generally unwell, so alongside the rash there’s headache, fever, and generalised yuck. When we bear in mind that shingles often occurs in people who are already run down – perhaps due to old age, stress, other infections such as HIV, or chemotherapy – we realise that this is potentially a pretty serious condition.

Usually that’s that; the rash clears up and everything’s fine. But sometimes even when the bout of shingles has resolved people can be left with a condition called post-herpetic neuralgia, which simply means pain caused by herpes zoster. NHS Choices sums this up well – it’s a painful, burning, itchy, throbbing or stabbing sensation. It can last for months and it can be absolutely debilitating for an unlucky few. Other complications are similar to those of chickenpox – pneumonia, encephalitis, and meningitis. When you consider that the people most likely to get shingles are already likely to be vulnerable, that’s pretty concerning.

So that’s all very interesting, but how does it relate to chickenpox vaccines? As alluded to right at the start of this post, regular exposure to people with chickenpox acts as a kind of refresher course to the immune system. It reminds our immune mechanisms that varicella zoster virus exists, and gives us the tools to fight it off quickly if it pops up – either in the environment or in our own nerve ganglia. If we started to vaccinate against chickenpox – as many parts of the world do, incidentally – entire generations of adults would lose this immunity boost, because our children, grandchildren and peers simply would not be catching chickenpox.

We would drastically reduce childhood chickenpox, but the price would be up to 50 years of more frequent cases of shingles. This rise has been clearly seen in the USA, where the introduction of routine chickenpox vaccination has led to roughly a two-thirds increase in the rate of shingles among veterans.

Is that a price worth paying? That’s not a simple question to answer. The last time they looked at the question in 2010, the UK’s Joint Committee on Vaccination and Immunisation thought that it wasn’t. The fact is that these decisions are never easy, and they have to be made to benefit the population as a whole, and not individuals. Is the decision not to vaccinate against chickenpox in the UK the right one? That’s not really answerable. But is it the best possible interpretation of the evidence we currently have? I think it probably is.

Homeopathic Harms Vol 1: Medicalisation (Cross-posted from A Healthy Dose of Skepticism)

As discussed in my previous, brief post, this is part of a series of blog posts written by my and my good friend HJo.  This piece is cross-posted from her blog A Healthy Dose of Skepticism; look out for more to follow soon!

In February 2013, my friend Nancy and I delivered a Newcastle Skeptics in the Pub talk entitled Homeopathy: Where’s The Harm? As a follow up to this, we’ve decided to write a series of blog posts about a number of points we covered in the talk. Here is the first:  

Doctor’s appointments: often you feel like you’re in and out before you know it, and they can’t get you out the door quick enough. They have a target number of minutes to spend with each patient, and sometimes you can feel like they don’t have as much time as you’d like to discuss all the things you want to with them.

There is, then, one aspect of homeopathic practice which can be superior to that of conventional medicine: the consultation. A homeopath might spend an hour or more assessing each individual, not just asking about particular symptoms but about their personality as well, how they think and feel about the world. I’ve never been to see a homeopath, but I’d imagine this is really valuable to a patient, particularly those with minor mental health complaints. I know myself that when I’ve been to see a good GP who I feel has really listened to me, I leave feeling a bit better already.

I suspect that the consultation itself may be part of what provides benefit to patients, rather than the sugar pills that are given out at the end of it. I’m not aware of any evidence that compared individualised homeopathic treatment to the OTC stuff though, which would be the only way to tease out and quantify any benefit from the consultation.

So what’s the problem here? If a consultation with someone who appears to listen to you and care makes you feel better, where’s the harm in that? The sort of subtle, indirect harms that we’ll be discussing in this series of posts are often theoretical and would be very, very difficult to assess via hard, clinical evidence, so you’ll have to bear with me while I discuss them with you and see if they make sense at the end of it. Consider the following story:

Imagine I’m quite an anxious person (in actual fact I am, so it doesn’t take that much imagining to those who know me). Imagine I’m particularly anxious at the moment because I maybe have a public speaking event (something like Skeptics In The Pub, say!) to deliver in a few week’s time. I might be finding it hard to sleep, I find I’m worrying about it quite often, and getting some physical symptoms- my heart is beating quite fast at times, say, and my stomach hurts at times, but it’s nothing too serious.

I go to visit a homeopath (admittedly, this would be an unlikely thing to do if I was actually talking about myself) who takes time to discuss with me my problems. I get on well with them, and feel like they are really listening to me. During the discussion, I find that vocalising my anxieties helps me to rationalise them and my fears are allayed somewhat. Just the act of talking about it makes me feel better- in other words, the homeopath is delivering a talking therapy service to me. By the end of the consultation, I’m already feeling more in control of my anxieties, yet I’m still given some tablets to take home, and I dutifully follow the instructions I’m given.

As I’ve discussed elsewhere, there is a stigma about mental health issues. This also, unfortunately, extends to talking therapies too. Its quite likely that some people would be happier to declare “I’m seeing a homeopath” than “I’m seeing a counsellor” in front of their friends or acquaintances. The handing over of the sugar pills at the end of the consultation will no doubt suggest the talking bit is more “justified”, and they can convince themselves that they’re not mad, or the sort of weak person who would have to resort to a talking therapy. And thus, the stigma is reinforced. Talking therapies shouldn’t be something to be ashamed of. You don’t need some inert sugar pills to justify and hide the fact that, now and then, you just need to be able to talk to someone about your problems or feelings.

There are wider issues with this kind of thing too. The visit to the homeopath has made me feel better. I’ve been to see someone, left with some pills in my hand, and I’ve improved, reinforcing the fact that I feel better when given something to take. Let’s say that in the next few months, I feel a bit rubbish because I’ve had a bit of a cold and I’m left with a cough that’s been there for a couple of weeks. I go to see my Dr, who tells me that my chest is clear, and the cough should clear up of its own accord. However, I’ve expected to get something out of the visit- I don’t want to leave the surgery with no pills in my hand, as I know that last time I left a consultation about my health I was given pills at the end of it and I felt better. It’s left to the Dr to explain to me that I don’t need antibiotics, and this can be a notoriously difficult thing to do. Some Drs might relent and give me a prescription for an antibiotic, contributing to the catastrophic situation we’re in now with antibiotic resistance. If the Dr doesn’t give me a prescription, I’m left with a bad taste in my mouth and a bit of mistrust in the conventional health care system. ‘Next time I’m feeling ill’, I think, ‘I’ll go back to that homeopath. They take me seriously because they gave me pills’.

And so the cycle goes on….

H Jo