Good news on the adult vaccination front: A new and superior shingles vaccine, Shingrix, manufactured by Glaxo SmithKline, has now been approved. Shingrix is more than 90% effective, as opposed to the around 50% effectiveness of the earlier version, Merck’s Zostavax. Also unlike Zostavax, the effectiveness of Shingrix doesn’t drop off dramatically among older individuals.
A few weeks ago I posted an essay about my sister’s experience with a relatively mild case of shingles, which I correctly attributed to her having been vaccinated with Zostavax. The operative word here is “relatively.” When I notified my family about the new and improved vaccine, her immediate response was, “Since studies have shown you can get shingles more than once, I will check it out. Having been there, [I advise you to] do what you can to avoid getting shingles!”
Because, as my sister noted, having shingles doesn't protect you from getting it again, the CDC is recommending that you have the Shingrix shot even if you've already had shingles. And even if you've already been inoculated with Zostavax, the CDC is recommending repeat vaccination with Shingrix.
A few comments. First, two doses of Shingrix are required, 2-6 months apart, as opposed to just one of Zostavax. Second, the side effects are a little more common and severe than those of Zostavax, so time your shot to allow 2-3 days to recover from being a little feverish and achy, and don’t schedule it just before an important event. Third, it is a little pricier than its predecessor - $280 for the two shots. (Medicare will cover Shingrix under Part D, not under Part B like the flu vaccine, which may favor being vaccinated in a pharmacy rather than a doctor's office.) I hope these drawbacks don’t reduce uptake but fear they will, given the shockingly low participation in the Zostavax program.
One additional point: Shingrix is recommended for everyone fifty and over, not sixty and over like Zostavax.
Among the wedding festivities when my nephew got married in New York in late September was a walking tour of Central Park. The day was sunny and unseasonably warm, and our guide was knowledgeable and articulate. It had been years since any of us had been to Central Park, so we had a great time reacquainting ourselves with its charms.
When we stopped to admire Frederick Roth’s beloved statue of Balto the Siberian husky, my grandchildren, like many before them, clambered astride the sculpture. Our guide took the occasion to point out how shiny Balto’s bronze back was from the buffing it received from all those youthful bottoms. The inscription on the statue reads, "Dedicated to the indomitable spirit of the sled dogs that relayed antitoxin 600 miles over rough ice, across treacherous waters, through arctic blizzards, from Nenana to the relief of stricken Nome.”
Gradually, with a little help from our guide, the story of the legendary Balto, Alaska’s best-known public health hero, bubbled up from the dark recesses of my memory.
In December of 1924, Dr. Curtis Welch, the only physician in the tiny town of Nome, Alaska (pop. 1,500, of whom about two thirds were settlers, the rest Native Alaskans), diagnosed first one and then several cases of diphtheria. Although a diphtheria vaccine had recently been developed, it was not yet in widespread use even in urban medical centers, much less in an Alaskan village just south of the Arctic Circle. The most widely used treatment was an antitoxin serum that could not eliminate an already established case of diphtheria but could neutralize any circulating toxins and thus greatly attenuate the disease.
Several months earlier, Dr. Welch had placed an order for serum to replace the expired lot he had on hand, but it never arrived. By now the harbor was icebound and the last ship of the year had left port. Nome’s main link with the outside world was via dogsled along the Iditarod Trail.
Realizing an epidemic was imminent, Dr. Welch appealed for help in obtaining an emergency supply of serum. Some brave bush pilots volunteered to make the flight to Nome, but the Board of Health feared that a not-unlikely crash would result in the loss of plane, pilot, and serum. In the end, it was decided to make the delivery by dogsled relay along the Iditarod Trail. The serum was perishable, so speed was of the essence.
There were twenty legs of the relay, twenty mushers, and twenty teams of dogs. The first musher started out on January 27, 1925; the last dogsled, with Balto in the lead, arrived in Nome on February 2, 1825. There has been much dispute among dogsled enthusiasts about whether Balto truly deserved the credit he subsequently received; he wasn’t necessarily the strongest nor the smartest nor the most capable sled dog, but he was the lead dog when the serum arrived, so he came to symbolize the spectacular success of the mission.
It has all the elements of a great story: A canine hero, struggling against great odds, saves the day, and is forever after memorialized in an annual event that everyone knows and loves, the Iditarod Trail Sled Dog Race. Without treatment, up to 10% of diphtheria victims die, with much higher rates among children and older adults. If it weren’t for the courageous mushers and their rugged dogs, pressing on under blizzard and white-out conditions, many hundreds of children would have died of diphtheria in the greater Nome area. Instead, only a handful of children are known to have lost their lives (though it is likely that at least 100 additional deaths - of children who failed to receive he serum - went unreported in the Native Alaskan community).
At the same time, it’s a testimonial to the superiority of vaccine over serum, of prevention over cure, of measures that can be taken calmly under non-emergent conditions rather than only after exposure. When children and adults can be systematically and routinely inoculated, there are no frantic decisions about how to proceed, no potential victims overlooked, no lives (human or canine) to be risked under highly unpredictable conditions.
In the Great Race of Mercy, everything went right, which is what shapes the narrative arc of the Balto story. Around the world thousands of children for whom everything did not go right die annually of diphtheria. No races are named after them, no dogs are lionized. This should never happen.