Identifying the Optimal Age for Herpes Zoster Vaccination - Yichang City, Hubei Province, China, 2017-2019

What is already known about this topic?

Herpes zoster (shingles) is a common skin condition in older adults, which usually presents as a painful rash with blisters. Vaccination is the most effective method to prevent shingles. However, there is not sufficient population-based epidemiological data in China to optimize the timing of zoster vaccination.

What is added by this report?

Clustering analyses of population-wide epidemiological data from the Healthcare Big Data Platform in Yichang, China showed that the average annual zoster incidence is the highest among people 55 years or older, at 10 cases per thousand persons per year, making this age group the optimal target population for vaccination. Incidence was lower but increased with age among younger adults, 28-54 years old.

What are the implications for public health practice?

With limited vaccination resources, zoster vaccinations should be targeted at adults 55 years or older who are at the greatest risk for shingles. Research should be conducted to understand the risk of shingles among young and middle-aged adults and identify triggers of shingles: potentially leading to preventive measures.

Sex Differences in the Role of Neurexin 3α in Zoster Associated Pain

Varicella zoster virus (VZV) induces orofacial pain and female rats show greater pain than male rats. During the proestrus phase of the estrous cycle the VZV induce pain response is attenuated in female rats. A screen of gene expression changes in diestrus and proestrus female rats indicated neurexin 3α (Nrxn3α) was elevated in the central amygdala of proestrus rats vs. diestrus rats. GABAergic neurons descend from the central amygdala to the lateral parabrachial region and Nrxn3α is important for presynaptic γ-Aminobutyric acid (GABA) release. Thus, we hypothesized that the reduced orofacial pain in male rats and proestrus female rats is the result of increased Nrxn3α within the central amygdala that increases GABA release from axon terminals within the parabrachial and inhibits ascending pain signals. To test this hypothesis Nrxn3 α expression was knocked-down by infusing shRNA constructs in the central amygdala. Then GABA release in the parabrachial was quantitated concomitant with measuring the pain response. Results revealed that knockdown of Nrxn3α expression significantly increases the pain response in both male rats and proestrus female rats vs. diestrus rats. GABA release was significantly reduced in the parabrachial of male and proestrus female rats after Nrxn3α knockdown. Neuronal activity of excitatory neurons was significantly inhibited in the parabrachial after Nrxn3α knockdown. These results are consistent with the idea that Nrxn3 within the central amygdala controls VZV associated pain by regulating GABA release in the lateral parabrachial that then modulates ascending orofacial pain signals.

Palmitoylethanolamide (PEA) in the treatment of neuropathic pain: a case study

BACKGROUND

Neuropathic pain is a condition caused by a lesion or disease of the somatosensory nervous system. It may present as debilitating pain with a sensation of burning and electric-like symptoms and is often difficult to manage effectively. Although pharmacological medications are the first line of treatment, multidisciplinary teams are sometimes required to provide appropriate treatment to improve quality of life and overall wellbeing.

AIM

The aim of this study is to present a case of post herpetic neuralgia relieved successfully by the compound palmitoylethanolamide (PEA) - a natural alternative to pharmacological pain relief.

METHODS

We present the case of a 67 year-old male with ongoing post-herpetic neuralgia, over a 3-year period, as a result of complications from shingles (herpes zoster). Previous studies on the relationship between PEA and neuropathy were reviewed, with an attempt to discuss the possible underlying mechanism of PEA on neuropathic pain.

RESULTS

PEA demonstrated effective pain relief within 48 hours at an administered daily dose of 900 mg (10 mg/kg).

CONCLUSIONS

PEA may offer a valid nutraceutical treatment for practitioners.

Knowledge, attitudes, and practices of the United Arab Emirates population towards Herpes Zoster vaccination: A cross-sectional study

Herpes Zoster is a viral infection that occurs due to reactivation of the Varicella Zoster virus. A vaccine has been approved for adults aged 50 and above for the prevention of Herpes Zoster and its complications. This study aims to assess the at-risk population’s awareness of the disease and its vaccine, and attitudes and practices toward the vaccine. A quantitative, observational, cross-sectional study was conducted among 420 adults above the age of 50. Non-probability, convenience sampling was used to select participants from public venues. SPSS-25 was used to analyze the data. 64.3% (n = 270) of participants heard of Herpes Zoster. 78.3% (n = 329) did not recognize the link between chickenpox and Herpes Zoster. Multiple linear regression showed that being female, Arab expatriate, or healthcare professional were the only positive predictors of Herpes Zoster knowledge. 14.8% (n = 62) heard of Herpes Zoster vaccine but 96.7% (n = 406) had not taken it. Participants with chronic diseases were 2.064 times more likely to hear about the vaccine than healthy participants (p = 0.026). Multiple linear regression showed that being a healthcare professional was the only significant predictor of Herpes Zoster vaccine knowledge. 28.1% (n = 118) were not willing to take optional vaccines. Those reluctant to take optional vaccines were 26.023 times more likely to take them if recommended by a healthcare professional (p < 0.001). Attitudes toward Herpes Zoster vaccine were generally positive; however, due to lack of knowledge, poor practices were observed. Nationwide campaigns aimed toward at-risk groups can raise awareness on Herpes Zoster and its vaccine, subsequently improving Herpes Zoster vaccination rate.

Cellular Immune Response after Vaccination with an Adjuvanted, Recombinant Zoster Vaccine in Allogeneic Hematopoietic Stem Cell Transplant Recipients

Hematopoietic stem cell transplant (HSCT) recipients have a high risk of developing primary varicella-zoster virus (VZV) infection and reactivation. VZV vaccination may prevent infection and reactivation. In the current study, recipients of allogeneic HSCT (34 females, 45 males) were vaccinated with adjuvanted, recombinant zoster vaccine Shingrix™, which contains the VZV glycoprotein E. Cellular immunity against various VZV antigens was analyzed by interferon-gamma ELISpot. Peripheral blood mononuclear cells (PBMC) of recipients with versus without prior shingles (n = 36 and n = 43, respectively) showed approximately twofold higher VZV-specific responses prior to and post vaccination. After the first and second vaccination, ELISpot responses towards the glycoprotein E were significantly higher in males versus females (median of spots increment 18 versus 1 and 17 versus 4, respectively, p ≤ 0.02 each). Multivariate analysis showed that shingles and sex both impacts significantly on VZV immunity. Whereas vaccination-induced changes could hardly be detected after stimulation with a whole VZV antigen, there was a significant increase in responses towards glycoprotein E after vaccination (p < 0.005). These data indicate that vaccination with Shingrix™ augmented cellular, VZV-specific immunity in HSCT recipients. Shingles and male sex could both be identified as factors leading to increased immunity.

Characteristics of herpes zoster infection in patients with COVID-19: a systematic scoping review

Background

Although there is literature reporting correlations between varicella zoster virus (VZV) infections and COVID‐19, insufficient evidence exists in this regard. This scoping review aims to identify the existing evidence regarding clinical characteristics of primary VZV infection or reactivation in COVID‐19.

Methods

Following the PRISMA Extension for Scoping Reviews, MEDLINE and EMBASE were searched for all peer‐reviewed articles with relevant keywords including “Zoster,” “Herpes,” and “COVID‐19” from their inception to November 20, 2021.

Results

A total of 19 articles with three observational studies and 16 case reports or series were included. Primary VZV infections or reactivation were observed in 25 patients. Forty‐eight percent of the patients had disseminated VZV infection. The median time of VZV‐related rash after the onset of respiratory symptoms was 7.0 days (interquartile range: 0–18.8). Those with COVID‐19 and primary VZV infection or reactivation had low lymphocyte counts with a median of 0.67 × 10³/μl.

Conclusion

This scoping review identified uncertainty and a lack of strong evidence to see the association between primary VZV infection or reactivation and COVID‐19. However, those with COVID‐19 may be more likely to have disseminated VZV, which poses an additional challenge from an infection prevention standpoint. Future studies are warranted to determine the association between primary VZV infection or reactivation and long‐term consequences related to COVID‐19.

Real-world evidence from over one-million COVID-19 vaccinations is consistent with reactivation of the varicella-zoster virus

BACKGROUND

Reactivation of the varicella-zoster virus (VZV), which causes herpes zoster (HZ, synonym: shingles) in humans, can be a rare adverse reaction to vaccines. Recently, reports of cases after COVID-19 vaccination have arisen.

OBJECTIVES

The aim of this study was to assess if the frequency of HZ is found to increase after COVID-19 vaccination in a large cohort, based on real-world data. As a hypothesis, the incidence of HZ was assumed to be significantly higher in subjects who received a COVID-19 vaccine (Cohort I) versus unvaccinated individuals (Cohort II).

METHODS

Initial cohorts of 1,095,086 vaccinated and 16,966,018 unvaccinated patients were retrieved from the TriNetX database, and were matched on age and gender in order to mitigate confounder bias.

RESULTS

After matching, each cohort accounted for 1,095,086 patients. For the vaccinated group (Cohort I), 2,204 subjects developed HZ within 60 days of COVID-19 vaccination, while among Cohort II, 1,223 patients were diagnosed with HZ within 60 days after having visited the clinic for any other reason (i.e., not vaccination). The risk of developing shingles was calculated as 0.20% and 0.11% for cohort I and cohort II, respectively. The difference was statistically highly significant (p < 0.0001; log-rank test). The risk ratio and odds ratio were 1.802 (95% confidence interval [CI] = 1.680; 1.932) and 1.804 (95% CI = 1.682; 1.934).

CONCLUSIONS

Consistent with the hypothesis, a higher incidence of HZ was statistically detectable post-COVID-19 vaccine. Accordingly, eruption of HZ may be a rare adverse drug reaction to COVID-19 vaccines. Even though the molecular basis of VZV reactivation remains murky, temporary compromising of VZV-specific T cell-mediated immunity may play a mechanistic role in post-vaccination pathogenesis of HZ. Note that VZV reactivation is a well-established phenomenon both with infections and with other vaccines (i.e., this adverse event is not COVID-specific).

Global herpes zoster incidence, burden of disease, and vaccine availability: a narrative review

Herpes zoster (HZ) is a neurocutaneous disease that causes significant morbidity worldwide. The disease is caused by the reactivation of the varicella-zoster virus (VZV), which leads to the development of a painful, vesicular rash and can cause complications such as post-herpetic neuralgia and vision loss. Globally, the incidence of HZ is increasing, and it incurs billions in cost annually to the healthcare system and to society through loss of productivity. With the advent of effective vaccines such as the live attenuated vaccine, Zostavax®, in 2006, and more recently the adjuvant recombinant subunit vaccine, Shingrix®, in 2017, HZ has become a preventable disease. However, access to the vaccines remains mostly limited to countries with developed economies, such as the United States and Canada. Even among countries with developed economies that license the vaccine, few have implemented HZ vaccination into their national immunization schedules due to cost-effectiveness considerations. In this review, we discuss the currently available HZ vaccines, landscape of HZ vaccine guidelines, and economic burden of disease in countries with developed and developing economies, as well as barriers and considerations in HZ vaccine access on a global scale.

Multicenter Evaluation of the Simplexa VZV Direct Assay for Detection of Varicella-Zoster Virus in Cerebrospinal Fluid and Lesion-Swab Specimens

Varicella-zoster virus (VZV) is the etiologic agent of varicella (chickenpox) and herpes zoster (shingles) infections commonly involving skin, mucous membranes, and less frequently the central nervous system. Traditional methods for the laboratory diagnosis of these infections are time-consuming, labor-intensive, and often insensitive. As such, these tests are being replaced by more sensitive and rapid molecular methods. This study evaluated the performance of two different molecular assays, the Simplexa VZV Direct and Simplexa VZV Swab Direct, to detect VZV DNA in cerebrospinal fluid (CSF) and lesion-swab specimens, respectively. The Simplexa VZV Direct and Simplexa VZV Swab Direct assays were compared against individual composite reference methods that varied depending on the sample cohort examined. A total of 883 CSF and 452 cutaneous and mucocutaneous prospective, retrospective, and contrived specimens were evaluated in this multicenter study. The results of this study showed that the Simplexa assays demonstrated near perfect agreement (k = 0.98) compared to the composite reference methods for the detection of VZV in CSF and lesion swab specimens. A further comparison between the standard of care molecular assays employed at the site of specimen collection and the Simplexa assays demonstrated excellent agreement (k = 1.0). The Simplexa assays offer rapid and reliable alternatives for the detection of VZV in certain clinical specimens without the need for nucleic acid extraction.

Serial Thoracic Transforaminal Epidural Steroid Injections for Post-herpetic Neuralgia: A Case Report

The chronic neuropathic pain of post-herpetic neuralgia (PHN) often persists for months or years after the acute herpes zoster (shingles) episode, may be severe and intractable, and can severely impact the overall quality of life. Antivirals, analgesics, and nerve blocks can effectively shorten the course of shingles and may help to prevent PHN. Although vaccination effectively prevents shingles and PHN, current therapies may be ineffective, and pain management can be challenging when PHN occurs. A 78-year-old female with severe PHN pain in the right thoracolumbar spine, right flank, and right lower abdomen showed poor responses to treatment with amitriptyline, gabapentin, and oxycodone/acetaminophen. However, a series of three thoracic transforaminal epidural steroid injections (TFESIs) effectively treated the PHN and achieved near-complete pain resolution. TFESI can be considered an early and first-choice treatment for PHN, but several courses may be required to achieve adequate and prolonged symptom control.

Modeled impact of the COVID-19 pandemic and associated reduction in adult vaccinations on herpes zoster in the United States

Due to COVID-19, vaccinations dropped in 2020 and 2021. We estimated the impact of reduced recombinant zoster vaccine (RZV) use on herpes zoster (HZ) cases, complications, and quality-adjusted life-year (QALY) losses among older adults. Various scenarios were compared with Markov models using data from national sources, clinical trials, and literature. Missed series initiations were calculated based on RZV distributed doses. In 2020, 3.9 million RZV series initiations were missed, resulting in 31,945 HZ cases, 2,714 postherpetic neuralgia cases, and 610 lost QALYs. Scenarios further projected disease burden increases if individuals remain unvaccinated in 2021 or the same number of initiations are missed in 2021. Health professionals should emphasize the importance of vaccination against all preventable diseases during the COVID-19 era.

Reduced dementia incidence after varicella zoster vaccination in Wales 2013-2020

Introduction

Chronic infection with herpes viruses is a potential contributing factor to the development of dementia. The introduction of nationwide shingles (varicella zoster) vaccination in Wales might therefore be associated with reduced incident dementia.

Methods

We analyzed the association of shingles vaccination with incident dementia in Wales between 2013 and 2020 using retrospectively collected national health data.

Results

Vaccinated individuals were at reduced risk of dementia (adjusted hazard ratio: 0.72; 95% confidence interval: 0.69 to 0.75). The association was not modified by a reduction in shingles diagnosis and was stronger for vascular dementia than for Alzheimer's disease. Vaccination was also associated with a reduction in several other diseases and all-cause mortality.

Discussion

Our study shows a clear association of shingles vaccination with reduced dementia, consistent with other observational cohort studies. The association may reflect selection bias with people choosing to be vaccinated having a higher healthy life expectancy.

Organizing Pneumonia Following Recombinant Zoster Vaccination: A Rare Adverse Reaction

We describe a case of a severe but rare adverse reaction to recombinant varicella-zoster virus (VZV) vaccination: a 67-year-old female admitted with gradual onset of shortness of breath, hypoxia, and fever following VZV vaccination. The clinical picture and radiologic presentation mimicked COVID-19 pneumonia. However, repeated testing for COVID-19 by PCR was negative. A diagnosis of organizing pneumonia was made on transbronchial biopsies. The patient responded well to steroids and improved both clinically and radiographically. This case illustrates not only a rare and unreported complication from vaccination but also raises the awareness during the COVID-19 pandemic that other etiologies can mimic COVID-19 pneumonia. Physicians should be aware of other diagnoses that can mimic COVID-19 infection.

Risk of Guillain-Barré syndrome following herpes zoster, United States, 2010-2018

Epidemiologic data regarding the risk of Guillain-Barré syndrome (GBS) following herpes zoster (HZ) are limited. We conducted a self-controlled case series analysis using two large national data sources to evaluate the risk of GBS following HZ among U.S. adults. We analyzed medical claims from the IBM® MarketScan® Commercial Claims and Encounters (persons 18-64 years during 2010-2018) and Centers for Medicare and Medicaid Services Medicare (persons ≥65 years during 2014-2018) databases. HZ cases were defined as persons with an outpatient claim with a primary or secondary ICD-9 or ICD-10 diagnostic code for HZ. GBS cases were defined as persons with an inpatient claim with a principle diagnostic code for GBS and an associated procedural code. We compared the rates of GBS following HZ in the 1-42-day risk window versus primary (100-365-day) or secondary (43-99-day) control windows. We identified 489,516 persons 18-64 years of age and 650,229 persons ≥65 years of age with HZ, among whom 11 and 41, respectively, developed GBS 1-365 days following HZ. The risk of GBS following HZ was increased during the risk window as compared to the primary control window for both groups, with a rate ratio of 6.3 (95% CI, 1.8-21.9) for those 18-64 years and 4.1 (95% CI, 1.9-8.7) for those ≥65 years. This study provides new and methodologically rigorous epidemiologic support for an association between HZ and GBS, and useful context regarding the benefits versus potential risks of zoster vaccination.

Healing of Severe Herpes Zoster Ophthalmicus Within a Few Days: An Autobiographical Case Report

Herpes zoster (shingles) is caused by the herpes zoster virus and is characterized by pain and unilateral vesicular rash that typically affects one dermatome. Symptoms tend to resolve over 10-15 days. This case report describes the 75-year-old author’s herpes zoster ophthalmicus (HZO) accompanied by severe orbital edema. The upper eyelid and the proximal nasal area were also affected. The author felt an intermittent throbbing pain in more than three dermatomes including the frontal, orbital, temporal, and occipital/nuchal areas. Since the prodromal and erythematous phase started with atypical signs, conventional acyclovir treatment was administered only 96 hours after the appearance of the first symptoms. Acyclovir treatment was therefore complemented with the experimental viral superinfection therapy (SIT). Superinfection is a host-directed therapy, during which the non-pathogenic avian live-attenuated infectious bursal disease virus (IBDV) vaccine delivers its double-stranded RNA (dsRNA) cargo to host cells and activates their natural antiviral interferon (IFN) gene defense system from within. Most symptoms resolved within five days. Given the author's advanced age of 75 years, such speedy recovery is unlikely to be explained by the belated acyclovir treatment alone.

Shingles: a harbinger of chronic HIV infection

Early diagnosis and treatment are essential to reduce the risk of community transmission and morbidity and mortality of individuals infected with HIV. A 49-year-old woman presented with a painful, vesicular rash on the left side of her neck after being treated with valacyclovir for a separate perianal rash. She admitted recent weight loss and diffuse lymphadenopathy. She reported one family member with HIV but denied intravenous drug use or recently new sexual partners. Serum HIV-1 antibody screen was positive. Herpes zoster reactivation is associated with waning immunity in chronic HIV and should prompt testing. Delays in treatment impacts short-term and long-term prognosis for patients infected with HIV.

Increased Health Care Resource Utilization and Costs Associated with Herpes Zoster Among Patients Aged ≥50 Years with Chronic Obstructive Pulmonary Disease in the United States

Background

Patients with chronic obstructive pulmonary disease (COPD) are potentially at increased risk of herpes zoster (HZ). Little is known about the impact of an HZ episode on health care resource utilization (HRU) and costs among patients with COPD.

Methods

This retrospective cohort study of individuals aged ≥50 years in the United States (US) used administrative claims data from Optum's de-identified Clinformatics Data Mart Database for commercially insured and Medicare Advantage members (2013-2018). Two cohorts of patients with COPD, with HZ (COPD+/HZ+) and without HZ (COPD+/HZ-), were identified. All-cause and COPD-related HRU rates and costs (2018 US dollars) were compared between cohorts for up to 12 months of follow-up. Comparisons were controlled for baseline differences through propensity score adjustment.

Results

A total of 3415 COPD+/HZ+ and 35,360 COPD+/HZ- patients (mean ages 73.2 ± 9.0 and 72.4 ± 9.4 years, respectively) were identified. Patients in the COPD+/HZ+ versus COPD+/HZ- cohort had increased use of all-cause (adjusted incidence rate ratio [aIRR] 1.17; 95% confidence interval [CI] 1.14, 1.21) and COPD-related (aIRR 1.27; 95% CI 1.21, 1.34) medical services (both P<0.001) and higher mean total all-cause ($4140 versus $3749 per person per month [PPPM]; adjusted cost difference +$313 PPPM) and COPD-related ($1541 versus $1231 PPPM; +$152 PPPM) costs (both P<0.004) in the year after HZ.

Conclusions

HRU and cost burden is higher in patients with COPD with vs without HZ. These results could help to estimate the potential cost benefits of HZ vaccination among patients with COPD.

COVID-19 Rekindling Herpes Zoster in an Immunocompetent Patient

During the coronavirus 2019 (COVID-19) pandemic, sundry dermatological conditions related to COVID-19 pneumonia have been published. COVID-19 primarily affects the respiratory system, but secondarily it also affects the heart, kidney, brain, skin, spinal cord, etc. Herpes Zoster (HZ) is considerably important morbidity associated with COVID-19 pneumonia. Recrudescence of HZ occurs because of the latent varicella-zoster virus (VZV) predominantly because of the decline in cell-mediated immunity (CMI). Abating CMI is due to the increasing age, but could also occur if the patient is suffering from an immunosuppressive disease or is using immunosuppressive drugs. In our case, the patient had no lymphopenia unlike the other cases, yet still, he developed HZ. HZ is associated with post-herpetic neuralgia (PHN), HZ ophthalmicus (HZO), and cerebral arteritis increasing morbidity and mortality, especially in elderly people and those who are immunocompromised.

Biological basis of child health 13: structure and functions of the skin, and common children's skin conditions

This article, the 13th in a series on the biological basis of child health, focuses on the skin. The skin is the largest organ in the body and covers its whole outer surface, protecting it from external threats, assisting in retaining body fluids, eliminating waste products and regulating temperature. The skin also has a crucial role in wound healing and vitamin D synthesis. Skin conditions in children are often distressing for children and parents, and may significantly affect their everyday lives. This article explains how the skin develops in utero, describes the structure and functions of the skin, and explores the aetiology, manifestations and management of skin conditions commonly seen in children.

A practitioner's guide to the recombinant zoster vaccine: review of national vaccination recommendations

Introduction: The adjuvanted recombinant zoster vaccine (RZV) is currently licensed in over 30 countries for the prevention of herpes zoster (HZ) in adults aged ≥50 years. We conducted a review of available national guidelines or recommendations on RZV use to identify the similarities and differences and highlight any potential gaps.Areas covered: National recommendations from ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the UK and the USA) are summarized under the following seven topics: HZ vaccine preference, age group recommendations, considerations prior to vaccination, dose schedule, co-administration with other vaccines, vaccination of special populations, and vaccine safety profile. In seven of these countries, RZV is the preferred or the only recommended HZ vaccine. There were some differences in age group recommendations, reflecting evaluations dependent on public funding. There were also differences with respect to use in immunocompromised and other special populations.Expert opinion: The high efficacy and anticipated public health impact of RZV led to expanded national recommendations for RZV vaccination compared to previous HZ recommendation in many countries. Possible areas that could be considered in future revisions of national recommendations, including use in immunocompromised adults ≥18 years, are also highlighted.PLAIN LANGUAGE SUMMARY:The varicella-zoster virus causes chickenpox, usually in childhood. After the chickenpox episode, the virus remains in the body in a latent state and can reactivate later in life, causing herpes zoster, or shingles. Adults over 50 years of age or those who have a weakened immune system are more vulnerable to developing herpes zoster. Herpes zoster appears as a painful localized skin rash. While live attenuated vaccines against herpes zoster have existed for many years, a recombinant vaccine against herpes zoster (RZV) has recently become available in several countries. Guidelines issued by national health authorities or vaccination committees provide healthcare professionals with information on practical aspects of vaccination. However, given the novelty of the RZV vaccine, we identified such guidelines in only ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the United Kingdom, and the United States of America). We summarized these national RZV recommendations, focusing on herpes zoster vaccine preference, the age at which RZV is recommended, considerations before vaccination, vaccination schedule, the possibility of administering RZV together with other vaccines, vaccinating vulnerable populations and the safety of RZV. While national recommendations varied, most guidelines indicate that RZV is the preferred herpes zoster vaccine due to its high and persistent efficacy and as it can be administered to vulnerable populations who are at increased risk of herpes zoster and its complications. Recommendations have noted that side effects are common with RZV, however, most are of mild-moderate intensity and temporary (see also Figure 1).

An unusual presentation to the burn' unit - a cautionary tale

We report a case of a 34-year old female with systemic lupus erythematosus (SLE) and lupus nephritis who was referred to the regional burns service with a suspected contact burn to the left flank and hypogastrium from a hot water bottle. The patient had been applying a hot-water bottle to the area at night for pain relief and after 3-days she noticed a localised area of erythema which became larger and began to blister over a period of 5-days. The blistered areas were erythematous and wet, however the capillary refill time was sluggish. The lesion was initially diagnosed and treated as a superficial partial thickness burn that had developed secondary to prolonged contact with a hot water bottle. However, due to the history of immunosuppression as well as elements of the lesion being unusual for a burn, we consequently diagnosed this as herpes zoster infection. This case highlights the importance of always thinking of alternative diagnoses. There are several cases in the literature where shingles has been dangerously misdiagnosed, furthermore leading to patients being mistakenly treated and even operated on. In the early stages, abdominal shingles may present very similarly to superficial partial thickness burns, both with neuropathic pain, erythema and blistering. It is important for the burns surgeon to be aware of this diagnosis as a differential in atypical presentations, and to pay particular attention to the timeline of events is the key to diagnosis.

Potential public health impact of the adjuvanted recombinant zoster vaccine among people aged 50 years and older in Beijing

Herpes zoster (HZ) is a painful, unilateral rash which occurs upon reactivation of latent varicella zoster virus due to age-related immunity decline or immuno-suppression. In 2019, the recombinant zoster vaccine (RZV) was the first vaccine to be approved in China for HZ prevention. This study aimed to estimate the potential public health impact of RZV vaccination, compared with the status quo of no vaccination, in individuals ≥50 years of age (YOA) in Beijing, by adapting the published ZOster ecoNomic Analysis (ZONA) model. We considered 5% and 50% vaccination coverage for the private market (near-term post-launch) and mass vaccination (long-term) settings respectively. In the base-case analysis of both market settings, second-dose compliance was set to 80%. Coverage and second-dose compliance rates were varied under scenario and sensitivity analyses. In the base case, mass vaccination with RZV was estimated to prevent 435,681 HZ cases, 51,558 postherpetic neuralgia (PHN) cases, and 15,703 cases of other HZ-related complications in the overall ≥50 YOA cohort over their remaining lifetime, compared with no vaccination. Under the same base-case scenario, 14,247 hospitalizations and 1,031,387 outpatient visits could be avoided. The 50-59 YOA cohort had the highest contributions to the overall reduction in HZ cases, its complications and related healthcare resource utilization. Results were robust under numerous scenario and sensitivity analyses. This analysis demonstrates the potential of RZV vaccination to substantially reduce the public health burden of HZ among individuals ≥50 YOA, and may inform appropriate vaccination strategies for HZ prevention, particularly in urban settings within China.