Characteristics of patients with herpes zoster on presentation to practitioners in France

The impact of the varicella vaccination program on herpes zoster epidemiology in the United States: a review

Speculation that a universal varicella vaccination program might lead to an increase in herpes zoster (HZ) incidence has been supported by modeling studies that assume that exposure to varicella boosts immunity and protects against reactivation of varicella-zoster virus (VZV) as HZ. Such studies predict an increase in HZ incidence until the adult population becomes predominantly composed of individuals with vaccine-induced immunity who do not harbor wild-type VZV. In the United States, a varicella vaccination program was implemented in 1995. Since then, studies monitoring HZ incidence have shown inconsistent findings: 2 studies have shown no increase in overall incidence, whereas 1 study has shown an increase. Studies from Canada and the United Kingdom have shown increasing rates of HZ incidence in the absence of a varicella vaccination program. Data suggest that heretofore unidentified risk factors for HZ also are changing over time. Further studies are needed to identify these factors, to isolate possible additional effects from a varicella vaccination program. Untangling the contribution of these different factors on HZ epidemiology will be challenging.

The epidemiological, clinical, and pathological rationale for the herpes zoster vaccine

Worldwide, herpes zoster (HZ) affects millions of patients (particularly older adults) annually and causes significant suffering due to acute and chronic pain, or postherpetic neuralgia (PHN). The objective of this article is to explain the rationale for the HZ vaccine by summarizing data on the epidemiology of HZ in the immunocompetent host, with a focus on recent incidence and risk factor studies; to review information on the burden of HZ; and to discuss the challenges of lessening the morbidity of the disease. The incidence and severity of HZ and PHN are highest in older adults. Given the central nervous system damage caused by HZ, the difficulty of adequately treating HZ to prevent PHN, and the intractability of PHN, the advent of the HZ vaccine appears to be a crucial innovation for preventing HZ and PHN.

Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom

Recent information on epidemiology and management of herpes zoster (HZ) and post-herpetic neuralgia (PHN), a painful complication of HZ, is scarce. The objective of this study was to document the burden of HZ and PHN in the United Kingdom. This retrospective analysis of the UK General Practice Research Database aimed to estimate HZ incidence and proportion of HZ patients developing PHN and to assess management costs in immunocompetent individuals aged ⩾50 years. A cohort of 27 225 HZ patients was selected, corresponding to an incidence of 5·23/1000 person-years. Respectively 19·5% and 13·7% of patients developed PHN at least 1 and 3 months after HZ diagnosis. Mean direct cost was £103 per HZ patient and £341 and £397 per PHN episode (1- and 3-month definition respectively). Both HZ and PHN costs increased markedly with pain severity. This study confirms that HZ and PHN are frequent and costly diseases in the United Kingdom.

Prevention of herpes zoster and its painful and debilitating complications

BACKGROUND

Reactivation of latent varicella-zoster virus in sensory neurons to cause herpes zoster (shingles) is common in adults 50 years of age and older; half of adults experience an episode by age 85 years. Herpes zoster is attributable to the progressive decline in the VZV-specific cell-mediated immunity that occurs with aging or other conditions that cause immune compromise. Herpes zoster and complications, such as postherpetic neuralgia (PHN), can have a substantial negative impact on quality of life.

DISCUSSION

The incidence of herpes zoster and its associated morbidity is increasing worldwide as the population ages. Nevertheless, the severity and impact of this condition, and its painful sequelae, are often unrecognized. Many patients delay seeking medical attention, complicating both diagnosis and treatment. Prevention appears to be the best option. A new herpes zoster vaccine significantly reduced the burden of illness (61.1%), the incidence of PHN (66.5%), and the incidence of herpes zoster (51.3%) (p < 0.001). Vaccine tolerability was good, with minor local injection site reactions the most common adverse event.

CONCLUSIONS

Herpes zoster and PHN represent a substantial burden in terms of suffering and associated costs. Immunization of older adults is a good option to prevent herpes zoster and PHN.

Diagnosis and assessment of pain associated with herpes zoster and postherpetic neuralgia

Accurate evaluation of pain plays a critical role in identifying new interventions for the treatment and prevention of herpes zoster and postherpetic neuralgia (PHN). Different types of pain and other sensory symptoms are found in patients with herpes zoster, and these vary greatly with respect to their presence, location, duration, intensity, and quality. The results of recent studies of herpes zoster and PHN and the development of new methods for assessing neuropathic pain provide a foundation for diagnosing and assessing the pain associated with herpes zoster. We review the results of recent research to identify the essential components that must be considered in developing an evidence-based description of pain associated with herpes zoster and PHN.

PERSPECTIVE

Comprehensive assessments of pain are necessary for clinical research on the epidemiology, natural history, pathophysiologic mechanisms, treatment, and prevention of pain in herpes zoster and PHN.

Natural history and treatment of herpes zoster

The objective of this article is to provide an overview of the natural history and treatment of herpes zoster, with a focus on pain management. Herpes zoster has the highest incidence of all neurological diseases, occurring annually in approximately 1 million people in the United States. A basic feature of herpes zoster is a marked increase in incidence with aging and with diseases and drugs that impair cellular immunity. Herpes zoster begins with reactivation of varicella zoster virus in dorsal root or cranial nerve ganglia, which is often accompanied by a prodrome of dermatomal pain or abnormal sensations. Varicella zoster virus spreads in the affected primary afferent nerve to the skin and produces a characteristic dermatomal maculopapular and vesicular rash and pain. Herpes zoster acute pain lowers quality of life and interferes with activities of daily living. Antiviral therapy and scheduled analgesics form the pharmacotherapeutic foundation for herpes zoster acute pain reduction. If moderate to severe herpes zoster pain is not adequately relieved by antiviral agents in combination with oral analgesic medications, then corticosteroids, anticonvulsants (eg, gabapentin or pregabalin), tricyclic antidepressants (eg, nortriptyline or desipramine), or neural blockade can be considered.

PERSPECTIVE

This article presents information on the clinical features and treatment of herpes zoster. This information will help clinicians diagnose and manage herpes zoster pain.

The epidemiology of children hospitalized with herpes zoster in Canada: Immunization Monitoring Program, Active (IMPACT), 1991-2005

BACKGROUND

Varicella zoster virus causes varicella (chickenpox) and can reactivate to cause herpes zoster (HZ). In Canada, live attenuated varicella vaccine was recommended for routine use among healthy susceptible children age 1 year and older, in 1999. Varicella vaccine has had a profound impact on the incidence of varicella; however the impact on HZ remains uncertain.

METHODS

Surveillance for HZ admissions was conducted by the Immunization Monitoring Program, Active (IMPACT) surveillance network comprising 12 centers representing over 90% of pediatric tertiary care beds in Canada. Active surveillance for HZ was undertaken in 1991-1996 and reintroduced in 1999. A clinical diagnosis was accepted, with or without laboratory confirmation. For each case, a detailed case report form was completed.

RESULTS

In total, 648 children were admitted with HZ; 342 (52.8%) were boys and the mean age was 9.9 +/- 4.4 years. Five hundred seventy-seven (89.0%) were immunocompromised and 71 immunocompetent (10.8%). Five hundred seventy-one (88.1%) had a history of varicella zoster virus infection. Varicella vaccination was documented in 4 children before admission. Most (85.5%) presented with localized disease. Immunocompetent children were more likely than immunocompromised children to be hospitalized with ophthalmic disease (odds ratio 5.1, P < 0.001) or with at least 1 complication (odds ratio 3.0, P < 0.001). Only 1 death was attributable to HZ.

CONCLUSIONS

Immunocompromised children represented the overwhelming majority of IMPACT hospitalized cases. Complications directly resulting from HZ were common in immunocompetent children. As varicella vaccine use becomes more widespread, the IMPACT network will continue to play an important role in monitoring the changing epidemiology of HZ in children.

Postherpetic neuralgia: epidemiology, pathophysiology and management

Postherpetic neuralgia (PHN) is a neuropathic pain syndrome and is the most common complication of herpes zoster (HZ; shingles). PHN occurs mainly in HZ patients 60 years of age and older, in particular in those suffering from more severe acute pain and rash. Administration of antiviral drugs reduces the duration of pain associated with HZ. The pathophysiology of PHN may be distinctly different between patients with either reduced or increased skin sensitivity. Therapy is with tricyclic drugs (e.g., nortriptyline), alpha 2 delta-ligands (e.g., gabapentin) or opiates with adjunctive topical lidocaine or capsaicin. Mechanism-based therapy is a desirable goal but so far proves elusive. The incidence of HZ, and therefore that of PHN, is likely to increase as a result of greater longevity and increasing numbers of patients receiving treatment that compromises cell-mediated immunity. A zoster vaccine for administration to adults reduces the incidence of HZ and PHN, as well as the burden of illness associated with these conditions.

Epidemiology and costs of herpes zoster: background data to estimate the impact of vaccination

In 2004, we conducted a study in Piemonte (Italy), in order to describe incidence, treatment, hospitalizations and costs of herpes zoster (HZ), in population over 14 years of age. Twenty-four regional general practitioners, with 26,394 patients >14 years in charge (0.71% of the regional population), reported prospectively all diagnosed HZ cases. In addition, all regional hospital discharge records were reviewed. Forty-six HZ cases treated at home were reported, accounting for a total incidence of 1.74 cases/1000 population >14 years per year. HZ rate standardized by age on regional population 14 years older is 1.59/1000. The cost per observed home case was 136.06 euros. The incidence of hospital admissions was 0.12/1000 inhabitants. The mean cost of hospitalized cases was 4082.59 euros. These results contribute to depict the impact of HZ in the general population, and to provide background data for setting-up either mathematical models aimed to estimate the impact of vaccination on HZ, and the cost-benefit analyses of various preventive and therapeutic scenarios.

Clinical diagnosis of herpes zoster in family practice

PURPOSE

Family physicians usually diagnose herpes zoster on clinical grounds only, possibly resulting in false-positive diagnoses and unnecessary treatment. We wanted to determine the positive predictive value of the physicians' judgment in diagnosing herpes zoster and to assess the applicability of dried blood spot analysis for diagnosis of herpes zoster in family practice.

METHODS

Our study population consisted of 272 patients older than 50 years with herpes zoster (rash for less than 7 days). Dried blood spot samples were collected from all patients and sent by mail to the laboratory. Baseline measurements included clinical signs (localization, severity, and duration of rash) and symptoms (duration and severity of pain). Varicella-zoster virus antibodies were determined at baseline and 5 to 10 days later. Multivariate logistic regression was used to assess independent associations between clinical variables and serological confirmation of herpes zoster.

RESULTS

Dried blood spot analysis was possible in 260 patients (96%). In 236 the diagnosis of herpes zoster was confirmed serologically (positive predictive value of clinical judgment 90.8%; 95% confidence interval, 87.3%-94.3%). Independent clinical variables for serologically confirmed herpes zoster were severity and duration of rash at first examination.

CONCLUSION

Family physicians have good clinical judgment when diagnosing herpes zoster in older patients. Dried blood spot analysis is a logistically convenient method for serological investigation of patients in family practice, but it is rarely needed for diagnosing herpes zoster.

Topical lidocaine for the treatment of postherpetic neuralgia

BACKGROUND

The cause of postherpetic neuralgia is damage to peripheral neurons, dorsal root ganglia, and the dorsal horn of the spinal cord, secondary to herpes zoster infection (shingles). In postherpetic neuralgia, peripheral neurons discharge spontaneously and have lowered activation thresholds, and exhibit an exaggerated response to stimuli. Topical lidocaine dampens peripheral nociceptor sensitisation and central nervous system hyperexcitability, and may benefit patients with postherpetic neuralgia.

OBJECTIVES

To examine the efficacy and safety of topical lidocaine in the treatment of postherpetic neuralgia.

SEARCH STRATEGY

We searched the Cochrane Pain, Palliative and Supportive Care Group Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and LILACS, SIGLE for conference proceedings, Citation Index, the reference lists of all eligible trials, key textbooks, and previous systematic reviews. We also wrote to authors of all identified trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials comparing all topical applications of lidocaine, including gels and patches in patients of all ages with postherpetic neuralgia (pain persisting at the site of shingles at least one month after the onset of the acute rash).

DATA COLLECTION AND ANALYSIS

Two review authors extracted data, and a third checked them. We obtained some missing data from the US Food and Drugs Administration.

MAIN RESULTS

Three trials involving 182 topical lidocaine treated participants and 132 control participants were included. Two trials gave data on pain relief, and the remaining study provided data on secondary outcome measures. The largest trial published as an abstract compared topical lidocaine patch to a placebo patch and accounted for 150 of the 314 patients (48%).A meta-analysis combining two of the three studies identified a significant difference between the topical lidocaine and control groups for the primary outcome measure: a mean improvement in pain relief according to a pain relief scale. Topical lidocaine relieved pain better than placebo (P = 0.003). There was a statistical difference between the groups for the secondary outcome measure of mean VAS score reduction (P = 0.03), but this was only for a single small trial. There were a similar number of adverse skin reactions in both treatment and placebo groups. The highest recorded blood lidocaine concentration varied between 59 ng/ml and 431 ng/ml between trials. The latter figure is high and the authors of the study suggest that the sample had been contaminated during the assay procedure.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend topical lidocaine as a first-line agent in the treatment of postherpetic neuralgia with allodynia. Further research should be undertaken on the efficacy of topical lidocaine for other chronic neuropathic pain disorders, and also to compare different classes of drugs (e.g. topical anaesthetics versus anti-epileptics).

Clinical and psychosocial correlates of acute pain in herpes zoster

BACKGROUND

Acute and persistent pain are the most significant clinical manifestations of herpes zoster (HZ), but the characteristics of acute pain in HZ patients have been inadequately investigated.

OBJECTIVES

To correlate the severity of acute pain with clinical, demographic and psychosocial characteristics of HZ patients.

STUDY DESIGN

Five hundred thirty-three patients with acute HZ were recruited by 119 dermatologists who collected medical and demographic data at diagnosis, provided counselling and therapy where appropriate and asked the patients to complete the Short Italian Questionnaire designed for comprehensive evaluation of HZ patients.

RESULTS

In a univariate analysis, greater acute pain severity was significantly associated with female gender, number of dermatomes affected, presence of prodromal pain, abnormal sensations (dysesthesia), education level, anxiety and depression. Quality of life, even if greatly reduced, did not correlate with the intensity of pain. In a multivariate model, the intensity of pain was independently associated with the extent of rash (p=0.042), presence of prodromal pain (p=0.005), dysesthesia, education level (p=0.040), and depression (p<0.001), but not with gender, anxiety or quality of life.

CONCLUSIONS

This study suggests that in patients with acute HZ the severity of the disease and depression at presentation are the main correlates of pain intensity.

Vaccination des adultes contre la varicelle et le zona

PURPOSE

Following the commercialisation in France of the varicella vaccine and the European marketing authorization for a vaccine against zoster, this article intends to review the epidemiology of varicella and herpes zoster, to expose the characteristics of the available vaccines, and to consider the advantages and caveats of the different immunisation strategies.

CURRENT KNOWLEDGE AND KEY POINTS

In France, from 550.000 to 750.000 cases of varicella are reported each year, which result in more than 3.500 hospitalizations and about 20 deaths. Subjects>or=15 years old represent 8.3% of the total number of cases of varicella, 26% of varicella-related hospitalisations and 69% of all varicella-related deaths. The susceptibility rate for the 15 years old is 10,3 and 79% of these non-immune subjects are expected to contract varicella. The vaccines currently marketed against varicella are safe, have a good immunogenicity and remain effective over the evaluated periods. Two vaccination strategies are considered: a generalized vaccination of the infants and children, or a vaccination targeted against high-risk populations and non-immune teenagers and adults. The incidence of herpes zoster is estimated in France at 235.000 new cases per year, from which 1% is hospitalized. A live attenuated vaccine using the same strain as the varicella vaccine, but at a much higher dose, proved its efficacy in terms of reducing shingles and postherpetic neuralgia incidences, of 51 and 67% respectively. This vaccine received a marketing authorisation in France, for adults>or=60 years old.

FUTURE PROSPECTS

Uncertainties about the impact of vaccination on varicella and herpes zoster epidemiology have yet to be solved, such as the potential increase in herpes zoster incidence or in the absolute number of diagnosed varicella cases in older age groups, or the loss of vaccination-induced immunity with time. These questions demonstrate the need for an operational real-time surveillance network to monitor varicella and herpes zoster incidence in the setting of general population immunisation.

Acute/subacute herpes zoster: healthcare resource utilisation and costs in a group of US health plans

BACKGROUND

Although there are estimated to be nearly 1 million cases of herpes zoster diagnosed in the US each year, the economic costs associated with herpes zoster in the US have not been well described.

OBJECTIVE

To describe the healthcare resource utilisation and costs associated with physician-diagnosed acute/subacute herpes zoster, from a payer perspective, using a large US healthcare claims database.

METHODS

Data for the period 2000-1 were obtained from the Medstat Marketscan healthcare claims database. The duration of acute/subacute herpes zoster was considered to include the 21 days preceding, and 90 days following, the initial herpes zoster diagnosis. Resource utilisation was examined for individuals with newly diagnosed acute/subacute herpes zoster (n = 8741) and compared, through regression analyses, with that observed for control individuals from the same population (n = 50,000). Similar analyses were conducted for costs; the costs included reflected healthcare payments from patients, insurers and other sources. Regression analyses controlled for demographics (age, gender), conditions that have been observed with greater frequency among patients with acute/subacute herpes zoster in prior studies (cancer, HIV infection, organ transplantation, other immunosuppressive conditions and therapies) and the number of billed services within each of seven categories of care that were potentially related to acute/subacute herpes zoster and that were utilised within the 30-180 days prior to the diagnosis for affected patients, and over an analogous period for controls.

RESULTS

The acute/subacute phase of herpes zoster was estimated to result in an average of 1.7 (standard error [SE] 0.02) additional physician and hospital outpatient visits, 0.05 (SE 0.003) additional emergency room visits, 0.03 (SE 0.003) additional inpatient hospital admissions, 2.1 (SE 0.03) additional prescriptions filled and $US431 (SE 17.60) in additional healthcare costs per patient. Among patients with acute/subacute herpes zoster, 21.1% had a diagnosis code with a designation for a herpes zoster-related complication, and 9.4% had three or more outpatient visits with a diagnosis code for herpes zoster. The average estimated incremental costs per patient with acute/subacute disease increased with age, ranging from $US258 (SE 37.70) among patients aged < or =19 years to $US805 (SE 106.30) among those aged > or =80 years. The numbers of additional outpatient visits, inpatient admissions, prescriptions filled for pain medications and coded complications were also substantially higher among older than younger patients with acute/subacute herpes zoster.

CONCLUSIONS

The management of acute/subacute herpes zoster was found to result in substantial healthcare costs, with outpatient care and prescription drugs comprising the majority of the cost burden. To more fully understand the overall cost of herpes zoster disease to society, future studies should examine the healthcare costs associated with post-herpetic neuralgia and productivity losses due to herpes zoster and post-herpetic neuralgia.

Skin manifestations of herpesvirus infections

Currently there are eight human herpesviruses identified that cause disease in both adults and children. Although the manifestations of disease differ with each herpesvirus, cutaneous presentations are common among almost all of them. These skin manifestations may be visually similar among several of these viruses, occasionally making it challenging to diagnose the patient's illness. Laboratory diagnostic testing is commercially available for most of these viruses. Because many herpesvirus infections are self-limiting in immunocompetent hosts, patients require only supportive care. Effective antiviral therapy is available for the more severe cases of infection caused by herpes simplex virus (HSV), varicella zoster virus (VZV), or cytomegalovirus (CMV). Healthcare practitioners should become familiar with the different cutaneous manifestations these viruses may exhibit.

Herpes zoster in immunocompromised patients: incidence, timing, and risk factors

PURPOSE

To evaluate the risk factors for herpes zoster as well as the incidence and timing of this complication in patients who were treated with immunosuppression because of active Wegener's granulomatosis.

SUBJECTS AND METHODS

We studied the 180 Wegener's granulomatosis patients in the Wegener's Granulomatosis Etanercept Trial (WGET). Herpes zoster events during WGET were documented prospectively. Follow-up questionnaires were employed to describe the location, treatment, and complication(s) of herpes zoster and its therapy. Univariate and multivariate analyses were performed to evaluate risk factors, including history of herpes zoster, for the occurrence of herpes zoster during the trial. All analyses were based on the time to first occurrence of herpes zoster.

RESULTS

Eighteen patients (10% of the WGET cohort) suffered a total of 19 herpes zoster episodes over a mean follow-up period of 27 months. The annual incidence of herpes zoster in the WGET cohort was 45 cases/1000 patient-years (95% confidence interval [CI]: 27, 70). The median time from enrollment to the occurrence of herpes zoster in the subgroup of patients with that complication was 16.5 months (+/- 9.4). Fifteen of the 19 herpes zoster events (79%) occurred between months 6 and 36, many months after the period of most intensive immunosuppression. In univariate analyses, history of serum creatinine > or =1.5 mg/dL before enrollment was associated with a relative risk (RR) of 3.0 (95% CI: 1.1, 7.8) for herpes zoster during WGET (P=.03). In multivariate analyses, serum creatinine > or =1.5 mg/dL was associated with an RR of 6.3 (95% CI: 2.0, 19.8; P=.002), and female sex with an RR of 4.6 (95% CI: 1.6, 13.2; P=.004).

CONCLUSION

Renal dysfunction and female sex were consistently strong risk factors for herpes zoster events in this population. Contrary to expectation, most herpes zoster events did not occur during periods of most intensive immunosuppression. These data may inform studies of interventions designed to prevent herpes zoster in patients on treatment for immune-mediated diseases.

Pain, medication use, and health-related quality of life in older persons with postherpetic neuralgia: results from a population-based survey

Persons aged >65 years with pain caused by postherpetic neuralgia (PHN) were recruited via advertisements in 24 US newspapers and were mailed a questionnaire that addressed pain intensity (average, worst, least, current), pain interference (with general activity, mood, relations with other people, sleep, enjoyment of life), and health-related quality of life (using the EuroQoL health measure [EQ-5D] and a global rating scale). Respondents also were asked about their use of medication for shingles pain. A total of 385 persons completed the survey; 61% were >75 years of age. Mean (+/-standard deviation) duration of PHN was 3.3 (+/-4.0) years. Only about one half had taken prescription medication for shingles pain during the prior week; dosages were typically low. Mean average, worst, least, and current pain caused by shingles (0- to 10-point scale) was 4.6 (+/-2.1), 6.0 (+/-2.4), 2.9 (+/-2.3), and 4.0 (+/-2.7), respectively. Mean pain interference with general activity, mood, relations with other people, sleep, and enjoyment of life (0- to 10-point scale) was 3.7 (+/-3.1), 4.3 (+/-2.9), 3.0 (+/-2.8), 3.8 (+/-2.9), and 4.5 (+/-3.1), respectively. The mean EQ-5D health index score was 0.61; respondents rated their overall health as 65.7 (+/-21.1) on a 100-point scale. PHN causes substantial pain, dysfunction, and poor health-related quality of life in older persons, many of whom might be suboptimally treated.

PERSPECTIVE

Many older persons (age >65 years) with PHN experience longstanding, severe, and debilitating pain and poor health-related quality of life; levels of dissatisfaction with treatment are high. Our study highlights the need for improved management of this disease.

The incidence of herpes zoster in a United States administrative database

BACKGROUND

Few recent studies have reported data on the incidence of herpes zoster (HZ) in U.S. general clinical practice.

OBJECTIVE

To estimate the age- and sex-specific incidence of HZ among U.S. health plan enrollees.

DESIGN

Data for the years 2000 to 2001 were obtained from the Medstat MarketScan database, containing health insurance enrollment and claims data from over 4 million U.S. individuals. Incident HZ cases were identified through HZ diagnosis codes on health care claims. The burden of HZ among high-risk individuals with recent care for cancer, HIV, or transplantation was examined in sub-analyses. Overall incidence rates were age- and sex-adjusted to the 2000 U.S. population.

PARTICIPANTS

MarketScan U.S. health plan enrollees of all ages.

MEASUREMENTS AND MAIN RESULTS

We identified 9,152 incident cases of HZ (3.2 per 1,000 person-years) (95% confidence interval [CI], 3.1 to 3.2 per 1,000). Annual HZ rates per 1,000 person-years were higher among females (3.8) than males (2.6) (P<.0001). HZ rates rose sharply with age, and were highest among individuals over age 80 (10.9 per 1,000 person-years) (95% CI, 10.2 to 11.6). The incidence of HZ per 1,000 person-years among patients with evidence of recent care for transplantation, HIV infection, or cancer (10.3) was greater than for individuals without recent care for these conditions (3.0) (P<.0001).

CONCLUSIONS

The overall incidence of HZ reported in the present study was found to be similar to rates observed in U.S. analyses conducted 10 to 20 years earlier, after age- and sex-standardizing estimates from all studies to the 2000 U.S. population. The higher rate of HZ in females compared with males contrasts with prior U.S. studies.

The incidence of varicella and herpes zoster in Massachusetts as measured by the Behavioral Risk Factor Surveillance System (BRFSS) during a period of increasing varicella vaccine coverage, 1998-2003

BACKGROUND

The authors sought to monitor the impact of widespread varicella vaccination on the epidemiology of varicella and herpes zoster. While varicella incidence would be expected to decrease, mathematical models predict an initial increase in herpes zoster incidence if re-exposure to varicella protects against reactivation of the varicella zoster virus.

METHODS

In 1998-2003, as varicella vaccine uptake increased, incidence of varicella and herpes zoster in Massachusetts was monitored using the random-digit-dial Behavioral Risk Factor Surveillance System.

RESULTS

Between 1998 and 2003, varicella incidence declined from 16.5/1,000 to 3.5/1,000 (79%) overall with > or = 66% decreases for all age groups except adults (27% decrease). Age-standardized estimates of overall herpes zoster occurrence increased from 2.77/1,000 to 5.25/1,000 (90%) in the period 1999-2003, and the trend in both crude and adjusted rates was highly significant (p < 0.001). Annual age-specific rates were somewhat unstable, but all increased, and the trend was significant for the 25-44 year and 65+ year age groups.

CONCLUSION

As varicella vaccine coverage in children increased, the incidence of varicella decreased and the occurrence of herpes zoster increased. If the observed increase in herpes zoster incidence is real, widespread vaccination of children is only one of several possible explanations. Further studies are needed to understand secular trends in herpes zoster before and after use of varicella vaccine in the United States and other countries.

The consistency of shingles and its significance for health monitoring

Accurate estimation of monitored populations is essential for epidemiological study. Many countries do not have systems of patient registration and routine disease surveillance is thereby hindered. We studied the incidence of shingles over time and investigated the hypothesis that the incidence is consistent and could be used as a proxy for estimating the monitored population. Annual incidence rates of shingles reported in the Weekly Returns Service (WRS) since 1970 and in the Dutch Sentinel Network (DSN) over the period 1998--2001 were studied. Gender specific annual rates (1998--2001) were compared after standardising for age. The population in the DSN was estimated by applying the WRS incidence rates to the numbers of DSN incident cases. The incidence of shingles was annually and seasonally consistent. Incidence in males was similar in both networks and in females approximately 18% greater in the WRS: in age groups 15-64 years, incidence was similar in both networks, but in children 0-14 years and in persons 65 years and over, it was higher in the WRS. The total populations in the DSN estimated from average age/gender specific rates in the WRS were within 12% of the observed in each of the 4 years surveyed. The incidence of shingles in the two countries was sufficiently close to estimate the surveyed population aged 15-64 years from knowledge of incident cases in the community. Routine monitoring of shingles in sentinel practice networks is commended as a method of assuring recording quality and as a means of estimating the survey population where the registered population is not known.

Treatment of postherpetic neuralgia: a review of therapeutic options

Postherpetic neuralgia (PHN) is a disabling consequence of the reactivation of the varicella zoster infection. The observation that patients with PHN experience various types of pain suggests that multiple pathophysiologic mechanisms are involved, which may include the peripheral and central nervous systems. A reasonable initial strategy would involve selecting from among multiple agents that have complementary mechanisms of action and that have been proven effective in controlled clinical trials, such as the lidocaine patch 5%, gabapentin, tricyclic antidepressants, and opioids. Based on initial assessment and ongoing reassessment, sequential trials should be undertaken until adequate pain relief is achieved. This may ultimately lead to therapy with more than one medication. Safety and tolerability are important considerations in choosing initial therapy, particularly in older patients. Physicians can either add another agent to the current regimen or switch to a new type of monotherapy if there is inadequate response to initial therapy. Alternative therapies, (i.e., ketamine, intrathecal corticosteroid injections) have not been adequately studied. Well-designed, multicenter, controlled clinical trials are needed to develop a treatment algorithm that provides an evidence-based, rational approach to treating PHN.

Risk factors for postherpetic neuralgia in patients with herpes zoster

OBJECTIVES

To identify risk factors for postherpetic neuralgia (PHN) using a validated definition of this chronic neuropathic pain syndrome, to determine combinations of risk factors that identify patients with a high risk of developing PHN, and to examine the characteristics of patients with subacute herpetic neuralgia, that is, pain that persists beyond the acute phase of herpes zoster but that resolves before PHN can be diagnosed.

METHODS

The authors examined baseline and follow-up data from 965 herpes zoster patients enrolled within 72 hours of rash onset in two clinical trials of famciclovir.

RESULTS

Univariate and multivariate analyses indicated that older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity made independent contributions to identifying which patients developed PHN. Patients with subacute herpetic neuralgia who did not develop PHN were significantly younger and had less severe acute pain than PHN patients but were significantly more likely to have severe and widespread rash than patients without persisting pain.

CONCLUSIONS

The independent contributions to the prediction of PHN made by older age, female sex, presence of a prodrome, greater rash severity, and greater acute pain severity suggest that these risk factors reflect different mechanisms that each contribute to the development of PHN. Subacute herpetic neuralgia that does not progress to PHN may reflect peripheral tissue damage and inflammation caused by a particularly severe or widespread rash.

What does epidemiology tell us about risk factors for herpes zoster?

Reactivation of latent varicella zoster virus as herpes zoster is thought to result from waning of specific cell-mediated immunity, but little is known about its determinants in individuals with no underlying immunosuppression. We systematically reviewed studies of zoster epidemiology in adults and analysed data from a large morbidity study to identify factors that might be modulated to reduce the risk of zoster. Annual zoster incidence in population-based studies varied from 3.6-14.2/10(3) in the oldest individuals. Risk factors identified in analytical studies that could explain this variation included age, sex, ethnicity, genetic susceptibility, exogenous boosting of immunity from varicella contacts, underlying cell-mediated immune disorders, mechanical trauma, psychological stress, and immunotoxin exposure. Our review highlights the lack of information about risk factors for zoster. We suggest areas of research that could lead to interventions to limit the incidence of zoster. Such research might also help to identify risk factors for age-related immune decline.

Consequences and management of pain in herpes zoster

Postherpetic neuralgia (PHN) is a common complication of herpes zoster, particularly in the elderly and in persons with severe symptoms at presentation. Unless varicella vaccination reduces the incidence of herpes zoster and attenuates the risk and/or severity of complications, PHN will continue to result in significant suffering and remain a consumer of health care and related social support resources. Although there have been useful advances in the management of PHN (e.g., the use of the anticonvulsant gabapentin), some cases remain intractable. Prevention remains the preferred strategy, and antiviral drugs are the most well established means of preventing the development of pain. Other interventions require further evaluation (nerve blocks, acute-phase tricyclic antidepressant or anticonvulsant use). Because prevention of PHN requires early recognition and prompt management of patients presenting with herpes zoster, public education and dissemination of information to all health care personnel involved with the disease are essential.