Preventing and managing herpes zoster: key actions to foster healthy aging

Healthy ageing: Herpes zoster infection and the role of zoster vaccination

Populations are ageing worldwide, with considerable time lived in ill-health, putting upwards pressure on healthcare budgets. Healthy ageing is defined as maintaining functional ability, including the ability to: meet basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society. The risk and impact of infectious diseases increase with age due to immunosenescence. Vaccination can help to prevent disease in older adults, promoting healthy ageing and active lives. Herpes zoster (HZ) occurs when the varicella zoster virus is reactivated due to declining immunity. HZ is common, with a lifetime risk of one-third, and increases in incidence with age. HZ is associated with severe and intense pain, substantially affecting the functional status of patients as well as their overall health-related quality of life. HZ and its complications may result in prolonged morbidity, including persistent pain (post-herpetic neuralgia, PHN), hearing impairment, vision loss and increased risk of stroke and myocardial infarction. HZ and PHN are difficult to treat, substantiating the benefits of prevention. Vaccines to prevent HZ include a recombinant zoster vaccine (RZV). RZV has shown efficacy against the HZ burden of disease and HZ burden of interference on activities of daily living of over 90% in immunocompetent adults aged ≥50 years. Vaccine efficacy against HZ was maintained at over 70% at 10 years post-vaccination. Adult vaccination, including against HZ, has the potential to reduce burden of disease, thus helping to maintain functioning and quality of life to support healthy ageing in older adults.

Cross-sectional study on hospitalizations related to herpes zoster in an Italian region, 2008-2016

INTRODUCTION

To assess the burden of herpes zoster (HZ) by analyzing HZ-related hospital admissions.

METHODS

We conducted a population-based descriptive cross-sectional study on all hospitalizations for HZ among the resident population admitted to all public and accredited private hospitals in the Veneto Region (north-east Italy) during the years 2008-2016. HZ hospitalizations were identified from the International Classification of Diseases codes in the hospital discharge records.

RESULTS

During the period considered, we identified 3566 HZ-associated admissions, 194 (5.4%) of which were readmissions within 30 days. A complicated HZ diagnosis was mentioned for 44.4% of the patients admitted once and for 65.9% of those admitted twice. In the sample as a whole, 27.0% of patients had at least one comorbidity. Overall, our analysis revealed a gradual increase in hospitalizations with age for both genders, reaching a hospitalization rate for the population over 80 years old of 51.2 × 100,000 for males and 52.8 × 100,000 for females. The average hospitalization rate for HZ-related conditions during the years 2008-2016 was 7.7 per 100,000 population. Postherpetic neuralgia was diagnosed in 8.2% of hospitalizations, with no difference between the genders. The estimated overall cost of HZ-related conditions was approximately €2.7 million a year.

CONCLUSIONS

This study suggests that the burden of HZ and its impact on quality of life are of critical relevance to public health decision-making.

A novel nonlive, adjuvanted herpes zoster subunit vaccine: a report on the emerging clinical data and safety profile

Herpes zoster (HZ) is an acute vesicular dermatitis with a typical dermatomal distribution, caused by the varicella zoster virus (VZV), often preceded and accompanied by prodromal pain or pruritus. HZ may be related to several complications such as postherpetic neuralgia (PHN). The incidence and severity of the disease increase with aging, due to immunosenescence and in particular to the decline of the specific cell-mediated immunity (CMI). The impact of HZ in terms of morbidity and short- and long-term complications, the availability of suboptimal treatment options to date, and the high costs for the diagnostic and clinical-therapeutic management of patients have motivated the search for a new preventive approach through the development of a vaccine. The vaccine currently in use with live-attenuated virus (ZVL) has been shown to be effective in reducing the incidence of HZ, its impact, and the onset of PHN, although the efficacy is lower in older subjects and tends to decrease some years after immunization. A new adjuvanted recombinant subunit vaccine (HZ/su), containing the VZV glycoprotein E (gE) and the AS01B adjuvant system, is now a very promising alternative to ZVL; in several clinical studies, it showed a good safety profile and was able to elicit high immune humoral and cell-mediated responses, both maintained up to 9 years. Furthermore, HZ/su vaccine was effective both in preventing HZ and in reducing the onset of PHN and other complications. HZ/su has been recommended and preferred over ZVL by the Advisory Committee on Immunization Practices (ACIP) for the prevention of HZ and its complications in immunocompetent adults aged ≥50 years, even if already vaccinated with ZVL, through a two-dose schedule. HZ/su has been approved in Canada, USA, Europe, and Japan and is currently being approved in Australia. The aim of this review was to describe the epidemiological data, HZ and PHN risks and their impact on the social life and common life of infected people, and ZVL and HZ/su vaccine development including various clinical trials and efficacy, safety, and tolerability profiles.

Herpes zoster in frail elderly patients: prevalence, impact, management, and preventive strategies

Population aging is a worldwide phenomenon with significant and manifold impacts on society. Advanced age correlates with the onset of frailty. In this vulnerable state, the immune response is weakened and a higher susceptibility to infectious diseases is observed. The present narrative review aims to cover the topic of herpes zoster (HZ) and its complications in frail populations. The lifetime risk of developing HZ is estimated at about 20-30%, and the risk increases with age. In older people, HZ can lead to the inability to recover the lifestyle, the interests, and the level of activity that existed before its development. Severity of the disease at presentation and depression are the major correlates of pain burden in patients with acute HZ and postherpetic neuralgia (PHN). The frail elderly need careful assessment prior to treatment initiation and could be affected to a greater extent by treatment-related adverse events. In light of the significant burden caused by HZ and its complications in the frail elderly, the adoption of a preventive strategy appears to be promising, particularly using vaccination in appropriate age- and risk-groups. Although very few vaccine studies consider explicitly the frail elderly as their study population, there is evidence that the live, attenuated vaccine induces significant immunological responses. An adjuvanted recombinant subunit vaccine has recently been approved in Canada, in the United States, in the European Union, and in Japan, and will likely provide additional opportunities for prevention.

Risk and impact of herpes zoster among COPD patients: a population-based study, 2009-2014

Background

The objective of this study was to assess the incidence of Herpes Zoster (HZ) among patients with chronic obstructive pulmonary disease (COPD) and the impact of HZ on the underlying COPD.

Methods

A retrospective cohort of all subjects older than 49 years was followed up between 2009 and 2014 using population and health databases of Valencia Region (Spain). HZ and COPD were identified using ICD-9 codes, differentiating COPD patients with inhaled corticosteroids prescriptions (COPD-ICS). The incidence of HZ was compared among 3 groups [non-COPD, COPD and COPD-ICS populations] and use of healthcare resource due to HZ for 6 months following HZ diagnosis through different statistical generalized linear models (GLM). We also compared resources consumption due to COPD before and after HZ.

Results

The cohort consisted of 2,289,485 subjects, including 161,317 COPD patients of which 29,708 were COPD-ICS. HZ incidence rates were 11 (95% confidence interval [CI]: 10.7–11.4) and 13 (95% CI: 12.3–13.8) cases/1000 persons-year for COPD and COPD-ICS populations respectively. Incidence increased with age in all groups. The risk of HZ rose by 45 and 61% among COPD and COPD-ICS patients respectively compared to non-COPD (95% credible intervals [CrI]: 1.41–1.5 and 1.52–1.71 respectively). COPD patients consumed more resources due to their HZ than non-COPD. There was no statistically significant impact of the HZ on the resources consumed due to COPD during the 6 months post-HZ compared to the 6 months pre-HZ.

Conclusions

The presence of COPD increases the risk, severity and impact of zoster episodes.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3121-x) contains supplementary material, which is available to authorized users.

Incidence and costs of herpes zoster and postherpetic neuralgia in German adults aged ≥50 years: A prospective study

OBJECTIVES

Herpes zoster (HZ) mainly affects elderly people and immunocompromised individuals. HZ is usually characterized by a unilateral painful skin rash. Its most common complication, postherpetic neuralgia (PHN), may cause chronic debilitating pain. This study aimed to estimate the HZ incidence in individuals aged ≥50 years in Germany, the proportion of PHN and the economic burden.

METHODS

From 2010 to 2014, HZ patients were recruited when consulting physicians in physician networks covering about 157,000 persons aged ≥50 years. PHN was defined as "worst pain" rated ≥3 on the zoster brief pain inventory persisting or appearing over 90 days after rash onset. Costs were calculated based on medical resource utilization and lost working time.

RESULTS

HZ incidence was estimated as 6.7/1000 person-years, increasing with age to 9.4/1000 in ≥80 year-olds. Among 513 HZ patients enrolled, the proportion of PHN was 11.9%, rising with age to 14.3% in HZ patients ≥80 years. Estimated total cost per HZ patient was €156 from the healthcare system perspective and €311 from the societal perspective.

CONCLUSIONS

The study confirmed previous findings that HZ causes a substantial clinical and economic burden in older German adults. It also confirmed the age-related increasing risk of HZ and PHN.

Impact of Underlying Conditions on Zoster-Related Pain and on Quality of Life Following Zoster

BACKGROUND

Chronic conditions have been investigated as risk factors for developing zoster, but in patients suffering from zoster, the impact of underlying conditions in zoster-related pain and quality of life (QOL) remains unclear.

METHODS

We performed a post hoc analysis of a prospective cohort study in immunocompetent zoster patients aged 50 years or older, conducted by general practitioners in Italy between 2009 and 2010. Zoster symptoms, pain intensity and characteristics, and physical and mental health scores were assessed at baseline (zoster diagnosis) and at 1, 3, and 6 months of follow-up.

RESULTS

Among 413 patients enrolled in the study, 73% (303/413) suffered from underlying conditions of which 69% (209/303) were aged 65 or older. Cardiovascular diseases (75%), diabetes (24%), and respiratory diseases (17%) were most frequent. One to three months after onset, zoster patients with underlying conditions experienced more intense zoster-related pain than those without. QOL scores were significantly lower in patients with underlying conditions, and age-adjusted difference in QOL scores between the groups increased over time, demonstrating a slower recovery for patients with underlying conditions.

CONCLUSIONS

In addition to age, the main risk factor of zoster occurrence and severity, the presence of underlying conditions results in more painful and impactful zoster episodes, creating a significant burden for these patients.

Temporal trends in herpes zoster-related hospitalizations in Italy, 2001-2013: differences between regions that have or have not implemented varicella vaccination

BACKGROUND

Herpes zoster (HZ) has a relevant impact on the population in terms of incidence and complications.

AIMS

The aim of this study was to estimate the HZ-related hospitalization rates in Italy in the period 2001-2013, and to evaluate the trend of hospitalizations in the course of time pointing out any differences between regions that have or have not introduced universal childhood varicella immunization (UVI).

METHODS

A retrospective analysis was conducted on hospital discharge records contained in the national database of the Ministry of Health for the period January 2001-December 2013. The comparison of hospitalization rates of "pilot" versus "not pilot" regions was performed taking into account as "pilot" regions the three that first introduced UVI (Sicily, Veneto, and Apulia). The average annual percentage change in hospitalization rates was used to highlight any significant change in time trends.

RESULTS

In the period 2001-2013, 93,808 HZ-related hospitalizations were registered altogether. Complicated HZ was diagnosed in 53.2% of cases; a relevant part (32.5%) of hospitalizations involved subjects with at least one co-morbidity. In the three Italian "pilot" regions, a greater decrease of HZ-related hospitalization rates occurred in comparison to other regions.

DISCUSSION

A good understanding of the epidemiology of HZ disease is required to assess the overall impact of the varicella immunization programs and to establish the most appropriate health strategies against HZ.

CONCLUSIONS

The data obtained confirm the epidemiological impact of HZ and its complications and the need of a preventive approach.

Late-Life Bereavement

Healthy aging is critical for the elderly to be independent and enjoy at least a satisfactory quality of life. However, late-life bereavement threatens healthy aging, as it may lead to adverse health effects. Using data from the Health and Retirement Survey, this study investigates the relationship between weight—specifically, body mass index (BMI)—and the loss of a parent, sibling, or spouse at an older age. It is the first attempt to investigate this relationship among the elderly population in the United States and makes the following notable contributions to the literature: (a) use of a large longitudinal dataset, (b) estimation of the effects of a familial death on a person’s BMI, and (c) investigation of the consequences of the bereavement for older people. Our results suggest that losing a family member at an older age results in a decrease in BMI.

Real-World Effectiveness and Safety of a Live-Attenuated Herpes Zoster Vaccine: A Comprehensive Review

Herpes zoster (HZ) is a common, painful and debilitating disease caused by the reactivation of latent varicella-zoster virus in ganglia. This clinical event occurs more frequently in the elderly and those who are immunocompromised. The most common complication of HZ is post-herpetic neuralgia (PHN) which is responsible for the highest HZ-related burden of illness and is challenging to treat. Due to the important clinical and economic impact of HZ and PHN, and the suboptimal treatments that are currently available, HZ vaccination is an important approach to reduce the burden of illness. Currently, one-dose, live-attenuated vaccine is licensed in the United States and Europe to prevent HZ and it is included in some national immunization programs. The clinical efficacy, safety and tolerability of the vaccine has been demonstrated in two large phase III clinical trials, involving more than 38,000 and 22,000 individuals aged ≥60 and 50-59 years, respectively. This comprehensive review summarizes the extensive "real-world" effectiveness and safety data from both immunocompetent and immunocompromised individuals. These data confirm those from the clinical trials, supporting the use of HZ vaccine in clinical practice and provide evidence that the current recommendations for immunocompromised individuals should be revised.

FUNDING

Funding for the editorial assistance, article processing charges, and open access fee for this publication was provided by Sanofi Pasteur MSD.