A population based study of the epidemiology of Herpes Zoster and its complications

Increased Risk of Herpes Zoster in Adult Patients with Inflammatory Bowel Disease After SARS-CoV2 Infection: A Propensity-Matched Cohort Study

BACKGROUND

There is evidence that SARS-CoV2 infection can increase the risk of herpes zoster (HZ) in the general population. However, the risk in patients with inflammatory bowel disease (IBD) is not known.

METHODS

The TriNetX database was utilized to conduct a retrospective cohort study in patients with IBD after SARS-CoV2 infection and patients without a SARS-CoV2 infection (IBD control cohort). The primary outcome was to evaluate the risk of HZ between the 2 cohorts. One-to-one (1:1) propensity score matching was performed for demographic parameters, HZ risk factors and IBD medications between the 2 cohorts. Adjusted odds ratio (aOR) with 95% confidence interval (CI) were calculated.

RESULTS

After propensity score matching, patients with IBD with a SARS-CoV2 infection were at an increased risk for HZ (aOR, 2.16; 95% CI, 1.53-3.04) compared with IBD control cohort in the pre-COVID-19 vaccine era. There was no difference in the risk (aOR, 0.87; 95% CI, 0.44-1.75) of a composite outcome of HZ complications (hospitalization, post-herpetic neuralgia, and neurologic complications) between the 2 cohorts. The IBD SARS-CoV2 cohort was also at an increased risk for HZ (aOR, 3.04; 95% CI, 1.48-6.24) compared with IBD control cohort in the postvaccine era. However, the risk of HZ in the postvaccine era was decreased (aOR, 0.45; 95% CI, 0.27-0.76) compared with IBD SARS-CoV2 cohort in the prevaccine era.

CONCLUSIONS

Our study showed that SARS-CoV2 infection is associated with an increased risk of HZ in patients with IBD.

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

Risk factors for herpes zoster infections: a systematic review and meta-analysis unveiling common trends and heterogeneity patterns

PURPOSE

The burden of herpes zoster (HZ) is substantial and numerous chronic underlying conditions are known as predisposing risk factors for HZ onset. Thus, a comprehensive study is needed to synthesize existing evidence. This study aims to comprehensively identify these risk factors.

METHODS

A systematic literature search was done using MEDLINE via PubMed, EMBASE and Web of Science for studies published from January 1, 2003 to January 1, 2023. A random-effects model was used to estimate pooled Odds Ratios (OR). Heterogeneity was assessed using the I2 statistic. For sensitivity analyses basic outlier removal, leave-one-out validation and Graphic Display of Heterogeneity (GOSH) plots with different algorithms were employed to further analyze heterogeneity patterns. Finally, a multiple meta-regression was conducted.

RESULTS

Of 6392 considered records, 80 were included in the meta-analysis. 21 different conditions were identified as potential risk factors for HZ: asthma, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), depression, diabetes, digestive disorders, endocrine and metabolic disorders, hematological disorders, HIV, inflammatory bowel disease (IBD), mental health conditions, musculoskeletal disorders, neurological disorders, psoriasis, renal disorders, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and transplantation. Transplantation was associated with the highest risk of HZ (OR = 4.51 (95% CI [1.9-10.7])). Other risk factors ranged from OR = 1.17-2.87, indicating an increased risk for all underlying conditions. Heterogeneity was substantial in all provided analyses. Sensitivity analyses showed comparable results regarding the pooled effects and heterogeneity.

CONCLUSIONS

This study showed an increased risk of HZ infections for all identified factors.

Herpes zoster after the third dose of SARS-CoV-2 mRNA-BNT162b2 vaccine in actively treated cancer patients: a prospective study

Several concerns have been raised about a causal relationship between COVID-19 mRNA-based vaccines and the development of herpes zoster (HZ). We performed a prospective analysis of the Vax-On-Third-Profile study to investigate the incidence of HZ after the third dose of mRNA-BNT162b2 (tozinameran) and its correlation with immune responses. Patients who had received a booster dose and had been actively treated for at least 8 weeks were eligible. Serologic assessment was performed before the third dose of tozinameran (timepoint-1) and 4 weeks later (timepoint-2). We also assessed the incidence of SARS-CoV-2 breakthrough infections at predefined time points. The current analysis included 310 patients, of whom 109 (35.2%) and 111 (35.8%) were being treated with targeted therapies and cytotoxic chemotherapy, respectively. All participants received a third dose of tozinameran between September 26 and October 30, 2021. After a mean follow-up of 17.3 (IQR 15.1-18.4) months, HZ occurred in 8 recipients, for a cumulative incidence of 2.6%, and an incidence rate of 0.310 per person-year (95% CI 0.267-0.333). All HZ cases occurred within 30 days of booster dosing (range 5-29 days), with a median time to onset of 15 (IQR 9-22) days. Among the 7 patients (2.2%) who also contracted a SARS-CoV-2 infection, all cases preceded COVID-19 outbreaks. No instances of complicated HZ were reported. In multivariate analysis, impaired T helper and T cytotoxic cell counts independently correlated with HZ occurrence. These findings provide the first evidence that cancer patients on active treatment have a not negligible risk of developing HZ within 30 days after the third dose of tozinameran. The favorable clinical outcome of all observed cases confirms that protective effects of boosters in reducing the risk of severe COVID-19 outweigh the potential risk of HZ occurrence.

The value of herpes zoster prevention in people aging with HIV: A narrative review

OBJECTIVE

Review the evidence on the incidence and impact of herpes zoster among people living with HIV and the potential impact of recombinant zoster vaccine for people aging with HIV.

METHODS

Narrative review.

RESULTS

Although antiretroviral therapy has substantially reduced the risk of herpes zoster among people living with HIV, they remain at an increased risk compared with the general population. Among people aging with HIV, aging per se is now the main risk factor for herpes zoster. Beyond pain, herpes zoster is also associated with a risk of sight-threatening complications in case of trigeminal involvement, disseminated diseases and stroke. Post-herpetic neuralgia is also a potential threat to the quality of life of people aging with HIV. The recombinant zoster vaccine has demonstrated high and sustained efficacy in the prevention of herpes zoster, post-herpetic neuralgia, and other herpes zoster complications in the general population. Immunogenicity data among people living with HIV with high CD4+ T-cell count and controlled viral load are comparable to those among the general population. Real-life effectiveness data indicate high vaccine efficacy among immunocompromised patients other than people living with HIV. High vaccine price, vaccine hesitancy, and limited disease and vaccine awareness represent potential hurdles for high vaccine uptake among people aging with HIV in Europe.

CONCLUSIONS

Herpes zoster, and its complications, is a vaccine-preventable disease of aging people. Given its impact on quality of life, herpes zoster prevention using recombinant zoster vaccine is a safe strategy to be considered in every person aging with HIV.

Cost-Effectiveness of Recombinant Zoster Vaccine for Adults Aged ≥50 Years in China

INTRODUCTION

Adjuvanted recombinant zoster vaccine (RZV) was the first vaccine made available for herpes zoster in China. Authors aimed to evaluate its economic and health impacts on Chinese adults aged ≥50 years.

METHODS

A lifetime Markov model was developed to compare the cost-effectiveness of RZV with that of no vaccination from a societal perspective. Model inputs were derived from published literature and analyzed in 2022. Outcomes included total costs, quality-adjusted life-years, incremental cost-effectiveness ratio, and number of herpes zoster and herpes zoster-related cases. Sensitivity analyses were performed to examine the robustness of the model results.

RESULTS

RZV was more costly than no vaccination by $2.78 billion with an additional 65,008 quality-adjusted life-years gained and could avoid 1,893,530 herpes zoster cases, 295,761 postherpetic neuralgia cases, 51,734 other complications, and 229 herpes zoster-related deaths. Incremental cost-effectiveness ratios of RZV varied in a range of $34,465.5-$51,002.7 per quality-adjusted life-year. RZV for the entire cohort would be cost-effective when discount rate was <2.4%, a waning rate of 2-dose RZV efficacy decreased to <0.8%, the utility of postherpetic neuralgia was <0.496, duration of postherpetic neuralgia was >12.86 months, or the cost of RZV per dose decreased to <$229.6. In a probabilistic sensitivity analysis, the probability of RZV being cost-effective was 43.95%, 59.32%, 45.27%, and 39.50% for people aged 50-59, 60-69, 70-79, and ≥80 years, respectively, with threefold gross domestic product per capita (37,654.5 per quality-adjusted life-year) as the willingness-to-pay threshold.

CONCLUSIONS

RZV was most likely to be cost-effective in people aged 60-69 years. A slight decrease in vaccine cost would result in RZV being cost-effective in all people aged ≥50 years.

Immunogenicity and Efficacy of Vaccination in People Living with Human Immunodeficiency Virus

People living with HIV (PLWH) remain at high risk of mortality and morbidity from vaccine-preventable diseases, even though antiretroviral therapy (ART) has restored life expectancy and general well-being. When, which, and how many doses of vaccine should be administered over the lifetime of PLWH are questions that have become clinically relevant. Immune responses to most vaccines are known to be impaired in PLWH. Effective control of viremia with ART and restored CD4+ T-cell count are correlated with an improvement in responsiveness to routine vaccines. However, the presence of immune alterations, comorbidities and co-infections may alter it. In this article, we provide a comprehensive review of the literature on immune responses to different vaccines in the setting of HIV infection, emphasizing the potential effect of HIV-related factors and presence of comorbidities in modulating such responses. A better understanding of these issues will help guide vaccination and prevention strategies for PLWH.

Acceptability of Herpes Zoster Vaccination among Patients with Diabetes: A Cross-Sectional Study in Saudi Arabia

Background: Vaccines have recently been made available free of charge by the Saudi Ministry of Health for people 50 years or older. Diabetes mellitus (DM) increases herpes zoster (HZ) susceptibility, severity, serious complications, and negative impacts on underlying DM conditions, which are highly prevalent in Saudi Arabia. This study aimed to assess the acceptability of the HZ vaccination and its predictors among patients with diabetes in the Qassim region of Saudi Arabia. Methods: A cross-sectional study of patients with diabetes from a primary healthcare center in the Qassim region was conducted. Information was obtained on sociodemographic characteristics, history of herpes zoster infection, knowing someone who had had herpes zoster, past vaccinations, and factors influencing their intention to receive the HZ vaccination through a self-administered online questionnaire. Results: The median age (IQR) was 56 years (53–62). Overall, 25% (n = 104/410) of the participants reported their acceptability of the HZ vaccination, and the predictors were being male (AOR 2.01, 95% CI 1.01–4.00, p = 0.047), believing the HZ vaccine was effective (AOR 3.94, 95% CI 2.25–6.90, p < 0.001), and awareness that immunocompromised individuals are at a higher risk of contracting HZ (AOR 2.32, 95% CI 1.37–3.93, p = 0.002). A total of 74.2% (n = 227/306) of the participants reported their acceptability of the HZ vaccination if advised by their physician, and the predictors were being male (AOR 2.37, 95% CI 1.18–4.79, p = 0.016) and having a history of varicella vaccine uptake (AOR 4.50, 95% CI 1.02–19.86, p = 0.047). Conclusions: One-quarter of the participants were ready to accept the HZ vaccine, but this proportion significantly increased when the patients were advised by their physicians. The uptake rate can be improved with the involvement of healthcare providers and focused awareness campaigns about the effectiveness of the vaccine.

Management of Invasive Infections in Diabetes Mellitus: A Comprehensive Review

Patients with diabetes often have more invasive infections, which may lead to an increase in morbidity. The hyperglycaemic environment promotes immune dysfunction (such as the deterioration of neutrophil activity, antioxidant system suppression, and compromised innate immunity), micro- and microangiopathies, and neuropathy. A greater number of medical interventions leads to a higher frequency of infections in diabetic patients. Diabetic individuals are susceptible to certain conditions, such as rhino-cerebral mucormycosis or aspergillosis infection. Infections may either be the primary symptom of diabetes mellitus or act as triggers in the intrinsic effects of the disease, such as diabetic ketoacidosis and hypoglycaemia, in addition to increasing morbidity. A thorough diagnosis of the severity and origin of the infection is necessary for effective treatment, which often entails surgery and extensive antibiotic use. Examining the significant issue of infection in individuals with diabetes is crucial. Comprehensive research should examine why infections are more common amongst diabetics and what the preventive treatment strategies could be.

The health and economic impact of switching vaccines in universal varicella vaccination programs using a dynamic transmission model: An Israel case study

Currently available health economic models for varicella infection are designed to inform the cost-effectiveness of universal varicella vaccination (UVV) compared with no vaccination. However, in countries with an existing UVV program, these models cannot be used to evaluate whether to continue with the current varicella vaccine or to switch to an alternative vaccine. We developed a dynamic transmission model that incorporates the historical vaccination program to project the health and economic impact of changing vaccination strategies. We applied the model to Israel, which initiated UVV in 2008 with a quadrivalent vaccine, MMRV-GSK, and switched to MMRV-MSD in 2016. The model was calibrated to pre-vaccination incidence data before projecting the impact of the historical and future alternative vaccination strategies on the clinical burden of varicella. Total costs and QALYs lost due to varicella infections were projected to compare continuing with MMRV-MSD versus switching to MMRV-GSK in 2022. Over a 50-year time horizon, continuing with MMRV-MSD reduced varicella incidence further by 64%, reaching 35 cases per 100,000 population by 2072, versus a 136% increase in incidence with MMRV-GSK. Continuing with MMRV-MSD reduced cumulative hospitalization and outpatient cases by 48% and 58% (vs. increase of 137% and 91% with MMRV-GSK), respectively. Continuing with MMRV-MSD resulted in 139 fewer QALYs lost with total cost savings of 3% compared with switching to MMRV-GSK, from the societal perspective. In Israel, maintaining the UVV strategy with MMRV-MSD versus switching to MMRV-GSK is projected to further reduce the burden of varicella and cost less from the societal perspective.

Efficacy, effectiveness, and safety of herpes zoster vaccine in the immunocompetent and immunocompromised subjects: A systematic review and network meta-analysis

Objective

To investigate the efficacy, effectiveness and safety of recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) in immunocompetent and immunocompromised subjects.

Methods

Data sources: PubMed, EMBASE, Cochrane Library, and Web of Science databases (up to Jan 2022) were searched to identify English articles. Search terms included randomized controlled trials (RCTs), observational studies, herpes zoster, RZV, ZVL. Study Selection: Only randomized controlled trials (RCTs) evaluating vaccine efficacy and safety and observational studies assessing vaccine effectiveness (after a vaccine was approved for marketing) were included. Data Extraction: Two researchers independently screened the literature, extracted the data, and checked the each other results.

Results

Seventeen RCTs and 19 cohort studies were included. Among immunocompetent subjects, RZV was superior to ZVL at wide intervals (relative vaccine efficacy: 84%, 95% CI: 53%–95%; relative vaccine effectiveness: 49%, 95% CI: 21%–67%), across genders and subjects aged ≥ 60 years. Among immunocompromised subjects, RZV was superior to placebo in terms of vaccine efficacy (60%, 95% CI: 49%–69%). There was no difference between ZVL and placebo in those with selected immunosuppressive conditions. RZV was 45% (95% CI: 30%–59%) superior to ZVL in real-world practice. Compared with placebo, adverse events related to RZV were primarily related to injection-site and systemic, and RZV did not increase the risk of serious adverse events (SAEs) or death. There was no difference in the incidence of adverse events between groups with and without immunosuppression.

Conclusions

Both RZV and ZVL can reduce the risk of herpes zoster in both immunocompetent and immunocompromised subjects. RZV was well-tolerated in the study population and demonstrated stronger protection than ZVL.

Systematic review registration

Prospero CRD42022310495.

Association Between Diabetes Mellitus and the Risk of Herpes Zoster: A Systematic Review and Meta-analysis

CONTEXT

Individuals with diabetes mellitus (DM) are susceptible to various infections.

OBJECTIVE

We estimated the risk of herpes zoster (HZ) among individuals with DM compared with individuals in the general population.

METHODS

We searched the PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and PerioPath databases from their inception to January 30, 2021, for studies on the risk of HZ in individuals with DM. Two authors independently screened all articles identified. The same 2 authors independently extracted the data. Four case-control studies and 12 cohort studies were included.

RESULTS

Meta-analyses were performed using fixed and mixed-effects models. In the pooled analysis, individuals with DM had a higher risk of developing HZ (pooled relative risk [RR]: 1.38; 95% CI, 1.21-1.57) than individuals in the general population. The results were consistent in subgroup analyses stratified by type of diabetes, age, and study design. In individuals with DM, cardiovascular disease had an additive effect on increasing the risk of HZ (pooled RR: 1.19; 95% CI, 1.11-1.28). There was a linear dose-response association between age and the risk of HZ in individuals with DM.

CONCLUSION

Individuals with DM have an increased risk of HZ compared with the general population. Varicella vaccination should be provided to individuals with DM regardless of their age, prioritizing older adults and those with cardiovascular disease. Varicella vaccination policies for individuals with DM should be updated based on the evidence.

An Analysis of Spontaneously Reported Data of Vesicular and Bullous Cutaneous Eruptions Occurring Following Vaccination with the Adjuvanted Recombinant Zoster Vaccine

Introduction

With the approval of the adjuvanted recombinant zoster vaccine (RZV; Shingrix, GSK) in October 2017, GSK established enhanced safety surveillance measures to allow prompt identification of potential safety signals not observed during clinical development. In Germany, cases of vesicular and bullous cutaneous eruptions following RZV vaccination were reported.

Objective

Our objective was to search and analyse 2.5 years of worldwide spontaneously reported post-marketing data for vesicular and bullous cutaneous eruptions, represented by adverse events suggestive of (1) herpes zoster (HZ) and (2) non-HZ vesicular and bullous cutaneous eruptions, that occurred following RZV vaccination.

Methods

We conducted a descriptive analysis of all identified reports of HZ and non-HZ vesicular and bullous cutaneous eruptions following RZV vaccination and an observed versus expected (O/E) analysis of reports of HZ that met criteria of varicella zoster virus (VZV) reactivations following RZV vaccination (i.e., time to onset [TTO] of the event < 30 days or missing after any dose).

Results

Until the data lock point, 32,597,779 RZV doses had been distributed globally. There were 2423 reports of HZ (including complications) identified, of which 645 met the criteria of possible vaccination failure (i.e., TTO of the event ≥ 30 days or missing following a complete RZV vaccination schedule). The O/E analysis of 1928 reports assessed as possible VZV reactivations indicated that the observed number of cases was lower than that expected in the general population. Additionally, 810 reports of non-HZ vesicular and bullous cutaneous eruptions were identified, including injection site rashes attributed to the vaccine’s reactogenicity.

Conclusion

This review of spontaneously reported post-marketing data did not raise safety concerns regarding the occurrence of vesicular and bullous cutaneous eruptions following vaccination with RZV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01118-3.

Shingles is a disease caused by reactivation of the chickenpox virus. It mostly affects adults aged 50 years and older and patients of all ages who have an impaired immune system. Diagnosis of shingles is often based only on the presence of symptoms such as a typical rash and pain. However, rashes can have various other causes (e.g., allergies, autoimmune diseases, and infections). Consequently, rashes with other causes may be misdiagnosed as shingles. Adults at increased risk of shingles and/or aged 50 years and older may be vaccinated with Shingrix (GSK, Belgium) to protect them from shingles and its complications. Since Shingrix became available in Germany, blister-like skin rashes have been reported that occurred shortly after vaccination. We searched the GSK safety database for reports of blister-like skin rashes that occurred following vaccination with Shingrix and that were spontaneously reported from countries where Shingrix was first marketed. To analyse these reports of rashes, we described the reports that we retrieved, we performed a statistical analysis to quantify whether the number of events assessed as reactivations of the chickenpox virus following Shingrix vaccination was higher than the number of reactivations that would be expected in the general population, and we described possible explanations for the observed rashes and underlying disease mechanisms. Our analyses did not raise safety concerns related to the onset of these rashes after vaccination with Shingrix. This paper raises awareness about the varying causes of rashes since a shingles-like rash that onsets shortly after vaccination with Shingrix is not necessarily caused by vaccination. In conclusion, this analysis shows that caution is needed when evaluating rashes in older adults and that all potential contributing factors (e.g., pre-existing diseases, medication, vaccination) should be considered.

Clinical Manifestations of Herpes Zoster Associated with Complications in Children

Herpes zoster (HZ) is caused by latent varicella-zoster virus (VZV) reactivation when VZV-specific cell-mediated immunity declines. Information on HZ in children is limited. Therefore, we retrospectively investigated HZ's clinical course and complications in children. We extracted the outpatient and hospitalization medical records of pediatric patients (<19 years) primarily diagnosed with HZ (ICD-10 B02 code) between January 2010 and November 2020. HZ was defined as a typical unilateral dermatomal vesicular rash where HZ was the treating physician's primary diagnosis. Recognized HZ complications included combined bacterial skin infection, ophthalmic zoster, zoster oticus without facial paralysis, meningitis, and PHN. We identified 602 HZ cases, among which 54 developed HZ complications and were included in our analysis. The median age was 14.7 years, most patients were aged ≥13 years (42, 79%), and none were aged <4 years. Fifty-three were immunocompetent, and only one had systemic lupus erythematosus. The most frequent complication was zoster ophthalmicus (n = 26, 48%). HZ complications were also observed in immunocompetent or vaccinated children exhibiting a head or neck rash before and after VZV immunization. Current VZV vaccination programs may be insufficient in preventing HZ complications. Therefore, close varicella and HZ burden monitoring and the establishment of effective VZV vaccination programs are imperative.

Diagnosis and management of ophthalmic zoster sine herpete accompanied by cervical spine disc protrusion: A case report

BACKGROUND

Zoster sine herpete (ZSH) can be misdiagnosed because there are no typical vesicular eruptions characterized by a dermatomal distribution. However, incorrect treatment due to a misdiagnosis can lead to severe pain and fatal complications.

CASE SUMMARY

A 75-year-old woman complained of sudden onset right shoulder pain and atypical headache. After 18 d, sudden hearing loss occurred in the left ear. In serology tests conducted after the onset of hearing loss, varicella-zoster virus IgM was positive. She had no history of a rash or trauma. Under the suspicion of ZSH, antiviral treatment and stellate ganglion block were administered four times, and the pain was effectively controlled.

CONCLUSION

Early diagnosis and treatment of ZSH can help not only by reducing pain but also by preventing fatal complications.

Increased frequency of HLA-A*02 in patients with atherosclerosis is associated with VZV seropositivity

BACKGROUND

HLA molecules are inherited key molecules in the immune inflammation and specific responses to environmental pathogens. We investigated the association of HLA-A alleles with Varicella zoster virus (VZV) seropositivity in patients with atherosclerosis (AS).

MATERIALS AND METHODS

Plasma Anti-VZV IgG and molecular HLA type were detected in 203 (100 AS⁺ and 103 AS^-) individuals.

RESULTS

Of 100 AS⁺ individuals, 66 were anti-VZV⁺ and 34 were anti-VZV^-. Of 103 age/sex-matched AS^- individuals, 59 were anti-VZV⁺ and 44 were anti-VZV^-. Anti-VZV-IgG in AS⁺ cases was higher than AS^- controls (p = .034). The mean anti-VZV IgG in HLA-A*02⁺AS⁺ individuals was higher than HLA-A*02⁺AS^- controls (p < .001). HLA-A*02 was associated with VZV-seropositivity (p = .01) in AS⁺ patients. A higher frequency of HLA-A*02-allele in AS⁺ patients compared to AS^- controls (p = .015) and an accumulation of HLA-A*02-allele in AS⁺ anti-VZV⁺ group (33.3%, p = .004) was observed.

CONCLUSIONS

HLA-A alleles and immune responses to VZV are associated with clinical atherosclerosis.

A systematic literature review of herpes zoster incidence worldwide

We conducted a systematic review to characterize the incidence rate of herpes zoster (HZ) in the general population, specifically in individuals ≥50 years of age. A total of 69 publications were included in the review. We found a cumulative incidence of HZ ranging from 2.9–19.5 cases per 1,000 population and an incidence rate of HZ ranging from 5.23–10.9 cases per 1,000 person-years. The cumulative incidence (3.22–11.2 versus 2.44–8.0 cases per 1,000 population) and incidence rates (6.05–12.8 versus 4.30–8.5 cases per 1,000 person-years) were higher in females than males. Studies revealed a trend of increasing incidence of HZ with increasing age and over time. Variations in incidence estimates can be attributed to the various study designs, case ascertainments, age distributions of the population and year of the study. HZ is associated with a substantial disease burden and is expected to increase due to population aging.

Short-Term Peripheral Nerve Stimulation Relieve Pain for Elder Herpes Zoster Ophthalmicus Patients: A Retrospective Study

OBJECTIVE

Ophthalmic postherpetic neuralgia (PHN) is the final stage of herpes zoster (HZ) ophthalmicus and a severe refractory neuropathic pain, thus there is no curative treatment that could alleviate pain and reduce the incidence of ophthalmic PHN now. The purpose of this study is to evaluate therapeutic efficacy of short-term peripheral nerve stimulation (PNS) for elder patients with HZ ophthalmicus.

MATERIALS AND METHODS

We performed a retrospective study from March 2015 to August 2019 in our pain department. All the HZ ophthalmicus patients underwent supraorbital nerve short-term PNS were included. The patients' data, including numeric rating scale (NRS), 36-Item short form health survey (SF-36), and analgesic consumptions, were retrospectively analyzed. Severe side effects also were recorded.

RESULTS

A total of 68 patients were enrolled in this study. The NRS scores were significantly decreased at different time points after short-term PNS compared to baseline (p < 0.001). The SF-36 scores, including general health, social function, emotional role, mental health, bodily pain, physical functioning, physical role, and vitality, were significantly improved at different time points after treatment (p < 0.001). The average dosages of tramadol and pregabalin administered (mg/d) were both significantly reduced compared to baseline (p < 0.001). There was no bleeding, infection, pain increase, and other side effects after treatment.

CONCLUSIONS

Short-term PNS is an effective and safe therapeutic alternative for elder patients with HZ ophthalmicus and could reduce the incidence of ophthalmic PHN.

Post-herpetic Neuralgia: A Systematic Review of Current Interventional Pain Management Strategies

Background:

Post-herpetic neuralgia (PHN) is usually a constant or intermittent burning, stabbing, or sharp shooting pain with hyperalgesia or allodynia, persisting beyond the healing of herpetic skin lesions. This review was carried out in concordance to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We used PICOS (Population, Intervention, Control, and Outcome Study) design for inclusion of potential studies into this review. Online literature available in PubMed, Cochrane, and Embase was searched for studies from January 1995 till March 2020, which evaluated interventional treatments in PHN by an independent reviewer, using the relevant medical subject heading (MeSH) terms. We analyzed the following outcome parameters with regard to each intervention—pain status at predefined fixed intervals after the intervention, quality of sleep using any of the reported questionnaires, analgesic consumption, functional evaluation, and quality of life assessment after the intervention.

Conclusion:

Interventional pain management options provide effective and long-lasting pain relief to patients not responding to medical management. The choice of intervention will depend on the region involved, cost, and invasiveness. Simple procedures such as intercostal nerve blocks/neurolysis, stellate ganglion blocks, paravertebral neurolysis, epidural steroid injections, and dorsal root ganglion–radiofrequency ablation are effective interventions, and if they fail, spinal cord stimulators could be effective in the hands of experienced pain physicians.

Risk of recurrent herpes zoster in a population-based cohort study of older adults

BACKGROUND

There are limited data on zoster recurrence.

OBJECTIVE

To examine in detail zoster recurrence in a population-based cohort.

METHODS

Using data from a large cohort (The 45 and Up Study) with linked medical data (2004-2015), the incidences of first and recurrent zoster were examined by using survival analysis methods.

RESULTS

Over 1,846,572 person-years of follow-up, of 17,413 participants who had a first zoster episode (incidence, 9.43 per 1000 person-years; 95% confidence interval, 9.29-9.57), 675 (3.9%) experienced a recurrence. The mean time between first and recurrent zoster was 2 years for those aged 45-54 years and 3 years for those aged 55 years and older. Among those with a first zoster, the incidence of recurrence was 11.05 (95% confidence interval, 10.24-11.91) per 1000 person-years, and higher recurrence incidence occurred in women compared to men, in younger compared to older participants, and in immunosuppressed compared to nonimmunosuppressed participants. Recurrence appeared lower in the 12 months after zoster onset but then remained consistent at approximately 12.00 per 1000 person-years in the following 8 years.

LIMITATIONS

Recurrence may be underestimated because of the use of administrative data for case ascertainment. Potential misclassification of nonimmunosuppressed participants.

CONCLUSIONS

Our results support the vaccination of people who have already experienced zoster and underpin the need for additional studies on immunogenicity and vaccine efficacy in these populations.

Radiation therapy and the risk of herpes zoster in patients with cancer

BACKGROUND

The role and impact of radiation therapy (RT) on the development of herpes zoster (HZ) has not been well studied. The objective of this study was to investigate the association between RT and HZ.

METHODS

A propensity score-matched, retrospective cohort study was conducted using institutional cancer registry data and medical records from 2011 to 2015. The risk of developing HZ in the RT and non-RT groups was compared using a Cox proportional hazards model. Associations also were explored between the RT field and the anatomic location of HZ in patients who developed HZ after RT. The expected number of HZ events within the radiation field was calculated according to the RT received by each patient; then, this number was compared with the observed number of in-field events.

RESULTS

Of 17,655 patients, propensity score matching yielded 4350 pairs; of these, 3891 pairs were eligible for comparison. The cumulative incidence of HZ in the RT group (vs the non-RT group) during the first 5 years after the index date was 2.1% (vs 0.7%) at 1 year, 3.0% (vs 1.0%) at 2 years, 3.4% (vs 1.3%) at 3 years, 4.1% vs 1.7% at 4 years, and 4.4% vs 1.8% at 5 years. The RT group showed a significantly higher risk of HZ than the non-RT group (hazard ratio, 2.59, 95% CI, 1.84-3.66). In the 120 patients who developed HZ after RT, HZ events were observed significantly more frequently within the RT field than expected (74 vs 43.8 events; P < .001).

CONCLUSIONS

Patients with cancer who received RT showed a significantly higher risk of HZ, which was commonly observed within the radiation field.

Incidence, Clinical Features, Management, and Prevention of Herpes Zoster in Patients Receiving Antitumor Necrosis Factor Therapy: A Clinical Review

Tumor necrosis factor (TNF) inhibitors have been used as an excellent therapeutic option in a variety of chronic inflammatory conditions. However, a recognized significant adverse effect of TNF inhibitor therapy is the increased risk of infections. The influence of TNF inhibitors on the course of coexisting or newly developed viral infections has not been extensively investigated. Therefore, we reviewed the recent publications to highlight the incidence, clinical features, management, and prevention of herpes zoster in patients who are receiving TNF inhibitors.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.

Diabetes as a risk factor for herpes zoster in adults: A synthetic literature review

AIM

The objective of this review was to evaluate the role of diabetes as a risk factor for herpes zoster (HZ) and to discuss implications of prevention by vaccination with available HZ vaccines.

METHODS

We reviewed studies that investigated the incidence rates of HZ in patients with diabetes. Papers in English or French published between January 2000 and December 2018 have been selected from PubMed and Google Scholarship by using appropriate key words.

RESULTS

The risk of HZ was significantly higher in patients with diabetes as compared to controls in 11 studies out of 16, although the magnitude of risk associated to diabetes varied across studies from 1.06 to 2.38 (p < 0.05). The incidence of HZ in patients with diabetes increased with age and was higher in women than in men. The incidence of the most common complication of HZ, i.e. post-herpetic neuralgia was also higher in patients with diabetes.

CONCLUSIONS

The presence of HZ adds supplementary complications to the pre-existing comorbidity in patients with diabetes. Investigating the impact of preventive measure by HZ vaccination is therefore of paramount importance in patients with diabetes.

Ischemia-modified albumin (IMA) and dynamic thiol-disulfide homeostasis in patients with postherpetic neuralgia

Background

Ischemia-modified albumin (IMA) is an isotype of albumin that increases under oxidative stress, and plasma thiols are main defense mechanisms against oxidative stress. The objective of this study was to investigate thiol-disulfide homeostasis and serum IMA levels in postherpetic neuralgia (PHN) patients.

Methods

A total of 29 PHN patients and 30 healthy controls were included in the study. Serum total and native thiol concentrations and serum disulfide concentration were measured using the method described by Erel and Neselioglu. The albumin cobalt binding test was used to measure serum IMA levels.

Results

Serum IMA levels were 1.21 ± 0.58 AU and 0.75 ± 0.09 AU in the PHN and control groups, respectively (p < 0.001). Serum total thiol concentrations were found to be 421.62 ± 90.28 μmol/L and 598.36 ± 73.63 μmol/L in the PHN and control groups, respectively (p < 0.001). Serum native thiol concentrations were found to be 365.75 ± 92.07 μmol/L and 531.90 ± 72.9 μmol/L in the PHN and control groups, respectively (p < 0.001). Serum disulfide concentrations were found to be 33.23 ± 5.33 μmol/L and 27.93 ± 7.81 μmol/L in the PHN and control groups, respectively (p = 0.003). The native thiol/total thiol ratio was significantly lower, and the disulfide/total thiol and disulfide/native thiol ratios were significantly higher in the PHN group compared to the controls.

Conclusions

IMA levels are high and dynamic thiol/disulfide homeostasis is disrupted in PHN patients.

Cost-effectiveness analysis of universal varicella vaccination in Turkey using a dynamic transmission model

BACKGROUND

In 2013, Turkey introduced one-dose universal varicella vaccination (UVV) at 12 months of age. Inclusion of a second dose is being considered.

METHODS

We developed a dynamic transmission model to evaluate three vaccination strategies: single dose at 12 months (1D) or second dose at either 18 months (2D-short) or 6 years of age (2D-long). Costs and utilization were age-stratified and separated into inpatient and outpatient costs for varicella and herpes zoster (HZ). We ran the model including and excluding HZ-related costs and impact of exogenous boosting.

RESULTS

Five years post-introduction of UVV (1D), the projected varicella incidence rate decreases from 1,674 cases pre-vaccine to 80 cases/100,000 person-years. By 25 years, varicella incidence equilibrates at 39, 12, and 16 cases/100,000 person-years for 1D, 2D-short, and 2D-long strategies, respectively, using a highly effective vaccine. With or without including exogenous boosting impact and/or HZ-related costs and health benefits, the 1D strategy is least costly, but 2-dose strategies are cost-effective considering a willingness-to-pay threshold equivalent to the gross domestic product. The model predicted a modest increase in HZ burden during the first 20-30 years, after which time HZ incidence equilibrates at a lower rate than pre-vaccine.

CONCLUSIONS

Our findings support adding a second varicella vaccine dose in Turkey, as doing so is highly cost-effective across a wide range of assumptions regarding the burden associated with varicella and HZ disease.

Recurrence Rate of Herpes Zoster and Its Risk Factors: a Population-based Cohort Study

BACKGROUND

Herpes zoster (HZ) is generally thought to occur once in a lifetime and recurrence is considered to be limited to immunocompromised individuals. Although HZ recurrence rates seem to be increasing, there have been few studies exploring these rates in the general population. We investigated the recurrence rate and associated risk factors in the general population.

METHODS

We used the population-based samples of the National Health Insurance Service database to identify cases of initial HZ episodes from January 1, 2002 to December 31, 2013. We also followed up on these cases through December 31, 2013 to identify recurrence.

RESULTS

Overall, the incidence rate of HZ is 5.1 per 1,000 person years and the recurrence rate is 12.0 per 1,000 person years. There were 2,100 recurrent cases out of 39,441 initial episodes with 4.4 years of the mean follow-up period. We identified significant risk factors for recurrence such as old age (51-70 years) (hazard ratio [HR], 1.447; 95% confidence interval [CI], 1.311-1.598), women (1.476; 1.345-1.619), zoster-related pain (ZRP) longer than 30 days (cases of ZRP lasting 31-90 days [1.200; 1.042-1.383], and ZRP lasting longer than 90 days [2.293; 1.990-2.643]). Concurrent hematologic malignancies (2.864; 1.929-4.251), autoimmune diseases (1.466; 1.252-1.715), dyslipidemia (1.390; 1.263-1.530), and hypertension (1.222; 1.107-1.350) were also significant risk factors.

CONCLUSION

Our results suggest that the recurrence of HZ is much more common than generally expected, and that the associated risk factors can play an important role in predicting recurrence.

[Results of laser confocal microscopy of the cornea in viral uveitis (a preliminary report)]

Herpesviruses involve neurotropic activity (they affect nerve cells) and have the ability to induce an immune response (a special tropism for immune tissue), which provides a valid reason for studying the possibilities of visualizing nerve fibers of the cornea and Langerhans cells (LC) in viral uveitis (with prospective applications in early diagnosis).

PURPOSE

To evaluate the results of laser corneal confocal microscopy (CCM) in viral uveitis of varying localization.

MATERIAL AND METHODS

The main study group included 23 patients (23 eyes) diagnosed with unilateral herpesviral uveitis (chorioretinitis), the patients' age varied from 18 to 79 years. The control group comprised 19 healthy volunteers (38 eyes) aged 20 to 75 years. In addition, the paired eyes of the main group patients were examined. In all patients, standard ophthalmologic examination was complemented with CCM performed on the HRT III device with a corneal module, followed by analysis of the course and structure of corneal nerve fibers (CNF) using copyrighted software Liner 1.2.

CONCLUSION

The preliminary results achieved in this study outline the prospects for further research on the state of cornea (in particular, changes in the course and structure of CNF, and the presence of dendritiform cells of Langerhans) with laser CCM in patients with uveitis of various etiologies. These morphological changes also has potential use as diagnostic markers of inflammation of the uveal tract. The main criteria for assessing the state of cornea in viral uveitis include the following: increased tortuosity of CNF, increase in the number and size of Langerhans cells. Further research - in particular, studying the integrated use of diagnostic methods necessary for the verification of viral uveitis, as well as detailed analysis of the history and clinical picture of the disease - is required to substantiate the inclusion of laser confocal microscopy method in the algorithm for the diagnosis of viral uveitis.

The effect of ultrasound-guided percutaneous ozone injection around cervical dorsal root ganglion in zoster-associated pain: a retrospective study

Objective

This study was to evaluate the effectiveness of ultrasound-guided percutaneous ozone injections around the cervical dorsal root ganglions of zoster-associated pain (ZAP) patients.

Study design

Retrospective comparative study.

Settings

The study was conducted at a pain center of a university hospital.

Patients and methods

From June 2016 to July 2017, a total number of 30 patients with ZAP were treated with ultrasound-guided percutaneous ozone injection around the cervical dorsal root ganglion (DRG) at the injured nerve level (C2-C8). A volume of 3 mL ozone-oxygen mixture at a concentration of 30 µg/mL was injected into the area around the DRG. Patients were divided into two groups according to their disease duration: group A (at or <3 months) and group B (>3 months). The pain severity was assessed according to a visual analog scale, and imaging changes were evaluated by ultrasound. Patient improvements in pain and neurologic function were evaluated during a follow-up period from 1 to 3 months.

Results

The data showed that ozone injections reduced pain in patients with ZAP. However, the success rate of group A was higher than group B. After the injection, the von Frey data demonstrated decreases in both groups, but, there were no significant differences between the groups. Moreover, univariate logistic regression analysis and multivariate regression analysis showed a history of diabetes mellitus had a significant effect on the treatment results.

Conclusions

Percutaneous ozone injection around the DRG might be a useful method for treatment-resistant cases of ZAP at the cervical level. Institutional Review Board (IRB) approval number: HK2017-1130.

Development of adjuvanted recombinant zoster vaccine and its implications for shingles prevention

INTRODUCTION

GSK has developed a two-dose adjuvanted recombinant zoster vaccine (Shingrix, RZV) to protect people aged ≥50 years (50+) against herpes zoster (HZ) and its complications. RZV showed >90% efficacy against HZ, sustained over 4 years of follow-up, in all studied age groups.

AREAS COVERED

This article reviews the scientific rationale underlying the design of RZV; the clinical evidence demonstrating immunogenicity, safety, and efficacy in persons 50+; and the public health implications and cost-effectiveness.

EXPERT COMMENTARY

A decline in varicella zoster virus (VZV) immunity is associated with increased risk of HZ in adults 50+ and immunocompromised individuals. RZV was designed to restore levels of anti-VZV cellular and humoral immunity to prevent VZV reactivation. RZV includes the recombinant gE glycoprotein antigen, and Adjuvant System AS01_B which promotes cellular and antibody responses. In two Phase III studies in subjects aged 50+ and 70+ years, RZV efficacy against HZ compared to placebo was >90% and ≥89% against post-herpetic neuralgia (PHN). RZV is expected to dramatically impact HZ morbidity including its complications, and associated health-care costs. In the US population aged 50+ years, vaccination with RZV can be cost-effective compared to no vaccination and cost-saving compared to the currently available live-attenuated HZ vaccine (Zostavax, Merck).

The Severity of Herpes Zoster in Inflammatory Bowel Disease Patients Treated With Anti-TNF Agents

AIM

There is a paucity of data on the clinical course and the factors affecting the clinical course of herpes zoster (HZ) in inflammatory bowel disease (IBD). Our aim was to determine the impact of anti-TNF therapy and other factors on the clinical course of HZ in IBD patients.

METHODS

We conducted a retrospective cohort study among a cohort of nation-wide Veterans Affairs patients with IBD who developed incident HZ. The exposed group consisted of eligible study patients who were actively exposed to anti-TNF alone or anti-TNF plus thiopurines at the time of HZ onset. The unexposed group consisted of patients who were only exposed to 5-ASA agents before the onset of HZ without any exposure to anti-TNF medications. The outcome of interest was the development of severe HZ that was defined by including various HZ complications.

RESULTS

A total of 295 patients were identified with an incident HZ flare during follow- up duration, and among them 69 met the definition of having a severe flare. In multivariable logistic regression analysis adjusting for sex, age at HZ flare onset, race, Charlson comorbidity score, and receipt of oral anti-HZ treatment, exposure to anti-TNF agent was not associated with an increased risk of severe HZ flare compared to exposure to mesalamine alone (adjusted relative risk (RR) 1.1, 95% confidence intervals (CI): 0.75-1.55). Among the covariates, receipt of oral anti-HZ treatment (adjusted RR 0.42, 95% CI: 0.29-0.61), advancing age at HZ onset (adjusted RR for each year increase in age 1.02, 95% CI: 1.00-1.04), and African-American race (adjusted RR with whites as reference 1.58, 95% CI: 1.02-2.44) were significantly associated with the risk of having severe HZ flare.

CONCLUSION

Our study showed that among IBD patients who developed HZ, treatment with anti-TNF agents was not associated with increased risk of developing severe HZ as compared to patients treated with 5-ASA therapy only. 10.1093/ibd/izx115_video1izx115_Video_15786486963001.

Impact of postherpetic neuralgia: A six year population-based analysis on people aged 50 years or older

OBJECTIVES

To estimate the incidence and burden of postherpetic neuralgia (PHN) and to investigate risk factors for PHN in the Valencia Region of Spain.

METHODS

Data were extracted from population and healthcare databases from the Valencia Region (2009-2014). Herpes zoster (HZ) and PHN were defined using ICD-9 codes and drug prescriptions in people aged ≥50 years. The risk of HZ patients for developing PHN and potential risk factors (diabetes mellitus, COPD and heart failure) were investigated. A survival analysis was developed to estimate the cumulative hazard of developing HZ and PHN between ages 50-90 years.

RESULTS

From a total of 2,289,485 subjects, 87,086 cases of HZ were registered, 13,658 (15.7%) of whom developed PHN. PHN risk was higher in women and increased sharply with age and comorbidities as diabetes mellitus, COPD and heart failure. The cumulative risk of developing HZ between ages 50-90 years was 31.7% (95% CI: 31.3-32.1) and 6.9 (95% CI: 6.7-7.1) for PHN.

CONCLUSIONS

PHN risk was higher in women and increased with age and comorbidities. At least 32% and 7% of people will develop HZ and PHN, respectively, between ages 50-90 years. These results should be considered for vaccine policy implementation.

No increased risk of herpes zoster in TNF inhibitor and non-TNF inhibitor users with rheumatoid arthritis: epidemiological study using the Japanese health insurance database

OBJECTIVE

It is controversial whether the use of biological disease-modifying antirheumatic drugs (DMARDs) increases the risk of herpes zoster (HZ). We aimed to evaluate the risks of HZ in tumor necrosis factor inhibitor (TNFI) and non-TNFI users with rheumatoid arthritis (RA) over 3 years in Japan.

METHOD

Using the Japanese health insurance database, we assigned patients with at least one RA diagnostic code and one prescription for any DMARDs (RA cases) recorded between January 2005 and December 2013 to the RA group. We randomly selected five age-, sex-, calendar year- and observation length-matched non-RA cases for each RA case (non-RA group), and assessed associations between RA and HZ. To evaluate the risks of HZ in TNFI and non-TNFI users, we conducted a nested case-control study (NCC) in the RA group.

RESULTS

The RA group (n = 6712) had a significantly higher crude incidence rate of HZ than the non-RA group (n = 33 560) (14.2 vs. 8.3/1000 patient-years), and the adjusted odds ratio (95% confidence interval) of the RA versus non-RA groups was 1.43 (1.17-1.75). The NCC demonstrated that use of TNFI, non-TNFI, methotrexate, or immunosuppressive DMARDs did not increase the risks of HZ. Use of corticosteroid ≥ 5 mg/day conveyed a significant risk of HZ in patients with RA.

CONCLUSIONS

Rheumatoid arthritis was significantly associated with the development of HZ, and use of corticosteroids ≥ 5 mg/day was identified as a significant risk factor, whereas either TNFI or non-TNFI use were not.

Herpes Zoster and Diabetes Mellitus: A Review

Accumulating evidence suggests that diabetes mellitus (DM) represents an important risk factor for both herpes zoster and post-herpetic neuralgia. Moreover, post-herpetic neuralgia appears to be more severe and persistent in diabetic patients. On the other hand, a novel vaccine against varicella-zoster virus (VZV) was recently introduced in clinical practice. Given the increased risk and severity of herpes zoster infection in patients with DM, this vaccine might be useful in this population. However, there are limited data regarding the efficacy and safety of vaccination against herpes zoster in the diabetic population. The aim of the present review is to discuss the incidence and consequences of herpes zoster infection in DM and to comment on the role of vaccination against VZV in these patients.

Diabetes and the occurrence of infection in primary care: a matched cohort study

Background

People with diabetes may be at higher risk for acquiring infections through both glucose-dependent and biologic pathways independent of glycemic control. Our aim was to estimate the association between diabetes and infections occurring in primary care.

Methods

Using the Newfoundland and Labrador Sentinel of the Canadian Primary Care Sentinel Surveillance Network, patients with diabetes ≥18 years between 1 January 2008 and 31 March 2013 were included with at least 1-year of follow-up. We randomly matched each patient with diabetes on the date of study entry with up to 8 controls without diabetes. Primary outcome was the occurrence of ≥1 primary care physician visits for any infectious disease. Secondary outcomes included primary visits for head & neck, respiratory, gastrointestinal, genitourinary, skin and soft tissue, musculoskeletal, and viral infections. Using multivariable conditional logistic regression analysis, we measured the independent association between diabetes and the occurrence of infections.

Results

We identified 1779 patients with diabetes who were matched to 11,066 patients without diabetes. Patients with diabetes were older, had a higher prevalence of comorbidities, and were more often referred to specialists. After adjusting for potential confounders, patients with diabetes had an increased risk of any infection compared to patients without diabetes (adjusted odds ratio = 1.21, 95% confidence interval 1.07–1.37). Skin and soft tissue infections had the strongest association, followed by genitourinary, gastrointestinal, and respiratory infections. Diabetes was not associated with head and neck, musculoskeletal, or viral infections.

Conclusion

Patients with diabetes appear to have an increased risk of certain infections compared to patients without diabetes.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-2975-2) contains supplementary material, which is available to authorized users.

Associations of Perceived Mental Stress, Sense of Purpose in Life, and Negative Life Events With the Risk of Incident Herpes Zoster and Postherpetic Neuralgia: The SHEZ Study

In the present population-based prospective study, we examined the associations of psychosocial factors with the incidence of herpes zoster (HZ) and postherpetic neuralgia (PHN). Data were collected from 12,359 participants (≥50 years of age) who answered a self-completed health questionnaire in the Shozu County of Kagawa Prefecture in Japan. During a 3-year follow-up between December 2008 and November 2012, HZ and PHN were diagnosed in 400 and 79 subjects, respectively. We used Cox regression analysis to estimate hazard ratios of incident HZ and PHN according to psychosocial factors, adjusting for age, sex, histories of HZ, cancer, and diabetes, smoking and drinking habits, and time from disease onset to treatment. Men with high levels of mental stress were twice as likely to be at risk for incident HZ. The risk of incident HZ was approximately 60% lower among men and women who reported a high sense of purpose in life. Women who experienced negative life events-particularly changes in their work, living environment, and relationships-had a 2- to 3-fold higher risk of incident PHN. Psychosocial factors such as perceived mental stress, sense of purpose in life, and negative life events may contribute to the development of HZ and PHN in the general population.

Does herpes zoster predispose to giant cell arteritis: a geo-epidemiologic study

Purpose

Giant cell arteritis (GCA) is the most common systemic vasculitis in the elderly and can cause irreversible blindness and aortitis. Varicella zoster (VZ), which is potentially preventable by vaccination, has been proposed as a possible immune trigger for GCA, but this is controversial. The incidence of GCA varies widely by country. If VZ virus contributes to the immunopathogenesis of GCA we hypothesized that nations with increased incidence of GCA would also have increased incidence of herpes zoster (HZ). We conducted an ecologic analysis to determine the relationship between the incidence of HZ and GCA in different countries.

Methods

A literature search for the incidence rates (IRs) of GCA and HZ from different countries was conducted. Correlation and linear regression was performed comparing the disease IR of each country for subjects 50 years of age or older.

Results

We found the IR for GCA and HZ from 14 countries. Comparing the IRs for GCA and HZ in 50-year-olds, the Pearson product-moment correlation (r) was −0.51, with linear regression coefficient (β) −2.92 (95% CI −5.41, −0.43; p=0.025) using robust standard errors. Comparing the IRs for GCA and HZ in 70-year-olds, r was −0.40, with β −1.78, which was not statistically significant (95% CI −4.10, 0.53; p=0.12).

Conclusion

Although this geo-epidemiologic study has potential for aggregation and selection biases, there was no positive biologic gradient between the incidence of clinically evident HZ and GCA.

Risk and impact of herpes zoster on patients with diabetes: A population-based study, 2009-2014

AIMS

This study was designed to assess the impact of diabetes on the risk and severity of herpes zoster (HZ), and the impact of HZ on diabetes. It focused primarily on immunocompetent patients aged ≥ 50 years who would be eligible for preventive vaccination.

METHODS

Using population and healthcare databases of Valencia Region (Spain), a retrospective cohort of all subjects ≥ 50 years was followed up between 2009 and 2014. HZ and diabetes were defined using ICD-9 codes. We compared the incidence of HZ between non-diabetes and diabetes groups and healthcare resource consumption due to HZ in the 6 months following HZ diagnosis using different statistical generalized linear models (GLM). We also compared resources consumption due to diabetes treatment and haemoglobinA1c(HbA1c) levels before and after HZ.

RESULTS

The cohort consisted of 2,289,485 individuals ≥ 50 years old, 397,940 of whom had diabetes. HZ incidence rate was 9.3 cases/1000 persons with diabetes-year (95% CI: 9.1-9.4). Incidence increased with age in all groups. The risk of HZ increased in the diabetes group compared to the non-diabetes group (RR 1.2, 95% credibility interval [CrI] 1.17-1.22). Patients with diabetes utilized more health care resources due to their HZ episodes than patients without diabetes. In 24% of well controlled patients with diabetes (HbA1C levels ≤ 6.5%), HbA1C increased after HZ.

CONCLUSIONS

Diabetes increased by 20% the risk of HZ. HZ contributed to the deterioration of glycaemic control and higher healthcare resource consumption in people with diabetes, becoming a priority population for HZ immunization.

Incidence of herpes zoster amongst adults varies by severity of immunosuppression

OBJECTIVES

We examined the incidence of herpes zoster in immunocompromised adults (≥18 years) with different severities of immunosuppression and assessed the prevalence of complications and of various kinds of healthcare resource utilisation.

METHODS

German claims data from more than ten million adults were used to calculate annual incidence rates of herpes zoster for the years 2006-2012 and to analyse the prevalence of complications, physician visits, hospitalisations, and antiviral and analgesic treatments using a cohort design. The analyses were stratified by age, sex, and severity of immunosuppression, defined by immunocompromising conditions and drug therapies.

RESULTS

The incidence rate per 1000 person-years of herpes zoster was almost twice as high in immunocompromised patients (11.5 (95% confidence interval (CI): 11.4-11.6)) compared to immunocompetent subjects (5.9 (95% CI: 5.8-5.9)). The incidence rate was higher in highly immunocompromised patients (13.4 (95% CI: 13.2-13.6)) than in patients with a low severity of immunosuppression (10.0 (95% CI: 9.8-10.1)). These differences were observed for both sexes and in all age groups. Complications, outpatient physician visits, hospitalisations, and analgesic treatments occurred more frequently in immunocompromised patients as well.

CONCLUSIONS

Our results show that immunocompromised individuals are affected by the disease in particular and that the burden of herpes zoster is highest in severely immunocompromised patients.

Postherpetic foot drop in an elderly case: undiagnosed diabetes mellitus?

Postherpetic neuralgia is the most commonly seen complication of herpes zoster, primarily in elderly and immunocompromised patients. However, motor involvement due to herpes zoster is very rare. A 65-year-old male patient presented with left leg pain, numbness and difficulty walking. He was diagnosed with having herpes zoster and treated with valacyclovir. Despite anti-convulsant and physical therapy, the patient developed foot drop and had an unexplained weight loss. Clinical and laboratory findings suggested previously undiagnosed diabetes mellitus. Three weeks after initiation of insulin treatment, he became normoglycemic, his pain was reduced, and foot drop disappeared almost completely. Postherpetic motor involvement as an unusual complication may signal an underlying systemic disease, particularly in elderly.

Herpes zoster risk after 21 specific cancers: population-based case-control study

BACKGROUND

Some malignancies are known to be associated with increased risk of herpes zoster, but little is known about how associations between cancer and subsequent zoster risk vary by cancer site, by time since cancer diagnosis, and by age.

METHODS

An age-, sex-, calendar time-, and practice-matched case-control study, nested in the broadly UK representative Clinical Practice Research Datalink (CPRD) primary care database, was analysed using conditional logistic regression to estimate the association between 21 of the most common specific malignancies and subsequent zoster risk. We adjusted for comorbid conditions and other potential confounders, and investigated effect modification by age and time since malignancy diagnosis.

RESULTS

A total of 192 081 adult zoster patients and 732 035 controls were included. Malignancy overall was positively associated with zoster risk (adjusted OR 1.29, 95% CI 1.27-1.32), and the association was especially strong for haematological malignancies (OR 2.46, 2.33-2.60). Among specific malignancies, there was evidence that oral, oesophageal, stomach, colorectal, lung, breast, ovarian, prostate, kidney, bladder, and CNS cancers, as well as lymphoma, myeloma, and leukaemia were associated with increased zoster odds (P⩽0.05 in each case), but the magnitude of associations varied widely. The association was typically strongest within 2 years of malignancy diagnosis and decreased with older age for both haematological and solid malignancies.

CONCLUSIONS

Several cancers were associated with an increased risk of zoster, particularly within the first 2 years after diagnosis and among younger individuals. Knowledge that patients with a recent diagnosis of cancer are at high risk of zoster may encourage initiation of antiviral therapy earlier in the course of zoster when the benefits are greater. Evaluation of whether patients diagnosed with cancer would benefit from early zoster vaccination is warranted.

Cost of shingles: population based burden of disease analysis of herpes zoster and postherpetic neuralgia

Background

Around 30% of the population will experience herpes zoster (HZ), 10% of whom develop postherpetic neuralgia (PHN). Together, these illnesses produce a significant economic burden to the healthcare system.

Methods

Administrative healthcare data collected over the period of April 1^st 1997 to March 31^st 2014 were analyzed to determine the healthcare system burden of HZ using direct medical costs. Episodes of HZ were identified using international classification of disease (ICD) codes. Trends in age-adjusted (AA) HZ-rates were analyzed by piecewise-regression. Total annual and per-episode costs were determined for drug treatment, medical care, and hospitalizations within each year.

Results

The incidence of HZ increased by 49.5% from 1997/98 to 2013/14. Piecewise-regression of AA-rates revealed a steady AA-rate of 4.7 episodes/1000 person-years (PY) from 1997/98 to a breakpoint in 2008/09, after which rates began to increase reaching 5.7 episodes/1000 PY in 2013/14.

Drug costs rose significantly (p <0.03) from $89.77/episode (95% CI: $82.96, $96.59) to $127.34/episode (95% CI: $117.24, $137.44). Medical costs increased (p <0.0001) from $57.98/episode (95% CI; $55.26, $60.70) to $78.84/episode (95% CI; $74.08, $83.61). Hospitalization rates declined from 3.10% in 1997/98 to 1.36% in 2011/12, resulting in cost dropping from $397/episode (95% CI; $284, $511) to $195/episode (95% CI; $129, $260).

Total annual costs of HZ and PHN were $1,997,183 in 2011/12, 4.7% lower than the 1997/98 costs of $2,095,633.

Conclusion

A significant increase in annual number of HZ cases was observed, driven largely by demographic factors. A 21% increase in the AA-incidence reveals changes in HZ rates beyond those expected by population shifts.

The large increase in incidence of HZ, with rising per episode medical and prescription costs were offset by dramatic drops in hospitalization rates, the net effect of which has been to hold the total costs relatively constant. However, the decrease in hospitalization rates slowed over the last half of the study, settling at 1.3% in the last 4 study years. The likely future of HZ burden is one of rising costs, primarily driven by the demographic shifts of an increasing and aging population.

Immunogenicity and safety of an adjuvanted herpes zoster subunit candidate vaccine in adults ≥ 50 years of age with a prior history of herpes zoster: A phase III, non-randomized, open-label clinical trial

This phase III, non-randomized, open-label, multi-center study (NCT01827839) evaluated the immunogenicity and safety of an adjuvanted recombinant subunit herpes zoster (HZ) vaccine (HZ/su) in adults aged ≥ 50 y with prior physician-documented history of HZ. Participants (stratified by age: 50–59, 60–69 and ≥ 70 y) received 2 doses of HZ/su 2 months apart and were followed-up for another 12 months. Anti-glycoprotein E (gE) antibodies were measured by enzyme-linked immunosorbent assay before vaccination and 1 month after the second dose (Month 3). Solicited local and general adverse events (AEs) were recorded for 7 d and unsolicited AEs for 30 d after each vaccination. Serious AEs were recorded until study end. The primary immunogenicity objective was met if the lower limit of the 95% confidence interval (CI) of the vaccine response rate (VRR), defined as a 4-fold increase in anti-gE over baseline, at Month 3 was ≥ 60%. 96 participants (32/age group) were enrolled. The primary immunogenicity objective was met, as the VRR at Month 3 was 90.2% (95% CI: 81.7–95.7). Geometric mean anti-gE antibody concentrations at Month 3 were similar across age groups. 77.9% and 71.6% of participants reported local and general solicited AEs, respectively. The most frequent solicited AEs were pain at injection site, fatigue, headache, myalgia and shivering. The HZ/su vaccine was immunogenic in adults aged ≥ 50 y with a physician-documented history of HZ, and no safety concerns were identified.

Risk and severity of herpes zoster in patients with rheumatoid arthritis receiving different immunosuppressive medications: a case-control study in Asia

OBJECTIVE

Increasing evidence indicates that the risk of herpes zoster (HZ) is elevated in rheumatoid arthritis (RA). Little is known about the epidemiology of HZ in patients with RA in Asia. The aim of this study was to determine the risk factors and outcomes of HZ among patients with RA.

DESIGN

A case-control study.

SETTING

A medical centre in Asia.

PARTICIPANTS

A total of 9025 newly diagnosed and eligible patients with RA (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes 714.0) during the period 2001-2014. Among them, 275 (3.05%) were newly diagnosed with HZ (ICD-9-CM code 053.0) after the RA identification. As the control group, patients with RA without HZ were matched for age, gender and RA disease duration at the time of HZ infection with the RA-HZ case group at a ratio of 4:1, and a total of 1100 control subjects were selected.

OUTCOME MEASURES

We estimated ORs using conditional logistic regression to investigate the risk and severity of HZ among patients with RA receiving different immunosuppressive medications.

RESULTS

Exposure to corticosteroids (≥10 mg/day adjusted OR (aOR)=2.30, 95% CI 1.25 to 4.22, p=0.01), anti-tumour necrosis factor biologicals (aOR=2.07, 95% CI 1.34 to 3.19, p=0.001) and conventional synthetic disease-modifying anti-rheumatic drugs (methotrexate (aOR=1.98, 95% CI 1.43 to 2.76, p<0.001) and hydroxychloroquine (aOR=1.95, 95% CI 1.39 to 2.73, p<0.001)) was associated with an increased HZ risk in patients with RA. The association between the use of corticosteroids and HZ risk was dose-dependent (p_trend<0.001). Time-to-HZ diagnosis among patients with RA receiving biological medications was significantly shorter than that in patients not receiving biological medications. A higher proportion of severe HZ and ophthalmic involvement was found in patients with RA receiving biologicals.

CONCLUSIONS

There was an increased risk of HZ in patients with RA taking specific immunosuppressive medication. Biologicals used were associated with severe HZ occurrence. Therefore, it is important to closely monitor and prevent severe HZ complications during specific immunosuppressive therapy.

Burden of herpes zoster and postherpetic neuralgia in Japanese adults 60 years of age or older: Results from an observational, prospective, physician practice-based cohort study

Approximately one in three persons will develop herpes zoster during their lifetime, and it can lead to serious complications such as postherpetic neuralgia. However, evidence on burden of herpes zoster and postherpetic neuralgia in Japan is limited. This prospective, observational, multicenter, physician practice-based cohort study was conducted in Kushiro, Hokkaido, Japan (Clinicaltrials.gov identifier NCT01873365) to assess the incidence and hospitalization rates of herpes zoster, and the proportion, clinical burden and risk factors for postherpetic neuralgia in adults aged 60 years or more. Within the study area, 800 subjects developed herpes zoster and 412 were eligible for the study. Herpes zoster incidence was 10.2/1000 person-years and higher among women and older subjects. Subjects with herpes zoster required on average 5.7 outpatient consultations. Herpes zoster-associated hospitalization rate was 3.4% (27/800). The proportion of postherpetic neuralgia and other complications was 9.2% (38/412) and 26.5% (109/412), respectively. Statistically significant association with the development of postherpetic neuralgia was male sex (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.17-5.38), age of 70-74 years (OR, 3.51; 95% CI, 1.09-11.3), immunosuppressive therapy (OR, 6.44; 95% CI, 1.26-32.9), severe herpes zoster pain at first consultation (OR, 3.08; 95% CI, 1.10-8.62) and rash on upper arms (vs no rash on upper arms; OR, 3.46; 95% CI, 1.10-10.9). Considerable herpes zoster and postherpetic neuralgia burden exists among elderly in Japan, and there may be predictive factors at the first visit which could be indicative of the risk of developing postherpetic neuralgia.

Predicting risk factors for varicella zoster virus infection and postherpetic neuralgia after hematopoietic cell transplantation using ordered logistic regression analysis

To identify risk factors for varicella zoster virus (VZV) infection and postherpetic neuralgia (PHN) after hematopoietic cell transplantation (HCT), we conducted a retrospective chart review of 163 consecutive patients who underwent HCT between November 2004 and July 2014. Overall, the male/female (M/F) ratio was 80/83, median age at HCT was 54 (range 15-69) years, and autologous/allogeneic HCT (auto/allo-HCT) ratio was 71/92. Forty-four patients [M/F, 25/19; median age, 57 (range: 16-68) years; auto/allo-HCT, 26/18] developed VZV infection after HCT. All cases were successfully treated with acyclovir (ACV) or valacyclovir, and there was no VZV-related death. Nine (20%) of the 44 patients [M/F, 5/4; median age, 58 (range: 21-63) years; auto/allo-HCT, 7/2] developed PHN after resolution of zoster. Multivariate ordered logistic analysis identified receiving immunosuppressive therapy at the cessation of ACV [odds ratio (OR) = 74.53; 95% confidence interval (CI) = 6.99-794.32; P = 0.0004] as a risk factor for VZV infection and PHN in allo-HCT recipients. However, in auto-HCT recipients, only advanced age was identified as a risk factor (OR = 1.06, 95% CI = 1.002-1.127, P = 0.0429). Our findings indicate receiving immunosuppressive therapy at the cessation of ACV is a significant risk factor for allo-HCT recipients, while advanced age is a significant risk factor for auto-HCT recipients.

Vaccination of special populations: Protecting the vulnerable

One of the strategic objectives of the 2011-2020 Global Vaccine Action Plan is for the benefits of immunisation to be equitably extended to all people. This approach encompasses special groups at increased risk of vaccine-preventable diseases, such as preterm infants and pregnant women, as well as those with chronic and immune-compromising medical conditions or at increased risk of disease due to immunosenescence. Despite demonstrations of effectiveness and safety, vaccine uptake in these special groups is frequently lower than expected, even in developed countries with vaccination strategies in place. For example, uptake of the influenza vaccine in pregnancy rarely exceeds 50% in developed countries and, although data are scarce, it appears that only half of preterm infants are up-to-date with routine paediatric vaccinations. Many people with chronic medical conditions or who are immunocompromised due to disease or aging are also under-vaccinated. In the US, coverage among people aged 65years or older was 67% for the influenza vaccine in the 2014-2015 season and 55-60% for tetanus and pneumococcal vaccines in 2013, while the coverage rate for herpes zoster vaccination among those aged 60years or older was only 24%. In most other countries, rates are far lower. Reasons for under-vaccination of special groups include fear of adverse outcomes or illness caused by the vaccine, the inconvenience (and in some settings, cost) of vaccination and lack of awareness of the need for vaccination or national recommendations. There is also evidence that healthcare providers' attitudes towards vaccination are among the most important influences on the decision to vaccinate. It is clear that physicians' adherence to recommendations needs to be improved, particularly where patients receive care from multiple subspecialists and receive little or no care from primary care providers.