1
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Shan DM, Chandy RJ, Fultz A, Sanders JW, Feldman SR. Live vaccinations in dermatology for immunosuppressed patients: a narrative review. Arch Dermatol Res 2024; 316:96. [PMID: 38430244 DOI: 10.1007/s00403-024-02827-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/06/2023] [Accepted: 01/25/2024] [Indexed: 03/03/2024]
Abstract
Given the higher susceptibility to infectious disease in patients receiving immunosuppressive therapies for inflammatory dermatologic conditions, immunization is important in this population. While live vaccines protect against life-threatening diseases, they can be harmful in immunosuppressed patients given the risk of replication of the attenuated pathogen and adverse reactions. The utilization of live vaccines in immunosuppressed patients depends on multiple factors such as the vaccine and therapy regimen. To provide an overview of evidence-based recommendations for the use of live vaccines in patients receiving immunosuppressive therapies for dermatological conditions. A literature search of the PubMed database was performed using keywords live vaccine, live-attenuated vaccine, dermatology, immunosuppressed, and immunocompromised, and specific immunosuppressive therapies: corticosteroids, glucocorticoids, methotrexate, azathioprine, cyclosporine, mycophenolate mofetil, biologics. Relevant articles written in English were included. Using these keywords, 125 articles were reviewed, of which 28 were ultimately selected. Recommendations for live vaccines can be determined on a case-by-case basis. Measles, mumps, rubella, varicella (MMRV) vaccines may be safely administered to patients on low-dose immunosuppressive agents while the yellow fever vaccine is typically contraindicated. It may be safe to administer live MMRV boosters to children on immunosuppressive therapies and the live herpes zoster vaccine to patients on biologics. Given poor adherence to immunization guidelines in immunosuppressed patients, dermatologists have a critical role in educating patients and general practitioners regarding live vaccines. By reviewing a patient's vaccination history and following immunization guidelines prior to initiating immunosuppressive therapies, physicians can mitigate morbidity and mortality from vaccine-preventable diseases.
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Affiliation(s)
- Divya M Shan
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
| | - Rithi J Chandy
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Andrew Fultz
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - John W Sanders
- Department of Infectious Diseases, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Dermatology, University of Southern Denmark, Odense, Denmark
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2
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Mbinta JF, Wang AX, Nguyen BP, Paynter J, Awuni PMA, Pine R, Sporle AA, Bowe S, Simpson CR. Herpes zoster vaccine safety in the Aotearoa New Zealand population: a self-controlled case series study. Nat Commun 2023; 14:4330. [PMID: 37468475 DOI: 10.1038/s41467-023-39595-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
In Aotearoa New Zealand, zoster vaccine live is used for the prevention of zoster and associated complications in adults. This study assessed the risk of pre-specified serious adverse events following zoster vaccine live immunisation among adults in routine clinical practice. We conducted a self-controlled case series study using routinely collected national data. We compared the incidence of serious adverse events during the at-risk period with the control period. Rate ratios were estimated using Conditional Poisson regression models. Falsification outcomes analyses were used to evaluate biases in our study population. From April 2018 to July 2021, 278,375 received the vaccine. The rate ratio of serious adverse events following immunisation was 0·43 (95% confidence interval [CI]: 0·37-0·50). There was no significant increase in the risk of cerebrovascular accidents, acute myocardial infarction, acute pericarditis, acute myocarditis, and Ramsay-Hunt Syndrome. The herpes zoster vaccine is safe in adults in Aotearoa New Zealand.
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Affiliation(s)
- James F Mbinta
- School of Health, Wellington Faculty of Health, Victoria University of Wellington, Wellington, New Zealand.
| | - Alex X Wang
- School of Mathematics and Statistics, Wellington Faculty of Engineering, Victoria University of Wellington, Wellington, New Zealand
| | - Binh P Nguyen
- School of Mathematics and Statistics, Wellington Faculty of Engineering, Victoria University of Wellington, Wellington, New Zealand
| | - Janine Paynter
- Department of General Practice & Primary Healthcare, University of Auckland, Auckland, New Zealand
| | | | - Russell Pine
- School of Health, Wellington Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Andrew A Sporle
- iNZight Analytics Ltd., Department of Statistics, Faculty of Science, University of Auckland, Auckland, New Zealand
| | - Steve Bowe
- School of Health, Wellington Faculty of Health, Victoria University of Wellington, Wellington, New Zealand
| | - Colin R Simpson
- School of Health, Wellington Faculty of Health, Victoria University of Wellington, Wellington, New Zealand.
- Usher Institute, The University of Edinburgh, Edinburgh, UK.
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3
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Approaches for Selective Vaccinations in Cirrhotic Patients. Vaccines (Basel) 2023; 11:vaccines11020460. [PMID: 36851337 PMCID: PMC9967540 DOI: 10.3390/vaccines11020460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023] Open
Abstract
Bacterial and viral infections are common in cirrhotic patients, and their occurrence is associated with the severity of liver disease. Bacterial infection may increase the probability of death by 3.75 times in patients with decompensated cirrhosis, with ranges of 30% at 1 month and 63% at 1 year after infection. We illustrate the indications and the modalities for vaccinating cirrhotic patients. This topic is important for general practitioners and specialists.
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4
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Li-Kim-Moy J, Phillips A, Morgan A, Glover C, Jayasinghe S, Hull BP, Dey A, Beard FH, Hickie M, Macartney K. Disseminated varicella zoster virus infection following live attenuated herpes zoster vaccine: descriptive analysis of reports to Australia's spontaneous vaccine pharmacovigilance system, 2016-2020. BMJ Open 2023; 13:e067287. [PMID: 36707120 PMCID: PMC9884885 DOI: 10.1136/bmjopen-2022-067287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To examine the reported incidence and features of disseminated varicella zoster virus (VZV) infection following live attenuated herpes zoster vaccine live (ZVL: Zostavax, Merck) in immunocompromised people in Australia. DESIGN AND SETTING ZVL was funded in 2016 in Australia for people aged 70 years, with a catch-up programme for those 71-79 years. From 2016 to 2020, three deaths due to disseminated vaccine-strain VZV infection occurred following inadvertent ZVL administration in individuals with varying levels of immunocompromise. This descriptive study examined 4 years of national surveillance data reported to the Therapeutic Goods Administration's Adverse Event Monitoring System (AEMS). Denominator data for rates were from doses recorded in the Australian Immunisation Register. PARTICIPANTS Individuals vaccinated between 1 November 2016 and 31 December 2020 who experienced adverse event(s) following immunisation (AEFI) after ZVL recorded in the AEMS. PRIMARY AND SECONDARY OUTCOME MEASURES Rates and outcomes of confirmed (Oka strain positive) or probable disseminated VZV infection, and inadvertent administration of ZVL in immunocompromised individuals. RESULTS 854 AEFI were reported from 1 089 966 doses of ZVL administered (78.4 per 100 000 doses). Of those, 14 were classified as confirmed (n=6, 0.55 per 100 000) or probable (n=8) disseminated VZV infection. The confirmed cases were all hospitalised, and most (5/6) were immunocompromised; three cases died. Thirty-seven individuals were reported as vaccinated despite a contraindication due to immunocompromise (3.4 per 100 000), with 12/37 (32%) hospitalised. CONCLUSIONS Disseminated VZV is potentially life-threatening and occurs mostly in those with severe immunocompromise. Inadvertent administration of ZVL to immunocompromised individuals has occurred despite initial provider guidance and education. Multiple additional strategies to assist providers to identify contraindications have been implemented to prevent adverse outcomes.
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Affiliation(s)
- Jean Li-Kim-Moy
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Anastasia Phillips
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Adelaide Morgan
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Catherine Glover
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Sanjay Jayasinghe
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
- Children's Hospital Westmead, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Brynley P Hull
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
| | - Aditi Dey
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Frank H Beard
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Megan Hickie
- Medicines Regulation Division, Pharmacovigilance Branch, Therapeutic Goods Administration, Woden, Australian Capital Territory, Australia
| | - Kristine Macartney
- National Centre for Immunisation Research and Surveillance, Westmead, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
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5
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Scalabrin S, Becco A, Vitale A, Nuzzi R. Ocular effects caused by viral infections and corresponding vaccines: An overview of varicella zoster virus, measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2. Front Med (Lausanne) 2022; 9:999251. [PMID: 36388944 PMCID: PMC9643669 DOI: 10.3389/fmed.2022.999251] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/30/2022] [Indexed: 09/19/2023] Open
Abstract
Many viral infections can affect vision and the visual system. Vaccination to prevent diseases is commonplace today, acting by stimulating an immune response without developing the pathology. It involves the production of persisting antibodies against the pathogen and the activation of T cells. Certain diseases have already been eradicated by rigorous vaccination campaigns, while others are hoped to be eliminated soon. Vaccines currently available on the market are largely safe, even if they can rarely cause some adverse effects, such as ocular complications. Analyzing existing literature, we aimed to compare the pathological effects on the eye due to the most common viral infections [in particular varicella zoster virus (VZV), measles virus, influenza viruses, hepatitis B virus, and SARS-CoV-2] with the possible ocular adverse effects of their relative vaccines, in order to establish a risk-benefit relationship from an ophthalmological point of view.
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Affiliation(s)
| | | | | | - Raffaele Nuzzi
- Department of Surgical Sciences, Eye Clinic, University of Turin, Turin, Italy
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6
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Herpes Zoster and Vaccination Strategies in Inflammatory Bowel Diseases: A Practical Guide. Clin Gastroenterol Hepatol 2022; 20:481-490. [PMID: 33080353 DOI: 10.1016/j.cgh.2020.10.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/13/2020] [Accepted: 10/13/2020] [Indexed: 02/07/2023]
Abstract
Herpes zoster is a painful dermatomal cutaneous eruption resulting from reactivation of the latent varicella-zoster virus. Patients with inflammatory bowel diseases have an increased risk of shingles compared with the general population and this risk can be increased with the use of immunosuppressive therapy. Live zoster vaccine and recombinant zoster vaccine have shown efficacy for the prevention of herpes zoster. The recombinant zoster vaccine seems to offer greater efficacy and long-term protection profile compared with the life zoster vaccine. However, their use in clinical practice still is unclear and updated vaccination recommendations are lacking. This review discusses the risk for shingles in patients with inflammatory bowel diseases, available vaccines, and their efficacy and safety profiles. We also provide guidance on who, when, and how to vaccinate for herpes zoster in routine clinical practice among patients with inflammatory bowel diseases.
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7
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Abstract
Introduction Janus Kinase inhibitors (JAKi) have shown to be highly effective in the treatment of immune-mediated inflammatory diseases. As with all immunomodulatory therapies, careful assessment of any treatment-associated infection risk is essential to inform clinical decision-making. Areas covered We summarize current literature on infection rates among the licensed JAKi using published phase II/III trial results, post-licensing and registry data. Expert opinion licensed JAKi show increased risk of infection across the class compared to placebo, most commonly affecting respiratory and urinary tracts, nasopharynx and skin. This risk is dose-dependent. Risks are similar at licensed JAKi doses to that seen with biologic therapies. The risk is compounded by other risk factors for infection, such as age and steroid co-prescription. Herpes zoster reactivation is more common with JAKi compared to other targeted immune modulation, making screening for varicella exposure and vaccination in appropriate cohorts an advisable strategy. Crucially, these small risk increases must be balanced against the known harms (including infection) of uncontrolled autoimmune disease. JAKi are a safe and potentially transformative treatment when used for appropriately selected patients.
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Affiliation(s)
- Maryam A Adas
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK.,Department of Physiology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Edward Alveyn
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Emma Cook
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Mrinalini Dey
- Institute of Life Course & Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Rheumatology, Countess of Chester Hospital Nhs Foundation Trust, Chester, UK
| | - James B Galloway
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
| | - Katie Bechman
- Centre of Rheumatic diseases, School of Immunology & Microbial Sciences, King's College London, London, UK
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8
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Gresham LM, Marzario B, Dutz J, Kirchhof MG. An evidence-based guide to SARS-CoV-2 vaccination of patients on immunotherapies in dermatology. J Am Acad Dermatol 2021; 84:1652-1666. [PMID: 33482251 PMCID: PMC7816618 DOI: 10.1016/j.jaad.2021.01.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 12/15/2022]
Abstract
Immune-mediated diseases and immunotherapeutics can negatively affect normal immune functioning and, consequently, vaccine safety and response. The COVID-19 pandemic has incited research aimed at developing a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. As SARS-CoV-2 vaccines are developed and made available, the assessment of anticipated safety and efficacy in patients with immune-mediated dermatologic diseases and requiring immunosuppressive and/or immunomodulatory therapy is particularly important. A review of the literature was conducted by a multidisciplinary committee to provide guidance on the safety and efficacy of SARS-CoV-2 vaccination for dermatologists and other clinicians when prescribing immunotherapeutics. The vaccine platforms being used to develop SARS-CoV-2 vaccines are expected to be safe and potentially effective for dermatology patients on immunotherapeutics. Current guidelines for the vaccination of an immunocompromised host remain appropriate when considering future administration of SARS-CoV-2 vaccines.
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Affiliation(s)
- Louise M Gresham
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Barbara Marzario
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada
| | - Jan Dutz
- Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, Canada
| | - Mark G Kirchhof
- Division of Dermatology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Canada.
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9
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Dubey V, MacFadden D. Disseminated varicella zoster virus infection after vaccination with a live attenuated vaccine. CMAJ 2020; 191:E1025-E1027. [PMID: 31527188 DOI: 10.1503/cmaj.190270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Vinita Dubey
- Toronto Public Health (Dubey); Dalla Lana School of Public Health (Dubey) and Division of Infectious Disease (MacFadden), University of Toronto, Toronto, Ont.
| | - Derek MacFadden
- Toronto Public Health (Dubey); Dalla Lana School of Public Health (Dubey) and Division of Infectious Disease (MacFadden), University of Toronto, Toronto, Ont
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10
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Grint DJ, McDonald HI, Walker JL, Amirthalingam G, Andrews N, Thomas S. Safety of inadvertent administration of live zoster vaccine to immunosuppressed individuals in a UK-based observational cohort analysis. BMJ Open 2020; 10:e034886. [PMID: 32001495 PMCID: PMC7045073 DOI: 10.1136/bmjopen-2019-034886] [Citation(s) in RCA: 237] [Impact Index Per Article: 59.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To investigate the safety of live attenuated varicella zoster vaccination when administered to immunosuppressed individuals. DESIGN Prospective observational cohort study. SETTING The study used anonymised data from the Clinical Practice Research Datalink (CPRD), comprising a representative sample of routinely collected primary care data in England between 2013 and 2017 and and linked Hospital Episode Statistics data. PARTICIPANTS 168 767 individuals age-eligible for varicella zoster vaccination registered at a general practice in England contributing data to CPRD. MAIN OUTCOME MEASURES Electronic health records indicating immunosuppression, zoster vaccination, diagnoses of specific varicella-zoster virus (VZV)-related disease and non-specific rash/encephalitis compatible with VZV-related disease. RESULTS Between 1 September 2013 and 31 August 2017, a period of immunosuppression was identified for 9093/168 767 (5.4%; 95% CI: 5.3%-5.5%) individuals age-eligible for zoster vaccination. The overall rate of vaccination while immunosuppressed was 1742/5251 (33.2 per 100 adjusted person years at risk; 95% CI: 31.9%-34.5%). Follow-up of the 1742 individuals who were inadvertently vaccinated while immunosuppressed identified only two cases of VZV-related disease within 8 weeks of vaccination (0.1%; 95% CI: 0.01%-0.4%), both primary care diagnoses of 'shingles', neither with a related hospital admission. CONCLUSIONS Despite evidence of inadvertent vaccination of immunosuppressed individuals with live zoster vaccination, there is a lack of evidence of severe consequences including hospitalisation. This should reassure primary care staff and encourage vaccination of mildly immunosuppressed individuals who do not meet current thresholds for contraindication. These findings support a review of the extent to which live zoster vaccination is contraindicated among the immunosuppressed.
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Affiliation(s)
- Daniel J Grint
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Helen I McDonald
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Jemma L Walker
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Gayatri Amirthalingam
- Immunisation and Countermeasures Division, National Infection Service, Public Health England, London, UK
| | - Nick Andrews
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
- Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Sara Thomas
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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11
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Curtis JR, Foster PJ, Saag KG. Tools and Methods for Real-World Evidence Generation: Pragmatic Trials, Electronic Consent, and Data Linkages. Rheum Dis Clin North Am 2019; 45:275-289. [PMID: 30952398 PMCID: PMC6499376 DOI: 10.1016/j.rdc.2019.01.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Real-world evidence requires use of new tools and methods to support efficient evidence generation. Among those tools are pragmatic trials, utilization of central/single institutional review board and electronic consent, and data linkages between diverse types of data sources (eg, a trial or registry to administrative claims or electronic medical record data). This article reviews these topics in the context of describing several exemplar use cases specific to rheumatology and provides perspective regarding both the promise and potential pitfalls in using these tools and approaches.
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Affiliation(s)
- Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - P Jeff Foster
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kenneth G Saag
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Weinmann S, Naleway AL, Koppolu P, Baxter R, Belongia EA, Hambidge SJ, Irving SA, Jackson ML, Klein NP, Lewin B, Liles E, Marin M, Smith N, Weintraub E, Chun C. Incidence of Herpes Zoster Among Children: 2003-2014. Pediatrics 2019; 144:peds.2018-2917. [PMID: 31182552 PMCID: PMC7748320 DOI: 10.1542/peds.2018-2917] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES After the 1996 introduction of routine varicella vaccination in the United States, most studies evaluating pediatric herpes zoster (HZ) incidence reported lower incidence over time, with varying degrees of decline. Using the combined databases of 6 integrated health care organizations, we examined HZ incidence in children over a 12-year period in the varicella vaccine era. METHODS This study included children aged 0 through 17 years from 2003 through 2014. Using electronic medical records, we identified HZ cases through International Classification of Diseases, Ninth Revision diagnosis code 053. We calculated HZ incidence rates per 100 000 person years of health plan membership for all children and among children who were vaccinated versus unvaccinated. We calculated rates for the 12-year period and examined temporal trends. Among children who were vaccinated, we compared HZ rates by month and year of age at vaccination. RESULTS The study included 6 372 067 children with ≥1 month of health plan membership. For the 12-year period, the crude HZ incidence rate for all subjects was 74 per 100 000 person years, and the rate among children who were vaccinated was 38 per 100 000 person years, which was 78% lower than that among children who were unvaccinated (170 per 100 000 person years; P < .0001). Overall HZ incidence declined by 72% (P < .0001) from 2003 through 2014. Annual rates in children who were vaccinated were consistently lower than in children who were unvaccinated. CONCLUSIONS With this population-based study, we confirm the decline in pediatric HZ incidence and the significantly lower incidence among children who are vaccinated, reinforcing the benefit of routine varicella vaccination to prevent pediatric HZ.
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Affiliation(s)
- Sheila Weinmann
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon;
| | - Allison L. Naleway
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Padma Koppolu
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Roger Baxter
- Vaccine Study Center, Kaiser Permanente Northern California, Oakland, California
| | | | | | | | | | - Nicola P. Klein
- Vaccine Study Center, Kaiser Permanente Northern California, Oakland, California
| | - Bruno Lewin
- Kaiser Permanente Southern California, Pasadena, California
| | - Elizabeth Liles
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Mona Marin
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ning Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Eric Weintraub
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Colleen Chun
- Division of Pediatric Infectious Diseases (Emeritus), Department of Pediatrics, Northwest Permanente, Portland, Oregon
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13
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Papp KA, Haraoui B, Kumar D, Marshall JK, Bissonnette R, Bitton A, Bressler B, Gooderham M, Ho V, Jamal S, Pope JE, Steinhart AH, Vinh DC, Wade J. Vaccination Guidelines for Patients With Immune-Mediated Disorders on Immunosuppressive Therapies. J Cutan Med Surg 2018; 23:50-74. [PMID: 30463418 PMCID: PMC6330697 DOI: 10.1177/1203475418811335] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND: Patients with immune-mediated diseases on immunosuppressive therapies have more infectious episodes than healthy individuals, yet vaccination practices by physicians for this patient population remain suboptimal. OBJECTIVES: To evaluate the safety and efficacy of vaccines in individuals exposed to immunosuppressive therapies and provide evidence-based clinical practice recommendations. METHODS: A literature search for vaccination safety and efficacy in patients on immunosuppressive therapies (2009-2017) was conducted. Results were assessed using the Grading of Recommendation, Assessment, Development, and Evaluation system. RESULTS: Several immunosuppressive therapies attenuate vaccine response. Thus, vaccines should be administered before treatment whenever feasible. Inactivated vaccines can be administered without treatment discontinuation. Similarly, evidence suggests that the live zoster vaccine is safe and effective while on select immunosuppressive therapy, although use of the subunit vaccine is preferred. Caution regarding other live vaccines is warranted. Drug pharmacokinetics, duration of vaccine-induced viremia, and immune response kinetics should be considered to determine appropriate timing of vaccination and treatment (re)initiation. Infants exposed to immunosuppressive therapies through breastmilk can usually be immunized according to local guidelines. Intrauterine exposure to immunosuppressive agents is not a contraindication for inactivated vaccines. Live attenuated vaccines scheduled for infants and children ⩾12 months of age, including measles, mumps, rubella, and varicella, can be safely administered as sufficient time has elapsed for drug clearance. CONCLUSIONS: Immunosuppressive agents may attenuate vaccine responses, but protective benefit is generally maintained. While these recommendations are evidence based, they do not replace clinical judgment, and decisions regarding vaccination must carefully assess the risks, benefits, and circumstances of individual patients.
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Affiliation(s)
- Kim A Papp
- 1 K Papp Clinical Research, Waterloo, ON, Canada.,2 Probity Medical Research, Waterloo, ON, Canada
| | - Boulos Haraoui
- 3 Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Deepali Kumar
- 4 University Health Network, Toronto, ON, Canada.,5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - John K Marshall
- 6 Department of Medicine and Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, ON, Canada
| | | | - Alain Bitton
- 8 McGill University Health Centre, Montreal, QC, Canada
| | - Brian Bressler
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,10 St Paul's Hospital, Vancouver, BC, Canada
| | - Melinda Gooderham
- 2 Probity Medical Research, Waterloo, ON, Canada.,11 Faculty of Medicine, Queen's University, Kingston, ON, Canada
| | - Vincent Ho
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shahin Jamal
- 12 Vancouver Coastal Health, Vancouver, BC, Canada
| | - Janet E Pope
- 13 Faculty of Medicine, University of Western Ontario, London, ON, Canada.,14 St Joseph's Health Care, London, ON, Canada
| | - A Hillary Steinhart
- 5 Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,15 Mount Sinai Hospital, Toronto, ON, Canada
| | - Donald C Vinh
- 8 McGill University Health Centre, Montreal, QC, Canada.,16 Research Institute, McGill University Health Centre, Montreal, QC, Canada
| | - John Wade
- 9 Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,17 Vancouver General Hospital, Vancouver, BC, Canada
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Wong PKK, Hanrahan P, Johnson DF. Author reply. Intern Med J 2018; 48:1280-1281. [DOI: 10.1111/imj.14053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Peter K. K. Wong
- Mid-North Coast Arthritis Clinic; Coffs Harbour and UNSW Rural Clinical School; Coffs Harbour New South Wales Australia
| | - Patrick Hanrahan
- Private Rheumatology Practice; Perth Western Australia Australia
- Faculty of Medicine; University of Western Australia; Perth Western Australia Australia
| | - Doug F. Johnson
- Department of General Medicine; Royal Melbourne Hospital; Melbourne Victoria Australia
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Kim SH, Park SH, Choi SM, Lee DG. Implementation of Hospital Policy for Healthcare Workers and Patients Exposed to Varicella-Zoster Virus. J Korean Med Sci 2018; 33:e252. [PMID: 30181734 PMCID: PMC6115693 DOI: 10.3346/jkms.2018.33.e252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 08/12/2018] [Indexed: 01/04/2023] Open
Abstract
Varicella-zoster virus (VZV) causes a highly contagious and generally benign, self-limited disease. However, in high-risk populations including immunocompromised patients, pregnant women, and neonates, VZV infection can be associated with significant morbidity and mortality. Healthcare-associated transmission of VZV occurs among healthcare workers (HCWs) and patients by airborne transmission or by direct contact with the index case. To minimize the risk of transmission in healthcare settings, all VZV-susceptible HCWs should be encouraged strongly to be immunized with the varicella vaccine. For post-exposure management, active immunization (varicella vaccine), passive immunization (varicella-zoster immune globulin) and/or antiviral agents, and isolation could be used in specific situations. To prevent the transmission of VZV infection in the hospital settings, the development and implementation of hospital policies for appropriate infection control is also warranted. This article reviews the general information and healthcare-associated transmission of VZV and summarizes the recommendations for the pre- and post-exposure management of HCWs and patients, in hospital settings.
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Affiliation(s)
- Si-Hyun Kim
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Sun Hee Park
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Su-Mi Choi
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Gun Lee
- Division of Infectious Diseases, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Vaccine Bio Research Institute, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Catholic Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Miller ER, Lewis P, Shimabukuro TT, Su J, Moro P, Woo EJ, Jankosky C, Cano M. Post-licensure safety surveillance of zoster vaccine live (Zostavax®) in the United States, Vaccine Adverse Event Reporting System (VAERS), 2006-2015. Hum Vaccin Immunother 2018; 14:1963-1969. [PMID: 29580194 DOI: 10.1080/21645515.2018.1456598] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Herpes zoster (HZ), or shingles, is caused by reactivation of varicella-zoster virus in latently infected individuals. Live-attenuated HZ vaccine (zoster vaccine live, ZVL) is approved in the United States for persons aged ≥50 years and recommended by the CDC for persons ≥60 years. METHODS We analyzed U.S. reports of adverse events (AEs) following ZVL submitted to the Vaccine Adverse Event Reporting System (VAERS), a spontaneous reporting system to monitor vaccine safety, for persons vaccinated May 1, 2006, through January 31, 2015. We conducted descriptive analysis, clinical reviews of reports with selected pre-specified conditions, and empirical Bayesian data mining. RESULTS VAERS received 23,092 reports following ZVL, of which 22,120 (96%) were classified as non-serious. Of reports where age was documented (n = 18,817), 83% were in persons aged ≥60 years. Reporting rates of AEs were 106 and 4.4 per 100,000 ZVL doses distributed for all reports and serious reports, respectively. When ZVL was administered alone among persons aged ≥50 years, injection site erythema (27%), HZ (17%), injection site swelling (17%), and rash (14%) were the most commonly reported symptoms among non-serious reports; HZ (29%), pain (18%), and rash (16%) were the most commonly reported symptoms among serious reports. Six reports included laboratory evidence of vaccine-strain varicella-zoster virus (Oka/Merck strain) infection; AEs included HZ, HZ- or varicella-like illness, and local reaction with vesicles. In our review of reports of death with sufficient information to determine cause (n = 46, median age 75 years), the most common causes were heart disease (n = 28), sepsis (n = 4), and stroke (n = 3). Empirical Bayesian data mining did not detect new or unexpected safety signals. CONCLUSIONS Findings from our safety review of ZVL are consistent with those from pre-licensure clinical trials and other post-licensure assessments. Transient injection-site reactions, HZ, and rashes were most frequently reported to VAERS following ZVL. Overall, our results are reassuring regarding the safety of ZVL.
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Affiliation(s)
- Elaine R Miller
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
| | - Paige Lewis
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
| | - Tom T Shimabukuro
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
| | - John Su
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
| | - Pedro Moro
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
| | - Emily Jane Woo
- b Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration , Silver Spring , Maryland , USA
| | - Christopher Jankosky
- b Office of Biostatistics and Epidemiology, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration , Silver Spring , Maryland , USA
| | - Maria Cano
- a Immunization Safety Office, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention , Atlanta , Georgia , USA
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Côté-Daigneault J, Luong ML, Colombel JF, Peerani F. Letter: the safety of herpes zoster vaccination for patients with inflammatory bowel disease being treated with anti-TNF medications. Aliment Pharmacol Ther 2018; 47:446-447. [PMID: 29314127 DOI: 10.1111/apt.14435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- J Côté-Daigneault
- Division of Gastroenterology, CHUM/CRCHUM, University of Montreal, Quebec, Canada
| | - M L Luong
- Division of Microbiology and Infectious Diseases, CHUM, University of Montreal, Quebec, Canada
| | - J-F Colombel
- The Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine, New York, NY, USA
| | - F Peerani
- Division of Gastroenterology, University of Alberta, Alberta, Canada
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18
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Khan N, Shah Y, Trivedi C, Lewis JD. Safety of herpes zoster vaccination among inflammatory bowel disease patients being treated with anti-TNF medications. Aliment Pharmacol Ther 2017; 46:668-672. [PMID: 28805309 DOI: 10.1111/apt.14257] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND The risk of herpes zoster (HZ) is elevated in inflammatory bowel disease (IBD) patients treated with anti-TNF medications. While it is optimal to give herpes zoster vaccine prior to initiation of therapy clinical circumstances may not always allow this. AIM To determine the safety of giving herpes zoster vaccine while patients are on anti-TNF therapy. METHODS We conducted a retrospective cohort study involving IBD patients who were followed in the Veterans Affairs (VA) healthcare system between 2001 and 2016. Patients who received herpes zoster vaccine while on anti-TNF medication were identified through vaccination codes and confirmed through individual chart review. Our outcome of interest was development of HZ between 0 and 42 days after herpes zoster vaccine administration. RESULTS Fifty-six thousand four hundred and seventeen patients with IBD were followed in the VA healthcare system. A total of 59 individuals were on anti-TNF medication when they were given herpes zoster vaccine, and amongst them, 12 (20%) were also taking a thiopurine. Median age at the time of herpes zoster vaccine was 64.9 years and 95% of patients had a Charlson Comorbidity Index of ≥2. Median number of encounters within 42 days after receiving herpes zoster vaccine was two. No case of HZ was found within 0-42 days of HZV administration. CONCLUSION Our data suggest that co-administering the herpes zoster vaccine to patients who are taking anti-TNF medications is relatively safe. This study significantly expands the evidence supporting the use of herpes zoster vaccine in this population, having included an elderly group of patients with a high Charlson Comorbidity Index who are likely at a much higher risk of developing HZ.
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Affiliation(s)
- N Khan
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Y Shah
- Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - C Trivedi
- Section of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - J D Lewis
- Section of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, PA, USA
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Scotch AH, Hoss E, Orenstein R, Budavari AI. Disseminated Varicella-Zoster Virus After Vaccination in an Immunocompetent Patient. J Osteopath Med 2017; 116:402-5. [PMID: 27214778 DOI: 10.7556/jaoa.2016.082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Severe adverse events associated with varicella-zoster virus (VZV) vaccination are rare. The authors describe a 53-year-old woman with no known immunodeficiency who presented with diffuse pruritic rash 17 days after receiving the varicella virus vaccine live. She had a low level of white blood cells and received a diagnosis of thrombocytopenia with elevated aminotransferase levels. Punch biopsy demonstrated positive VZV immunostaining and viral culture positive for VZV. After treatment with acyclovir, her rash improved and her white blood cell and platelet counts returned to normal. Mild reactions to vaccines including localized rash are well recognized. Disseminated infections have been reported in patients with congenital and acquired immunodeficiency, but systemic postvaccination infections are rare in immunocompetent adults. This case highlights the importance of recognizing adverse events associated with vaccination.
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20
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Chhabra P, Ranjan P, Bhasin DK. Simultaneous Occurrence of Varicella Zoster Virus-Induced Pancreatitis and Hepatitis in a Renal Transplant Recipient: A Case Report and Review of Literature. Perm J 2017; 21:16-083. [PMID: 28333601 DOI: 10.7812/tpp/16-083] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Gastrointestinal complications are common after renal transplantation, including oral lesions, esophagitis, gastritis, diarrhea, and colon carcinoma. The differential diagnosis is difficult in this scenario because multiple factors such as drugs, infections, and preexisting gastrointestinal disease come into play. CASE PRESENTATION We report a case of varicella zoster virus-induced pancreatitis and hepatitis in a renal transplant recipient. The patient underwent renal transplantation 3 years earlier and now presented with severe pain in the epigastrium radiating to his back and had raised serum lipase levels and skin lesions characteristic of varicella. Liver enzyme levels were also elevated. He was started on a regimen of acyclovir. His pain improved in 24 hours, and liver enzyme levels returned to normal in 48 hours. DISCUSSION There is a paucity of literature on the simultaneous occurrence of varicella zoster virus-induced hepatitis and pancreatitis in both immunocompetent and immunocompromised patients. Our case highlights the gastrointestinal complications of varicella infection in immunocompromised patients that may precede the characteristic dermatologic manifestations, and the fact that rarely both hepatitis and pancreatitis may be seen.
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Affiliation(s)
- Puneet Chhabra
- Attending Consultant in the Department of Gastroenterology and Hepatology at the Fortis Hospital Mohali in Chandigarh, Mohali, Punjab, India.
| | - Priyadarshi Ranjan
- Director of the Urology and Kidney Transplantation Department at the Fortis Hospital Mohali in Chandigarh, Mohali, Punjab, India.
| | - Deepak K Bhasin
- Director of Gastroenterology, Hepatology and Interventional Endoscopy at the Fortis Hospital Mohali in Chandigarh, Mohali, Punjab, India.
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Bollea-Garlatti M, Bollea-Garlatti L, Vacas A, Torre A, Kowalczuk A, Galimberti R, Ferreyro B. Clinical Characteristics and Outcomes in a Population With Disseminated Herpes Zoster: A Retrospective Cohort Study. ACTAS DERMO-SIFILIOGRAFICAS 2017. [DOI: 10.1016/j.adengl.2016.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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22
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Chakravarty EF. Incidence and Prevention of Herpes Zoster Reactivation in Patients with Autoimmune Diseases. Rheum Dis Clin North Am 2017; 43:111-121. [DOI: 10.1016/j.rdc.2016.09.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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23
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Shingles (Herpes Zoster) Vaccine (Zostavax(®)): A Review in the Prevention of Herpes Zoster and Postherpetic Neuralgia. BioDrugs 2017; 30:243-54. [PMID: 27189459 DOI: 10.1007/s40259-016-0180-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Zostavax(®) is a live attenuated shingles (herpes zoster) vaccine approved in the EU for the prevention of herpes zoster (HZ) and postherpetic neuralgia (PHN) in adults aged ≥50 years. Zoster vaccine protected against HZ in adults aged 50-59 years (ZEST trial) and ≥60 years [Shingles Prevention Study (SPS)], and also reduced the burden of illness associated with HZ and the risk of PHN in adults aged ≥60 years (SPS). A large amount of real-world data also supports the efficacy of zoster vaccine. Results of the SPS Short- and Long-Term Persistence Substudies and real-world studies indicate that zoster vaccine provided continued benefit in the longer term, albeit with a gradual decline in vaccine efficacy over time; long-term effectiveness studies are ongoing. The need for a booster dose is still unknown, but a study showed that, if necessary, a booster dose administered to adults aged ≥70 years who received their first dose of zoster vaccine ≥10 years previously was immunogenic. Zoster vaccine had a favourable safety and tolerability profile, with the most commonly reported adverse events being non-severe injection-site reactions. In conclusion, zoster vaccine reduces the incidence of HZ and PHN, thereby reducing the burden of illness associated with HZ; improved uptake of zoster vaccine is needed.
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Bollea-Garlatti ML, Bollea-Garlatti LA, Vacas AS, Torre AC, Kowalczuk AM, Galimberti RL, Ferreyro BL. Clinical Characteristics and Outcomes in a Population With Disseminated Herpes Zoster: A Retrospective Cohort Study. ACTAS DERMO-SIFILIOGRAFICAS 2016; 108:145-152. [PMID: 27938930 DOI: 10.1016/j.ad.2016.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Revised: 09/07/2016] [Accepted: 10/09/2016] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Shingles is the cutaneous expression of the reactivation of latent varicella zoster virus infection in sensory ganglia. It presents as vesicles in the corresponding dermatome. The condition is called disseminated herpes zoster (DHZ) when more than 2 contiguous dermatomes are affected, more than 20 vesicles are observed outside the initial dermatome, or involvement is systemic. DHZ is rare and most frequently occurs in immunocompromised patients. OBJECTIVES To describe the epidemiology, predisposing factors, clinical presentation, laboratory findings, and clinical course of patients with DHZ, and to compare the findings in immunocompromised and immunocompetent patients. METHODOLOGY We analyzed a retrospective case series of adults hospitalized between February 2010 and October 2015. RESULTS Forty-one patients with virologically confirmed manifestations of DHZ were included. Stress as a trigger factor was detected in 39% and immunodepression in 58.5%. Immunocompromised patients were younger than the immunocompetent patients (mean ages, 60.5 vs 82 years, P<.01). The 8 immunocompetent patients with no detectable trigger factors were older (mean age, 85 years). In 95% of cases, DHZ was initially limited to a single dermatome and then spread to other dermatomes or became disseminated. Thrombocytopenia was detected in 56% of cases. Complication rates were similar in immunocompromised and immunocompetent patients (54% vs 59%, P>.01). Six patients died; there was no difference in mortality between the 2 groups. CONCLUSION This study provides evidence on the relationship between DHZ, the presence of underlying immunodepression, and complications. Immunosenescence may play an important role in the onset of this disease in older immunocompetent patients.
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Affiliation(s)
- M L Bollea-Garlatti
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - L A Bollea-Garlatti
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A S Vacas
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A C Torre
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A M Kowalczuk
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - R L Galimberti
- Departamento de Dermatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Cátedra de Dermatología, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - B L Ferreyro
- Departamento de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Cátedra de Farmacología, Universidad de Buenos Aires, Buenos Aires, Argentina
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Management and Prevention of Herpes Zoster in the Immunocompromised Inflammatory Bowel Disease Patient: A Clinical Quandary. Inflamm Bowel Dis 2016; 22:2538-47. [PMID: 27598743 DOI: 10.1097/mib.0000000000000902] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Crohn's disease (CD) and ulcerative colitis (UC), the 2 main clinical phenotypes of inflammatory bowel disease (IBD), are diseases that result from a dysregulated immune response to gut microbiota in genetically susceptible hosts. This aberrant immune response may intrinsically predispose IBD patients to infectious complications. Moreover, immunosuppressive medications used to treat IBD including corticosteroids, thiopurines, methotrexate, calcineurin inhibitors, anti-tumor necrosis factor (anti-TNF) agents and other biologics, further increase patients' susceptibility to opportunistic infections. Herpes zoster (HZ), also known as shingles, is an opportunistic viral reactivation often observed in IBD patients with several case reports demonstrating complicated or disseminated disease in those on immunosuppression. While HZ vaccination is recommended in all immunocompetent adults aged ≥60 years, as a live virus vaccine, it is currently contraindicated in IBD patients on anti-TNF therapy and in other significantly immunocompromised patient groups. While caution is still warranted in these circumstances, recent clinical data has emerged which has prompted us to review and examine the universal approach to HZ vaccination in the immunosuppressed IBD population. In the following narrative review, we will discuss and provide an overview of the clinical manifestations, incidence, management and prevention of HZ in the IBD patient.
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John ES, Katz K, Saxena M, Chokhavatia S, Katz S. Management of Inflammatory Bowel Disease in the Elderly. ACTA ACUST UNITED AC 2016; 14:285-304. [PMID: 27387455 DOI: 10.1007/s11938-016-0099-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT A substantial and growing proportion of patients with inflammatory bowel disease (IBD) are elderly, and these patients require tailored treatment strategies. However, significant challenges exist in the management of this population due to the paucity of data. Establishing the initial diagnosis and assessing the etiology of future symptoms and flares can be challenging as several other prevalent diseases can masquerade as IBD, such as ischemic colitis, diverticular disease, and infectious colitis. Important pharmacologic considerations include reduced glomerular filtration rate and drug-drug interactions in the elderly. No drug therapy is absolutely contraindicated in this population; however, special risk and benefit assessments should be made. Older patients are more susceptible to side effects of steroids such as delirium, fractures, and cataracts. Budesonide can be an appropriate alternative for mild to moderate ulcerative colitis (UC) or Crohn's disease (CD) as it has limited systemic absorption. Pill size and quantity, nephrotoxicity, and difficulty of administration of rectal preparations should be considered with 5-aminosalicylic (5-ASA) therapy. Biologics are very effective, but modestly increase the risk of infection in a susceptible group. Based on their mechanisms, integrin receptor antagonists (e.g., vedolizumab) may reduce these risks. Use of antibiotics for anorectal or fistulizing CD or pouchitis in UC increases the risk of Clostridium difficile infection. Pre-existing comorbidities, functional status, and nutrition are important indicators of surgical outcomes. Morbidity and mortality are increased among IBD patients undergoing surgery, often due to postoperative complications or sepsis. Elderly adults with IBD, particularly UC, have very high rates of venous thromboembolism (VTE). Colonoscopy appears safe, but the optimal surveillance interval has not been well defined. Should the octogenarian, nonagenarian, and centurion undergo colonoscopy? The length of surveillance should likely account for the individual's overall life expectancy. Specific health maintenance should emphasize administering non-live vaccines to patients on thiopurines or biologics and regular skin exams for those on thiopurines. Smoking cessation is crucial to overall health and response to medical therapy, even among UC patients. This article will review management of IBD in the elderly.
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Affiliation(s)
- Elizabeth S John
- Department of Internal Medicine, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA. .,Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA.
| | - Kristina Katz
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Mark Saxena
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Sita Chokhavatia
- Division of Gastroenterology, Rutgers Robert Wood Johnson, New Brunswick, NJ, USA
| | - Seymour Katz
- New York University School of Medicine, 1000 Northern Blvd, Great Neck, NY, 11020, USA
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Cheetham TC. In Reply II-Risk of Disseminated Disease in Immunocompromised Patients Receiving Live Zoster Vaccine. Mayo Clin Proc 2016; 91:971-2. [PMID: 27378042 DOI: 10.1016/j.mayocp.2016.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 04/12/2016] [Indexed: 11/24/2022]
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Real-World Effectiveness and Safety of a Live-Attenuated Herpes Zoster Vaccine: A Comprehensive Review. Adv Ther 2016; 33:1094-104. [PMID: 27262452 PMCID: PMC4939147 DOI: 10.1007/s12325-016-0355-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Indexed: 12/19/2022]
Abstract
UNLABELLED 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.
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Tran KD, Falcone MM, Choi DS, Goldhardt R, Karp CL, Davis JL, Galor A. Epidemiology of Herpes Zoster Ophthalmicus: Recurrence and Chronicity. Ophthalmology 2016; 123:1469-75. [PMID: 27067924 DOI: 10.1016/j.ophtha.2016.03.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 11/17/2022] Open
Abstract
PURPOSE A hospital-based epidemiology study to describe herpes zoster ophthalmicus (HZO) prevalence and risk factors for recurrent and chronic disease. DESIGN Retrospective, hospital-based cohort study. PARTICIPANTS All patients evaluated in the Broward and Miami Veterans Administration Healthcare System (MIAVHS) during the study period. METHODS Retrospective medical record review of patients seen in the MIAVHS from January 1, 2010, through December 31, 2014, with a HZO clinical diagnosis. Assessment of the patient's clinical course was defined by the following: an acute episode of HZO was defined as quiescence of disease within 90 days of initial presentation, HZO recurrence was defined as any recurrent eye disease or rash 90 days or more after quiescence of disease was noted off therapy, and chronic HZO was defined as active disease persisting more than 90 days from initial presentation. MAIN OUTCOME MEASURES Main outcome measures included the frequency of HZO with and without eye involvement, HZO recurrence rates, and risk factors for recurrent or chronic HZO. RESULTS Ninety patients with HZO were included in the study. The mean age at incident episode of HZO was 68±13.8 years (range, 27-95 years). Most patients were white (73%), immune competent (79%), and did not receive zoster vaccination at any point during the follow-up (82%). Patients were followed for a mean of 3.9±5.9 years (range, 0-33 years). The period prevalence of HZ in any dermatome was 1.1%, the frequency of HZ involving V1 (HZO) was 0.07%, and the frequency of HZO with eye involvement was 0.05%. The overall 1-, 3-, and 5-year recurrence rates for either recurrent eye disease or rash were 8%, 17%, and 25%, respectively. Ocular hypertension (hazard ratio [HR], 4.6; 95% confidence interval [CI], 1.3-16.5; odds ratio [OR], 6.7; 95% CI, 1.5-31.2) and uveitis (HR, 5.7; 95% CI, 1.7-19.0; OR, 6.7; 95% CI, 1.5-31.2) increased the risk of recurrent and chronic disease. CONCLUSIONS This study supports newer data indicating that a significant proportion of patients experience recurrent and chronic HZO. Further study is needed to guide preventative and therapeutic approaches to recurrent and chronic HZO.
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Affiliation(s)
- Kimberly D Tran
- Ophthalmology Service, Miami Veterans Administration Medical Center, Miami, Florida; Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | | | - Daniel S Choi
- Ophthalmology Service, Miami Veterans Administration Medical Center, Miami, Florida; Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Raquel Goldhardt
- Ophthalmology Service, Miami Veterans Administration Medical Center, Miami, Florida; Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Carol L Karp
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Janet L Davis
- Bascom Palmer Eye Institute, University of Miami, Miami, Florida
| | - Anat Galor
- Ophthalmology Service, Miami Veterans Administration Medical Center, Miami, Florida; Bascom Palmer Eye Institute, University of Miami, Miami, Florida.
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Cheetham TC, Sy LS, Jacobsen SJ. In reply--Risk of Disseminated Varicella Zoster in Immunosuppressed Patients Receiving Zoster Vaccination. Mayo Clin Proc 2015; 90:1586-7. [PMID: 26541255 DOI: 10.1016/j.mayocp.2015.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/29/2022]
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Bubb MR. Risk of Disseminated Varicella Zoster in Immunosuppressed Patients Receiving Zoster Vaccination. Mayo Clin Proc 2015; 90:1585-6. [PMID: 26541254 DOI: 10.1016/j.mayocp.2015.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/03/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Michael R Bubb
- University of Florida College of Medicine, Gainesville, FL
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