Herpes zoster burden of illness and health care resource utilisation in the Australian population aged 50 years and older

Efficacy of Intravenous Lidocaine and Magnesium in the Management of Herpes Zoster Neuritis and Postherpetic Neuralgia: A Case Series

OBJECTIVES

Herpes zoster is a common disease encountered in clinical practice. The neuropathic pain caused by herpes zoster can be severe enough to interfere with daily life in challenging cases. Although it is said that intervening as early as possible after the onset of the disease improves outcomes, there are some cases that are difficult to treat as immediate interventional therapy is not possible. While there are some reports on the efficacy of intravenous magnesium and lidocaine, we investigated the efficacy of intravenous magnesium and lidocaine in patients with herpes zoster neuritis and postherpetic neuralgia. Patient criteria: A total of 23 patients with herpes zoster neuritis and postherpetic neuralgia were included in the study. We included only cases in which immediate interventional therapy was not possible.

METHODS

The treatment protocol was an intravenous infusion of a combination of 1.2 g of magnesium and 100 mg of lidocaine for one hour every week for four weeks (five times in total). Patients were assessed using the Numerical Rating Scale (NRS) for pain before and after the treatment at week zero and before the treatment at weeks one, two, three, and four.

RESULTS

There was a statistically significant difference between the median NRS before treatment at week zero and the median NRS before treatment at week one. Similarly, there was a statistically significant difference between the median NRS before treatment at week zero and the median NRS before treatment at weeks two, three, and four. In addition, the NRS tended to decrease as the number of treatments increased.

CONCLUSIONS

Intravenous lidocaine and magnesium may be effective for herpes zoster neuritis and postherpetic neuralgia. It may be a treatment method for when immediate interventional therapy is not possible.

Lipids, lipid-lowering drugs and the risk of herpes zoster: a Mendelian randomization study

Observational studies have shown that the risk of developing herpes zoster (HZ) increases with the use of statins. However, there are many confounding factors in observational studies. Therefore, our Mendelian randomization (MR) study aimed to explore the causal role of lipids in HZ and to assess the causal impact of lipid-lowering drug targets on HZ risk. Our study used low-density lipoprotein (LDL) as a biomarker, and MR analysis was applied to study the effects of genetic inhibition of 3-hydroxy-3-methylglutaryl CoA reductase (HMGCR, targeted by statins), Niemann-Pick C1-like 1 (NPC1L1, targeted by ezetimibe), and proprotein convertase subtilisin/kexin type 9 (PCSK9, targeted by, e.g., alirocumab) on the risk of HZ. Second, we analyzed the overall effect of different lipid traits, including LDL, high-density lipoprotein cholesterol (HDL-C), and triglycerides (TGs), on the HZ. Finally, we analyzed the causal association between cardiovascular disease (CVD) and HZ. The primary MR analysis employed the inverse variance weighted (IVW) approach, which MR supplemented‒Egger, weighted median and weighted mode methods. In addition, we performed sensitivity analysis to assess the robustness of the results and the presence of bias. Heterogeneity and pleiotropy analyses were performed to ensure the accuracy of the results. Genetically modified HMGCR inhibition was significantly associated with an increased risk of HZ (OR: 2.02, per standard deviation reduction in LDL; 95% CI 1.05-3.90; P = 0.035, P(BH) = 0.0525 < 0.1). Moreover, genetically proxied PCSK9 inhibition was associated with a reduced risk of HZ (OR: 0.58, per standard deviation reduction in LDL; 95% CI 0.42-0.80; P = 0.001, P(BH) = 0.003 < 0.1). Sensitivity analysis did not provide statistical evidence of bias from pleiotropy or genetic confounding. No robust association was found for NPC1L1 inhibition. No significant effect of lipid traits or CVD on HZ risk was found. Our findings did not support dyslipidemia and CVD as causal factors for HZ. Among the three lipid-lowering drug targets, HMGCR inhibition (targeted by statins) was associated with an increased risk of HZ, and PCSK9 is a promising candidate drug target in HZ. These findings have important implications for understanding the pathogenesis of HZ and for the development of new therapeutic strategies.

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

Knowledge of Herpes Zoster Virus and Its Vaccines Among Older Adults in Jazan Province, Saudi Arabia: A Cross-Sectional Study

Introduction Herpes zoster (HZ) is caused by the reactivation of the varicella-zoster virus (VZV) and can lead to complications such as postherpetic neuralgia. Although vaccines are available to prevent HZ, the level of concern about HZ and its vaccines in our region remains unknown. This study assessed the knowledge, attitudes, and practices regarding HZ and the HZ vaccines among adults aged ≥50 years in Jazan, Saudi Arabia. Methods A cross-sectional study was conducted using a questionnaire distributed to adults aged ≥50 years and data were collected on demographics, knowledge of HZ and its vaccines, attitudes, and practices. Multiple logistic regression examined factors associated with knowledge levels. Results Of 295 participants, 58% and 67.5% had low knowledge of HZ and its vaccines, respectively. Knowledge of HZ significantly differed by age, education, and occupation. Only 50% knew HZ affects nerves and skin and 28.8% knew HZ can be transmitted between individuals. Knowledge of the vaccine significantly differed by gender and information source. Conclusions This population has substantial knowledge gaps regarding HZ and vaccination. Targeted educational initiatives are needed to promote greater awareness of HZ immunization, especially for higher-risk groups like older adults and females.

Foot, ankle, and leg problems in Australian primary care: consultation patterns, management practices, and costs

OBJECTIVE

To explore consultation patterns, management practices, and costs of foot, ankle, and leg problems in Australian primary care.

STUDY DESIGN

We analyzed data from the Bettering the Evaluation and Care of Health program, April 2000 to March 2016. Foot, ankle, and leg problems were identified using the International Classification of Primary Care, Version 2 PLUS terminology. Data were summarized using descriptive statistics examining general practitioner (GP) and patient characteristics associated with a foot, ankle, or leg problem being managed. Cost to government was estimated by extracting fees for GP consultations, diagnostic imaging, and pathology services from the Medicare Benefits Schedule (MBS) database. Costs for prescription-only medicines were extracted from the Pharmaceutical Benefits Schedule and for nonprescribed medications, large banner discount pharmacy prices were used.

RESULTS

GPs recorded 1,568,100 patient encounters, at which 50,877 foot, ankle, or leg problems were managed at a rate of 3.24 (95% confidence intervals [CIs] 3.21-3.28) per 100 encounters. The management rate of foot, ankle, or leg problems was higher for certain patient characteristics (older, having a health care card, socioeconomically disadvantaged, non-Indigenous, and being English speaking) and GP characteristics (male sex, older age, and Australian graduate). The most frequently used management practice was the use of medications. The average cost (Australian dollars) per encounter was A$52, with the total annual cost estimated at A$256m.

CONCLUSIONS

Foot, ankle, and leg problems are frequently managed by GPs, and the costs associated with their management represent a substantial economic impact in Australian primary care.

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.

Assessing the impact of chickenpox and shingles vaccination using intermittent enhanced surveillance in Queensland, Australia

INTRODUCTION

Chickenpox and shingles are vaccine preventable diseases caused by varicella-zoster virus (VZV). Chickenpox is more common in children before adolescence and shingles among ≥50 years of age. With this study we aimed to determine changes in VZV epidemiology following chickenpox and shingles vaccine introduction in Queensland.

METHODS

This case series study used notified cases of VZV infection in Queensland from January 2010 to December 2021. In Queensland, VZV notifications are received as mostly clinically unspecified cases from pathology laboratories. Intermittent enhanced surveillance was conducted using clinician follow up to determine chickenpox and shingles clinical presentation, and we then analysed these by age-group, time period, and within vaccine eligible cohorts.

RESULTS

Of the 87,759 VZV notifications received, 70 % (n = 61,298) were notified as unspecified, followed by 23 % shingles (n = 19,927), and 7 % chickenpox (n = 6,534). Over the study period, the percent change in total notifications adjusted by age and sex was estimated to be an increase of 5.7 % (95 % CI 4.9-6.4) each year. The chickenpox notifications fell sharply at 18 months of age (eligible for chickenpox vaccine) with the rate being 57 % and 36 % lower among those aged 18-23 months compared to <12 and 12-17 months of age, respectively. Assuming all cases aged 60 years and older were shingles, notification rates of shingles decreased by 12-22 % among 70-79 years old (eligible for shingles vaccination) over the years 2017-2021 after vaccine introduction in 2016.

CONCLUSION

The VZV notification rate has increased over time in Queensland. Impact of chickenpox and shingles vaccines funded under National Immunisation Program is seen with a decline in notification rates among age-specific cohorts eligible to receive the vaccines under the program. Introduction of a second childhood dose chickenpox vaccine and more effective recombinant shingles vaccine may further improve the impact of the vaccination program.

Increasing Rates of Herpes Zoster Ophthalmicus and the COVID-19 Pandemic

Purpose

This epidemiologic study evaluates the variance in incidence of Herpes Zoster (HZ) and Herpes Zoster Ophthalmicus (HZO) within a single healthcare system with an aim to analyze their relationship to the COVID-19 pandemic.

Methods

All patients attending the Duke University Health System (DUHS) from January 1, 2018, to December 31, 2021, were included. General and COVID-related trends of HZO and HZ were analyzed based on new ICD-9 or ICD-10 diagnosis codes, compared with the total number of patients seen at DUHS during this period, and the number of reported COVID-19 cases in North Carolina obtained using the CDC data tracker.

Results

This study included 16,287 cases of HZ of whom 1,294 (7.94%) presented with HZO. The overall incidence of HZO showed an average yearly increase of 5.6%, however HZ incidence decreased by 5.3% per year. When comparing incidence rates of HZO in the 12-months before and after the COVID-19 pandemic onset in the United States (March 2020), the average incidence from March 2020 to February 2021 was 27.6 ± 11.6 compared to 18.0 ± 2.7 from March 2019 to February 2020 (p = 0.01). Moreover, 10/12 (83.3%) of the months had a higher incidence rate of HZO in the post-COVID onset year compared to their corresponding month in the pre-COVID year.

Conclusion

The results show HZO incidence may be increasing, despite an overall lower HZ incidence. This could suggest a distinct mechanism for HZO appearance. The COVID pandemic, directly or indirectly, may have accelerated the already increasing HZO incidence.

Reduction in Herpes Zoster Antiviral Use Since the Introduction of the Live-Attenuated Zoster Vaccine on Australia's National Immunisation Program: A Population-Based Study from 1994 to 2019

INTRODUCTION

Zostavax, the live-attenuated vaccine used to prevent herpes zoster (HZ), has been available to individuals aged 70 and 71-79 years (phased catch-up) via Australia's National Immunisation Program (NIP) since 2016. There are limited data characterising the incidence of HZ at the level of the Australian population. National prescription data for antivirals used to treat HZ may be used as a proxy for HZ incidence. We aimed to examine trends in antiviral prescriptions supplied for the treatment of HZ in Australia pre- and post-2016, and to assess whether Zostavax's inclusion on the NIP correlated with a reduction in HZ antiviral prescription rates.

METHODS

Using the Australian Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme prescribing data, we analysed antiviral prescriptions supplied for the treatment of HZ Australia-wide between 1994 and 2019. Annual prescription rates were calculated, and trends and changes in HZ antiviral use were explored descriptively and using Poisson models.

RESULTS

HZ antiviral prescription rates increased 2.6-fold (160%) between 1995 and 2015 [25.4 (95% CI 25.2, 25.6) and 65.3 (95% CI 64.9, 65.6) prescriptions per 10,000 people, respectively], and then decreased 0.45-fold (55%) between 2016 and 2018 [60.9 (95% CI 60.6, 61.2) and 27.5 (95% CI 27.3, 27.9) prescriptions per 10,000 people, respectively]. The prescription rate for the antiviral famciclovir restricted specifically for treating HZ in immunocompromised individuals increased 8.5-fold (750%) between 2006 (year first listed) and 2019 [0.3 (95% CI 0.3, 0.3) and 2.5 (95% CI 2.4, 2.6) prescriptions per 10,000 people, respectively].

CONCLUSION

The introduction of the live-attenuated HZ vaccine on Australia's formal national vaccination program was associated with a reduction in HZ antiviral prescription rates within the Australian population. The data suggest that the introduction of Shingrix, the non-live subunit zoster vaccine, may also be associated with a similar reduction in HZ antiviral prescriptions used to treat the immunocompromised, as well as the general population, given its accepted greater efficacy over Zostavax.

A Cross-Sectional Study of the Knowledge, Practice, and Attitude Towards Herpes Zoster Vaccination Among the General Population in the Western Region of Saudi Arabia

Introduction Herpes zoster (HZ) is a viral infection that occurs due to the reactivation of the varicella-zoster virus. The vaccination against herpes zoster to prevent its complications has been approved for individuals 50 years of age and older. This study aims to evaluate the knowledge, attitudes, and habits of at-risk populations about the varicella-zoster virus and its vaccination. Methodology A quantitative, observational, cross-sectional study was conducted among 500 adults over 50 years of age. Participants were selected by non-probability, convenience sampling from public places. RStudio (R version 4.1.1) was used to analyze the data. Result Eighty-three percent (n = 416) of participants had heard of herpes zoster (HZ). Seventy-four percent of respondents (n = 368) did not recognize the link between varicella and herpes zoster. Multiple linear regression showed that individuals who had varicella and heard about herpes zoster were the only positive predictors of herpes zoster knowledge. Out of all the respondents, 55.8% (n = 279) had heard of the herpes zoster vaccine, but 94.6% (n = 473) had not taken it. Among the respondents, 28.1% (n = 118) were unwilling to take optional vaccines; 77.4% (n = 387) agreed to take the HZ vaccine if recommended by a healthcare professional. Conclusion The general Saudi population had a good understanding of HZ and its vaccine. Their attitudes toward the HZ vaccine were generally positive; however, poor practices were observed. We recommend that arranging national campaigns targeting at-risk populations can enhance awareness about herpes zoster and its vaccine, subsequently increasing the rate of HZ immunization.

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

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

Decline in hospitalization rates for herpes zoster in Italy (2003-2018): reduction in the burden of disease or changing of hospitalization criteria?

BACKGROUND

Herpes Zoster (HZ) is a very demanding disease caused by the reactivation of latent Varicella Zoster Virus. The main aim of this study was to estimate the burden of the HZ hospitalizations in Italy from 2003 to 2018 evaluating temporal trends.

METHODS

Retrospective population-based study analyzing Hospital Discharge Records. Hospitalization records reporting the ICD-9 CM 053.X code in the principal diagnosis or in any of the five secondary diagnoses were considered as cases. Trends of hospitalization rates have been evaluated by Joinpoint analyses.

RESULTS

Overall, 99,036 patients were hospitalized with HZ in the 16-year period of the study, and 83,720 (84.5%) of these patients were over 50 years. Hospitalization rate was 10.4 per 100,000 persons/year with a significant decreasing trend from 13.9 in 2003-2006 to 7.8 in 2015-2018 (p < 0.001). Hospitalization rates showed a 20-fold higher risk among subjects aged over 80 years and 11-fold higher risk among 70-79-year-old subjects with respect to those aged less than 50 years. Over time, a statistically significant increase was observed for the case fatality rate (from 1.2 to 1.7%; p < 0.001) and the median length of stay (from 7 to 8 days; p < 0.001).

CONCLUSIONS

Zoster is a disease that causes hospitalization as relatively frequent complication and the observed reduced trend over time could be due to a restriction in hospitalization criteria instead of a reduced burden of disease. The decreasing trend should be carefully interpreted, since it could have an impact on promoting herpes zoster vaccination.

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

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

Incidence of complications of herpes zoster in individuals on immunosuppressive therapy: A register-based population study

OBJECTIVES

Herpes zoster (HZ) exposes to alterations of the quality-of-life. HZ is more frequent in immunocompromised individuals, but whether immunosuppression is associated with a higher rate of complications is not well documented. We aimed to assess association between drug-induced immunosuppression and HZ complications.

METHODS

Data from a sample of the French healthcare claims from 01/01/2006 to 12/31/2018 were analyzed. Complicated zoster (CZ) was defined as a hospitalization with a code for HZ or the first-time dispensation of high-dose valacyclovir and specific neuralgia analgesics. Drug-induced immunosuppression was identified through medication dispensation. Risk ratios were calculated to compare incidences in exposed individuals (EI) and non-exposed to immunosuppressive therapy (NEI).

RESULTS

We identified 227 and 2838 CZ, accounting for an incidence of 178 per 100,000 person-year (95%CI[154.9-201.1]) and 51.7 per 100,000 person-year (95%CI[49.8-53.6]), in EI and NEI, respectively (risk ratio: 3.44 (95%CI[3.01-3.94]). Mean age was 66 years in both groups. CZ occurred after a median of 11.7 months (IQR[5.3-49.9]) of immunosuppressive therapy. Post-herpetic neuralgia (PHN) lasted at least 3 months in 32.6% and 22.5% of cases in EI and NEI, respectively (p=.01).

CONCLUSIONS

Drug-induced immunosuppression increases the risk of CZ and exposes to longer-lasting PHN. Figures provided in this study could help guide prophylaxis of HZ.

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.

Vaccination for quality of life: herpes-zoster vaccines

Current vaccination policy in most high-income countries aims to counteract the decline in cell-mediated immunity to varicella zoster virus that occurs with advancing age or immunosuppression. The aim of this review was to describe the burden of illness associated with herpes zoster (HZ) and post-herpetic neuralgia (PHN) risks and their impact on the social and common life in infected people. The effectiveness/efficacy and cost effectiveness of the immunization strategy will be presented through the review of the literature relevant to the live attenuated HZ vaccine (ZLV) licensed in 2006 and the recombinant HZ vaccine (RZV). The latter has very recently been approved to protect aged people aged ≥ 50 years against HZ morbidity including its complications, and associated health-care costs. Finally, this review also provides data with respect of precautions of using and safety of ZVL and RVZ.

Herpes zoster in older adults in Ontario, 2002-2016: Investigating incidence and exploring equity

Older adults are at increased risk of herpes zoster (HZ) and post-herpetic neuralgia (PHN) and HZ vaccines are available to help prevent infection. The objective of our study was to provide updated data on incidence of HZ and PHN related to clinical and demographic factors in older adults to inform immunization practices. We conducted a population-based, retrospective cohort study and included all cases of HZ seen in outpatient, emergency department, and hospital settings for adults aged 65 years and over between April 1, 2002 to August 31, 2016 in Ontario, Canada. We calculated the incidence of HZ and PHN, and estimated the proportion within each subgroup that developed PHN. We also assessed incidence by neighbourhood-level income quintile before and after the availability of vaccine for private purchase. The average annual incidence of HZ in any setting was 59.0 per 10,000 older adults, with higher incidence in outpatient as opposed to hospital settings. Incidence was higher in the oldest age groups, females, and those classified as immunocompromised or frail. Relative to the pre-vaccine era, the disparities in incidence of HZ by neighbourhood-level income increased, with higher rates of HZ and PHN seen in those residing in lower income quintiles. Additional prevention efforts should be targeted toward adults who are immunocompromised, frail, and those living in lower socioeconomic quintiles. Future work should assess the impact of the zoster vaccine program with a particular focus on equity in the publicly-funded era.

Modelling a cost-effective vaccination strategy for the prevention of varicella and herpes zoster infection: A systematic review

BACKGROUND

Varicella zoster virus (VZV) and its re-emergence as herpes zoster (HZ) is associated with significant morbidity and mortality. While studies show that VZV vaccination is effective in reducing VZV incidence, many decision makers have not added VZV to their vaccination schedule, largely due to uncertainty surrounding the effect of VZV vaccination on HZ incidence (exogenous boosting, EB), and the cost-effectiveness (CE) of vaccination.

METHODS

A systematic review was conducted to identify the current published evidence of CE of VZV vaccination strategies where both VZV and HZ incidence were modelled.

RESULTS

Six studies (one published in 2003 and five between 2010 and 2019), were identified with all conducting cost-utility analysis using a dynamic transmission modelling approach and assuming EB. All predicted that mass infant VZV vaccination would rapidly reduce VZV incidence, but HZ incidence would increase. Compared with no-vaccination, the CE of VZV vaccination strategies ranged from higher costs and poorer outcomes (dominated), towards CE (incremental cost-effectiveness ratios of between $7,000 to $61,000 USD), or lower cost and better outcomes (dominant). However, without EB, HZ incidence immediately dropped below pre-vaccination levels making VZV vaccination quickly CE and/or dominant to a no vaccination strategy.

CONCLUSIONS

Current models are sensitive to assumptions of EB suggesting that future studies consider an agent-based modelling approach to address the individual nature of variables that determine the infectiousness of VZV.

Australia's national zoster vaccination program: Knowledge, attitudes and behaviour of general practitioners

Objectives

To assess knowledge, attitudes and behaviour of Australian general practitioners (GPs) regarding herpes zoster vaccination under the National Immunisation Program (NIP) from 2016 for adults aged 70-79 years.

Design, setting, participants

National cross-sectional online survey of GPs, October-November 2017.

Outcome measures

Knowledge, attitudes and behaviour regarding zoster vaccination, including challenges experienced and recommendations for improvement.

Results

Of the 1026 GPs who responded (response rate 7.9%), 98.5% were aware that zoster vaccine is NIP-funded for adults aged 70-79 years and 85.4% that it is recommended for age 60-69 years; however, 51.3% incorrectly thought it is routinely recommended for age 50-59 years. A minority (4.6%) incorrectly believed that being immunocompromised is not a contraindication to zoster vaccination and 16.0% that it cannot be co-administered with influenza or pneumococcal vaccine. Almost half (48.9%) rarely or never reported zoster vaccination data to the Australian Immunisation Register (AIR). Challenges perceived included lack of adequate information on vaccine contraindications; efficacy and safety concerns; and difficulty applying age criteria for NIP eligibility in general practice. Respondents indicated a desire for program expansion to include younger and older adult age groups.

Conclusion

This Australian GP survey, conducted one year after the introduction of the national zoster vaccination program, identified some knowledge gaps. A repeat survey of GPs is warranted to determine whether these issues persist, particularly regarding contraindication to vaccination for immunocompromised individuals. We encourage all GPs to offer zoster vaccination in line with current Australian evidence-based guidelines, particularly for the NIP-funded 70-79 years cohort; ensuring compliance with relevant contraindications; and reporting to AIR.

Early impact of the Australian national shingles vaccination program with the herpes zoster live attenuated vaccine

Herpes zoster (shingles) is a painful condition resulting from reactivation of latent varicella zoster virus (VZV). The Australian National Shingles Vaccination Program (commenced November 2016) provides free herpes zoster vaccination for eligible adults aged 70 years, with a 5-year catch-up program (until October 2021) for adults aged 71-79 years. Patterns and impact of the program were evaluated by analysis of vaccine distribution and delivery data and specific antiviral prescription data from the Pharmaceutical Benefits Scheme. During the first 2 years, uptake of funded live attenuated shingles vaccine ZOSTAVAX® (Zoster Virus Vaccine Live; ZVL) was high across the ongoing and catch-up programs. Before program implementation (2006-2016), herpes zoster coded antiviral prescription rates increased by 2.2% per year (95% CI: 1.5, 2.9) in the 70-79 years age group. In the two years since program launch, herpes zoster antiviral prescription rates declined substantially in this age group, by an average of 13.6% per year (95% CI: 1.5, 24.2). These results indicate that the National Shingles Vaccination Program has been highly successful in vaccinating a considerable proportion of Australian adults aged 70-79 years against herpes zoster and suggest that vaccine uptake was associated with decreased incidence of herpes zoster.

Correlation between Galectin-3 and Early Herpes Zoster Neuralgia and Postherpetic Neuralgia: A Retrospective Clinical Observation

This study aims to explore the value of serum galectin-3 in patients with herpes zoster neuralgia (HZN) and postherpetic neuralgia (PHN) and other factors influencing HZN and PHN occurrence. Samples from forty patients with herpes zoster neuralgia (HZN) (Group H), 40 patients with nonherpes zoster neuralgia (Group N), and 20 cases of health check-up were collected. Patients were divided into PHN group (Group A) and non-PHN group (Group B) according to the occurrence of PHN in Group H. Galectin-3, T-lymphocyte subsets, and IL-6 were recorded in all patients. The changes of galectin-3 in patients with early HZN and PHN were analyzed by single-factor analysis and multifactor analysis. The age (P=0.012) and NRS scores (P < 0.001) of PHN patients were significantly higher than those of non-PHN patients and other neuralgia patients. The ratio of CD3+ (F = 80.336, P < 0.001), CD4+ (F = 12.459, P < 0.001) lymphocyte subsets, and CD4+/CD8+ (F = 15.311, P < 0.001) decreased significantly in PHN patients. The level of blood IL-6 (F = 139.446, P < 0.001) in PHN patients was significantly increased. Serum galectin-3 was significantly higher in HZN patients than in PHN patients (P < 0.05); IL-6 (OR = 10.002, 95% CI: 3.313-30.196, P < 0.001) and galectin-3 (OR = 3.719, 95% CI: 1.261-10.966, P=0.017) were the risk factors for HZN; galectin-3 (OR = 17.646, 95% CI: 2.795-111.428, P=0.002) was also the risk factor for PHN. ROC curve analysis also showed that serum galectin-3 was a better predictor of poor prognosis (AUC = 0.934, P < 0.001). Therefore, as an independent risk factor of HZN and PHN, serum galectin-3 may be used as a new biochemical marker in clinical practice.

Safety of live attenuated herpes zoster vaccine in adults 70-79 years: A self-controlled case series analysis using primary care data from Australia's MedicineInsight program

BACKGROUND

Australia introduced a funded shingles vaccination program for older adults in November 2016, administered predominantly in primary care clinics. MedicineInsight, a nationally representative primary care database, was used to investigate the risk of pre-specified outcomes following live attenuated herpes zoster vaccine (ZVL) in Australia.

METHODS

Individuals aged 70-79 years who received ZVL between 1 November 2016 and 31 July 2018 were identified from MedicineInsight. The self-controlled case series (SCCS) method was used to estimate the seasonally-adjusted relative incidence (RI) of seven pre-specified outcome events (injection site reaction (ISR) [positive control], burn [negative control], myocardial infarction (MI), stroke, rash, rash with an antiviral prescription, and clinical attendance) during a plausible post-vaccination at-risk window compared with times distant from vaccination. Sensitivity analyses examined the effect of common concomitant vaccinations and restriction to first outcome events.

RESULTS

A total of 332,988 vaccination encounters among 150,054 individuals were identified during the study period; over 2 million clinical attendances were observed. There was an increased RI of ISR in the seven days following ZVL (RI = 77.4, 95% CI 48.1-124.6); the RI of clinical attendance (RI = 0.94, 95% CI 0.94-0.95) and stroke (RI = 0.58, 95% CI 0.44-0.78) were lower in the 42 days following administration of ZVL compared to control periods. There was no evidence of a change in the RI of MI (RI = 0.74, 95% CI 0.41-1.33), rash (RI = 0.97, 95% CI 0.88-1.08), or rash with antiviral prescription (RI = 0.83, 95% CI 0.62-1.10) in the 42 days following ZVL compared to control periods.

CONCLUSION

No new safety concerns were identified for ZVL in this study based on a novel, Australian primary care data source. An expected increased risk of ISR was identified; findings in relation to cardiovascular disease were reassuring but require confirmation using additional data, including hospital records.

Oral Ulcers Presentation in Systemic Diseases: An Update

BACKGROUND

Diagnosis of oral ulceration is always challenging and has been the source of difficulty because of the remarkable overlap in their clinical presentations.

AIM

The objective of this review article is to provide updated knowledge and systemic approach regarding oral ulcers diagnosis depending upon clinical picture while excluding the other causative causes.

METHODS

For this, specialised databases and search engines involving Science Direct, Medline Plus, Scopus, PubMed and authentic textbooks were used to search topics related to the keywords such as oral ulcer, oral infections, vesiculobullous lesion, traumatic ulcer, systematic disease and stomatitis. Associated articles published from 1995 to 2019 in both dental and medical journals including the case reports, case series, original articles and reviews were considered.

RESULTS

The compilation of the significant data reveals that ulcers can be classified according to (i) duration of onset, (ii) number of ulcers and (iii) etiological factors. Causation of oral ulcers varies from slight trauma to underlying systemic diseases and malignancies.

CONCLUSION

Oral manifestations must be acknowledged for precise diagnosis and appropriate treatment.

The Epidemiology of Herpes Zoster and Postherpetic Neuralgia in China: Results from a Cross-Sectional Study

Introduction

Few studies have examined the epidemiology of herpes zoster (HZ) and postherpetic neuralgia (PHN) in China. The aim of this study was to estimate the prevalence of HZ and PHN in China, and to examine the clinical characteristics of patients identified with PHN.

Methods

This was a cross-sectional study conducted in 24 hospitals in seven cities in China. Prevalence of HZ and PHN was determined by physician (n = 100) chart review of patients (n = 36,170) aged ≥ 40 years seeking medical care over a 30- to 60-day period. The health history of patients identified with PHN was obtained and included time since diagnosis of HZ or PHN, time since onset of PHN-related pain, and the methods used for diagnosing HZ and PHN.

Results

The prevalence rates of HZ and PHN were 7.7% [95% confidence interval (CI) 7.5–8.0] and 2.3% (95% CI 2.2–2.5), respectively. Of patients with HZ, 29.8% developed PHN. Rates of HZ and PHN increased with age and were highest in patients aged ≥ 70 years (10.6% and 4.1%, respectively). The majority of patients with PHN were diagnosed with HZ (80.9%) and PHN (83.8%) for < 1 year, and had experienced PHN-related pain for < 1 year (80.5%). Patient description and clinical examination were most commonly used to diagnose HZ and PHN.

Conclusion

These results provide current estimates of the prevalence of HZ and PHN in the general adult population in urban China. These rates are similar to previously reported rates in China and worldwide, and highlight the global nature of HZ and PHN.

Funding

Pfizer Inc.

A Cost-Effectiveness Analysis of Vaccination for Prevention of Herpes Zoster and Related Complications: Input for National Recommendations

BACKGROUND

The U.S. Advisory Committee on Immunization Practices recently developed recommendations for use of a new recombinant zoster vaccine (RZV).

OBJECTIVE

To evaluate the cost-effectiveness of vaccination with RZV compared with zoster vaccine live (ZVL) and no vaccination, the cost-effectiveness of vaccination with RZV for persons who have previously received ZVL, and the cost-effectiveness of preferential vaccination with RZV over ZVL.

DESIGN

Simulation (state-transition) model using U.S. epidemiologic, clinical, and cost data.

DATA SOURCES

Published data.

TARGET POPULATION

Hypothetical cohort of immunocompetent U.S. adults aged 50 years or older.

TIME HORIZON

Lifetime.

PERSPECTIVE

Societal and health care sector.

INTERVENTION

Vaccination with RZV (recommended 2-dose regimen), vaccination with ZVL, and no vaccination.

OUTCOME MEASURES

The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

RESULTS OF BASE-CASE ANALYSIS

For vaccination with RZV compared with no vaccination, ICERs ranged by age from $10 000 to $47 000 per quality-adjusted life-year (QALY), using a societal perspective and assuming 100% completion of the 2-dose RZV regimen. For persons aged 60 years or older, ICERs were less than $60 000 per QALY. Vaccination with ZVL was dominated by vaccination with RZV for all age groups 60 years or older.

RESULTS OF SENSITIVITY ANALYSIS

Results were most sensitive to changes in vaccine effectiveness, duration of protection, herpes zoster incidence, and probability of postherpetic neuralgia. Vaccination with RZV after previous administration of ZVL yielded an ICER of less than $60 000 per QALY for persons aged 60 years or older. In probabilistic sensitivity analyses, RZV remained the preferred strategy in at least 95% of simulations, including those with 50% completion of the second dose.

LIMITATION

Few data were available on risk for serious adverse events, adherence to the recommended 2-dose regimen, and probability of recurrent zoster.

CONCLUSION

Vaccination with RZV yields cost-effectiveness ratios lower than those for many recommended adult vaccines, including ZVL. Results are robust over a wide range of plausible values.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Herpes zoster infection and statins: which implications in clinical practice?

Herpes zoster (HZ), which is caused by reactivation of latent varicella zoster virus (VZV), constitutes a major public health concern in both short- and long-term periods. Over the last years, several epidemiological studies have demonstrated that statin use is associated with increased risk of HZ at cerebral level. Because statins are among the most popular and best-selling drugs in western countries, this potential negative pleiotropic effect could have important implications in the daily clinical practice. In the present manuscript, we reviewed the available data on the statin use and the relative risk of HZ infection.

Epidemiology, treatment and prevention of herpes zoster: A comprehensive review

Herpes zoster is a major health burden that can affect individuals of any age. It is seen more commonly among individuals aged ≥50 years, those with immunocompromised status, and those on immunosuppressant drugs. It is caused by a reactivation of varicella zoster virus infection. Cell-mediated immunity plays a role in this reactivation. Fever, pain, and itch are common symptoms before the onset of rash. Post-herpetic neuralgia is the most common complication associated with herpes zoster. Risk factors and complications associated with herpes zoster depend on the age, immune status, and the time of initializing treatment. Routine vaccination for individuals over 60 years has shown considerable effect in terms of reducing the incidence of herpes zoster and post-herpetic neuralgia. Treatment with antiviral drugs and analgesics within 72 hours of rash onset has been shown to reduce severity and complications associated with herpes zoster and post-herpetic neuralgia. This study mainly focuses on herpes zoster using articles and reviews from PubMed, Embase, Cochrane library, and a manual search from Google Scholar. We cover the incidence of herpes zoster, gender distribution, seasonal and regional distribution of herpes zoster, incidence of herpes zoster among immunocompromised individuals, incidence of post-herpetic neuralgia following a zoster infection, complications, management, and prevention of herpes zoster and post-herpetic neuralgia.

Determining the optimal strategy for the live-attenuated herpes zoster vaccine in adults

The optimal strategy for the vaccinating against herpes zoster (HZ) vaccine remains unknown. Cost-effectiveness analyses provide insight to the most cost-effective age groups but results vary across studies. The optimal strategy is important given that vaccine efficacy and duration vary depending on vaccination age. Therefore, small changes from the optimal age can affect long-term outcomes and produce sub-optimal results. The objective of this research was to determine the optimal timing policy for HZ vaccination. We simulated cohorts of men and women and use stochastic dynamic programming to evaluate the decision to vaccinate or defer each year from age 50 to 100. If the decision was to defer, the cohort risked developing HZ. If HZ occurred, the cohort was subjected to cost and quality-adjusted life year (QALY) loss for a typical HZ infection (including complications) at that age. If HZ did not occur, the decision was evaluated at the next age. Then, we extend the model to consider the case in which a booster vaccine is available. A set of probabilistic sensitivity analyses were conducted to check model robustness. Results show the optimal policy for women is to vaccinate between ages 66 and 77, and for men between ages 66 and 74, assuming a willingness to pay (WTP) of $100,000 per QALY. It becomes optimal to vaccinate earlier if a booster vaccine is available, and women have a wider range of ages than men. This research is the first to examine exactly when the HZ vaccine should be administered. It is also the first study, to our knowledge, that used stochastic dynamic programming to examine the question of a second dose for any vaccine. This research provides the first simple policy on when to vaccinate and re-vaccinate against HZ.

Quantifying the incidence and burden of herpes zoster in New Zealand general practice: a retrospective cohort study using a natural language processing software inference algorithm

OBJECTIVE

To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis.

DESIGN

A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22 million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation.

SETTING

General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand.

PARTICIPANTS

Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded.

MAIN OUTCOME MEASURES

The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice.

RESULTS

Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10 000 patient-years (95% CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10 000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis.

CONCLUSIONS

Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.

Epidemiology and long-term disease burden of herpes zoster and postherpetic neuralgia in Taiwan: a population-based, propensity score-matched cohort study

Background

The objectives of this study were to characterize the burden of herpes zoster, as well as the longitudinal and incremental changes of healthcare service utilization among individuals with herpes zoster and postherpetic neuralgia (PHN) compared to those without.

Methods

Using the National Health Insurance Research Database (NHIRD), we established a herpes zoster cohort of people diagnosed with herpes zoster between 2004 and 2008 as study cases. Another subset of the NHIRD, which was randomly selected from all elderly beneficiaries between 2004 and 2008 served as a non-herpes-zoster elderly control pool. Each case was then assigned one matched control according to age, gender, index date and propensity score. PHN cases were defined as those with persisting pain for more than 90 days after the onset of herpes zoster.

Results

Between 2004 and 2008, about 0.6 million patients were newly diagnosed with herpes zoster. The incidence increased with age, and most cases were identified during the summer period. Herpes zoster cases were found to have higher consumption of all types of healthcare services in the first year after the index date. Such increases were particularly obvious for patients with PHN, who showed incremental increases on average of 16.3 outpatient visits, 0.4 emergency room visits and 0.24 inpatient admissions per year.

Conclusions

The incidence of herpes zoster increased with age and changed according to the seasons. Patients with herpes zoster were associated with higher healthcare utilization and this increase in healthcare utilization was most obvious for herpes zoster patients with PHN.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5247-6) contains supplementary material, which is available to authorized users.

A practical approach to vaccination of patients with autoimmune inflammatory rheumatic diseases in Australia

Autoimmune inflammatory rheumatic diseases (AIIRD), such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis are often complicated by infection, which results in significant morbidity and mortality. The increased risk of infection is probably due to a combination of immunosuppressive effects of the AIIRD, comorbidities and the use of immunosuppressive conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs) and more recently, targeted synthetic DMARDs and biologic DMARDs that block specific pro-inflammatory enzymes, cytokines or cell types. The use of these various DMARDs has revolutionised the treatment of AIIRD. This has led to a marked improvement in quality of life for AIIRD patients, who often now travel for prolonged periods. Many infections are preventable with vaccination. However, as protective immune responses induced by vaccination may be impaired by immunosuppression, where possible, vaccination may need to be performed prior to initiation of immunosuppression. Vaccination status should also be reviewed when planning overseas travel. Limited data regarding vaccine efficacy in patients with AIIRD make prescriptive guidelines difficult. However, a vaccination history should be part of the initial work-up in all AIIRD patients. Those caring for AIIRD patients should regularly consider vaccination to prevent infection within the practicalities of routine clinical practice.

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.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.

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.

Increasing incidence associated with herpes zoster infection in British Columbia, Canada

BACKGROUND

Recent studies have shown an increasing incidence of herpes zoster (HZ) infection, which may be related to the introduction of varicella vaccination programs in children. We examined the epidemiology and treatment costs of HZ and post-herpetic neuralgia (PHN) over time in British Columbia, Canada.

METHODS

The cohort consisted of all cases with HZ infection from January 1, 1997 and December 31, 2012. Incident zoster was defined as a case (ICD-9 053 or ICD-10 B02) without a previous episode of HZ or PHN in the previous 12 months. We determined the incidence for HZ and PHN and the age-sex standardized rate for the overall population. We determined the association between the varicella vaccination program and increased HZ rates by evaluating the rate ratios in the publicly-funded varicella vaccine period compared to the non-publicly funded period in a regression model. We evaluated the hospitalization rates, treatment by GPs and their associated yearly costs for HZ and PHN.

RESULTS

HZ incidence increased for the entire study period from 3.2 per 1000 population in 1997 to 4.5 in 2012. HZ rates were higher for females than males and all age groups had an increased incidence rate, except the 0-9 year olds, where the rate decreased. Crude and age-sex standardized incidence rates of PHN demonstrated very similar patterns to HZ incidence. Based on the regression model, rates of HZ were higher in the older individuals. No significant increase with HZ incidence was seen during the publically funded varicella vaccination program compared to the non-publicly funded period. From 1997 to 2012, the annual HZ-related costs associated with hospitalizations and GP visits were over $CDN4.9 million and $CDN537,286, respectively; treatment costs for hospitalizations have increased significantly over time. Majority of PHN-related cases are managed by GPs, with a steady increase over time in number of cases and associated annual costs.

CONCLUSIONS

The incidence of zoster and PHN is increasing with time, particularly in the elderly population and the risk is greater in the over 65 year olds. Treatment costs for both HZ and PHN represent a significant burden on the Canadian healthcare system.

Healthcare Resource Utilisation Associated with Herpes Zoster in a Prospective Cohort of Older Australian Adults

Background

Herpes zoster (HZ) is a common condition that increases in incidence with older age but vaccines are available to prevent the disease. However, there are limited data estimating the health system burden attributable to herpes zoster by age.

Methods

In this study, we quantified excess healthcare resource usage associated with HZ during the acute/sub-acute period of disease (21days before to 90 days after onset) in 5952 cases and an equal number of controls matched on age, sex, and prior healthcare resource usage. Estimates were adjusted for potential confounders in multivariable regression models. Using population-based estimates of HZ incidence, we calculated the age-specific excess number of health service usage events attributable to HZ in the population.

Results

Per HZ case, there was an average of 0.06 (95% CI 0.04–0.08) excess hospitalisations, 1.61 (95% CI 1.51–1.69) excess general practitioner visits, 1.96 (95% CI 1.86–2.15) excess prescriptions filled and 0.11 (95% CI 0.09–0.13) excess emergency department visits. The average number of healthcare resource use events, and the estimated excess per 100,000 population increased with increasing age but were similar for men and women, except for higher rates of hospitalisation in men. The excess annual HZ associated burden of hospitalisations was highest in adults ≥80 years (N = 2244, 95%CI 1719–2767); GP visits was highest in those 60–69 years (N = 50567, 95%CI 39958–61105), prescriptions and ED visits were highest in 70–79 years (N = 50524, 95%CI 40634–60471 and N = 2891, 95%CI 2319–3449 respectively).

Conclusions

This study provides important data to establish the healthcare utilisation associated with HZ against which detailed cost-effectiveness analyses of HZ immunisation in older adults can be conducted.

Risk Factors for Herpes Zoster Among Adults

Background. The causes of varicella-zoster virus reactivation and herpes zoster (HZ) are largely unknown. We assessed potential risk factors for HZ, the data for which cannot be obtained from the medical sector.

Methods. We conducted a matched case-control study. We established active surveillance in Olmsted County, Minnesota to identify HZ occurring among persons age ≥50 years during 2010–2011. Cases were confirmed by medical record review. Herpes zoster-free controls were age- and sex-matched to cases. Risk factor data were obtained by telephone interview.

Results. We enrolled 389 HZ case patients and 511 matched controls; the median age was 65 and 66 years, respectively. Herpes zoster was associated with family history of HZ (adjusted odds ratio [aOR] = 1.65); association was highest with first-degree or multiple relatives (aOR = 1.87 and 3.08, respectively). Herpes zoster was also associated with prior HZ episodes (aOR = 1.82), sleep disturbance (aOR = 2.52), depression (aOR = 3.81), and recent weight loss (aOR = 1.95). Stress was a risk factor for HZ (aOR = 2.80), whereas a dose-response relationship was not noted. All associations indicated were statistically significant (P < .05). Herpes zoster was not associated with trauma, smoking, tonsillectomy, diet, or reported exposure to pesticides or herbicides (P > .1).

Conclusions. We identified several important risk factors for HZ; however, the key attributable causes of HZ remain unknown.

Disease Burden Due to Herpes Zoster among Population Aged ≥50 Years Old in China: A Community Based Retrospective Survey

OBJECTIVE

To understand the disease burden due to Herpes Zoster (HZ) among people aged ≥50 years old in China and provide baseline data for future similar studies, and provide evidence for development of herpes zoster vaccination strategy.

METHODS

Retrospective cohort study was conducted in 4 townships and one community. A questionnaire was used to collect information on incidence and cost of HZ among people aged ≥ 50 years old.

RESULTS

The cumulative incidence rate was 22.6/1,000 among people aged ≥ 50 years old. The average annual incidence rate of HZ was 3.43/1,000 among people aged ≥ 50 years old in 2010-2012. Cumulative incidence and average annual incidence rate increased with age: the cumulative incidence of HZ among people aged ≥ 80 years old was 3.34 times of that among 50-years old (52.3/1000 vs 15.7/1,000); average annual incidence rate rises from 2.66/1,000 among 50-years old to 8.55/1,000 among 80-year old. Cumulative incidence and average annual incidence rate for females were higher than that for males (cumulative incidence, 26.5/1000 vs 18.7/1,000; annual incidence rate, 3.95/1000 vs 2.89/1,000). Cumulative incidence and average annual incidence rate in urban were higher than in rural (cumulative incidence, 39.5/1000 vs 17.2/1,000; annual incidence rate, 7.65/1000 vs 2.06/1,000). The hospitalization rate of HZ was 4.53%. And with the increase of age, the rate has an increasing trend. HZ costs 945,709.5 RMB in total, corresponding to 840.6 RMB per patient with a median cost of 385 RMB (interquartile range 171.7-795.6). Factors associated with cost included the first onset year, area, whether hospitalized and whether sequelae left.

CONCLUSION

Incidence rate, complications, hospitalization rate and average cost of HZ increase with age. We recommend that the HZ vaccinations should target people aged ≥50 years old if Zoster vaccine is licensed in China.

Herpes zoster vaccine effectiveness and manifestations of herpes zoster and associated pain by vaccination status

Options for managing herpes zoster (HZ)-related pain and complications have limited effectiveness, making HZ prevention through vaccination an important strategy. Limited data are available on HZ vaccine effectiveness against confirmed HZ and manifestations of HZ among vaccinated persons. We conducted a matched case-control study to assess HZ vaccine effectiveness for prevention of HZ and other HZ-related outcomes and a cohort study of persons with HZ to compare HZ-related outcomes by vaccination status. Cases were identified through active surveillance among persons age ≥ 60 years with HZ onset and health-care encounters during 2010-2011 in Southeastern Minnesota. Controls were age- and sex-matched to cases. Data were collected by medical record review and from participants via interviews and daily pain diaries. 266 HZ case-patients and 362 matched controls were enrolled in the vaccine effectiveness studies and 303 case-patients in the cohort study of HZ characteristics by vaccination status. Vaccination was associated with 54% (95% CI:32%-69%) reduction in HZ incidence, 58% (95% CI:31%-75%) reduction in HZ prodromal symptoms, and 70% (95% CI:33%-87%) reduction in medically-attended prodrome. HZ vaccine was statistically significant effective at preventing postherpetic neuralgia (PHN) measured at 30 d after rash onset, 61% (95% CI: 22%-80%). Among persons who developed HZ, no differences were found by vaccination status in severity or duration of HZ pain after rash onset. In this population-based study, HZ vaccination was associated with >50% reduction in HZ, HZ prodrome, and medically-attended prodrome.

Evaluation of the economic burden of Herpes Zoster (HZ) infection

The main objective of this systematic review was to evaluate the economic burden of Herpes Zoster (HZ) infection.   The review was conducted in accordance with the standards of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" guidelines. The following databases were accessed: ISI/Web of Knowledge (WoS), MEDLINE/PubMed, Scopus, ProQuest, the Cochrane Library and EconLit. Specific literature on health economics was also manually inspected. Thirty-three studies were included. The quality of the studies assessed in accordance with the Consolidated Health Economic Evaluation Reporting Standards checklist was good. All studies evaluated direct costs, apart from one which dealt only with indirect costs. Indirect costs were evaluated by 12 studies. The economic burden of HZ has increased over time. HZ management and drug prescriptions generate the highest direct costs. While increasing age, co-morbidities and drug treatment were found to predict higher direct costs, being employed was correlated with higher indirect costs, and thus with the onset age of the disease. Despite some differences among the selected studies, particularly with regard to indirect costs, all concur that HZ is a widespread disease which has a heavy social and economic burden.

Incidences of Herpes Zoster and Postherpetic Neuralgia in Japanese Adults Aged 50 Years and Older From a Community-based Prospective Cohort Study: The SHEZ Study

BACKGROUND

Many cross-sectional studies have examined the incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN), but prospective studies in Japanese older adults are lacking. Therefore, we conducted a community-based prospective cohort study to determine the incidence in Japanese adults aged ≥50 years.

METHODS

We recruited 12 522 participants from Shozu County, Kagawa Prefecture, between December 2008 and November 2009 and followed participants for 3 years. When a subject presented with symptoms suggestive of HZ, they were examined at collaborating medical institutions and cooperated with onset and recovery surveys (eg, measurement of varicella zoster virus-specific immunity and a pain survey). The hazard ratios (HRs) of HZ and PHN according to sex and age were analyzed by Cox regression analysis with a significance level of 5%.

RESULTS

The incidence of HZ was 10.9/1000 person-years (men: 8.5/1000 person-years; women: 12.8/1000 person-years) and was significantly higher in women than in men (HR 1.5; 95% confidence interval, 1.2-1.8). The incidence of PHN was 2.1/1000 person-years (men: 1.7/1000 person-years; women: 2.4/1000 person-years), with no significant sex differences. A total of 19% of HZ cases progressed to PHN; no sex-specific difference in the proportion of PHN cases was observed.

CONCLUSIONS

We clarified the accurate incidences of HZ and PHN in a population of Japanese older adults. These incidences increased with age. HZ incidence was higher in women than in men, while PHN incidence did not differ markedly between the sexes.

Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective

Herpes zoster (HZ) is primarily a disease of nerve tissue but the acute and longer-term manifestations require multidisciplinary knowledge and involvement in their management. Complications may be dermatological (e.g. secondary bacterial infection), neurological (e.g. long-term pain, segmental paresis, stroke), ophthalmological (e.g. keratitis, iridocyclitis, secondary glaucoma) or visceral (e.g. pneumonia, hepatitis). The age-related increased incidence of HZ and its complications is thought to be a result of the decline in cell-mediated immunity (immunosenescence), higher incidence of comorbidities with age and social-environmental changes. Individuals who are immunocompromised as a result of disease or therapy are also at increased risk, independent of age. HZ and its complications (particularly postherpetic neuralgia) create a significant burden for the patient, carers, healthcare systems and employers. Prevention and treatment of HZ complications remain a therapeutic challenge despite recent advances. This is an overview of the multidisciplinary implications and management of HZ in which the potential contribution of vaccination to reducing the incidence HZ and its complications are also discussed.

Increasing trends of herpes zoster in Australia

Background

Increasing trends in incidence of herpes zoster (HZ) have been reported in Australia and internationally. This may reflect the impact of childhood VZV vaccination programs introduced universally in Australia in late 2005. The objective of this study was to evaluate changes in incidence of HZ and PHN in Australia over time, and associated healthcare resource utilisation.

Methods

Australian data on general practice (GP) encounters for HZ, specific antiviral prescribing data from the pharmaceutical benefits scheme, emergency department presentations from the states of NSW and Victoria and national hospitalisation data for HZ were analysed for time trends using regression models. Two time periods (2000-2006 and 2006-2013) were compared which correspond broadly with the pre- and post- universal VZV vaccination period.

Results

All data sources showed increasing rates of HZ with age and over time. The GP database showed a significant annual increase in encounters for HZ of 2.5 per 100,000 between 1998 and 2013, and the rates of prescriptions for HZ increased by 4.2% per year between 2002 and 2012. In the 60+ population HZ incidence was estimated to increase from 11.9 to 15.4 per 1,000 persons using GP data or from 12.8 to 14.2 per 1,000 persons using prescription data (p<0.05, between the two periods). Hospitalisation data did not show the same increasing trend over time, except for the age group ≥80 years. Most emergency visits for HZ were not admitted, and showed significant increases over time.

Discussion

The burden of HZ in Australia is substantial, and continues to increase over time. This increase is seen both pre- and post-universal VZV vaccination in 2005, and is most prominent in the older population. The substantial burden of HZ, along with ageing of the Australian population and the importance of healthy ageing, warrants consideration of HZ vaccination for the elderly.