Evaluation of the effect of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study

Preferences and Willingness to Pay for Herpes Zoster Vaccination Among Chinese Adults: Discrete Choice Experiment

BACKGROUND

The incidence of herpes zoster (HZ) is rapidly increasing, causing both clinical and economic burdens in China. Very little is known about Chinese residents' HZ vaccine preferences and willingness to pay (WTP) for each vaccination attribute.

OBJECTIVE

This study aims to elicit the preferences of Chinese urban adults (aged 25 years or older) regarding HZ vaccination programs and to calculate WTP for each vaccination attribute.

METHODS

In this study, we interviewed 2864 residents in 9 cities in China. A discrete choice experiment was conducted to investigate the residents' preferences for HZ vaccination and to predict the uptake rate for different vaccine scenarios. A mixed logit model was used to estimate the preferences and WTP for each attribute. Seven attributes with different levels were included in the experiment, and we divided the coefficients of other attributes by the coefficient of price to measure WTP.

RESULTS

Vaccine effectiveness, protection duration, risk of side effects, place of origin, and cost were proven to influence Chinese adults' preferences for HZ vaccination. The effectiveness of the HZ vaccine was the attribute that had the most predominant impact on residents' preferences, followed by protection duration. The residents were willing to pay CN ¥974 (US $145) to increase the vaccine effectiveness from 45% to 90%, and they would barely pay to exchange the vaccination schedule from 2 doses to 1 dose. It is suggested that the expected uptake could be promoted the most (by 20.84%) with an increase in the protection rate from 45% to 90%.

CONCLUSIONS

Chinese urban adults made trade-offs between vaccine effectiveness, protection duration, place of origin, side effects, and cost of HZ vaccination. Vaccine effectiveness was the most important characteristic. The residents have the highest WTP (CN ¥974; US $145) for enhancing the effectiveness of vaccines. To maximize HZ vaccine uptake, health authorities should promote vaccine effectiveness.

The epidemiologic and economic impact of varicella and herpes zoster vaccination in South Korea: A mathematical modelling study

BACKGROUND

In South Korea, the National Immunization Program has included one-dose varicella vaccination for 1-year-olds since 2005. This study examines the potential impact of introducing a two-dose varicella vaccination for children, along with zoster vaccination for adults, using either the zoster vaccine live (ZVL) or recombinant zoster vaccine (RZV).

METHODS

The investigation considered four strategies in a base case scenario. The first involved introducing zoster vaccination for 60-year-olds, with a 60 % coverage. The second strategy combined zoster vaccination with a second-dose varicella vaccination for 4-year-olds, with a 90 % coverage. An age-structured model spanning 50 years was employed, assuming a zoster vaccine catch-up campaign over the initial 5 years. Cost-effectiveness analyses were conducted, assessing incremental cost-effectiveness ratios (ICERs), incremental net monetary benefits (INMBs), and net loss under different ages at zoster vaccination (50, 60, 65, and 70 years) and varying willingness-to-pay (WTP) levels from ₩40 million ($34,998) to ₩84 million ($74,000).

RESULTS

All strategies were cost-effective and significantly reduced herpes zoster (HZ) incidence, preventing approximately 3,077,000 to 7,609,000 cases, depending on the chosen strategy. The combined strategy prevented around 4,950,000 varicella and 653,000 HZ cases additionally. RZV outperformed ZVL by preventing twice as many HZ cases and offering greater QALY gains. However, ZVL was more cost-effective due to its lower cost. Probabilistic sensitivity analyses revealed that RZV became more cost-effective at higher WTP thresholds, exceeding ₩60.9 million ($53,193) in terms of ICER and ₩62.5 million ($54,591) for INMBs and net loss. The optimal age for zoster vaccination was 60 years concerning ICER but 50 years regarding INMB.

CONCLUSIONS

Combining RZV with a two-dose varicella vaccination strategy reduced the disease burden and improved QALY more effectively, though ZVL remained more cost-effective at lower WTP levels. Decisions regarding vaccination policies should be balanced between the public health needs and WTP levels.

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.

Use of invitations and reminders are associated with higher levels of Herpes zoster (shingles) vaccination uptake. A cross-sectional survey of general practices in Wales, and ecological analysis of uptake data, 2022

In 2013, shingles vaccination was introduced in Wales as a routine immunisation programme for older adults. Invitation for this vaccination has historically been recommended but not mandated by vaccination policy. We surveyed general practices to investigate if invitations and reminders are associated with higher uptake of shingles vaccine. Using data from general practices, we calculated practice-level shingles vaccine uptake between 01/07/2021 and 31/06/2022 for registered patients aged 70-84 years. We distributed an online survey via email to all general practices in Wales on their use of vaccination invitations and reminders, method of invitations, and characteristics of their vaccination delivery. We used linear regression to calculate coefficients and 95 %CI to measure associations between invitations and vaccine uptake, adjusting for key demographics, with a multi-level component to account for similarities between general practices within the same health board. Survey response rate was 37 % (143/384). Median vaccine uptake for responding general practices was 57 % (IQR 50-68 %) compared to 58 % (IQR 48-68 %) nationally. General practices inviting all eligible patients (n = 95) had a 9 % (95 %CI 6-13 %) higher vaccination uptake compared to those inviting none or some (n = 48, p < 0.001). Of practices sending invitations, those who reminded all patients (n = 42) had a 6 % (95 %CI 1-11 %, p = 0.02) higher uptake compared to those that reminded none (n = 30). Practice size was associated with higher uptake, with small practices (n = 11, p = 0.02) having coverage 9 % (95 %CI 2-16 %) higher compared to the reference population (medium-sized practices, n = 78). General practices inviting and reminding all eligible patients for shingles vaccination have a higher uptake compared to those inviting and reminding only some or none. From September 2023, shingles vaccination policy in Wales has been updated to explicitly mandate effective universal call and recall mechanisms in general practices.

Willingness to vaccinate against herpes zoster in Chinese urban population: a mixed-methods study

OBJECTIVE

Although the herpes zoster vaccine has been available in mainland China since June 2020, residents' knowledge of herpes zoster and the herpes zoster vaccine is poor, and vaccination rates are low, especially among the elderly, who are at high risk for herpes zoster. This study assessed willingness to be vaccinated against herpes zoster and factors associated with vaccination among urban residents in China.

METHODS

A mixed-methods study was conducted in community health centres from August 2022 to September 2022. We used convenience sampling to select 2864 residents from 9 Chinese cities for the quantitative study and 67 adults for the qualitative study. A structured questionnaire was used for the quantitative study, and data were collected through face-to-face interviews. Multinomial logistic regression was used to analyse factors associated with willingness to vaccinate. Qualitative data were analysed using thematic analysis of barriers to herpes zoster vaccination.

RESULTS

A total of 2864 eligible respondents were included in the study. Of these, 42.67% intended to receive the herpes zoster vaccine, 21.44% refused and 35.89% were hesitant. The results of the quantitative and qualitative analyses showed that the factors associated with respondents' willingness to be vaccinated against herpes zoster included: personal characteristics such as gender, age and income; knowledge and attitudes about herpes zoster and the vaccine; vaccine characteristics such as efficacy, safety and price; and other factors such as pain tolerance and accessibility to vaccination.

CONCLUSION

The low willingness to vaccinate, especially among the elderly, is mainly related to their poor knowledge and negative attitude towards the infection and vaccination. Therefore, health education about herpes zoster, immunisation promotion, and improvement of accessibility and affordability would be valuable in China.

Surveying a Sample of the Spanish Ophthalmologic Community about Vaccination against Herpes Zoster

There are currently two authorized vaccines against herpes zoster (HZ) that have been shown to be safe and effective in its prevention: Zostavax, a zoster vaccine live (ZVL), and Shingrix, a recombinant zoster Vaccine (RZV). Because ophthalmologists work with vision-threatening complications of zoster, such as herpes zoster ophthalmicus (HZO), they are in a good position to advocate for vaccination. Our aim was to determine the current knowledge among Spanish ophthalmologists about the effectiveness of the available vaccines against HZ. A Google Forms questionnaire was created and used as the survey platform for this study. It was an anonymous online survey of 16 questions, which was shared among Spanish ophthalmologists in-training and consultants from 27 April 2022 to 25 May 2022. The survey was completed by a total of 206 ophthalmologists of all subspecialties. We obtained responses from 17 of the 19 regions of Spain. Fifty-five percent of the respondents agreed that HZ is a frequent cause of vision loss. However, 27% of the professionals were unaware of the existence of vaccines against HZ and 71% of them did not know in which cases it could be indicated. Only nine ophthalmologists (4%) had ever suggested vaccination against HZ to their patients. Despite this, 93% considered it important to recommend vaccination against HZ if it proved to be safe and effective. Considering the sequelae, complications, and the existence of safe and effective vaccines against HZ, vaccination of the target population could be considered an important public health measure. We are convinced that it is time for ophthalmologists to take an active role in HZO prevention.

Hospitalization Burden Related to Herpes Zoster Infection in Spain (2016-2019)

INTRODUCTION

Herpes zoster (HZ) and its complications still represent a significant burden for patients and health care systems. In Spain, vaccination is progressively being introduced and recommended for patients between 65 and 80 years old and patients > 18 years of age suffering from certain immunosuppression conditions. The aim of this study is to estimate the number of hospital admissions related to HZ from 2016 to 2019 in Spain.

METHODS

Data were collected from the Minimum Basic DataSet (MBDS) and codified according to the Spanish version of the 10th International Classification of Disease (ICD-10-CM codes B02-B02.9). Among others, variables such as sex, age and presence of complications were included.

RESULTS

A total of 27,642 hospitalizations were identified (90% in patients > 50 and 45.8% in patients > 80). Women represented 51.2% of the patients, and 59.9% of patients presented complications related to HZ. The hospitalization rate was 17.74, the mortality rate was 1.2, and the case fatality rate was 6.75%. All rates were significantly higher with age, among men and in complicated HZ. Immunosuppression status for which vaccination had been recommended represented 22.7% of the total cases, affecting mostly individuals > 65 and causing more deaths in those > 80 years. The estimated annual cost of hospitalization for herpes zoster was €35,738,285, and the mean cost per patient was €5172.

CONCLUSION

The hospitalization burden for HZ is still important in Spain. Data on the current epidemiology are important to evaluate future vaccination strategies.

The effectiveness of influenza vaccine among elderly Chinese: A regression discontinuity design based on Yinzhou regional health information platform

In China, a free influenza vaccination policy is being implemented among individuals aged 70 years and over in Zhejiang province during the COVID-19 pandemic. The objective was to assess the effectiveness of influenza vaccine in reducing hospitalization and mortality in the elderly. We used data from the Regional Health Information Platform in Yinzhou located in Zhejiang province and applied a regression discontinuity design to estimate the intention-to-treat effect on admission and mortality rates by month of age in the population who was near the age of 70 years threshold. At age 70 years, the influenza vaccination rate increased by 29.1% (95% CI, 28.2% to 29.9%) compared to those under 70 in the study population. When turning age 70 years, the potential effectiveness of receiving influenza vaccine was 8.2% (95% CI, -36.8% to 51.3%) for total hospitalization and the evaluation of vaccine effectiveness was 13.1% (95% CI, -34.2 to 61.8) for the all-cause mortality. An increase in the influenza vaccination rate was associated with a weak decline in most outcomes, but no significance was found for all outcomes. Influenza vaccination had a limited effect on hospital admission and mortality for the free influenza vaccination program that can be related to the low vaccination rate among the Chinese elderly. Supplementation strategies and future studies may be needed to expand immunization coverage and validate this finding, and further provide a reference for other cities to promote the free influenza vaccination policy in China, especially under circumstances of the COVID-19 pandemic.

Association between vitamin D and incident herpes zoster: a UK Biobank study

BACKGROUND

Vitamin D has immunomodulatory effects, but any association with herpes zoster (HZ) is unclear.

AIM

To explore the association between vitamin D status and risk of incident HZ in adults in the UK.

DESIGN AND SETTING

A cohort study involving participants of UK Biobank (a database containing the health information from half a million individuals) across England, Wales, and Scotland, who had at least one vitamin D testing result with linked primary care electronic health records.

METHOD

The primary exposure was vitamin D status, categorised as deficient (<25 nmol/L), insufficient (25-49 nmol/L), or sufficient (≥50 nmol/L). The secondary exposures were self-reported vitamin D supplementation at baseline assessment and vitamin D prescription records. The outcome was diagnosed incident HZ, identified from linked primary care or hospital inpatient records. Weibull regression was used, adjusting for potential confounders, including demographic factors, comorbidities, and immunosuppression.

RESULTS

In total, 177 572 eligible participants were included in the analysis, with a mean follow-up time of 10.1 years (standard deviation 1.9 years). No evidence showed that low vitamin D was associated with a higher incidence of HZ, compared with people with sufficient vitamin D (deficient: adjusted hazard ratio [HR] 0.99, 95% confidence interval [CI] = 0.90 to 1.10; insufficient: HR 1.03, 95% CI = 0.96 to 1.10). No evidence was found that supplementing vitamin D or receiving vitamin D prescription was associated with HZ incidence (supplementation: HR 0.88, 95% CI = 0.67 to 1.16; prescription: HR 1.11, 95% CI = 0.91 to 1.34).

CONCLUSION

No association of vitamin D status, supplementation, or prescription with incident HZ was observed. No evidence supported vitamin D supplementation as a strategy to prevent HZ.

The Impact of Universal Varicella Vaccination on Herpes Zoster Incidence in the United States: Comparison of Birth Cohorts Preceding and Following Varicella Vaccination Program Launch

When the US varicella vaccination program was introduced in 1995, its impacts on the epidemiology of herpes zoster (HZ) were not precisely known. We used a large claims database to examine HZ incidence in the US during 1998-2019 among persons aged ≥30 years (the prevaccine cohort, born before 1990), and aged 1-29 years (includes the postvaccine cohort, born since 1990). We defined incident HZ as the first instance of an outpatient or emergency department (ED) claim with an HZ diagnostic code. Additionally, we examined the proportion of HZ visits among all ED visits as a complementary method to assess for healthcare-seeking artifacts in the findings. In persons aged ≥30 years (prevaccine cohort), we observed age-specific increases in HZ incidence during the earlier study years, with decelerations in later years, starting in 2007 with oldest age groups. Similar patterns were seen when we examined HZ visits as a proportion of all ED visits. For persons aged 1-29 years, age-specific HZ incidence increased early in the study period for the oldest age groups who were born prevaccine, but later declined in a stepwise pattern once each age group was comprised of persons born in the postvaccine period. Our results, corroborated with previously published studies, do not support prior modeling predictions that the varicella vaccination program would increase HZ incidence among adult cohorts who previously experienced varicella. Our findings also suggest that continued declines in age-specific HZ incidence as varicella-vaccinated cohorts age are likely.

Adherence to Herpes Zoster (Shingles) Catch-Up Campaign at the Romagna Local Health Authority (Italy), a Multi-Center Retrospective Observational Study

Herpes Zoster (shingles) is an infection that occurs when varicella-zoster virus reactivates from the latent state. Incidence and severity of Herpes Zoster disease increase with age. Antiviral drugs are the elective treatment; however, prevention of disease reactivation through effective and safe vaccines is available in Italy out-of-pocket from age 65 onwards. The Romagna Local Health Authority (northern Italy) administered catch-up vaccinations in March–May 2022 for immunizations not performed during the COVID-19 pandemic. In this study, adherence rates to the catch-up campaign and recall activities adopted in two centers were investigated. The uptakes for only the catch-up vaccinations were 11.4% and 12.4%. Having suffered from Herpes Zoster or having family members who suffered from it would not seem to be drivers of increased uptake. Although sending text-messages to all involved patients was the main motivation for vaccine uptake (85.7–95.1%), word of mouth and web/news advertising also contributed to adoption in Center No. 2. In both centers, the need for greater synergy between public health departments and general practitioners to engage their patients emerged, as did the need for additional recall measures. Studying the main drivers of vaccine hesitancy, especially at the local level, can help in targeting campaigns and catch-up activities in order to achieve widespread acceptance.

Post-licensure zoster vaccine effectiveness against herpes zoster and postherpetic neuralgia in older adults: a systematic review and meta-analysis

BACKGROUND

Given the substantial impact of herpes zoster on health and quality of life, and its considerable economic burden, prevention through vaccination is a priority. We aimed to evaluate the effectiveness of the herpes zoster vaccines (recombinant zoster vaccine [RZV] and zoster vaccine live [ZVL]) against incident herpes zoster and postherpetic neuralgia in older adults.

METHODS

We did a systematic review and meta-analysis of studies assessing the effectiveness of herpes zoster vaccines in adults aged 50 years or older, compared with no vaccination or another vaccine. We searched published literature on MEDLINE, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, ProQuest Central, and Dimensions, as well as unpublished studies, grey literature, and the reference lists of included studies. Observational studies published in any language between May 25, 2006, and Dec 31, 2020, were included. Eligible studies were appraised for methodological quality using standardised critical appraisal instruments from the Joanna Briggs Institute, and data were extracted from selected studies using a standardised tool. Random-effects meta-analysis models were used to estimate pooled vaccine effectiveness for outcomes of interest (herpes zoster, herpes zoster ophthalmicus, and postherpetic neuralgia) among clinically and methodologically comparable studies, with a fixed-effects model also used for herpes zoster ophthalmicus. Vaccine effectiveness was also assessed in people with comorbidities. As a post-hoc analysis, a forward citation search was done on Jan 31, 2021. This study is registered on PROSPERO, CRD42021232383.

FINDINGS

Our search identified 1240 studies, of which 1162 were excluded based on title and abstract screening. A further 56 articles were excluded on reading the full text. 22 studies (21 cohort studies and one case-control study, involving 9 536 086 participants and 3·35 million person-years in the USA, UK, Canada, and Sweden) were included in the quantitative analysis. Of these, 13 articles were included in the meta-analysis. The overall quality of evidence was very low for all outcomes. The pooled vaccine effectiveness for ZVL against herpes zoster in adults was 45·9% (95% CI 42·2-49·4; seven studies). The vaccine effectiveness for ZVL against postherpetic neuralgia was 59·7% (58·4-89·7; three studies) and against herpes zoster ophthalmicus (in a fixed-effects model) was 30·0% (20·5-38·4; two studies). ZVL was effective in preventing herpes zoster in people with comorbidities, including diabetes (vaccine effectiveness 49·8%, 45·1-54·1; three studies), chronic kidney disease (54·3%, 49·0-59·1; four studies), liver disease (52·9%, 41·6-62·1; two studies), heart disease (52·3%, 45·0-58·7; two studies), and lung disease (49·0%, 32·2-66·2; two studies). In a post-hoc analysis of two studies from the USA published after 2020, the pooled vaccine effectiveness for RZV against herpes zoster in adults was 79·2% (57·6-89·7). Substantial heterogeneity (I²≥75%) was observed in 50% of the meta-analyses.

INTERPRETATION

ZVL and RZV are effective in preventing herpes zoster in routine clinical practice. ZVL also reduces the risk of postherpetic neuralgia. Selection bias and confounding by unmeasured variables are inherent challenges of observational studies based on large health-care databases. Nevertheless, these findings will reassure policy makers, health practitioners, and the public that the vaccinations currently available for herpes zoster vaccination programmes are effective at preventing herpes zoster and related complications.

FUNDING

None.

Impact of a National Immunisation Program on herpes zoster incidence in Australia

OBJECTIVES

To evaluate the impact of the National Herpes Zoster (zoster) Immunisation Program in Australia on zoster incidence.

METHODS

Ecological analysis of zoster incidence related to timing of implementation of the national program in vaccine-targeted (70-79 years) and non-targeted age groups (60-69 and 80-89 years) during January 2013-December 2018 was estimated using interrupted time-series analyses.

RESULTS

Prior to program commencement (Jan 2013-Oct 2016) in patients aged 60-69, 70-79 and 80-89 years, incidence was mostly stable averaging respectively 7.2, 9.6 and 10.8 per 1000 person-years. In the two years following program commencement, incidence fell steadily in those aged 70-79 years, with an estimated decrease of 2.25 (95% CI: 1.34, 3.17) per 1000 person-years per year, with women having a greater decrease than men (2.83 versus 1.68, p-interaction<0.01). In the two non-vaccine-program-targeted groups there was no evidence of reduction in zoster incidence: 60-69 years, 0.46 (95% CI: -0.46, 1.38) and 80-89 years, 0.11 (95% CI: -1.64, 1.87).

CONCLUSIONS

Two years after implementation, an estimated 7000 zoster cases were prevented through the national program. With known waning vaccine efficacy, continued surveillance is needed to ensure these early reductions in incidence are sustained.

Case Report: Various Clinical Manifestations Caused by Varicella-Zoster Virus in a Family

A family cluster of varicella-zoster virus (VZV) infections was reported. Four family members (two children and their parents) continuously develop varicella after the grandmother's herpes zoster. The unvaccinated 16-month-old infant and his mother developed primary varicella with atypical clinical presentation; however, his 28-year-old father presented with a typical generalized vesicular rash. His vaccinated 4-year-old sister was clinically mild, which could be defined as a breakthrough varicella case. They infected the same virus strain but presented various clinical forms.

A re-assessment of 4CMenB vaccine effectiveness against serogroup B invasive meningococcal disease in England based on an incidence model

BACKGROUND

The four-component serogroup B meningococcal 4CMenB vaccine (Bexsero, GSK) has been routinely given to all infants in the United Kingdom at 2, 4 and 12 months of age since September 2015. After 3 years, Public Health England (PHE) reported a 75% [95% confidence interval 64%; 81%] reduction in the incidence of serogroup B invasive meningococcal disease (IMD) in age groups eligible to be fully vaccinated. In contrast, vaccine effectiveness (VE) evaluated in the same immunization program applying the screening method was not statistically significant. We re-analyzed the data using an incidence model.

METHODS

Aggregate data-stratified by age, year and doses received-were provided by PHE: serogroup B IMD case counts for the entire population of England (years 2011-2018) and 4CMenB vaccine uptake in infants. We combined uptake with national population estimates to obtain counts of vaccinated and unvaccinated person-time by age and time. We re-estimated VE comparing incidence rates in vaccinated and non-vaccinated subjects using a Bayesian Poisson model for case counts with person-time data as an offset. The model was adjusted for age, time and number of doses received.

RESULTS

The incidence model showed that cases decreased until 2013-2014, followed by an increasing trend that continued in the non-vaccinated population during the immunization program. VE in fully vaccinated subjects (three doses) was 80.1% [95% Bayesian credible interval (BCI): 70.3%; 86.7%]. After a single dose, VE was 33.5% [12.4%; 49.7%]95%BCI and after two doses, 78.7% [71.5%; 84.5%]95%BCI. We estimated that vaccination averted 312 cases [252; 368]95%BCI between 2015 and 2018. VE was in line with the previously reported incidence reduction.

CONCLUSIONS

Our estimates of VE had higher precision than previous estimates based on the screening method, which were statistically not significant, and in line with the 75% incidence reduction previously reported by PHE. When disease incidence is low and vaccine uptake is high, the screening method applied to cases exclusively from the population eligible for vaccination may not be precise enough and may produce misleading point-estimates. Precise and accurate VE estimates are fundamental to inform public health decision making. VE assessment can be enhanced using models that leverage data on subjects not eligible for vaccination.

Clinical Manifestations of Herpes Zoster Associated with Complications in Children

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

Varicella caused by airborne transmission of a localised herpes zoster infection in a family

Localised herpes zoster infections spread by direct contact with active skin lesion, but airborne transmission is rare. We report a case of varicella from airborne transmission of a localised herpes zoster infection in a family. The patient was a 15-year-old boy who had never been vaccinated against the varicella-zoster virus (VZV). He likely developed varicella from his father, whom the patient lived with. The patient’s father developed a localised herpes zoster infection 2 weeks prior. The patient’s varicella was hypothesised to be due to VZV spread via airborne transmission from the father’s localised infection. To decrease the number of varicella cases, routine vaccination of children against VZV is essential, and immunisation against VZV in middle-aged and elderly patients is also necessary.

A practitioner's guide to the recombinant zoster vaccine: review of national vaccination recommendations

Introduction: The adjuvanted recombinant zoster vaccine (RZV) is currently licensed in over 30 countries for the prevention of herpes zoster (HZ) in adults aged ≥50 years. We conducted a review of available national guidelines or recommendations on RZV use to identify the similarities and differences and highlight any potential gaps.Areas covered: National recommendations from ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the UK and the USA) are summarized under the following seven topics: HZ vaccine preference, age group recommendations, considerations prior to vaccination, dose schedule, co-administration with other vaccines, vaccination of special populations, and vaccine safety profile. In seven of these countries, RZV is the preferred or the only recommended HZ vaccine. There were some differences in age group recommendations, reflecting evaluations dependent on public funding. There were also differences with respect to use in immunocompromised and other special populations.Expert opinion: The high efficacy and anticipated public health impact of RZV led to expanded national recommendations for RZV vaccination compared to previous HZ recommendation in many countries. Possible areas that could be considered in future revisions of national recommendations, including use in immunocompromised adults ≥18 years, are also highlighted.PLAIN LANGUAGE SUMMARY:The varicella-zoster virus causes chickenpox, usually in childhood. After the chickenpox episode, the virus remains in the body in a latent state and can reactivate later in life, causing herpes zoster, or shingles. Adults over 50 years of age or those who have a weakened immune system are more vulnerable to developing herpes zoster. Herpes zoster appears as a painful localized skin rash. While live attenuated vaccines against herpes zoster have existed for many years, a recombinant vaccine against herpes zoster (RZV) has recently become available in several countries. Guidelines issued by national health authorities or vaccination committees provide healthcare professionals with information on practical aspects of vaccination. However, given the novelty of the RZV vaccine, we identified such guidelines in only ten countries (Austria, Canada, the Czech Republic, Germany, Ireland, Italy, Spain, the Netherlands, the United Kingdom, and the United States of America). We summarized these national RZV recommendations, focusing on herpes zoster vaccine preference, the age at which RZV is recommended, considerations before vaccination, vaccination schedule, the possibility of administering RZV together with other vaccines, vaccinating vulnerable populations and the safety of RZV. While national recommendations varied, most guidelines indicate that RZV is the preferred herpes zoster vaccine due to its high and persistent efficacy and as it can be administered to vulnerable populations who are at increased risk of herpes zoster and its complications. Recommendations have noted that side effects are common with RZV, however, most are of mild-moderate intensity and temporary (see also Figure 1).

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.

Postlicensure herpes zoster vaccine effectiveness: systematic review protocol

INTRODUCTION

Herpes zoster (HZ) and associated complications inflict substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable populations. Two HZ vaccines are available and are part of the national immunisation programmes in many countries. This review will evaluate the effectiveness of zoster vaccines against incident HZ and postherpetic neuralgia in adults 50 years and older.

METHODS AND ANALYSIS

The key information sources that will be searched include MEDLINE (Ovid), Embase (Ovid), Cochrane libraries and CINAHL. This search will consider postlicensure observational studies published in all languages between 2006 and 2020 that assessed the effectiveness of HZ/zoster vaccines in adults 50 years and older. The identification of studies will be complemented with the search of reference lists and citations, and contact with authors of papers to request missing or additional data, where required. Following the search, all identified citations will be collated, and duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Selected studies will follow the process of critical appraisal, data extraction and data synthesis. Statistical analyses will be performed using a random-effect model.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as primary data will not be collected. The review will be disseminated in peer-reviewed publications and conference presentations.

Vaccines for older adults

The proportion of the global population aged 65 and older is rapidly increasing. Infections in this age group, most recently with SARS-CoV-2, cause substantial morbidity and mortality. Major improvements have been made in vaccines for older people, either through the addition of novel adjuvants-as in the new recombinant zoster vaccine and an adjuvanted influenza vaccine-or by increasing antigen concentration, as in influenza vaccines. In this article we review improvements in immunization for the three most important vaccine preventable diseases of aging. The recombinant zoster vaccine has an efficacy of 90% that is minimally affected by the age of the person being vaccinated and persists for more than four years. Increasing antigen dose or inclusion of adjuvant has improved the immunogenicity of influenza vaccines in older adults, although the relative effectiveness of the enhanced influenza vaccines and the durability of the immune response are the focus of ongoing clinical trials. Conjugate and polysaccharide pneumococcal vaccines have similar efficacy against invasive pneumococcal disease and pneumococcal pneumonia caused by vaccine serotypes in older adults. Their relative value varies by setting, depending on the prevalence of vaccine serotypes, largely related to conjugate vaccine coverage in children. Improved efficacy will increase public confidence and uptake of these vaccines. Co-administration of these vaccines is feasible and important for maximal uptake in older people. Development of new vaccine platforms has accelerated following the arrival of SARS-CoV-2, and will likely result in new vaccines against other pathogens in the future.

Effectiveness of the live-attenuated herpes zoster vaccine 2 years after its introduction in Australia

BACKGROUND

The Australian National Herpes Zoster Immunisation Program commenced in November 2016 for people aged 70-79 years old in Australia but vaccine effectiveness (VE) in this setting has not previously been assessed.

METHODS

We extracted records from two cohorts of patients aged 70-79 years in 2017 and 2018 respectively who were regular attenders in a nationwide general practice dataset, MedicineInsight. Cox proportional hazards models were used to estimate VE. Models were adjusted for potential confounders including age, sex, and other covariates. Analyses were also stratified by sex, presence of comorbid conditions and number of general practitioner (GP) visits in the previous year.

RESULTS

The 2017 cohort included 40,275 regular attenders and the 2018 cohort 41,735. Both cohorts had a mean age of 73.9 years and 52% were women. In 2017, among vaccinated people, over 9,688 person-years of follow-up, 35 cases of zoster were diagnosed giving an incidence of 3.6 per 1000 person-years compared to 8.7 per 1000 person-years (264 cases/30,317 person-years) among unvaccinated people. For 2018, among vaccinated people there were 66 incident zoster cases over 16,716 person-years giving an incidence of 3.9 per 1000 person-years compared to 6.3 per 1000 person-years (156 cases/24,782 person-years) among the unvaccinated. Overall, in the first year of the program, when the average time since vaccination was about 8 months, VE was 63.5% (95% CI: 47.5, 74.6) but this fell to 48.2% (95% CI: 30.0, 61.7) in the second year when the average time since vaccination was about 18 months. We found no difference in VE across age, sex, presence of comorbid conditions, and prior GP visit frequency (P-interaction > 0.05).

CONCLUSIONS

VE was consistent with that estimated in other countries and international settings. However, our findings suggest waning effectiveness after the first year of the program. Further program evaluation is necessary.

Risk of common infections in people with inflammatory bowel disease in primary care: a population-based cohort study

OBJECTIVE

To evaluate the risk of common infections in individuals with inflammatory bowel disease (IBD) [ulcerative colitis and Crohn's disease] compared with matched controls in a contemporary UK primary care population.

DESIGN

Matched cohort analysis (2014-2019) using the Royal College of General Practitioners Research and Surveillance Centre primary care database. Risk of common infections, viral infections and gastrointestinal infections (including a subset of culture-confirmed infections), and predictors of common infections, were evaluated using multivariable Cox proportional hazards models.

RESULTS

18 829 people with IBD were matched to 73 316 controls. People with IBD were more likely to present to primary care with a common infection over the study period (46% vs 37% of controls). Risks of common infections, viral infections and gastrointestinal infections (including stool culture-confirmed infections) were increased for people with ulcerative colitis and Crohn's disease compared with matched controls (HR range 1.12-1.83, all p<0.001). Treatment with oral glucocorticoid therapy, immunotherapies and biologic therapy, but not with aminosalicylates, was associated with increased infection risk in people with IBD. Despite mild lymphopenia and neutropenia being more common in people with IBD (18.4% and 1.9%, respectively) than in controls (6.5% and 1.5%, respectively), these factors were not associated with significantly increased infection risk in people with IBD.

CONCLUSION

People with IBD are more likely to present with a wide range of common infections. Health professionals and people with IBD should remain vigilant for infections, particularly when using systemic corticosteroids, immunotherapies or biologic agents.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov (NCT03835780).

Impact of a Publicly Funded Herpes Zoster Immunization Program on the Burden of Disease in Ontario, Canada: A Population-based Study

Background

In September 2009, a live attenuated herpes zoster vaccine (ZVL) became available in Canada. Beginning in September 2016, ZVL was made available to all Ontario residents aged 65–70 through a publicly funded immunization program. We assessed the impact of ZVL availability and its subsequent public funding on herpes zoster burden in this population.

Methods

A population-based study of Ontario residents aged 65–70 between January 2005 and September 2018. We used interventional autoregressive integrated moving average models to examine the impact of ZVL market availability and the publicly funded ZVL program on monthly incidence rate of medically attended herpes zoster, defined as an outpatient visit for herpes zoster with a prescription for a herpes zoster antiviral dispensed ≤5 days before or after the visit, or a herpes zoster–related emergency department (ED) visit or hospitalization. In secondary analyses, we examined impacts on any herpes zoster–related ED visits and hospitalizations.

Results

We found no association between ZVL market availability and monthly incidence of herpes zoster (P = .32) or monthly rates of ED visits and hospitalizations (P = .88). Conversely, the introduction of publicly funded ZVL reduced the monthly rate of medically attended herpes zoster by 19.1% (from 4.8 to 3.8 per 10 000 population; P < .01) and herpes zoster–related ED visits and hospitalizations by 38.2% (from 1.7 to 1.0 per 10 000 population; P < .05).

Conclusions

The introduction of a publicly funded immunization program for herpes zoster was associated with reduced disease burden and related acute healthcare service use.

The Impact of Varicella Vaccination on the Incidence of Varicella and Herpes Zoster in the United States: Updated Evidence From Observational Databases, 1991-2016

BACKGROUND

Universal childhood vaccination against varicella began in the United States as a 1-dose schedule in 1996, changing to a 2-dose schedule in 2006. The exogenous boosting hypothesis, which postulates that reexposure to circulating wild-type varicella delays the onset of herpes zoster, predicts a transient increase in the incidence of herpes zoster, peaking in adults 15-35 years after the start of varicella vaccination.

METHODS

This was a retrospective study of administrative claims data from the MarketScan Commercial and Medicare databases between 1991-2016. Outcome measures were the incidences of herpes zoster per 100 000 person-years, by calendar year and age category, and the annual rates of change in herpes zoster by age category, in an interrupted time series regression analysis, for the periods of 1991-1995 (prevaccine), 1996-2006 (1-dose vaccination period), and 2007-2016 (2-dose vaccination period).

RESULTS

The annual incidences of herpes zoster increased throughout the period of 1991-2012 in all adult age categories, with a plateau in 2013-2016 that was most evident in the ≥65 age group. In 1991-1995, the herpes zoster incidences increased at annual rates of 4-6% in age categories 18-34, 35-44, 45-54, and 55-64 years. In the same age categories during 1996-2006 and 2007-2016, the herpes zoster incidences increased at annual rates of 1-5%.

CONCLUSIONS

Although the annual incidence of herpes zoster in adults has continued to increase, the rates of change decreased during both the 1- and 2-dose vaccination periods. The hypothesized increase in herpes zoster predicted from modelling of the exogenous boosting hypothesis was not observed.

Patterns of prescription, hospitalizations and costs of herpes zoster in patients at risk, from a large Italian claims database

Purpose

This observational study aimed to investigate the incidence of herpes zoster (HZ) among at-risk subjects aged ≥50 years, characterize them and assess annual healthcare utilization and costs from the Italian National Health System (NHS) perspective.

Methods

Records of reimbursed drug prescriptions, hospitalizations and outpatient specialist care from the Fondazione ReS database were linked to identify patients aged ≥50 years at HZ risk (i.e. cardiovascular disease/chronic obstructive pulmonary disease/diabetes/immunosuppression, according to the Italian National Vaccine Prevention Plan - PNPV 2017-2019) in 2013. New HZ events (incidence per 1,000) were researched in 2 years, and subjects with HZ in the previous year were excluded. Antiviral and pain therapy consumptions, hospitalizations for HZ and costs paid by NHS were assessed annually.

Results

From 12,562,609 inhabitants in 2013, a total of 1,004,705 patients (18.5% aged ≥50 years) at risk without a previous event were selected. The 2-year incidence of HZ was 5.9 per 1,000 (mean age 74 ± 10 years; 54.3% female). Patients aged 80-89 (7.2 per 1,000), females (6.7 per 1,000) and immunosuppressed subjects (6.9 per 1,000) had the highest incidence rates. One year after the new HZ episode, 82.2% were treated with specific antivirals (79.3% brivudine), generating an annual average cost/treated of €106; 8.0% were hospitalized for HZ, with an average cost/hospitalized of €3,927; the overall mean cost/incident patient was €402.

Conclusions

This analysis provided HZ incidence in subjects aged ≥50 years considered at risk by the PNPV and its burden from the NHS perspective. Our findings can help health governance to improve clinical decisions and economic positioning concerning zoster vaccine plan.

Vaccines in older age: moving from current practice to optimal coverage-a multidisciplinary consensus conference

Vaccines are a key strategy to promote healthy aging, but vaccine coverage remains below target levels in at-risk adults and older individuals. We present here the results of a multidisciplinary consensus conference convened to perform a multidimensional assessment of vaccination in geriatric medicine, with a view to developing a well-defined strategy for the promotion of vaccines in older people. We discuss recommended vaccines in older individuals, and describe the wide regional heterogeneity between regions in the Italian context. The main obstacles to implementation of vaccines in practice are reviewed, as well as potential strategies to remove these barriers. Finally, the importance of including vaccines and vaccination in undergraduate and postgraduate medical education is underlined. The information summarized in this document is expected to help develop educational and promotional initiatives to achieve greater uptake of vaccines among older individuals, as a key means to promote healthy aging.

The Epidemiology of Herpes Zoster in the United States During the Era of Varicella and Herpes Zoster Vaccines: Changing Patterns Among Older Adults

Historic herpes zoster incidence trends in US adults have been hard to interpret. Using administrative databases, we extended previous descriptions of these trends through 2016. We observed an age-specific transition, with ongoing increases among younger adults but deceleration in older adults. The patterns are not readily explained.

Impact of the herpes zoster vaccination programme on hospitalised and general practice consulted herpes zoster in the 5 years after its introduction in England: a population-based study

OBJECTIVES

To assess the impact of herpes zoster vaccination in the 5 years after introduction for 70- to 79-year-olds in England in September 2013.

DESIGN

Population based ecological impact assessment.

SETTING

Hospitals covering the whole English population for the period 2008 to 2018 and 293 general practices (GP) for the period 2005 to 2018, in England.

PARTICIPANTS

Over the period the population contributed 117·5 million person-years for hospitalisation events and 6.96 million person-years for GP events in individuals aged 60 to 89.

INTERVENTIONS

Live attenuated herpes zoster vaccination (Zostavax), first used on 1^st September 2013, in 70- and 79-year-olds with continued use in new 70 year-olds and with a staged catch-up of those aged 71 to 78 years in 2013.

OUTCOME MEASURES

Herpes zoster and postherpetic neuralgia (PHN) consultation and hospitalisation rates in age-cohorts according to vaccine eligibility. Incidence rate ratios in age-cohorts eligible for vaccination compared with those non-eligible were calculated by Poisson regression. This was used to estimate prevented cases and, along with vaccine coverage, to estimate vaccine effectiveness.

RESULTS

Large and prolonged reductions in herpes zoster and PHN consultations and hospitalisations were observed in the 5 years post-implementation. For example, in 79 year-olds first eligible in 2013, the incidence rate ratio for consultations 5 years later was 0·65 (95% CI: 0·52 to 0·81). Over the whole period an estimated 40 500 fewer zoster consultations and 1840 fewer zoster hospitalisations occurred because of the vaccination programme. These reductions were consistent with effectiveness in the routine cohorts (vaccinated aged 70) of between 37% (for hospitalised zoster) and 75% (for PHN consultations) and, in catch up cohorts (vaccinated aged 78 to 79) of between 49% (for hospitalised PHN) and 66% (for PHN consultations).

CONCLUSION

Given the clear and sustained impact of herpes zoster vaccination over the 5-year period since introduction, optimising vaccination coverage is important to attain maximum benefit.

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.

Herpes zoster: vaccination status and virtuous experiences

Herpes zoster (HZ) infection is widespread in the general population - especially in the elderly - and can be associated with major sequelae such as post-herpetic neuralgia. Live attenuated zoster vaccine was licensed in Europe in May 2006 and in Italy in 2010; since March 2014, it has been commercially available in Italy. In Italy, vaccination against HZV is recommended in all subjects at risk - for example, those with diabetes, cardiovascular disease, chronic obstructive pulmonary disease or patients on immunosuppressive agents - from the age of 50 years onwards and for all persons aged >64 years. This paper summarizes the virtuous experiences on the effectiveness of the HZ vaccine in the elderly, with a focus on the Italian scenario. Considering the current barriers to this immunization registered in some areas (difficulties of vaccine distribution, lack of physician recommendations, costs), proper educational and communication efforts should be pursued to guarantee a good coverage of HZ vaccination.

Burden of disease from shingles and post-herpetic neuralgia in the over 80 year olds in the UK

BACKGROUND

The current UK vaccination programme for herpes zoster (HZ) excludes people aged ≥80 years. This study aimed to quantify the number of individuals ≥80 years who missed HZ vaccination and the consequent epidemiological and economic burden of HZ and post-herpetic neuralgia (PHN).

METHODS

Immunocompetent individuals aged ≥80 years between 1st September 2013 and 31st December 2017 in the Clinical Practice Research Datalink were selected and linked to Hospital Episodes Statistics, where available. Rates of HZ and PHN and healthcare resource utilisation were investigated for the overall study population and by age group (80-84, 85-89, ≥90 years old) and the burden of HZ and PHN was projected to the UK population.

RESULTS

4,858 HZ episodes and 464 PHN cases were identified in 255,165 individuals over 576,421 person-years (PY). Rates of HZ and PHN were 8.43 (95% confidence interval [CI] 8.19-8.66) and 0.80 (0.73-0.87) per 1,000 PY respectively and lowest in those aged ≥90 (HZ rate 7.37/1,000 PY; PHN rate 0.56/1,000 PY). Within HZ episodes, 10.27% of GP visits, 5.82% of prescribed medications and 21.65% of hospitalisations were related to HZ/PHN. Median length of hospitalisation increased from 7.0 days for all-cause to 10.5 days for HZ/PHN related hospitalisations. Individuals ≥90 stayed in hospital a median of 3-4 days longer than younger groups. Approximately 2.23 million individuals in the UK missed HZ vaccination since 2013 (1.86 million had never been eligible and 365,000 lost eligibility for HZ vaccination), resulting in an estimated 43,149 HZ episodes.

CONCLUSION

This study highlights the impact of the 80-year upper age limit policy on the health system. Our study estimates that 2.23 million individuals in the UK may have lost the opportunity to be vaccinated and that their burden of HZ and PHN remains high, especially among the very elderly.

Knowledge about vaccines and vaccination in older people: Results of a national survey by the Italian Society for Gerontology & Geriatrics

BACKGROUND

There is wide variation among physicians in the level of knowledge regarding vaccines and vaccination. We sought to compare the level of vaccine knowledge between qualified specialists and postgraduate residents.

METHODS

A questionnaire designed ad hoc by a consensus group was circulated to the Directors of 51 geriatrics internship programs in Italy. It investigated demographics, information sources, knowledge about influenza, pneumonococcal and herpes zoster vaccines and target groups. The proportion of correct responders was compared between residents and qualified specialists, and between best (top quartile) and worst (bottom quartile) performers.

RESULTS

A total of 459 questionnaires were analyzed; 245 (53%) were females; 253 (55%) were qualified specialists, 206 (45%) were residents. Mean age was 40.3 (SD: 12.8) years, almost 60% worked in acute care wards. On average, 33% of patients asked for information about vaccination. Residents answered significantly better on 7 out of 18 questions, and numerically albeit non-statistically higher correct response rates on a further 8 questions. There were significantly more men among the poor performers (p < 0.001), and significantly more residents among the best performers (p < 0.001). Overall, the rates of correct answers were low, with >50% of correct responses achieved on only 5 out of 18 questions (27.8%); for 2 questions, <20% responded correctly.

CONCLUSIONS

Postgraduate residents in training have an overall better level of knowledge of vaccines, vaccination indications and practices than qualified specialists. This study provides avenues to develop targeted interventions to ensure health care providers are up to date and providing accurate information to patients.

Herpes zoster vaccination in Australia: what's available and who benefits?

Acute herpes zoster and associated postherpetic neuralgia is caused by reactivation of latent varicella zoster virus. It can be debilitating for older adults and interfere with activities of daily living

A live, attenuated single-dose vaccine, that protects against both acute herpes zoster and postherpetic neuralgia, is available for free to all Australians aged 70 years, and in a catch-up program for those aged 71–79 years

The vaccine is contraindicated in people who are immunocompromised, but can be considered in those who are receiving low doses of selected disease-modifying antirheumatic drugs

Records of the Australian Immunisation Register suggest that only a third of 70 year olds received the vaccine in the first year-and-a-half of the program. This is likely an underestimation, but emphasises the importance of ensuring the vaccine is offered to all eligible patients and that vaccination is recorded on the Register

A non-live recombinant herpes zoster vaccine has recently been developed which is more efficacious than the live vaccine in clinical trials. It is registered in Australia but not currently available

Safety of inadvertent administration of live zoster vaccine to immunosuppressed individuals in a UK-based observational cohort analysis

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.

Do varicella vaccination programs change the epidemiology of herpes zoster? A comprehensive review, with focus on the United States

Introduction: Policy-makers in many countries have been wary of introducing varicella vaccination programs because of concerns that reduced exposures to varicella-zoster virus could increase herpes zoster (HZ) incidence. The U.S. introduced varicella vaccination in 1996 and has empiric evidence regarding this concern. Areas covered: This comprehensive review provides background emphasizing the epidemiology of varicella and of HZ in the U.S. before and after the introduction of their respective vaccines. The epidemiology is complex, and interpretation is complicated by methodologic challenges, by unexplained increases in age-specific HZ incidence that preceded varicella vaccination, and by introduction of vaccines for prevention of HZ. Nonetheless, observations from studies using different platforms and designs have yielded consistent findings, suggesting they are robust. Expert opinion: There has been no evidence that the U.S. varicella vaccination program increased HZ incidence in the general adult population over baseline trends. Furthermore, HZ incidence in children is declining. The U.S. experience can inform the development of new generations of models to predict HZ trends. More importantly, it provides reassurance for countries considering varicella vaccination that an effective program can reduce varicella morbidity and mortality while reducing the likelihood of HZ among children, and potentially, over time, across the entire population.

Varicella zoster virus vaccines: an update

Varicella zoster virus (VZV) is the etiological agent of varicella, a highly infectious, self-limiting disease with serious complications. The decline in cell-mediated immunity (CMI) that occurs with aging or immunodepression causes a reactivation of the latent VZV as herpes zoster (HZ). Prevention of VZV through varicella vaccination strategies allows to avoid the primary infection in newborns and susceptible subjects. Available monovalent and combined VZV vaccines are effective, safe and generally well tolerated. Universal varicella vaccination has significantly impacted on incidence, complications and deaths related to this disease. Prevention of HZ through vaccination is a priority to avoid the significant burden of its incidence and complications. Currently two HZ vaccines are available. The recombinant zoster vaccine (RZV), approved by the FDA in 2017 and Zoster Vaccine Live (ZVL) licensed in the United States by the FDA in 2006. The advisory committee on immunization practices (ACIP) preferentially recommends RZV. ZVL remains an option for prevention of HZ in immunocompetent adults aged ≥60 years, although the CMI tends to wane a few years after vaccination.

Determinants of shingles vaccine acceptance in the United Kingdom

BACKGROUND

The United Kingdom (UK) was the first European country to introduce a national immunisation program for shingles (2013-2014). That year, vaccination coverage ranged from 50 to 64% across the UK, but uptake has declined ever since. This study explored determinants of the acceptance of the shingles vaccine in the UK.

METHODS

Vaccinated and unvaccinated individuals, who were eligible for the last catch-up cohort of the 2014-2015 shingles vaccination campaign, were identified using the Clinical Practice Research Datalink (the National Health Service data research service) and invited to participate by their general practitioner (GP). An anonymised self-administered questionnaire was developed using the Health Belief Model as a theoretical framework, to collect data on demographic and socio-economic characteristics, health status, knowledge, influences, experiences and attitudes to shingles and the shingles vaccine. Multivariable logistic regression was used to identify the factors associated with vaccination. Physicians' views concerning perceived barriers to vaccination were also assessed.

RESULTS

Of the 2,530 questionnaires distributed, 536 were returned (21.2%) from 69 general practices throughout the UK. The majority of responders were female (58%), lived in care homes (56%) and had completed secondary or higher education (88%). There were no differences between vaccinated and unvaccinated responders. Being offered the shingles vaccine by a GP/nurse (odds ratio (OR) = 2.3), and self-efficacy (OR = 1.2) were associated with being vaccinated (p<0.05). In contrast, previous shingles history (OR = 0.4), perceived barriers to vaccination (OR = 0.7) and perceived control of the disease (OR = 0.7) were associated with not being vaccinated against shingles (p<0.05). Less than half (44.0%) of GPs were aware of the local communication campaigns regarding shingles and the shingles vaccine.

CONCLUSIONS

Socio-psychological factors largely influence shingles vaccination acceptance in this study. The results add to existing evidence that healthcare providers (HCPs) have a pivotal role against vaccine hesitancy. Campaigns focusing on GPs and accessible information offered to eligible members of the public can further enhance shingles vaccine uptake.

The changing epidemiology of herpes zoster over a decade in South Korea, 2006-2015

BACKGROUND

In South Korea, the population is rapidly aging and the prevalence of comorbidities has increased. We investigated longitudinal changes in the herpes zoster (HZ) considering demographic changes and comorbidities in the era of universal single-dose varicella vaccination.

METHODS

We used the population-based database of the National Health Insurance Service in South Korea, with approximately 50 million subscribers during 2006-2015. HZ cases were identified using ICD-10 codes and comorbid conditions were also collected. Incidence rates (IRs) and incidence rate ratios (IRRs) per year were calculated adjusting for age, sex, comorbidities and socioeconomic status, and the temporal trends were examined using segmented negative binomial regression analysis.

RESULTS

Over a decade, the adjusted HZ IR increased significantly from 4.23 to 9.22 per 1000 person-years (adjusted IRR 1.05, 95% confidence interval [CI] 1.04-1.06). However, during 2012-2015, the increasing trends decelerated (adjusted IRR per year 1.01, 95% CI 0.98-1.04) and slope changes differed by age. There was a declining trend in children under 9 years, sustained increase in adults aged 30-39 years, and near-plateau in those aged 50-69 years. Nonetheless, the age distribution of HZ incidence did not change over a decade, with the peak in adults aged 60-79 years. HZ-associated hospitalization rates also increased, with a deceleration in the increasing trends during 2012-2015.

CONCLUSIONS

The HZ burden increased independently of demographic changes and prevalence of comorbidities. However, different trajectories by age group necessitate continuous HZ surveillance for better understanding of these changes, and to provide evidence for development of preventive strategies.

Public health impact model estimating the impact of introducing an adjuvanted recombinant zoster vaccine into the UK universal mass vaccination programme

OBJECTIVES

In 2013, the herpes zoster (HZ) immunisation programme was introduced in the UK, recommending vaccination of adults 70 years of age (YOA) with the zoster vaccine live (ZVL), the only vaccine available at the time. The recently approved adjuvanted recombinant zoster vaccine (RZV) has a substantially different clinical profile that may offer additional benefits.This study aimed to 1) assess the public health impact (PHI) of introducing RZV in the UK compared with the current vaccination strategy and 2) explore via scenario analyses the optimal age group of vaccination in terms of PHI.

DESIGN

A previously developed health economic model was adapted to the UK setting.

SETTING

Calculations were based on efficacy data from pivotal clinical trials, HZ incidence and postherpetic neuralgia (PHN) probability from a UK study and HZ-associated complication rates from published literature.

POPULATION

The base-case population considered a 2018-projected UK vaccination cohort of individuals 70 YOA.

INTERVENTIONS

Vaccination with ZVL or RZV, assuming a first-dose coverage of 48.3% for both vaccines and 70% compliance for the second dose of RZV.

OUTCOME MEASURES

Outcomes included reduction of HZ and PHN cases, complications and the use of healthcare resources over a life-time horizon. The impact of coverage and second-dose compliance was also explored.

RESULTS

Compared with no vaccination, RZV would lead to a reduction of 30 262 HZ and 5409 PHN cases while ZVL would lead to a reduction of 7909 HZ and 3567 PHN cases. The number needed to vaccinate to prevent 1 HZ case is 12 with RZV and 45 with ZVL. The highest PHI with RZV could be achieved in individuals 60 or 65 YOA.

CONCLUSION

Under the model assumptions, RZV is predicted to avert more HZ and PHN cases compared with ZVL. Results were robust under different scenario and sensitivity analyses.

Calabria: a successful experience implementing Herpes Zoster vaccination strategies

Recently, the National Immunization Plan (NIP) in Italy has highlighted the importance of immunization practices also for adults, including vaccinations against influenza, Pneumococcus (PNO) and HZ. In response to the NIP, the Calabria region decided to offer HZ vaccination to the two cohorts of 65- and 70-year-old subjects. We at the Reggio Calabria Local Health Services, concentrated our efforts on addressing all the above-mentioned shortcomings and, as a first measure, we addressed the convenience problem by scheduling the HZ vaccine administration during the same visit as the pneumococcal vaccination (PCV13 vaccine). The adhesion rates were satisfactory in both cohorts-such high levels of vaccine coverage for HZ and PCV13 had never been reached before in our region and are still among the highest in Italy. However, the main result was undoubtedly the significantly high rate of PCV13 and HZ vaccine co-administration without safety problems.

Adult vaccination as the cornerstone of successful ageing: the case of herpes zoster vaccination. A European Interdisciplinary Council on Ageing (EICA) expert focus group

Herpes zoster (HZ) is a painful cutaneous rash with vesicular lesions, lasting up to 3 weeks, and caused by reactivation of the latent varicella zoster virus (VZV). It may be associated with complications, the most feared being post-herpetic neuralgia. Effective vaccines are available to prevent HZ, but uptake remains low. We report here the conclusions of an expert focus group convened by the European Interdisciplinary Council on Ageing (EICA). The group discussed how existing recommendations regarding HZ vaccination could be better implemented, and how compliance and coverage with HZ vaccination could be enhanced. This report proposes strategies to increase awareness of HZ and its vaccine, enhance vaccine uptake, and educate regarding the role of prevention, including immunization, as a means to "age well". A key strategy that could rapidly and easily be implemented at low cost is co-administration of HZ vaccine with other vaccines scheduled in the target age group. The scientific evidence surrounding the safety and efficacy of co-administration is discussed. Other strategies, such as active calls, publicity campaigns and national vaccine registries are also outlined. There is a compelling need for a full consensus document that carries weight across all the healthcare professions involved in vaccination, to issue simple and basic recommendations for all healthcare providers.

Risk factors for modified vaccine effectiveness of the live attenuated zoster vaccine among the elderly in England

Background

The United Kingdom introduced routine vaccination with the live-attenuated zoster vaccine for 70 year-olds in 2013, with the vaccine also offered to 79 year-olds as part of a catch-up campaign. In the subsequent years, the catch-up campaign was extended to also include adults aged 78 years. We investigated 14 pre-identified potential risk factors for potential modified vaccine effectiveness.

Methods

This retrospective cohort study in England included subjects born in 1943-1946 (the routine cohort) and in 1934-1937 (the catch-up cohort). We used the Clinical Practice Research Datalink (CPRD) to identify herpes zoster (HZ) cases and the risk factors: age, gender, ethnicity, socio-economic status, asthma, type 2 diabetes, chronic obstructive pulmonary disease, smoking, body mass index, immunosuppression, history of HZ, co-administration with influenza or pneumococcal vaccine. We derived HZ incidence by risk groups, overall vaccine effectiveness (VE) and modified VE expressed as relative differences in VE from Poisson regression models.

Results

Overall VE was 66.8% [95% CI: 62.2; 71.0]. Two out of the 14 investigated risk factors modified the HZ VE. Notably, lower VE was observed in diabetics and in persons with a history of HZ with relative differences in VE of -22·2%, [95% CI: -39·6, -4·5] and -22·5%, [95% CI: -44·9, -0·1].

Conclusions

Live-attenuated zoster vaccine protection against HZ was lower in type 2 diabetics and in subjects with a history of HZ. Contrary to clinical trial results, age did not affect the observed VE. Further study is required to gain insights into why certain risk groups are less protected. Identifying and understanding the effect modifiers of VE is important for future vaccine development as well as vaccine recommendations.

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

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