Varicella zoster virus infection

Cost-Effectiveness of Varicella Vaccination for 1-4-Year-Olds in Shanghai, China

INTRODUCTION

Varicella has not yet been included in the National Immunization Program (NIP) in China, and varicella vaccination strategies vary by region. To determine the optimal varicella vaccination strategy in Shanghai, China, the cost-effectiveness and 5-year costs of 5 immunization scenarios were analyzed.

METHODS

A static decision tree-Markov model was developed in 2022 to assess the cost-effectiveness and 5-year costs of voluntary and routine varicella vaccination programs in the 2019 birth cohort in Shanghai from a societal perspective. Parameters were collected in 2022 from the varicella surveillance system, a questionnaire survey of 414 guardians of patients with childhood varicella, and semi-structured interviews with 20 experts on varicella outbreaks from different institutions in Shanghai. The outcomes included varicella cases avoided, quality-adjusted life year (QALY) loss, and incremental costs per QALY (ICER). The 5-year costs were compared with local medical expenditures.

RESULTS

Among the 5 scenarios, one dose of routine varicella vaccination was the most cost-saving (USD 70.2) and cost-effective (Dominant) with a 5-year immunization expenditure of USD 9.9 million. Two doses of routine varicella vaccination had the highest QALY (29.9), and its ICER (USD 791.9/QALY) was below the willingness-to-pay threshold (USD 5,203-23,767/QALY). The 5-year immunization expenditure was USD 19.8 million. The effectiveness and price of vaccines, vaccination coverage, and per capita income are the 4 main factors that affect ICERs.

CONCLUSIONS

In Shanghai, the 2 doses of routine varicella vaccination strategy for 1- and 4-year-olds with a 95% coverage rate was found to be the optimal varicella immunization strategy.

Pediatric Varicella-related Hospitalization in Turkey Between 2008 and 2018: Impact of Universal Single Dose Varicella Vaccine (VARICOMP Study)

BACKGROUND

A single-dose varicella vaccine at 12 months of age was introduced to the National Immunization Program in February 2013 in Turkey. This study aimed to evaluate varicella-related hospitalization in children and the impact of a single-dose live attenuated varicella vaccine over the first 5.5 years of introducing a universal varicella vaccination.

METHODS

We analyzed data collected from the medical records of children <18 years old who required hospitalization due to varicella in 17 cities representing 50% of the childhood population in Turkey between 2008 and 2018. We calculated the rate of hospitalization for varicella per 100,000 children during the study period. The main objective of this study was to determine the yearly rate of hospitalization due to varicella and to compare these rates in the pre-vaccine and post-vaccine periods. The secondary objective was to compare demographic features, varicella-related complications, and outcomes between the pre-vaccine and post-vaccine periods.

RESULTS

A total of 4373 children (2458 boys and 1915 girls; 72.3% previously healthy) were hospitalized for varicella over a 10-year period, including 2139 children during the pre-vaccine period and 2234 children during the post-vaccine period. Overall, varicella hospitalization rates decreased significantly after the introduction of varicella vaccination [pre-vaccine vs. post-vaccine period; 3.79 vs. 2.87 per 100,000 per year; P < 0.001; odds ratio 0.75; 95% confidence interval 0.64-0.88]. The incidence of varicella-related hospitalization among children between 1 and 5 years of age was significantly lower in the post-vaccine era than in the pre-vaccine era, with a 60.2% decrease in hospitalizations (2.43 vs. 6.12 per 100,000 children; P < 0.001, odds ratio 0.39; 95% confidence interval 0.34-0.46). In both the <1-year and 6- to 10-year age groups, the incidence of varicella-related hospitalizations was similar in the pre-vaccine and post-vaccine periods. The incidence of varicella-related hospitalization was higher in the post-vaccine era among 11-15 years and >15-year-old groups ( P < 0.01 and P < 0.05). The mean age was higher during the post-vaccine period than during the pre-vaccine period ( P < 0.001). The absolute number of secondary bacterial infections ( P < 0.01), respiratory complications ( P < 0.01), and neurological complications ( P < 0.001) was significantly lower during the post-vaccine period. The incidence of severe varicella was lower during the post-vaccine period than during the pre-vaccine period ( P < 0.001).

CONCLUSIONS

After 5.5 years of routine single-dose varicella vaccine use, we observed the impact of varicella vaccination on the incidence of varicella-related hospitalizations, especially in the target age group. However, we did not observe herd protection in the other age groups. The implementation of a second dose of the varicella vaccine in the National Immunization Program would help control disease activity.

Immunogenicity and safety of live attenuated and recombinant/inactivated varicella zoster vaccines in people living with HIV: A systematic review

Few papers focus their attention on VZV vaccination effectiveness among people living with HIV (PLWH). Flanking the live attenuated vaccine (VZL) available, a newly recombinant vaccine (RZV) was recently introduced and approved for HZ prevention among adults. PLWH represents a population on which a particular attention should be applied, in order to guarantee the vaccine efficacy and safety. We performed a literature search in USNLM, PubMed, PubMed Central, PMC and Cochrane Library. From all the publications found eligible, data were extracted and processed per population, vaccine type, immunogenicity and ADRs. The review of the 13 included studies shows that both RZV and VZL are immunogenic and have an acceptable safety profile in adults and children living with HIV. However, given the lack of research available about vaccine efficacy in preventing VZV and HZ in PLWH, additional studies need to be performed, in order to achieve a full completeness of data.

Analysis of the implementation effect and evaluation of the vaccine protection effect of the live attenuated varicella vaccine program for school-age children in Bao'an district of Shenzhen,China

The objective of the study is to analyze the implementation effect of the Live Attenuated Varicella Vaccine (VarV) Vaccination Program for eligible children in Bao'an District, Shenzhen, and evaluate the vaccine effectiveness. Children's vaccination data was obtained from the Shenzhen Immunization Planning Information Management System, while varicella case data came from the China Disease Prevention and Control Information System. The Joinpoint regression method examined vaccination rate trends, and a retrospective cohort study assessed vaccine effectiveness. After program implementation, VarV vaccination rates significantly increased, surpassing provincial and national averages. Overall incidence declined 54.6% across age groups, with the largest reductions among 7- and 6-year-olds. One year post-vaccination, single-dose vaccine effectiveness was 91.1% (95% CI: 79.2% to 96.2%). However, two doses remained 91.4% effective(95% CI: 89.1% to 93.2%) after 7 years. Overall, Shenzhen's VarV program achieved positive results. For children under six, routine immunization with two doses of VarV should be strengthened. Furthermore, we recommend that physicians conduct thorough inquiries to ascertain patients' vaccination history and previous varicella infections. This will enable doctors to provide tailored vaccination recommendations based on comprehensive, practical evaluations.

The contributions of T cell-mediated immunity to protection from vaccine-preventable diseases: A primer

In the face of the ever-present burden of emerging and reemerging infectious diseases, there is a growing need to comprehensively assess individual- and population-level immunity to vaccine-preventable diseases (VPDs). Many of these efforts, however, focus exclusively on antibody-mediated immunity, ignoring the role of T cells. Aimed at clinicians, public health practioners, and others who play central roles in human vaccine research but do not have formal training in immunology, we review how vaccines against infectious diseases elicit T cell responses, what types of vaccines elicit T cell responses, and how T cell responses are measured. We then use examples to demonstrate six ways that T cells contribute to protection from VPD, including directly mediating protection, enabling antibody responses, reducing disease severity, increasing cross-reactivity, improving durability, and protecting special populations. We conclude with a discussion of challenges and solutions to more widespread consideration of T cell responses in clinical vaccinology.

Expanded spectrum of varicella disease and the need for vaccination in India

Varicella vaccine was first licensed in Japan and South Korea in 1989 for use in healthy children and was introduced in US in 1995. So far, 29 countries have adopted varicella vaccine in their universal immunization program (UIP). No Asian country, India included, has adopted the varicella vaccine as part of their UIP. The extra-cutaneous sites for VZV diseases are central nervous system and gastrointestinal tract, the expanded disease spectrum includes vasculopathy, myelitis, inflammatory bowel disease, perforated ulcers, and gastritis. The actual disease burden of varicella is not known as most of the infected individuals may not visit the physician. The amplifiable VZV DNA will not always be detectable in cerebrospinal fluid (CSF) samples in protracted illnesses such as vasculopathies, but demonstrable anti-VZV IgG in CSF has diagnostic value. The World Health Organization (WHO) position paper 2014 recommends two doses of varicella and zoster vaccines in targeted population. In India, varicella vaccine is not included in the UIP due to the cost and the belief that lifelong immunity occurs following primary infection. The expanded spectrum of VZV disease and the mounting body of evidence, however, suggest the need for both varicella and zoster vaccines in routine immunization schedule.

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.

Post-infectious central nervous system vasculitides in adults: an underdiagnosed and treatable disease : Part I. Overview

INTRODUCTION

The differential diagnosis of Primary Central Nervous System Angiitis (PACNS) is complex and includes several inflammatory and non-inflammatory conditions. Among the first ones, post-infectious CNS vasculitides represent a relevant topic and they are often underdiagnosed.

AIMS

The main aim of this review is to summarize the clinical and neuroimaging features of post-infectious vasculitides, highlighting the diagnostic clues and the need to carefully consider them in the differential diagnosis of PACNS.

FINDINGS

Several infectious agents (viruses, bacteria, fungi and parasites) can be involved in documented post-infectious vasculitides, often with a pathological confirmation. Post-infectious vasculitides involve not only immunocompromised hosts but also immunocompetent people and the diagnosis might be complicated by the lack of close time relationship between infections and neuro-logical symptoms, as in Varicella Zoster Virus (VZV) related vasculopathy in adults. Several complications may occur, ranging from ischemic to hemorrhagic stroke, from arterial to venous thrombosis, from large to small vessel involvement, often simultaneously.

CONCLUSIONS

Post-infectious vasculitides are caused by a broad spectrum of microorganisms and they should be carefully considered in the differential diagnosis of some neurological pictures and neuroradiologicals findings in immunocompetent adults too.

Silent reactivation of Varicella Zoster virus in hemodialysis patients.: A management dilemma

OBJECTIVES

To determine the seroprevalence of Varicella Zoster virus (VZV) immunoglobulin (Ig)G and IgM antibodies among hemodialysis patients (HDP). Additionally, the presence of VZV viral DNA has been investigated for possible reactivation status.

METHODS

Sera from 265 individuals were collected and tested. The study was carried out from November 2023 to February 2024. Enzyme linked immunosorbent assay was accomplished to determine the VZV IgG and IgM antibody levels. The viral DNA was tested by qPCR.

RESULTS

We found a significantly higher proportion of Host defense peptides (HDP) have positive antibody levels compared to healthy controls (HC) (92.0% of HDP have positive immune responses compared to 79.1% of HC, p=0.005). Patients with both hypertension and diabetes showed lower VZV seropositivity (25.6%) than those without (74.4%). Only 3 HDP had positive IgG and IgM levels (1.9%, n=3), while 14 patients (100%) had negative IgG and IgM levels. Additionally, all IgM-positive patients appeared to have detectable viral DNA of the VZV.

CONCLUSION

In conclusion, significantly higher VZV seroprevalence and antibody levels in HDP indicate greater viral exposure than HC. Screening of hemodialysis (HD) to VZV serologically or at the molecular level is most important to avoid the consequences of viral reactivation, especially in those with asymptomatic HDP.

Increase in Adult Patients with Varicella Zoster Virus-Related Central Nervous System Infections, Japan

An increase in the number of herpes zoster patients has been reported since universal varicella immunization was introduced, perhaps because of reduced opportunities for varicella patients to experience the natural booster effect caused by reexposure. We investigated recent trends of varicella zoster virus (VZV)-related central nervous system (CNS) infections at a university hospital in Japan. We enrolled patients with suspected CNS infection during 2013-2022 and tested cerebrospinal fluid samples by real-time PCR for DNA from 7 human herpesviruses. VZV DNA was the most commonly detected in 62 (10.2%) of 615 patients. Kulldorff's circular spatial scan statistics demonstrated a significant temporal cluster of patients with VZV-related CNS infections during 2019-2022 (p = 0.008). Among persons with such infections, the percentage with aseptic meningitis was significantly higher during 2019-2022 (86.8%), when the temporal cluster of cases occurred, than during 2013-2018 (50.0%) (p = 0.0029).

Non-hepatotropic viral hepatitis: a narrative review

Non-hepatotropic viral hepatitis (NHVH) refers to acute hepatitis or acute liver failure caused by viruses that do not primarily target the liver. These viruses include the Epstein-Barr virus (EBV), cytomegalovirus (CMV), herpes simplex virus (HSV)-1 and -2, varicella zoster, parvovirus, adenovirus, adeno-associated virus type 2, measles, and severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). The epidemiology, pathogenesis, and clinical manifestations of hepatitis due to hepatotropic viruses (hepatitis A-E) have been well studied. However, there is a paucity of data on NHVH due to its rarity, self-limiting clinical course, and vague presentation. NHVH can occur as an isolated illness or as part of a disseminated disease, and its clinical features range from self-limiting transaminitis to acute liver failure. This activity reviews the most common non-hepatotropic viruses (NHV), with a focus on their biology, etiopathogenesis, clinical manifestations, and management.

Non-oral pharmacological interventions in the management of herpes zoster-related pain: a review of current research

Herpes zoster-associated pain is a difficult-to-treat pathologic pain that seriously affects patients' quality of life. In recent years, emerging therapeutic techniques such as autologous platelet-rich plasma, sympathetic nerve block and pulsed radiofrequency have been gradually applied in the field of pain with the advantages of less trauma, quicker recovery and significant efficacy. These therapeutic options have become a new hope for the treatment of herpes zoster-associated pain. This article reviews the studies on herpes zoster-associated pain in non-oral drug therapy, summarizes the efficacy, safety, and possible mechanisms, and provides a reference basis for clinical treatment.

The Emergence of Saliva as a Diagnostic and Prognostic Tool for Viral Infections

Saliva has emerged as a promising diagnostic fluid for viral infections, enabling the direct analysis of viral genetic material and the detection of infection markers such as proteins, metabolites, microRNAs, and immunoglobulins. This comprehensive review aimed to explore the use of saliva as a diagnostic tool for viral infections, emphasizing its advantages and limitations. Saliva stands out due to its simplicity and safety in collection, along with the convenience of self-collection without the need for healthcare supervision, while potentially being comparable to urine and blood in terms of effectiveness. Herein, we highlighted the significant potential of saliva in assessing viral loads and diagnosing viral infections, such as herpesviruses, HPV, PyV, TTV, SARS-CoV-2, and MPXV. The detection of viral shedding in saliva underscores its utility in early diagnosis, the monitoring of infection progression, and evaluating treatment responses. The non-invasive nature of saliva collection makes it an appealing alternative to more invasive methods, promoting better patient compliance and facilitating large-scale screening and surveillance. As such, we further highlight current evidence on the use of saliva as a prognostic tool. Although a significant amount of data is already available, further investigations are warranted to more comprehensively assess the added benefit from the utilization of salivary biomarkers in the clinics. Salivary biomarkers show great promise for the early detection and prevention of viral infection complications, potentially improving disease management and control at the population level. Integrating these non-invasive tools into routine clinical practice could enhance personalized healthcare strategies and patient outcomes. Future studies should focus on establishing standardization protocols, validating the accuracy of salivary diagnostics, and expanding clinical research to enhance the diagnostic and monitoring capabilities of salivary biomarkers.

Model-inferred timing and infectious period of the chickenpox outbreak source

BACKGROUND

In May 2024, a chickenpox outbreak was reported at Xiasha Primary School located in Nanshan District, Shenzhen City, China, with a total of 12 cases identified. Despite thorough on-site investigations, the source of infection remained undetected. The purpose of our study was to infer the timing and duration of the infectious period of the initial case using modeling techniques, thereby deducing the identity of the source.

METHODS

We conducted an individual contact survey within the class affected by the epidemic and utilized an agent-based model (ABM) to estimate the key parameters related to the timing of the infectious source's emergence and the duration of its infectiousness. The point estimates derived from the ABM served as prior information for a subsequent Bayesian analysis, which in turn provided the posterior distribution for these parameters.

RESULTS

Our models suggested the infection source entered the classroom around April 24th (95% credible interval: April 22nd to April 26th), with an infectious period of approximately two days. Based on these findings, we should aim to detect students who may have been absent due to atypical chickenpox symptoms during this period and closely examine teachers who were present for two consecutive days for any indication of potential infection.

CONCLUSION

This study demonstrates the efficacy of combining contact surveys with mathematical modeling for outbreak source tracing, offering a novel approach to supplement field epidemiological surveys.

CLINICAL TRIAL NUMBER

Not applicable.

Fatal Hyperacute Liver Failure due to Varicella Zoster Virus Immediately After Living-Donor Liver Transplantation: A Case Report and Review of the Literature

BACKGROUND

Although acute hepatitis caused by varicella zoster virus mostly develops in immunocompromised patients, hyperacute liver failure is very rare. To our knowledge, there are no previous reports on liver transplant patients.

METHODS

We report the first case of fatal hyperacute liver failure due to varicella zoster virus immediately after living-donor liver transplantation without cutaneous lesions and review the literature.

RESULT

The present case exhibited rapid development and progression of acute liver failure from postoperative days 11-13, despite being seropositive for varicella zoster virus but unvaccinated and on immunosuppression before transplantation. Especially in solid organ transplantation, only six cases of severe acute liver failure that included hepatic encephalopathy and/or impaired consciousness and sudden extremely high (> 4000 U/L) serum aspartate aminotransferase levels have been reported in heart, lung, and kidney transplant patients.

CONCLUSIONS

Early diagnosis of hyperacute liver failure due to varicella zoster virus is challenging because the disease progresses rapidly and skin lesions are absent.

[Zoster vaccination]

Herpes zoster (HZ) is a sequela of the reactivation of a latent varicella zoster virus (VZV) infection of the sensory dorsal root ganglia and cranial nerves due to a decrease in specific T cell-mediated immunity as a result of immunosenescence, immunodeficiency diseases, e.g., human immunodeficiency virus (HIV) infection or immunosuppressive therapy. The disease burden of HZ greatly increases with age; however, younger patients with, e.g., inflammatory rheumatic diseases, also have an increased risk of HZ, which is higher under certain immunosuppressive drugs, e.g., Janus kinase (JAK) inhibitors or glucocorticoids. The risk of complications, e.g., postherpetic neuralgia (PHN) is also increased in this patient group. Of the two vaccines licensed in Germany, the Standing Committee on Vaccination (STIKO) at the Robert Koch Institute recommends the recombinant adjuvanted HZ subunit vaccine for the standard vaccination of all persons ≥ 60 years and for persons ≥ 50 years with an increased HZ risk for prevention of HZ and PNH due to its better efficacy and longer duration of effectiveness. Clinical trials have demonstrated a 90-97% efficacy in preventing HZ in immune healthy adults aged ≥ 50 years, with a much higher reactogenicity in the vaccine group compared to placebo. Adequate efficacy, immunogenicity and safety have also been demonstrated in clinical trials in immunocompromised and immunosuppressed patients. An extension of the STIKO vaccination recommendation to all adults with an increased HZ risk in line with the approval would be welcome.

Advancements in LAMP-Based Diagnostics: Emerging Techniques and Applications in Viral Detection with a Focus on Herpesviruses in Transplant Patient Management

Loop-mediated isothermal amplification (LAMP) is a highly effective molecular diagnostic technique, particularly advantageous for point-of-care (POC) settings. In recent years, LAMP has expanded to include various adaptations such as DARQ-LAMP, QUASR, FLOS-LAMP, displacement probes and molecular beacons. These methods enable multiplex detection of multiple targets in a single reaction, enhancing cost-effectiveness and diagnostic efficiency. Consequently, LAMP has gained significant traction in diagnosing diverse viruses, notably during the COVID-19 pandemic. However, its application for detecting Herpesviridae remains relatively unexplored. This group of viruses is of particular interest due to their latency and potential reactivation, crucial for immunocompromised patients, including organ and hematopoietic stem cell transplant recipients. This review highlights recent advancements in LAMP for virus diagnosis and explores current research trends and future prospects, emphasizing the detection challenges posed by Herpesviridae.

Genotype of Varicella-zoster virus isolated in Jiangsu, China

OBJECTIVE

To analyze the genotypes of VZV in Jiangsu province to identify vaccine strains and wild strains, providing a molecular biological background for the effective prevention and control of varicella.

METHOD

Stratified sampling was used to collect herpes fluid or throat swab from patients diagnosed with varicella. ORF22 was carried out, and the restriction enzyme site of ORF38, ORF54 and ORF62 were detected.

RESULTS

All 207 virus strains were Clade 2 type by sequencing the PCR products of ORF22. The sequencing results showed that five SNP sites changed compared to the Dumas reference strain(Clade 1). From A to G at 37,902, from T to c at 38,055, from A to C at 38,081, and from G to A at 38,177, from G to A at 39,394. The prevalent VZV genotypes in Jiangsu is consistent with the P-Oka. The restriction enzyme site analysis of PCR amplification products from ORF38 (PstI), ORF54 (BglI), ORF62 (SmaI) showed that all 207 virus strains were wild-type. There were two different types of the wild strains, and 183 strains (88.4%) were PstI (+), BglI (+), SmaI (-). The wild strains between different regions showed no significant differences (χ2 = 0.05, P = 0.982).

CONCLUSIONS

The prevalent VZV genotypes are Clade 2 and the prevalent virus strains are wild strains in Jiangsu Province, the primary wild strain observed is mainly PstI (+), BglI (+), SmaI (-).

Upregulation of keratin 15 is required for varicella-zoster virus replication in keratinocytes and is attenuated in the live attenuated vOka vaccine strain

Varicella-zoster virus (VZV) is the etiological agent of chickenpox and shingles, diseases characterised by epidermal virus replication in skin and mucosa and the formation of blisters. We have previously shown that VZV infection has a profound effect on keratinocyte differentiation, altering the normal pattern of epidermal gene expression. In particular, VZV infection reduces expression of suprabasal keratins 1 and 10 and desmosomal proteins, disrupting epidermal structure to promote expression of a blistering phenotype. Here, we extend these findings to show that VZV infection upregulates the expression of keratin 15 (KRT15), a marker expressed by basal epidermal keratinocytes and hair follicles stem cells. We demonstrate that KRT15 is essential for VZV replication in the skin, since downregulation of KRT15 inhibits VZV replication in keratinocytes, while KRT15 exogenous overexpression supports viral replication. Importantly, our data show that VZV upregulation of KRT15 depends on the expression of the VZV immediate early gene ORF62. ORF62 is the only regulatory gene that is mutated in the live attenuated VZV vaccine and contains four of the five fixed mutations present in the VZV Oka vaccine. Our data indicate that the mutated vaccine ORF62 is not capable of upregulating KRT15, suggesting that this may contribute to the vaccine attenuation in skin. Taken together our data present a novel association between VZV and KRT15, which may open a new therapeutic window for a topical targeting of VZV replication in the skin via modulation of KRT15.

Risk factors for poor prognosis in patients with zoster-associated neuralgia who underwent interventional pain management

Background

Zoster-associated neuralgia (ZAN) is recognized as a challenging neuralgia that often leads to poor prognosis in patients receiving interventional pain management. Identifying risk factors early can enable clinicians to develop personalized treatment plans; however, research in this area is limited.

Methods

We retrospectively screened all patients with ZAN who received interventional therapy in the Pain Department of Soochow University First Affiliated Hospital from January 1, 2022 to August 31, 2023. Data on patient demographics, medical history, neutrophil-to-lymphocyte ratio (NLR), clinical scoring, and treatment methods were collected. Interventional therapy included short-term nerve electrical stimulation (st-NES), pulsed radiofrequency (PRF) and radiofrequency thermocoagulation (RF-TC). Patients were categorized into poor prognosis and control groups based on outcomes 3 months post-discharge. Multivariate logistic regression was used to identify risk factors for poor prognosis.

Results

The final analysis included 282 patients. The rate of poor prognosis was 32.6% (92/282). Multivariate logistic regression analysis revealed that age ≥ 65 years (odds ratio, 2.985; 95% confidence interval, 1.449-6.148; p = 0.003), disease duration >3 months (odds ratio, 3.135; 95% confidence interval, 1.685-5.832; p < 0.001), head and face pain (odds ratio, 3.140; 95% confidence interval, 1.557-6.330; p = 0.001), use of immunosuppressants (odds ratio, 2.737; 95% confidence interval, 1.168-6.416; p = 0.021), higher NLR (odds ratio, 1.454; 95% confidence interval, 1.233-1.715; p < 0.001), PRF (st-NES as reference) (odds ratio, 2.324; 95% confidence interval, 1.116-4.844; p = 0.024) and RF-TC (st-NES as reference) (odds ratio, 5.028; 95% confidence interval, 2.139-11.820; p < 0.001) were found to be independent risk factors for poor prognosis in patients with ZAN who underwent interventional pain management.

Conclusion

Age ≥ 65 years (odds ratio, 2.985; 95% confidence interval, 1.449-6.148; p = 0.003), disease duration >3 months (odds ratio, 3.135; 95% confidence interval, 1.685-5.832; p < 0.001), head and face pain (odds ratio, 3.140; 95% confidence interval, 1.557-6.330; p = 0.001), immunosuppressants use (odds ratio, 2.737; 95% confidence interval, 1.168-6.416; p = 0.021), higher NLR (odds ratio, 1.454; 95% confidence interval, 1.233-1.715; p < 0.001), PRF (odds ratio, 2.324; 95% confidence interval, 1.116-4.844; p = 0.024) and RF-TC (odds ratio, 5.028; 95% confidence interval, 2.139-11.820; p < 0.001) were identified as independent risk factors for poor prognosis in patients with ZAN who underwent interventional pain management.

Explore genetic susceptibility association between viral infections and Guillain-Barré syndrome risk using two-sample Mendelian randomization

BACKGROUND

Numerous observational studies have indicated that patients with Guillain-Barré syndrome (GBS) frequently had infections with various pathogens before the onset of the disease, particularly several viral infections. Some of these infections are linked to specific clinical and immunological subgroups of GBS, suggesting a potential correlation between viral infections and the development of GBS. However, observational studies have several limitations, including the presence of confounding factors.

METHOD

We explored the potential correlation between HIV, SARS-CoV-2, varicella-zoster virus, herpes simplex virus, Epstein-Barr virus, hepatitis B virus, and influenza virus with GBS using a two-sample Mendelian randomization approach. The data was derived from published summary statistics from genome-wide association studies (GWAS). After removing linkage disequilibrium, selecting strong instrumental variables and addressing confounding factors, we would conduct a two-sample Mendelian randomization analysis along with sensitivity testing and the MR-Steiger directional test.

RESULT

HIV may have a causal association with GBS (IVW: p = 0.010, OR [95% CI] 1.240 [1.052-1.463]), while no such relationship exists with COVID-19 (IVW: p = 0.275, OR [95% CI] 0.831[0.596-1.159]), varicella (IVW: p = 0.543, OR [95% CI] 0.919 [0.701-1.206]), herpes zoster (IVW: p = 0.563, OR [95% CI] 0.941 [0.766-1.156]), HSV (IVW: p = 0.280, OR [95% CI] 1.244 [0.837-1.851]), EBV (IVW: p = 0.218, OR [95% CI] 0.883 [0.724-1.076]), HBV (IVW: p = 0.179, OR [95% CI] 1.072 [0.969-1.187]), or influenza virus (IVW: p = 0.917, OR [95% CI] 0.971 [0.553-1.703]). We did not find any abnormal SNPs, pleiotropy, or heterogeneity, nor is there any reverse causation.

CONCLUSION

Our study results indicate a causal relationship between HIV and GBS, providing new research directions for the etiology of GBS.

Revisiting the dimensions of universal vaccine with special focus on COVID-19: Efficacy versus methods of designing

Even though the use of SARS-CoV-2 vaccines during the COVID-19 pandemic showed unprecedented success in a short time, it also exposed a flaw in the current vaccine design strategy to offer broad protection against emerging variants of concern. However, developing broad-spectrum vaccines is still a challenge for immunologists. The development of universal vaccines against emerging pathogens and their variants appears to be a practical solution to mitigate the economic and physical effects of the pandemic on society. Very few reports are available to explain the basic concept of universal vaccine design and development. This review provides an overview of the innate and adaptive immune responses generated against vaccination and essential insight into immune mechanisms helpful in designing universal vaccines targeting influenza viruses and coronaviruses. In addition, the characteristics, safety, and factors affecting the efficacy of universal vaccines have been discussed. Furthermore, several advancements in methods worthy of designing universal vaccines are described, including chimeric immunogens, heterologous prime-boost vaccines, reverse vaccinology, structure-based antigen design, pan-reactive antibody vaccines, conserved neutralizing epitope-based vaccines, mosaic nanoparticle-based vaccines, etc. In addition to the several advantages, significant potential constraints, such as defocusing the immune response and subdominance, are also discussed.

Analysis of risk factors and prediction model construction for varicella encephalitis in children: A retrospective cohort study

INTRODUCTION

This study aimed to analyze the risk factors for varicella encephalitis in children and establish a predictive model.

METHODS

This retrospective cohort study included a varicella encephalitis group (n = 75) and a varicella-non-encephalitis group (n = 135). Logistic regression analysis was employed to find risk factors for varicella encephalitis and create a predictive model.

RESULTS

Older age, vomiting, poor mental status, and prolonged rash duration were independent risk factors for varicella encephalitis (p < .05). The predictive model for varicella encephalitis combined above four factors. The ROC curve of the predictive model showed an area under the curve of 0.955 (95% CI 0.925-0.986) for varicella encephalitis in children with a sensitivity of 94.7%, and a specificity of 86.0%.

CONCLUSION

Children with varicella who are older, experience vomiting, exhibit poor mental status, or have a prolonged rash duration should be closely monitored clinically. The predictive model combining these four factors demonstrates good predictive efficiency.

Identifying and Evaluating Biological Markers of Postherpetic Neuralgia: A Comprehensive Review

Postherpetic neuralgia (PHN) manifests as persistent chronic pain that emerges after a herpes zoster outbreak and greatly diminishes quality of life. Unfortunately, its treatment efficacy has remained elusive, with many therapeutic efforts yielding less than satisfactory results. The research to discern risk factors predicting the onset, trajectory, and prognosis of PHN has been extensive. However, these risk factors often present as nonspecific and diverse, indicating the need for more reliable, measurable, and objective detection methods. The exploration of potential biological markers, including hematological indices, pathological insights, and supportive tests, is increasing. This review highlights potential biomarkers that are instrumental for the diagnosis, management, and prognosis of PHN while also delving deeper into its genesis. Drawing from prior research, aspects such as immune responsiveness, neuronal injury, genetic makeup, cellular metabolism, and pain signal modulation have emerged as prospective biomarkers. The immune spectrum spans various cell subtypes, with an emphasis on T cells, interferons, interleukins, and other related cytokines. Studies on nerve injury are directed toward pain-related proteins and the density and health of epidermal nerve fibers. On the genetic and metabolic fronts, the focus lies in the detection of predisposition genes, atypical protein manifestations, and energy-processing dynamics, with a keen interest in vitamin metabolism. Tools such as functional magnetic resonance imaging, electromyography, and infrared imaging have come to the forefront in the pain signaling domain. This review compiles the evidence, potential clinical implications, and challenges associated with these promising biomarkers, paving the way for innovative strategies for predicting, diagnosing, and addressing PHN.

Varicella zoster virus meningoencephalitis presenting as orbital myositis - a case report

The authors present a case of meningoencephalitis caused by Varicella zoster virus (VZV) infection, which initially manifested as orbital myositis followed by rapid progression to orbital apex syndrome, meningoencephalitis and death. There was no development of a cutaneous rash. An orbital biopsy demonstrated VZV infection, which was confirmed on a lumbar puncture. In this case, VZV meningoencephalitis was not responsive to steroid or antiviral therapy. This case highlights an atypical presentation of VZV with orbital myositis preceding intracranial involvement.

Successful Treatment of a Rare Complication of Varicella Pneumonitis in an Immunocompromised 11-Year-Old Child Using Pooled Intravenous Immunoglobulin

Varicella-zoster virus, or herpes zoster virus, is a human alphaherpesvirus. It causes varicella (chicken pox) and herpes zoster (shingles). Though a relatively common and benign childhood illness, it can lead to severe disseminated infections in immunocompromised patients. Varicella pneumonitis is a common complication of varicella found in adults but is rare in children. As such, we present a rare case of an 11-year-old immunosuppressed male on methotrexate who developed a disseminated varicella infection resulting in pneumonia. Methotrexate is not known to cause immunosuppression, as compared to infliximab, which is similarly indicated for rheumatoid autoimmune conditions. He was treated with high-dose acyclovir and pooled intravenous immunoglobulin (IVIG). Due to the efficacy of high-dose acyclovir in immunocompromised patients with varicella-zoster and modern preparations of IVIG containing high titers of zoster immunoglobulins, the treatment allowed the patient to recover fully.

Viral etiologies of acute liver failure

Acute liver failure (ALF) is a rare cause of liver-related mortality worldwide, with an estimated annual global incidence of more than one million cases. While drug-induced liver injury, including acetaminophen toxicity, is the leading cause of ALF in the Western world, viral infections remain a significant cause of ALF and the most common cause in many developing nations. Given the high mortality rates associated with ALF, healthcare providers should be aware of the broad range of viral infections that have been implicated to enable early diagnosis, rapid treatment initiation when possible, and optimal management, which may include liver transplantation. This review aims to provide a summary of viral causes of ALF, diagnostic approaches, treatment options, and expected outcomes.

Varicella-zoster virus recapitulates its immune evasive behaviour in matured hiPSC-derived neurospheroids

Varicella-zoster virus (VZV) encephalitis and meningitis are potential central nervous system (CNS) complications following primary VZV infection or reactivation. With Type-I interferon (IFN) signalling being an important first line cellular defence mechanism against VZV infection by the peripheral tissues, we here investigated the triggering of innate immune responses in a human neural-like environment. For this, we established and characterised 5-month matured hiPSC-derived neurospheroids (NSPHs) containing neurons and astrocytes. Subsequently, NSPHs were infected with reporter strains of VZV (VZVeGFP-ORF23) or Sendai virus (SeVeGFP), with the latter serving as an immune-activating positive control. Live cell and immunocytochemical analyses demonstrated VZVeGFP-ORF23 infection throughout the NSPHs, while SeVeGFP infection was limited to the outer NSPH border. Next, NanoString digital transcriptomics revealed that SeVeGFP-infected NSPHs activated a clear Type-I IFN response, while this was not the case in VZVeGFP-ORF23-infected NSPHs. Moreover, the latter displayed a strong suppression of genes related to IFN signalling and antigen presentation, as further demonstrated by suppression of IL-6 and CXCL10 production, failure to upregulate Type-I IFN activated anti-viral proteins (Mx1, IFIT2 and ISG15), as well as reduced expression of CD74, a key-protein in the MHC class II antigen presentation pathway. Finally, even though VZVeGFP-ORF23-infection seems to be immunologically ignored in NSPHs, its presence does result in the formation of stress granules upon long-term infection, as well as disruption of cellular integrity within the infected NSPHs. Concluding, in this study we demonstrate that 5-month matured hiPSC-derived NSPHs display functional innate immune reactivity towards SeV infection, and have the capacity to recapitulate the strong immune evasive behaviour towards VZV.

Natural Language Processing Versus Diagnosis Code-Based Methods for Postherpetic Neuralgia Identification: Algorithm Development and Validation

Background

Diagnosis codes and prescription data are used in algorithms to identify postherpetic neuralgia (PHN), a debilitating complication of herpes zoster (HZ). Because of the questionable accuracy of codes and prescription data, manual chart review is sometimes used to identify PHN in electronic health records (EHRs), which can be costly and time-consuming.

Objective

This study aims to develop and validate a natural language processing (NLP) algorithm for automatically identifying PHN from unstructured EHR data and to compare its performance with that of code-based methods.

Methods

This retrospective study used EHR data from Kaiser Permanente Southern California, a large integrated health care system that serves over 4.8 million members. The source population included members aged ≥50 years who received an incident HZ diagnosis and accompanying antiviral prescription between 2018 and 2020 and had ≥1 encounter within 90-180 days of the incident HZ diagnosis. The study team manually reviewed the EHR and identified PHN cases. For NLP development and validation, 500 and 800 random samples from the source population were selected, respectively. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), F-score, and Matthews correlation coefficient (MCC) of NLP and the code-based methods were evaluated using chart-reviewed results as the reference standard.

Results

The NLP algorithm identified PHN cases with a 90.9% sensitivity, 98.5% specificity, 82% PPV, and 99.3% NPV. The composite scores of the NLP algorithm were 0.89 (F-score) and 0.85 (MCC). The prevalences of PHN in the validation data were 6.9% (reference standard), 7.6% (NLP), and 5.4%-13.1% (code-based). The code-based methods achieved a 52.7%-61.8% sensitivity, 89.8%-98.4% specificity, 27.6%-72.1% PPV, and 96.3%-97.1% NPV. The F-scores and MCCs ranged between 0.45 and 0.59 and between 0.32 and 0.61, respectively.

Conclusions

The automated NLP-based approach identified PHN cases from the EHR with good accuracy. This method could be useful in population-based PHN research.

Immunity to Varicella Zoster Virus in Healthcare Workers: A Systematic Review and Meta-Analysis (2024)

Healthcare workers (HCWs) are occupationally exposed to varicella zoster virus (VZV), and their inappropriate vaccination status could contribute to an outbreak involving both professionals and the patients they care for, with a potential impact on the general population. Therefore, since 2007, the Advisory Committee on Immunization Practices (ACIP) recommends that all HCWs have evidence of immunity against varicella. The present meta-analysis was therefore designed to collect the available evidence on the seronegative status of VZV among HCWs. PubMed, Scopus, and Embase databases were searched without backward limit for articles reporting on the seroprevalence of VZV among HCWs, and all articles meeting the inclusion criteria were included in a random-effect meta-analysis model. From 1744 initial entries, a total of 58 articles were included in the quantitative analysis (publication range: 1988 to 2024), for a pooled sample of 71,720 HCWs. Moreover, the included studies reported on seroprevalence data on measles (N = 36,043 HCWs) and rubella (N = 22,086 HCWs). Eventually, the pooled seronegative status for VZV was estimated to be 5.72% (95% confidence interval [95% CI] 4.59 to 7.10) compared to 6.91% (95% CI 4.79 to 9.87) for measles and 7.21% (5.36 to 9.64) for rubella, with a greater risk among subjects younger than 30 years at the time of the survey (risk ratio [RR] 1.434, 95% CI 1.172 to 1.756). Interestingly, medical history of either VZV infection/vaccination had low diagnostic performances (sensitivity 76.00%; specificity 60.12%; PPV of 96.12% but PNV of 18.64%). In summary, the available data suggest that newly hired HCWs are increasingly affected by low immunization rates for VZV but also for measles and rubella, stressing the importance of systematically testing test newly hired workers for all components of the measles-pertussis-rubella-varicella vaccine.

Assessment of the humoral immune status of varicella-zoster virus in patients with diffuse connective tissue diseases

Background

Diffuse connective tissue diseases (DCTDs) require long-term immunosuppressive treatment, increasing the risk of varicella-zoster virus (VZV) infection. This study aims to evaluate the humoral immune status against VZV in DCTD patients and explore factors that may influence their immune levels.

Methods

This is a retrospective cohort study that collected data from adult DCTD patients (≥18 years) attending our outpatient clinic. The geometric mean concentration (GMC) of VZV-specific IgG antibodies in the patients' sera was measured using the enzyme-linked immunosorbent assay (ELISA).

Results

A total of 280 RA patients, 272 SLE + MCTD patients and 280 healthy controls were included. SLE + MCTD patients had significantly higher VZV IgG antibody levels than RA patients (p < 0.05) but showed no significant difference compared to healthy controls (p > 0.05). Notable differences were observed particularly among female patients and those aged 30-49 years, (p < 0.05). SLE + MCTD patients in an active disease state had significantly higher VZV IgG antibody titers than RA patients (p < 0.05). Additionally, patients with a history of herpes zoster, regardless of being in the SLE + MCTD, RA, or control group, exhibited higher VZV IgG titers (p < 0.05).

Conclusion

Although DCTD patients, particularly those with SLE and MCTD, exhibit higher VZV IgG antibody levels, they still face a higher risk of developing herpes zoster (HZ), which may be related to their underlying disease and immunosuppressive treatment. The presence of antibodies alone may not provide complete protection, necessitating consideration of cellular immune mechanisms. It is recommended to enhance monitoring of VZV antibody levels in high-risk patients and consider herpes zoster vaccination to reduce HZ-related complications.

A Hitchhiker's Guide Through the Cell: The World According to the Capsids of Alphaherpesviruses

The nucleoplasm, the cytosol, the inside of virions, and again the cytosol comprise the world in which the capsids of alphaherpesviruses encounter viral and host proteins that support or limit them in performing their tasks. Here, we review the fascinating conundrum of how specific protein-protein interactions late in alphaherpesvirus infection orchestrate capsid nuclear assembly, nuclear egress, and cytoplasmic envelopment, but target incoming capsids to the nuclear pores in naive cells to inject the viral genomes into the nucleoplasm for viral transcription and replication. Multiple capsid interactions with viral and host proteins have been characterized using viral mutants and assays that reconstitute key stages of the infection cycle. Keratinocytes, fibroblasts, mucosal epithelial cells, neurons, and immune cells employ cell type-specific intrinsic and cytokine-induced resistance mechanisms to restrict several stages of the viral infection cycle. However, concomitantly, alphaherpesviruses have evolved countermeasures to ensure efficient capsid function during infection.

Varicella Pneumonia in Immunocompetent Adults: Symptomatic and Asymptomatic Cases

Varicella zoster virus (VZV) is an enveloped, linear double-stranded DNA virus. It belongs to the Herpesviridae family and can manifest as primary varicella infection or secondary infection, also known as herpes zoster. Varicella pneumonia is an uncommon but potentially life-threatening complication of primary varicella infection. It mainly affects adults, and, if left untreated, the mortality rate is high. We report two cases involving adult male patients who presented with a generalized widespread vesicular rash compatible with primary varicella. Each patient had a different clinical presentation; the first patient had respiratory symptoms, while the second patient did not. Chest radiographs of both patients showed bilateral infiltrates. Treatment was initiated with the administration of intravenous acyclovir with a very good response. This report of two cases highlights the importance of early detection and prompt treatment of varicella-related complications, especially in higher-risk patients, to reduce morbidity and mortality and improve overall clinical outcomes. We also aim to reinforce the importance of immunization, which would aid in reducing the incidence of vaccine-preventable diseases such as varicella and its life-threatening complications.

Restriction factors regulating human herpesvirus infections

Herpesviruses are DNA viruses and the cause of diseases ranging from mild skin conditions to severe brain diseases. Mammalian antiviral host defense comprises an array of mechanisms, including restriction factors (RFs), which block specific steps in viral replication cycles. In recent years, knowledge of RFs that contribute to controlling herpesvirus infections has expanded significantly, along with a new understanding of viral evasion mechanisms and disease pathogenesis. By integrating findings from human genetics, murine models, and cellular studies, this review provides a current view of RF control of herpesvirus infections. We also explore the regulation of RF expression, discuss the roles of RFs in diseases, and point towards their growing potential as candidate therapeutic targets.

Primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome: a Mendelian randomization study

Background

Currently, evidence regarding the causal relationship between primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome is limited and inconsistent. Therefore, this study employs Mendelian randomization (MR) methodology to investigate the causal relationship between the two.

Methods

This study selected 110 single-nucleotide polymorphisms (SNPs) of primary immunodeficiency-related genes as instrumental variables (IVs). Genetic associations of primary immunodeficiency-related genes were derived from recent genome-wide association studies (GWAS) data on human plasma protein levels and circulating immune cells. Data on genes associated with varicella-zoster virus reactivation syndrome were obtained from the GWAS Catalog and FINNGEN database, primarily analyzed using inverse variance weighting (IVW) and sensitivity analysis.

Results

Through MR analysis, we identified 9 primary immunodeficiency-related genes causally associated with herpes zoster and its subsequent neuralgia; determined causal associations of 20 primary immunodeficiency-related genes with three vascular lesions (stroke, cerebral aneurysm, giant cell arteritis); revealed causal associations of 10 primary immunodeficiency-related genes with two ocular diseases (retinopathy, keratitis); additionally, three primary immunodeficiency-related genes each were associated with encephalitis, cranial nerve palsy, and gastrointestinal infections.

Conclusions

This study discovers a certain association between primary immunodeficiency-related genes and varicella-zoster virus reactivation syndrome, yet further investigations are warranted to explore the specific mechanisms underlying these connections.

Suppression of the host antiviral response by non-infectious varicella zoster virus extracellular vesicles

Varicella zoster virus (VZV) reactivates from ganglionic sensory neurons to produce herpes zoster (shingles) in a unilateral dermatomal distribution, typically in the thoracic region. Reactivation not only heightens the risk of stroke and other neurological complications but also increases susceptibility to co-infections with various viral and bacterial pathogens at sites distant from the original infection. The mechanism by which VZV results in complications remote from the initial foci remains unclear. Small extracellular vesicles (sEVs) are membranous signaling structures that can deliver proteins and nucleic acids to modify the function of distal cells and tissues during normal physiological conditions. Although viruses have been documented to exploit the sEV machinery to propagate infection, the role of non-infectious sEVs released from VZV-infected neurons in viral spread and disease has not been studied. Using multi-omic approaches, we characterized the content of sEVs released from VZV-infected human sensory neurons (VZV sEVs). One viral protein was detected (immediate-early 62), as well as numerous immunosuppressive and vascular disease-associated host proteins and miRNAs that were absent in sEVs from uninfected neurons. Notably, VZV sEVs are non-infectious yet transcriptionally altered primary human cells, suppressing the antiviral type 1 interferon response and promoting neuroinvasion of a secondary pathogen in vivo. These results challenge our understanding of VZV infection, proposing that the virus may contribute to distant pathologies through non-infectious sEVs beyond the primary infection site. Furthermore, this study provides a previously undescribed immune-evasion mechanism induced by VZV that highlights the significance of non-infectious sEVs in early VZV pathogenesis.

IMPORTANCE

Varicella zoster virus (VZV) is a ubiquitous human virus that predominantly spreads by direct cell-cell contact and requires efficient and immediate host immune evasion strategies to spread. The mechanisms of immune evasion prior to virion entry have not been fully elucidated and represent a critical gap in our complete understanding of VZV pathogenesis. This study describes a previously unreported antiviral evasion strategy employed by VZV through the exploitation of the infected host cell's small extracellular vesicle (sEV) machinery. These findings suggest that non-infectious VZV sEVs could travel throughout the body, affecting cells remote from the site of infection and challenging the current understanding of VZV clinical disease, which has focused on local effects and direct infection. The significance of these sEVs in early VZV pathogenesis highlights the importance of further investigating their role in viral spread and secondary disease development to reduce systemic complications following VZV infections.

Population immunity to varicella in Canada: A Canadian Immunization Research Network (CIRN) study

INTRODUCTION

The incidence of varicella in Canada has decreased by almost 99% since vaccination was introduced. However, variation in the timing and eligibility of vaccination programs across the country has resulted in some cohorts being under-vaccinated and therefore potentially susceptible to infection.

METHODS

We used nationally representative specimens from the Biobank of Statistics Canada's Canadian Health Measures Survey (CHMS) as well as residual specimens from Ontario collected between 2009-2014 to estimate population immunity across age-groups and geography, and identify any groups at increased risk of varicella infection.

RESULTS

The weighted proportion of specimens with antibody levels above the threshold of protection was 93.6% (95% CI: 92.4, 95.0). Protection was lowest among those aged 3-5 years (54.3%; 95% CI: 47.3, 61.4), but increased with age. Individuals born outside Canada had more than twice the odds of varicella susceptibility than those born in Canada (aOR: 2.7; 95% CI: 1.4, 5.0; p = 0.004). There were no differences by sex or geography within Canada, and there were no statistically significant differences when Ontario CHMS sera were compared to Ontario residual sera, apart from in participants aged 12-19 year age-group, for whom the CHMS estimate (91.2%; 95% CI: 86.7, 95.7) was significantly higher (p = 0.03) than that from residual specimens (85.9%, 95% CI: 81.1, 90.8).

DISCUSSION

Varicella immunity in Canada is changing. Children appear to have low population immunity, placing them at greater risk of infection and at increased risk of severe disease as they age. Our results underscore the importance of performing periodic serosurveys to monitor further population immunity changes as the proportion of vaccine-eligible birth-cohorts increases, and to continually assess the risk of outbreaks.

Lipo-pam™ adjuvanted herpes zoster vaccine induces potent gE-specific cellular and humoral immune responses

Herpes zoster (HZ), also known as shingles, is caused by the reactivation of latent varicella-zoster virus (VZV). Decreased VZV-specific T-cell immune responses significantly contribute to the development of HZ. Shingrix is a recombinant zoster vaccine that is currently used to prevent HZ. However, Shingrix has high reactogenicity and pain at the injection site due to QS21, one of the adjuvant components. In this study, we developed a new herpes zoster vaccine formulation called CVI-VZV-001, containing gE protein and a novel liposome-based adjuvant Lipo-pam™, which consists of two TLR agonists. We evaluated the immunogenicity of CVI-VZV-001 in mouse and rabbit models. CVI-VZV-001 elicited robust gE-specific T-cell immune responses and gE-specific antibody production. Specifically, CVI-VZV-001 induced polyfunctional CD4+ T cell populations that secrete multiple cytokines. Furthermore, CVI-VZV-001 sustained the gE-specific immune responses for up to six months after immunization. To ensure CVI-VZV-001's safety for further development, we conducted a good laboratory practice (GLP) toxicity test, which confirmed that CVI-VZV-001 is safe for use. At present, CVI-VZV-001 is undergoing phase I clinical trials. This study suggests that CVI-VZV-001 can be a potent candidate for the HZ vaccine with high immunogenicity and safety.

Causal effect of lifestyle and metabolic indicator with herpes zoster: a two-sample Mendelian randomization study

Background

Previous observational studies have reported certain causal relationships between factors such as smoking, alcohol consumption, obesity, physical activity, metabolic disorders, and the incidence of herpes zoster (HZ). However, there is controversy regarding the observed results across different studies. Our objective was to investigate the causal effects of these risk factors on the risk of herpes zoster through a Mendelian randomization analysis using two-sample bidirectional approaches.

Methods

We conducted two-sample bidirectional Mendelian randomization analyses to explore the causal relationships between different lifestyles, obesity assessment indices, metabolic indicators, and the risk of herpes zoster. All exposure and outcome data were sourced from publicly available data from genome-wide association studies.

Results

In the inverse-variance weighted (IVW) analysis, body mass index (BMI) (OR: 1.160, 95% CI: 1.030-1.307, p = 0.014), Body fat percentage (BFP) (OR: 1.241, 95% CI: 1.050-1.467, p = 0.011), and whole body fat mass (WBFM) (OR: 1.199, 95% CI: 1.057-1.362, p = 0.005) exhibited positive associations with the risk of HZ. However, usual walking pace (UWP) (OR: 0.498, 95% CI: 0.254-0.976, p = 0.042) demonstrated a significant negative correlation with HZ risk. Other factors including alcohol intake frequency, smoking initiation, smoking status, insomnia, and sleep duration did not show significant causal relationships with HZ.

Conclusion

Mendelian randomization studies revealed that BMI, BFP, and WBFM are risk factors for HZ. UWP showed a protective effect against HZ. These findings provide a straightforward method for evaluating future clinical practices aiming to develop personalized management strategies and assess high-risk populations for HZ.

Heterologous Prime-Boost Immunization Strategies Using Varicella-Zoster Virus gE mRNA Vaccine and Adjuvanted Protein Subunit Vaccine Triggered Superior Cell Immune Response in Middle-Aged Mice

Purpose

Heterologous immunization using different vaccine platforms has been demonstrated as an efficient strategy to enhance antigen-specific immune responses. In this study, we performed a head-to-head comparison of both humoral and cellular immune response induced by different prime-boost immunization regimens of mRNA vaccine and adjuvanted protein subunit vaccine against varicella-zoster virus (VZV) in middle-aged mice, aiming to get a better understanding of the influence of vaccination schedule on immune response.

Methods

VZV glycoprotein (gE) mRNA was synthesized and encapsulated into SM-102-based lipid nanoparticles (LNPs). VZV-primed middle-aged C57BL/6 mice were then subjected to homologous and heterologous prime-boost immunization strategies using VZV gE mRNA vaccine (RNA-gE) and protein subunit vaccine (PS-gE). The antigen-specific antibodies were evaluated using enzyme-linked immunosorbent assay (ELISA) analysis. Additionally, cell-mediated immunity (CMI) was detected using ELISPOT assay and flow cytometry. Besides, in vivo safety profiles were also evaluated and compared.

Results

The mRNA-loaded lipid nanoparticles had a hydrodynamic diameter of approximately 130 nm and a polydispersity index of 0.156. Total IgG antibody levels exhibited no significant differences among different immunization strategies. However, mice received 2×RNA-gE or RNA-gE>PS-gE showed a lower IgG1/IgG2c ratio than those received 2×PS-gE and PS-gE> RNA-gE. The CMI response induced by 2×RNA-gE or RNA-gE>PS-gE was significantly stronger than that induced by 2×PS-gE and PS-gE> RNA-gE. The safety evaluation indicated that both mRNA vaccine and protein vaccine induced a transient body weight loss in mice. Furthermore, the protein vaccine produced a notable inflammatory response at the injection sites, while the mRNA vaccine showed no observable inflammation.

Conclusion

The heterologous prime-boost strategy has demonstrated that an mRNA-primed immunization regimen can induce a better cell-mediated immune response than a protein subunit-primed regimen in middle-aged mice. These findings provide valuable insights into the design and optimization of VZV vaccines with the potentials to broaden varicella vaccination strategies in the future.

Exploring viral neuropathic pain: Molecular mechanisms and therapeutic implications

As the Coronavirus Disease 2019 (COVID-19) pandemic continues, there is a growing concern regarding the relationship between viral infections and neuropathic pain. Chronic neuropathic pain resulting from virus-induced neural dysfunction has emerged as a significant issue currently faced. However, the molecular mechanisms underlying this phenomenon remain unclear, and clinical treatment outcomes are often suboptimal. Therefore, delving into the relationship between viral infections and neuropathic pain, exploring the pathophysiological characteristics and molecular mechanisms of different viral pain models, can contribute to the discovery of potential therapeutic targets and methods, thereby enhancing pain relief and improving the quality of life for patients. This review focuses on HIV-related neuropathic pain (HNP), postherpetic neuralgia (PHN), and neuropathic pain caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infections, examining rodent models and relevant cellular molecular pathways. Through elucidating the connection between viral infections and neuropathic pain, it aims to delineate the current limitations and challenges faced by treatments, thereby providing insights and directions for future clinical practice and research.

Sequence analysis of isolated strains of herpes zoster virus among patients with shingles

Background and Objectives

Herpes zoster, or shingles, is caused by the varicella-zoster virus (VZV), which initially presents as chickenpox in children. VZV is a global health concern, especially in winter and spring, affecting 10-20% of adults over 50 and posing a 30% risk for the general population. This study used PCR to detect VZV, confirming results with duplicated DNA samples and identifying 234 bp fragments by targeting the gpB gene.

Materials and Methods

This study examined 50 herpes zoster cases from October 2020 to April 2021, involving 30 males and 20 females aged 10 to 90, diagnosed by dermatologists. Data were collected via a questionnaire. PCR detected VZV by amplifying the gpB and MCP genes from skin lesion samples. Six positive 234-bp PCR products were sequenced at Macrogen Inc. in Seoul, South Korea.

Results

Six DNA samples with 234 bp amplicons were sequenced, showing 99-100% similarity to human alpha herpesvirus sequences in the gpB gene. NCBI BLAST matched these sequences to a reference (GenBank acc. MT370830.1), assigning accession numbers LC642111, LC642112, and LC642113. Eight nucleic acid substitutions caused amino acid changes in the gpB protein: isoleucine to threonine, serine to isoleucine, and threonine to Proline. These variants were deposited in NCBI GenBank as gpB3 samples.

Conclusion

The study found high sequence similarity to known VZV sequences, identifying six nucleic acid variations and eight SNPs. Notable amino acid changes in the gpB protein were deposited in NCBI GenBank as the gpB3 sample.

Herpes zoster in neuro-ophthalmology: a practical approach

Herpes Zoster (HZ) or shingles is the reactivation of the Varicella Zoster Virus (VZV), usually along a single sensory nerve, but can affect both sensory and motor cranial nerves. Major risk factors for HZ include immunosuppressed status and age older than 60 years. In the United States, the lifetime risk of HZ is approximately 30%. Worldwide, the median incidence of HZ is 4-4.5 per 1000 person-years across the Americas, Eurasia, and Australia. HZ ophthalmicus, occurring in 10-20% of patients, is an ophthalmic emergency characterized by VZV reactivation along the V1 branch of the trigeminal nerve. Approximately half of this patient subgroup will go on to develop ocular manifestations, requiring prompt diagnosis and management. While anterior segment complications are more common, neuro-ophthalmic manifestations are rarer and can also occur outside the context of overt HZ ophthalmicus. Neuro-ophthalmic manifestations include optic neuropathy, acute retinal necrosis or progressive outer retinal necrosis, cranial neuropathy (isolated or multiple), orbitopathy, and CNS manifestations. Although typically a clinical diagnosis, diagnosis may be aided by neuroimaging and laboratory (e.g., PCR and serology) studies. Early antiviral therapy is indicated as soon as a presumptive diagnosis of VZV is made and the role of corticosteroids remains debated. Generally, there is wide variation of prognosis with neuro-ophthalmic involvement. Vaccine-mediated prevention is recommended. In this review, we summarize neuro-ophthalmic manifestations of VZV.

Factors Influencing Herpes Zoster Vaccine Utilization Among Adults Aged 50 and Above Attending Primary Healthcare Center in Saudi Arabia: A Cross-Sectional Study

INTRODUCTION

Herpes zoster, or shingles, is a significant health concern for older adults caused by the varicella-zoster virus (VZV) reactivation. The availability of effective herpes zoster vaccines offers a crucial preventive measure to reduce the incidence and severity of this condition. However, the uptake of the available vaccine remains suboptimal, especially among adults aged 50 and above. Understanding the factors that influence vaccine utilization is not only essential for developing strategies to improve vaccination rates but also has the potential to significantly reduce the disease burden.

METHODS

This cross-sectional study aimed to identify factors influencing herpes zoster vaccine utilization among adults aged 50 and above attending primary healthcare center in Saudi Arabia. Data were collected using a validated questionnaire administered to visitors attending Al-Wazarat Primary Healthcare Center in Riyadh. Descriptive and inferential statistics were employed to analyze the data.

RESULTS

A total of 403 participants were included in the study, with 73.7% of participants having heard of the disease, yet only 34.2% had received the vaccine. Vaccine uptake was significantly associated with gender, educational level, and healthcare provider recommendations. Common barriers to vaccination included fear of side effects, lack of perceived susceptibility, concerns about vaccine effectiveness, and access to healthcare facilities.

CONCLUSION

Herpes zoster vaccine utilization among older adults in Saudi Arabia is relatively low despite moderate awareness. Enhancing public education through targeted campaigns and strengthening healthcare provider recommendations are crucial to improving vaccine uptake. Addressing specific barriers and misconceptions is essential to reduce the burden of herpes zoster in this population. The need for future research to explore strategies to overcome these challenges and promote higher vaccination rates is urgent and important.

Analysis of factors selectively related to herpes zoster involving peripheral sensory ganglia: Retrospective study

Herpes zoster (HZ), resulting from the reactivation of the varicella-zoster virus, is a significant disease. This study aimed to explore the factors influencing sensory neuron involvement in HZ at different locations and its association with postherpetic neuralgia (PHN). A total of 3143 cases were retrieved from an electronic medical record system, including 2676 cases of HZ and 467 cases of PHN. Gender, age, site of onset, past surgical history, and comorbidities were analyzed using a multifactorial logistic regression model. The results revealed correlations between age, gender, comorbidities (diabetes, coronary heart disease, percutaneous coronary intervention [PCI]), and sensory neuron involvement in HZ. Specifically, older age, female gender, and comorbid conditions such as diabetes/coronary heart disease were associated with sacral dorsal root ganglion (DRG) involvement, while PCI history was associated with lumbar DRG involvement. Additionally, sensory neuron involvement at different locations by HZ was linked to PHN. Furthermore, independent risk factors for PHN included thoracic DRG involvement, older age, and comorbidities (diabetes, surgical history, malignancy). It is crucial to prevent damage to the DRG, especially in individuals with comorbidities, through activities avoidance and active treatment, to minimize the occurrence of PHN.

Clinical and radiological features of a cluster of immunocompetent adolescents with varicella pneumonia: a descriptive study

Background

Varicella pneumonia is one of the most common and severe complications of chickenpox infection. This study aimed to describe the clinical and radiological features of varicella pneumonia in a cluster of immunocompetent adolescents.

Methods

A retrospective analysis was conducted on a cohort of adolescent patients diagnosed with varicella pneumonia at Wuhan Jinyintan Hospital between February 2023 and May 2023. The clinical and imaging data were collected and analyzed. A total of 116 patients were divided into two groups by the absence (group 1, n=57) or presence (group 2, n=59) of lower respiratory symptoms for data comparison.

Results

Among 116 patients (median age, 16 years; 60 males), rash (100%) was the most prevalent clinical symptom. The most common respiratory symptom and sign were fever (42.2%) and coarse breath sounds (41.4%). Chest computed tomography (CT) performed within five days of symptoms onset revealed multiple (89.7%), peripheral (51.7%), and ill-defined (73.3%) lung nodules in most patients, which gradually improved 6-10 days after symptom onset. Group 2 had higher levels of interleukin-6 (P<0.001), C-reactive protein (P=0.02), serum amyloid-A protein (P=0.002), longer hospital stays (P=0.04), more involved lung lobes (P=0.02), and a higher incidence of multiple nodules (P=0.043) than those of group 1.

Conclusions

In immunocompetent adolescents, clustered varicella pneumonia often presents as mild and more uniform in clinical and radiological presentations than sporadic cases. The most common CT findings were multiple pulmonary nodules. Patients with lower respiratory symptoms exhibited more severe clinical and radiological manifestations. Generally, it is not recommended that patients undergo frequent CT scans in a short period.

The Clinical and Economic Burden of Antibiotic Use in Pediatric Patients With Varicella Infection: A Retrospective Cohort Analysis of Real-World Data in England

BACKGROUND

Varicella is a highly infectious disease, particularly affecting children, that can lead to complications requiring antibiotics or hospitalization. Antibiotic use for varicella management is poorly documented. This study assessed antibiotic use for varicella and its complications in a pediatric population in England.

METHODS

Data were drawn from medical records in the Clinical Practice Research Datalink and Hospital Episode Statistics data sets. The study included patients <18 years old with varicella diagnosed during 2014-2018 and 3-month follow-up available. We determined varicella-related complications, medication use, healthcare resource utilization, and costs from diagnosis until 3 months after diagnosis.

RESULTS

We identified 114 578 children with a primary varicella diagnosis. Of these, 7.7% (n = 8814) had a varicella-related complication, the most common being ear, nose, and throat related (37.1% [n = 3271]). In all, 25.9% (n = 29 706 of 114 578) were prescribed antibiotics. A higher proportion of patients with complications than without complications were prescribed antibiotics (64.3% [n = 5668 of 8814] vs 22.7% [n = 24 038 of 105 764]). Mean annualized varicella-related costs were £2 231 481 for the study cohort. Overall, antibiotic prescriptions cost approximately £262 007.

CONCLUSIONS

This study highlights high antibiotic use and healthcare resource utilization associated with varicella management, particularly in patients with complications. A national varicella vaccination program in England may reduce varicella burden and related complications, medication use, and costs.

Primary Varicella Infection in a Young Adult from the Democratic Republic of the Congo: A Case Report and Mini-Review

We describe a case of an immunocompetent adult male patient originally from the Democratic Republic of Congo (DRC), who was referred to our unit for a several-day history of fever and a pruritic, vesicular rash. There was initial concern in the Emergency Department for Mpox (formerly known as "monkeypox") given the current epidemiology versus other viral etiologies. Primary varicella zoster virus (pVZV) infection was ultimately diagnosed by PCR from a swabbed, unroofed lesion, and he recovered completely with supportive management and without antiviral therapy. We herein describe how common viral exanthems may best be differentiated in an emergency or outpatient setting.