Varicella-zoster vaccine for the prevention of herpes zoster

The public health impact of recombinant herpes zoster vaccination in adults over 50 years in Spain

The recombinant zoster vaccine (RZV) is included in the Spanish National Immunisation Programme for adults 65 years of age (years), with a potential progressive catch-up program for adults 66-80 years, starting with 80 years. However, the risk of herpes zoster (HZ) increases significantly from 50 years. We estimated the public health impact (PHI) of vaccinating adults ≥50 years in Spain versus no vaccination, using a Markov model adapted to the Spanish setting. The model simulated a hypothetical ≥50 years cohort over a lifetime, with inputs from Spanish publications, databases, or publications from other countries where Spanish data were unavailable. Base case inputs included 67.7% RZV coverage and 61.1% second dose compliance. Outputs included clinical outcomes avoided, healthcare resource use avoided, and number-needed-to-vaccinate (NNV) to prevent one HZ case. Deterministic (DSA) and probabilistic sensitivity analyses (PSA) were also conducted. The model estimated that, compared with no vaccination, vaccinating adults ≥50 years in Spain (N = 19,850,213) with RZV could prevent 1,533,353 HZ cases, 261,610 postherpetic neuralgia episodes, 274,159 other complications, and 138 deaths through the cohorts' remaining lifetime, mostly in the 50-59 years cohort. Furthermore, 3,500,492 primary care visits and 71,156 hospitalizations could be avoided, with NNV = 9 to prevent one HZ case. DSA predicted NNV = 7 to prevent one HZ case when second dose compliance was increased to 100%. PSA demonstrated ≥200,000 and ≥1,400,000 cases could be prevented in 86.9% and 18.4% of simulations, respectively. Starting RZV from 50 years could therefore prevent a substantial number of HZ cases and complications. Increasing RZV coverage and second dose compliance could further alleviate PHI of HZ.

Logistic and organizational barriers to herpes zoster vaccination in europe: A systematic review

Background

The Herpes Zoster (HZ) poses a significant public health threat, leading to morbidity and occasional mortality in unvaccinated adults aged 50 and older. With over 95 % of individuals in this age group globally having prior exposure to Varicella-Zoster Virus, a substantial portion of the world's population is susceptible to developing HZ. Without vaccination, individuals reaching 85 years face a 50 % lifetime risk of HZ. Organizational and logistical barriers further hinder vaccination efforts, involving complexities in cost management, demanding vaccine storage requirements, supply limitations, distribution challenges, absence of a streamlined status collection system, and healthcare system deficiencies.

Methods

A systematic review was conducted on the studies that examined the logistical and organizational barriers to HZ vaccination among frail and older adults, aligning with the PRISMA guidelines. Eligibility criteria focus on English studies in Europe, excluding pediatric or irrelevant populations. Rayyan AI was used for data extraction, and bias was assessed using the AXIS tool.

Results

After excluding 841 based on titles and abstracts, 22 publications were selected. A thorough analysis identified 4 studies meeting inclusion criteria, conducted between 2009 and 2022, unveiling several barriers on HZ vaccination: challenges with healthcare professionals, obstacles related to patients' perceptions and knowledge, difficulties in accessibility, structural issues, social dynamics.

Conclusions

The study represents a comprehensive examination, emphasizing the need for targeted interventions to overcome these barriers. The findings underscore the urgency of addressing these challenges to enhance vaccination rates and mitigate the public health burden associated with HZ.

Immunogenicity and safety of an ORF7-deficient skin-attenuated and neuro-attenuated live vaccine for varicella: a randomised, double-blind, controlled, phase 2a trial

BACKGROUND

The Oka varicella vaccine strain remains neurovirulent and can establish lifelong latent infection, raising safety concerns about vaccine-related herpes zoster. In this study, we aimed to evaluate the immunogenicity and safety of a skin-attenuated and neuro-attenuated varicella vaccine candidate (v7D vaccine).

METHODS

We did this randomised, double-blind, controlled, phase 2a clinical trial in Jiangsu, China. Healthy children aged 3-12 years with no history of varicella infection or vaccination were enrolled and randomly assigned (1:1:1:1) to receive a single subcutaneous injection of the v7D vaccine at 3·3 log10 plaque forming units (PFU; low-dose v7D group), 3·9 log10 PFU (medium-dose v7D group), and 4·2 log10 PFU (high-dose v7D group), or the positive control varicella vaccine (vOka vaccine group). All the participants, laboratory personnel, and investigators other than the vaccine preparation and management staff were masked to the vaccine allocation. The primary outcome was assessment of the geometric mean titres (GMTs) and seroconversion rates of anti-varicella zoster virus immunoglobulin G (IgG) induced by different dose groups of v7D vaccine at 0, 42, 60, and 90 days after vaccination in the per-protocol set for humoral immune response analysis. Safety was a secondary outcome, focusing on adverse events within 42 days post-vaccination, and serious adverse events within 6 months after vaccination. This study was registered on Chinese Clinical Trial Registry, ChiCTR2000034434.

FINDINGS

On Aug 18-21, 2020, 842 eligible volunteers were enrolled and randomly assigned treatment. After three participants withdrew, 839 received a low dose (n=211), middle dose (n=210), or high dose (n=210) of v7D vaccine, or the vOka vaccine (n=208). In the per-protocol set for humoral immune response analysis, the anti-varicella zoster virus IgG antibody response was highest at day 90. At day 90, the seroconversion rates of the low-dose, medium-dose, and high-dose groups of v7D vaccine and the positive control vOka vaccine group were 100·0% (95% CI 95·8-100·0; 87 of 87 participants), 98·9% (93·8-100·0; 87 of 88 participants), 97·8% (92·4-99·7; 91 of 93 participants), and 96·4% (89·8-99·2; 80 of 83 participants), respectively; the GMTs corresponded to values of 30·8 (95% CI 26·2-36·0), 31·3 (26·7-36·6), 28·2 (23·9-33·2), and 38·5 (31·7-46·7). The v7D vaccine, at low dose and medium dose, elicited a humoral immune response similar to that of the vOka vaccine. However, the high-dose v7D vaccine induced a marginally lower GMT compared with the vOka vaccine at day 90 (p=0·027). In the per-protocol set, the three dose groups of the v7D vaccine induced a similar humoral immune response at each timepoint, with no statistically significant differences. The incidence of adverse reactions in the low-dose, medium-dose, and high-dose groups of v7D vaccine was significantly lower than that in the vOka vaccine group (17% [35 of 211 participants], 20% [41 of 210 participants], and 13% [27 of 210 participants] vs 24% [50 of 208 participants], respectively; p=0·025), especially local adverse reactions (10% [22 of 211 participants], 14% [30 of 210 participants] and 9% [18 of 210 participants] vs 18% [38 of 208 participants], respectively; p=0·016). None of the serious adverse events were vaccine related.

INTERPRETATION

The three dose groups of the candidate v7D vaccine exhibit similar humoral immunogenicity to the vOka vaccine and are well tolerated. These findings encourage further investigations on two-dose vaccination schedules, efficacy, and the potential safety benefit of v7D vaccine in the future.

FUNDING

The National Natural Science Foundation of China, CAMS Innovation Fund for Medical Sciences, the Fundamental Research Funds for the Central Universities, and Beijing Wantai.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

A Synergistic Lipid Nanoparticle Encapsulating mRNA Shingles Vaccine Induces Potent Immune Responses and Protects Guinea Pigs from Viral Challenges

Shingles is caused by the reactivation of varicella zoster virus (VZV) and manifests as painful skin rashes. While the recombinant protein-based vaccine proves highly effective, it encounters supply chain challenges due to a shortage of the necessary adjuvant. Messenger RNA (mRNA)-based vaccines can be rapidly produced on a large scale, but their effectiveness relies on efficient delivery and sequence design. Here, an mRNA-based VZV vaccine using a synergistic lipid nanoparticle (Syn-LNP) containing two different ionizable lipids is developed. Syn-LNP shows superior mRNA expression compared to LNPs formulated with either type of ionizable lipid and to a commercialized LNP. After encapsulating VZV glycoprotein E (gE)-encoding mRNA, mgE@Syn-LNP induces robust humoral and cellular immune responses in two strains of mice. The magnitude of these responses is similar to that induced by adjuvanted recombinant gE proteins and significantly higher than that observed with live-attenuated VZV. mgE@Syn-LNP exhibits durable humoral responses for over 7 months without obvious adverse effects. In addition, mgE@Syn-LNP protects vaccinated guinea pigs against live VZV challenges. Preliminary studies on the mRNA antigen design reveal that the removal of glycosylation sites of gE greatly reduces its immune responses. Collectively, Syn-LNP encapsulating gE-encoded mRNA holds great promise as a shingles vaccine.

Associations between income changes and the risk of herpes zoster: LIFE study

Economic stability is thought to be associated with health outcomes. Income changes may affect the occurrence of herpes zoster (HZ), which is a neurocutaneous disease caused by the varicella-zoster virus. This retrospective cohort study aimed to examine the associations between annual income changes and incident HZ in a Japanese population. The analysis was conducted using a database of public health insurance claims data linked with administrative data containing income levels. The study population comprised 48,317 middle-aged persons aged 45-64 years from five municipalities, and participants were followed-up from April 2016 until March 2020. Income changes were categorized as income unchanged (income in the year of interest remained within 50% of income in the previous year), income rise (income increased by more than 50% from the previous year to the year of interest), and income drop (income decreased by more than 50% from the previous year to the year of interest). Cox proportional hazards regression analyses were performed to calculate the hazard ratios of HZ for income drop and income rise (reference: income unchanged) as time-varying variables. Covariates included age, sex, and immune-related conditions. The results showed that income drop was significantly associated with a higher hazard ratio (1.15, 95% confidence interval: 1.00-1.31) for HZ. In contrast, income rise was not associated with HZ. A subgroup analysis revealed that the lowest baseline income group had a significantly higher risk of HZ when experiencing an income drop (HR: 1.56, 95% CI: 1.13-2.15). As zoster vaccination is voluntary and vaccination coverage in middle-aged persons is low in Japan, our findings indicate that it may be advantageous to promote and subsidize voluntary vaccinations for middle-aged people with low baseline income who have experienced substantial income reductions in order to reduce the risk of HZ.

Expert consensus on vaccination in patients with inflammatory bowel disease in Japan

Immunosuppressive therapies can affect the immune response to or safety of vaccination in patients with inflammatory bowel disease (IBD). The appropriateness of vaccination should be assessed prior to the initiation of IBD treatment because patients with IBD frequently undergo continuous treatment with immunosuppressive drugs. This consensus was developed to support the decision-making process regarding appropriate vaccination for pediatric and adult patients with IBD and physicians by providing critical information according to the published literature and expert consensus about vaccine-preventable diseases (VPDs) [excluding cervical cancer and coronavirus disease 2019 (COVID-19)] in Japan. This consensus includes 19 important clinical questions (CQs) on the following 4 topics: VPDs (6 CQs), live attenuated vaccines (2 CQs), inactivated vaccines (6 CQs), and vaccination for pregnancy, childbirth, and breastfeeding (5 CQs). These topics and CQs were selected under unified consensus by the members of a committee on intractable diseases with support by a Health and Labour Sciences Research Grant. Physicians should provide necessary information on VPDs to their patients with IBD and carefully manage these patients' IBD if various risk factors for the development or worsening of VPDs are present. This consensus will facilitate informed and shared decision-making in daily IBD clinical practice.

A Case of Herpes Zoster Due to Varicella-Zoster Virus Vaccines in a 14-Month-old Girl

Herpes zoster (HZ) due to Varicella-Zoster virus (VZV) vaccines is rare and the accurate incidence remains unknown. We report a case of HZ due to VZV vaccines presented in an immunocompetent 14-month-old girl 62 days after vaccination which is the youngest case from the first dose of the VZV vaccine in immunocompetent children.

Varicella zoster virus and cardiovascular diseases

Varicella zoster virus (VZV) is a Herpesviridae family double-stranded DNA virus that only affects humans. The first clinical manifestation appears to be varicella, typical of childhood. VZV, on the other hand, becomes latent in ganglion neurons throughout the neuroaxis after primary infection. The VZV reactivates and travels along peripheral nerve fibers in the elderly and immunocompromised individuals, resulting in Zoster. It can, however, spread centrally and infect cerebral and extracranial arteries, resulting in vasculopathy, which can lead to transient ischemic attacks, strokes, aneurysms, cavernous sinus thrombosis, giant cell arteritis, and granulomatous aortitis. Although the mechanisms of virus-induced pathological vascular remodeling are not fully understood, recent research indicates that inflammation and dysregulation of ligand-1 programmed death play a significant role. Few studies, on the other hand, have looked into the role of VZV in cardiovascular disease. As a result, the purpose of this review is to examine the relationship between VZV and cardiovascular disease, the efficacy of the vaccine as a protective mechanism, and the target population of heart disease patients who could benefit from vaccination.

Corticosteroids Contribute to Serious Adverse Events Following Live Attenuated Varicella Vaccination and Live Attenuated Zoster Vaccination

Corticosteroids, when given in high dosages, have long been recognized as a risk factor for severe infection with wild-type varicella-zoster virus in both children and adults. The goal of this review is to assess the degree to which both low-dosage and high-dosage corticosteroids contribute to serious adverse events (SAEs) following live varicella vaccination and live zoster vaccination. To this end, we examined multiple published reports of SAEs following varicella vaccination (Varivax^TM) and zoster vaccination (Zostavax^TM). We observed that five of eight viral SAEs following varicella vaccination, including two deaths, occurred in children receiving corticosteroids, while one of three fatal viral SAEs following live zoster vaccination occurred in an adult being treated with low-dosage prednisone. The latter death after live zoster vaccination occurred in a 70 year-old man with rheumatoid arthritis, being treated with prednisone 10 mg daily. Thus, corticosteroids contributed to more severe infectious complications in subjects immunized with each of the two live virus vaccines. Further, when we surveyed the rheumatology literature as well as individual case reports, we documented examples where daily dosages of 7.5–20 mg prednisone were associated with increased rates of severe wild-type varicella-zoster virus infections in children and adults.

Acceptability and perception of the herpes zoster vaccine in the 65 and over population: A French observational study

The aim of the study was to evaluate the acceptability and to describe the perception of vaccination against herpes zoster (HZ) for outpatients and hospitalized patients in Lyon, France, aged 65 years and over. An observational study was based on a questionnaire completed from a face-to-face interview from January 2018 to March 2019. Volunteer outpatients who attended private medical laboratories or who were hospitalized in the geriatric department, or who were at the ambulatory medical clinic for a consultation were asked to participate. A total of 907 individuals were interviewed, with a mean age of 75.8 years. A large majority 87.6% (795) knew about HZ and 68.9% (625) would agree to be vaccinated against HZ if they had risk factors. The participants had knowledge of HZ as a disease but vaccine awareness is still lacking among the general public.

Recombinant zoster vaccine (Shingrix®): a new option for the prevention of herpes zoster and postherpetic neuralgia

Postherpetic neuralgia (PHN) is a challenging condition for pain management specialists. The prevention of herpes zoster (HZ) and subsequent PHN in individuals aged 50 years and older, via the development of new vaccines, is an ongoing research project. The live zoster vaccine (LZV, Zostavax^®) was the first proof of concept that vaccination could prevent HZ, but LZV cannot be used in various immune-compromised patients. This led to the development of a new non-live recombinant zoster vaccine (RZV, Shingrix^®). This RZV has shown promising results in many clinical trials, with high reactogenicity and similar systemic adverse effects compared to those of LZV. The National Advisory Committee on Immunization has recommended LZV as a standard vaccine for HZ prevention in adults ≥ 50 years of age, but no studies directly comparing the safety and efficacy of RZV and LZV vaccines have been conducted. This article reviews the brief history, efficacy, and safety of the two vaccines and discusses the advantage of RZV over LZV based on the available literature.

Interferon Gamma Inhibits Varicella-Zoster Virus Replication in a Cell Line-Dependent Manner

The major immediate early 62 (IE62) protein of varicella-zoster virus (VZV) is delivered to newly infected cell nuclei, where it initiates VZV replication by transactivating viral immediate early (IE), early (E), and late (L) genes. Interferon gamma (IFN-γ) is a potent cytokine produced following primary VZV infection. Furthermore, VZV reactivation correlates with a decline in IFN-γ-producing immune cells. Our results showed that treatment with 20 ng/ml of IFN-γ completely reduced intracellular VZV yield in A549 lung epithelial cells, MRC-5 lung fibroblasts, and ARPE-19 retinal epithelial cells at 4 days post-VZV infection. However, IFN-γ reduced virus yield only 2-fold in MeWo melanoma cells compared to that of untreated cells. IFN-β significantly inhibited VZV replication in both ARPE-19 and MeWo cells. In luciferase assays with VZV open reading frame 61 (ORF61) promoter reporter plasmid, IFN-γ abrogated the transactivation activity of IE62 by 95%, 97%, and 89% in A549, ARPE-19, and MRC-5 cells, respectively. However, IFN-γ abrogated IE62's transactivation activity by 16% in MeWo cells, indicating that IFN-γ inhibits VZV replication as well as IE62-mediated transactivation in a cell line-dependent manner. The expression of VZV IE62 and ORF63 suppressed by IFN-γ was restored by JAK1 inhibitor treatment, indicating that the inhibition of VZV replication is mediated by JAK/STAT1 signaling. In the presence of IFN-γ, knockdown of interferon response factor 1 (IRF1) increased VZV replication. Ectopic expression of IRF1 reduced VZV yields 4,000-fold in MRC-5 and ARPE-19 cells but 3-fold in MeWo cells. These results suggest that IFN-γ blocks VZV replication by inhibiting IE62 function in a cell line-dependent manner.IMPORTANCE Our results showed that IFN-γ significantly inhibited VZV replication in a cell line-dependent manner. IFN-γ inhibited VZV gene expression after the immediate early stage of infection and abrogated IE62-mediated transactivation. These results suggest that IFN-γ blocks VZV replication by inhibiting IE62 function in a cell line-dependent manner. Understanding the mechanisms by which IFN-γ plays a role in VZV gene programming may be important in determining the tissue restriction of VZV.

Humoral immunity to varicella zoster virus is altered in patients with rheumatoid arthritis

INTRODUCTION

The prevalence of herpes zoster (HZ) is high in patients with rheumatologic diseases. The incidence in patients with rheumatoid arthritis (RA) is at least twice as high as in healthy people. Nevertheless, little is known about humoral immunity against varicella zoster virus (VZV), in particular in patients with RA. We, therefore, aimed to retrospectively compare VZV antibody concentrations in a collective of patients with RA in a German outpatient clinic with age- and sex-matched controls without RA.

METHODS

We included n = 247 patients with RA from one single university centre as well as n = 250 age- and sex-matched controls from the in-house routine in this retrospective analysis. The concentration of VZV IgG antibody concentration was either available from the records or was measured using an enzyme-linked immunosorbent assay (ELISA). Additionally, avidity for specific IgG was analysed for some of the samples. The antibody concentrations have been compared between the two groups. Moreover, a consecutive subgroup analysis after stratification by age was performed.

RESULTS

A total of 68.4% (n = 169) of the included patients were treated with conventional synthetic DMARDs, either as monotherapy or in combination. Biological originator DMARDs were used in 45.8% (n = 113) of the patients, with the majority (85%, n = 96) of them being on tumour necrosis factor (TNF)-inhibiting agents. As the main result of this study, antibody titres for VZV were found to be significantly lower in RA patients compared with healthy controls (p < 0.0001). The observed difference was most pronounced for the older patients being in the sixth and seventh decade. Antibody avidity was high in both groups with a significantly higher avidity among the controls (p = 0.0006).

CONCLUSIONS

A possible explanation for the low VZV antibody concentration in RA patients might be premature immunosenescence, which most likely also effects the B cell compartment and humoral immunity. This thesis is emphasised by the significantly higher antibody avidity among the controls. The data also suggest that the increased HZ risk is a consequence of a poor humoral immunity. The available HZ vaccinations should contribute to decreasing the elevated HZ risk in RA patients.

KEY POINTS

• Humoral immunity to varicella zoster virus seems to be reduced in patients with RA. • This impaired immunity might contribute to the increased herpes zoster susceptibility in RA patients. • An accelerated immunosenescence in RA could be causative for this finding.

Cost-effectiveness of an adjuvanted recombinant zoster vaccine in older adults in the United States who have been previously vaccinated with zoster vaccine live

Zoster Vaccine Live (ZVL) is marketed in the US since 2008, and a non-live adjuvanted Recombinant Zoster Vaccine (RZV) was approved in 2017. Literature suggests that waning of ZVL efficacy may necessitate additional vaccination. The Advisory Committee on Immunization Practices recommended vaccination with RZV in immunocompetent adults aged 50+ years old, including those previously vaccinated with ZVL. The objective of this study was to determine the cost-effectiveness of vaccinating US adults aged 60+ years old, previously vaccinated with ZVL. The ZOster ecoNomic Analysis (ZONA) model, a deterministic Markov model, was adapted to follow a hypothetical 1 million(M)-person cohort of US adults previously vaccinated with ZVL. Model inputs included demographics, epidemiology, vaccine characteristics, utilities and costs. Costs and quality-adjusted life-years (QALYs) were presented over the lifetimes of the cohort from the year of additional vaccination, discounted 3% annually. The model estimated that, vaccination with RZV 5 years after previous vaccination with ZVL, would reduce disease burden compared with no additional vaccination, resulting in a gain of 1,633 QALYs at a total societal cost of $96M (incremental cost-effectiveness ratio: $58,793/QALY saved). Compared with revaccinating with ZVL, vaccination with RZV would result in a gain of 1,187 QALYs and societal cost savings of almost $84M. Sensitivity, scenario, and threshold analyses demonstrated robustness of these findings. Vaccination with RZV is predicted to be cost-effective relative to no additional vaccination, assuming a threshold of $100,000/QALY, and cost-saving relative to ZVL revaccination of US adults aged 60+ years old who have been previously vaccinated with ZVL.

Systematic review of the evidence on the epidemiology of herpes zoster: incidence in the general population and specific subpopulations in Spain

OBJECTIVES

Herpes zoster (HZ) is an important cause of morbidity around the world, especially among the adult population aged >50 years.

STUDY DESIGN

A systematic review of the literature (up to October 31, 2016) was performed to identify available evidence on incidence of HZ in the general population and in a specific subpopulation in Spain.

METHODS

PubMed and Embase databases were searched, combining the following search terms: 'herpes zoster', 'diabetes mellitus (DM)', 'chronic obstructive pulmonary disease (COPD)', 'chronic heart failure', 'mental disorders' and 'immunocompromised'. Supplements for local scientific congresses, non-indexed Spanish journals and official epidemiological reports, potentially HZ related, were also manually searched. The inclusion criteria were the following: English or Spanish publications reporting incidence of HZ in the Spanish general population and/or specific subpopulations. No restrictions were applied on the study design or population age.

RESULTS

Among 269 references retrieved (48 PubMed, 148 Embase and 73 manual searching), 34 were finally included. Incidence of HZ in the general population ranged from 2.1 to 5.5/1000 person-years. HZ incidence ranged from 9.4 to 15.3/1000 patients with DM and from 11.0 to 11.4/1000 population with COPD or cardiovascular disease. In asthmatic patients, 6.9 HZ cases/1000 subjects were reported. The highest HZ incidence (1.3-400.0/1000 person-years) was in immunocompromised persons (10.0/1000 patients with cancer, 12.5/1000 patients with AIDS, from 5.0 to 240.0/1000 transplanted patients and from 6.6 to 27.0/1000 population with rheumatic diseases). Three studies estimated an increased risk of HZ in comparison with general population, for patients with DM (24%), COPD (39%) and COPD receiving inhaled corticosteroids (61%).

CONCLUSIONS

The results suggest a high risk of HZ in certain age groups and specific subpopulations. This study could contribute to identify target age populations and at-risk groups if implementation of HZ vaccination programmes in Spain would be considered.

Reciprocal relationship between herpes zoster and cardiovascular diseases: A nationwide population-based case-control study in Korea

Recently, herpes zoster (HZ) has been identified as a risk factor for stroke, but there have been few studies on the relationship between HZ and other cardiovascular diseases (CVD), including myocardial infarction (MI) and heart failure (HF). The purpose of this study was to investigate the risk of HZ occurrence after CVD and the occurrence of CVD after HZ. This was a retrospective case-control study based on the National Health Insurance System claims database for 20 311 patients with HZ and 13 980 patients with CVD and 1:5 age- and sex-matched control subjects for each from January 2006 to December 2013. We evaluated the reciprocal relationship between HZ and CVD including MI, ischemic stroke and HF. Severe HZ requiring hospitalization independently increased the risk of subsequent MI (hazard ratio [HR], 1.831; 95% confidence interval [CI], 1.354-2.476)], ischemic stroke (HR, 1.523; 95% CI, 1.212-1.915) and HF (HR, 2.034; 95% CI, 1.615-2.562) during the study period. Likewise, patients with an episode of MI, ischemic stroke or HF were also at increased risk of HZ hospitalization (after MI: HR, 1.625; 95% CI, 1.144-2.308; after stroke: HR, 1.518; 95% CI, 1.177-1.957; and after HF: HR, 1.485, 95% CI 1.041-2.117). Our results suggest that there is a significant reciprocal relationship between severe HZ requiring hospitalization and CVD including MI, ischemic stroke and HF.

Effect of 2% lidocaine continuous epidural infusion for thoracic or lumbar herpes-zoster-related pain

Few treatments are effective to manage herpes-zoster (HZ)-related pain. This retrospective study focused on the efficacy of 2% lidocaine continuous epidural infusion on pain control and quality of life in patients with thoracic or lumbar HZ.A total of 256 patients with thoracic or lumbar HZ were reviewed for this study. Patients included in the study were divided into continuous epidural infusion (70 mL 2% lidocaine + 180 mL 0.9% normal saline) and medical therapy group (group1) and only medical therapy group (group2). European Organization for Research and Treatment of Cancer and Izbicki pain score were used to evaluate the pain control and quality of life before therapy, and 6 and 9 months after therapy.For 256 patients with HZ (thoracic HZ = 162, lumbar HZ = 94), 53.1% was women. Mean ± standard deviation age was 69.4 ± 9.5 ( range, 38-85) years. Significant differences between the 2 groups in terms of quality of life and pain control were detected after 6 and 9 months follow-up (P < .001). For patients with HZ at 1 to 3 months after rash onset, the pain score was significantly lower in group 1 (P < .001). Sixteen patients with postherpetic neuralgia (PHN) underwent continuous epidural infusion therapy. Only 4 patients achieved satisfactory pain relief. Seven patients required analgesic drugs, and 6 patients still were unable to work, 10/16 (62.5%) patients had readmission. In addition, the pain score was higher in patients with HZ with diabetes (P < .001). Epidural infection occurred in 6 patients (8.8%), catheter dislodgement in 4 patients (5.8%), and catheter leakage in 3 patients (4.4%). There was no spinal epidural abscesses occurred.2% lidocaine continuous epidural infusion therapy can lead to sustained pain relief and improve the quality of life in patients with for thoracic or lumbar HZ at 1 to 3 months after rash onset. Epidural lidocaine is avoided for the treatment PHN, and the level of glucose might be associated with zoster-related pain.

The public health value of vaccination for seniors in Europe

Longer life expectancy and decreasing fertility rates mean that the proportion of older people is continually increasing worldwide, and particularly in Europe. Ageing is associated with an increase in the risk and severity of infectious diseases. These diseases are also more difficult to diagnose and manage in seniors who often have at least one comorbid condition (60% of seniors have two or more conditions). Infectious diseases increase the risk of hospitalization, loss of autonomy and death in seniors. Effective vaccines are available in Europe for infectious diseases such as influenza, pneumococcal diseases, herpes zoster, diphtheria, tetanus and pertussis. Their effectiveness has been demonstrated in terms of reducing the rates of hospitalization, disability, dependency and death. The prevention of diseases in seniors also results in savings in healthcare and societal costs each year in Europe. Despite the availability of vaccines, vaccine-preventable diseases affect millions of European citizens annually, with the greatest burden of disease occurring in seniors, and the medical and economic benefits associated with are not being achieved. Vaccination coverage rates must be improved to achieve the full benefits of vaccination of seniors in Europe.

Persistence of immune response to an adjuvanted varicella-zoster virus subunit vaccine for up to year nine in older adults

Background: In adults aged ≥60 years, two doses of the herpes zoster subunit vaccine (HZ/su; 50 µg varicella-zoster virus glycoprotein E [gE] and AS01_B Adjuvant System) elicited humoral and cell-mediated immune responses persisting for at least six years. We assessed immunogenicity nine years post-initial vaccination.

Methods: This open extension study (NCT02735915) followed 70 participants who received two HZ/su doses in the initial trial (NCT00434577). Blood samples to assess the cellular (intracellular cytokine staining) and humoral (ELISA) immunity were taken at year nine post-initial vaccination.

Results: Participants' mean age at dose 1 was 72.3 years. The fold increases over pre-vaccination in the mean frequency of gE-specific CD4+ T-cells expressing ≥2 activation markers plateaued from year four post-dose 1 until year nine. Anti-gE antibody geometric mean concentrations plateaued and remained above pre-vaccination levels from year four onwards. Immunogenicity at year nine was similar across age strata (60–69, ≥70 years) and confirmed statistical prediction model results using data for up to year six. Further modeling using all data up to year nine predicted immune responses would remain above the pre-vaccination level up to year 15.

Conclusion: In adults aged ≥60 years, HZ/su-induced immunogenicity remained above pre-vaccination levels for at least nine years post-initial vaccination.

Summary: After vaccination with HZ/su, both cell mediated and humoral immunity remained above pre-vaccination levels up to year 9 regardless of age group. Immune responses are predicted to remain above baseline up to 15 years post initial vaccination.

Decreased Immunity to Varicella Zoster Virus in Giant Cell Arteritis

Introduction

Herpes zoster, which can have a major impact on quality of life, results from reactivation of a latent varicella zoster virus (VZV) infection. We hypothesized that giant cell arteritis (GCA) patients are at increased risk of herpes zoster because of treatment with high-dose glucocorticoids and advanced age. Aim of the study, therefore, was to determine cell-mediated and humoral immunity to VZV in patients with GCA, patients with closely related disease polymyalgia rheumatica (PMR; treated with lower doses of glucocorticoids) and healthy controls (HCs).

Methods

Cell-mediated immunity to VZV was determined by performing interferon-γ (IFNγ) enzyme-linked immunospot and intracellular cytokine flow cytometry measurements in 11 GCA and 15 PMR patients and in 26 age/sex-matched HCs. Immunoglobulin G antibodies to VZV glycoprotein (VZV-IgG) were measured in serum samples of 35 GCA and 26 PMR patients at different times of follow-up and in 58 age and sex-matched HCs by an enzyme-linked immunosorbent assay.

Results

The number of VZV-specific IFNγ spot-forming cells was significantly lower in GCA patients on treatment, than in age-matched HCs (p = 0.029), but was not different in PMR patients on treatment. Similar levels of VZV-IgG were found in GCA and PMR patients at baseline, compared to HCs.

Conclusion

The finding of a decreased cell-mediated immunity to VZV, known to be of great importance in defense to the virus, indicates an increased herpes zoster risk in GCA patients compared to an already at-risk elderly population. Herpes zoster vaccination is, therefore, of special importance in GCA patients, and would ideally be administered at time of diagnosis. Interestingly, as VZV was suggested to be the trigger in GCA pathogenesis, similar levels of VZV-IgG were found in GCA patients at time of diagnosis and age-matched HCs, indicating that GCA patients did not experience herpes zoster substantially more often in the months preceding diagnosis than controls.

Herpes zoster in patients with systemic lupus erythematosus: Clinical features, complications and risk factors

Herpes Zoster (HZ) is reported as the most prevalent viral infection in patients with systemic lupus erythematosus (SLE). The aim of the present study was to investigate the clinical features, complications, and potential risk factors of HZ in patients with SLE from Southern China. A retrospective study was performed among patients with SLE admitted to the First Affiliated Hospital of Sun Yet-Sen University (Guangzhou, China) between 2009 and 2013. Demographic information, clinical and laboratory data, and medications used were collected and analyzed. A total of 48 instances of HZ from 46 individuals in a cohort of 1,265 SLE patients during the follow-up period were identified, with an overall prevalence of 3.6%. Complications occurred in 23.9% of patients with HZ (11/46). The risk of HZ was highest within 3-6 months following SLE diagnosis and reduced thereafter. The multivariate logistic regression analysis demonstrated that lymphopenia (OR=4.6; 95% CI=1.5-13.8; P=0.006) and treatment with high-dose glucocorticoids (GC; OR=4.3; 95% CI=1.6-11.7; P=0.004) were both significantly associated with occurrence of HZ. Lymphopenia was the only independent risk factor for the occurrence of complicated HZ (OR=15.2; 95% CI=2.7-85.1; P=0.002). There are some notable characteristics of HZ in patients with SLE in Southern China, such as the tendency to manifest in an early stage of SLE, and frequent complications with benign outcomes. The present data supported the role of lymphopenia and high-dose of GC therapy as risk factors for the occurrence of HZ. Lymphopenia was also shown to contribute to complicated HZ.

Current antiviral drugs and their analysis in biological materials-Part I: Antivirals against respiratory and herpes viruses

This review article is the first in the series providing an overview of currently used antiviral drugs and presenting contemporary approaches to their analysis. Large number of available antivirals and their structural variability makes this task very challenging. Trying to cover this topic comprehensively while maintaining reasonable size of the article, the review is presented in two parts. For the purpose of the overall review, antivirals were divided into four groups: (i) antivirals against herpes viruses, (ii) antivirals against respiratory viruses, (iii) antivirals against hepatitis viruses, and (iv) antivirals against HIV. Part one is devoted to the groups (i) and (ii) and also concerns the key features of the bioanalytical method. The mechanisms of action of antivirals against respiratory and herpes viruses and their use in clinical practice are briefly outlined, and the analytical methods for selected representatives of each class are described in more detail. The methods developed for the determination of drugs from these classes mostly include conventional procedures. In contrast, current trends such as UHPLC are used rarely and proper method validation based on requirements of bioanalytical guidelines can be often considered insufficient.

COST-EFFECTIVENESS ANALYSIS OF HERPES ZOSTER VACCINATION IN ITALIAN ELDERLY PERSONS

Objectives:Herpes zoster (HZ) is characterized by a painful skin rash. Its main complication is postherpetic neuralgia (PHN), pain persisting or occurring after the rash onset. HZ treatment aims to reduce acute pain, impede the onset complications, and disease progression. The aim of this study was to assess the cost-effectiveness of HZ vaccination compared with no vaccination strategy, within the Italian context.

Methods:The natural history of HZ and PHN was mapped through a Markov model with lifetime horizon. A population of patients aged between 60 and 79 years was hypothesized. Third party payer (Italian National Health Service, I-NHS) and societal perspectives were adopted. Data were derived from literature.

Results and Conclusions:The incremental cost-effectiveness ratio of the vaccination equaled EUR 11,943 per quality-adjusted life-year (QALY) under the I-NHS perspective and EUR 11,248 per QALY under the societal perspective. Considering a cost-effectiveness threshold of EUR 30,000/QALY, the multi-way sensitivity analysis showed that vaccination is cost-effective regardless of the perspective adopted, in 99 percent of simulations.

Approved Antiviral Drugs over the Past 50 Years

Since the first antiviral drug, idoxuridine, was approved in 1963, 90 antiviral drugs categorized into 13 functional groups have been formally approved for the treatment of the following 9 human infectious diseases: (i) HIV infections (protease inhibitors, integrase inhibitors, entry inhibitors, nucleoside reverse transcriptase inhibitors, nonnucleoside reverse transcriptase inhibitors, and acyclic nucleoside phosphonate analogues), (ii) hepatitis B virus (HBV) infections (lamivudine, interferons, nucleoside analogues, and acyclic nucleoside phosphonate analogues), (iii) hepatitis C virus (HCV) infections (ribavirin, interferons, NS3/4A protease inhibitors, NS5A inhibitors, and NS5B polymerase inhibitors), (iv) herpesvirus infections (5-substituted 2'-deoxyuridine analogues, entry inhibitors, nucleoside analogues, pyrophosphate analogues, and acyclic guanosine analogues), (v) influenza virus infections (ribavirin, matrix 2 protein inhibitors, RNA polymerase inhibitors, and neuraminidase inhibitors), (vi) human cytomegalovirus infections (acyclic guanosine analogues, acyclic nucleoside phosphonate analogues, pyrophosphate analogues, and oligonucleotides), (vii) varicella-zoster virus infections (acyclic guanosine analogues, nucleoside analogues, 5-substituted 2'-deoxyuridine analogues, and antibodies), (viii) respiratory syncytial virus infections (ribavirin and antibodies), and (ix) external anogenital warts caused by human papillomavirus infections (imiquimod, sinecatechins, and podofilox). Here, we present for the first time a comprehensive overview of antiviral drugs approved over the past 50 years, shedding light on the development of effective antiviral treatments against current and emerging infectious diseases worldwide.

The use of Zostavax in Spain: the economic case for vaccination of individuals aged 50 years and older

Background Population aging brings up a number of health issues, one of which is an increased incidence of herpes zoster (HZ) and its complication, post-herpetic neuralgia (PHN). Zostavax vaccine has recently become available to prevent HZ and PHN. This study evaluates the cost-effectiveness of vaccination against HZ in Spain considering a vaccination of the population aged 50 years and older and comparing this to the current situation where no vaccination is being administered. Methods An existing, validated, and published economic model was adapted to Spain using relevant local input parameters and costs from 2013. Results Vaccinating 30% of the Spanish population aged 50 years and older resulted in €16,577/QALY gained, €2025/HZ case avoided, and €5594/PHN case avoided under the third-party payer perspective. From a societal perspective, the ICERs increased by 6%, due to the higher price of the vaccine. The number needed to vaccinate to prevent one case was 20 for HZ, and 63 for PHN3. Sensitivity analyses showed that the model was most sensitive to the HZ and PHN epidemiological data, the health state utilities values, and vaccine price used. Conclusion Considering an acceptable range of cost-effectiveness of €30,000-€50,000 per QALY gained, vaccination of the 50+ population in Spain against HZ with a new vaccine, Zostavax, is cost-effective and makes good use of the valuable healthcare budget.

[Vaccines against Herpes zoster: Effectiveness, safety, and cost/benefit ratio]

CONTEXT

A vaccination against herpes zoster and its complication is available in France since June 2015. Its exact benefit for public health is still controversial and its level of protection is not optimal. All those reasons seem to suggest a low acceptation rate from general practitioners.

OBJECTIVE

To evaluate the effectiveness, the safety, and the cost/benefit ratio of the vaccination against herpes zoster in people aged 50 year or over.

DOCUMENTARY SOURCE

Systematic review in Medline and PubMed with research by key words: "herpes zoster vaccine", "zoster vaccine" and "post herpetic neuralgia vaccine".

SELECTION OF STUDIES

Randomized and observational studies published in English and French language have been selected by two readers.

RESULTS

On 1886 articles identified, 62 studies were included in this systematic review of which 21 randomized trials, 21 observational studies, and 17 medico-economic studies concerned the unadjuvanted vaccine. Considered studies showed an effectiveness of 50% against herpes zoster and 60% on post-herpetic neuralgia incidence of the unadjuvanted vaccine. Five randomized controlled studies were identified for the adjuvanted vaccine. The overall effectiveness of this vaccine was > 90% whatever the age of subjects including those over age 70 and 80. The medico-economic studies conducted in many countries have shown that vaccine policies were beneficial in individuals aged 60 years or over.

LIMITATION OF THE WORK

Most of data of effectiveness, and tolerance result from 2 large controlled studies only (SPS and ZEST) for the unadjuvanted vaccine and only one for the adjuvanted vaccine.

CONCLUSION

Despite controversy and few uncertainties, the vaccine significantly reduces herpes zoster and its complication incidence. In terms of public health objectives, it reduces the burden of the disease and has a positive medico-economic impact. Preliminary data concerning the adjuvanted vaccine, whilst very promising, are still too limited. Up to now, no group of people with particularly high risk of herpes zoster-related complication who will beneficiate the most of the vaccination has been identified yet and only an age criteria has been considered for the recommendation.

Ruocco's immunocompromised cutaneous district

The concept of 'locus minoris resistentiae' (lmr) is an old but still effective way of thinking in Medicine. In Dermatology, there are many reports of privileged localization of cutaneous diseases on injured skin, which therefore represents a typical condition of lmr. Lately the innovative concept of immunocompromised cutaneous district (ICD) has been introduced to explain why a previously injured cutaneous site may become in time a privileged location for the outbreak of opportunistic infections, tumors, and immune reactions. An ample documentation of multifarious disorders (infectious, neoplastic, immune) appearing in ICDs was delineated by Ruocco et al. in 2009. These cases were grouped according to the clinical settings responsible for the local immune imbalance: regional chronic lymphedema; herpes-infected sites, which feature the well-known Wolf's isotopic response; and otherwise damaged areas, comprising sites of vaccination, ionizing or UV radiation, thermal burns, and traumas. In the following five years, what was a "novel" pathogenic concept has been extended to an enlarging variety of clinical conditions. This paper focuses on ICD and the expanding spectrum of this now established pathogenic concept.

[Vaccinations in respiratory medicine]

Vaccinations are the most successful and cost-effective measures for prevention of infections. Important pathogens of respiratory tract infections (e.g. influenza viruses and pneumococci) can be effectively treated by vaccinations. The seasonal trivalent and recently now quadrivalent influenza vaccines include antigens from influenza A and B type viruses, which have to be modified annually oriented to the circulating strains. The effective protection by influenza vaccination varies considerably (too short protection time, mismatch); therefore, administration late in the year is the best approach (November/December). Two pneumococcal vaccines are recommended for adults: the over 30-year-old 23-valent polysaccharide vaccine (PPV23) and the 4-year-old 13-valent conjugate vaccine (PCV13). The immunological and clinical efficacy of PPV23 is controversially discussed; however, a moderate reduction of invasive pneumococcal infections is widely accepted. The PCV13 stimulates a T-cell response and has currently demonstrated its clinical efficacy in an impressive study (CAPiTA). The problem of PCV13 is the relatively limited coverage of only 47% of the currently circulating invasive pneumococcal serotypes.

Burden of herpes zoster-associated chronic pain in Italian patients aged 50 years and over (2009-2010): a GP-based prospective cohort study

Background

Post-herpetic neuralgia (PHN) is the most common complication in herpes zoster (HZ) patients.

Methods

We performed a longitudinal, prospective study in 108 general practices throughout Italy to assess how many immunocompetent patients aged ≥50 years with newly diagnosed HZ develop HZ-associated pain, its duration and management over 6-months. HZ-associated pain was assessed by a direct question to the patient and by self-assessment of the worst pain felt in the previous two weeks on a visual analogue scale (VAS), a score ≥3 was taken as pain. PHN was defined as pain reported during the study period persisting for ≥3 months. Quality of life (QoL) was measured using the SF-12 questionnaire.

Results

At enrolment, 370 of the 413 patients (89.6%) reported HZ-associated pain which was still present in 20.6% and 9.2% of patients after three and six months, respectively, despite many patients receiving recommended anti-viral therapy. The overall QoL scores were lower than those in healthy Italians of similar age; scores for patients with HZ-associated pain were lower. The presence of >50 vesicles and VAS score ≥3 at enrolment, and being male were significantly associated with PHN at three months.

Conclusions

These results suggest that HZ and PHN represent an important burden of disease in the elderly. There is a need for interventions that can prevent and reduce the burden of HZ to help improve the quality of life of the elderly. These data may be useful as baseline epidemiology data for the assessment of the impact of the VZV vaccine in Italy, after its implementation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0637-6) contains supplementary material, which is available to authorized users.

Reducing the burden of Herpes Zoster in Italy

Herpes Zoster (HZ) is a viral disease with painful neuro-dermatologic manifestations. Incidence increases with age. In Italy, the estimated incidence is 6.3 cases/1000 person/year; hospital admissions are less than 2%, 69% in patients aged over 65 years. The most frequent complication of HZ is Post-Herpetic Neuralgia (PHN) characterized by metameric pain, allodynia, and hyperalgesia. In Italy 20.6% and 9.2% of HZ patients experience PHN after 3 and 6 months, respectively. Available antiviral and analgesic treatments are relatively unsatisfactory in reducing pain and length of the disease. Prevention has recently become possible with the live attenuated vaccine Oka/Merck. Clinical studies show a reduction of 51% in the incidence of the disease, 61% of its burden and 67% of PHN in vaccinees. Protection seems to be long lasting and vaccine safety matches registration requirements. Available evidence suggests that the costs for QALY (less than € 20 000) and avoided cases is favorable. Due to the heavy burden of disease, it is time to offer this vaccination to elderly population.

Varicella zoster virus vaccines: potential complications and possible improvements

Varicella zoster virus (VZV) is the causative agent of varicella (chicken pox) and herpes zoster (shingles). After primary infection, the virus remains latent in sensory ganglia, and reactivates upon weakening of the cellular immune system due to various conditions, erupting from sensory neurons and infecting the corresponding skin tissue. The current varicella vaccine (v-Oka) is highly attenuated in the skin, yet retains its neurovirulence and may reactivate and damage sensory neurons. The reactivation is sometimes associated with postherpetic neuralgia (PHN), a severe pain along the affected sensory nerves that can linger for years, even after the herpetic rash resolves. In addition to the older population that develops a secondary infection resulting in herpes zoster, childhood breakthrough herpes zoster affects a small population of vaccinated children. There is a great need for a neuro-attenuated vaccine that would prevent not only the varicella manifestation, but, more importantly, any establishment of latency, and therefore herpes zoster. The development of a genetically-defined live-attenuated VZV vaccine that prevents neuronal and latent infection, in addition to primary varicella, is imperative for eventual eradication of VZV, and, if fully understood, has vast implications for many related herpesviruses and other viruses with similar pathogenic mechanisms.

Management of primary care issues common to CKD and ESRD patients: a brief primer for the nephrology provider

This article provides a brief overview of the diagnosis and management of selected primary care issues that are common to CKD and ESRD patients. The elements of diagnosis and management unique to kidney patients and controversies and updates in management will be presented. The topics reviewed are neuropathy, pruritus, zoster, hyperuricemia, gout, and gastroparesis.

Risk of depressive disorder among patients with herpes zoster: a nationwide population-based prospective study

OBJECTIVE

Herpes zoster results from reactivation of the endogenous varicella zoster virus infection. Previous studies have shown that herpes zoster and postherpetic neuralgia were associated with anxiety, depression, and insomnia. However, no prospective study has investigated the association between herpes zoster and the development of depressive disorder.

METHODS

Subjects were identified through the Taiwan National Health Insurance Research Database. Patients 18 years or older with a diagnosis of herpes zoster and without a psychiatric history were enrolled in 2000 and compared with age-/sex-matched controls (1:4). These participants were followed up to the end of 2010 for new-onset depressive disorder.

RESULTS

A total of 1888 patients with herpes zoster were identified and compared with 7552 age-/sex-matched controls in 2000. Those with herpes zoster had a higher incidence of developing major depression (2.2% versus 1.4%, p = .018) and any depressive disorder (4.3% versus 3.2%, p = .020) than did the control group. The follow-up showed that herpes zoster was an independent risk factor for major depression (hazard ratio = 1.49, 95% confidence interval = 1.04-2.13) and any depressive disorder (hazard ratio = 1.32, 95% confidence interval = 1.03-1.70), after adjusting demographic data and comorbid medical diseases.

CONCLUSIONS

This is the first study to investigate the temporal association between herpes zoster and depressive disorder. Further studies would be required to clarify the underlying pathophysiology about this association and whether proper treatment of herpes zoster could decrease the long-term risk of depressive disorder.

Relationship between persistent pain and 5-year mortality: a population-based prospective cohort study

OBJECTIVES

To assess the association between self-reported noncancer pain and 5-year mortality.

DESIGN

Cohort.

SETTING

Community-dwelling older adults.

PARTICIPANTS

Canadian Study of Health and Aging 1996 wave.

MEASUREMENTS

Registrar of Vital Statistics-established 5-year mortality. Noncancer pain was assessed using the 5-point verbal descriptor scale, dichotomized into no or very mild versus moderate, severe, or very severe pain. Frailty was the accumulation of health deficits. Cognitive status (Modified Mini-Mental State Examination) and depressed mood (five-item mental health screening questionnaire) were also assessed. Multivariable logistic regression and Cox proportional hazards were used to analyze the relationship between pain and 5-year mortality.

RESULTS

Of 5,703 participants, 4,694 (82.3%) had complete data for analysis; 1,663 of these (35.4%) reported moderate, severe, or very severe pain, and 1,343 (28.6%) had died at 5-year follow-up. Four hundred ninety-six of those who died (29.8%) reported moderate, severe, or very severe pain and 847 (27.9%) no or very mild pain. Multivariate logistic analysis found that individuals with moderate, severe, or very severe pain had lower odds of 5-year mortality than those with no or very mild pain (odds ratio=0.78, 95% confidence interval (CI)=0.66-0.92; P<.001). The risk of death was lower in persons reporting moderate or greater pain than in those with no or very mild pain (HR=0.85, 95% CI=0.75-0.96; P=.01). An interaction between pain and sex explained this effect. Men with pain were not significantly more likely than men without pain to die (HR=1.00, 95% CI=0.84-1.19; P=.99), whereas women without pain (HR=0.54, 95% CI=0.47-0.63; P<0.01) and women with pain (HR=0.40; CI=0.33-0.47; P<.01) had less risk of death than men without and with pain, respectively.

CONCLUSION

Older women with pain were less likely to die within 5 years than older women without pain, men in pain, or men without pain.

Herpes zoster vaccine in Korea

Herpes zoster and post-herpetic neuralgia deteriorate the quality of life because of severe pain and complications, and cause considerable social and economic burden of disease. In 2012, herpes zoster vaccine was released in Korea. The efficacy of herpes zoster vaccine is known to be 51.3-66.5% among the aged over 60 and 69.8-72.4% among adults between 50 and 59. It is also known that preventive efficacy is maintained for at least 5 years. Although there can be local reactions such as redness, pain and swelling at the site of injection and systemic reaction such as headache and eruption after herpes zoster vaccination, most of the adverse reactions are minor and disappear within days by themselves. As it is a live vaccine, persons with severe immune-suppression and pregnant women should not be vaccinated with the vaccine. Currently, Korean Society of Infectious Diseases recommended for the aged over 60 to be vaccinated with herpes zoster vaccine by subcutaneous route. In this article, clinical aspects and burden of disease of herpes zoster, efficacy and effects of herpes zoster vaccine, and herpes zoster vaccine recommendation by Korean Society of Infectious Diseases are discussed.

Recommended routine vaccinations for older adults

A goal of primary prevention is to avoid the development of disease. Immunizations are one of several strategies used by clinicians in primary prevention. Influenza and pneumococcal disease--both preventable--cause significant morbidity and mortality in older adults who have an altered immune system, often have several chronic health problems, and are at higher risk for complications. Tetanus, while not as common in older adults, carries a high mortality rate in those 65 and older. These infections are associated with significant disability that results from hospitalizations for congestive heart failure, hip fracture, stroke, and pneumonia. The goal of immunizing older adults is to decrease functional decline and disability, as well as potential hospital admissions linked to these preventable diseases, which often exacerbate underlying health problems. Age-defined recommendations are available to guide clinicians on the appropriate vaccinations and schedules for administration to older adults.

ORF7 of varicella-zoster virus is a neurotropic factor

Varicella-zoster virus (VZV) is the causative agent of chickenpox and herpes zoster (shingles). After the primary infection, the virus remains latent in sensory ganglia and reactivates upon weakening of the cellular immune system due to various conditions, erupting from sensory neurons and infecting the corresponding skin tissue. The current varicella vaccine is highly attenuated in the skin and yet retains its neurovirulence and may reactivate and damage sensory neurons. The factors involved in neuronal invasion and establishment of latency are still elusive. Previously, we constructed a library of whole-gene deletion mutants carrying a bacterial artificial chromosome sequence and a luciferase marker in order to perform a comprehensive VZV genome functional analysis. Here, screening of dispensable gene deletion mutants in differentiated neuronal cells led to the identification of ORF7 as the first known, likely a main, VZV neurotropic factor. ORF7 is a virion component localized to the Golgi compartment in infected cells, whose deletion causes loss of polykaryon formation in epithelial cell culture. Interestingly, ORF7 deletion completely abolishes viral spread in human nervous tissue ex vivo and in an in vivo mouse model. This finding adds to our previous report that ORF7 is also a skin-tropic factor. The results of our investigation will not only lead to a better understanding of VZV neurotropism but could also contribute to the development of a neuroattenuated vaccine candidate against shingles or a vector for delivery of other antigens.