Herpes zoster vaccination efficacy in the long-term care facility population: a qualitative systematic review

Preclinical immunogenicity of an adenovirus-vectored vaccine for herpes zoster

Herpes zoster (HZ) results from waning immunity following childhood infection with varicella zoster virus (VZV) but is preventable by vaccination with recombinant HZ vaccine or live HZ vaccine (two doses or one dose, respectively). Vaccine efficacy declines with age, live HZ vaccine is contraindicated in immunosuppressed individuals, and severe local reactogenicity of recombinant HZ vaccine is seen in up to 20% of older adults, indicating a potential need for new vaccines. Nonreplicating chimpanzee adenovirus (ChAd) vectors combine potent immunogenicity with well-established reactogenicity and safety profiles. We evaluated the cellular and humoral immunogenicity of ChAdOx1 encoding VZV envelope glycoprotein E (ChAdOx1-VZVgE) in mice using IFN-γ ELISpot, flow cytometry with intracellular cytokine staining, and ELISA. In outbred CD-1 mice, one dose of ChAdOx1-VZVgE (1 × 10⁷ infectious units) elicited higher gE-specific T cell responses than two doses of recombinant HZ vaccine (1 µg) or one dose of live HZ vaccine (1.3 × 10³ plaque-forming units). Antibody responses were higher with two doses of recombinant HZ vaccine than with two doses of ChAdOx1-VZVgE or one dose of live HZ vaccine. ChAdOx1-VZVgE boosted T cell and antibody responses following live HZ vaccine priming. The frequencies of polyfunctional CD4+ and CD8+ T cells expressing more than one cytokine (IFN-γ, TNF-α and IL-2) were higher with ChAdOx1-VZVgE than with the conventional vaccines. Results were similar in young and aged BALB/c mice. These findings support the clinical development of ChAdOx1-VZVgE for prevention of HZ in adults aged 50 years or over, including those who have already received conventional vaccines.

Handlungsempfehlungen zur Risikominimierung beim Einsatz von Januskinase-Inhibitoren zur Therapie chronisch-entzündlicher Hauterkrankungen

Der Ausschuss für Risikobewertung (PRAC) der Europäischen Arzneimittelagentur (EMA) hat gemäß Artikel 20 der Verordnung (EG) Nr. 726/2004 die Sicherheit für Januskinase‐Inhibitoren für die Behandlung von Entzündungserkrankungen neu bewertet und von den bisherigen Hinweisen in den jeweiligen Fachinformationen der betreffenden Präparate abweichende Sicherheitsangaben formuliert. Diese beziehen sich arzneistoff‐ und indikationsübergreifend auf die Beachtung eines möglicherweise erhöhten Risikos für venöse thromboembolische oder schwere kardiovaskuläre Ereignisse, eine erhöhte Infektionsrate sowie eine Erhöhung der Prävalenz von Hautkrebs. Deshalb wird empfohlen, bei Patienten mit unabhängigen Risikofaktoren (Alter ab 65 Jahre, Raucher oder ehemalige Raucher, Patientinnen mit oraler Kontrazeption beziehungsweise Hormonersatztherapie sowie anderen Risikofaktoren) Januskinase‐Inhibitoren nur dann therapeutisch einzusetzen, wenn es keine geeigneten Behandlungsalternativen gibt. Um im klinischen Alltag eine pragmatische und sorgfältige Erfassung von Risikopatienten zu ermöglichen, wurde interdisziplinär eine Checkliste erarbeitet, die aus der Perspektive des Dermatologen als Arbeitsmittel geeignet ist.

Recommendations for risk minimization when using Janus kinase inhibitors for the treatment of chronic inflammatory skin diseases

In accordance with article 20 of Regulation (EC) No 726/2004, the Pharmacovigilance Risk Assessment Committee (PRAC) of the European Medicines Agency (EMA) has re-evaluated the safety of Janus kinase inhibitors for the treatment of inflammatory diseases and formulated safety information deviating from the previous indications in the respective summary of product characteristics of the products concerned. These refer to the consideration of a possibly increased risk of venous thromboembolic or severe cardiovascular events, an increased infection rate and an increase in the prevalence of skin cancer across drugs and indications. Therefore, in patients with independent risk factors (age 65 years and older, smokers or former smokers, patients with oral contraception or hormone replacement therapy and other risk factors), it is recommended to use Janus kinase inhibitors therapeutically only if there are no suitable treatment alternatives. To facilitate a pragmatic and thorough detection of high-risk patients in everyday clinical practice, an interdisciplinary checklist was developed that is suitable as a working tool from the perspective of the dermatologist.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

None.

Postlicensure herpes zoster vaccine effectiveness: systematic review protocol

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

Provincial legislative and regulatory standards for pain assessment and management in long-term care homes: a scoping review and in-depth case analysis

BACKGROUND

Among Canadian residents living in long-term care (LTC) facilities, and especially among those with limited ability to communicate due to dementia, pain remains underassessed and undermanaged. Although evidence-based clinical guidelines for the assessment and management of pain exist, these clinical guidelines are not widely implemented in LTC facilities. A relatively unexplored avenue for change is the influence that statutes and regulations could exert on pain practices within LTC. This review is therefore aimed at identifying the current landscape of policy levers used across Canada to assess and manage pain among LTC residents and to evaluate the extent to which they are concordant with evidence-based clinical guidelines proposed by an international consensus group consisting of both geriatric pain and public policy experts.

METHODS

Using scoping review methodology, a search for peer-reviewed journal articles and government documents pertaining to pain in Canadian LTC facilities was carried out. This scoping review was complemented by an in-depth case analysis of Alberta, Saskatchewan, and Ontario statutes and regulations.

RESULTS

Across provinces, pain was highly prevalent and was associated with adverse consequences among LTC residents. The considerable benefits of using a standardized pain assessment protocol, along with the barriers in implementing such a protocol, were identified. For most provinces, pain assessment and management in LTC residents was not specifically addressed in their statutes or regulations. In Alberta, Saskatchewan, and Ontario, regulations mandate the use of the interRAI suite of assessment tools for the assessment and reporting of pain.

CONCLUSION

The prevalence of pain and the benefits of implementing standardized pain assessment protocols has been reported in the research literature. Despite occasional references to pain, however, existing regulations do not recommend assessments of pain at the frequency specified by experts. Insufficient direction on the use of specialized pain assessment tools (especially in the case of those with limited ability to communicate) that minimize reliance on subjective judgements was also identified in current regulations. Existing policies therefore fail to adequately address the underassessment and undermanagement of pain in older adults residing in LTC facilities in ways that are aligned with expert consensus.