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Alexandra Echeverria Proano D, Zhu F, Sun X, Zoco J, Soni J, Parmar N, Ali SO. Efficacy, reactogenicity, and safety of the adjuvanted recombinant zoster vaccine for the prevention of herpes zoster in Chinese adults ≥ 50 years: A randomized, placebo-controlled trial. Hum Vaccin Immunother 2024; 20:2351584. [PMID: 38838170 PMCID: PMC11253707 DOI: 10.1080/21645515.2024.2351584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/03/2024] [Indexed: 06/07/2024] Open
Abstract
Phase III multi-country studies (ZOE-50/70) demonstrated that the adjuvanted recombinant zoster vaccine (RZV) was well tolerated and prevented herpes zoster (HZ) in healthy ≥ 50-year-olds, with a vaccine efficacy (VE) > 90% across age groups. These pivotal trials did not enroll participants from mainland China where RZV is licensed, therefore similar clinical data are missing for this population. In this phase IV observer-blind study (NCT04869982) conducted between 2021 and 2023 in China, immunocompetent and medically stable ≥ 50-year-olds were randomized 1:1 to receive two RZV or placebo doses, 2 months apart. This study assessed the VE (overall, as confirmatory objective, and descriptively by age category [50-69-year-olds/≥ 70-year-olds]), reactogenicity, and safety of RZV in this Chinese population. Of the 6138 enrolled participants, 99.2% completed the study. During a mean follow-up period of 15.2 (±1.1) months, 31 HZ episodes were confirmed (RZV = 0; placebo = 31) for an incidence rate of 0.0 vs 8.2 per 1000 person-years and an overall VE of 100% (89.82-100). The descriptive VE was 100% (85.29-100) for 50-69-year-olds and 100% (60.90-100) for ≥ 70-year-olds. Solicited adverse events (AEs) were more frequent in the RZV vs the placebo group (median duration: 1-3 days for both groups). Pain and fatigue were the most frequent local and general AEs (RZV: 72.1% and 43.4%; placebo: 9.2% and 5.3%). The frequencies of unsolicited AEs, serious AEs, potential immune-mediated diseases, and deaths were similar between both groups. RZV is well tolerated and efficacious in preventing HZ in Chinese ≥ 50-year-olds, consistent with efficacy studies including worldwide populations with similar age and medical characteristics.
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Affiliation(s)
| | - Fengcai Zhu
- Department of Acute Infectious Disease Control and Prevention, Jiangsu Province Center for Disease Control and Prevention, Nanjing, China
| | - Xiaodong Sun
- Department of Immunization Program, Shanghai Municipal Center for Disease Control and Prevention, Shanghai, China
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Lin KY, Wang CH, Su LY, Lin IF, Liu CW, Wu PF, Tsai WC, Chang CN, Hung MC, Huang CH, Chiu NC, Cheng MF, Hsieh SM, Wang NC, Wang HW, Wong SS, Lin PC, Tsai MH, Yang SC, Lin HC, Lee SSJ, Chen YC, Wang FD. Recommendations and guidance for herpes zoster vaccination for adults in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00108-7. [PMID: 38987064 DOI: 10.1016/j.jmii.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 04/24/2024] [Accepted: 06/15/2024] [Indexed: 07/12/2024]
Abstract
Herpes zoster (HZ) is a painful, vesicular, cutaneous eruption from reactivation of varicella zoster virus (VZV), which can lead to potentially debilitating complications. The lifetime risk of HZ is estimated to be 20%-30% in the general population, with an increased risk in the elderly and immunocompromised populations. The most effective strategy to prevent HZ and its complications is by vaccination. Two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, have been approved for use. This guidance offers recommendations and suggestions for HZ vaccination in adults, aiming to reduce the disease burden of HZ and its complications. It is intended as a guide to first-line healthcare providers, but does not supersede clinical judgement when assessing risk and providing recommendations to individuals. The Working Group on Adult Immunization Practice was appointed by the Infectious Diseases Society of Taiwan (IDST) and recommendations were drafted after a full literature review, using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. The recommendations were reviewed and revised by expert review panels during a series of consensus meetings and endorsed by the IDST, Taiwan Association of Family Medicine, the Taiwanese Dermatological Association, the Taiwan Oncology Society, the Taiwan Society of Blood and Marrow Transplantation, the Transplantation Society of Taiwan, the Taiwan AIDS Society, and the Taiwan College of Rheumatology. This guidance describes the epidemiology of HZ and provides recommendations for HZ vaccination in adults with varying levels of risk, differing history of previous VZV infection and past varicella or zoster vaccinations.
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Affiliation(s)
- Kuan-Yin Lin
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Ching-Hsun Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Lian-Yi Su
- Department of Pharmacy, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - I-Fan Lin
- Division of Infectious Diseases, Department of Internal Medicine, E-Da Hospital and I-Shou University, Kaohsiung, Taiwan; Department of Microbiology and Immunology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Wei Liu
- Division of Infectious Diseases, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ping-Feng Wu
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Chia Tsai
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Chia-Ning Chang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Miao-Chiu Hung
- Division of Infectious Diseases, Department of Pediatrics, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Hsien Huang
- Division of Infectious Diseases, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Fu Jen Catholic University, Taiwan
| | - Nan-Chang Chiu
- Department of Pediatrics, MacKay Children's Hospital, MacKay Memorial Hospital, Taipei, Taiwan
| | - Ming-Fang Cheng
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Szu-Min Hsieh
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Ning-Chi Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsiao-Wei Wang
- Division of Infectious Diseases, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Swee Siang Wong
- Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Po-Chang Lin
- Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Ming-Han Tsai
- Department of Pediatrics, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Shun-Cheng Yang
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsiao-Chuan Lin
- Division of Pediatric Infectious Diseases, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan
| | - Susan Shin-Jung Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan.
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan.
| | - Fu-Der Wang
- Division of Infectious Diseases, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Infectious Diseases, Taipei Medical University Hospital, Taipei, Taiwan
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Kornelius E, Lo SC, Huang CN, Wang CC, Wang YH, Yang YS. Assessing herpes zoster vaccine efficacy in patients with diabetes: A community-based cohort study. J Med Virol 2024; 96:e29667. [PMID: 38738524 DOI: 10.1002/jmv.29667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/06/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Abstract
The effectiveness of herpes zoster (HZ) vaccines in patients with diabetes over the age of 50 remains an active area of research. Utilizing a real-world database from the US community, this study spanning from 2006 to 2023, aimed to evaluate the impact of HZ vaccination on newly diagnosed diabetes patients who received an HZ vaccination within 1 year of diagnosis. Exclusion criteria were established to omit patients with immune deficiencies. The cohort consisted of 53 885 patients, with an average age of 63.5 years, including 43% females and 58% whites. After implementing 1:1 propensity score matching for age, sex, race, comorbidities, diabetes medication, and hemoglobin A1c to ensure comparability, the study population was further stratified into four groups: N1 comparing any HZ vaccination to non-HZ vaccination (53 882 matched pairs), N2 for Shingrix versus non-HZ vaccination (16 665 matched pairs), N3 for Zostavax versus non-HZ vaccination (12 058 matched pairs), and N4 for Shingrix versus Zostavax (11 721 matched pairs). Cox proportional hazards regression analysis revealed a hazard ratio (HR) for HZ incidence post any HZ vaccination of 0.92 (95% confidence interval [CI]: 0.83-1.01). Additional analyses yielded HRs of 1.12 (95% CI: 0.93-1.34) for Shingrix versus non-HZ vaccine, 1.02 (95% CI: 0.86-1.20) for Zostavax versus non-HZ vaccine, and 1.06 (95% CI: 0.87-1.29) for Shingrix versus Zostavax. Subgroup analyses across age, sex, and follow-up duration also showed no significant differences. These findings underscore the lack of a significant benefit from HZ vaccination in newly diagnosed diabetes patients aged over 50, highlighting the necessity for further prospective research.
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Affiliation(s)
- Edy Kornelius
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shih-Chang Lo
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chien-Ning Huang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chung Shan Medical University Hospital, Taichung, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chi-Chih Wang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yu-Hsun Wang
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Yi-Sun Yang
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Chung Shan Medical University Hospital, Taichung, Taiwan
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Ali SO, Dessart C, Parikh R. Co-administration of the adjuvanted recombinant zoster vaccine with other adult vaccines: An overview. Vaccine 2024; 42:2026-2035. [PMID: 38423814 DOI: 10.1016/j.vaccine.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND The adjuvanted recombinant zoster vaccine (RZV; Shingrix®, GSK) is a subunit vaccine that has been approved for the prevention of herpes zoster in adults. Co-administration of two vaccines in a single visit is a strategy to improve overall vaccine coverage. OBJECTIVES This review aims to consolidate available clinical data on RZV co-administration, providing an overview of safety, reactogenicity and immunogenicity. METHODS RZV co-administration data were obtained from five randomised, open-label, phase III clinical trials with similar study designs. The co-administered vaccines included: quadrivalent seasonal inactivated influenza vaccine (IIV4; NCT01954251), 23-valent pneumococcal polysaccharide vaccine (PPSV23; NCT02045836), reduced-antigen-content diphtheria-tetanus-acellular pertussis vaccine (Tdap; NCT02052596), 13-valent pneumococcal conjugate vaccine (PCV13; NCT03439657) and COVID-19 mRNA-1273 booster (NCT05047770). Eligible participants were healthy adults aged ≥50 years. RESULTS A total of 3,974 participants were vaccinated (co-administration: 1,973; sequential: 2,001) across the five trials. Vaccine response rates to RZV were similar for co-administration (range: 95.8-99.1 %) and sequential groups (range: 95.1-99.1 %). Immune responses to RZV and the other vaccines (with the exception of pertactin) were non-inferior when the vaccines were co-administered compared with sequentially administered. Overall incidences of solicited local and general adverse events (AEs), unsolicited AEs, serious AEs or potential immune-mediated diseases were similar after co-administration or sequential administration. Myalgia was the most common solicited systemic AE (co-administration: 38-64 %; sequential: 30-59 %). Shivering and fever were more common after co-administration (16 % and 21 %, respectively) than after sequential administration (both 7 %) of RZV and PPSV23. CONCLUSIONS Co-administration of RZV with routine vaccines does not significantly alter the reactogenicity, immunogenicity or safety of RZV or the co-administered vaccine. Healthcare practitioners should consider routine co-administration of RZV with other adult vaccines to improve vaccination coverage.
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Affiliation(s)
- S Omar Ali
- GSK, 14200 Shady Grove Rd, Rockville, MD, USA.
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Södergren E, Mårdberg K, Nishimwe M, Bhavsar A, Marijam A, Bergström T, Stäck P. Incidence and Burden of Herpes Zoster in Sweden: A Regional Population-Based Register Study. Infect Dis Ther 2024; 13:121-140. [PMID: 38193987 PMCID: PMC10828402 DOI: 10.1007/s40121-023-00902-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/05/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION Herpes zoster (HZ) is a painful disease that mainly affects individuals whose immune system has been weakened because of increasing age (> 50 years) or certain diseases or treatments. We estimated the complete burden of HZ. METHODS This population-based register study analysed healthcare data from the VEGA and Digitalis databases of Västra Götaland Region (VGR), Sweden. The VEGA database includes all patients in VGR, covering both hospital and primary care. The Digitalis records prescribed medications. The study population included patients aged ≥ 18 years with at least one registered primary or secondary HZ diagnosis (based on International Classification of Diseases [ICD] codes) between 2005 and 2021. Incidence rates (95% confidence intervals [CI]) were stratified by age, sex and diagnosis/analgesic prescription. RESULTS Overall HZ incidence increased from 2.5 (95% CI 2.4-2.6) in 2005 to 4.2 (95% CI 4.1-4.3) in 2021. The increase in incidence was rapid from 2005 to 2013, followed by a plateauing trend. From 2014-2019, the lifetime risk of HZ, excluding recurrent cases, was 36.5% (95% CI 35.5-37.4%). Municipal differences ranged from 34.4% (95% CI 32.5-36.4%) to 43.6% (95% CI 39.9-47.4%). Recurrence rates of HZ were 8.7% and 9.1% with follow-up periods of 5.5 and 10.5 years, respectively. Reported postherpetic neuralgia (PHN) cases increased five-fold over the study period. In 2019, 19% of all HZ patients developed HZ-related neuropathic pain; 13.6% had signs of persistent pain (> 90 days; i.e. PHN). An increased occurrence of cerebral and cardiovascular disease was observed in HZ patients. Among high-risk groups the occurrence of HZ peaked among those with inflammatory and autoimmune diseases. CONCLUSION HZ and PHN risk in Sweden is comparable to that in other European countries prior to implementing HZ national vaccination programs. Municipal differences suggest that the lifetime risk of HZ in Sweden is at least 36.5%. CLINICAL TRIAL REGISTRATION NCT Number ( www. CLINICALTRIALS gov ).
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Affiliation(s)
| | | | | | | | | | - Tomas Bergström
- Department of Infectious Diseases, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
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Giannelos N, Ng C, Curran D. Cost-effectiveness of the recombinant zoster vaccine (RZV) against herpes zoster: An updated critical review. Hum Vaccin Immunother 2023; 19:2168952. [PMID: 36916240 PMCID: PMC10054181 DOI: 10.1080/21645515.2023.2168952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
The objective of this study was to critically review the cost-effectiveness (CE) of the recombinant zoster vaccine (RZV) against herpes zoster (HZ). A literature review was conducted in PubMed, Embase, and Cochrane between January 1, 2017, and February 28, 2022, and on select public healthcare agency websites to identify and collect data from CE studies comparing RZV to zoster vaccine live (ZVL) or to no vaccination. Study characteristics, inputs, and outputs were collected. The overall CE of RZV was assessed. RZV vaccination against HZ is cost-effective in 15 out of 18 studies included in the present review. Varying incremental cost-effectiveness ratios (ICERs) observed may be associated with different assumptions on the duration of protection of RZV, as well as different combinations of structural and disease-related study (model) inputs driving the estimation of ICERs.
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Affiliation(s)
| | - Cheryl Ng
- GSK, Value Evidence, Singapore, Singapore
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Curran D, Patterson BJ, Carrico J, Salem A, La EM, Lorenc S, Hicks KA, Poston S, Carpenter CF. Public health impact of recombinant zoster vaccine for prevention of herpes zoster in US adults immunocompromised due to cancer. Hum Vaccin Immunother 2023; 19:2167907. [PMID: 36880669 PMCID: PMC10038038 DOI: 10.1080/21645515.2023.2167907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Individuals who are immunocompromised (IC) due to therapy or underlying disease are at increased risk of herpes zoster (HZ). This study evaluates the public health impact of recombinant zoster vaccine (RZV) relative to no HZ vaccination for the prevention of HZ among adults aged ≥18 years diagnosed with selected cancers in the United States (US). A static Markov model was used to simulate three cohorts of individuals who are IC with cancer (time horizon of 30 years; one-year cycle length): hematopoietic stem cell transplant (HSCT) recipients, patients with breast cancer (BC; a solid tumor example), and patients with Hodgkin's lymphoma (HL; a hematological malignancy example). Cohort sizes reflect the estimated annual incidence of each condition in the US population (19,671 HSCT recipients, 279,100 patients with BC, and 8,480 patients with HL). Vaccination with RZV resulted in 2,297; 38,068; and 848 fewer HZ cases for HSCT recipients, patients with BC, and patients with HL, respectively (each versus no vaccine). Vaccination with RZV also resulted in 422; 3,184; and 93 fewer postherpetic neuralgia cases for HSCT, BC, and HL, respectively. Analyses estimated the quality-adjusted life years gained to be 109, 506, and 17 for HSCT, BC, and HL, respectively. To prevent one HZ case, the number needed to vaccinate was 9, 8, and 10, for HSCT, BC, and HL, respectively. These results suggest RZV vaccination may be an effective option to significantly reduce HZ disease burden among patients diagnosed with selected cancers in the US.
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Affiliation(s)
| | | | - Justin Carrico
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA
| | | | | | | | - Katherine A Hicks
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA
| | | | - Christopher F Carpenter
- Internal Medicine, Beaumont Hospital, Royal Oak, MI, USA
- Internal Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Ulaszewska M, Merelie S, Sebastian S, Lambe T. Preclinical immunogenicity of an adenovirus-vectored vaccine for herpes zoster. Hum Vaccin Immunother 2023; 19:2175558. [PMID: 36785938 PMCID: PMC10026912 DOI: 10.1080/21645515.2023.2175558] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
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.
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Affiliation(s)
- Marta Ulaszewska
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Merelie
- Jenner Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Teresa Lambe
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
- Chinese Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, UK
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
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Dauby N, Motet C, Libois A, Martin C. The value of herpes zoster prevention in people aging with HIV: A narrative review. HIV Med 2023; 24:1190-1197. [PMID: 37772682 DOI: 10.1111/hiv.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/11/2023] [Indexed: 09/30/2023]
Abstract
OBJECTIVE Review the evidence on the incidence and impact of herpes zoster among people living with HIV and the potential impact of recombinant zoster vaccine for people aging with HIV. METHODS Narrative review. RESULTS Although antiretroviral therapy has substantially reduced the risk of herpes zoster among people living with HIV, they remain at an increased risk compared with the general population. Among people aging with HIV, aging per se is now the main risk factor for herpes zoster. Beyond pain, herpes zoster is also associated with a risk of sight-threatening complications in case of trigeminal involvement, disseminated diseases and stroke. Post-herpetic neuralgia is also a potential threat to the quality of life of people aging with HIV. The recombinant zoster vaccine has demonstrated high and sustained efficacy in the prevention of herpes zoster, post-herpetic neuralgia, and other herpes zoster complications in the general population. Immunogenicity data among people living with HIV with high CD4+ T-cell count and controlled viral load are comparable to those among the general population. Real-life effectiveness data indicate high vaccine efficacy among immunocompromised patients other than people living with HIV. High vaccine price, vaccine hesitancy, and limited disease and vaccine awareness represent potential hurdles for high vaccine uptake among people aging with HIV in Europe. CONCLUSIONS Herpes zoster, and its complications, is a vaccine-preventable disease of aging people. Given its impact on quality of life, herpes zoster prevention using recombinant zoster vaccine is a safe strategy to be considered in every person aging with HIV.
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Affiliation(s)
- Nicolas Dauby
- Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
- School of Public Health, Université Libre de Bruxelles (ULB), Brussels, Belgium
- U-CRI, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Christian Motet
- Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Agnès Libois
- Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Charlotte Martin
- Department of Infectious Diseases, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Curran D, Doherty TM, Lecrenier N, Breuer T. Healthy ageing: Herpes zoster infection and the role of zoster vaccination. NPJ Vaccines 2023; 8:184. [PMID: 38017011 PMCID: PMC10684688 DOI: 10.1038/s41541-023-00757-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/12/2023] [Indexed: 11/30/2023] Open
Abstract
Populations are ageing worldwide, with considerable time lived in ill-health, putting upwards pressure on healthcare budgets. Healthy ageing is defined as maintaining functional ability, including the ability to: meet basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society. The risk and impact of infectious diseases increase with age due to immunosenescence. Vaccination can help to prevent disease in older adults, promoting healthy ageing and active lives. Herpes zoster (HZ) occurs when the varicella zoster virus is reactivated due to declining immunity. HZ is common, with a lifetime risk of one-third, and increases in incidence with age. HZ is associated with severe and intense pain, substantially affecting the functional status of patients as well as their overall health-related quality of life. HZ and its complications may result in prolonged morbidity, including persistent pain (post-herpetic neuralgia, PHN), hearing impairment, vision loss and increased risk of stroke and myocardial infarction. HZ and PHN are difficult to treat, substantiating the benefits of prevention. Vaccines to prevent HZ include a recombinant zoster vaccine (RZV). RZV has shown efficacy against the HZ burden of disease and HZ burden of interference on activities of daily living of over 90% in immunocompetent adults aged ≥50 years. Vaccine efficacy against HZ was maintained at over 70% at 10 years post-vaccination. Adult vaccination, including against HZ, has the potential to reduce burden of disease, thus helping to maintain functioning and quality of life to support healthy ageing in older adults.
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Petherbridge L, Davis C, Robinson A, Evans T, Sebastian S. Pre-Clinical Development of an Adenovirus Vector Based RSV and Shingles Vaccine Candidate. Vaccines (Basel) 2023; 11:1679. [PMID: 38006010 PMCID: PMC10674764 DOI: 10.3390/vaccines11111679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/24/2023] [Accepted: 10/28/2023] [Indexed: 11/26/2023] Open
Abstract
Respiratory syncytial virus (RSV) infection and shingles are two viral diseases that affect older adults, and a combined vaccine to protect against both could be beneficial. RSV infection causes hospitalisations and significant morbidity in both children and adults and can be fatal in the elderly. The RSV fusion (F) envelope glycoprotein induces a strong RSV-neutralising antibody response and is the target of protective immunity in the first RSV vaccine for older adults, recently approved by the FDA. An initial childhood infection with the varicella zoster virus (VZV) results in chickenpox disease, but reactivation in older adults can cause shingles. This reactivation in sensory and autonomic neurons is characterized by a skin-blistering rash that can be accompanied by prolonged pain. The approved protein-in-adjuvant shingles vaccine induces VZV glycoprotein E (gE)-fspecific antibody and CD4+ T cell responses and is highly effective. Here we report the evaluation of RSV/shingles combination vaccine candidates based on non-replicating chimpanzee adenovirus (ChAd) vectors. We confirmed the cellular and humoral immunogenicity of the vaccine vectors in mice using T cell and antibody assays. We also carried out an RSV challenge study in cotton rats which demonstrated protective efficacy following a homologous prime-boost regimen with our preferred vaccine candidate.
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Affiliation(s)
| | | | | | | | - Sarah Sebastian
- Vaccitech Ltd., Harwell OX11 0DF, UK; (L.P.); (A.R.); (T.E.)
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Silverii GA, Clerico A, Fornengo R, Gabutti G, Sordi V, Peruzzi O, Tafuri S, Mannucci E, Dicembrini I. Efficacy and effectiveness of Herpes zoster vaccination in adults with diabetes mellitus: a systematic review and meta-analysis of clinical trials and observational studies. Acta Diabetol 2023; 60:1343-1349. [PMID: 37340183 PMCID: PMC10442285 DOI: 10.1007/s00592-023-02127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023]
Abstract
AIM The risk for Herpes zoster (HZ) and its complications is higher in people with diabetes mellitus (DM). Our aim is to assess efficacy and effectiveness of the currently available live-attenuated zoster vaccine (LZV) and recombinant zoster vaccine (RZV) in adults with DM. METHODS A Systematic Review and Meta-analysis of clinical trials and observational studies comparing incidence of HZ and its complications in vaccinated and unvaccinated people with DM was performed, on PubMed, Cochrane, Clinical Trials.gov and Embase databases, up to January 15th, 2023. Risk of bias was assessed through the Cochrane Collaboration tool and the Newcastle-Ottawa Scale. The protocol was registered on the PROSPERO website (CRD42022370705). RESULTS Only three observational studies reported LZV efficacy and effectiveness in people with DM. A lower risk for HZ infection (MH-OH Ratio 95% CI = 0.52 [0.49, 0.56] was observed, for unadjusted analysis, and 0.51 [0.46, 0.56] for adjusted analysis, both with P < 0.00001 and no heterogeneity). No data on LZV safety were reported. A pooled analysis of two trials comparing RZV and placebo, showed a reduced risk for HZ incidence: (95% CI Odds Ratio: 0.09 [0.04-0.19]), with no difference in severe adverse events and mortality. CONCLUSIONS In our meta-analysis of three observational studies LZV showed a 48% effectiveness in reducing HZ incidence in adults with diabetes whereas in a pooled analysis of two RCTs, RZV showed a 91% efficacy. No data are available on the effects of vaccination on the incidence and severity of HZ-related complications among subjects with diabetes.
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Affiliation(s)
- Giovanni Antonio Silverii
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio" Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | | | | | - Giovanni Gabutti
- Coordinator Working Group "Vaccines and Immunization Policies", Italian Scientific Society of Hygiene, Preventive Medicine and Public Health (SItI), Cogorno, Genoa, Italy
| | - Valeria Sordi
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milan, Italy
| | - Ottavia Peruzzi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio" Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Silvio Tafuri
- Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Edoardo Mannucci
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio" Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy
| | - Ilaria Dicembrini
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio" Department, University of Florence, Viale Pieraccini, 6, 50139, Florence, Italy.
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Chan XBV, Tan NC, Ng MCW, Ng DX, Koh YLE, Aau WK, Ng CJ. Prevalence and healthcare utilization in managing herpes zoster in primary care: a retrospective study in an Asian urban population. Front Public Health 2023; 11:1213736. [PMID: 37780417 PMCID: PMC10540814 DOI: 10.3389/fpubh.2023.1213736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 10/03/2023] Open
Abstract
Herpes zoster (HZ) causes significant morbidity, particularly in older adults. With the advent of a recombinant zoster vaccine, HZ is potentially preventable. However, data on HZ burden and healthcare utilization in primary care populations remains scarce. This study described the prevalence and healthcare utilization in managing HZ in a developed community. A retrospective database review was conducted across a cluster of 8 public primary care clinics in urban Singapore. Data of multi-ethnic Asian patients with a diagnosis code of "herpes zoster" from 2018 to 2020 was extracted from their electronic medical records. Socio-demographic, clinical, visitation, medical leave, prescription, and referral data were analyzed. A total of 2,987 out of 737,868 individuals were diagnosed with HZ over 3 years. The mean age was 59.9 (SD + 15.5) years; 49.2% were male; 78.5% Chinese, 12.2% Malay, and 4.1% Indian. The prevalence was 221, 224, 203 per 100,000 persons in 2018, 2019, and 2020, respectively. The 70 to 79-year age group had the highest prevalence (829/100,000) across 3 years. Oral acyclovir (median daily dose 4,000 mg; median duration 7 days) and topical acyclovir were prescribed in 71.6 and 47.6%, respectively. Analgesia prescribed were gabapentin (41.0%), paracetamol combinations (30.1%), oral NSAIDs (23.7%), opioids (6.0%), and tricyclic antidepressants (1.9%). Most individuals consulted only once (84.3%); 32.7% of them required medical leave and 5.6% had more than 7 days of absenteeism. HZ-related referrals to the hospital were required in 8.9% (4.9% emergency, 2.8% ophthalmology). The findings of this study suggest a need for HZ vaccination among older age groups. Visitation and referral rates were low. The use of topical acyclovir was uncovered, and further research should evaluate the underlying reasons, benefits, and harms of such practice. The use of analgesia combinations may be explored further.
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Affiliation(s)
- Xin-Bei Valerie Chan
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | - Ngiap Chuan Tan
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | - Mark Chung Wai Ng
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
| | | | | | | | - Chirk Jenn Ng
- SingHealth Polyclinics, Singapore, Singapore
- SingHealth Duke-NUS Family Medicine Academic Clinical Programme, Singapore, Singapore
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Malahe SRK, van Kampen JJA, Manintveld OC, Hoek RAS, den Hoed CM, Baan CC, Kho MML, Verjans GMGM. Current Perspectives on the Management of Herpesvirus Infections in Solid Organ Transplant Recipients. Viruses 2023; 15:1595. [PMID: 37515280 PMCID: PMC10383436 DOI: 10.3390/v15071595] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/12/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Solid organ transplant recipients (SOTRs) are at high risk of human herpesvirus (HHV)-related morbidity and mortality due to the use of immunosuppressive therapy. We aim to increase awareness and understanding of HHV disease burden in SOTRs by providing an overview of current prevention and management strategies as described in the literature and guidelines. We discuss challenges in both prevention and treatment as well as future perspectives.
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Affiliation(s)
- S Reshwan K Malahe
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Jeroen J A van Kampen
- Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Olivier C Manintveld
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Rogier A S Hoek
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Pulmonary Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Caroline M den Hoed
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Carla C Baan
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Marcia M L Kho
- Department of Internal Medicine, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- Erasmus MC Transplant Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
| | - Georges M G M Verjans
- Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
- HerpeslabNL, Department of Viroscience, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands
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Herpes Simplex Virus and Varicella Zoster Virus Infections in Cancer Patients. Viruses 2023; 15:v15020439. [PMID: 36851652 PMCID: PMC9961783 DOI: 10.3390/v15020439] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/28/2023] [Accepted: 02/03/2023] [Indexed: 02/08/2023] Open
Abstract
Herpes simplex virus (HSV) and varicella zoster virus (VZV) are alpha herpesviruses that establish life-long latent infection in neuronal ganglia after primary infection. Periodic reactivation of these viruses results in recurrent infections that can have significant impact on patients' quality of life. HSV commonly causes oral and genital mucocutaneous infections whereas VZV is responsible for varicella/chickenpox and herpes zoster/shingles, but cancer patients are at particularly higher risk of complications including disseminated and visceral infections due to impaired cell-mediated immunity. While diagnosis of more common HSV and/or VZV infections is frequently clinically based, immunocompromised hosts may have atypical skin presentation or visceral involvement. Thus, diagnostic confirmation using virus-specific tests such as polymerase chain reaction or immunohistochemical staining is crucial in some cases. Oral acyclovir, valacyclovir and famciclovir are usually used for mild to moderate infections and intravenous acyclovir is the drug of choice for severe or disseminated infections. Foscarnet can be used when acyclovir-resistance is confirmed or suspected. Pharmaceutical prophylaxis against HSV and/or VZV should be considered in high-risk cancers patients. Currently, there is no commercially available vaccine against HSV, but VZV vaccines are available to prevent varicella and zoster.
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Altukhaim F, Mutlaq M, Alghamdi M, Hakami S. Reactivation of Herpes Zoster After Recombinant Vaccine (Shingrix): A Case Report. Cureus 2023; 15:e34431. [PMID: 36874700 PMCID: PMC9979095 DOI: 10.7759/cureus.34431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
Herpes zoster (HZ) is a common contagious dermatological condition that results from reactivation of varicella-zoster virus (VZV), which currently could be prevented by vaccination. We describe a rare case of varicella infection reactivation after routine zoster vaccination in an immunocompetent female in her 60s who developed dermatomal pruritic and vesicular rash one week after receiving Shingrix vaccine, along with fever, sweating, headache, and fatigue. The patient was treated as a case of herpes zoster reactivation with a seven days course of acyclovir. She continued to do well on follow-up with no significant complications. Though uncommon, it is important for healthcare providers to recognize this adverse reaction to expedite testing and treatment.
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Affiliation(s)
| | - May Mutlaq
- College of Medicine, Sulaiman Al Rajhi University, Qassim, SAU
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Leung J, Anderson TC, Dooling K, Xie F, Curtis JR. Recombinant Zoster Vaccine Uptake and Risk of Flares Among Older Adults with Immune-Mediated Inflammatory Diseases in the United States. Arthritis Rheumatol 2022; 74:1833-1841. [PMID: 35666070 DOI: 10.1002/art.42261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/24/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Persons with immune-mediated inflammatory diseases (IMIDs) are at increased risk of herpes zoster (HZ). In 2018, CDC recommended a highly efficacious vaccine, recombinant zoster vaccine (RZV), for prevention of HZ in immunocompetent ≥50 years-olds. We estimated RZV vaccination among adults age ≥50 years with IMIDs during 2018-2019 and examined possible vaccine-related flares following RZV. METHODS We identified a cohort of IMID patients using medical claims data from IBM® MarketScan® (age 50-64 years) and Centers for Medicare and Medicaid Services Medicare (age ≥65 years). Presumed flares were defined as hospitalization/emergency department visit for their respective IMIDs, or steroid treatment with a short-acting oral glucocorticoid or parenteral glucocorticoid injection. We conducted a self-controlled case series (SCCS) analysis to examine a temporal association between RZV and flares. RESULTS Among enrollees with IMIDs, 14.8% of 55,654 MarketScan and 43.2% of 160,545 Medicare enrollees received ≥1-dose of RZV during 2018-2019. Two-dose series completion was 76.6% in MarketScan and 85.4% in Medicare enrollees. In the SCCS analysis, 10% and 13% developed flares in the control as compared to 9% and 11-12% in the risk window following 1- or 2-doses of RZV among MarketScan and Medicare enrollees, respectively. We found no statistically significant increase in flares following RZV administration for any IMID in either age group following RZV dose-1 or dose-2. CONCLUSIONS We did not find an increase in presumed flares following RZV vaccination. Among adults aged ≥50 years with IMIDs, a substantial proportion received RZV compared to general zoster coverage estimates and series-completion was high. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Jessica Leung
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Tara C Anderson
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Kathleen Dooling
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Fenglong Xie
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey R Curtis
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
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Pan CX, Lee MS, Nambudiri VE. Global herpes zoster incidence, burden of disease, and vaccine availability: a narrative review. Ther Adv Vaccines Immunother 2022; 10:25151355221084535. [PMID: 35340552 PMCID: PMC8941701 DOI: 10.1177/25151355221084535] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/11/2022] [Indexed: 12/30/2022] Open
Abstract
Herpes zoster (HZ) is a neurocutaneous disease that causes significant morbidity
worldwide. The disease is caused by the reactivation of the varicella-zoster
virus (VZV), which leads to the development of a painful, vesicular rash and can
cause complications such as post-herpetic neuralgia and vision loss. Globally,
the incidence of HZ is increasing, and it incurs billions in cost annually to
the healthcare system and to society through loss of productivity. With the
advent of effective vaccines such as the live attenuated vaccine,
Zostavax®, in 2006, and more recently the adjuvant recombinant
subunit vaccine, Shingrix®, in 2017, HZ has become a preventable
disease. However, access to the vaccines remains mostly limited to countries
with developed economies, such as the United States and Canada. Even among
countries with developed economies that license the vaccine, few have
implemented HZ vaccination into their national immunization schedules due to
cost-effectiveness considerations. In this review, we discuss the currently
available HZ vaccines, landscape of HZ vaccine guidelines, and economic burden
of disease in countries with developed and developing economies, as well as
barriers and considerations in HZ vaccine access on a global scale.
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Affiliation(s)
- Catherina X. Pan
- Harvard Medical School, Boston, MA, USADepartment of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michelle S. Lee
- Harvard Medical School, Boston, MA, USADepartment of Dermatology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Vinod E. Nambudiri
- Department of Dermatology, Brigham and Women’s Hospital, 221 Longwood Avenue, Boston, MA 02115, USA Harvard Medical School, Boston, MA, USA
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