The incidence of herpes zoster in a United States administrative database

Infectious Keratitis in Patients Over 65: A Review on Treatment and Preserving Eyesight

Infectious keratitis (IK) represents a significant global health concern, ranking as the fifth leading cause of blindness worldwide despite being largely preventable and treatable. Elderly populations are particularly susceptible due to age-related changes in immune response and corneal structure. However, research on IK in this demographic remains scarce. Age-related alterations such as increased permeability and reduced endothelial cell density further compound susceptibility to infection and hinder healing mechanisms. Additionally, inflammaging, characterized by chronic inflammation that develops with advanced age, disrupts the ocular immune balance, potentially exacerbating IK and other age-related eye diseases. Understanding these mechanisms is paramount for enhancing IK management, especially in elderly patients. This review comprehensively assesses risk factors, clinical characteristics, and management strategies for bacterial, viral, fungal, and acanthamoeba keratitis in the elderly population, offering crucial insights for effective intervention.

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

Herpes Zoster Chorioretinopathy: A Case Series

PURPOSE

To report two patients with herpetic zoster panuveitis and chorioretinopathy with choroidal hypopigmentation.

METHODS

Retrospective chart review of two patients.

RESULTS

We report a series of two patients with a history of HZO with orbital inflammation and panuveitis, who developed patchy choroidal depigmentation consistent with a choroidopathy. The lesions were extensive and involved the posterior pole and mid-periphery in both cases. Both cases demonstrated scattered areas of ellipsoid zone loss, and fluorescein angiography showed corresponding late hyperfluorescence. OCTA in one case demonstrated flow voids at the level of choriocapillaris.

CONCLUSIONS

Our series suggests that herpetic chorioretinopathy may be a relatively benign process that presents late and may involve large areas of the posterior choroid.

Corneal reinnervation in patients with severe neurotrophic keratopathy secondary to herpes zoster ophthalmicus after treatment with autologous serum tear drops

Purpose

To study potential corneal reinnervation and recovery of corneal sensation in patients with severe neurotrophic keratopathy (NK) secondary to herpes zoster ophthalmicus (HZO) after treatment with topical autologous serum tears (AST).

Method

Four cases of HZO with severe NK were followed clinically and by serial laser in vivo confocal microscopy (IVCM, HRT3/RCM, Heidelberg Engineering) before and during treatment with 20% AST drops eight times a day. Two masked observers reviewed the IVCM images and assessed corneal nerve alterations.

Results

At baseline, all patients had complete loss of corneal sensation. In addition, IVCM showed complete lack of the subbasal corneal nerve plexus in all patients. All four patients were refractory to conventional therapies and were treated with AST drops. All patients demonstrated significant nerve regeneration by IVCM within 3-7 months of treatment. The total nerve density increased to a mean ± SEM of 10,085.88±2,542.74 μm/mm2 at the last follow up. Corneal sensation measured by Cochet-Bonnet esthesiometry improved to a mean ± SEM of 3.50±1.30 cm. Interestingly, 3 of 4 patients developed stromal keratitis with ulceration within weeks of corneal reinnervation, which was reversed by adding topical steroids.

Conclusion

Autologous serum tears are effective in restoring corneal subbasal nerves and sensation in patients with severe NK secondary to HZO. However, this group of patients may require concurrent topical immunomodulation and antiviral therapy while on AST to prevent stromal keratitis.

Background incidence rates of health outcomes in populations at risk for Lyme disease using US administrative claims data

BACKGROUND

Background incidence rates (IRs) of health outcomes in Lyme disease endemic regions are useful to contextualize events reported during Lyme disease vaccine clinical trials or post-marketing. The objective of this study was to estimate and compare IRs of health outcomes in Lyme disease endemic versus non-endemic regions in the US during pre-COVID and COVID era timeframes.

METHODS

IQVIA PharMetrics® Plus commercial claims database was used to estimate IRs of 64 outcomes relevant to vaccine safety monitoring in the US during January 1, 2017-December 31, 2019 and January 1, 2020-December 31, 2021. Analyses included all individuals aged ≥ 2 years with ≥ 1 year of continuous enrollment. Outcomes were defined by International Classification of Diseases Clinical Modification, 10th Revision (ICD-10-CM) diagnosis codes. IRs and 95 % confidence intervals (CIs) were calculated for each outcome and compared between endemic vs. non-endemic regions, and pre-COVID vs. COVID era using IR ratios (IRR).

RESULTS

The study population included 8.7 million (M) in endemic and 27.8 M in non-endemic regions. Mean age and sex were similar in endemic and non-endemic regions. In both study periods, the IRs were statistically higher in endemic regions for anaphylaxis, meningoencephalitis, myocarditis/pericarditis, and rash (including erythema migrans) as compared with non-endemic regions. Conversely, significantly lower IRs were observed in endemic regions for acute kidney injury, disseminated intravascular coagulation, heart failure, myelitis, myopathies, and systemic lupus erythematosus in both study periods. Most outcomes were statistically less frequent during the COVID-era.

CONCLUSION

This study identified potential differences between Lyme endemic and non-endemic regions of the US in background IRs of health conditions during pre-COVID and COVID era timeframes to inform Lyme disease vaccine safety monitoring. These regional and temporal differences in background IRs should be considered when contextualizing possible safety signals in clinical trials and post-marketing of a vaccine targeted at Lyme disease prevention.

Herpes Zoster after COVID-19 Infection or Vaccination: A Prospective Cohort Study in a Tertiary Dermatology Clinic

Background

Herpes zoster (HZ) has been observed to occur after COVID-19 infection and vaccination; however, knowledge regarding the demographic data, clinical presentations, and treatment outcomes of HZ is limited.

Objective

To compare the demographic data, clinical manifestations, treatments, and outcomes of patients with and without HZ within 14 days of COVID-19 infection or vaccination.

Methods

This prospective cohort study involving patients diagnosed with cutaneous HZ was conducted at a dermatology clinic from October 2021 to January 2023.

Results

Among a total of 232 patients with HZ, the median age was 62.0 years and 59.1% were female. HZ developed in 23 (9.9%) and four (1.7%) patients after COVID-19 vaccination and infection, respectively. The mean duration from vaccination and the median duration from infection to HZ onset were 5.7 and 8.5 days, respectively. The proportion of female patients was significantly higher in the group of patients with COVID-19 vaccination or infection than in those without such a history (P = 0.035). Patients who developed HZ following the recent COVID-19 infection had a median age of 42.5 years, which was lower than that of the other groups. Dissemination occurred in 8.7% of the patients after COVID-19 vaccination. HZ recurrence was reported in five cases, of which 80% had been vaccinated or infected with COVID-19 during the previous 21 days. All patients had similar durations of antiviral treatment, crust-off time, and duration of neuralgia.

Conclusions

HZ after COVID-19 vaccination is more frequently observed in females, while HZ after COVID-19 infection tends to occur in younger patients. Disseminated HZ is more common in patients recently vaccinated against COVID-19. COVID-19 vaccination or infection may trigger recurrent HZ infection.

Impact of herpes zoster and post-herpetic neuralgia on health-related quality of life in Miyun District of Beijing, China: An EQ-5D survey

Background

Herpes zoster (HZ) and post-herpetic neuralgia (PHN) cause considerable morbidity, especially in elderly adults, but the burden is under-recognized in mainland China.

Methods

We conducted a case registry and follow-up study of HZ in Miyun District, Beijing from January 1, 2017 through December 31, 2018. Registered HZ cases were followed-up for pain to 365 days. The first 50 patients with HZ in each age group (≤14, 15-29, 30-39, 40-49, 50-59, 60- 69, 70-79, ≥80 years) and all those with PHN completed the EuroQoL five dimensions questionnaire (EQ-5D) to evaluate health-related quality of life (HRQoL) in patients with HZ and PHN. Ratings using the EQ-5D dimensions, visual analogue scale (VAS), health utility score (HUS) and quality-adjusted life years (QALYs) lost were compared among age groups.

Results

In total, 2008 patients with HZ were followed for a median 22 days (interquartile range[IQR] = 20-90), with an estimated incidence of 4.39 per 1000 person-years. We identified 122 (6.08 %) PHN cases. The median age of patients with PHN (65 years, IQR = 55-71) was older than that of patients with HZ (54 years, IQR = 43-64) (P < 0.001). The median duration of pain was 170 days (IQR = 144-355.5) for PHN and 15 days (IQR = 9-25) for HZ. All 95 patients with PHN and 319 sampled patients with HZ completed the EQ-5D survey. The median QALY loss of HZ increased from 0.004 (IQR = 0.001-0.02) in patients 50-59 years old to 0.02 (IQR = 0.01-0.06) in those ≥ 80 years old (P < 0.01). After weighting for age, the mean QALY loss per HZ case was estimated at 0.02 (standard deviation [SD] 0.04). The mean QALY loss per PHN case was 0.13 years (SD 0.12).

Conclusions

HZ and PHN caused a substantial burden, especially among adults aged ≥ 50 years in Miyun District, Beijing, China. Vaccination should be considered to alleviate the burden of this painful disease.

The value of herpes zoster prevention in people aging with HIV: A narrative review

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.

Shingles Vaccine Uptake Among Older Adults: Identifying Early, Later, and Nonadopters

Introduction

There is growing interest in accelerating adoptions of vaccines. This study examined factors that differentiate the acceptance and timing of uptake of the first shingles vaccine, Zostavax, among older adults in the U.S.

Methods

Data from Health and Retirement Study respondents who were aged ≥62 years in 2008 were analyzed to determine whether they received a shingles vaccination from 2006 to 2016. Multinomial logistic regression was used to examine the characteristics associated with vaccine uptake and timing.

Results

Of those eligible, 15.2% were vaccinated early (between 2006 and 2010), 20.2% were vaccinated later, and 64.6% remained unvaccinated 10 years after the shingles vaccine was introduced. Respondents more likely to be vaccinated were those who had higher education and income, experience with influenza vaccination, more frequent social interaction with friends, or were residing in an area with higher shingles vaccination rates.

Conclusions

Shingles vaccination rates vary by social and geographic characteristics. Efforts to improve and expedite vaccination and other new preventive measures should target specific populations and geographic areas.

Herpes Zoster in Hospitalized Patients With Inflammatory Bowel Disease: National Analysis of Disease Presentation and Age Distribution

BACKGROUND

Studies have demonstrated an increased risk of herpes zoster (HZ) in patients with inflammatory bowel disease (IBD). Most recently, the Advisory Committee on Immunization Practices recommended HZ vaccination for adults aged 19 years and older who are at increased risk of shingles due to their disease or drug-related immunosuppression. We aimed to assess the burden of HZ in IBD inpatients and contribute with scientific evidence for an appropriate age cut-off vaccination recommendation.

MATERIALS AND METHODS

Population-based cross-sectional analysis using the 2014 US National Inpatient Sample (NIS). We measured the frequencies and demographics of adult patients with IBD admitted to the hospital with an HZ diagnosis. Age-stratification analysis was performed, and age groups were compared with non-IBD inpatients with an HZ diagnosis.

RESULTS

From 307,260 IBD discharges, 1110 (0.35%) patients were found to have HZ as follows: shingles 63%; post-herpetic neuralgia 26%; HZ with ophthalmic involvement 7%; HZ with neurological involvement 4%. Women with IBD were more likely to have shingles ( P =0.002) and post-herpetic neuralgia ( P =0.001) than men with IBD. The shingles distribution by age in IBD inpatients was 18 to 39 (13%), 40 to 49 (19%), 50 to 59 (18%), 60 to 99 (50%) compared with 18 to 39 (8%), 40 to 49 (6%), 50 to 59 years (14%), 60 to 99 (72%) in non-IBD inpatients ( P =0.0004).

CONCLUSIONS

Hospitalized patients with IBD were found to have a higher frequency of shingles at younger ages when compared with hospitalized patients without IBD. Shingles is more frequent in women, and their prevalence steadily increases with aging though 32% of cases were seen in patients younger than age 50.

Comparison of efficacy of acupuncture-related therapy in the treatment of herpes zoster: A network meta-analysis of randomized controlled trials

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to evaluate the efficacy and safety of acupuncture-related therapy in the treatment of herpes zoster (HZ) and to provide a reference for the clinical treatment of herpes zoster.

METHODS

PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, VIP database, Wanfang Database, and SinoMED Chinese and English databases were systematically searched for RCTs on acupuncture-related therapy for HZ until February 2023. Literature screening, data extraction, and risk of bias assessment were performed independently by 2 researchers. R4.2.1 and Stata15.1 software were used for data analysis.

RESULTS

A total of 26 RCTs involving 1929 HZ patients were included, and the network meta-analysis results showed that acupotomy appeared to be most effective in terms of improving VAS scores and the time of incrustation; SUCRA cumulative probability ranking showed the best efficacy of bloodletting in improving efficiency and the time of ceasing new blisters, acupuncture in improving the time of decrustation, and moxibustion in reducing the incidence of postherpetic neuralgia (PHN).

CONCLUSIONS

Through a comprehensive comparison of 9 different acupuncture therapies, acupotomy was the optimal treatment to improve VAS pain scores and the time of incrustation; bloodletting, acupuncture, fire needle, and moxibustion could be effective intervention measures to improve the time of ceasing new blisters and decrustation and reduce the incidence of PHN; Western medicine was closely related to adverse reactions. The conclusions need to be further verified due to the limitations of the study.

Clinical and economic implications of increasing access to herpes zoster vaccination rate in community pharmacies

BACKGROUND

A community pharmacist plays an important role in providing vaccination to the general public in the United States. No economic models have been used to assess the impact of these services on public health and economic benefits.

OBJECTIVE

This study aimed to estimate the clinical and economic implications of community pharmacy-based herpes zoster (HZ) vaccination services with a hypothetical scenario of nonpharmacy-based vaccination in the State of Utah.

METHODS

A hybrid model of decision tree and Markov models was used to estimate lifetime cost and health outcomes. This open-cohort model was populated based on Utah population statistics and included a population of 50 years and older who were eligible for HZ vaccination between the years 2010 and 2020. Data were derived from the U.S. Bureau of Labor Statistics, the Utah Immunization Coverage Report, the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, the CDC National Health Interview Survey, and existing literature. The analysis was performed from a societal perspective. A lifetime time horizon was used. The primary outcomes were the number of vaccination cases increased and the number of shingles and postherpetic neuralgia (PHN) cases averted. Total costs and quality-adjusted life-years (QALYs) were also estimated.

RESULTS

Based on a cohort of 853,550 people eligible for HZ vaccination in Utah, an additional 11,576 individuals were vaccinated in the community pharmacy-based scenario compared with the nonpharmacy-based vaccination, resulting in 706 averted cases of shingles and 143 averted cases of PHN. Community pharmacy-based HZ vaccination was less costly (-$131,894) and gained more QALYs (52.2) compared with the nonpharmacy-based vaccination. A series of sensitivity analyses showed that the findings were robust.

CONCLUSIONS

Community pharmacy-based HZ vaccination was less costly and gained more QALYs and was associated with improved other clinical outcomes in the State of Utah. This study might be used as a model for future evaluations of other community pharmacy-based vaccination programs in the United States.

Cost-Effectiveness Analysis of Vaccination With Recombinant Zoster Vaccine Among Hematopoietic Cell Transplant Recipients and Persons With Other Immunocompromising Conditions Aged 19 to 49 Years

OBJECTIVES

This study aimed to estimate the cost-effectiveness of the use of recombinant zoster vaccine (RZV) (Shingrix), which protects against herpes zoster (HZ), among immunocompromised adults aged 19 to 49 years, as a contribution to deliberations of the Advisory Committee on Immunization Practices.

METHODS

Hematopoietic cell transplant (HCT) recipients experience a high incidence of HZ, and the efficacy of RZV in preventing HZ has been studied in clinical trials. The cost-effectiveness model calculated incremental cost-effectiveness ratios that compared vaccination with RZV with a no vaccination strategy among adults aged 19 to 49 years. Costs and outcomes were calculated until age 50 years using the healthcare sector perspective and summarized as cost per quality-adjusted life-year (QALY) gained. The base case represents HCT recipients, with scenario analyses representing persons with other immunocompromising conditions, including hematologic malignancies, human immunodeficiency virus, and autoimmune and inflammatory conditions. Uncertainty was investigated using univariate, multivariate, and probabilistic sensitivity analyses.

RESULTS

Base-case results indicated vaccination with RZV would avert approximately 35% of HZ episodes and complications, while saving approximately 11% of net costs. Compared with no vaccination, vaccination of HCT recipients with RZV generated cost-savings (ie, lower costs and improved health) in the base case and in 81% of simulations in the probabilistic analysis. In scenario analyses, vaccination cost US dollar ($) 9500/QALY among patients with hematologic malignancies, $79 000/QALY among persons living with human immunodeficiency virus, and $208 000/QALY among persons with selected autoimmune and inflammatory conditions.

CONCLUSIONS

Generally favorable economic estimates supported recommendations for vaccination of immunocompromised adults with RZV to prevent episodes of HZ and related complications.

Risk factors for herpes zoster: should people with asthma or COPD be vaccinated?

Without vaccination, an estimated 1 in 3 individuals will develop herpes zoster (HZ) in their lifetime. Increased risk of HZ is attributed to impaired cell-mediated immunity, as observed in age-related immunosenescence or in individuals immunocompromised due to disease or immunosuppressive treatments. Most vaccination guidelines recommend HZ vaccination in all adults ≥ 50 years of age, although Shingrix® was recently approved by the U.S. Food and Drug Administration for use in individuals aged ≥ 18 years who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy, followed by approval by the European Medicines Agency for use in immunocompromised individuals aged ≥ 18 years. Chronic respiratory diseases are also risk factors for HZ. A new meta-analysis reported 24% and 41% increased risks of HZ in those with asthma and chronic obstructive pulmonary disorder (COPD), respectively, compared with healthy controls. Asthma and COPD increase a person's risk of HZ and associated complications at any age and may be further elevated in those receiving inhaled corticosteroids. Despite the increased risks, there is evidence that HZ vaccination uptake in those aged ≥ 50 years with COPD may be lower compared with the age-matched general population, potentially indicating a lack of awareness of HZ risk factors among clinicians and patients. The 2022 Global Initiative for Chronic Lung Disease report recognizes that Centers for Disease Control and Prevention recommended to vaccinate those aged ≥ 50 years against HZ, although health systems should consider the inclusion of all adults with asthma or COPD into their HZ vaccination programs. Further research into HZ vaccine efficacy/effectiveness and safety in younger populations is needed to inform vaccination guidelines.

Safety and efficacy of recombinant and live herpes zoster vaccines for prevention in at-risk adults with chronic diseases and immunocompromising conditions

Compared with the general population, older adults with immune senescence and individuals who are immunocompromised (IC) due to disease or immunosuppressive therapy are at increased risk for herpes zoster (HZ) and its associated complications, which can be debilitating and life-threatening. Vaccination can be an effective strategy against HZ and studies have shown that HZ vaccination in IC individuals can elicit immune responses and provide protection from infection. Recently, the first approvals have been granted in the United States and the European Union for the recombinant HZ vaccine (RZV) in adults ≥ 18 years of age at risk of HZ due to immunodeficiency or immunosuppression. Existing systematic reviews have highlighted the risks for HZ in limited immunocompromising conditions and have only examined clinical data for RZV. This review details the risks and burden of HZ in a broad range of clinically relevant IC populations and summarizes key efficacy and safety data for RZV and live HZ vaccine in these individuals. Research has shown IC individuals can benefit from HZ vaccination; however, these insights have yet to be fully incorporated into vaccination guidelines and clinical care. Clinicians should consider HZ vaccination in eligible at-risk populations to protect against HZ and its associated complications and thereby, reduce the burden that HZ poses on the healthcare system. Electronic health records and linked personal health records could be used to identify and contact patients eligible for HZ vaccination and provide clinical decision support-generated alerts for missing or delayed vaccinations. This review will help clinicians identify eligible IC individuals who may benefit from HZ vaccination. A video abstract linked to this article is available on Figshare https://doi.org/10.6084/m9.figshare.21517605.

PAQR8 and PAQR9 expression is altered in the ventral tegmental area of aged rats infected with varicella zoster virus

Infection with varicella zoster virus (VZV) results in chicken pox and reactivation of VZV results in herpes zoster (HZ) or what is often referred to as shingles. Patients with HZ experience decreased motivation and increased emotional distress consistent with functions of the ventral tegmental area (VTA) of the brain. In addition, activity within the ventral tegmental area is altered in patients with HZ. HZ primarily affects individuals that are older and the VTA changes with age. To begin to determine if the VTA has a role in HZ symptoms, a screen of 10,000 genes within the VTA in young and old male rats was completed after injecting the whisker pad with VZV. The two genes that had maximal change were membrane progesterone receptors PAQR8 (mPRβ) and PAQR9 (mPRε). Neurons and non-neuronal cells expressed both PAQR8 and PAQR9. PAQR8 and PAQR9 protein expression was significantly reduced after VZV injection of young males. In old rats PAQR9 protein expression was significantly increased after VZV injection and PAQR9 protein expression was reduced in aged male rats versus young rats. Consistent with previous results, pain significantly increased after VZV injection of the whisker pad and aged animals showed significantly more pain than young animals. Our data suggests that PAQR8 and PAQR9 expression is altered by VZV injection and that these changes are affected by age.

Efficacy, effectiveness, and safety of herpes zoster vaccine in the immunocompetent and immunocompromised subjects: A systematic review and network meta-analysis

Objective

To investigate the efficacy, effectiveness and safety of recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) in immunocompetent and immunocompromised subjects.

Methods

Data sources: PubMed, EMBASE, Cochrane Library, and Web of Science databases (up to Jan 2022) were searched to identify English articles. Search terms included randomized controlled trials (RCTs), observational studies, herpes zoster, RZV, ZVL. Study Selection: Only randomized controlled trials (RCTs) evaluating vaccine efficacy and safety and observational studies assessing vaccine effectiveness (after a vaccine was approved for marketing) were included. Data Extraction: Two researchers independently screened the literature, extracted the data, and checked the each other results.

Results

Seventeen RCTs and 19 cohort studies were included. Among immunocompetent subjects, RZV was superior to ZVL at wide intervals (relative vaccine efficacy: 84%, 95% CI: 53%–95%; relative vaccine effectiveness: 49%, 95% CI: 21%–67%), across genders and subjects aged ≥ 60 years. Among immunocompromised subjects, RZV was superior to placebo in terms of vaccine efficacy (60%, 95% CI: 49%–69%). There was no difference between ZVL and placebo in those with selected immunosuppressive conditions. RZV was 45% (95% CI: 30%–59%) superior to ZVL in real-world practice. Compared with placebo, adverse events related to RZV were primarily related to injection-site and systemic, and RZV did not increase the risk of serious adverse events (SAEs) or death. There was no difference in the incidence of adverse events between groups with and without immunosuppression.

Conclusions

Both RZV and ZVL can reduce the risk of herpes zoster in both immunocompetent and immunocompromised subjects. RZV was well-tolerated in the study population and demonstrated stronger protection than ZVL.

Systematic review registration

Prospero CRD42022310495.

Complete recovery from segmental zoster paresis confirmed by magnetic resonance imaging: A case report

BACKGROUND

Segmental zoster paresis, depending on the affected area, can present with severe clinical manifestations and render patients unable to perform activities of daily living. Therefore, it is necessary to diagnose and treat such a condition rapidly. No studies have reported using magnetic resonance imaging (MRI) to identify clinical abnormalities associated with this condition or its complete recovery. This rare case report evaluated the changes in MRI findings before and after the patient's motor symptoms recovered.

CASE SUMMARY

A 79-year-old woman with a history of rheumatoid arthritis and psoriasis visited the hospital for skin rashes and pain in the C5-T2 segments. The diagnosis was herpes zoster infection, and treatment was initiated. However, motor weakness suddenly occurred 14 d after the initial symptom presentation. We confirmed abnormal findings in the nerves and muscles invaded by the shingles using electromyography and MRI. After 17 mo, the patient's symptoms had completely normalized, and MRI confirmed that there were no abnormalities.

CONCLUSION

MRI can be a useful diagnostic modality for segmental zoster paresis and patient evaluation during recovery from motor complications.

Baculovirus Display of Varicella-Zoster Virus Glycoprotein E Induces Robust Humoral and Cellular Immune Responses in Mice

Varicella-zoster virus (VZV) is the causative agent of varicella and herpes zoster (HZ) and can pose a significant challenge to human health globally. The initial VZV infection-more common in children-causes a self-limiting chicken pox. However, in later life, the latent VZV can become reactivated in these patients, causing HZ and postherpetic neuralgia (PHN), a serious and painful complication. VZV glycoprotein E (gE) has been developed into a licensed subunit vaccine against HZ (Shingrix). However, its efficacy relies on the concomitant delivery of a robust adjuvant (AS01B). Here, we sought to create a new immunogen for vaccine design by displaying the VZV-gE on the baculovirus surface (Bac-gE). Correct localization and display of gE on the engineered baculovirus was verified by flow cytometry and immune electron microscopy. We show that Bac-gE provides excellent antigenicity against VZV and induces not only stronger gE-specific CD4+ and CD8+ T cell responses but also higher levels of VZV-specific neutralizing antibodies as compared with other vaccine strategies in mice. Collectively, we show that the baculovirus display of VZV-gE confers ideal humoral and cellular immune responses required for HZ vaccine development, paving the way for a baculovirus-based vaccine design.

Herpes Zoster Vaccination Rates in Hematological and Oncological Patients-Stock Taking 2 Years after Market Approval

BACKGROUND

Vaccinations have the potential to significantly lower the burden of disease for many major infections in the high-risk population of hematological and oncological patients. In this regard Shingrix®, an inactivated Varicella Zoster Virus vaccine, received market approval in the European Union in March 2018, after prior US approval in October 2017, and recommendations specifically state immunocompromised, including oncological, patients. As vaccination rates are considered to be poor in oncological patients, determining the current vaccination rates for Shingrix® two years after market approval is important in defining the need for intervention to bring this potentially high-impact vaccine to the patients.

METHODS

We analyzed data of the EVO Study to provide data for Herpes zoster vaccination rates in oncological patients. The EVO Study was an interventional study evaluating the potential of increasing vaccination rates of specified must-have vaccinations by an instructional card in the oncological setting. Numbers presented in this publication merged baseline data and follow-up data of the control group; hence data not affected by the intervention.

RESULTS

Data of 370 patients were analyzed; 21.1% with hematological malignancies and 78.9% with solid cancer. Only 3.0% were vaccinated with Shingrix®. Patients with hematological malignancy were more likely to be vaccinated than those with solid cancer (7.7 vs. 1.7%).

CONCLUSION

Despite clear recommendations and a pressing need in the high-risk population of hematological and oncological patients, the vast majority of patients are still left without vaccine protection against Herpes zoster by Shingrix®.

Alterations in local activity and functional connectivity in patients with postherpetic neuralgia after short-term spinal cord stimulation

Introduction

The efficacy of short-term spinal cord stimulation (stSCS) as a treatment for neuropathic pain in patients with postherpetic neuralgia (PHN) has already been validated. However, the potential alterations in brain functionality that are induced by such treatment have yet to be completely elucidated.

Methods

This study use resting-state functional magnetic resonance imaging (rs-fMRI) to detect the changes in regional homogeneity (ReHo) and degree centrality (DC) related to stimulator-induced pain relief in patients with PHN. A total of 10 patients with PHN underwent an MRI protocol at baseline and after stSCS. Alterations in ReHo and DC were then compared between baseline and after stSCS. We investigated the relationship between clinical parameters and functional changes in the brain.

Results

Clinical parameters on pain, emotion, and sleep quality were correlated with ReHo and DC. ReHo and DC were significantly altered in the middle temporal gyrus, precuneus, superior frontal gyrus, supramarginal gyrus, inferior parietal lobule, rolandic operculum, middle occipital gyrus, superior parietal gyrus, and the precentral gyrus after stSCS. A significant correlation was detected between ReHo changes in the middle occipital gyrus, precuneus, inferior parietal gyrus, and changes in pain, emotion, and sleep quality. A significant negative correlation was detected between DC changes in the middle temporal gyrus, rolandic operculum, supramarginal gyrus, precuneus, inferior parietal gyrus, and changes in pain, emotion, and sleep quality.

Conclusion

This study found that stSCS is able to induce ReHo and DC changes in patients with PHN, thus suggesting that stSCS can change brain function to alleviate pain, sleep, and emotional disorder.

Sero-positivity, risks, and morbidity from Varicella-Zoster Virus (VZV) infections in an adult PWH (people with HIV) cohort from 2000-2020

Background

Varicella-zoster virus (VZV) infection disproportionately affects people with HIV (PWH), primarily presenting as herpes zoster. However, VZV seroprevalence, its association with zoster, and clinical outcomes remain understudied in era of modern antiretroviral therapy (ART). We assessed VZV seroprevalence, rates of VZV illness, and associated health care costs in a large cohort of PWH over 20 years.

Methods

We performed retrospective chart reviews of patients followed at a regional HIV clinic from January 1, 2000, to December 31, 2020. Serological, immunization, clinical, and costing data were extracted from in-house databases. VZV-related inpatient admissions, emergency department (ED), and urgent care (UC) visits were identified using relevant International Classification of Disease (ICD-10) codes and validated where possible by 2 physicians. Health care utilization costs were adjusted to 2020 Canadian dollars.

Results

Of 3006 PWH, VZV serology was available for 2628; of these, 2503 (95.2%) were seropositive. Only 39% of known seronegative patients were subsequently immunized for varicella. During 29 768 years of patient follow-up, 38 hospitalizations and 138 ED/UC visits due to VZV infection were identified. Most occurred in VZV-seropositive PWH <50 years of age (82%) who were unimmunized (99.2%) and not on ART (64.8%). Nearly 25% of hospitalizations were due to laboratory-confirmed VZV meningitis/encephalitis. The average admission cost was CDN$33 001; the total measured cost of VZV illness was CDN$1 258 718.

Conclusions

Despite ART and vaccines for chickenpox and shingles, VZV still caused significant costs and morbidity for PWH, occurring at younger ages and often as encephalitis/meningitis. Supporting ART adherence may reduce VZV illness and hospitalization costs in PWH, and the cost-effectiveness of expanding shingles vaccine use warrants further study.

A Case With Herpes Zoster Ophthalmicus Mimicking Delayed Complication of Rhinoplasty

Herpes zoster ophthalmicus (HZO) occurs due to reactivation of dormant varicella zoster virus infection in the ophthalmic division of the trigeminal nerve. Hutchinson’s sign, a herpetic skin lesion in the nasal tip, is a predictor of ocular complications, as the nasal tip area and ocular structure are innervated by the same nasociliary nerve. Patients who present with Hutchinson’s sign should be referred to an ophthalmologist due to possibility of ocular complications. Here, we present a case of a 44-year-old man with HZO that was confused with delayed rhinoplasty complication. The patient presented with nasal tip skin lesions 17 years after undergoing augmentation rhinoplasty. A graft-related infection was suspected due to operation history and skin lesions. However, surgical exploration disclosed no infection or inflammation, and serological tests revealed positive varicella zoster virus immunoglobulin M, and immunoglobulin G, antibodies. Based on these findings, the patient was diagnosed with HZO. Further, the patient received antiviral treatment with famciclovir. The lesions gradually improved with conservative treatment and became almost unrecognizable. Therefore, HZO should be considered when there is an unexplained skin lesion at the nasal tip in patients with history of rhinoplasty.

Prevalence of and factors associated with herpes zoster in England: a cross-sectional analysis of the Health Survey for England

BACKGROUND

Herpes zoster (commonly called shingles) is caused by the reactivation of varicella zoster virus, and results in substantial morbidity. While the risk of zoster increases significantly with age and immunosuppression, relatively little is known about other risk factors for zoster. Moreover, much evidence to date stems from electronic healthcare or administrative data. Hence, the aim of this study was to explore potential risk factors for herpes zoster using survey data from a nationally-representative sample of the general community-dwelling population in England.

METHODS

Data were extracted from the 2015 Health Survey for England, an annual cross-sectional representative survey of households in England. The lifetime prevalence of self-reported herpes zoster was described by age, gender and other socio-demographic factors, health behaviours (physical activity levels, body mass index, smoking status and alcohol consumption) and clinical conditions, including; diabetes, respiratory, digestive and genito-urinary system and mental health disorders. Logistic regression models were then used to identify possible factors associated with shingles, and results were presented as odds ratios with 95% confidence intervals.

RESULTS

The lifetime prevalence of shingles among the sample was 11.5% (12.6% among women, 10.3% among men), which increased with age. After adjusting for a range of covariates, increased age, female gender (odds ratio: 1.21; 95%CI: 1.03, 1.43), White ethnic backgrounds (odds ratio: 2.00; 95%CI: 1.40, 2.88), moderate physical activity 7 days per week (odds ratio: 1.29; 95%CI: 1.01, 1.66) and digestive disorders (odds ratio: 1.51; 95%CI: 1.13, 1.51) were each associated with increased odds of having had herpes zoster.

CONCLUSIONS

Age, gender, ethnicity and digestive disorders may be risk factors for herpes zoster among a nationally representative sample of adults in England. These potential risk factors and possible mechanisms should be further explored using longitudinal studies.

Prospective, Longitudinal Study on Specific Cellular Immune Responses after Vaccination with an Adjuvanted, Recombinant Zoster Vaccine in Kidney Transplant Recipients

Solid organ transplant recipients have an up to ninefold higher risk of varicella-zoster virus (VZV) reactivation than the general population. Due to lifelong immunosuppressive therapy, vaccination against VZV may be less effective in kidney transplant (KTX) recipients. In the current study, twelve female and 17 male KTX recipients were vaccinated twice with the adjuvanted, recombinant zoster vaccine Shingrix™, which contains the VZV glycoprotein E (gE). Cellular immunity against various VZV antigens was analyzed with interferon-gamma ELISpot. We observed the strongest vaccination-induced changes after stimulation with a gE peptide pool. One month after the second vaccination, median responses were 8.0-fold higher than the responses prior to vaccination (p = 0.0006) and 4.8-fold higher than responses after the first vaccination (p = 0.0007). After the second vaccination, we observed an at least twofold increase in ELISpot responses towards gE peptides in 22 out of 29 patients (76%). Male sex, good kidney function, early time point after transplantation, and treatment with tacrolimus or mycophenolate were correlated significantly with higher VZV-specific cellular immunity, whereas diabetes mellitus was correlated with impaired responses. Thus, our data indicate that vaccination with Shingrix™ significantly augmented cellular, VZV gE-specific immunity in KTX recipients, which was dependent on several covariates.

Effect of Implantable Electrical Nerve Stimulation on Cortical Dynamics in Patients With Herpes Zoster–Related Pain: A Prospective Pilot Study

Implantable electrical nerve stimulation (ENS) can be used to treat neuropathic pain caused by herpes zoster. However, little is known about the cortical mechanism underlying neuromodulation therapy. Here, we recorded a 16-channel resting-state electroencephalogram after the application of spinal cord stimulation (n = 5) or peripheral nerve stimulation (n = 3). The neuromodulatory effect was compared between specific conditions (active ENS versus rest). To capture the cortical responses of ENS, spectral power and coherence analysis were performed. ENS therapy achieved satisfactory relief from pain with a mean visual analog scale score reduction of 5.9 ± 1.1. The spectral analysis indicated that theta and alpha oscillations increased significantly during active neuromodulation compared with the resting state. Furthermore, ENS administration significantly increased frontal-frontal coherence in the alpha band. Our findings demonstrate that, despite methodological differences, both spinal cord and peripheral nerve stimulation can induce cortical alpha oscillation changes in patients with zoster-related pain. The dynamic change may, in part, mediate the analgesic effect of ENS on herpes zoster–related pain.

Effect of Routine Varicella Immunization on the Epidemiology and Immunogenicity of Varicella and Shingles

Varicella-zoster virus (VZV) causes varicella as a primary infection and remains latent in the ganglia until it becomes reactivated to cause herpes zoster. Individuals with varicella develop adaptive humoral and cell-mediated immunity. Compromised cell-mediated immunity is thought to contribute to the development of herpes zoster. Recent evidence suggests that changes in the epidemiology of varicella have affected the epidemiology of herpes zoster. The incidence of herpes zoster is higher in older adults; thus, the herpes zoster vaccine is recommended for older adults. However, the incidence of herpes zoster is expected to rise among younger individuals; hence, vaccination with the varicella vaccine should also be considered in younger adults. In order to determine the need for vaccination in different populations, it is important to establish methods to accurately assess the activity of cell-mediated immunity and humoral immunity.

Knowledge and Attitudes Concerning Herpes Zoster among People with COPD: An Interventional Survey Study

Herpes zoster (HZ) is common in older adults with conditions such as chronic obstructive pulmonary disease (COPD). Effective prevention is available through vaccination, but HZ vaccine uptake remains incomplete. Using an online survey of people with self-reported COPD, ShiPPS assessed HZ risk awareness, HZ vaccine use and barriers, and the impact of an HZ educational video on vaccine intent. USA members of the COPD Foundation’s Patient-Powered Research Network aged >50 years were surveyed in fall 2020. The responses were analyzed using descriptive and comparative statistics. Of the 735 respondents (59.6% female, mean age 68.5 years), 192 (26.1%) reported previous HZ, of whom 49 (25.5%) reported increased COPD symptoms during HZ episodes. Most participants (94.0%) knew of HZ vaccines, but only 33.1% reported receiving the Advisory Committee on Immunization Practices-preferred recombinant HZ vaccination. The recall of receiving HZ vaccine recommendations differed by the site attended: 68.8% primary care, 26.6% pulmonology offices. Most (74.7%) were unaware that COPD increases HZ risk. Among unvaccinated participants, interest in getting the HZ vaccine increased from 32.0% to 73.5% after watching the video. These results highlight the need for people with COPD to receive further HZ education, such as the five-minute video, and HZ vaccine recommendations from healthcare professionals.

Increased risk of herpes zoster in adults ≥50 years old diagnosed with COVID-19 in the United States

Background

Case reports have described herpes zoster (HZ) in patients with coronavirus disease 2019 (COVID-19). However, this constitutes low-quality evidence for an association. We therefore performed a retrospective cohort study to assess the risk of developing HZ following a COVID-19 diagnosis.

Methods

We compared the HZ incidence in ≥50-year-olds diagnosed with COVID-19 vs those never diagnosed with COVID-19. We used data from the US MarketScan Commercial Claims and Encounters and Medicare Supplemental (3/2020–2/2021) and Optum Clinformatics Data Mart (3–12/2020) databases. Individuals with COVID-19 were exact-matched 1:4 to those without COVID-19 by age, sex, presence of HZ risk factors, and health care cost level. Adjusted incidence rate ratios (aIRRs) were estimated by Poisson regression.

Results

A total of 394 677 individuals ≥50 years old with COVID-19 were matched with 1 577 346 individuals without COVID-19. Mean follow-up time after COVID-19 diagnosis and baseline characteristics were balanced between cohorts. Individuals diagnosed with COVID-19 had a 15% higher HZ risk than those without COVID-19 (aIRR, 1.15; 95% CI, 1.07–1.24; P < .001). The increased HZ risk was more pronounced (21%) following COVID-19 hospitalization (aIRR, 1.21; 95% CI, 1.03–1.41; P = .02).

Conclusions

We found that COVID-19 diagnosis in ≥50-year-olds was associated with a significantly increased risk of developing HZ, highlighting the relevance of maintaining HZ vaccination.

Reactivation of varicella-zoster virus following mRNA COVID-19 vaccination in a patient with moderately differentiated adenocarcinoma of rectum: A case report

Herpes zoster which is the reactivation of varicella-zoster virus, a pathogenic human alpha-herpes virus, following primary infection or chicken pox, is known to occur especially in advanced age and in the immunocompromised among other predisposing factors. COVID-19 vaccination-induced immunomodulation is a novel scenario, hypothesized to be a result of shifting of T-lymphocyte population towards vaccine-induced naïve CD8+ subset, offsetting the balance of varicella-zoster virus responsive T-helper cells, thereby defecting the cell-mediated immunity which suppresses the latent varicella-zoster virus. The exact mechanism, however, is still elusive. Herein, we discuss a case of reactivation of varicella-zoster virus following BNT162b2 mRNA COVID-19 vaccine in an elderly female on oral medication for long-term diabetes and hypertension with good control who has undergone local radiotherapy for an underlying adenocarcinoma of rectum awaiting surgical resection, highlighting the key features of pathogenesis of the disease in relation to COVID-19 vaccination with a pertinent survey of the literature. This case report highlights the importance of differentiating vaccine-related cutaneous reactions with clinically more significant adverse events, early specific therapy thus preventing poorer acute and chronic outcomes.

Elsberg Syndrome, Lumbosacral Radiculopathy, and Myelitis Due to Herpes Zoster in a Patient With Smoldering Myeloma

Herpes zoster (HZ) is a common illness caused by the reactivation of latent varicella zoster virus (VZV) due to waning immunity, often secondary to old age or an underlying immunocompromised state. Its complications can manifest in variety of ways, including persistent neuralgias, vasculopathies, and stroke. Here, we describe a case of a 45-year-old man with a history of cryptogenic stroke and smoldering myeloma who was admitted with sacral HZ complicated by right lumbosacral radiculopathy and myelitis, otherwise known as Elsberg syndrome (ES). He was found to have an enhancing lesion in the peripheral conus medullaris on magnetic resonance imaging (MRI) with nonspecific inflammation and necrosis on biopsy pathology and cerebrospinal fluid (CSF) polymerase chain reaction (PCR) positive for VZV. The patient was initially treated with intravenous acyclovir and dexamethasone and discharged with a steroid taper and indefinite valacyclovir therapy. Twelve months postdischarge, the patient’s right lumbosacral radiculopathy and myelitis had almost completely resolved; however, he continued to require bladder self-catheterization. We believe that the patient’s underlying smoldering myeloma lead to an immunocompromised state, allowing for reactivation of latent VZV, resulting in both the patient’s cryptogenic stroke years earlier and recent ES.

Safety and reactogenicity of the adjuvanted recombinant zoster vaccine: experience from clinical trials and post-marketing surveillance

An adjuvanted recombinant zoster vaccine (RZV) is licensed for the prevention of herpes zoster. This paper reviews its safety and reactogenicity. A pooled analysis of two pivotal randomized Phase-3 trials (NCT01165177, NCT01165229) in adults ⩾50 years found that more solicited adverse events (AEs) were reported with RZV than placebo. Injection site pain was the most common solicited AE (RZV: 78.0% participants; placebo: 10.9%). Grade-3 pain occurred in 6.4% of RZV and 0.3% of placebo recipients. Myalgia, fatigue, and headache were the most commonly reported general solicited AEs (RZV: 44.7%, 44.5%, and 37.7%, respectively; placebo: 11.7%, 16.5%, and 15.5%, respectively). Most symptoms were mild to moderate in intensity with a median duration of 2–3 days. The intensity of reactogenicity symptoms did not differ substantially after the first and second vaccine doses. The pooled analysis of the pivotal Phase-3 trials did not identify any clinically relevant differences in the overall incidence of serious adverse events (SAEs), fatal AEs or potential immune-mediated diseases (pIMDs) between RZV and placebo. Reactogenicity in five studies of immunocompromised patients ⩾18 years (autologous stem cell transplant, human immunodeficiency virus, solid tumors, hematological malignancies, and renal transplant; NCT01610414, NCT01165203, NCT01798056, NCT01767467, and NCT02058589) was consistent with that observed in the pivotal Phase-3 trials. There were no clinically relevant differences between RZV and placebo in the immunocompromised populations with regard to overall incidence of SAEs, fatal AEs, pIMDs, or AEs related to patients’ underlying condition. Post-marketing surveillance found that the most commonly reported AEs were consistent with the reactogenicity profile of the vaccine in clinical trials. Overall, the clinical safety data for RZV are reassuring.

Incidence of complications of herpes zoster in individuals on immunosuppressive therapy: A register-based population study

OBJECTIVES

Herpes zoster (HZ) exposes to alterations of the quality-of-life. HZ is more frequent in immunocompromised individuals, but whether immunosuppression is associated with a higher rate of complications is not well documented. We aimed to assess association between drug-induced immunosuppression and HZ complications.

METHODS

Data from a sample of the French healthcare claims from 01/01/2006 to 12/31/2018 were analyzed. Complicated zoster (CZ) was defined as a hospitalization with a code for HZ or the first-time dispensation of high-dose valacyclovir and specific neuralgia analgesics. Drug-induced immunosuppression was identified through medication dispensation. Risk ratios were calculated to compare incidences in exposed individuals (EI) and non-exposed to immunosuppressive therapy (NEI).

RESULTS

We identified 227 and 2838 CZ, accounting for an incidence of 178 per 100,000 person-year (95%CI[154.9-201.1]) and 51.7 per 100,000 person-year (95%CI[49.8-53.6]), in EI and NEI, respectively (risk ratio: 3.44 (95%CI[3.01-3.94]). Mean age was 66 years in both groups. CZ occurred after a median of 11.7 months (IQR[5.3-49.9]) of immunosuppressive therapy. Post-herpetic neuralgia (PHN) lasted at least 3 months in 32.6% and 22.5% of cases in EI and NEI, respectively (p=.01).

CONCLUSIONS

Drug-induced immunosuppression increases the risk of CZ and exposes to longer-lasting PHN. Figures provided in this study could help guide prophylaxis of HZ.

Humoral and cellular immune responses to recombinant herpes zoster vaccine in patients with chronic lymphocytic leukemia and monoclonal B cell lymphocytosis

Monoclonal B-cell lymphocytosis (MBL) and chronic lymphocytic leukemia (CLL) are clonal B-cell disorders associated with an increased risk of infections and impaired vaccination responses. We investigated the immunogenicity of recombinant zoster vaccine (RZV) in these patients. Individuals with MBL/untreated CLL and Bruton tyrosine kinase inhibitor (BTKi)-treated CLL patients were given two doses of RZV separated by 2 months. Responses assessed at 3 and 12 months from the first dose of RZV by an anti-glycoprotein E ELISA antibody assay and by dual-color Interferon-γ and Interleukin-2FLUOROSPOT assays were compared to historic controls matched by age and sex. About 62 patients (37 MBL/untreated CLL and 25 BTKi-treated CLL) were enrolled with a median age of 68 years at vaccination. An antibody response at 3 months was seen in 45% of participants, which was significantly lower compared to historic controls (63%, p = .03). The antibody response did not significantly differ between MBL/untreated CLL and BTKi-treated CLL (51% vs. 36%, respectively, p = .23). The CD4+ T-cell response to vaccination was significantly lower in study participants compared to controls (54% vs. 96%, p < .001), mainly due to lower responses among BTKi-treated patients compared to untreated MBL/CLL (32% vs. 73%, p = .008). Overall, only 29% of participants achieved combined antibody and cellular responses to RZV. Among participants with response assessment at 12 months (n = 47), 24% had antibody titers below the response threshold. Hypogammaglobulinemia and BTKi therapy were associated with reduced T-cell responses in a univariate analysis. Strategies to improve vaccine response to RZV among MBL/CLL patients are needed.

Incidence of life-threatening events in children with Wolff-Parkinson-White syndrome: Analysis of a large claims database

BACKGROUND

Previous estimates of life-threatening event (LTE) risk in Wolff-Parkinson-White (WPW) syndrome are limited by selection bias inherent to tertiary referral-based cohorts.

OBJECTIVE

This analysis sought to measure LTE incidence in children with WPW syndrome in a large contemporary representative population.

METHODS

A retrospective cohort study was conducted using claims data from the IBM MarketScan Research Databases, evaluating patients with WPW syndrome (age 1-18 years) from any encounter between January 1, 2013, and December 31, 2018. Subjects with congenital heart disease and cardiomyopathy were excluded. The primary outcome was diagnosis of ventricular fibrillation (VF); a composite outcome, LTE, was defined as occurrence of VF and/or cardiac arrest. VF and LTE rates were compared to matched representative controls without WPW syndrome (3:1 ratio).

RESULTS

The prevalence of WPW syndrome was 0.03% (8733/26,684,581) over a median follow-up of 1.6 years (interquartile range 0.7-2.9 years). Excluding congenital heart disease/cardiomyopathy, 6946 subjects were analyzed. LTE occurred in 49 subjects, including VF in 20. The incidence of VF was 0.8 events per 1000 person-years, and the incidence of LTE was 1.9 events per 1000 person-years. There were no occurrences of VF in controls; the rate of LTE was 70 times higher in patients with WPW syndrome (0.7%; 95% confidence interval 0.5%-0.9%) than in controls (0.01%; 95% confidence interval 0%-0.02%).

CONCLUSION

The use of a large claims data set allowed for an evaluation of VF and LTE risk in an unselected pediatric population with WPW syndrome. The observed range of 0.8-1.9 events per 1000 person-years is consistent with prior reports from selected populations. A comparison of event rates to matched controls confirms and quantifies the significant elevation in VF and LTE risk in pediatric WPW syndrome.

Meta-Regression of Herpes Zoster Incidence Worldwide

Introduction

Many studies have been conducted worldwide to estimate herpes zoster (HZ) incidence rates. We synthesized studies of HZ incidence rates in the general population using meta-analysis models.

Methods

A random effects meta-analysis was conducted to estimate HZ incidence from a published worldwide systematic literature review (SLR) including only individuals aged 50 years and older. Meta-regression was used to explore whether variability in incidence rates could be explained by a combination of study-specific characteristics including age, gender, continent and year of study data. The impact of adding additional covariates—case detection method (general practitioner surveillance, healthcare database, sentinel network, etc.), case definition (medical record-based, self-reported), study design (retrospective passive surveillance, retrospective active surveillance, etc.), incidence type (cumulative incidence/1000 persons or incidence rate/1000 person-years), patient type (outpatients or in- and out-patients) and latitude to the base model—was also assessed.

Results

Sixty-one records from 59 studies were included in the analysis: 25, 20, 11 and 5 from Europe, North America, Asia and Oceania, respectively. There was variation in study methodology and outcomes. Heterogeneity of incidence rates was greatest among studies conducted in Asia. Meta-analysis showed that incidence increased with age, was lower in males compared to females, tended to be lower in Europe and North America compared to Asia and Oceania and increased with year of study data. The data-driven meta-regression model included continent, year of study data, gender, age and an age × gender interaction term. The difference in incidence between males and females was greater in younger ages (e.g., 50–59) compared to older age groups (e.g., 80+). None of the additional covariates contributed significantly to the model.

Conclusion

Incidence rates were shown to vary by age, gender, continent and year of study data.

Graphical Plain Language Summary

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00567-8.

Risk of Guillain-Barré syndrome following herpes zoster, United States, 2010-2018

Epidemiologic data regarding the risk of Guillain-Barré syndrome (GBS) following herpes zoster (HZ) are limited. We conducted a self-controlled case series analysis using two large national data sources to evaluate the risk of GBS following HZ among U.S. adults. We analyzed medical claims from the IBM® MarketScan® Commercial Claims and Encounters (persons 18-64 years during 2010-2018) and Centers for Medicare and Medicaid Services Medicare (persons ≥65 years during 2014-2018) databases. HZ cases were defined as persons with an outpatient claim with a primary or secondary ICD-9 or ICD-10 diagnostic code for HZ. GBS cases were defined as persons with an inpatient claim with a principle diagnostic code for GBS and an associated procedural code. We compared the rates of GBS following HZ in the 1-42-day risk window versus primary (100-365-day) or secondary (43-99-day) control windows. We identified 489,516 persons 18-64 years of age and 650,229 persons ≥65 years of age with HZ, among whom 11 and 41, respectively, developed GBS 1-365 days following HZ. The risk of GBS following HZ was increased during the risk window as compared to the primary control window for both groups, with a rate ratio of 6.3 (95% CI, 1.8-21.9) for those 18-64 years and 4.1 (95% CI, 1.9-8.7) for those ≥65 years. This study provides new and methodologically rigorous epidemiologic support for an association between HZ and GBS, and useful context regarding the benefits versus potential risks of zoster vaccination.

Herpes Zoster and Postherpetic Neuralgia: Changing Incidence Rates From 1994 to 2018 in the United States

BACKGROUND

The incidence of herpes zoster (HZ) has been increasing in recent decades. Although 2 vaccines for HZ are available, there have been few studies on the incidence rates of HZ and postherpetic neuralgia (PHN) since their introduction. This study examined the incidence rates of HZ and PHN from 1994 to 2018 in the United States to determine if they have continued to increase since introduction of the HZ vaccines.

METHODS

A de-identified longitudinal administrative claims database, the OptumLabs Data Warehouse, was used to assess incidence rates among individuals continuously enrolled in the database for ≥365 days with no prior history of HZ or PHN. Unstandardized and standardized incidence rates were calculated by year, 10-year age groups, sex, and race/ethnicity.

RESULTS

There were 610 766 individuals with HZ (median age, 56.3; interquartile range, 43.0-68.7 years; 59.8% women; 70.6% white). From 1994 to 2018, the incidence of HZ increased from 286.0 (95% confidence interval [CI], 259.1-312.8) to 579.6 (95% CI, 554.2-605.0) cases per 100 000 person-years, an annual increase of 3.1% (95% CI, 2.5-3.6%). Since 2007, annual HZ incidence rates have decreased in individuals ≤20 and >60 years old. The overall incidence rate of PHN was 57.5 (95% CI, 56.0-59.0) cases per 100 000 person-years. The proportion of individuals with HZ who developed PHN was higher from 2007 to 2018 than from 1994 to 2006.

CONCLUSIONS

HZ incidence rates have continued to increase in age groups for which HZ vaccines are not currently recommended, warranting a review of current vaccine recommendations.

Impact of disease-modifying antirheumatic drugs on vaccine immunogenicity in patients with inflammatory rheumatic and musculoskeletal diseases

Patients with rheumatic diseases are at increased risk of infectious complications; vaccinations are a critical component of their care. Disease-modifying antirheumatic drugs may reduce the immunogenicity of common vaccines. We will review here available data regarding the effect of these medications on influenza, pneumococcal, herpes zoster, SARS-CoV-2, hepatitis B, human papilloma virus and yellow fever vaccines. Rituximab has the most substantial impact on vaccine immunogenicity, which is most profound when vaccinations are given at shorter intervals after rituximab dosing. Methotrexate has less substantial effect but appears to adversely impact most vaccine immunogenicity. Abatacept likely decrease vaccine immunogenicity, although these studies are limited by the lack of adequate control groups. Janus kinase and tumour necrosis factor inhibitors decrease absolute antibody titres for many vaccines, but do not seem to significantly impact the proportions of patients achieving seroprotection. Other biologics (interleukin-6R (IL-6R), IL-12/IL-23 and IL-17 inhibitors) have little observed impact on vaccine immunogenicity. Data regarding the effect of these medications on the SARS-CoV-2 vaccine immunogenicity are just now emerging, and early glimpses appear similar to our experience with other vaccines. In this review, we summarise the most recent data regarding vaccine response and efficacy in this setting, particularly in light of current vaccination recommendations for immunocompromised patients.

Insurance reimbursements for recombinant zoster vaccine in the private sector

A two-dose series of the recombinant zoster vaccine (RZV, Shingrix) was licensed by the Food and Drug Administration in 2017 and recommended by the Advisory Committee on Immunization Practices in 2018 for adults in the United States age 50 years and older. Despite the health benefits of shingles vaccination, coverage has remained low, with financial barriers among healthcare providers identified as one potential factor. This study estimates the reimbursement levels for RZV among a large sample of privately insured individuals in the US from the 2018 IBM® MarketScan® Commercial Claims and Encounters database. Of 198,534 claims for an RZV dose, the mean reimbursement was $149. Most claims (83%) exceeded $140, which was the private sector vaccine price reported on the CDC vaccine price list in April 2018. These results can be useful for providers considering procuring RZV and for state immunization programs considering ways to improve vaccination coverage.

Herpes Zoster: A Brief Definitive Review

ABSTRACT

This brief definitive review of herpes zoster (HZ) will cover the current state of knowledge and questions that remain to be answered regarding HZ in general and HZ ophthalmicus in particular. A question-and-answer format will be used to address various important topics related to this common and serious disease. Questions to be addressed relate to common misconceptions, contagiousness of infection, unknowns regarding pathogenesis, rising incidence, risk factors and complications, relationship with temporal arteritis, vaccination, and current and future antiviral treatment. In addition, the importance of the Zoster Eye Disease Study to determine the efficacy of suppressive valacyclovir treatment in preventing complications of HZ ophthalmicus and the need to support enrollment will be discussed.

Incidence of herpes zoster in adult solid organ transplant recipients: A meta-analysis and comprehensive review

BACKGROUND

Chronic immunosuppressive therapy in solid organ transplant (SOT) recipients can trigger latent varicella zoster virus reactivation even in those with stable graft function. The inactivated herpes zoster (HZ) vaccine can be effective in preventing post-transplant HZ, which can cause severe neuralgia or disseminated disease. This meta-analysis aims to assess the incidences of HZ across transplant organs in SOT recipients.

METHODS

We included 12 observational studies (6560 recipients) from a PubMed and EMBASE search of articles through October 2019 and collected data from single-center dating from January 2001 to December 2017 (3498 recipients). The pooled HZ incidence and its differences between subgroups were obtained from random-effect models and meta-analysis of variance tests using R package.

RESULTS

The overall pooled crude incidence was 9.1% (95% confidence interval [CI], 7.6%-10.8%). The pooled incidence was similar between sexes but significantly different between transplanted organs (P < .001). Heart transplants (HT) (n = 644) have the highest pooled incidence with 15.2% (95% CI, 12.7%-18.2%), followed by lung transplants (LTX) (n = 780) with 11.0% (8.3%-14.4%). Kidney transplants (n = 5435) have the lowest incidence of 6.7 (5.1%-8.8%). The meta-regression analysis revealed that HZ development had a relationship with past graft rejection (P = .024).

CONCLUSION

These data support the need for subunit HZ vaccination in SOT recipients with a high risk for HZ, especially HT and LTX recipients, without respect to the late post-transplant period.

A systematic literature review of herpes zoster incidence worldwide

We conducted a systematic review to characterize the incidence rate of herpes zoster (HZ) in the general population, specifically in individuals ≥50 years of age. A total of 69 publications were included in the review. We found a cumulative incidence of HZ ranging from 2.9–19.5 cases per 1,000 population and an incidence rate of HZ ranging from 5.23–10.9 cases per 1,000 person-years. The cumulative incidence (3.22–11.2 versus 2.44–8.0 cases per 1,000 population) and incidence rates (6.05–12.8 versus 4.30–8.5 cases per 1,000 person-years) were higher in females than males. Studies revealed a trend of increasing incidence of HZ with increasing age and over time. Variations in incidence estimates can be attributed to the various study designs, case ascertainments, age distributions of the population and year of the study. HZ is associated with a substantial disease burden and is expected to increase due to population aging.

Effect of the varicella vaccination implementation on the development of herpes zoster in children and adolescents

Herpes zoster (HZ) is an infectious disease caused by latent varicella-zoster virus reactivation. There are conflicting reports on the varicella vaccine's effect on the incidence of HZ in children and adolescents. This study aimed to determine the impact of the single dose of varicella vaccination on HZ prevalence during childhood and adolescence. The study included children and adolescents aged <18 years who presented to the dermatology outpatient clinic between 2005 and 2019 and were diagnosed with HZ. Considering that the universal vaccination program started to be implemented in Turkey in 2013, non-vaccinated cases in the prevaccination period, vaccinated cases in the postvaccination period, and non-vaccinated patients in the postvaccination period were compared in terms of HZ prevalence and demographic features. After the initiation of the varicella vaccination program, the prevalence of HZ was found to decrease by 24.7% in all. The HZ prevalence was significantly reduced in vaccinated children, while the rate of decrease in non-vaccinated children was low (58.6% and 16.4%, respectively). The median age of the non-vaccinated cases in the postvaccination period (10 [min 0.5-max 17] years) was significantly higher compared to the other groups (p < 0.001). The number of cases aged <2 years was the highest in the vaccinated group (p < 0.001). Administration of a single dose of varicella vaccine was insufficient to decrease the prevalence of HZ <18 years of age. In the post-vaccination period, the frequency of HZ in unvaccinated cases increased in adolescence. In vaccinated children, HZ seems to develop at an earlier age.

Validation of International Classification of Diseases, Tenth Revision, Clinical Modification Codes for Identifying Cases of Chlamydia and Gonorrhea

BACKGROUND

While researchers seek to use administrative health data to examine outcomes for individuals with sexually transmitted infections (STIs), the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes used to identify persons with chlamydia and gonorrhea have not been validated. Objectives were to determine the validity of using ICD-10-CM codes to identify individuals with chlamydia and gonorrhea.

METHODS

We used data from electronic health records gathered from public and private health systems from October 1, 2015, to December 31, 2016. Patients were included if they were aged 13 to 44 years and received either (1) laboratory testing for chlamydia or gonorrhea or (2) an ICD-10-CM diagnosis of chlamydia, gonorrhea, or an unspecified STI. To validate ICD-10-CM codes, we calculated positive and negative predictive values, sensitivity, and specificity based on the presence of a laboratory test result. We further examined the timing of clinical diagnosis relative to laboratory testing.

RESULTS

The positive predictive values for chlamydia, gonorrhea, and unspecified STI ICD-10-CM codes were 87.6%, 85.0%, and 32.0%, respectively. Negative predictive values were high (>92%). Sensitivity for chlamydia diagnostic codes was 10.6%, and gonorrhea was 9.7%. Specificity was 99.9% for both chlamydia and gonorrhea. The date of diagnosis occurred on or after the date of the laboratory result for 84.8% of persons with chlamydia, 91.9% for gonorrhea, and 23.5% for unspecified STI.

CONCLUSIONS

Disease-specific ICD-10-CM codes accurately identify persons with chlamydia and gonorrhea. However, low sensitivities suggest that most individuals could not be identified in administrative data alone without laboratory test results.