One-year follow-up of zoster-associated pain in 764 immunocompetent patients with acute herpes zoster treated with famciclovir (FAMILIAR study)

The association between age and acute pain sensitivity in patients with Herpes Zoster

Herpes zoster has a well-established increased incidence in older adults, but the relationship between age and acute pain severity remains less clear. This retrospective study aimed to explore the association between age and pain intensity in Herpes zoster patients. A total of 613 patients treated at the Second Affiliated Hospital of Guangxi Medical University were included. Pain intensity was measured using the Numerical Rating Scale-11, and statistical models were applied to evaluate age-related pain differences while controlling for confounders. While older age was associated with higher pain scores (β = 0.02, p < 0.001), the effect size was small. Other factors, such as pain duration and inflammatory markers (e.g., CRP levels), showed stronger associations with pain severity. These findings suggest that age may not be the dominant factor in Herpes zoster pain severity, and a more comprehensive approach is required for risk assessment and pain management in clinical practice.

A systematic literature review of the epidemiology and burden of herpes zoster in selected locales in Asia Pacific

Herpes zoster (HZ) is a painful rash which typically affects older adults. This is of concern in Asia-Pacific given its aging population. As HZ epidemiology and burden are evolving, this systematic literature review aimed to update the current understanding of HZ burden and associated costs for selected Asia-Pacific locales. MEDLINE and Embase were searched for English articles of HZ studies conducted in Australia, China, Hong Kong, Japan, Korea, New Zealand, Singapore, and Taiwan. Eligible outcomes included HZ incidence and prevalence, occurrence of HZ-related complications, healthcare resource utilization, costs, and HZ-associated quality of life outcomes. This paper focused on HZ data in the general adult population (N = 90 articles). Substantial HZ-related disease and economic burden were observed in these locales, consistent with global trends. These findings reinforce the increasing burden of HZ and need for preventive strategies, which may include raising awareness and encouraging timely vaccination.

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.

Real-world safety and efficacy of amenamevir in patients with herpes zoster in Japan: A postmarketing observational study (REWARD)

The helicase-primase inhibitor amenamevir (AMNV) was approved for herpes zoster in Japan in 2017. The authors conducted a 1-month postmarketing observational study to evaluate the real-world safety and efficacy (cutaneous improvement and pain resolution) of AMNV in patients with herpes zoster. Of the 3453 patients registered between March 2018 and December 2020, 3110 were included in the safety analyses. The mean age (±standard deviation) was 63.7 ± 17.5 years, with 57.9% of patients aged ≥65 years. Most patients had mild (53.3%) or moderate (41.0%) cutaneous lesions. Regarding pain, 43.9%, 25.6%, and 12.5% of patients had pain at the levels of 1-3, 4-6, and 7-10 on the numerical rating scale. In total, 30.0%, 27.2%, and 16.1% of patients were concomitantly treated with analgesics: acetaminophen, nonsteroidal anti-inflammatory drugs, and Ca2+ channel α 2δ ligands, respectively, and 10.6% were treated with topical antiherpetic drugs. Adverse drug reactions occurred in 0.77% of patients, including four serious adverse drug reactions in four patients (hyponatremia, thrombocytopenia, rash, and rhabdomyolysis). Regarding important potential risks, renal disorder, cardiovascular events, and decreased platelets were observed in one, one, and two patients, respectively. Concerning efficacy, the cutaneous improvement rate (significantly improved or improved) was 95.5%, with significantly higher improvement rates in patients treated with AMNV for 7 days and in patients with less severe cutaneous lesions or less pain. Factors affecting the time to pain resolution were the severity of cutaneous lesions and pain at the start of AMNV treatment and older age. This study demonstrated that the AMNV is safe and effective in patients with herpes zoster in a real-world clinical setting.

Correlation between pain catastrophizing in acute herpes zoster and postherpetic neuralgia: a retrospective analysis

PURPOSE

The objective of this study was to examine the association between pain catastrophizing in acute phase herpes zoster and the development of postherpetic neuralgia.

METHODS

The medical records of all patients diagnosed with herpes zoster between February 2016 and December 2021 were retrieved. Inclusion criteria were patients aged > 50 years who visited our pain center within 60 days after rash onset and reported a pain intensity of ≥ 3 in a numerical rating scale. Patients with a score of 30 or more in the pain catastrophizing scale at baseline were assigned to the catastrophizer group, and those with a score < 30 were assigned to the non-catastrophizer group. We defined patients with "postherpetic neuralgia" and "severe postherpetic neuralgia" as those with a numerical rating scale score of 3 or more and 7 or more at 3 months after baseline, respectively.

RESULTS

Data of 189 patients were available for complete analysis. Age, baseline numerical rating scale, and prevalence of anxiety and depression were significantly higher in the catastrophizer than those in the non-catastrophizer group. Incidence of postherpetic neuralgia did not differ significantly between the groups (p = 0.26). Multiple logistic regression analysis showed that age, severe pain at baseline, and immunosuppressive state were the factors which were independently associated with developing postherpetic neuralgia. Severe pain at baseline was the only factor related to developing severe postherpetic neuralgia.

CONCLUSION

Pain catastrophizing in the acute phase of herpes zoster may not be related to the development of postherpetic neuralgia.

Risk Factors for Poor Pain Control in Zoster-Associated Pain: A Retrospective Study

INTRODUCTION

The objective was to investigate the risk factors for poor pain control in patients with herpes zoster (HZ)-associated neuropathic pain treated with drugs combined with nerve block therapy. Neuropathic pain commonly follows HZ. Nerve block therapy is the most commonly used clinical treatment for such pain, combining anti-inflammation and analgesia to prevent peripheral sensitization of nerve.

METHODS

Using clinical practice data from a cohort study at our research center, we established a multivariate logistic regression model to investigate potential risk factors for poor control of zoster-associated pain (ZAP) treated with drugs plus nerve block therapy, including demographic characteristics, complications, laboratory tests, and characteristics of HZ attacks.

RESULTS

Of the 429 patients with ZAP who received drugs plus nerve block therapy, 95 (22.14%) had poor pain control after treatment. The risk of poor pain control was closely related to presence of cancer (odds ratio (OR) 4.173, 95% confidence interval (CI) 1.342-12.970), numerical rating scale score on admission (OR 1.929, 95% CI 1.528-2.434), and red blood cell count (OR 0.560, 95% CI 0.328-0.954). Area under the receiver operator characteristic curve was 0.730. Goodness of fit (Hosmer-Lemeshow) was 0.874.

CONCLUSIONS

The risk of poor pain control in patients with ZAP increased as a result of certain patient characteristics and complications, especially severe pain before treatment and cancer.

A 1-Year Survey of Zoster-Associated Pain after Amenamevir Treatment

INTRODUCTION

Amenamevir is a new anti-varicella-zoster virus drug that inhibits the helicase-primase complex involved in viral replication. Amenamevir has the same effect as valaciclovir on acute pain and skin eruption, but no studies have examined the presence of long-term zoster-associated pain (ZAP) or postherpetic neuralgia (PHN) after amenamevir treatment.

METHODS

A total of 785 herpes zoster patients treated with amenamevir were followed up for 12 months. Patients recorded their pain status on a questionnaire once a month.

RESULTS

The proportion of patients with pain was 20.8% at 90 days, 8.0% at 180 days, 3.8% at 270 days, and 2.7% at 360 days after treatment. The median residual pain duration was 48 days. ZAP resolution rate slowed between 90 and 120 days, suggesting that the main feature of ZAP is a shift from nociceptive pain to neuropathic pain. Older age and more severe skin symptoms at the first visit were associated with a higher risk of developing PHN. Median ZAP duration was high for the head, face, and upper back and chest. Regarding the nature of pain, sudden pain attacks that felt like electric shocks, sensation of numbness, burning sensation, and cold/heat pain tended to remain as PHN.

CONCLUSIONS

Although conclusions must remain tentative without further comparative studies, amenamevir seems to have a similar effect on PHN as conventional nucleoside analogs, despite having a different action mechanism.

CLINICAL TRIAL REGISTRATION

UMIN000035938.

[Herpes zoster and subunit vaccine]

Varicella-zoster virus (VZV) causes varicella (chickenpox) as primary infection, and latently infects neuronal cells in the dorsal root ganglia (DRG). Reactivation of VZV from DRG results in herpes zoster, often decades later. VZV is the only airborne human herpesvirus and the only herpesvirus whose symptoms (both varicella and herpes zoster) can be prevented by vaccination. Herpes zoster is significantly more common in patients with bone marrow transplants, hematological malignancies, oral Jak inhibitors, SLE, and the elderly. The brand new subunit vaccine, ShingrixⓇ, for preventing herpes zoster is a mixture of adjuvant and recombinant VZV glycoprotein gE, which is highly effective in preventing zoster even in elderly people. In this review, the author discuss the onset mechanism of zoster from the clinical findings and summarize the result of clinical trials of the subunit vaccine.

Cost-Effectiveness of the Adjuvant Recombinant Zoster Vaccine in Japanese Adults Aged 65 Years and Older

INTRODUCTION

The incidence of herpes zoster (HZ) rises steeply after the age of 50 years and the number of HZ cases and complications such as postherpetic neuralgia (PHN) is predicted to increase because of the ageing population. The objective of this study was to estimate the cost-effectiveness of recombinant zoster vaccine (RZV) compared with no vaccine for the Japanese population aged ≥ 65 years.

METHODS

A multi-cohort static Markov model with a cycle length of 1 year was used to follow a hypothetical cohort of 1 million people aged ≥ 65 years over their remaining lifetime. Vaccination at ≥ 65 years was used in alignment with the influenza and pneumococcal vaccines recommended from 65 years. Japan-specific data inputs for the model were obtained from local data sources. Age-stratified vaccine efficacy and waning rates were based on published clinical trial data. In the base-case analysis, vaccine coverage was assumed to be 40% with a second dose compliance of 95%. Costs and outcomes were discounted at 2% annually and the incremental cost-effectiveness ratio (ICER) was calculated from both a payer's and the societal perspective. Sensitivity analyses were carried out to explore the overall uncertainty in the model.

RESULTS

Vaccination with RZV was projected to prevent 48,943 HZ cases and 12,136 PHN cases per million people aged ≥ 65 years compared with no vaccination. The incremental costs and quality-adjusted life years (QALYs) gained were ¥9.99 billion and 2314 QALYs from a payer's perspective and ¥9.34 billion and 2314 QALYs from a societal perspective. The resulting ICERs were approximately ¥4,320,000 and ¥4,040,000 per QALY gained from a payer's and the societal perspective, respectively. The ICER remained below a willingness-to-pay threshold of ¥5,000,000 for most sensitivity analyses carried out.

CONCLUSION

Vaccination against HZ with RZV would be cost-effective compared with no vaccination for the Japanese population aged ≥ 65 years.

TRIAL REGISTRATION

GSK study identifier: HO-16-17837.

FUNDING

GlaxoSmithKline Biologicals SA.

Burden of Herpes Zoster in the Japanese Population with Immunocompromised/Chronic Disease Conditions: Results from a Cohort Study Claims Database from 2005-2014

Introduction

The aim of this study is to describe the disease burden and costs of herpes zoster (HZ) in the general adult Japanese population or patients with immunocompromised (IC) conditions or chronic disorders.

Methods

A retrospective cohort study of individuals aged 18–74 years was conducted using January 2005 to December 2014 records from the Japan Medical Data Center claims database. Twenty-eight IC conditions and chronic disorders were defined by diagnosis codes and/or procedures/treatments. HZ and its related complications were identified. Incidence rates (IR), frequency of HZ-related complications, healthcare resource utilization (HRU), and direct medical costs were estimated. HRU and costs were estimated on a subcohort of HZ cases occurring April 2012–January 2014.

Results

The overall IR of HZ in the total cohort of 2,778,476 adults was 4.92/1000 person-years (PY) [95% confidence interval (CI): 4.86–4.98] and increased with age. The IR in the IC cohort (51,818 subjects) was 8.87/1000 PY (95% CI: 8.29–9.48), ranging from 5.55/1000 PY (95% CI: 4.26–7.09) in psoriasis to 151.68/1000 PY (95% CI: 111.45–201.71) in hematopoietic stem cell transplant recipients; most IRs were in the range 6–10/1000 PY. The IRs in individuals with chronic disorders were also relatively high, in the range 5.40–12.90/1000 PY. The frequency of postherpetic neuralgia was 4.01% (95% CI: 3.72–4.33) in the total cohort and 11.73% (95% CI: 9.01–14.93) in the IC cohort. The mean [standard deviation (SD)] number of outpatient visits was 3.4 (4.9) and 5.0 (5.7), respectively, and the proportion of HZ patients hospitalized was 2.20% and 6.70%, respectively. The mean (SD) direct medical cost per HZ episode was ¥34,664 (¥54,433) and ¥55,201 (¥92,642) in the total and IC cohort, respectively.

Conclusions

The elevated burden of HZ in Japanese individuals harboring IC conditions and chronic disorders documented in our study underlines the need for prevention of HZ in people with these conditions.

Funding

GlaxoSmithKline Biologicals SA.

Electronic supplementary material

The online version of this article (10.1007/s13555-018-0268-8) contains supplementary material, which is available to authorized users.

The Potential Public Health Impact of Herpes Zoster Vaccination of People Aged ≥ 50 Years in Japan: Results of a Markov Model Analysis

INTRODUCTION

The aim of this study was to compare the public health impact of introducing two herpes zoster (HZ) vaccines into the vaccination programs for the Japanese population aged ≥ 50 years: a single-dose Varicella Vaccine Live (VVL) or a two-dose adjuvanted Recombinant Zoster Vaccine (RZV).

METHODS

A multi-cohort static Markov model was developed to follow age cohorts (50-59, 60-69, 70-79 and ≥ 80 years) over their remaining lifetime. Japan-specific data inputs for the model were obtained from Japanese data sources. Age-stratified vaccine efficacy and waning rates were based on published clinical trial data. In the base-case analysis, vaccine coverage was assumed to be 40% for both vaccines, and compliance with second-dose of the RZV vaccine was set to 95%.

RESULTS

Vaccination with RZV was projected to prevent approximately 3.3 million HZ cases, 692,000 cases of postherpetic neuralgia (PHN), and 281,000 cases of other complications, compared with the prevention of 0.8 million HZ cases, 216,000 PHN cases, and 57,000 other complications with vaccination with VVL. The number of individuals needed to vaccinate in order to prevent one HZ case ranged from 6 to 14 using RZV (depending on age and assumed second-dose compliance) and from 21 to 138 depending on age using VVL. By preventing a higher number of HZ cases and its complications, RZV vaccination led to fewer outpatient visits and hospitalizations than vaccination with VVL.

CONCLUSION

Both vaccines had a positive public health impact compared to no vaccination, but due to its higher vaccine efficacy, RZV demonstrated a superior public health impact compared with VVL.

FUNDING

GlaxoSmithKline Biologicals SA.

[Herpes Zoster Vaccine]

Herpes zoster, or shingles, results from the reactivation of latent varicella- zoster virus (VZV) in the dorsal-root or cranial-nerve ganglia, usually decades after primary infection. Herpes zoster is characterized by a vesicular rash with a unilateral and dermatomal distribution and is almost always accompanied by pain. Herpes zoster is not only skin disease, but also sometimes affects other organs, including central nerve system, eye, and facial nerve. The most common complications, such as postherpetic neuralgia (PHN), are more frequent, severe and impair patients' quality of life. For more than 10 years, in US, EU, and Australia, a live-attenuated vaccine against herpes zoster (Zostavax) containing the Oka VZV strain is licensed for use in adults who are 50 years of age or older. In Japan, a live attenuated varicella vaccine is also licensed for preventing herpes zoster in 2016. Two large randomized multinational efficacy trials (ZOE-50 and ZOE-70) showed that the novel herpes zoster subunit vaccine (shinglix) candidate containing varicella-zoster virus glycoprotein E (gE) and the AS01B adjuvant system reduced the risk of herpes zoster and PHN by more than 90%. This article aimed to review the epidemiology, pathophysiology and complications of herpes zoster and mention the efficacies and problems of the live-attenuated and the new recombinant herpes zoster vaccines.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.