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Maja AK, Gu D, Ge L, Lopez-Jimenez C, Cohen EJ, Zegans ME. Characteristics of Prescreened Patients Who Did Not Participate in the Zoster Eye Disease Study. Eye Contact Lens 2024; 50:311-314. [PMID: 38722254 PMCID: PMC11209790 DOI: 10.1097/icl.0000000000001098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 06/27/2024]
Abstract
PURPOSE The Zoster Eye Disease Study (ZEDS) is a multicenter randomized clinical trial (RCT) funded by the National Eye Institute aiming to determine the efficacy of suppressive valacyclovir treatment in herpes zoster ophthalmicus (HZO) that enrolled fewer participants than planned (527/780, 67.6%). Understanding reasons for nonparticipation of likely eligible prescreened patients provides insights into patient populations that are not represented by ZEDS and barriers in clinical trials. METHODS In this retrospective cohort study, HZO adults likely eligible for ZEDS with a history of a typical rash and a medical record within the past year of an episode of epithelial or stromal keratitis or iritis were prescreened at activated Participating Clinical Centers from 2017 to 2022 using a standard prescreening log. De-identified data including demographic information, reasons for exclusion because of ineligibility, and patient refusal were retrospectively entered into REDCap and analyzed. RESULTS Prescreening logs with reasons for nonconsent (1244/1706, 72.9%) were included in the data set. Patients were excluded from the study (915/1244, 73.6%) because they did not meet all inclusion criteria (619/915, 67.7%) or met an exclusion criterion (296/915, 32.3%). Among the 12 exclusion criteria for the ZEDS study, immunocompromise (76/296, 25.7%) and renal insufficiency (50/296, 16.9%) were most frequently reported. Patient refusal to participate (327/1,244, 26.3%) was common. CONCLUSION The most common reasons for ineligibility were immunocompromise and renal insufficiency. There may be benefits to long-term antiviral use in these populations not captured in ZEDS. A quarter (26.3%) of prescreened patients refused participation, showing the substantial impact of patient preferences on trial participation.
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Affiliation(s)
- Ayodele K. Maja
- Dartmouth Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover NH
| | - Darren Gu
- Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Lily Ge
- NYU Grossman School of Medicine (NYUGSoM), New York, NY
| | - Carlos Lopez-Jimenez
- Office of Science and Research, NYUGSoM, NYU Langone Health (NYULH), New York, NY
| | | | - Michael E. Zegans
- Dartmouth Hitchcock Medical Center, Lebanon, NH
- Geisel School of Medicine at Dartmouth, Hanover NH
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Giannelos N, Curran D, Nguyen C, Kagia C, Vroom N, Vroling H. The Incidence of Herpes Zoster Complications: A Systematic Literature Review. Infect Dis Ther 2024; 13:1461-1486. [PMID: 38896390 PMCID: PMC11219681 DOI: 10.1007/s40121-024-01002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
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.
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Affiliation(s)
| | | | - Chi Nguyen
- Pallas Health Research & Consultancy, a P95 Company, Leuven, Belgium
| | - Carol Kagia
- Pallas Health Research & Consultancy, a P95 Company, Leuven, Belgium
| | - Nikki Vroom
- Pallas Health Research & Consultancy, a P95 Company, Rotterdam, Netherlands
| | - Hilde Vroling
- Pallas Health Research & Consultancy, a P95 Company, Rotterdam, Netherlands
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Chen HL, Chen CH, Hsieh WC, Huang YH, Hsu TJ, Tsai FJ, Cheng YC, Hsu CY. The risk of herpes zoster is positively associated with obesity, especially morbid obesity. Sci Rep 2024; 14:14330. [PMID: 38906945 PMCID: PMC11192763 DOI: 10.1038/s41598-024-65195-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 06/18/2024] [Indexed: 06/23/2024] Open
Abstract
This study aimed to investigate the association between obesity and herpes zoster (HZ) occurrence. This study used data covering 2 million people in Taiwan in 2000, which were obtained from the National Health Insurance Research Database. The cohort study observed aged 20-100 years with obesity from 2000 to 2017 (tracking to 2018). Obesity was indicated by the presence of two or more outpatient diagnoses or at least one admission record. And, obesity was categorized into non-morbid obesity and morbid obesity. Patients with HZ before the index date were excluded. The obesity cohort and control cohort were matched 1:1 according to age, sex, comorbidities, and index year. There were 18,855 patients in both the obesity and control cohorts. The obesity cohort [adjusted hazard ratio (aHR) 1.09] had a higher risk of HZ than the control cohort. Further analysis, the morbid obesity group (aHR 1.47), had a significantly higher risk of HZ than the non-morbid obesity group. Among the patients without any comorbidities, the patients with obesity had a significantly higher risk of developing HZ than the patients without obesity (aHR 1.18). Obese patients are at a higher risk of HZ development, especially in the patients with morbid obesity. Weight reduction is critical for preventing the onset of chronic diseases and decreasing the risk of HZ in patients with obesity.
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Affiliation(s)
- Hsiao-Lan Chen
- Division of Respiratory Therapy, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chia-Hung Chen
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
- Department of Medical Imaging, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Wen-Che Hsieh
- Department of Chinese Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Yu-Han Huang
- Management Office for Health Data, Clinical Trial Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Tzu-Ju Hsu
- Management Office for Health Data, Clinical Trial Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- Division of Medical Genetics, China Medical University Children's Hospital, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Yung-Chi Cheng
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
- Department of Rehabilitation, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Chao-Yu Hsu
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan.
- Department of Artificial Intelligence and Healthcare Management, Central Taiwan University of Science and Technology, Taichung, Taiwan.
- Center for General Education, National Taichung University of Science and Technology, Taichung, Taiwan.
- Department of General Education, National Chin-Yi University of Technology, Taichung, Taiwan.
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Przygocka A, Magnoni G, Picotti M, Rapanà R, La Manna G. Rare case of postherpetic abdominal pseudohernia in a patient on peritoneal dialysis. J Nephrol 2024:10.1007/s40620-024-01954-3. [PMID: 38837002 DOI: 10.1007/s40620-024-01954-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/06/2024] [Indexed: 06/06/2024]
Abstract
Patients affected by chronic kidney disease, especially those requiring maintenance dialysis therapy, are particularly susceptible to infections, including reactivation of herpes zoster and are also at increased risk of herpes zoster complications. Postherpetic abdominal pseudohernia is a rare sequela of the infection, caused by motor neuropathy with muscle paresis, that manifests as an abdominal protrusion. In patients receiving peritoneal dialysis who may often present slight abdominal distension, the diagnosis of this complication may be challenging. We present a case of this rare neurological complication in a patient on peritoneal dialysis and discuss its etiology and management. To the best of our knowledge, this is the first report of postherpetic abdominal pseudohernia in a patient receiving kidney replacement therapy.
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Affiliation(s)
- Agnieszka Przygocka
- Nephrology and Dialysis Unit, Santa Maria della Scaletta Hospital, Imola, Italy
| | - Giacomo Magnoni
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matilde Picotti
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Renato Rapanà
- Nephrology and Dialysis Unit, Santa Maria della Scaletta Hospital, Imola, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Kidney Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum - University of Bologna, Bologna, Italy.
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Steinmann M, Lampe D, Grosser J, Schmidt J, Hohoff ML, Fischer A, Greiner W. Risk factors for herpes zoster infections: a systematic review and meta-analysis unveiling common trends and heterogeneity patterns. Infection 2024; 52:1009-1026. [PMID: 38236326 PMCID: PMC11142967 DOI: 10.1007/s15010-023-02156-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/04/2023] [Indexed: 01/19/2024]
Abstract
PURPOSE The burden of herpes zoster (HZ) is substantial and numerous chronic underlying conditions are known as predisposing risk factors for HZ onset. Thus, a comprehensive study is needed to synthesize existing evidence. This study aims to comprehensively identify these risk factors. METHODS A systematic literature search was done using MEDLINE via PubMed, EMBASE and Web of Science for studies published from January 1, 2003 to January 1, 2023. A random-effects model was used to estimate pooled Odds Ratios (OR). Heterogeneity was assessed using the I2 statistic. For sensitivity analyses basic outlier removal, leave-one-out validation and Graphic Display of Heterogeneity (GOSH) plots with different algorithms were employed to further analyze heterogeneity patterns. Finally, a multiple meta-regression was conducted. RESULTS Of 6392 considered records, 80 were included in the meta-analysis. 21 different conditions were identified as potential risk factors for HZ: asthma, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), depression, diabetes, digestive disorders, endocrine and metabolic disorders, hematological disorders, HIV, inflammatory bowel disease (IBD), mental health conditions, musculoskeletal disorders, neurological disorders, psoriasis, renal disorders, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and transplantation. Transplantation was associated with the highest risk of HZ (OR = 4.51 (95% CI [1.9-10.7])). Other risk factors ranged from OR = 1.17-2.87, indicating an increased risk for all underlying conditions. Heterogeneity was substantial in all provided analyses. Sensitivity analyses showed comparable results regarding the pooled effects and heterogeneity. CONCLUSIONS This study showed an increased risk of HZ infections for all identified factors.
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Affiliation(s)
- Maren Steinmann
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany.
| | - David Lampe
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - John Grosser
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Juliana Schmidt
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Marla Louise Hohoff
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Anita Fischer
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wolfgang Greiner
- Department of Health Economics and Health Care Management, School of Public Health, Bielefeld University, Bielefeld, Germany
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Wang CA, Hsieh WC, Hsu TJ, Tsai FJ, Hsu CY. Obstructive sleep apnea increases the risk of herpes zoster and postherpetic neuralgia. Postgrad Med 2024; 136:22-29. [PMID: 38011906 DOI: 10.1080/00325481.2023.2288562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/23/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Diseases associated with chronic pain are typically a major source of stress for patients; and have been linked to herpes zoster (HZ) development. Here, we investigated whether obstructive sleep apnea (OSA) is a potential stressor that increases the risk of HZ and postherpetic neuralgia (PHN) in affected individuals. METHODS The data used in this study were obtained from the National Health Insurance Research Database. The study cohort included patients aged between 20 and 100 years who had OSA during the period from 2000 to 2017 (with tracking completed until 2018). The case group and the control group were matched at a 1:1 ratio on the basis of age, sex, comorbidities, and index year, with patients who had outcomes before the index date being excluded. The outcomes considered in this study were HZ and PHN. The risk of HZ and PHN with and without OSA was calculated, and age, sex, comorbidities, and index year were adjusted for. RESULTS There were 25,211 patients in each group. Patients with OSA had a significantly higher risk of HZ (adjusted hazard ratio [aHR] = 1.22) than those without did. The patients with OSA had also a significantly higher risk of PHN (aHR = 1.36) than those without did. In term of comorbidities, the patients with OSA without (aHR = 1.28) and with (aHR = 1.17) comorbidities had a significantly higher risk of HZ compared with those without OSA. In addition, the patients with OSA but no other comorbidities (aHR = 1.68) had a significantly higher risk of PHN than those without did. CONCLUSION OSA increases the risk of not only HZ but also PHN. Therefore, patients with OSA should be aware of the potential effect of the disease on their stress levels, as well as the increased risk of developing HZ and PHN.
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Affiliation(s)
- Chih-An Wang
- Division of Respiratory Therapy, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Wen-Che Hsieh
- Department of Chinese Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Tzu-Ju Hsu
- Management Office for Health Data, Clinical Trial Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Fuu-Jen Tsai
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- Division of Medical Genetics, China Medical University Children's Hospital, Taichung, Taiwan
- Department of Biotechnology and Bioinformatics, Asia University, Taichung, Taiwan
| | - Chao-Yu Hsu
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
- Department of Artificial Intelligence and Healthcare Management, Central Taiwan University of Science and Technology, Taichung, Taiwan
- Center for General Education, National Taichung University of Science and Technology, Taichung, Taiwan
- Department of General Education, National Chin-Yi University of Technology, Taichung, Taiwan
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Kho MML, Weimar W, Malahe SRK, Zuijderwijk JM, de Kuiper R, Boer-Verschragen MJ, van der Eijk AA, Hesselink DA, Reinders MEJ, van Besouw NM. Boosting the VZV-Specific Memory B and T Cell Response to Prevent Herpes Zoster After Kidney Transplantation. Front Immunol 2022; 13:927734. [PMID: 35935972 PMCID: PMC9352887 DOI: 10.3389/fimmu.2022.927734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Background Solid organ transplant recipients are at high risk to develop (complicated) herpes zoster (HZ). Booster vaccination could prevent HZ. However, end-stage renal disease (ESRD) patients show poor immunological responses to vaccinations. We studied the effect of a live attenuated VZV booster vaccine on VZV-specific B and T cell memory responses in ESRD patients and healthy controls. NL28557.000.09, www.toetsingonline.nl Methods VZV-seropositive patients, aged ≥50 years, awaiting kidney transplantation, were vaccinated with Zostavax®. Gender and age-matched VZV-seropositive potential living kidney donors were included as controls. VZV-specific IgG titers were measured before, at 1, 3 and 12 months post-vaccination. VZV-specific B and T cell responses before, at 3 months and 1 year after vaccination were analysed by flow-cytometry and Elispot, respectively. Occurrence of HZ was assessed at 5 years post-vaccination. Results 26 patients and 27 donors were included. Median VZV-specific IgG titers were significantly higher at all time-points post-vaccination in patients (mo 1: 3104 IU/ml [1967-3825], p<0.0001; mo 3: 2659 [1615-3156], p=0.0002; mo 12: 1988 [1104-2989], p=0.01 vs. pre: 1397 [613-2248]) and in donors (mo 1: 2981 [2126-3827], p<0.0001; mo 3: 2442 [2014-3311], p<0.0001; mo 12: 1788 [1368-2460], p=0.0005 vs. pre: 1034 [901-1744]. The patients’ IgG titers were comparable to the donors’ at all time-points. The ratio VZV-specific B cells of total IgG producing memory B cells had increased 3 months post-vaccination in patients (0.85 [0.65-1.34] vs. pre: 0.56 [0.35-0.81], p=0.003) and donors (0.85 [0.63-1.06] vs. pre: 0.53 [0.36-0.79], p<0.0001) and remained stable thereafter in donors. One year post-vaccination, the percentage of CD4+ central memory cells had increased in both patients (0.29 [0.08-0.38] vs. 0.12 [0.05-0.29], p=0.005) and donors (0.12 [0.03-0.37] vs. 0.09 [0.01-0.20], p=0.002) and CD4+ effector memory cells had increased in donors (0.07 [0.02-0.14] vs. 0.04 [0.01-0.12], p=0.007). Only 1 patient experienced HZ, which was non-complicated. Conclusion VZV booster vaccination increases VZV-specific IgG titers and percentage VZV-specific memory T-cells for at least 1 year both in ESRD patients and healthy controls. VZV-specific memory B cells significantly increased in patients up to 3 months after vaccination. Prophylactic VZV booster vaccination prior to transplantation could reduce HZ incidence and severity after transplantation.
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Affiliation(s)
- Marcia M. L. Kho
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
- *Correspondence: Marcia M. L. Kho,
| | - Willem Weimar
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - S. Reshwan K. Malahe
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joke M. Zuijderwijk
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ronella de Kuiper
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marieken J. Boer-Verschragen
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Annemiek A. van der Eijk
- Department of Viroscience, Erasmus Medical Centre (MC), University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Dennis A. Hesselink
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marlies E. J. Reinders
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Nicole M. van Besouw
- Erasmus Medical Centre (MC) Transplant Institute, Department of Internal Medicine, University Medical Center Rotterdam, Rotterdam, Netherlands
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Abstract
OBJECTIVE Both physical diseases such as infection and chronic pain and psychological disorders such as depression have been associated with herpes zoster (HZ) reactivation. However, the relationship between de Quervain syndrome (DQS), a painful tenosynovitis and HZ remains unclear. We investigated whether DQS increases the risk of HZ reactivation. DESIGN A retrospective population-based cohort study. SETTING Taiwan. PARTICIPANTS We used a subset of Taiwan's National Health Insurance Research Database, the Longitudinal Health Insurance Database which contains the registration files and original claims data of 1 million randomly selected individuals from the National Health Insurance programme. The case group in this study comprised patients newly diagnosed with DQS between 2000 and 2012. Individuals without DQS comprised the control group. Cases and controls were 1:1 matched by age, sex and index year (defined as the year of DQS diagnosis). RESULTS Approximately 55% of the participants were ≤49 years. Most participants were women (77%). The incidence rate of HZ in the DQS group was 8.39 per 1000 person years. After adjustments for age, sex and comorbidities, patients with DQS had a 1.30 times higher risk of HZ reactivation than the control group. Stratification analysis revealed taht DQS increases the HZ risk in individuals ≤64 years, women, and patients without comorbidities. CONCLUSION DQS is associated with an increased risk of HZ. Clinicians should be aware of this risk when dealing with patients with DQS, particularly in young adults.
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Affiliation(s)
- Chao-Yu Hsu
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
- Department of Optometry / Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung, Taiwan
- Center for General Education, National Taichung University of Science and Technology, Taichung, Taiwan
- Department of General Education, National Chin-Yi University of Technology, Taichung, Taiwan
- Rural Generalist Program Japan, GENEPRO, Japan
| | - Der-Shin Ke
- Department of Medical Education, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chia-Yi, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
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Risk Factors for Herpes Zoster in Patients with Chronic Kidney Disease: A Case-Control Study. Vaccines (Basel) 2021; 9:vaccines9090963. [PMID: 34579200 PMCID: PMC8473266 DOI: 10.3390/vaccines9090963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/21/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Chronic kidney disease (CKD) increases the susceptibility to the presence of herpes zoster (HZ). Little is known about the risk factors of HZ in CKD patients; (2) Methods: This is a case-control study. CKD patients diagnosed with HZ between January 2015 and June 2021 in a tertiary hospital were identified. One age- and gender- matched control was paired for each case, matched to the date of initial HZ diagnosis. Conditional multiple logistic regression was used to evaluate the risk factors associated with the presence of HZ; (3) Results: Forty-seven HZ patients and controls were identified. In general, about 73.40% (69 out of 94) patients were classified at IV to V stages of CKD. Immunosuppressive agents (p = 0.0012) and dialysis therapy (p = 0.021) were reported more frequently in the HZ cohort. Compared with the control group, the total white cell count and lymphocyte count were significantly lower in the HZ group (p value of 0.032 and 0.003, respectively). The conditional logistics regression model revealed that previous immunosuppressants administration (odds ratio: 10.861, 95% CI: 2.092~56.392, p = 0.005) and dialysis therapy (odds ratio: 3.293, 95% CI: 1.047~10.355, p = 0.041) were independent risk factors of HZ in the CKD population; (4) Conclusions: Dialysis and immunosuppressants therapy were associated with greater risk of HZ disease in CKD patients. Further guideline may highlight the necessity of zoster vaccine for patients with CKD, who undertake associated treatment.
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Babu TM, Kotton CN. Immunizations in Chronic Kidney Disease and Kidney Transplantation. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2021; 13:47-65. [PMID: 34025219 PMCID: PMC8126514 DOI: 10.1007/s40506-021-00248-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW Infection is a significant cause of morbidity and mortality in both patients with chronic kidney disease (CKD) and in recipients of a kidney transplant (KT). We review the current data in patients with CKD, on dialysis, and in KT recipients to provide further guidance for clinicians regarding vaccine optimization in this patient population. RECENT FINDINGS This patient population remains under-vaccinated and thus more vulnerable to vaccine-preventable illness. Despite diminished responses to immunization in this population, significant protection is generally achieved. SUMMARY Vaccines are an important preventative tool and offer protection against infection. In the setting of suboptimal and waning immunity in this patient population, future studies are indicated to determine optimal vaccination regimens.
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Affiliation(s)
- Tara M. Babu
- Division of Allergy and Infectious Diseases, University of Washington, 908 Jefferson Street, Suite 11NJ-1166, Seattle, WA 98104 USA
- Division of Infectious Diseases, University of Rochester Medical Center, Rochester, NY USA
| | - Camille N. Kotton
- Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Cox 5, Boston, MA 02114 USA
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Systematic Review and Meta-analysis of Herpes Zoster Vaccine in Patients With CKD. Kidney Int Rep 2021; 6:1254-1264. [PMID: 34013103 PMCID: PMC8116755 DOI: 10.1016/j.ekir.2021.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/04/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Chronic kidney disease (CKD) is a risk factor for herpes zoster (HZ) infection. Few studies have examined HZ vaccine (HZV) in this population. We conducted a systematic review and meta-analysis investigating the efficacy and safety of HZV in patients with renal disease (CKD, dialysis, and transplant). Methods MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases (up to May 2020) were searched for randomized controlled trials and nonrandomized controlled studies evaluating HZV in patients with CKD for effectiveness and adverse event risks. Studies without a control group (placebo or no vaccine) were excluded. Extraction of prespecified data and risk of bias assessments using the Newcastle-Ottawa scale for cohort studies and the Cochrane Risk of Bias Tool for randomized controlled trials were done by 3 authors. Random-effects meta-analysis was used to generate pooled treatment effects and 95% confidence intervals. Results Included were 404,561 individuals from 8 studies (3 randomized controlled trials and 5 nonrandomized). All 8 studies examined HZ as an outcome, with 3 reporting adverse events. Risk of HZ was lower in patients who received HZV compared with controls (hazard ratio, 0.55; 95% confidence interval, 0.37–0.82; P < 0.01); however, heterogeneity was high (I2 = 88%, P < 0.01). There was no significant difference in adverse events associated with HZV (hazard ratio, 1.03; 95% confidence interval, 0.54–1.28; P = 0.8). Conclusions HZV compared with control significantly lowers the risk of HZ without an increase in adverse events in CKD patients. However, significant heterogeneity was present. HZV should be actively considered in CKD patients because the prevalence of HZ is higher in this population.
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Lai SW, Kuo YH, Lin CL, Liao KF. Risk of herpes zoster among patients with predialysis chronic kidney disease in a cohort study in Taiwan. Int J Clin Pract 2020; 74:e13566. [PMID: 32479686 DOI: 10.1111/ijcp.13566] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/02/2020] [Accepted: 05/26/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND/OBJECTIVE Patients on chronic dialysis are at risk of developing herpes zoster, but little systematic research focuses on the association between predialysis chronic kidney disease and herpes zoster. The objective of the study was to explore the association between predialysis chronic kidney disease and herpes zoster in Taiwan. METHODS A nation-based retrospective cohort study was performed using the 2005-2012 database of the Taiwan National Health Insurance Program. There were 16 655 subjects aged 20-84 years with newly diagnosed predialysis chronic kidney disease as the study group and 33 310 randomly selected subjects without chronic kidney disease as the comparison group. Both groups were matched with sex, age, comorbidities and the year of the index date. The incidence rates of herpes zoster in both groups were calculated. The multivariable Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for herpes zoster associated with predialysis chronic kidney disease. RESULTS The overall incidence rate of herpes zoster was 1.4-fold higher in the predialysis chronic kidney disease group than that in the non-chronic kidney disease group (8.76 vs 6.27 per 1000 person-years, 95% CI 1.27-1.54; P < .001). After controlling for co-variables, the adjusted HR of herpes zoster was 1.38 (95% CI 1.25-1.53; P < .001) for subjects with predialysis chronic kidney disease compared with non-chronic kidney disease subjects. The adjusted HR increased to 1.65 for subjects with predialysis chronic kidney disease and with any comorbidity (95% CI 1.42-1.92; P < .001). CONCLUSIONS Patients with predialysis chronic kidney disease correlate with approximately 1.4-fold increased hazard of developing herpes zoster.
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Affiliation(s)
- Shih-Wei Lai
- College of Medicine, and College of Public Health, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Hung Kuo
- Department of Research, Taichung Tzu Chi Hospital, Taichung, Taiwan
| | - Cheng-Li Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Fu Liao
- College of Medicine, Tzu Chi University, Hualien, Taiwan
- Division of Hepatogastroenterology, Department of Internal Medicine, Taichung Tzu Chi Hospital, Taichung, Taiwan
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Yin D, Van Oorschot D, Jiang N, Marijam A, Saha D, Wu Z, Tang H, Diaz-Decaro J, Watson P, Xie X, Ren Y, He Y, Feng Y. A systematic literature review to assess the burden of herpes zoster disease in China. Expert Rev Anti Infect Ther 2020; 19:165-179. [PMID: 32997550 DOI: 10.1080/14787210.2020.1792290] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Herpes zoster (HZ) or shingles occurs as a result of reactivation after a primary infection with varicella zoster virus (chickenpox). The burden of HZ in older adults in China is not well understood. We conducted a systematic literature review to understand the burden of disease related to HZ, its complications, and associated costs in China. AREAS COVERED Using publications retrieved from Chinese and English literature databases, we described incidence and prevalence of HZ, occurrence of HZ-related complications, and costs associated with HZ in mainland China, Taiwan, and Hong Kong. EXPERT OPINION The data, although limited, indicate that the burden of disease due to HZ is substantial in China, with incidence rates that are comparable to the rest of the world. Recently, an adjuvanted recombinant HZ vaccine was approved for use in China. Disease prevention is likely to reduce the burden of disease, with potentially significant economic benefits. However, understanding the public health impact of vaccination in China will require extensive baseline information about incidence, complication rates, and associated costs. This review gives an overview of available research, but also reveals existing gaps. Well-designed observational studies are needed to quantify the total burden of disease and potential impact of prevention through vaccination.
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Affiliation(s)
- Dapeng Yin
- Epidemiology Office, Chinese Center for Disease Control and Prevention , Beijing, China
| | | | - Ning Jiang
- Vaccines Medical/Clinical, GSK China , Beijing, China
| | - Alen Marijam
- Value Evidence and Outcomes, GSK Upper Providence , PA, USA
| | - Debasish Saha
- Epidemiology & Health Economics, GSK , Wavre, Belgium
| | - Zhenhua Wu
- Vaccines Medical/Clinical, GSK China Al , Beijing, China
| | - Haiwen Tang
- China/Hong Kong Vaccines Research & Development, GSK , Shanghai, China
| | | | - Phil Watson
- Medical Affairs Lead, Zoster, New Wave Countries, GSK , Leeds, UK
| | - Xueqiong Xie
- R&D, Xiamen Chazen Biomedical Technology Co. Ltd , Xiamen, China
| | - Yifan Ren
- R&D, Xiamen Chazen Biomedical Technology Co. Ltd , Xiamen, China
| | - Yu He
- Vaccines Medical, GSK China , Shanghai, China
| | - Yang Feng
- R&D, Xiamen Chazen Biomedical Technology Co. Ltd , Xiamen, China
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14
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Ma BM, Yap DYH, Yip TPS, Hung IFN, Tang SCW, Chan TM. Vaccination in patients with chronic kidney disease-Review of current recommendations and recent advances. Nephrology (Carlton) 2020; 26:5-11. [PMID: 32524684 DOI: 10.1111/nep.13741] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/07/2020] [Accepted: 06/01/2020] [Indexed: 12/11/2022]
Abstract
Hepatitis B virus (HBV), influenza, pneumococcus and herpes zoster are important infections which could result in significant morbidity and mortality in patients with chronic kidney disease (CKD). While seroconversion rates after vaccination are often lower in CKD patients compared with healthy adults due to impaired innate and adaptive immunity, vaccinations for HBV, influenza, pneumococcus and herpes zoster are generally effective in reducing the transmission and/or severity of these infections. Practical issues that have an impact on the efficacy of vaccination in the CKD population include the timing, dose, schedule of vaccination, the route of administration, and adjuncts applied at time of vaccination. This review discusses the vaccination regimens and the efficacy of HBV, influenza, pneumococcus and zoster vaccines in CKD patients, and highlights recent advances in enhancing vaccine seroconversion rates.
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Affiliation(s)
- Becky Mingyao Ma
- Division of Nephrology, Department of Medicine, Queen Mary Hospital and Tung Wah Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Desmond Yat Hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital and Tung Wah Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Terence Pok Siu Yip
- Division of Nephrology, Department of Medicine, Queen Mary Hospital and Tung Wah Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Ivan Fan Ngai Hung
- Division of Infectious Disease, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Sydney Chi Wai Tang
- Division of Nephrology, Department of Medicine, Queen Mary Hospital and Tung Wah Hospital, The University of Hong Kong, Hong Kong, Hong Kong
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital and Tung Wah Hospital, The University of Hong Kong, Hong Kong, Hong Kong
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15
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Marra F, Parhar K, Huang B, Vadlamudi N. Risk Factors for Herpes Zoster Infection: A Meta-Analysis. Open Forum Infect Dis 2020; 7:ofaa005. [PMID: 32010734 PMCID: PMC6984676 DOI: 10.1093/ofid/ofaa005] [Citation(s) in RCA: 118] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 01/07/2020] [Indexed: 12/19/2022] Open
Abstract
Background The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ. Methods The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling. Results From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85). Conclusions This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.
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Affiliation(s)
- Fawziah Marra
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kamalpreet Parhar
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bill Huang
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nirma Vadlamudi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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16
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Krueger KM, Ison MG, Ghossein C. Practical Guide to Vaccination in All Stages of CKD, Including Patients Treated by Dialysis or Kidney Transplantation. Am J Kidney Dis 2019; 75:417-425. [PMID: 31585683 DOI: 10.1053/j.ajkd.2019.06.014] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/08/2019] [Indexed: 01/26/2023]
Abstract
Infection is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), including those receiving maintenance dialysis or with a kidney transplant. Although responses to vaccines are impaired in these populations, immunizations remain an important component of preventative care due to their favorable safety profiles and the high rate of infection in these patients. Most guidelines for patients with CKD focus on the importance of the hepatitis B, influenza, and pneumococcal vaccines in addition to age-appropriate immunizations. More data are needed to determine the clinical efficacy of these immunizations and others in this population and define optimal dosing and timing for administration. Studies have suggested that there may be a benefit to immunization before the onset of dialysis or transplantation because patients with early-stage CKD generally have higher rates of seroconversion. Because nephrologists often serve as primary care physicians for patients with CKD, it is important to understand the role of vaccinations in the preventive care of this patient population.
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Affiliation(s)
- Karen M Krueger
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Michael G Ison
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, IL; Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Cybele Ghossein
- Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, IL
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17
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Low level of hemoglobin A1c and the increased incidence of herpes zoster: longitudinal study. Eur J Clin Microbiol Infect Dis 2019; 38:1539-1545. [DOI: 10.1007/s10096-019-03584-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/07/2019] [Indexed: 12/27/2022]
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18
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Rondaan C, de Joode AAE, van Assen S, Bos NA, Westerhuis R, Westra J. Increased incidence of herpes zoster in patients on renal replacement therapy cannot be explained by intrinsic defects of cellular or humoral immunity to varicella-zoster virus. Antiviral Res 2018; 158:206-212. [PMID: 30102958 DOI: 10.1016/j.antiviral.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/08/2018] [Accepted: 08/09/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients in need of long-term renal replacement therapy (RRT) are known to be at increased risk of herpes zoster, occurring when the latently present varicella-zoster virus (VZV) reactivates. In this study we investigated immunity to VZV in patients receiving RRT, with the aim of better understanding the mechanism behind the increased risk. METHODS Patients treated for at least three months with hemodialysis or peritoneal dialysis, and matched healthy controls (HC) were included. Cellular immunity to varicella-zoster virus (VZV) was studied using an interferon-γ (IFNγ) enzyme-linked immunospot (ELISpot) assay, flow-cytometric analysis of cytokine production and a proliferation assay. Humoral immunity was determined by measuring immunoglobulin (Ig)G antibody levels to VZV using an in-house glycoprotein enzyme-linked immunosorbent assay (ELISA). Multiple regression was used to assess variables of influence on measures of cellular and humoral immunity to VZV in patients receiving RRT. RESULTS Similar numbers of IFNγ spot-forming cells and levels of VZV-IgG were found in 97 patients and 89 HC. Age and transplantation history were negatively associated with cellular immunity (p = 0.001 and p = 0.012, respectively) while treatment modality, gender and urea levels were not. No variables were found to be associated with VZV-IgG levels. CONCLUSIONS Increased incidence of herpes zoster in patients receiving RRT cannot be explained by intrinsic defects of cellular or humoral immunity to VZV as measured by the methods used in this study, although older age and previous transplantation were associated with decreased cellular immunity to VZV. Herpes zoster susceptibility might be caused by a diminished function of otherwise capable T cells in a uremic environment.
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Affiliation(s)
- Christien Rondaan
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Anoek A E de Joode
- Department of Internal Medicine, Division of Nephrology, University Medical Centre Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Sander van Assen
- Department of Internal Medicine (Infectious Diseases), Treant Care Group, Dr. G.H. Amshoffweg 1, 7909 AA, Hoogeveen, The Netherlands.
| | - Nicolaas A Bos
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Ralf Westerhuis
- Dialysis Centre Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen and University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
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Miller G, Schaefer H, Yoder S, Miller R, Winokur P, Kotloff K, Klassen D, Wierzbicki M, Amegashie C, Edwards K. A randomized, placebo-controlled phase I trial of live, attenuated herpes zoster vaccine in subjects with end-stage renal disease immunized prior to renal transplantation. Transpl Infect Dis 2018; 20:e12874. [DOI: 10.1111/tid.12874] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/11/2017] [Accepted: 12/28/2017] [Indexed: 12/16/2022]
Affiliation(s)
- Geraldine Miller
- Division of Infectious Disease; Department of Medicine; Vanderbilt University Medical Center; Nashville TN USA
| | - Heidi Schaefer
- Division of Nephrology; Department of Medicine; Vanderbilt University Medical Center; Nashville TN USA
| | - Sandra Yoder
- Vanderbilt Vaccine Research Program; Department of Pediatrics; Vanderbilt University Medical Center; Nashville TN USA
| | - Rachel Miller
- Division of Infectious Diseases; Department of Medicine; University of Iowa; Carver College of Medicine; Iowa City IA USA
| | - Patricia Winokur
- University of Iowa; Carver College of Medicine; Iowa City IA USA
| | - Karen Kotloff
- Division of Infectious Disease and Tropical Pediatrics; Department of Medicine; Center for Vaccine Development; Institute for Global Health; University of Maryland School of Medicine; Baltimore MD USA
| | - David Klassen
- Division of Nephrology; Department of Medicine; University of Maryland School of Medicine; Baltimore MD USA
| | | | | | - Kathryn Edwards
- Vanderbilt Vaccine Research Program; Division of Infectious Diseases; Department of Pediatrics; Vanderbilt University Medical Center; Nashville TN USA
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20
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Levin MJ, Bresnitz E, Popmihajlov Z, Weinberg A, Liaw KL, Willis E, Curtis JR. Studies with herpes zoster vaccines in immune compromised patients. Expert Rev Vaccines 2017; 16:1217-1230. [PMID: 29053937 DOI: 10.1080/14760584.2017.1395703] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The active component of the herpes zoster vaccine (ZVL), licensed for people ≥50 years of age, is a live attenuated varicella-zoster virus. ZVL is contraindicated for immune compromised individuals, with limited regard to the degree of immunosuppression. Areas covered: This review evaluates phase I and II and observational studies for ZVL, and published reports of the off-label use of ZVL, for conditions and therapies for which investigators considered the risk-benefit for using ZVL to be favorable. It also discusses exploratory trials of ZVL for additional immune compromising conditions, and summarizes clinical guidelines from many countries and professional societies that are based upon recent investigations. Studies in immune compromised patients of investigational vaccines that do not contain live virus are reviewed. Expert commentary: It is likely that past and ongoing research with ZVL will define immune compromising diseases and/or therapies for which the risk-benefit for using ZVL vaccine is favorable. The main variables to consider in this assessment in immune compromised patients are safety, immunogenicity, protection against herpes zoster, and persistence of protection. Vaccination against herpes zoster prior to suppressing immunity is an important clinical strategy, although efficacy of this approach has not been evaluated in a clinical trial.
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Affiliation(s)
- Myron J Levin
- a Section of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | | | | | - Adriana Weinberg
- a Section of Pediatric Infectious Diseases, Departments of Pediatrics and Medicine , University of Colorado Anschutz Medical Campus , Aurora , CO , USA
| | | | | | - Jeffrey R Curtis
- c Division of Clinical Immunology and Rheumatology , University of Alabama , Birmingham , AL , USA
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Akimoto T, Muto S, Nagata D. Bilateral herpes zoster in a patient with end-stage kidney disease. Int Med Case Rep J 2017; 10:209-212. [PMID: 28684923 PMCID: PMC5484569 DOI: 10.2147/imcrj.s138398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Herpes zoster (HZ) is caused by the reactivation of a latent varicella-zoster virus (VZV) infection within the cranial or dorsal root ganglia. The cutaneous lesions of HZ are typically limited to a single dermatome, while non-contiguous HZ involving two or more dermatomes is a very rare clinical entity. In this report, we describe a case of HZ involving the left and right side of the abdomen corresponding to the T11 dermatome in a 63-year-old man on chronic peritoneal dialysis. The characteristic cutaneous manifestation encouraged us to ascribe the disease to HZ duplex bilateralis, and the patient was given a single dose of oral valacyclovir and achieved a favorable outcome. The therapeutic concerns regarding the reactivation of VZV in patients with end-stage kidney disease are also discussed.
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Affiliation(s)
- Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
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22
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Chen LK, Arai H, Chen LY, Chou MY, Djauzi S, Dong B, Kojima T, Kwon KT, Leong HN, Leung EMF, Liang CK, Liu X, Mathai D, Pan JY, Peng LN, Poblete ERS, Poi PJH, Reid S, Tantawichien T, Won CW. Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific. BMC Infect Dis 2017; 17:213. [PMID: 28298208 PMCID: PMC5353949 DOI: 10.1186/s12879-017-2198-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 01/09/2017] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan. .,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, 7-340 Morioka-cho, Obu, Aichi, 474-8511, Japan
| | - Liang-Yu Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan
| | - Ming-Yueh Chou
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan
| | - Samsuridjal Djauzi
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Salemba Raya No. 6, Jakarta, 10430, Indonesia
| | - Birong Dong
- The Center of Gerontology and Geriatrics, West China Medical School/West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Renmin Nan Lu, Chengdu, Sichuan, 610041, China
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Jongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ki Tae Kwon
- Division of Infectious Diseases, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu, 710-600, Korea
| | - Hoe Nam Leong
- Rophi Clinic, 38 Irrawaddy Rd. #07-54/55, Mount Elizabeth Novena Specialist Centre, Singapore, 329563, Singapore
| | - Edward M F Leung
- Geriatric Medicine Centre (Healthy Ageing), Hong Kong Sanatorium and Hospital, 2 Village Rd. Happy Valley, Hong Kong S.A.R., China
| | - Chih-Kuang Liang
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Xiaohong Liu
- Division of Geriatrics, Department of Internal Medicine, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Dilip Mathai
- Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Jubilee Hills, Hyderabad, 500096, India
| | - Jiun Yit Pan
- National Skin Centre, 1 Mandalay Rd., Singapore, 308205, Singapore
| | - Li-Ning Peng
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | - Eduardo Rommel S Poblete
- Geriatric Center, St. Luke's Medical Center, 279 E. Rodriguez Sr. Ave., Quezon City, 1102, Philippines
| | - Philip J H Poi
- Division of Geriatrics, Department of Medicine, University Malaya Medical Centre, Lembah Pantai, 59100, Kuala Lumpur, Malaysia
| | - Stewart Reid
- Ropata Medical Centre, Lower Hutt, 5010, New Zealand
| | - Terapong Tantawichien
- Division of Infectious Diseases, Department of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Chang Won Won
- Department of Family Medicine, College of Medicine, Kyung Hee University, 1 Hoigi-dong, Dongdaemun-gu, Seoul, 130-720, Korea
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23
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Langan SM, Thomas SL, Smeeth L, Margolis DJ, Nitsch D. Zoster vaccination is associated with a reduction of zoster in elderly patients with chronic kidney disease. Nephrol Dial Transplant 2016; 31:2095-2098. [PMID: 26769683 PMCID: PMC5146705 DOI: 10.1093/ndt/gfv432] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/24/2015] [Indexed: 11/13/2022] Open
Abstract
Background Growing epidemiological evidence demonstrates increased zoster risks in people with chronic kidney disease (CKD). Study objectives were to determine zoster vaccine effectiveness in individuals with CKD in pragmatic use. Methods A population-based cohort study was undertaken in a 5% random sample of US Medicare from 2007 to 2009 involving 766 330 eligible individuals aged ≥65 years who were (29 785) and were not (736 545) exposed to the zoster vaccine. Incidence rates for zoster in vaccinated and unvaccinated individuals and hazard ratios for zoster comparing vaccinated with unvaccinated were determined for individuals with CKD. Time-updated Cox proportional hazards models were used, adjusting for relevant confounders. Results CKD was present in 183 762 (24%) of individuals (15% of vaccinees). Adjusted vaccine effectiveness [95% confidence intervals (CIs)] in individuals with CKD was 0.49 (0.36–0.65). The adjusted vaccine effectiveness in participants with both CKD and diabetes mellitus was 0.46 (95% CI 0.09–0.68). Vaccine effectiveness estimates were similar to those previously reported for the general population [vaccine effectiveness 0.48 (95% CI 0.39–0.56)]. Conclusions Zoster vaccine is effective against incident zoster in older individuals with CKD. Extra efforts are warranted to increase vaccine uptake in individuals with CKD given the known low uptake in these higher risk individuals.
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Affiliation(s)
- Sinéad M Langan
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Sara L Thomas
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - David J Margolis
- Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
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24
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Tseng HF, Luo Y, Shi J, Sy LS, Tartof SY, Sim JJ, Hechter RC, Jacobsen SJ. Effectiveness of Herpes Zoster Vaccine in Patients 60 Years and Older With End-stage Renal Disease. Clin Infect Dis 2015; 62:462-7. [PMID: 26671505 DOI: 10.1093/cid/civ930] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 10/21/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Unlike in a healthy population, the protection of herpes zoster (HZ) vaccine in end-stage renal disease (ESRD) patients might be insufficient, considering data demonstrating suboptimal response to other vaccines. The study evaluates the association between HZ vaccination and the subsequent HZ risk among ESRD patients. METHODS This cohort study included ESRD patients age ≥60 years who were enrolled in Kaiser Permanente Southern California. The vaccinated cohort included 582 patients who received HZ vaccine during 01/01/2007 through 12/31/2013. Each vaccinated patient was matched to five unvaccinated patients on age, sex, and dialysis duration. Subjects were passively followed through their electronic health records to identify HZ incidence. Cox regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) associated with vaccination. Kaplan-Meier estimates of the cumulative incidence were generated. RESULTS The number of HZ cases was 16 in 1373 person-years (11.7 per 1000 person-years; 95% CI, 7.1-19.0) among the vaccinated and 126 in 5644 person-years (22.3 per 1000 person-years; 95% CI, 18.7-26.6) among the unvaccinated. The 36-month cumulative risk of incident HZ was 4.1% and 6.6%, respectively. HZ vaccination was associated with a reduced risk of HZ (adjusted HR = 0.49; 95% CI, .29-.85). The reduced risk seems more prominent if the vaccine is given within two years of dialysis initiation. CONCLUSIONS Among ESRD patients age ≥60 years, receipt of HZ vaccine was associated with a lower incidence of HZ. In addition, HZ vaccination soon after the initiation of dialysis may provide greater protection.
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Affiliation(s)
- Hung Fu Tseng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Yi Luo
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jiaxiao Shi
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Lina S Sy
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Sara Y Tartof
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - John J Sim
- Division of Nephrology and Hypertension, Kaiser Permanente Los Angeles Medical Center, California
| | - Rulin C Hechter
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Steven J Jacobsen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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25
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High Risk of Herpes Zoster among Patients with Advance Acute Kidney Injury--A Population-Based Study. Sci Rep 2015; 5:13747. [PMID: 26333822 PMCID: PMC4558719 DOI: 10.1038/srep13747] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 08/03/2015] [Indexed: 12/23/2022] Open
Abstract
The risk for herpes zoster (HZ) in acute kidney injury (AKI) survivors was never explored. We identified 2,387 adults in the Taiwan National Health Insurance Research Database who recovered from dialysis-requiring AKI and matched them with non-recovery and non-AKI patients by propensity score. During a mean follow-up of 2.7 years, the incidences of HZ were 6.9, 8.2 and 4.8 episodes per 1,000 person-years in AKI-non-recovery, AKI-recovery and non-AKI group, respectively. The recovery group was more likely to develop herpes zoster than those without acute kidney injury [incidence-rate ratios 1.71, 95% confidence interval 1.16-2.52; p = 0.007]. Patients without acute kidney injury were less likely to develop herpes zoster than those AKI, recovered from dialysis or not (hazard ratio HR 0.66, 95% CI 0.46-0.95). Dialysis-requiring acute kidney injury poses a long-term risk of herpes zoster after hospital discharge. Even patients who have recovered from dialysis still carry a significantly higher risk of developing herpes zoster.
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26
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Vikrant S. Long-term clinical outcomes of peritoneal dialysis patients: 9-year experience of a single center from north India. Perit Dial Int 2014; 34:426-33. [PMID: 24385327 DOI: 10.3747/pdi.2013.00050] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE There is a paucity of published data on the outcome of maintenance peritoneal dialysis (PD) since the initiation of continuous ambulatory PD (CAPD) in India in 1991. The purpose of this study is to report long-term clinical outcomes of PD patients at a single center. DESIGN Retrospective study. SETTING A government-owned tertiary-care hospital in North India. PATIENTS Patients who were initiated on CAPD between October 2002 and June 2011, and who survived and/or had more than 6 months' follow-up on this treatment with last follow-up till December 31, 2011, were studied. RESULTS A total of 60 patients were included in the analysis. The mean age of the patients was 60.2 ± 9.2 years. The majority (65%) of the patients lived in rural areas. A high proportion (47%) were diabetic and 62% had ≥ 2 comorbidities. Total duration on peritoneal dialysis treatment was 1,773 patient-months (148 patient-years) with a mean duration of 29.6 ± 23 patient-months and median duration of 25 patient-months (range 6 - 110 patient-months). Overall patient and technique survival at 1, 2, 3, 4 and 5 years was 77%, 53%, 25%, 15%, and 10% respectively. Patient survival of diabetics vs non-diabetics at 1, 2, 3, 4, and 5 years was 68% vs 84%, 54% vs 53%, 14% vs 34%, 11% vs 19%, and 11% vs 13%, respectively. The mortality in non-diabetics (16/32) was less than that in diabetic (18/28) patients (p = not significant). The main cause of mortality in these patients was cardiac followed by sepsis. There were 58 episodes of peritonitis. The rate of peritonitis was 1 episode per 30.6 patient-months or 0.39 episodes per patient-year. Furthermore, the total number of episodes of peritonitis and number of episodes of peritonitis per patient were higher in the non-survival group (p < 0.05). The incidence of tuberculosis (TB), herpes zoster (HZ) and hernias was 15%, 10% and 5% respectively. CONCLUSION The study reports long-term outcomes of the PD patients, the majority of whom were elderly with a high burden of comorbidities. There was a high proportion of diabetics. The survival of diabetic vs non-diabetic and elderly vs non-elderly PD patients was similar in our study. The mortality in non-diabetics was less than that in diabetic patients. TB and HZ were common causes of morbidity. Peritonitis was associated with mortality in these patients.
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Affiliation(s)
- Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College, Shimla (Himachal Pradesh), 171001 India
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27
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Soni R, Horowitz B, Unruh M. Immunization in end-stage renal disease: opportunity to improve outcomes. Semin Dial 2013; 26:416-26. [PMID: 23751048 DOI: 10.1111/sdi.12101] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Infection is the second most common cause of death in patients with end-stage renal disease (ESRD), following cardiovascular causes. Immunization is a fairly simple, but underutilized, strategy for prevention of infectious morbidity and mortality in patients with kidney failure. It is imperative for nephrologists and primary care providers to have an understanding of immunization as an essential component of preventive healthcare measures in this high-risk population. Patients with ESRD represent a unique population due to their immunosuppressed state, dialysis-related exposures and suboptimal response to routine vaccines. While the Advisory Committee on Immunization Practices (ACIP) provides guidelines for vaccination of patients with renal disease against Hepatitis B, influenza and pneumococcal disease, the data on immunization against other commonly preventable infectious diseases are lacking. This article reviews the recent evidence on immunization in the ESRD population and synthesizes the related implications for maximizing prevention of infectious diseases in this high-risk population.
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Affiliation(s)
- Ritu Soni
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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