Varicella seroprevalence in the U.S.: data from the National Health and Nutrition Examination Survey, 1999-2004

Herpes zoster and long-term risk of subjective cognitive decline

BACKGROUND

Herpes zoster (HZ), commonly known as "shingles," may contribute to cognitive decline through mechanisms such as neuroinflammation or direct neuronal injury. However, evidence on the longitudinal association between HZ and cognitive decline is conflicting and whether the risk differs by APOE ε4-carrier status has not been studied; prospective cohort studies on the association between HZ vaccination and cognitive decline are also lacking.

METHODS

We included 149,327 participants from three large cohorts-the Nurses' Health Study (NHS), NHSII, and Health Professionals Follow-Up Study (HPFS)-to prospectively examine the association between HZ and subsequent subjective cognitive decline (SCD). Poisson regression was used to estimate the multivariable-adjusted relative risk (MVRR) of a 3-unit increment in SCD score according to years since HZ compared with participants with no history of HZ.

RESULTS

Compared with individuals with no history of HZ, the MVRR (95% CI) of a 3-unit increment in SCD score was significantly and independently higher among individuals with a history of HZ, but the duration of time since HZ when the elevated risk of SCD was statistically significant differed among the cohorts. In NHS, HZ was associated with higher long-term risk of SCD; compared with individuals with no history of HZ, the MVRR (95% CI) of a 3-unit increment in SCD score was 1.14 (1.01, 1.32) for ≥ 13 years since HZ. In NHS II, HZ was associated with higher risk of SCD in both the short-term [MVRR 1.34 (1.18, 1.53) for 1-4 years] and long-term [MVRR 1.20 (1.08, 1.34) for ≥ 13 years since HZ]. In HPFS, an elevated risk of SCD was suggested across all time points. Among the subset of participants with information on APOE ε4, there was a suggestion that the association differed by APOE ε4 carrier status, but the results were not consistent between women and men. Among the subset of women with information on HZ vaccination, there was a suggestion that the long-term risk of SCD may be greater among women who were not vaccinated against HZ.

CONCLUSIONS

Data from three large independent cohorts of women and men showed that HZ was associated with higher long-term risk of SCD, and the risk may differ by APOE ε4-carrier status.

Primary Varicella Infection in a Young Adult from the Democratic Republic of the Congo: A Case Report and Mini-Review

We describe a case of an immunocompetent adult male patient originally from the Democratic Republic of Congo (DRC), who was referred to our unit for a several-day history of fever and a pruritic, vesicular rash. There was initial concern in the Emergency Department for Mpox (formerly known as "monkeypox") given the current epidemiology versus other viral etiologies. Primary varicella zoster virus (pVZV) infection was ultimately diagnosed by PCR from a swabbed, unroofed lesion, and he recovered completely with supportive management and without antiviral therapy. We herein describe how common viral exanthems may best be differentiated in an emergency or outpatient setting.

Zoster Vaccine Lowers Stroke and Myocardial Infarction Risk in Chronic Disease

INTRODUCTION

Herpes zoster increases stroke and myocardial infarction risk. The objective of this study is to evaluate the impact of live attenuated zoster vaccination on stroke and myocardial infarction risk in patients at risk of zoster, including those with hypertension, diabetes mellites, obesity, hypercholesterolemia, chronic kidney disease, chronic obstructive pulmonary disease, emphysema, asthma, and chronic liver disease.

METHODS

This is a retrospective cohort study utilizing continuous de-identified claims data from the IBM MarketScan Commercial Claims and Encounters Database (collected from 2005-2018) containing data for 200 million commercially insured Americans. Participants included 27,093 adults vaccinated against zoster with at least 5 years of continuous enrollment, age and sex-matched 1:5 with unvaccinated controls. OR, risk difference, and the number needed to treat evaluated the effect of vaccination on stroke and myocardial infarction while controlling for relevant comorbidities.

RESULTS

Over the period of 5 years, proportions of myocardial infarction (1.29% vs 1.82%; p<0.05) and stroke (1.61% vs 2.20%; p<0.05) were lower in vaccinated versus unvaccinated individuals, respectively, controlling for age and sex, with the greatest benefit for people with diabetes (stroke OR=0.64, 95% CI=0.58, 0.71; myocardial infarction OR=0.63, 95% CI=0.57, 0.71). Although hypertension and chronic obstructive pulmonary disease had the highest odds of stroke and myocardial infarction, vaccination still provided significant risk-reduction (hypertension: stroke 0.75 [0.68, 0.83], myocardial infarction 0.73 [0.65, 0.81]; chronic obstructive pulmonary disease: stroke 0.75 [0.68, 0.83], myocardial infarction 0.74 [0.66, 0.83]).

CONCLUSIONS

Live attenuated zoster vaccination is associated with lower risk of stroke and myocardial infarction in adults with at-risk comorbidities, controlling for age and sex. Vaccination may provide cardiovascular benefits beyond zoster prevention.

Contribution of CNS and extra-CNS infections to neurodegeneration: a narrative review

Central nervous system infections have been suggested as a possible cause for neurodegenerative diseases, particularly sporadic cases. They trigger neuroinflammation which is considered integrally involved in neurodegenerative processes. In this review, we will look at data linking a variety of viral, bacterial, fungal, and protozoan infections to Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis and unspecified dementia. This narrative review aims to bring together a broad range of data currently supporting the involvement of central nervous system infections in the development of neurodegenerative diseases. The idea that no single pathogen or pathogen group is responsible for neurodegenerative diseases will be discussed. Instead, we suggest that a wide range of susceptibility factors may make individuals differentially vulnerable to different infectious pathogens and subsequent pathologies.

Intravenous Immunoglobulin and Intravenous Acyclovir as an Alternative Therapy to Varicella Zoster Immunoglobulin in the Prevention of Serious Complications of Neonatal Varicella

Neonatal varicella, arising from maternal infection with the varicella-zoster virus (VZV), is a rare but potentially severe condition with diverse clinical presentations. This case report highlights an instance where the mother developed a maculopapular rash seven days before delivery, indicating a possible transmission of VZV to the neonate. The patient's family history included recent diagnoses of herpes zoster and varicella among household members. On the second day of life, the newborn developed a discrete vesicular rash on an erythematous background, affecting the trunk and neck. Due to the unavailability of varicella zoster immunoglobulin (VZIG), intravenous immunoglobulin (IVIG) was administered along with a seven-day course of intravenous acyclovir. Despite the absence of VZIG, the combined treatment with IVIG and acyclovir proved effective in resolving the rash by the sixth day of life, without any ensuing complications. This case underscores the challenges of managing neonatal varicella in resource-limited settings and suggests that combination therapy may not prevent the occurrence of neonatal varicella but can mitigate serious complications and expedite clinical recovery.

Oncolytic varicella-zoster virus engineered with ORF8 deletion and armed with drug-controllable interleukin-12

BACKGROUND

The varicella-zoster virus (VZV), belonging to the group of human α-herpesviruses, has yet to be developed as a platform for oncolytic virotherapy, despite indications from clinical case reports suggesting a potential association between VZV infection and cancer remission.

METHODS

Here, we constructed oncolytic VZV candidates based on the vaccine strain vOka and the laboratory strain Ellen. These newly engineered viruses were subsequently assessed for their oncolytic properties in the human MeWo melanoma xenograft model and the mouse B16-F10-nectin1 melanoma syngeneic model.

RESULTS

In the MeWo xenograft model, both vOka and Ellen exhibited potent antitumor efficacy. However, it was observed that introducing a hyperfusogenic mutation into glycoprotein B led to a reduction in VZV's effectiveness. Notably, the deletion of ORF8 (encodes viral deoxyuridine triphosphatase) attenuated the replication of VZV both in vitro and in vivo, but it did not compromise VZV's oncolytic potency. We further armed the VZV Ellen-ΔORF8 vector with a tet-off controlled mouse single-chain IL12 (scIL12) gene cassette. This augmented virus was validated for its oncolytic activity and triggered systemic antitumor immune responses in the immunocompetent B16-F10-nectin1 model.

CONCLUSIONS

These findings highlight the potential of using Ellen-ΔORF8-tet-off-scIL12 as a novel VZV-based oncolytic virotherapy.

Herpes zoster infection in pregnancy: features and consequences

Herpes (varicella) zoster (HZ) infection occurs in 4 people per 1000 in the general US population (irrespective of prior varicella infection and vaccination status) each year and has been the subject of scientific inquiry for decades. The consequences of infection are myriad and may depend on the dermatome of involvement as well as host factors such as age, comorbidities, prior treatment or immunization, and immunologic status. Pregnancy is associated with an altered immune and hormonal status in the mother. While maternal HZ infection during pregnancy is not uncommon, the implications for both mother and child are not well established, although multiple studies of perinatal maternal HZ infection suggest no intrauterine transmission to the fetus. We review the current literature on herpes zoster infection in pregnancy, including epidemiology, diagnosis, potential immunologic sequelae, and strategies for prevention and treatment.

Viral meningoencephalitis in pediatric solid organ or hematopoietic cell transplant recipients: a diagnostic and therapeutic approach

Neurologic complications, both infectious and non-infectious, are frequent among hematopoietic cell transplant (HCT) and solid organ transplant (SOT) recipients. Up to 46% of HCT and 50% of SOT recipients experience a neurological complication, including cerebrovascular accidents, drug toxicities, as well as infections. Defects in innate, adaptive, and humoral immune function among transplant recipients predispose to opportunistic infections, including central nervous system (CNS) disease. CNS infections remain uncommon overall amongst HCT and SOT recipients, compromising approximately 1% of total cases among adult patients. Given the relatively lower number of pediatric transplant recipients, the incidence of CNS disease amongst in this population remains unknown. Although infections comprise a small percentage of the neurological complications that occur post-transplant, the associated morbidity and mortality in an immunosuppressed state makes it imperative to promptly evaluate and aggressively treat a pediatric transplant patient with suspicion for viral meningoencephalitis. This manuscript guides the reader through a broad infectious and non-infectious diagnostic differential in a transplant recipient presenting with altered mentation and fever and thereafter, elaborates on diagnostics and management of viral meningoencephalitis. Hypothetical SOT and HCT patient cases have also been constructed to illustrate the diagnostic and management process in select viral etiologies. Given the unique risk for various opportunistic viral infections resulting in CNS disease among transplant recipients, the manuscript will provide a contemporary review of the epidemiology, risk factors, diagnosis, and management of viral meningoencephalitis in these patients.

Immunogenicity and safety of a live-attenuated varicella vaccine in a healthy population aged 13 years and older: A randomized, double-blind, controlled study

OBJECTIVES

Vaccines for prevention against varicella are important for adolescents and adults, who have an increased risk of severe varicella. This study aimed to evaluate the immunogenicity and safety of a two-dose immunization schedule of a live-attenuated varicella vaccine (VarV) manufactured by Sinovac (Dalian) in healthy adolescents and adults.

METHODS

A randomized, double-blind, controlled clinical trial was conducted in healthy population aged ≥ 13 years old in China. Participants in block 1 were randomly assigned (1:1) to receive two doses of either the test vaccine or an active control vaccine, administered 4, 6 or 8 weeks apart. Participants in block 2 were randomly assigned (2:1) to receive two doses of test vaccine or placebo, administered 10 weeks apart. The primary immunogenicity endpoint was the seroconversion rates and GMTs of varicella zoster virus (VZV) antibodies measured by fluorescent-antibody-to-membrane-antigen (FAMA) 4 weeks post-immunization. The primary safety endpoint was the incidence of adverse reactions within 4 weeks after each dose.

RESULTS

A total of 2398 participants were enrolled. The seroconversion rates of VZV antibodies were 79.55 % in the test group and 76.41 % in the active control group respectively 4 weeks after two doses of pooled schedule, with the difference of 3.14 % (95 %CI: -0.69 %, 6.97 %). The GMTs were 1:162.07 and 1:160.04 respectively, with the ratio of 1.013 (95 %CI: 0.910, 1.127). Both the seroconversion rates and GMTs reached the prespecified non-inferiority criteria. Two-dose schedule with an interval of 10 weeks could also induce high immune responses, with a seroconversion rate of 83.22 % and a GMT of 1:160.38 in the test group. Safety profiles were similar among the test group, active control group and placebo group.

CONCLUSION

VarV, manufactured by Sinovac (Dalian), demonstrated higher immune response and better flexibility in the immunization schedule among heathy population aged 13 years and older, without increased safety risk.

Antibodies to varicella-zoster virus and three other herpesviruses and survival in adults with glioma

BACKGROUND

Lifetime exposure to the varicella-zoster virus (VZV) has been consistently inversely associated with glioma risk, however, the relationship of VZV with survival in adults with glioma has not been investigated. In this study, we analyzed the survival of adults with glioma in relation to their antibody measurements to 4 common herpes viral infections, including VZV, measured post-diagnosis.

METHODS

We analyzed IgG antibody measurements to VZV, cytomegalovirus (CMV), herpes simplex virus 1/2 (HSV), and Epstein-Barr virus (EBV) collected from 1378 adults with glioma diagnosed between 1991 and 2010. Blood was obtained a median of 3 months after surgery. Associations of patient IgG levels with overall survival were estimated using Cox models adjusted for age, sex, self-reported race, surgery type, dexamethasone usage at blood draw, and tumor grade. Models were stratified by recruitment series and meta-analyzed to account for time-dependent treatment effects.

RESULTS

VZV antibody seropositivity was associated with improved survival outcomes in adults with glioma (Hazard ratio, HR = 0.70, 95% Confidence Interval 0.54-0.90, P = .006). Amongst cases who were seropositive for VZV antibodies, survival was significantly improved for those above the 25th percentile of continuous reactivity measurements versus those below (HR = 0.76, 0.66-0.88, P = .0003). Antibody seropositivity to EBV was separately associated with improved survival (HR = 0.71, 0.53-0.96, P = .028). Antibody positivity to 2 other common viruses (CMV, HSV) was not associated with altered survival.

CONCLUSIONS

Low levels of VZV or EBV antibodies are associated with poorer survival outcomes for adults with glioma. Differential immune response rather than viral exposure may explain these findings.

Zoster-Associated Prothrombotic Plasma Exosomes and Increased Stroke Risk

Herpes zoster (HZ; shingles) caused by varicella zoster virus reactivation increases stroke risk for up to 1 year after HZ. The underlying mechanisms are unclear, however, the development of stroke distant from the site of zoster (eg, thoracic, lumbar, sacral) that can occur months after resolution of rash points to a long-lasting, virus-induced soluble factor (or factors) that can trigger thrombosis and/or vasculitis. Herein, we investigated the content and contributions of circulating plasma exosomes from HZ and non-HZ patient samples. Compared with non-HZ exosomes, HZ exosomes (1) contained proteins conferring a prothrombotic state to recipient cells and (2) activated platelets leading to the formation of platelet-leukocyte aggregates. Exosomes 3 months after HZ yielded similar results and also triggered cerebrovascular cells to secrete the proinflammatory cytokines, interleukin 6 and 8. These results can potentially change clinical practice through addition of antiplatelet agents for HZ and initiatives to increase HZ vaccine uptake to decrease stroke risk.

2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases

OBJECTIVE

To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs).

METHODS

This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation.

RESULTS

This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence.

CONCLUSION

Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.

2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases

OBJECTIVE

To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs).

METHODS

This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation.

RESULTS

This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence.

CONCLUSION

Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.

Role of Epitranscriptomic and Epigenetic Modifications during the Lytic and Latent Phases of Herpesvirus Infections

Herpesviruses are double-stranded DNA viruses occurring at a high prevalence in the human population and are responsible for a wide array of clinical manifestations and diseases, from mild to severe. These viruses are classified in three subfamilies (Alpha-, Beta- and Gammaherpesvirinae), with eight members currently known to infect humans. Importantly, all herpesviruses can establish lifelong latent infections with symptomatic or asymptomatic lytic reactivations. Accumulating evidence suggest that chemical modifications of viral RNA and DNA during the lytic and latent phases of the infections caused by these viruses, are likely to play relevant roles in key aspects of the life cycle of these viruses by modulating and regulating their replication, establishment of latency and evasion of the host antiviral response. Here, we review and discuss current evidence regarding epitranscriptomic and epigenetic modifications of herpesviruses and how these can influence their life cycles. While epitranscriptomic modifications such as m⁶A are the most studied to date and relate to positive effects over the replication of herpesviruses, epigenetic modifications of the viral genome are generally associated with defense mechanisms of the host cells to suppress viral gene transcription. However, herpesviruses can modulate these modifications to their own benefit to persist in the host, undergo latency and sporadically reactivate.

Cross-Sectional Retrospective Study to Identify Clinical and Radiographic Features Associated With VZV Reactivation in Cryptogenic Stroke Patients With CSF Testing

BACKGROUND AND PURPOSE

A large proportion of ischemic stroke patients lack a definitive stroke etiology despite extensive diagnostic testing. Varicella-Zoster Virus (VZV) can directly invade blood vessels causing vasculitis and may be associated with cryptogenic stroke (CS).

METHODS

We conducted a retrospective cross-sectional study of CS patients tested for VZV. The following were considered evidence of VZV reactivation (VZV+): positive CSF VZV PCR, anti-VZV IgM in CSF, or anti-VZV IgG CSF/serum ratio of 1:10 or higher. We describe the cohort, report VZV+ proportion with 95% confidence intervals (CI) determined with the Wald method, and compare patient groups using standard statistical tests.

RESULTS

A total of 72 CS patients met full study inclusion criteria. Most of the patients were <65 years old, had few traditional vascular risk factors, and had multifocal infarcts. Mean age was 49 years (SD ±13) and 47% were women. A total of 14 patients (19.4%; CI: 11.4-30.8%) had evidence of CNS VZV reactivation. There was no difference in evaluated demographic or radiographic features between those with versus without evidence of VZV reactivation. History of ischemic stroke in the past year (11/14 vs 25/43, P<.05) and hypertension (13/14 vs 35/58 and P<.05) were associated with VZV+.

CONCLUSION

We found a high proportion of CNS VZV reactivation in a cross-sectional cohort of CS patients selected for CSF testing. Testing for VZV might be reasonable in CS patients who are young, have multifocal infarcts, or had an ischemic stroke within the past year, but additional research is needed.

Risk, Mechanisms and Implications of Asthma-Associated Infectious and Inflammatory Multimorbidities (AIMs) among Individuals With Asthma: a Systematic Review and a Case Study

Our prior work and the work of others have demonstrated that asthma increases the risk of a broad range of both respiratory (e.g., pneumonia and pertussis) and non-respiratory (e.g., zoster and appendicitis) infectious diseases as well as inflammatory diseases (e.g., celiac disease and myocardial infarction [MI]), suggesting the systemic disease nature of asthma and its impact beyond the airways. We call these conditions asthma-associated infectious and inflammatory multimorbidities (AIMs). At present, little is known about why some people with asthma are at high-risk of AIMs, and others are not, to the extent to which controlling asthma reduces the risk of AIMs and which specific therapies mitigate the risk of AIMs. These questions represent a significant knowledge gap in asthma research and unmet needs in asthma care, because there are no guidelines addressing the identification and management of AIMs. This is a systematic review on the association of asthma with the risk of AIMs and a case study to highlight that 1) AIMs are relatively under-recognized conditions, but pose major health threats to people with asthma; 2) AIMs provide insights into immunological and clinical features of asthma as a systemic inflammatory disease beyond a solely chronic airway disease; and 3) it is time to recognize AIMs as a distinctive asthma phenotype in order to advance asthma research and improve asthma care. An improved understanding of AIMs and their underlying mechanisms will bring valuable and new perspectives improving the practice, research, and public health related to asthma.

Serum Concentration of Antibodies to Mumps, but Not Measles, Rubella, or Varicella, Is Associated with Intake of Dietary Fiber in the NHANES, 1999-2004

Treatment with prebiotics, a type of dietary fiber, was recently shown to increase antibody concentrations following influenza vaccination in a meta-analysis of clinical trials. In observational epidemiologic studies it is not possible to estimate intake of prebiotics, but quantifying intake of dietary fiber is routine. Our objective was to investigate the potential effect of dietary fiber on immunogenicity. We examined serum antibody concentrations (Measles, Mumps, Rubella, and Varicella) in relation to dietary fiber in more than 12,000 subjects in the U.S. National Health and Nutrition Examination Survey (NHANES) for the period 1999-2004. Data from one (1999-2002) or two (2003-2004) dietary recalls were used to calculate fiber intake. For Mumps the adjusted percentage difference in antibody concentration per interquartile range intake in energy-adjusted dietary fiber was 6.34% (95% confidence interval, 3.10, 9.68). Fiber from grain-based foods was more positively associated than fiber from other fiber-containing food groups. The association was slightly larger among subgroups with higher fiber intake, greater interquartile range in fiber intake, and less measurement error. Furthermore, based on the reliability of the diet recalls in 2003-2004, we calculated that the percentage difference per interquartile increment was substantially attenuated by measurement error. Dietary fiber may have a favorable influence on the immunogenicity of some vaccines or natural infections.

Evaluation of Recombinant Herpes Zoster Vaccine for Primary Immunization of Varicella-seronegative Transplant Recipients

BACKGROUND

Immunization of VZV-seronegative solid organ transplant (SOT) patients using the live-attenuated varicella vaccine is generally contraindicated, leaving no widely applicable immunization option. The recombinant subunit herpes zoster vaccine (RZV) is indicated for VZV seropositive persons to prevent shingles but could potentially also protect VZV-seronegative persons against varicella. We performed a safety and immunogenicity evaluation of RZV in VZV-seronegative SOT recipients as an option for protection.

METHODS

VZV-seronegative adult SOT patients with no history of varicella/shingles vaccine or disease were given 2 doses of RZV vaccine 2-6 months apart. Blood was drawn prevaccination (V1), prior to the second dose (V2) and 4 weeks after second dose (V3). Humoral (anti-gE) and cell-mediated immunity was evaluated, with polyfunctional cells defined as cells producing ≥2 cytokines.

RESULTS

Among 31 eligible VZV-seronegative SOT patients screened, 23 were enrolled. Median age was 38 years and median time since transplant procedure was 38 years. The most frequent transplant types were liver (35%) and lung (30%). Median anti-gE levels significantly increased from V1 to V3 (p=0001) and V2 to V3 (p<0001), even though only 55% had a positive seroresponse. Median polyfunctional CD4 T-cells counts increased from V1 to V2 (54/10 vs 104/10 cells; p=0041), and from V2 to V3 (380/10; p=0002). Most adverse events were mild with no rejection episodes.

CONCLUSION

RZV was safe and elicited significant humoral and cellular responses in VZV-seronegative SOT patients, and has the potential to be considered as a preventive strategy against primary varicella.

From conifers to cognition: Microbes, brain and behavior

A diversity of bacteria, protozoans and viruses ("endozoites") were recently uncovered within healthy tissues including the human brain. By contrast, it was already recognized a century ago that healthy plants tissues contain abundant endogenous microbes ("endophytes"). Taking endophytes as an informative precedent, we overview the nature, prevalence, and role of endozoites in mammalian tissues, centrally focusing on the brain, concluding that endozoites are ubiquitous in diverse tissues. These passengers often remain subclinical, but they are not silent. We address their routes of entry, mechanisms of persistence, tissue specificity, and potential to cause long-term behavioral changes and/or immunosuppression in mammals, where rabies virus is the exemplar. We extend the discussion to Herpesviridae, Coronaviridae, and Toxoplasma, as well as to diverse bacteria and yeasts, and debate the advantages and disadvantages that endozoite infection might afford to the host and to the ecosystem. We provide a clinical perspective in which endozoites are implicated in neurodegenerative disease, anxiety/depression, and schizophrenia. We conclude that endozoites are instrumental in the delicate balance between health and disease, including age-related brain disease, and that endozoites have played an important role in the evolution of brain function and human behavior.

Herpes Zoster Presentation, Management, and Prevention: A Modern Case-Based Review

Herpes zoster (HZ) is a common cutaneous entity with protean clinical presentations, management options, complication rates, and prevention strategies, all of which are rife with dogma. During an inpatient consultation for HZ, have you ever been approached by a frantic staff or family member, worried that a pregnant, elderly, or infant contact will be 'infected' if they get too close? Have your patients ever asked you about their risk of having HZ twice, or claimed that they have frequent 'recurrences'? In what timeline should antiviral therapy be employed? Is there evidence for prednisone or gabapentin in acute HZ treatment? Who should be vaccinated against HZ and what are the benefits and risks? In case-based form, these and other complex but common scenarios will be examined using clinical and viral mechanistic clues, along with updated treatment and prevention guidelines, to provide a modern HZ case management compendium, comprehensive of the diverse age and health populations now presenting with this condition.

Herpesviridae Infection: Prevention, Screening, and Management

Bacterial, viral, and parasitic pathogens add significant morbidity and even mortality to pregnancy-with adverse effects extending to both the gravida and the newborn. Three herpesviruses deserve considerable attention given the effects of perinatal infection on obstetric outcomes, specifically maternal and neonatal morbidity. In the following review, we will provide a description of cytomegalovirus, herpes simplex virus, and varicella zoster virus. For each viral pathogen, we will describe the epidemiology, natural history, screening and diagnosis modalities, treatments, and implications for antepartum care. Furthermore, we will highlight future directions of work in reducing the morbidities associated with these viral pathogens.

Herpes Zoster

Primary care providers and hospitalists frequently encounter older or immunocompromised patients with herpes zoster accompanied by debilitating pain. Atypical presentations and zosteriform herpes simplex may present diagnostic challenges to clinicians. This article summarizes the background, evidence, and guidelines for the diagnosis, complications, treatment, and prevention of herpes zoster. Diagnosis of challenging cases relies on polymerase chain reaction as the preferred test. Treatment focuses on optimal use of antiviral therapy and analgesics. Prevention emphasizes utilization of a new recombinant zoster vaccine, which reduces the incidence of herpes zoster by more than 90% and is preferred to the live attenuated herpes zoster vaccine.

Managing varicella zoster virus contact and infection in patients on anti-rheumatic therapy

Chickenpox and shingles can be more severe and occasionally life threatening in immunosuppressed patients. As such, some groups warrant a more detailed history, serological testing and consideration of prophylaxis following contact with the virus. Active disease may also require more aggressive treatment with antivirals. Guidance for the use of varicella zoster immunoglobulin has recently been updated by Public Health England with important implications for rheumatology patients.

Prevalence of Inadequate Immunity to Measles, Mumps, Rubella, and Varicella in MLB and NBA Athletes

BACKGROUND

Multiple outbreaks of vaccine-preventable viral diseases have occurred in professional sports in recent years. Currently, there is no established protocol for vaccination or immunity screening for professional athletes.

HYPOTHESIS

There are significant differences in the prevalence of inadequate immunity dependent on age, sport, country of birth, and participation in collegiate sports.

STUDY DESIGN

Cross-sectional cohort study.

LEVEL OF EVIDENCE

Level 4.

METHODS

A sample of Major League Baseball (MLB) and National Basketball Association (NBA) players were screened for serologic evidence of immunity to measles, mumps, rubella, and varicella prior to the 2015 and 2016 seasons. The results were designated as adequate (immune) or inadequate (equivocal or nonimmune) based on laboratory criteria. Comparison with an age-matched control group was performed using data from the National Health and Nutrition Examination Survey (NHANES).

RESULTS

A total of 98 athletes (62 MLB, 36 NBA) were screened. The prevalence of inadequate immunity for any virus was 35.5% in MLB players and 33.3% in NBA players. There was a significantly greater risk of inadequate immunity to rubella (risk ratio, 6.38; P < 0.01) and varicella (risk ratio, 4.21; P < 0.01) in athletes compared with the age-matched NHANES population. Our analysis did not reveal differences in rates of immunity based on sport, country of birth (US born vs international), or participation in college athletics. There was a lower rate of inadequate immunity to varicella with increasing age (odds ratio, 0.72; P = 0.05).

CONCLUSION

One-third of athletes studied had inadequate immunity to 1 of the 4 viruses tested. Younger players had a significantly greater risk of inadequate immunity to varicella. Birth outside the US and lack of participation in college athletics were not found to influence immunity rates.

CLINICAL RELEVANCE

These results can inform the development of future screening programs to prevent outbreaks of viral infections in professional athletes.

Serological Susceptibility to Varicella Among U.S. Immigration and Customs Enforcement Detainees

U.S. Immigration and Customs Enforcement (ICE) is responsible for detaining unauthorized aliens during immigration proceedings. During 2014 to 2015, adult ICE detainees at a California facility were invited to complete a survey concerning self-reported varicella history and risk factors. Participants underwent serological testing for varicella-zoster virus (VZV) IgG; susceptible individuals were offered varicella vaccination. Among 400 detainees with available serology results, 48 (12%) were susceptible to varicella. Self-reported varicella history was negatively associated with susceptibility (adjusted odds ratio = 0.16; 95% confidence interval [0.07, 0.35]). Among 196 detainees reporting a positive history, 95% had VZV IgG levels suggestive of varicella immunity. Among 44 susceptible detainees offered vaccination, 86% accepted. Given relatively high varicella susceptibility, targeted screening and vaccination among ICE detainees lacking a positive history might reduce varicella transmission risks.

Herpes Simplex Virus and Varicella-Zoster Virus

The most common specimens from immunocompromised patients that are analyzed for detection of herpes simplex virus (HSV) or varicella-zoster virus (VZV) are from skin lesions. Many types of assays are applicable to these samples, but some, such as virus isolation and direct fluorescent antibody testing, are useful only in the early phases of the lesions. In contrast, nucleic acid (NA) detection methods, which generally have superior sensitivity and specificity, can be applied to skin lesions at any stage of progression. NA methods are also the best choice, and sometimes the only choice, for detecting HSV or VZV in blood, cerebrospinal fluid, aqueous or vitreous humor, and from mucosal surfaces. NA methods provide the best performance when reliability and speed (within 24 hours) are considered together. They readily distinguish the type of HSV detected or the source of VZV detected (wild type or vaccine strain). Nucleic acid detection methods are constantly being improved with respect to speed and ease of performance. Broader applications are under study, such as the use of quantitative results of viral load for prognosis and to assess the efficacy of antiviral therapy.

Varicella seroepidemiology in United States air force recruits: A retrospective cohort study comparing immunogenicity of varicella vaccination and natural infection

BACKGROUND/OBJECTIVES

Infection with varicella zoster virus (VZV) produces lifelong immunity, but duration of post-vaccination immunity has not been established. The purpose of this study is to determine if a difference exists in the long-term seropositivity of anti-VZV antibodies in a cohort of young adults who were vaccinated against varicella as compared to a similar cohort with a history of chickenpox disease, and to determine which variables best predict waning seropositivity following varicella vaccination.

METHODS

This retrospective cohort study captures immunization and serology data from approximately 10,000 recruits who entered basic military training between January 1, 2008, and December 31, 2015, and who have childhood immunization records in the Air Force Aeromedical Services Information Management System. Varicella vaccine immunogenicity was determined relative to the immunogenicity of chickenpox disease, as measured by multiplex flow immunoassay. Among vaccine recipients, waning seroimmunity was modeled and adjusted for several important covariates.

RESULTS

Basic military trainees who received varicella vaccine in childhood were 24% less likely to be seropositive to VZV than trainees who were exempt from vaccine due to a history of chickenpox disease. There was no significant difference in seropositivity between male and female trainees. The odds of a vaccinated trainee being seropositive to VZV decreased by 8% with each year elapsed since vaccination. Seroprevalence declined below estimated herd immunity thresholds in vaccinated trainees born after 1994, and in the cohort as a whole for trainees born after 1995.

CONCLUSION

Despite prior vaccination, seroimmunity in a large cohort of young adults unexposed to wild-type VZV failed to meet the estimated threshold for herd immunity. If vaccination in accordance with the current US VZV vaccination schedule is inadequate to maintain herd immunity, young adults not previously exposed to wild-type VZV may be at increased risk for varicella outbreaks.

The pregnant healthcare worker: fact and fiction

PURPOSE OF REVIEW

A pregnant healthcare worker (HCW) may be at risk of occupational exposure to pathogens associated with increased maternal morbidity and mortality as well as perinatal complications. In this article, we review recent literature on infectious diseases commonly encountered in the healthcare setting and of highest concern for a pregnant HCW, focusing on prevention and management of exposures.

RECENT FINDINGS

Pregnancy does not seem to be an independent risk factor for occupationally acquired infectious diseases. Vaccination and standard precautions continue to be the most effective means of preventing transmission to HCWs. Pandemic 2009 influenza A (H1N1) is associated with increased risk of fetal death, highlighting the importance of influenza vaccination. A recent meta-analysis highlights the safety of influenza vaccination during pregnancy. New treatments for hepatitis C have not been studied in pregnancy but pose an important area for research and advancement. Cytomegalovirus immunoglobulin may play a role in postexposure prophylaxis but recent results are inconclusive.

SUMMARY

Primary prevention with vaccination and use of appropriate infection control precautions is imperative for prevention of occupationally acquired infectious diseases. Pregnant HCWs with occupational exposure to communicable diseases should be evaluated immediately for appropriate postexposure prophylaxis and followed for development of active infection.

Surveillance of Vaccination Coverage Among Adult Populations - United States, 2014

PROBLEM/CONDITION

Overall, the prevalence of illness attributable to vaccine-preventable diseases is greater among adults than among children. Adults are recommended to receive vaccinations based on their age, underlying medical conditions, lifestyle, prior vaccinations, and other considerations. Updated vaccination recommendations from CDC are published annually in the U.S. Adult Immunization Schedule. Despite longstanding recommendations for use of many vaccines, vaccination coverage among U.S. adults is low.

REPORTING PERIOD

August 2013-June 2014 (for influenza vaccination) and January-December 2014 (for pneumococcal, tetanus and diphtheria [Td] and tetanus and diphtheria with acellular pertussis [Tdap], hepatitis A, hepatitis B, herpes zoster, and human papillomavirus [HPV] vaccination).

DESCRIPTION OF SYSTEM

The National Health Interview Survey (NHIS) is a continuous, cross-sectional national household survey of the noninstitutionalized U.S. civilian population. In-person interviews are conducted throughout the year in a probability sample of households, and NHIS data are compiled and released annually. The survey objective is to monitor the health of the U.S. population and provide estimates of health indicators, health care use and access, and health-related behaviors.

RESULTS

Compared with data from the 2013 NHIS, increases in vaccination coverage occurred for Tdap vaccine among adults aged ≥19 years (a 2.9 percentage point increase to 20.1%) and herpes zoster vaccine among adults aged ≥60 years (a 3.6 percentage point increase to 27.9%). Aside from these modest improvements, vaccination coverage among adults in 2014 was similar to estimates from 2013 (for influenza coverage, similar to the 2012-13 season). Influenza vaccination coverage among adults aged ≥19 years was 43.2%. Pneumococcal vaccination coverage among high-risk persons aged 19-64 years was 20.3% and among adults aged ≥65 years was 61.3%. Td vaccination coverage among adults aged ≥19 years was 62.2%. Hepatitis A vaccination coverage among adults aged ≥19 years was 9.0%. Hepatitis B vaccination coverage among adults aged ≥19 years was 24.5%. HPV vaccination coverage among adults aged 19-26 years was 40.2% for females and 8.2% for males. Racial/ethnic differences in coverage persisted for all seven vaccines, with higher coverage generally for whites compared with most other groups. Adults without health insurance were significantly less likely than those with health insurance to report receipt of influenza vaccine (aged ≥19 years), pneumococcal vaccine (aged 19-64 years with high-risk conditions and aged ≥65 years), Td vaccine (aged ≥19 years), Tdap vaccine (aged ≥19 years and 19-64 years), hepatitis A vaccine (aged ≥19 years overall and among travelers), hepatitis B vaccine (aged ≥19 years, 19-49 years, and 19-59 years with diabetes), herpes zoster vaccine (aged ≥60 years and 60-64 years), and HPV vaccine (females aged 19-26 years and males aged 19-26 years). Adults who reported having a usual place for health care generally were more likely to receive recommended vaccinations than those who did not have a usual place for health care, regardless of whether they had health insurance. Vaccination coverage was significantly higher among those reporting one or more physician contacts in the past year compared with those who had not visited a physician in the past year, regardless of whether they had health insurance. Even among adults who had health insurance and ≥10 physician contacts within the past year, 23.8%-88.8% reported not having received vaccinations that were recommended either for all persons or for those with some specific indication. Overall, vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents with few exceptions (influenza vaccination [adults aged 19-49 years], hepatitis A vaccination [adults aged ≥19 years], hepatitis B vaccination [adults with diabetes aged ≥60 years], and HPV vaccination [males aged 19-26 years]).

INTERPRETATION

Overall, increases in adult vaccination coverage are needed. Although modest gains occurred in Tdap vaccination coverage among adults aged ≥19 years and herpes zoster vaccination coverage among adults aged ≥60 years, coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Coverage for all vaccines for adults remained low, and missed opportunities to vaccinate adults continued. Although having health insurance coverage and a usual place for health care are associated with higher vaccination coverage, these factors alone do not assure optimal adult vaccination coverage.

PUBLIC HEALTH ACTIONS

Assessing associations with vaccination is important for understanding factors that contribute to low coverage rates and to disparities in vaccination, and for implementing strategies to improve vaccination coverage. Practices that have been demonstrated to improve vaccination coverage should be used. These practices include assessment of patients' vaccination indications by health care providers and routine recommendation and offer of needed vaccines to adults, implementation of reminder-recall systems, use of standing-order programs for vaccination, and assessment of practice-level vaccination rates with feedback to staff members. For vaccination to be improved among those least likely to be up-to-date on recommended adult vaccines, efforts also are needed to identify adults who do not have a regular provider or insurance and who report fewer health care visits.

Evaluation of a vaccination strategy by serosurveillance data: The case of varicella

Serological studies have many important epidemiologic applications. They can be used to investigate acquisition of various infections in different populations, measure the induction of an immune response in the host, evaluate the persistence of antibody, identify appropriate target groups and the age for vaccination. Serological studies can also be used to determine the vaccine efficacy. Since 1995 a varicella vaccine is available and it has been recommended in several countries (e.g. USA, Australia, Canada, Costa Rica, Ecuador, etc.). Nevertheless few varicella seroprevalence studies in countries that adopted an URV are available. It is related to the relatively recent introduction of the vaccination and to the lack of structured and collaborative surveillance systems based on serosurvey at national or regional level. Varicella seroprevalence data collected before the introduction of vaccination strategies allowed to establish the age of vaccination (e.g., indicated the opportunity to offer the vaccine to Italian susceptible adolescents). In the post-vaccination era, seroprevalence data demonstrated vaccine as immunogenic and excluded an increase of the age of infection linked to the vaccination strategy. New seroprevalence studies should be performed to answer to open questions, such as the long-term immunity and the change of the herpes zoster epidemiological pattern related to the vaccine.

Asthma as a risk factor for zoster in adults: A population-based case-control study

BACKGROUND

We recently reported an increased risk of herpes zoster (shingles or zoster) in children with asthma, but little is known about whether the same is true for adults with asthma.

OBJECTIVE

We determined whether asthma is associated with an increased risk of zoster in adults.

METHODS

This study was designed as a population-based case-control study. Zoster cases during the study period were identified among adults (aged ≥50 years) who resided in Olmsted County, Minnesota. We compared the frequency of asthma between zoster cases and birthday- and sex-matched control subjects (1:2 matching) without a history of zoster. Asthma status was ascertained based on predetermined criteria. A conditional logistic regression model was used to assess the association of asthma with risk of zoster.

RESULTS

A total of 371 zoster cases and their 742 matched control subjects were enrolled. Of the 371 cases, 246 (66%) were female, 348 (94%) were white, and the mean ± SD age was 66.8 ± 10.7 years. Twenty-three percent (n = 87) of zoster cases had a history of asthma compared with 15% (n = 114) of control subjects. Controlling for pertinent covariates and confounders, there was a significant association between a history of asthma and risk of zoster (adjusted odds ratio, 1.70; 95% CI, 1.20-2.42; P = .003). The population attributable risk percentage for asthma was about 10%.

CONCLUSIONS

Asthma is an unrecognized risk factor for zoster in adults. Consideration should be given to immunizing adults with asthma aged more than 50 years as a target group.

Antibody induced by one-dose varicella vaccine soon became weak in children: evidence from a cross-sectional seroepidemiological survey in Beijing, PRC

BACKGROUND

Numerous post-licensure studies, mostly from field epidemiological evidences such as outbreak surveys, have demonstrated the effectivenesss and insufficiency of one-dose varicella vaccine in outbreak control. Serological evidence of immunization failure is, however, relatively less reported in contrast. A cross-sectional seroepidemiological survey of Beijing residents was performed in 2012 in the People's Republic of China, after the one-dose varicella vaccine had been widely used for several years.

METHODS

Multistage stratified random sampling method was designed to recruit 2 144 subjects. The ELISA method was used to test the present blood samples collected and the reserve samples collected in 2008 to assess the trends of anti-VZV seroprevalence in the past 5 years and to determine the risk factors for varicella infection.

RESULTS

The age- and sex- adjusted overall anti-VZV seropositivity of Beijing residents in 2012 was 84.5%. Two groups' adjusted overall anti-VZV seroprevalence in 2012 showed obvious growth compared with 2008 (<1 yr old: from 6.3% to 16.9%; 1-4 yr old: from 27.6% to 57.2%). Reported one-dose vaccination history was 71.6% (149/208), 80.9% (182/225) and 82.2% (180/219) in the 1-4 yr, 5-9 yr, 10-14 yr age groups, respectively. Of subjects who had received the one-dose vaccine, 36% (216/603) showed negative anti-VZV concentrations (<110 mIU/mL); additionally 15.9% (96/603) of such subjects' anti-VZV concentrations were in the lowest positive concentration group (110-299 mIU/mL). Seropositivity in permanent residents of 1-9 yr old with verified vaccination was merely 61.8%. Various age groups (1-3 yr, 4-6 yr, and 7-9 yr) all showed seropositivity that gradually decreased with increasing of the interval between vaccination and blood sampling.

CONCLUSION

Mass varicella vaccination significantly improved the immunity of younger Beijing residents. However, vaccine-induced anti-VZV antibody soon became weak in children with high coverage (approximately 80%) after vaccination for several years which is significantly higher than reported in pre-licensure studies. A government-funded 2-dose immunization program with mandatory vaccination schedule for Beijing residents may need consideration in the near future.

Association Between Prenatal Exposure to Maternal Infection and Offspring Mood Disorders: A Review of the Literature

The purpose of this article is to provide a systematic review of studies that have examined the association between prenatal exposure to maternal infection and development of mood disorders across the life course. Drawing from both human- and animal-based studies, we give an overview of hypothesized biological mechanisms by which exposure to maternal infection during critical periods of gestation may contribute to fetal programming of mood disorders in offspring. We discuss studies examining the association between prenatal exposure to maternal infection with pathogens including influenza as well as other respiratory viruses, herpesviruses, hepatitis viruses, and Toxoplasma gondii and mood disorders in human populations. Moreover, we outline strengths and limitations of the current body of evidence and make recommendations for future research. We also discuss findings in the context of well-documented gender and socioeconomic disparities in the prevalence and severity of mood disorders, particularly major depression, and the role that early exposure to infection may play in explaining the perpetuation of such disparities across generations. Overall, this review of the current knowledge on this topic has important implications for determining future research directions, designing interventions as well as prenatal care guidelines targeted at prevention or treatment of infection during pregnancy, and clinical practice for the identification of individuals that may be at increased risk for mood disorders beginning early in life. Importantly, such efforts may not only lower the overall burden of mood disorders but also serve to address social disparities in these adverse mental health conditions in the U.S.

Prevalence and Persistence of Varicella Antibodies in Previously Immunized Children and Youth With Perinatal HIV-1 Infection

BACKGROUND

Two doses of live-attenuated varicella-zoster vaccine are recommended for human immunodeficiency virus 1 (HIV-1)-infected children with CD4% ≥ 15%. We determined the prevalence and persistence of antibody in immunized children with perinatal HIV (PHIV) and their association with number of vaccinations, combination antiretroviral therapy (cART), and HIV status.

METHODS

The Adolescent Master Protocol is an observational study of children with PHIV and perinatally HIV-exposed but uninfected (PHEU) children conducted at 15 US sites. In a cross-sectional analysis, we tested participants' most recent stored sera for varicella antibody using whole-cell and glycoprotein enzyme-linked immunosorbent assay. Seropositivity predictors were identified using multivariable logistic regression models and C statistics.

RESULTS

Samples were available for 432 children with PHIV and 221 PHEU children; 82% of children with PHIV and 97% of PHEU children were seropositive (P < .001). Seropositivity after 1 vaccine dose among children with PHIV and PHEU children was 100% at <3 years (both), 73% and 100% at 3-<7 years (P < .05), and 77% and 97% at ≥ 7 years (P < .01), respectively. Seropositivity among recipients of 2 vaccine doses was >94% at all intervals. Independent predictors of seropositivity among children with PHIV were receipt of 2 vaccine doses, receipt of 1 dose while on ≥ 3 months of cART, compared with none (adjusted odds ratio [aOR]: 14.0 and 2.8, respectively; P < .001 for overall dose effect), and in those vaccinated ≥ 3 years previously, duration of cART (aOR: 1.29 per year increase, P = .02).

CONCLUSIONS

Humoral immune responses to varicella vaccine are best achieved when children with PHIV receive their first dose ≥ 3 months after cART initiation and maintained by completion of the 2-dose series and long-term cART use.

Viral immunology. Comprehensive serological profiling of human populations using a synthetic human virome

The human virome plays important roles in health and immunity. However, current methods for detecting viral infections and antiviral responses have limited throughput and coverage. Here, we present VirScan, a high-throughput method to comprehensively analyze antiviral antibodies using immunoprecipitation and massively parallel DNA sequencing of a bacteriophage library displaying proteome-wide peptides from all human viruses. We assayed over 10(8) antibody-peptide interactions in 569 humans across four continents, nearly doubling the number of previously established viral epitopes. We detected antibodies to an average of 10 viral species per person and 84 species in at least two individuals. Although rates of specific virus exposure were heterogeneous across populations, antibody responses targeted strongly conserved "public epitopes" for each virus, suggesting that they may elicit highly similar antibodies. VirScan is a powerful approach for studying interactions between the virome and the immune system.

Arsenic exposure and prevalence of the varicella zoster virus in the United States: NHANES (2003-2004 and 2009-2010)

BACKGROUND

Arsenic is an immunotoxicant. Clinical reports observe the reactivation of varicella zoster virus (VZV) in people who have recovered from arsenic poisoning and in patients with acute promyelocytic leukemia that have been treated with arsenic trioxide.

OBJECTIVE

We evaluated the association between arsenic and the seroprevalence of VZV IgG antibody in a representative sample of the U.S.

METHODS

We analyzed data from 3,348 participants of the National Health and Nutrition Examination Survey (NHANES) 2003-2004 and 2009-2010 pooled survey cycles. Participants were eligible if they were 6-49 years of age with information on both VZV IgG and urinary arsenic concentrations. We used two measures of total urinary arsenic (TUA): TUA1 was defined as the sum of arsenite, arsenate, monomethylarsonic acid, and dimethylarsinic acid, and TUA2 was defined as total urinary arsenic minus arsenobetaine and arsenocholine.

RESULTS

The overall weighted seronegative prevalence of VZV was 2.2% for the pooled NHANES sample. The geometric means of TUA1 and TUA2 were 6.57 μg/L and 5.64 μg/L, respectively. After adjusting for age, sex, race, income, creatinine, and survey cycle, odds ratios for a negative VZV IgG result in association with 1-unit increases in natural log-transformed (ln)-TUA1 and ln-TUA2 were 1.87 (95% CI: 1.03, 3.44) and 1.40 (95% CI: 1.0, 1.97), respectively.

CONCLUSIONS

In this cross-sectional analysis, urinary arsenic was inversely associated with VZV IgG seroprevalence in the U.S.

POPULATION

This finding is in accordance with clinical observations of zoster virus reactivation from high doses of arsenic. Additional studies are needed to confirm the association and evaluate causal mechanisms.

Seroprevalence of measles, mumps, rubella and varicella antibodies in the United States population, 2009-2010

Background.  In the United States, measles, mumps, rubella, and varicella immunity is now primarily achieved through vaccination. Monitoring population immunity is necessary. Methods.  We evaluated seroprevalence of antibodies to measles, mumps, rubella, and varicella using the National Health and Nutrition Examination Survey during 2009-2010. Results.  Measles, mumps, rubella, and varicella seroprevalence was 92.0% (95% confidence interval [CI], 90.9%-93.0%), 87.6% (CI, 85.8%-89.2%), 95.3% (CI, 94.3%-96.2%), and 97.8% (CI, 97.1%-98.3%), respectively. United States (US)-born persons had lower mumps seroprevalence and higher varicella seroprevalence than non-US born persons. Conclusions.  Seroprevalence was high (88%-98%) for all 4 viruses in the US population during 2009-2010.

Trends in hospitalizations with primary varicella and herpes zoster during the prevaricella and initial postvaricella and herpes zoster vaccine eras, connecticut, 1994-2012

Background.  The introductions of the varicella vaccine in 1995 and herpes zoster (HZ) vaccine in 2006 have an ongoing potential to modify the epidemiology of both diseases. Analysis of data on hospitalizations can be conducted to examine trends in the occurrence of severe disease over time and to assess the possible impact of vaccination on the incidence of hospitalization. Methods.  Statewide hospital discharge data 1994-2012 in Connecticut were used to identify individuals discharged with a diagnosis of varicella and the initial admissions of persons with a discharge diagnosis of HZ in the first or second diagnostic position. Trends in overall age-standardized and age group-specific hospitalization rates for preselected time intervals before and after the introduction of vaccines were examined using Poisson regression models or Mantel-Haenszel χ(2) tests. Results.  Beginning in 2001, 5 years after the introduction of varicella vaccine, HZ hospitalization rates decreased significantly in individuals <15 years at an average rate of 19.4% per year through 2012. Among individuals ≥60 years, HZ hospitalization rates increased by 5.1% per year from 2001 to 2006 but decreased by 4.2% per year from 2007 to 2012. Primary varicella hospitalization rates declined 82.9% from the prevaccine era (1994-1995) to the 1-dose era (2001-2005) (P < .001). Rates further decreased significantly in the 2-dose era (2010-2012) among 5 to 9 year olds (100% decrease). Conclusions.  Varicella vaccine seems to have had an impact on both varicella and HZ hospitalizations, and introduction of the HZ vaccine may be having an impact on HZ hospitalizations.

Adult vaccination disparities among foreign-born populations in the U.S., 2012

BACKGROUND

Foreign-born persons are considered at higher risk of undervaccination and exposure to many vaccine-preventable diseases. Information on vaccination coverage among foreign-born populations is limited.

PURPOSE

To assess adult vaccination coverage disparities among foreign-born populations in the U.S.

METHODS

Data from the 2012 National Health Interview Survey were analyzed in 2013. For non-influenza vaccines, the weighted proportion vaccinated was calculated. For influenza vaccination, Kaplan-Meier survival analysis was used to assess coverage among individuals interviewed during September 2011-June 2012 and vaccinated in August 2011-May 2012.

RESULTS

Overall, unadjusted vaccination coverage among U.S.-born respondents was significantly higher than that of foreign-born respondents: influenza, age ≥18 years (40.4% vs 33.8%); pneumococcal polysaccharide vaccine (PPV), 18-64 years with high-risk conditions (20.8% vs 13.7%); PPV, ≥65 years (62.6% vs 40.5%); tetanus vaccination, ≥18 years (65.0% vs 50.6%); tetanus, diphtheria, and acellular pertussis (Tdap), ≥18 years (15.5% vs 9.3%); hepatitis B, 18-49 years (37.2% vs 28.4%); shingles, ≥60 years (21.3% vs 12.0%); and human papilloma virus (HPV), women 18-26 years (38.7% vs 14.7%). Among the foreign born, vaccination coverage was generally lower for non-U.S. citizens, recent immigrants, and those interviewed in a language other than English. Foreign-born individuals were less likely than U.S.-born people to be vaccinated for pneumococcal (≥65 years), tetanus, Tdap, and HPV (women) after adjusting for confounders.

CONCLUSIONS

Vaccination coverage is lower among foreign-born adults than those born in the U.S. It is important to consider foreign birth and immigration status when assessing vaccination disparities and planning interventions.

Challenges with controlling varicella in prison settings: experience of California, 2010 to 2011

This article describes the epidemiology of varicella in one state prison in California during 2010 and 2011, control measures implemented, and associated costs. Eleven varicella cases were reported, of which nine were associated with two outbreaks. One outbreak consisted of three cases and the second consisted of six cases with two generations of spread. Among exposed inmates serologically tested, 98% (643/656) were varicella-zoster virus seropositive. The outbreaks resulted in > 1,000 inmates exposed, 444 staff exposures, and > $160,000 in costs. The authors documented the challenges and costs associated with controlling and managing varicella in a prison setting. A screening policy for evidence of varicella immunity for incoming inmates and staff and vaccination of susceptible persons has the potential to mitigate the impact of future outbreaks and reduce resources necessary to manage cases and outbreaks.

Risks for infection in patients with asthma (or other atopic conditions): is asthma more than a chronic airway disease?

Most of the research effort regarding asthma has been devoted to its causes, therapy, and prognosis. There is also evidence that the presence of asthma can influence patients' susceptibility to infections, yet research in this aspect of asthma has been limited. There is additional debate in this field, with current literature tending to view the increased risk of infection among atopic patients as caused by opportunistic infections secondary to airway inflammation, especially in patients with severe atopic diseases. However, other evidence suggests that such risk and its underlying immune dysfunction might be a phenotypic or clinical feature of atopic conditions. This review argues (1) that improved understanding of the effects of asthma or other atopic conditions on the risk of microbial infections will bring important and new perspectives to clinical practice, research, and public health concerning atopic conditions and (2) that research efforts into the causes and effects of asthma must be juxtaposed because they are likely to guide each other.

Zostavax : a subcutaneous vaccine for the prevention of herpes zoster

INTRODUCTION

Herpes zoster (HZ) occurs as a reactivation of dormant varicella zoster virus (VZV), and occurs more frequently in the aging population or the immunocompromised due to waning cell-mediated immunity. Up to 1 million cases of HZ are reported annually in the USA with an estimated 10 - 30% of the population being affected by shingles in their lifetime. HZ is a debilitating illness, and while mortality is low, morbidity remains a significant cause for concern with prevention efforts aimed at reducing VZV reactivation and its complications. The HZ vaccine was approved by the US Food and Drug Administration for individuals aged 50-years or older. However, the Center for Disease Control and Prevention's Advisory Committee for Immunization Practices recommends the vaccine in individuals aged 60-years or older.

AREAS COVERED

Recent literature investigating the efficacy and indications of live attenuated zoster vaccine.

EXPERT OPINION

Live attenuated zoster vaccine is safe and efficacious in preventing HZ and decreasing the morbidity associated with postherpetic neuralgia. The vaccine is FDA approved in individuals aged 50-years or older but further studies are warranted to investigate the vaccine's efficacy in immunosuppressed and immunocompromised patients.

Varicella zoster virus in American Samoa: seroprevalence and predictive value of varicella disease history in elementary and college students

The epidemiology of varicella is believed to differ between temperate and tropical countries. We conducted a varicella seroprevalence study in elementary and college students in the US territory of American Samoa before introduction of a routine varicella vaccination programme. Sera from 515 elementary and 208 college students were tested for the presence of varicella-zoster virus (VZV) IgG antibodies. VZV seroprevalence increased with age from 76·0% in the 4-6 years group to 97·7% in those aged ⩾23 years. Reported history of varicella disease for elementary students was significantly associated with VZV seropositivity. The positive and negative predictive values of varicella disease history were 93·4% and 36·4%, respectively, in elementary students and 97·6% and 3·0%, respectively, in college students. VZV seroprevalence in this Pacific island appears to be similar to that in temperate countries and suggests endemic VZV circulation.

Varicella in infants after implementation of the US varicella vaccination program

OBJECTIVE

To describe varicella disease in infants since implementation of the varicella vaccination program in the United States.

PATIENTS AND METHODS

From 1995 to 2008, demographic, clinical, and epidemiologic data on cases of varicella in infants were collected prospectively through a community-based active surveillance project. We examined disease patterns for infants in 2 age groups: 0 to 5 and 6 to 11 months.

RESULTS

Infant varicella disease incidence declined 89.7% from 1995 to 2008. Infants aged 0 to 5 months had milder clinical disease than those aged 6 to 11 months: ≥50 lesions, 49% vs 58% (P = .038); fever (body temperature > 38°C), 12% vs 21% (P = .014); and varicella-related complications, 6% vs 14% (P = .009), respectively. Age was an independent predictor of the occurrence of complications.

CONCLUSIONS

The varicella vaccination program has resulted in substantial indirect benefits for infants, who are not eligible for vaccination. Presence of maternal varicella-zoster virus antibodies might explain attenuated disease in very young infants likely born to mothers with history of varicella. Although varicella disease incidence has declined, exposure to varicella-zoster virus continues to occur. Improving varicella vaccination coverage in all age groups will further reduce the risk of varicella exposure and protect those not eligible for varicella vaccination.

Subclinical reactivation of varicella zoster virus in all stages of HIV infection

Analysis of 200 paired serum and cerebrospinal fluid (CSF) samples from 180 HIV-positive individuals, 136 of whom had AIDS, revealed intrathecal synthesis of antibodies specific for varicella zoster virus (VZV) in 28 (16%) individuals, measles virus in 15 (8%), herpes simplex virus-1 (HSV-1) in 1 (0.6%), and HSV-2 in none. Of the 28 subjects with a positive VZV antibody specificity index, only 1 had zoster rash at the time of serum and CSF sampling; of the total 180 HIV-positive subjects, 146 (81%) had no history of zoster. Based on an estimated 33.4 million HIV-positive individuals worldwide, subclinical reactivation of VZV in even less than 16% of HIV-positive people suggests the possibility that millions of people have active VZV infection of the central nervous system. In cases of VZV vasculopathy, myelopathy and even zoster sine herpete, the CSF is often positive for anti-VZV antibody, but negative for VZV DNA. To rule out VZV infection of the nervous system, CSF must be tested for VZV DNA and anti-VZV IgG and IgM antibody.

Neonatal varicella: A case report

Chicken pox is an infectious childhood disease. It is rare in infants and newborns due to passive immunity received from the mother. The characteristic skin eruptions in chicken pox are vesicular with erythematous base and accompanied with pruritus. The skin of the palms and soles is typically spared. We report a case of neonatal varicella where the mother was having skin eruptions at the time of delivery and the neonate contracted it during the perinatal period and developed clinical disease on the day five of life. Specific anti-viral therapy was given to the mother and the baby and the recovery was uneventful.