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

Knowledge, attitude, and practice toward herpes zoster (HZ) and HZ vaccination: Concept elicitation findings from a multi-country study in the Asia Pacific

Herpes zoster (HZ) is a prevalent disease characterized by a painful rash. A multi‑country study was conducted to elicit public and physician knowledge, attitude, and practice (KAP) toward HZ disease and vaccination for the assessment of local factors influencing HZ vaccine perceptions in four Asian-Pacific countries/territories One-to-one qualitative interviews were conducted in 2022, among the public (people aged ≥ 50 years, adults with parents aged ≥ 50 years, zoster vaccine live-vaccinated individuals aged ≥ 50 years in Republic of Korea, and HZ patients; n = 78) and physicians (general practitioners and specialists; n = 24). Themes surrounding KAP toward HZ and HZ vaccination were summarized using a thematic analysis. A substantial knowledge gap related to HZ was observed among the public, including its causes, long-term impacts, and the at-risk population. There was a low perceived risk of HZ and low general awareness of HZ vaccine availability, although country/territory-specific differences existed. Fear of HZ-associated pain contributed toward vaccination intent among HZ patients and adults with parents aged ≥ 50 years. HZ-naïve adults who were encouraged to receive the vaccine by others were not motivated to do so due to optimism bias. Physicians were perceived to be a reliable source of information. However, physicians did not always proactively discuss HZ vaccination due to time constraints and a perceived need to prioritize other vaccinations including influenza and pneumococcal vaccines. Initiatives are needed to improve public awareness of HZ and its complications, in terms of overall impact on individuals and society, and highlight the important role of physicians in recommending vaccination.

Public health impact of herpes zoster vaccination on older adults in Singapore: a modeling study

In Singapore, population aging and rising life expectancy are increasing herpes zoster (HZ) burden, which may be reduced by vaccination. The present study modeled the public health impact of HZ vaccination in Singapore using ZOster ecoNomic Analysis (ZONA) model adapted with Singapore-specific key model inputs, where available. Base case analysis was conducted in adults ≥ 50 years of age (YOA), exploring three vaccination strategies (no vaccination, recombinant zoster vaccine [RZV], zoster vaccine live [ZVL]) under mass vaccination setting (30% coverage). Scenario and sensitivity analyses were performed. Out of 1.51 million adults in 2021 (base case population), 406,513 (27.0%) cases of HZ, 68,264 (4.5%) cases of post-herpetic neuralgia (PHN), and 54,949 (3.6%) cases of other complications were projected without vaccination. RZV was estimated to avoid 73,129 cases of HZ, 11,094 cases of PHN, and 9,205 cases of other complications over the subjects' remaining lifetime; ZVL would avoid 17,565 cases of HZ, 2,781 cases of PHN, and 1,834 cases of other complications. The number needed to vaccinate to prevent one case of HZ/PHN was lower for RZV (7/41) than ZVL (26/163). Among all five age-stratified cohorts (50-59/60-64/65-69/70-79/≥80 YOA), RZV (versus no vaccination/ZVL) avoided the largest number of cases in the youngest cohort, 50-59 YOA. Results were robust under scenario and sensitivity analyses. Mass vaccination with RZV is expected to greatly reduce the public health burden of HZ among Singapore individuals ≥ 50 YOA. Findings support value assessment and decision-making regarding public health vaccination strategies for HZ prevention in Singapore.

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

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

Knowledge, attitudes, and practices of the general population, herpes zoster patients, and dermatologists toward herpes zoster in China: A quantitative cross-sectional survey

The burden of herpes zoster (HZ) is anticipated to increase among the aging population of China over time. The knowledge, attitudes, and practices (KAP) of the population toward HZ can help inform the design of public health strategies. As there is a paucity of KAP data in China, this cross-sectional survey therefore sought to assess KAP related to HZ from the general population, patients with HZ, and dermatologists in China. The total number of respondents from the general population, HZ patients, and dermatologists were 804, 282, and 160, respectively. Notably, some gaps in knowledge regarding the severity, transmission, and prevention of HZ were identified across all groups. For example, less than half of respondents from the general population and HZ patients understood that vaccination does not treat HZ. For dermatologists, not all were aware of adverse reactions following HZ vaccination and some had misconceptions regarding the mode of transmission of HZ. Given the link between an individual's disease knowledge to their attitudes and practices, improved understanding of HZ could underlie positive attitudes and help reinforce healthcare professionals' recommendations in the management and prevention of HZ. In particular, doctors may be well-positioned to support HZ prevention initiatives, as most of the general population and HZ patients found vaccination more acceptable if recommended by a doctor (78.9% and 81.6%, respectively). Therefore, consideration of these KAP attributes may support the development of targeted educational interventions and effective public health strategies against HZ in China.

Modelling the Public Health Burden of Herpes Zoster and the Impact of Adjuvanted Recombinant Zoster Vaccine in Five Selected Countries in Southeast Asia

INTRODUCTION

Herpes zoster (HZ) can cause substantial patient morbidity and lead to large healthcare costs. However, the disease burden of HZ in Southeast Asia may be underestimated. This study aimed to estimate the public health burden of HZ and the impact of vaccinating adults aged ≥ 50 years old in five Southeast Asian countries (Indonesia, Malaysia, Philippines, Thailand, and Vietnam), with adjuvanted recombinant zoster vaccine (RZV) compared with no vaccination.

METHODS

For each country, we adapted a static multicohort Markov model developed with a 1-year cycle length and lifetime horizon. Demographics were obtained from the World Health Organization, HZ incidence from a worldwide meta-regression reporting Asian-specific values, proportions of postherpetic neuralgia (PHN) and non-PHN complications from local/regional studies, and vaccine efficacy from a long-term follow-up trial. First-dose coverage and second-dose compliance were assumed to be 30% and 70%, respectively. A one-way deterministic sensitivity analysis (OWSA) and probabilistic sensitivity analysis (PSA) were performed to assess the robustness and uncertainty of inputs for each country.

RESULTS

Without RZV, it was estimated that there would be a total of approximately 10 million HZ cases, 2.1 million PHN cases, and 1.4 million non-PHN complications in individuals aged ≥ 50 years included in the model. Introducing RZV under 30% coverage could avoid approximately 2.2 million (22%) HZ cases, almost 500,000 (21%) PHN cases, and around 300,000 (22%) non-PHN complications. OWSA showed that first-dose coverage and initial HZ incidence had the largest impact on the estimated number of HZ cases avoided. The number needed to vaccinate ranged from 15 to 21 to prevent one case of HZ and from 68 to 104 to prevent one case of PHN across each country.

CONCLUSIONS

This study demonstrated that there is substantial HZ disease burden in older adults for the five selected countries in Southeast Asia, negatively impacting national healthcare systems. Introducing RZV could potentially reduce this burden. A graphical abstract is available with this article.

Healthy ageing: Herpes zoster infection and the role of zoster vaccination

Populations are ageing worldwide, with considerable time lived in ill-health, putting upwards pressure on healthcare budgets. Healthy ageing is defined as maintaining functional ability, including the ability to: meet basic needs; learn, grow and make decisions; be mobile; build and maintain relationships; and contribute to society. The risk and impact of infectious diseases increase with age due to immunosenescence. Vaccination can help to prevent disease in older adults, promoting healthy ageing and active lives. Herpes zoster (HZ) occurs when the varicella zoster virus is reactivated due to declining immunity. HZ is common, with a lifetime risk of one-third, and increases in incidence with age. HZ is associated with severe and intense pain, substantially affecting the functional status of patients as well as their overall health-related quality of life. HZ and its complications may result in prolonged morbidity, including persistent pain (post-herpetic neuralgia, PHN), hearing impairment, vision loss and increased risk of stroke and myocardial infarction. HZ and PHN are difficult to treat, substantiating the benefits of prevention. Vaccines to prevent HZ include a recombinant zoster vaccine (RZV). RZV has shown efficacy against the HZ burden of disease and HZ burden of interference on activities of daily living of over 90% in immunocompetent adults aged ≥50 years. Vaccine efficacy against HZ was maintained at over 70% at 10 years post-vaccination. Adult vaccination, including against HZ, has the potential to reduce burden of disease, thus helping to maintain functioning and quality of life to support healthy ageing in older adults.

Opioids Prescribing Among Patients with Zoster-Related Pain in Real-Life: A Retrospective, Cohort Study Based on the Clinical Database

Purpose

The aim of this study was to analysis of the opioid use of opioid native zoster-related pain (ZRP) patients to evaluate the impact of opioid use on pain control and quality of life improvement based on the clinical database.

Patients and Methods

We conducted a retrospective cohort study to identify opioid native patients who were hospitalized in the pain department between May 1, 2020, and May 1, 2021. The primary outcomes were persistent opioid use after discharge, visual analogue scale (VAS) at the admission, VAS remission rate during hospitalization, VAS score and quality of life at follow-up. Then, we assessed patient-level risk factors for persistent opioid use after the discharge.

Results

A total of 350 patients met the inclusion criteria. Of those patients, 255 (72.9%) were administered with opioid during hospitalization, and 95 (27.1%) patients were not. Opioid prescription during hospitalization was independently associated with increased odds of persistent use after the discharge (adjusted odds ratio, 20.74; 95% CI, 4.504-95.474; P < 0.01). In the two groups, the VAS score at admission and the VAS score at follow-up were different. In the group with opioids during hospitalization, the persistent opioid use after discharge was more common (38% vs 2.1%) compared to patients without opioids, and VAS remission rate during hospitalization was less, restrictions on daily life, work or housework, and social activities were more common, and mood, diet and sleep were worse, respectively.

Conclusion

Opioids prescription during hospitalization might increase the risk of chronic opioid use in opioid native ZRP patients, and it has limited benefits in pain control and quality of life improvement. Even though PHN was painful and intractable, the use of opioids should also be more cautious, and strict follow-up, management in this population.

Cost-Effectiveness of Recombinant Zoster Vaccine for Adults Aged ≥50 Years in China

INTRODUCTION

Adjuvanted recombinant zoster vaccine (RZV) was the first vaccine made available for herpes zoster in China. Authors aimed to evaluate its economic and health impacts on Chinese adults aged ≥50 years.

METHODS

A lifetime Markov model was developed to compare the cost-effectiveness of RZV with that of no vaccination from a societal perspective. Model inputs were derived from published literature and analyzed in 2022. Outcomes included total costs, quality-adjusted life-years, incremental cost-effectiveness ratio, and number of herpes zoster and herpes zoster-related cases. Sensitivity analyses were performed to examine the robustness of the model results.

RESULTS

RZV was more costly than no vaccination by $2.78 billion with an additional 65,008 quality-adjusted life-years gained and could avoid 1,893,530 herpes zoster cases, 295,761 postherpetic neuralgia cases, 51,734 other complications, and 229 herpes zoster-related deaths. Incremental cost-effectiveness ratios of RZV varied in a range of $34,465.5-$51,002.7 per quality-adjusted life-year. RZV for the entire cohort would be cost-effective when discount rate was <2.4%, a waning rate of 2-dose RZV efficacy decreased to <0.8%, the utility of postherpetic neuralgia was <0.496, duration of postherpetic neuralgia was >12.86 months, or the cost of RZV per dose decreased to <$229.6. In a probabilistic sensitivity analysis, the probability of RZV being cost-effective was 43.95%, 59.32%, 45.27%, and 39.50% for people aged 50-59, 60-69, 70-79, and ≥80 years, respectively, with threefold gross domestic product per capita (37,654.5 per quality-adjusted life-year) as the willingness-to-pay threshold.

CONCLUSIONS

RZV was most likely to be cost-effective in people aged 60-69 years. A slight decrease in vaccine cost would result in RZV being cost-effective in all people aged ≥50 years.

Validity of claims-based diagnoses for infectious diseases common among immunocompromised patients in Japan

BACKGROUND

To validate Japanese claims-based disease-identifying algorithms for herpes zoster (HZ), Mycobacterium tuberculosis (MTB), nontuberculous mycobacteria infections (NTM), and Pneumocystis jirovecii pneumonia (PJP).

METHODS

VALIDATE-J, a multicenter, cross-sectional, retrospective study, reviewed the administrative claims data and medical records from two Japanese hospitals. Claims-based algorithms were developed by experts to identify HZ, MTB, NTM, and PJP cases among patients treated 2012-2016. Diagnosis was confirmed with three gold standard definitions; positive predictive values (PPVs) were calculated for prevalent (regardless of baseline disease-free period) and incident (preceded by a 12-month disease-free period for the target conditions) cases.

RESULTS

Of patients identified using claims-based algorithms, a random sample of 377 cases was included: HZ (n = 95 [55 incident cases]); MTB (n = 100 [58]); NTM (n = 82 [50]); and PJP (n = 100 [84]). PPVs ranged from 67.4-70.5% (HZ), 67.0-90.0% (MTB), 18.3-63.4% (NTM), and 20.0-45.0% (PJP) for prevalent cases, and 69.1-70.9% (HZ), 58.6-87.9% (MTB), 10.0-56.0% (NTM), and 22.6-51.2% (PJP) for incident cases, across definitions. Adding treatment to the algorithms increased PPVs for HZ, with a small increase observed for prevalent cases of NTM.

CONCLUSIONS

VALIDATE-J demonstrated moderate to high PPVs for disease-identifying algorithms for HZ and MTB using Japanese claims data.

Prevalence and healthcare utilization in managing herpes zoster in primary care: a retrospective study in an Asian urban population

Herpes zoster (HZ) causes significant morbidity, particularly in older adults. With the advent of a recombinant zoster vaccine, HZ is potentially preventable. However, data on HZ burden and healthcare utilization in primary care populations remains scarce. This study described the prevalence and healthcare utilization in managing HZ in a developed community. A retrospective database review was conducted across a cluster of 8 public primary care clinics in urban Singapore. Data of multi-ethnic Asian patients with a diagnosis code of "herpes zoster" from 2018 to 2020 was extracted from their electronic medical records. Socio-demographic, clinical, visitation, medical leave, prescription, and referral data were analyzed. A total of 2,987 out of 737,868 individuals were diagnosed with HZ over 3 years. The mean age was 59.9 (SD + 15.5) years; 49.2% were male; 78.5% Chinese, 12.2% Malay, and 4.1% Indian. The prevalence was 221, 224, 203 per 100,000 persons in 2018, 2019, and 2020, respectively. The 70 to 79-year age group had the highest prevalence (829/100,000) across 3 years. Oral acyclovir (median daily dose 4,000 mg; median duration 7 days) and topical acyclovir were prescribed in 71.6 and 47.6%, respectively. Analgesia prescribed were gabapentin (41.0%), paracetamol combinations (30.1%), oral NSAIDs (23.7%), opioids (6.0%), and tricyclic antidepressants (1.9%). Most individuals consulted only once (84.3%); 32.7% of them required medical leave and 5.6% had more than 7 days of absenteeism. HZ-related referrals to the hospital were required in 8.9% (4.9% emergency, 2.8% ophthalmology). The findings of this study suggest a need for HZ vaccination among older age groups. Visitation and referral rates were low. The use of topical acyclovir was uncovered, and further research should evaluate the underlying reasons, benefits, and harms of such practice. The use of analgesia combinations may be explored further.

The landscape of herpes zoster management and prevention in the Philippines: Proceedings from two advisory boards

Although 1 in 3 people globally are expected to develop herpes zoster (HZ; i.e. shingles), HZ vaccination is not currently part of the Philippine National Immunization Program and HZ is not considered as one of the main vaccine-preventable diseases highlighted by the Department of Health. We report the findings from two advisory boards held with healthcare professionals (HCPs) to understand the current landscape of HZ management and prevention in the Philippines. The first advisory board focused on the management and prevention of HZ in patients aged ≥50 years, the second in immunocompromised patients aged ≥18 years. HCPs reported seeing HZ cases across specialties, with the most common complication being postherpetic neuralgia. HZ was reported to impose a substantial burden on patients, due to both the cost of treatment and distress caused due to pain. HZ could also complicate the treatment of ongoing conditions. HCPs agreed that the introduction of the recombinant zoster vaccine, which was recently approved by the Philippines Food and Drug Administration, could help in the prevention of HZ, addressing the needs of both HCPs and patients. Suggested steps to establish HZ vaccination in the Philippines included improved HCP and patient education, and establishing local HZ vaccine recommendations.

Review of the unmet medical need for vaccination in adults with immunocompromising conditions: An Indian perspective

Immunocompromised (IC) populations are at increased risk of vaccine-preventable diseases (VPDs). In India, the concern of VPDs in IC populations is particularly acute due to the prevalence of crowded living situations, poor sanitation and variable access to healthcare services. We present a narrative review of IC-related disease and economic burden, risk of VPDs and vaccination guidelines, based on global and India-specific literature (2000-2022). IC conditions considered were cancer, diabetes mellitus, chronic kidney disease, respiratory disorders, disorders treated with immunosuppressive therapy, and human immune deficiency virus (HIV). The burden of IC populations in India is comparable to the global population, except for cancer and HIV, which have lower prevalence compared with the global average. Regional and socioeconomic inequalities exist in IC prevalence; VPDs add to the burden of IC conditions, especially in lower income strata. Adult vaccination programs could improve health and reduce the economic impact of VPDs in IC populations.

Systematic Literature Review of Herpes Zoster Disease Burden in Southeast Asia

INTRODUCTION

Herpes zoster (HZ; i.e., shingles) is caused by the reactivation of varicella zoster virus leading to a painful dermatomal rash. An increasing trend in cases of HZ is evident worldwide; however, there is a lack of comprehensive reviews for Southeast Asian countries.

METHODS

We performed a systematic literature review of articles published until May 2022 that reported HZ epidemiology, clinical management, and health economic data in six Southeast Asian countries: Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. Literature searches were conducted in Medline, Scopus, Embase, and gray literature. Articles written in English or local languages were considered for inclusion.

RESULTS

In total, 72 publications were included in the study; 22 were case studies and over 60% originated in Singapore and Thailand. Only two studies (data from Thailand) reported incidence of HZ. The proportion of patients reported with HZ was 0.68-0.7% among dermatology clinics, 0.14% at one emergency department (5.3% of dermatology cases) in Singapore, and 3% of admissions at another hospital in Singapore. Pain was the most common symptom associated with HZ, reported in 74.21-100% of patients. HZ complications were reported in 10.2-21.2% of patients, and the proportions with postherpetic neuralgia and HZ ophthalmicus were 6.3-50% and 4.98-28.57%, respectively. Additionally, there is a lack of comprehensive, up-to-date HZ economic data, with only six studies identified for the Philippines, Singapore, and Thailand.

CONCLUSIONS

Overall, there are limited data reporting incidence and prevalence of HZ in Southeast Asia at a national level. High rates of complications, symptoms, and abundance of case reports suggest substantial healthcare resource utilization for patients with HZ and highlight the need for further research in Southeast Asia assessing the societal impact.

Varicella Zoster Reactivation Manifesting as Serpiginous Peripheral Keratitis and Disciform Keratitis Occurring After Necrotizing Fasciitis in an Immunocompromised Male: A Case Report

Reactivation of herpes zoster ophthalmicus (HZO) can present as corneal involvement without any precedent neuralgia or characteristic herpetic rash. This form of HZO can be the first manifestation of reactivation of varicella zoster virus and can masquerade as peripheral ulcerative keratitis. A 45-year-old male treated for necrotizing fasciitis (NF) one month back presented with painful diminution of vision in the right eye (RE) for two weeks without any associated vesicular rash or neuralgia. On examination, best-corrected visual acuity in RE was 2/60 with non-marginal upper lid defect, and multiple linear contracture scars involving the upper lid, right temple, and preauricular region. There were associated peripheral corneal ring infiltrates, disc-shaped central stromal edema, and reduced corneal sensation. The patient had a history of chicken pox in childhood and was recently diagnosed with seropositive rheumatoid arthritis (RA). Though corneal scrapings were negative on Tzanck smear, a presumptive clinical diagnosis of herpetic disciform keratitis was made, and the patient was started on oral and topical acyclovir with steroids. This was confirmed with improving clinical course and detection of herpes zoster DNA on polymerase chain reaction from corneal scrapings. Lid reconstruction for associated lid defect was performed using paramedian forehead flap, which was remodeled at 16 weeks. Our case, a seropositive RA patient, had reactivation of varicella zoster manifesting as peripheral serpiginous and disciform keratitis activated after NF. There are a few case reports of periorbital NF following HZO in immunocompromised patients. However, till date, no case of HZO occurring after periorbital NF has been reported. Also, in our case, reactivation of HZO presented as disciform and serpiginous keratitis without any precedent herpetic rash or neuralgia.

Low Trend for VZV-Associated Disease Patients to Visit Neurologists

Background

Herpes zoster (HZ) is a skin disease that can also cause virus-infectious peripheral neuropathies. Despite this, there is limited information on patient preferences for seeking medical attention for HZ and zoster-associated pain (ZAP). Our study aimed to evaluate how frequently patients with ZAP choose to visit neurologists for their symptoms.

Methods

This study conducted a retrospective review of electronic health records in three general hospitals from January 2017 to June 2022. Using association rule mining, the study analyzed referral behaviors.

Results

We identified 33,633 patients with 111,488 outpatient visits over 5.5 years. The study found that the majority of patients (74.77-91.22%) visited dermatologists during their first outpatient visit, while only a small percentage (0.86-1.47%) preferred to consult a neurologist. The proportion of patients referred to a specialist during their medical visit varied significantly between different specialties within the same hospital (p <0.05) and even within the same specialty (p<0.05). There was a weak association (Lift:1.00-1.17) of referral behaviors between dermatology and neurology. Across the three hospitals, the average number of visits to a neurologist for ZAP was 1.42-2.49, with an average electronic health record duration of 11-15 days per patient. After consulting with a neurologist, some patients were referred to other specialists.

Conclusion

It was observed that patients with HZ and ZAP tended to visit a variety of specialists, with only a small number seeking the assistance of neurologists. However, from the perspective of neuroprotection, it is the duty of neurologists to provide more means.

Optimal Use of Jak Inhibitors and Biologics for Atopic Dermatitis on the Basis of the Current Evidence

Recently, Jak inhibitors such as baricitinib, upadacitinib, and abrocitinib were approved for the treatment of atopic dermatitis (AD) in addition to biologics, including dupilumab, tralokinumab, and nemolizumab. The increase in treatment options can be a benefit to patients with AD. Meanwhile, it could make it difficult for physicians to choose the best treatment among those treatment options. Biologics and Jak inhibitors differ in efficacy, safety, route of administration, and whether or not there is a concern about immunogenicity in addition to the evidence on comorbidities. Among the three Jak inhibitors, the degree of inhibition of signal transducer and activator of transcription differs in each Jak inhibitor. Therefore, the efficacy and safety profiles of the three Jak inhibitors are different. Physicians who treat patients with AD with Jak inhibitors and biologics need to understand the current evidence and choose the best treatment for individual patients. In this review, we discuss how integrating knowledge of the mechanisms of action of Jak inhibitors and biologics, the potential significant adverse events of these drugs, and the age and comorbidities of the patient can help achieve optimal clinical benefit for patients with moderate-to-severe AD refractory to topical agents.

Ultrasound-Guided Thoracic Paravertebral Block Using Paraventricular Oblique Sagittal (POS) Approach for the Treatment of Acute Herpes Zoster: A Two-Blind Randomized Controlled Trial

INTRODUCTION

The aim of this work is to examine the efficacy and benefits of ultrasound (US)-guided thoracic paravertebral block (TPVB) using paraventricular oblique sagittal (POS) approach for the treatment of herpes zoster related acute pain (ZAP) and its preventive effects on post-herpetic neuralgia (PHN).

METHODS

A total of 136 patients suffering from ZAP within 2 weeks of rash onset were randomly allocated to transverse short axial approach (TSA) and paraventricular oblique sagittal (POS) group in 1:1 ratio. All patients received a standard antiviral treatment and rescue analgesics besides TPVB. Primary outcome was HZ illness burden (HZ-BOI) measured by a severity-by-duration composite pain assessment during 30 days. The non-inferiority margin (NIM) was set at - 10. Secondary outcomes included visual analog pain scores (VAS) and Kolcaba's General Comfort Questionnaire discomfortable scores (GCQ) during block needle insertion, quality of life (QoL), and PHN incidence during follow-up. Adverse events were also recorded.

RESULTS

VAS pain scores (30 (IQR: 20, 40) vs. 65 (IQR: 45, 90), p < 0.001) and GCQ discomfortable scores (p < 0.001) were significantly lower in the POS group during needle insertion. The POS approach was not inferior to the proved TSA method in terms of BOI-30_AUC when the lower limit of 95% confidence interval (CI) of two mean differences (13.54 (95% CI - 3.55, 30.63)) lay within the NIM. There were no differences between the two groups in BOI-30-90_AUC, and BOI-90-180_AUC (p = 0.260 and 0.182). Greater QoL improvement and lower PHN incidence were comparable between the two groups. No serious adverse events occurred.

CONCLUSIONS

US-guided TPVB using less-invasive POS technique was as an optimal early intervention to reduce ZAP and a possible preventive strategy for PHN.

TRIAL REGISTRATION

The study was retrospectively registered in the Chinese Clinical Trial Registry on November 15, 2022 (ChiCTR2200065783).

Lifetime risk of herpes zoster in the population of Beijing, China

Objectives

We aimed to estimate the current and future lifetime risks (LTR) of herpes zoster (HZ) and postherpetic neuralgia (PHN), as well as their respective number of annual incident cases in Beijing, China, if individuals were not vaccinated against HZ.

Study design

Mathematical model built in Microsoft Excel, de novo.

Methods

A hypothetical cohort of 1,000 people was simulated from age 0-100 or until death to generate LTRs of HZ/PHN in Beijing, China. LTR was defined as the risk of developing HZ/PHN at least once in the person's lifetime. The current number of annual incident HZ/PHN cases were also calculated by multiplying up-to-date population data and the annual age-specific incidence of HZ/PHN. For both LTR and annual incident cases, current estimates were projected into the year 2035 to investigate the impact of an aging population. Scenario and deterministic sensitivity analyses (DSA) were conducted to validate the model outcomes.

Results

In Beijing, the current and future LTRs of HZ (PHN) were 32.4% (2.8%) and 34.8% (3.3%), respectively. The current and future annual incident cases of HZ (PHN) of individuals aged ≥50 years were 68,394 (7,801) cases among 7.04 million individuals and 88,676 (9,649) cases among 9.08 million individuals, respectively. The scenario analyses demonstrated that modelled results were likely to underestimate the LTR of HZ. Results were robust under the DSA.

Conclusions

Given an aging population, HZ poses a significant, growing burden on individuals, the society, and healthcare system of China, highlighting the need for preventative measures such as vaccination.

Cellular metabolism changes in bilateral hippocampi in patients with herpes zoster

OBJECTIVES

Herpes zoster (HZ) has been found to be associated with arisk of developing dementia. However, changes of cellular metabolism in the hippocampus in HZ have received little attention. This study aimed to investigate the cellular metabolism changes in bilateral hippocampi in acute HZ.

METHODS

¹H-MRS (magnetic resonance spectroscopy) was used to detect the cellular metabolism of bilateral hippocampi in 62 patients with acute HZ and 12 volunteers (control group) from July 2020 to December 2021. Mini-Mental State Examination (MMSE), Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA) and Numerical Rating Scale (NRS) were used to evaluate their cognitive function, depression, anxiety and pain intensity, as well as a the correlation between them.

RESULTS

The MMSE score in patients with HZ was not significantly different from that of controls (P>0.05), while the scores of HAMD and HAMA were significantly higher (P<0.05) than those of controls. Also 12.9% and 21.0% of the patients with acute HZ had depression and anxiety disorders, respectively. The level of Cho/Cr in the left/right hippocampi of HZ patients was significantly lower than that of the control group (P<0.05). The level of Cho/Cr in the right hippocampus, duration of disease and NRS score in HZ patients with anxiety/depression were significantly higher than those without anxiety/depression, but the level of NAA/Cr in the right hippocampus was lower (P<0.05). The NRS score and duration of disease in HZ patients were positively correlated with the scores of HAMD and HAMA.

CONCLUSION

The cellular metabolism of bilateral hippocampi in patients with acute HZ is altered. Those with longer duration of disease and severe pain are more likely to have depression and anxiety disorder, and the changes in cellular metabolism of hippocampi in those with depression and anxiety were more prominent.

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

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

Incidence trend and disease burden of seven vaccine-preventable diseases in Shandong province, China, 2013-2017: Findings from a population-based observational study

Introduction

Although vaccines provide a cost-effective solution to vaccine-preventable diseases (VPDs), the disease burden of VPDs is still very high in most parts of the world.

Methods

A population-based observational study was conducted in Shandong province, China, from 2013 to 2017, giving an insight into the epidemiological characteristics and disease burden of seven VPDs. The incidence trend was estimated using the Poisson regression model. The disease burden was calculated using the disability-adjusted life years (DALYs).

Results

Most VPDs included in the China’s National Immunization Program had higher incidence density (ID) in inland cities. The ID of mumps decreased significantly, while herpes zoster increased (both P < 0.05). The top three causes of the disease burden as assessed with DALYs included tuberculosis, herpes zoster, and hepatitis B, with the rates of 72.21, 59.99, and 52.10 DALYs/100 000, respectively. The disease burden of influenza and herpes zoster were relatively high in people aged > 50 years, while highest DALYs of hepatitis B were found in young adults.

Conclusion

Inequalities in the vaccine coverage by geography, socio-economic status, and targeted population contribute to the increasing incidence and high burden of VPDs and call for renewed and sustained immunization strategies in China.

Global herpes zoster incidence, burden of disease, and vaccine availability: a narrative review

Herpes zoster (HZ) is a neurocutaneous disease that causes significant morbidity worldwide. The disease is caused by the reactivation of the varicella-zoster virus (VZV), which leads to the development of a painful, vesicular rash and can cause complications such as post-herpetic neuralgia and vision loss. Globally, the incidence of HZ is increasing, and it incurs billions in cost annually to the healthcare system and to society through loss of productivity. With the advent of effective vaccines such as the live attenuated vaccine, Zostavax^®, in 2006, and more recently the adjuvant recombinant subunit vaccine, Shingrix^®, in 2017, HZ has become a preventable disease. However, access to the vaccines remains mostly limited to countries with developed economies, such as the United States and Canada. Even among countries with developed economies that license the vaccine, few have implemented HZ vaccination into their national immunization schedules due to cost-effectiveness considerations. In this review, we discuss the currently available HZ vaccines, landscape of HZ vaccine guidelines, and economic burden of disease in countries with developed and developing economies, as well as barriers and considerations in HZ vaccine access on a global scale.

Acupuncture therapies for postherpetic neuralgia: a protocol for a systematic review and Bayesian network meta-analysis

INTRODUCTION

Postherpetic neuralgia (PHN) is the most common sequela of herpes zoster, and it is often refractory to guideline-recommended treatments. Acupuncture therapy, a wildly applied complementary-alternative treatment, may help in the management of PHN. Diverse types of acupuncture therapy for PHN have been proposed, however, their comparative efficacies remain unclear. This study protocol plans to compare the efficacy and safety of different acupuncture therapies for PHN.

METHODS AND ANALYSIS

Databases including MEDLINE, Embase, Cochrane Library, Web of Science, Chinese Biomedical Database, China National Knowledge Infrastructure, VIP Database, Wanfang Database, WHO International Clinical Trials Registry Platform, ClinicalTrials.gov, Chinese Clinical Trial Register and OpenGrey will be searched from their inception to January 2022. Randomised controlled trials (RCTs) assessing the effectiveness of acupuncture therapy on the management of PHN will be selected. The primary outcome is pain intensity. Secondary outcomes include negative emotions, sleep condition, quality of life and adverse events. Reviewers will conduct study selection, data extraction and risk of bias assessment procedures. Then, standard pair-wised meta-analysis and Bayesian network meta-analysis will be performed (if applicable). The Confidence in Network Meta-Analysis application will be used to assess the confidence in the evidence for the primary outcome.

ETHICS AND DISSEMINATION

All data used for this study will be extracted from published RCTs, thus, no ethical approval will be required. The results of this systematic review will be disseminated through peer-reviewed journal and conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42020219576.

Incremental net monetary benefit of herpes zoster vaccination: a systematic review and meta-analysis of cost-effectiveness evidence

OBJECTIVES

To perform a systematic review and meta-analysis to pool the incremental net benefit (INB) of each herpes zoster vaccine [i.e. Zoster Vaccine Live (ZVL) and Recombinant Zoster Vaccine (RZV)].

METHODS

We initially identified individual studies by hand-searching reference lists of the relevant systematic review articles. An updated comprehensive search was performed in Medline, Scopus, and Embase until June 2020 for additional studies. Studies were eligible if they assessed the cost-effectiveness/utility of any pair among ZVL and RZV, and no vaccine and reported economic outcomes. Details of the study characteristics, economic model inputs, costs, and outcomes were extracted. INB was calculated with monetary units adjusting for purchasing power parity for 2019 US dollars and pooled by meta-analysis.

RESULTS

A total of 37 studies were pooled for meta-analysis stratified by perspectives [i.e. societal (SP) and third-party payer (TPP)] and vaccine types. In SP, ZVL was cost-effective compared to no vaccine when vaccinated at ages of 50-59 and 70-79 years with INBs (95% CI) of $0.61 (0.37, 0.85) and $9.67 (5.20, 14.14), respectively. RZV was cost-effective for those aged 60-69 and 70-79 years with INBs of $75.61 (17.98, 133.23) and $85.01 (30.02, 140.01), respectively. In TPP, ZVL was cost-effective compared to no vaccine when vaccinated at age 70-79 years with INB of $7.57 (0.27, 14.86) and RZV was cost-effective at 60-69 years with INB $220.87 (47.80, 393.93). The cost-effectiveness of RZV was robust across a series of sensitivity analyses, but ZVL differs on different vaccination ages.

CONCLUSIONS

RZV may be cost-effective for vaccination in ages of 60-79 years for both SP and TPP perspectives, while ZVL might be cost-effective in some age groups, but results are not robust.

Clinical Manifestations of Herpes Zoster Associated with Complications in Children

Herpes zoster (HZ) is caused by latent varicella-zoster virus (VZV) reactivation when VZV-specific cell-mediated immunity declines. Information on HZ in children is limited. Therefore, we retrospectively investigated HZ's clinical course and complications in children. We extracted the outpatient and hospitalization medical records of pediatric patients (<19 years) primarily diagnosed with HZ (ICD-10 B02 code) between January 2010 and November 2020. HZ was defined as a typical unilateral dermatomal vesicular rash where HZ was the treating physician's primary diagnosis. Recognized HZ complications included combined bacterial skin infection, ophthalmic zoster, zoster oticus without facial paralysis, meningitis, and PHN. We identified 602 HZ cases, among which 54 developed HZ complications and were included in our analysis. The median age was 14.7 years, most patients were aged ≥13 years (42, 79%), and none were aged <4 years. Fifty-three were immunocompetent, and only one had systemic lupus erythematosus. The most frequent complication was zoster ophthalmicus (n = 26, 48%). HZ complications were also observed in immunocompetent or vaccinated children exhibiting a head or neck rash before and after VZV immunization. Current VZV vaccination programs may be insufficient in preventing HZ complications. Therefore, close varicella and HZ burden monitoring and the establishment of effective VZV vaccination programs are imperative.

Herpes zoster in outpatient departments of healthcare centers in India: a review of literature

In India, although incidence of Herpes zoster has not been assessed, regional cases have been reported. We revisited the peer-reviewed literature on clinical cases of HZ to depict the trends in population characteristics, disease presentation, and predisposing factors for the disease in India. Systematically conducted literature search yielded 27 studies, published between January 2011 and May 2020, reporting 3124 HZ clinical cases, with high proportions in older adults (>50 years of age: 15.0–81.3%). Thoracic dermatome was consistently reported as the most frequent site affected by HZ (38.9–71.0%). Post-herpetic neuralgia and secondary bacterial infections were the two most frequent complications (10.2–54.7% and 3.5–21.0%, respectively). Despite the paucity of data and gaps in the reporting of HZ cases, available evidence indicate that the disease causes an important burden to older adults in India, suggesting that preventive strategies, along with recommendations to healthcare practitioners, can help mitigate the burden of HZ.

What is the context?

Herpes zoster is caused by reactivation of the varicella virus in sensory gangila usually during older age.

The most common complication involve skin and neurological disorders, such as post herpetic neuralgia.

Herpes zoster can impact quality of life for months or even years (especially for those >50 years of age).

In India, there is a lack of population-based studies on herpes zoster to reflect burden of disease.

What is new?

We reviewed the literature on clinical cases of herpes zoster in India from last decade and found that:

High propotions of older adults (>50 years of age) are reported to have the disease.

Thoracic dermatomes and post herpetic neuralgia are common clinical presentation and complication.

Post herpetic neuralgia is observed more frequently in older patients.

What is the impact?

Our review highlights sigificant number of cases of herpes zoster are reported and the disease causes a substantial burden to older adults in India.

In view of the growing elderly population in India, the finding of greater proportion of cases in >50 years of age holds importance.

Implementation of preventive strategies along with guidance to healthcare pracitioners can help prevent the disease and complications in vulnerable population.

Ganoderma lucidum: A potential source to surmount viral infections through β-glucans immunomodulatory and triterpenoids antiviral properties

Ganoderma lucidum (G. lucidum) polysaccharides and triterpenoids are the major bioactive compounds and have been used as traditional medicine for ancient times. Massive demands of G. lucidum have fascinated the researchers towards its application as functional food, nutraceutical and modern medicine owing to wide range of application in various diseases include immunomodulators, anticancer, antiviral, antioxidant, cardioprotective, hepatoprotective. G. lucidum polysaccharides exhibit immunomodulatory properties through boosting the action of antigen-presenting cells, mononuclear phagocyte system, along with humoral and cellular immunity. β-Glucans isolated from G. lucidum are anticipated to produce an immune response through pathogen associated molecular patterns (PAMPs). β-Glucans after binding with dectin-1 receptor present on different cells include macrophages, monocytes, dendritic cells and neutrophils produce signal transduction that lead to trigger the mitogen-activated protein kinases (MAPKs), T cells and Nuclear factor-κB (NF-κB) that refer to cytokines production and contributing to immune response. While triterpenoids produce antiviral effects through inhibiting various enzymes like neuraminidase, HIV-protease, DENV2 NS2B-NS3 protease and HSV multiplication. Polysaccharides and triterpenoids adjunct to other drugs exhibit potential action in prevention and treatment of various diseases. Immunomodulators and antiviral properties of this mushroom could be a potential source to overcome this current pandemic outbreak.

Risk factors for herpes zoster in patients with rheumatic diseases: a nationwide cohort study in Korea

OBJECTIVE

To determine the risk factors for herpes zoster (HZ) in patients with rheumatic diseases in Korea.

METHODS

We used the nationwide database of the Health Insurance Review & Assessment Service to analyse patients aged ≥20 years who had visited a hospital more than twice for rheumatic disease as a principal diagnosis from January 2009 to April 2013. HZ was identified using HZ-related Korean Standard Classification of Diseases 6 (KCD-6) codes and the prescription of antiviral agents. The relationship between demographics, comorbidities and medications and HZ risk was analysed by Cox proportional hazards models.

RESULTS

HZ developed in 1869 patients. In Cox proportional hazards models, female sex but not age showed an increased adjusted hazard ratio (HR) for HZ. Comorbidities such as haematologic malignancies, hypertension, diabetes mellitus, and chronic lung and liver diseases led to an increased HR. HZ risk was higher in patients with SLE (HR: 4.29, 95% CI: 3.49, 5.27) and Behçet's syndrome (BS, HR: 4.54; 95% CI: 3.66, 5.64) than with RA. The use of conventional DMARDs, immunosuppressants, TNF inhibitors, glucocorticoids and NSAIDs increased the HR. Infliximab and glucocorticoids (equivalent prednisolone dose >15 mg/day) produced the highest HZ risk (HR: 2.91, 95% CI: 1.72, 4.89; HR: 2.85, 95% CI: 2.15, 3.77, respectively).

CONCLUSION

Female sex, comorbidities and medications increased HZ risk in patients with rheumatic diseases and even young patients could develop HZ. Compared with RA, SLE and BS are stronger HZ risk factors. Patients with rheumatic diseases and these risk factors are potential target populations for HZ vaccination.

Herpes Zoster (Shingles) Patient-Centered Wound Outcomes: A Literature Review

GENERAL PURPOSE

To present a comprehensive review of patient-centered outcomes of topical or systemic interventions applied to those with shingles or postherpetic neuralgia to inform clinical practice and identify related research needs.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will be able to:1. Explain the importance of early diagnosis and treatment of herpes zoster (HZ).2. Identify interventions that have resulted in documented improvement of validated patient-centered outcomes in patients with HZ or postherpetic neuralgia.3. Recognize the average per patient medical costs of HZ in the US.

Postlicensure herpes zoster vaccine effectiveness: systematic review protocol

INTRODUCTION

Herpes zoster (HZ) and associated complications inflict substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable populations. Two HZ vaccines are available and are part of the national immunisation programmes in many countries. This review will evaluate the effectiveness of zoster vaccines against incident HZ and postherpetic neuralgia in adults 50 years and older.

METHODS AND ANALYSIS

The key information sources that will be searched include MEDLINE (Ovid), Embase (Ovid), Cochrane libraries and CINAHL. This search will consider postlicensure observational studies published in all languages between 2006 and 2020 that assessed the effectiveness of HZ/zoster vaccines in adults 50 years and older. The identification of studies will be complemented with the search of reference lists and citations, and contact with authors of papers to request missing or additional data, where required. Following the search, all identified citations will be collated, and duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Selected studies will follow the process of critical appraisal, data extraction and data synthesis. Statistical analyses will be performed using a random-effect model.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as primary data will not be collected. The review will be disseminated in peer-reviewed publications and conference presentations.

Epidemiology of Viral Induced Anterior Uveitis

Purpose: Viral agents are the most common cause of infectious anterior uveitis worldwide. The purpose of this review is to analyze the frequency, gender and racial differences of viral anterior uveitis (VAU) in various populations.Methods: Systematized literature review of epidemiological reports of VAU cited in PubMed, EMBASE and the Cochrane Library database published until June 30th, 2020.Results: A total of 12 clinical studies on epidemiology of definite VAU and 36 clinical studies of presumed VAU were identified. Members of Herpesviridae family represent the most common causes of VAU. Other less frequently reported causes, such as rubella and endemic viruses (HTLV-1, Chikungunya, Dengue, Ebola, Zika virus) were also analyzed.Conclusion: HSV, VZV are prevalent worldwide. CMV is more frequent in Asia, and rubella in the West. However, due to globalization and air travel, HTLV-1, Chikungunya, Dengue and Ebola may become important causes of VAU across the world.

The adjuvanted recombinant zoster vaccine is efficacious and safe in Asian adults ≥ 50 years of age: a sub-cohort analysis of the ZOE-50 and ZOE-70 randomized trials

In two large clinical trials (ZOE-50 [NCT01165177] and ZOE-70 [NCT01165229]), two doses of the adjuvanted recombinant zoster vaccine (RZV) demonstrated >90% efficacy (VE) against herpes zoster (HZ) in adults ≥50 years of age (YOA). This post-hoc analysis assessed the VE against HZ and postherpetic neuralgia (PHN), in participants from Asian study sites enrolled in ZOE-50/70. Reactogenicity and safety were also assessed. Participants ≥50 YOA were randomized 1:1 to receive 2 doses of either RZV or placebo, 2 months apart. VE was evaluated for a median follow-up of 4 years post-vaccination overall and by age in the ZOE-50 Asian population ≥50 YOA and in the pooled ZOE-50/70 Asian population ≥70 YOA. Of the 2,729 participants included in the ZOE-50 Asian population ≥50 YOA, 3 RZV and 66 placebo recipients reported a confirmed HZ episode. Overall VE was 95.6% (95% confidence interval [CI]: 86.4–99.1) against HZ and 100% (95% CI: 35.44–100) against PHN. In the pooled ZOE-50/70 Asian population ≥70 YOA, 4 RZV and 75 placebo recipients out of the 2,723 participants reported a confirmed HZ episode. Overall VE was 94.7% (95% CI: 85.9–98.6) against HZ and 89.8% (95% CI: 28.39–99.77) against PHN. Pain and myalgia were the most frequent solicited local and general adverse events, respectively, in both populations. No safety concern was identified during the study periods. RZV is highly efficacious against HZ and PHN and has an acceptable safety profile in Asian populations ≥50 YOA, similar to what was observed in the general ZOE-50/70 populations.

Trademark statement: Shingrix is a trademark owned by or licensed to the GSK group of companies.

A fixed nitrous oxide/oxygen mixture as an analgesic for patients with postherpetic neuralgia: study protocol for a randomized controlled trial

BACKGROUND

The pain management of postherpetic neuralgia (PHN) remains a major challenge, with no immediate relief. Nitrous oxide/oxygen mixture has the advantages of quick analgesic effect and well-tolerated. The purpose of this study is to investigate the analgesic effect and safety of nitrous oxide/oxygen mixture in patients with PHN.

METHODS/DESIGN

This study is a single-center, two-group (1:1), randomized, placebo-controlled, double-blind clinical trial. A total of 42 patients with postherpetic neuralgia will be recruited and randomly divided into the intervention group and the control group. The control group will receive routine treatment plus oxygen, and the intervention group will receive routine treatment plus nitrous oxide/oxygen mixture. Data collectors, patients, and clinicians are all blind to the therapy. The outcomes of each group will be monitored at baseline (T0), 5 min (T1), and 15 min (T2) after the start of the therapy and at 5 min after the end of the therapy (T3). The primary outcome measure will be the pain intensity. Secondary outcomes included physiological parameters, adverse effects, patients' acceptance of analgesia, and satisfaction from patients.

DISCUSSION

Previous studies have shown that nitrous oxide/oxygen mixture can effectively relieve cancer patients with breakthrough pain. This study will explore the analgesic effect of oxide/oxygen mixture on PHN. If beneficial to patients with PHN, it will contribute to the pain management of PHN.

TRIAL REGISTRATION

Chinese Clinical Trial Register ChiCTR1900023730 . Registered on 9 June 2019.

Update on the Safety Profile of Tofacitinib in Rheumatoid Arthritis from Clinical Trials to Real-World Studies: A Narrative Review

Tofacitinib is approved for the treatment of moderate to severe active rheumatoid arthritis (RA) in adult patients who do not respond adequately or are intolerant to one or more disease-modifying anti-rheumatic drugs. The tofacitinib RA clinical development program included randomized controlled trials of 6–24-month duration and long-term extension studies with > 7061 patients and 22,875 patient-years of exposure. To date, there are no data from other randomized studies in patients with cardiovascular risk factors comparing the long-term safety of a JAK inhibitor versus an anti-TNF. Real-world studies are necessary to complete the body of evidence supporting the effectiveness and safety of a therapeutic agent. In the case of tofacitinib, real-world data derive from health insurance claims databases, registries (US Corrona Registry, Swiss Registry, and others), national pharmacovigilance programs, and hospital databases (case series). The present article provides complete and up-to-date information on the safety profile of tofacitinib in RA, from clinical trials to real-world studies. Tofacitinib has demonstrated a consistent safety profile during up to 9.5 years of experience in randomized controlled trials and long-term extension studies. Real-world evidence has not added new safety issues with respect to those found in the clinical program. In general, the safety profile of tofacitinib is consistent with that of biologic disease-modifying anti-rheumatic drugs, with an increased risk of herpes zoster that seems to be a class effect of Janus kinase inhibitors. The continuous follow-up of therapeutic agents to treat rheumatoid arthritis is needed to adequately establish the safety profile for new mechanisms of action and potential risks associated with their longer term use.

A systematic literature review to assess the burden of herpes zoster disease in China

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.

Risk of cutaneous herpes zoster in patients with spondyloarthritis treated with conventional and biologic disease-modifying antirheumatic drugs

OBJECTIVES

To investigate the risk of cutaneous herpes zoster (HZ) in spondyloarthritis (SpA) compared with that in rheumatoid arthritis (RA), and in disease-modifying antirheumatic drugs (DMARDs) used in SpA.

METHOD

A total of 727 patients with an expert diagnosis of SpA were identified retrospectively from four rheumatology centers in Hong Kong. Electronic medical records from 1995 to 2018 were reviewed for incidence of cutaneous HZ and demographic data including age, sex, comorbidities, smoking and drinking status. DMARDs used included sulphasalazine, methotrexate, leflunomide, steroids, etanercept, infliximab, adalimumab, golimumab, secukinumab and ustekinumab. Cox regression models were used to evaluate hazard ratios (HRs) of different DMARDs in patients with SpA. Propensity score was used for matching and comparison with 857 patients with RA.

RESULTS

There were 23 cases of cutaneous HZ in patients with SpA and 59 cases in patients with RA. Among patients with SpA, 7 cases of cutaneous HZ may be attributed to sulfasalazine treatment, 7 to methotrexate, 2 to leflunomide, 2 to infliximab, 1 to etanercept, 2 to adalimumab, and 1 to secukinumab. Risks of cutaneous HZ were the same in SpA (stratified HR 0.97; 95% CI 0.58; 1.61; P = .89) and RA. Methotrexate (adjusted HR 3.47; 95% CI 1.25; 9.63; P = .02) and infliximab (adjusted HR 10.67; 95% CI 1.37; 82.88; P = .02) were found to be associated with HZ after adjustments for traditional risk factors.

CONCLUSION

Risk of cutaneous HZ in SpA was not lower than in RA. Methotrexate and infliximab were associated with cutaneous HZ in SpA.

The changing epidemiology of herpes zoster over a decade in South Korea, 2006-2015

BACKGROUND

In South Korea, the population is rapidly aging and the prevalence of comorbidities has increased. We investigated longitudinal changes in the herpes zoster (HZ) considering demographic changes and comorbidities in the era of universal single-dose varicella vaccination.

METHODS

We used the population-based database of the National Health Insurance Service in South Korea, with approximately 50 million subscribers during 2006-2015. HZ cases were identified using ICD-10 codes and comorbid conditions were also collected. Incidence rates (IRs) and incidence rate ratios (IRRs) per year were calculated adjusting for age, sex, comorbidities and socioeconomic status, and the temporal trends were examined using segmented negative binomial regression analysis.

RESULTS

Over a decade, the adjusted HZ IR increased significantly from 4.23 to 9.22 per 1000 person-years (adjusted IRR 1.05, 95% confidence interval [CI] 1.04-1.06). However, during 2012-2015, the increasing trends decelerated (adjusted IRR per year 1.01, 95% CI 0.98-1.04) and slope changes differed by age. There was a declining trend in children under 9 years, sustained increase in adults aged 30-39 years, and near-plateau in those aged 50-69 years. Nonetheless, the age distribution of HZ incidence did not change over a decade, with the peak in adults aged 60-79 years. HZ-associated hospitalization rates also increased, with a deceleration in the increasing trends during 2012-2015.

CONCLUSIONS

The HZ burden increased independently of demographic changes and prevalence of comorbidities. However, different trajectories by age group necessitate continuous HZ surveillance for better understanding of these changes, and to provide evidence for development of preventive strategies.

The Epidemiology of Herpes Zoster and Postherpetic Neuralgia in China: Results from a Cross-Sectional Study

Introduction

Few studies have examined the epidemiology of herpes zoster (HZ) and postherpetic neuralgia (PHN) in China. The aim of this study was to estimate the prevalence of HZ and PHN in China, and to examine the clinical characteristics of patients identified with PHN.

Methods

This was a cross-sectional study conducted in 24 hospitals in seven cities in China. Prevalence of HZ and PHN was determined by physician (n = 100) chart review of patients (n = 36,170) aged ≥ 40 years seeking medical care over a 30- to 60-day period. The health history of patients identified with PHN was obtained and included time since diagnosis of HZ or PHN, time since onset of PHN-related pain, and the methods used for diagnosing HZ and PHN.

Results

The prevalence rates of HZ and PHN were 7.7% [95% confidence interval (CI) 7.5–8.0] and 2.3% (95% CI 2.2–2.5), respectively. Of patients with HZ, 29.8% developed PHN. Rates of HZ and PHN increased with age and were highest in patients aged ≥ 70 years (10.6% and 4.1%, respectively). The majority of patients with PHN were diagnosed with HZ (80.9%) and PHN (83.8%) for < 1 year, and had experienced PHN-related pain for < 1 year (80.5%). Patient description and clinical examination were most commonly used to diagnose HZ and PHN.

Conclusion

These results provide current estimates of the prevalence of HZ and PHN in the general adult population in urban China. These rates are similar to previously reported rates in China and worldwide, and highlight the global nature of HZ and PHN.

Funding

Pfizer Inc.

Burden of varicella in the Asia-Pacific region: a systematic literature review

INTRODUCTION

Varicella is a highly contagious infection that can lead to serious complications, particularly in high-risk groups; however, it is vaccine preventable. Disease awareness and understanding of the disease burden can strongly influence vaccine coverage. This review provides insight into the current epidemiology and the importance of varicella from both public health and economic perspectives across the Asia-Pacific (APAC) region. Areas covered: A systematic literature review was conducted to identify studies on the incidence, seroprevalence, fatality rate and complication rate of varicella. Economic burden studies were also captured. Altogether, 125 studies were identified across the region; these were supplemented by government reports (gray data). Reported vaccine coverage varied from 2.8% to 97%; a key influencing factor was inclusion of the varicella vaccine in national immunization programs. In general, varicella incidence in the unvaccinated population was highest in children ≤5 years old and seroprevalence increased with age. Economic analyses highlighted the cost-saving potential of vaccination programs, especially from a societal perspective. Expert opinion: Varicella-related data varied greatly across the APAC region, highlighting the need to better understand the burden of varicella in this area, and particularly identified the need for better surveillance and reporting.

Tuberculosis, hepatitis B and herpes zoster in tofacitinib-treated patients with rheumatoid arthritis

There is currently interest in the risk of infections during treatment with new targeted synthetic disease-modifying antirheumatic drugs (DMARDs), specifically the Janus kinase inhibitor tofacitinib. Tofacitinib has been studied extensively in patients with rheumatoid arthritis and has been shown to be effective and generally safe. East Asian countries have a high background rate of tuberculosis (TB) and hepatitis B virus (HBV) infection and the risk of recurrence or reactivation of infections such as TB, HBV and herpes zoster during DMARD therapy is of particular interest in the region. This paper reviews available data on the risk of TB, HBV and herpes zoster infections, including recurrence/reactivation of infections, during treatment with tofacitinib, with a focus on east Asia.

Global impact of varicella vaccination programs

Although varicella is usually a mild and self-limited disease, complications can occur. In 1998, the World Health Organization recommended varicella vaccination for countries where the disease has a significant public health burden. Nonetheless, concerns about a shift in the disease to older groups, an increase in herpes zoster in the elderly and cost-effectiveness led many countries to postpone universal varicella vaccine introduction. In this review, we summarize the accumulating evidence, available mostly from high and middle-income countries supporting a high impact of universal vaccination in reductions of the incidence of the disease and hospitalizations and its cost-effectiveness. We have also observed the effect of herd immunity and noted that there is no definitive and consistent association between vaccination and the increase in herpes zoster incidence in the elderly.

Modalities in managing postherpetic neuralgia

Postherpetic neuralgia (PHN) is the most troublesome side effect of Herpes Zoster (HZ), which mainly affects the elderly and immunocompromised populations. Despite the current advancement of treatments, PHN persists in many individuals influencing their daily activities and reducing their quality of life. Anticonvulsants, antidepressants, topical therapies including lidocaine and capsaicin, and opioids, are the most widely used therapies for the treatment of PHN. These medications come with their adverse effects, so they should be used carefully with the elderly or with patients with significant comorbidities. Other measures like botulinum toxin, nerve blocks, spinal cord stimulation, and radiofrequency have also contributed significantly to the management of PHN. However, the efficacy, safety, and tolerability of these invasive methods need to be carefully monitored when administering them. Early diagnosis and early initiation of treatment can reduce the burden associated with PHN. The zoster vaccine has effectively reduced the incidence of HZ and PHN. In this article, we discuss the treatment options available for the management of PHN, mainly focusing on the efficacy and safety of different therapeutic modalities.

Induction of plasmablasts by follicular helper T cell-CXCL13 axis upon occurrence of herpes zoster

Herpes zoster (HZ) is a recurrent varicella zoster virus (VZV) infection. Follicular helper T (Tfh) cells produce IL-21 and CXCL13, which contributes to the differentiation of plasmablasts. Plasmablasts are involved in the VZV-specific antibody production. We investigated the kinetics of circulating plasmablasts and circulating Tfh (cTfh) cells in 43 HZ patients. Plasma IL-21 and CXCL13 levels were also measured. We found an increase of circulating plasmablasts during the clinical course of HZ. The frequency of circulating plasmablasts positively correlated with VZV-specific IgG titers, frequency of activated cTfh cells, and plasma CXCL13 levels, but did not correlate with plasma IL-21 levels. In a representative case, the kinetics peaked in the order of cTfh cells, CXCL13, plasmablasts, and VZV IgG titer. These results suggest that cTfh-CXCL13 may have a crucial role in the differentiation of B cells into VZV-specific IgG-producing plasmablasts, resulting in boosting immunity against VZV reactivation.

Herpes zoster ophthalmicus caught in the (Tr)act!

To emphasize the utility of contrast enhanced MRI for identifying the extent of disease in herpes zoster ophthalmicus with intracranial extension to help determine proper management. We present a rare case of herpes zoster ophthalmicus (HZ/HZO) with intracranial extension and MRI demonstration of involvement of the trigeminal nerve, the trigeminal nucleus, and the spinal trigeminal nucleus and tract. Herpes zoster is caused by reactivation of varicella zoster virus. Herpes zoster ophthalmicus with involvement of the ophthalmic division of the trigeminal nerve has been estimated to account for 10-20% of the cases (Yawn et al. in Mayo Clin Proc 88:562-570, 2013). While postherpetic neuralgia is the most common complication, HZ/HZO can rarely manifest in a more sinister manner resulting in multi-dermatomal involvement, disseminated disease, cranial arteritis (Walker in Radiology 107:109-110, 1973), cranial nerve paresis (O.d in Clinical Eye and Vision Care 11:75-80, 1999), hemiplegia (Cavaletti in The Italian Journal of Neurological Sciences 11:297-300, 1990), ocular/dysfunction (Kocaoğlu in Türk Oftalmoloji Dergisi 48:42-46, 2018), and intracranial extension (Chen in BMC Infectious Diseases 17:213, 2017; Yawn in Mayo Clin Proc. 88:562-570, 2013). Contrast enhanced MRI (CE-MRI) can be of great benefit to elucidate the extent of disease and intracranial involvement for institution of more aggressive management to prevent further complications.

An Evaluation of Efficacy and Safety of Commonly Prescribed Drugs and Effect of These Drugs on Quality of Sleep in Patients Suffering From Zoster-Associated Pain

This observational, prospective, single-center study was conducted to evaluate the efficacy and safety of commonly prescribed drugs for zoster-associated pain and their impact on quality of sleep at a tertiary care hospital in western India. Patients ≥18 years of age, newly diagnosed with zoster-associated pain were evaluated on days 0, 7, 14, 30, 60, 90, 120, 150, and 180 or until resolution of pain, whichever was earlier, using the Wong Baker FACES Pain Rating Scale, Neuropathic Pain Scale, and Insomnia Severity Index for intensity of pain, quality of pain, and quality of sleep, respectively. A total of 78 patients (46.0 [16.3] years) completed the study. They received nonsteroidal anti-inflammatory drugs (65), gabapentin (30), amitriptyline (27), and amitriptyline + gabapentin (21) for mean durations of 7.7 (3.0), 89.2 (7.2), 107.6 (46.3), and 104.5 (46) days, respectively. Improvement in the Wong Baker FACES Pain Rating Scale and Neuropathic Pain Scale score was similar among treatment groups except for a greater fall in Wong Baker FACES Pain Rating Scale score at days 7 and 120 and that in deep pain score at day 7 in combination treatment group vs the amitriptyline group. Clinically significant insomnia was detected in 35 patients at baseline and demonstrated progressive and similar improvement among groups. Treatment modification was required in 20 patients. Zoster-associated pain resolved in 69 patients. Nine adverse drug reactions, mostly mild, nonserious, and nonpreventable, were reported. To conclude, drugs commonly used for zoster-associated pain are effective and well tolerated. These have a similar effect on pain and quality of sleep, except for a possible greater effect of combination treatment in the early phase of intense and deep pain.