The humanistic, economic and societal burden of herpes zoster in Europe: a critical review

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.

Logistic and organizational barriers to herpes zoster vaccination in europe: A systematic review

Background

The Herpes Zoster (HZ) poses a significant public health threat, leading to morbidity and occasional mortality in unvaccinated adults aged 50 and older. With over 95 % of individuals in this age group globally having prior exposure to Varicella-Zoster Virus, a substantial portion of the world's population is susceptible to developing HZ. Without vaccination, individuals reaching 85 years face a 50 % lifetime risk of HZ. Organizational and logistical barriers further hinder vaccination efforts, involving complexities in cost management, demanding vaccine storage requirements, supply limitations, distribution challenges, absence of a streamlined status collection system, and healthcare system deficiencies.

Methods

A systematic review was conducted on the studies that examined the logistical and organizational barriers to HZ vaccination among frail and older adults, aligning with the PRISMA guidelines. Eligibility criteria focus on English studies in Europe, excluding pediatric or irrelevant populations. Rayyan AI was used for data extraction, and bias was assessed using the AXIS tool.

Results

After excluding 841 based on titles and abstracts, 22 publications were selected. A thorough analysis identified 4 studies meeting inclusion criteria, conducted between 2009 and 2022, unveiling several barriers on HZ vaccination: challenges with healthcare professionals, obstacles related to patients' perceptions and knowledge, difficulties in accessibility, structural issues, social dynamics.

Conclusions

The study represents a comprehensive examination, emphasizing the need for targeted interventions to overcome these barriers. The findings underscore the urgency of addressing these challenges to enhance vaccination rates and mitigate the public health burden associated with HZ.

Impact of Herpes Zoster and Postherpetic Neuralgia on the Quality of Life in China: A Prospective Study

Background

Herpes zoster (HZ) and postherpetic neuralgia (PHN) significantly affect patients' quality of life (QoL). Cultural differences may lead to different patient-reported outcomes across countries. The current study aims to evaluate the detrimental impact of HZ and PHN on QoL in China.

Methods

This prospective study was conducted from January 2020 to April 2023. We used the Zoster Brief Pain Inventory (ZBPI) and 5-level EuroQol-5 Dimension (EQ-5D-5L) questionnaire to assess the QoL of HZ and PHN patients. Patients were required to complete the questionnaires at 15, 30, 60, and 90 days after the onset of the HZ rash. Additional questionnaires were administered at 120, 150, and 180 days for those who developed PHN within three months of the rash's onset.

Results

A cohort of 633 patients with a median age of 63 years were included in the study. The mean delay from the appearance of the initial HZ rash to the first medical consultation was 5.1 ± 2.8 days. Approximately 30% of the HZ patients (189/633) went on to develop PHN. For patients with HZ who did not progress to PHN, the ZBPI worst pain score and impaired QoL had nearly resolved by day 90 post-rash onset. Conversely, there was no significant improvement in the ZBPI worst pain score and QoL for those with PHN, even by day 180 post-rash onset.

Conclusion

Both HZ and PHN significantly impaired patients' QoL. However, the impairment caused by PHN was more severe in both intensity and duration.

Lipo-pam™ adjuvanted herpes zoster vaccine induces potent gE-specific cellular and humoral immune responses

Herpes zoster (HZ), also known as shingles, is caused by the reactivation of latent varicella-zoster virus (VZV). Decreased VZV-specific T-cell immune responses significantly contribute to the development of HZ. Shingrix is a recombinant zoster vaccine that is currently used to prevent HZ. However, Shingrix has high reactogenicity and pain at the injection site due to QS21, one of the adjuvant components. In this study, we developed a new herpes zoster vaccine formulation called CVI-VZV-001, containing gE protein and a novel liposome-based adjuvant Lipo-pam™, which consists of two TLR agonists. We evaluated the immunogenicity of CVI-VZV-001 in mouse and rabbit models. CVI-VZV-001 elicited robust gE-specific T-cell immune responses and gE-specific antibody production. Specifically, CVI-VZV-001 induced polyfunctional CD4+ T cell populations that secrete multiple cytokines. Furthermore, CVI-VZV-001 sustained the gE-specific immune responses for up to six months after immunization. To ensure CVI-VZV-001's safety for further development, we conducted a good laboratory practice (GLP) toxicity test, which confirmed that CVI-VZV-001 is safe for use. At present, CVI-VZV-001 is undergoing phase I clinical trials. This study suggests that CVI-VZV-001 can be a potent candidate for the HZ vaccine with high immunogenicity and safety.

Global herpes zoster burden in adults with asthma: a systematic review and meta-analysis

BACKGROUND

Asthma is a common respiratory disease, which may be associated with an increased risk of herpes zoster (HZ), often a debilitating disease associated with severe pain. This is the first systematic review with the objective of summarising evidence on HZ burden in adults with asthma.

METHODS

A global systematic literature review and meta-analysis was conducted (MEDLINE and Embase, 2003-2024) on HZ burden (incidence, risk and complications) in adults (≥18 years) with asthma.

RESULTS

There were 19 studies included on HZ outcomes in adults with asthma. Pooled HZ incidence per 1000 person-years was 5.71 (95% CI 4.68-6.96) in adults aged ≥18 years (4.20 (95% CI 3.09-5.70) in those aged <60 years versus 10.33 (95% CI 9.17-11.64) in those aged ≥60 years). The pooled rate ratio for developing HZ was 1.23 (95% CI 1.11-1.35) in those aged ≥18 years and 1.36 (95% CI 1.15-1.61) in those aged ≥50 years. The risk of HZ was higher in people with asthma using systemic corticosteroids, long-acting β-agonists plus inhaled corticosteroids and "add-on therapy". Asthma was also associated with an increased risk of post-herpetic neuralgia (OR 1.21, 95% CI 1.06-1.37) and HZ ophthalmicus (OR 1.9, 95% CI 1.1-3.2). Differences in study design, setting, case definitions and follow-up durations led to heterogeneity.

CONCLUSIONS

This systematic literature review and meta-analysis found that adults with asthma have an increased risk of HZ, with higher risks in older age groups and in those on certain treatments, such as oral corticosteroids. HZ vaccines are available for adults, including those with comorbidities such as asthma, and can be considered as part of integrated respiratory care.

Herpes zoster in Belgium: a new solution to an old problem

Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus. The life-time risk of developing HZ is ~ 30%. Management of HZ can be challenging due to limited efficacy of oral antivirals on pain control, and neuropathic pain that may require aggressive management. Post-herpetic neuralgia (PHN) can cause substantial pain and occurs in up to one-quarter of patients with HZ. Up to 48,000 HZ cases are estimated to occur annually in Belgium, estimated to cost almost 7 million euros in treatment. The recombinant zoster vaccine (RZV, Shingrix, GSK) was approved in Europe in 2017. In 2022, the Belgian Superior Health Council recommended vaccination with RZV for immunocompetent adults aged ≥ 60 years, and immunocompromised patients aged ≥ 16 years, including those receiving immunosuppressive therapy, in particular Janus kinase inhibitors. RZV showed high age-independent efficacy in preventing HZ infection and in clinical trials that has since been confirmed in real-world effectiveness studies. In clinical trials, protection was sustained for at least 10 years after vaccination. As of 1 November 2023, RZV is reimbursed for three immunocompromised patient groups aged ≥ 18 years: malignancy treated in the past 5 years, HIV infection, and organ or haematological stem cell transplantation or are a transplant candidate. HZ is vaccine-preventable and RZV provides a highly effective tool for HZ prevention. While reimbursement for some at-risk groups is welcomed, reimbursement currently falls well short of Superior Health Council recommendations. Adult immunisation strategies should be promoted to achieve high vaccination coverage against HZ, contributing to healthy aging in Belgium.

Cerebral Venous Sinus Thrombosis Complicating Herpes Zoster Ophthalmicus Ophthalmoplegia

Cerebral venous sinus thrombosis (CVST) is a rare cause of strokes and is most common in younger patients particularly those less than 50 years of age. It is more common in females than in males and is known to be associated with pregnancy, puerperium, oral contraception, congenital and acquired thrombophilia, and malignancy. Less commonly, it has been shown to be associated with infections and more recently has been found to be associated with COVID-19 infection with thrombocytopenia and the COVID-19 vaccine AstraZeneca. Rare cases have been reported in association with varicella zoster virus (VZV) infection (chickenpox) and its reactivated version of herpes zoster virus (HZV) infection (shingles). We report the case of a 68-year-old lady with herpes zoster ophthalmicus ophthalmoplegia who developed cerebral venous thrombosis (CVT).

Preclinical immunogenicity of an adenovirus-vectored vaccine for herpes zoster

Herpes zoster (HZ) results from waning immunity following childhood infection with varicella zoster virus (VZV) but is preventable by vaccination with recombinant HZ vaccine or live HZ vaccine (two doses or one dose, respectively). Vaccine efficacy declines with age, live HZ vaccine is contraindicated in immunosuppressed individuals, and severe local reactogenicity of recombinant HZ vaccine is seen in up to 20% of older adults, indicating a potential need for new vaccines. Nonreplicating chimpanzee adenovirus (ChAd) vectors combine potent immunogenicity with well-established reactogenicity and safety profiles. We evaluated the cellular and humoral immunogenicity of ChAdOx1 encoding VZV envelope glycoprotein E (ChAdOx1-VZVgE) in mice using IFN-γ ELISpot, flow cytometry with intracellular cytokine staining, and ELISA. In outbred CD-1 mice, one dose of ChAdOx1-VZVgE (1 × 10⁷ infectious units) elicited higher gE-specific T cell responses than two doses of recombinant HZ vaccine (1 µg) or one dose of live HZ vaccine (1.3 × 10³ plaque-forming units). Antibody responses were higher with two doses of recombinant HZ vaccine than with two doses of ChAdOx1-VZVgE or one dose of live HZ vaccine. ChAdOx1-VZVgE boosted T cell and antibody responses following live HZ vaccine priming. The frequencies of polyfunctional CD4+ and CD8+ T cells expressing more than one cytokine (IFN-γ, TNF-α and IL-2) were higher with ChAdOx1-VZVgE than with the conventional vaccines. Results were similar in young and aged BALB/c mice. These findings support the clinical development of ChAdOx1-VZVgE for prevention of HZ in adults aged 50 years or over, including those who have already received conventional vaccines.

Characteristics and economic burden of hospitalized patients with herpes zoster in China, before vaccination

Herpes zoster (HZ) brings a significant economic burden. The HZ vaccine was introduced in China for the first time in 2020, and there is a lack of up-to-date information on the hospitalization costs and characteristics prior to vaccination. This study aimed to describe the characteristics and economic burden of HZ inpatients in Hunan Province, China, and analyze the factors influencing the length of stay (LOS) and costs. This was a retrospective study and we extracted information from the Chinese National Health Statistics Network Reporting System on HZ inpatients in Hunan Province, China from 2017 to 2019. Spatial join tools and Global or Local Moran's Index were used for the geographic analysis of hospitalized HZ incidence. Multivariate linear regression models were used to analyze the factors influencing LOS and costs. There were 44,311 HZ inpatients included in this study, incurring a total of $31,857,734 medical costs. These patients had a median LOS of 8 days and a median expenditure of $573.47. Older age, more comorbidities, and the presence of complications with nervous system involved were all significantly associated with longer LOS and higher costs. HZ infection resulted in a large direct medical cost and heavy disease burden, especially in patients with advanced age or underlying medical conditions. The HZ vaccine has the potential to effectively reduce the disease burden and should be widely popularized especially among high-risk groups.

Novel Bipolar High-Voltage Pulsed Radiofrequency Targeting the Cervical Sympathetic Chain for Treating Acute Herpetic Neuralgia

INTRODUCTION

Postherpetic neuralgia (PHN) in the oral, maxillofacial, neck, and upper limb regions is a refractory neuropathic pain and severely affects the quality of life of patients. Because of the absence of ideal treatments for this condition, relieving pain in the acute stage and preventing the occurrence of PHN are of great clinical significance. However, the optimal intervention for this acute herpetic neuralgia remains obscure.

OBJECTIVES

This study aimed to investigate whether bipolar high-voltage pulsed radiofrequency (PRF) targeting the cervical sympathetic chain could effectively treat acute herpetic neuralgia in the oral, maxillofacial, neck, and upper limb regions and reduce the incidence of PHN.

MATERIALS AND METHODS

A total of 60 patients with acute herpetic neuralgia in the oral, maxillofacial, neck, and upper limb regions were enrolled. The radiofrequency group (n = 30) received bipolar high-voltage PRF under ultrasound guidance at the level of the transverse processes of C6 and C7 to modulate the cervical sympathetic chain. In the sham group (n = 30), the electrodes were simply placed at the same position as in the radiofrequency group, but no radiofrequency energy was applied. The same treatment was repeated in each group after 72 hours. If patients were reported to have a visual analog scale (VAS) score ≥4, they would receive oral tramadol and gabapentin as rescue analgesics. The VAS score, Pittsburgh Sleep Quality Index (PSQI), 36-Item Short Form Health Survey (SF-36) score, use of tramadol and gabapentin, incidence of PHN, and adverse reactions were recorded to assess the effect and safety of therapy during three months of follow-up.

RESULTS

Decreased VAS scores, PSQI scores, and improved SF-36 scores were detected in the two groups at different time points after treatment (all p < 0.05). The VAS scores, PSQI scores, use of tramadol and gabapentin, and incidence of PHN were significantly lower, whereas the SF-36 scores were significantly higher in the radiofrequency group than in the Sham group (all p < 0.05). No serious adverseness related to the treatment was detected in either group.

CONCLUSIONS

Bipolar high-voltage PRF treatment targeting the cervical sympathetic chain could effectively relieve acute herpetic neuralgia in the oral, maxillofacial, neck, and upper limb regions and reduce PHN incidence. The efficacy and safety of this novel treatment make it worthy of recommendation for clinical application.

Pre-Clinical Development of an Adenovirus Vector Based RSV and Shingles Vaccine Candidate

Respiratory syncytial virus (RSV) infection and shingles are two viral diseases that affect older adults, and a combined vaccine to protect against both could be beneficial. RSV infection causes hospitalisations and significant morbidity in both children and adults and can be fatal in the elderly. The RSV fusion (F) envelope glycoprotein induces a strong RSV-neutralising antibody response and is the target of protective immunity in the first RSV vaccine for older adults, recently approved by the FDA. An initial childhood infection with the varicella zoster virus (VZV) results in chickenpox disease, but reactivation in older adults can cause shingles. This reactivation in sensory and autonomic neurons is characterized by a skin-blistering rash that can be accompanied by prolonged pain. The approved protein-in-adjuvant shingles vaccine induces VZV glycoprotein E (gE)-fspecific antibody and CD4+ T cell responses and is highly effective. Here we report the evaluation of RSV/shingles combination vaccine candidates based on non-replicating chimpanzee adenovirus (ChAd) vectors. We confirmed the cellular and humoral immunogenicity of the vaccine vectors in mice using T cell and antibody assays. We also carried out an RSV challenge study in cotton rats which demonstrated protective efficacy following a homologous prime-boost regimen with our preferred vaccine candidate.

Impact of Type 1 Versus Type 2 Diabetes on Developing Herpes Zoster and Post-herpetic Neuralgia: A Population-based Cohort Study

Type 2 diabetes is associated with an increased risk of herpes zoster and postherpetic neuralgia. However, the association of type 1 diabetes with herpes zoster or postherpetic neuralgia remains unclear. This retrospective cohort study using Taiwan's Health Insurance Research Database included 199,566 patients with type 1 diabetes and 1,458,331 with type 2 diabetes, identified during the period 2000 to 2012. Patients with type 1 diabetes had a significantly higher risk of developing herpes zoster than those with type 2 diabetes (p < 0.001). Across all age groups, the impact of diabetes on herpes zoster was greater in type 1 than in type 2 diabetes. Patients with both type 1 and type 2 diabetes had a 1.45-fold higher risk of post-herpetic neuralgia than those without diabetes (hazard ratio 1.45, 95% confidence interval 1.28-1.65; hazard ratio 1.45, 95% confidence interval 1.37-1.52, respectively), and there was no difference between the 2 types of diabetes (hazard ratio 1.06; 95% confidence interval 0.93-1.21). The results recommend consideration of herpes zoster vaccination at an earlier age in patients with type 1 diabetes.

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).

A Dynamic Compartmental Model to Explore the Optimal Strategy of Varicella Vaccination: An Epidemiological Study in Jiangsu Province, China

Varicella (chickenpox) is highly contagious among children and frequently breaks out in schools. In this study, we developed a dynamic compartment model to explore the optimal schedule for varicella vaccination in Jiangsu Province, China. A susceptible-infected-recovered (SIR) model was proposed to simulate the transmission of varicella in different age groups. The basic reproduction number was computed by the kinetic model, and the impact of three prevention factors was assessed through the global sensitivity analysis. Finally, the effect of various vaccination scenarios was qualitatively evaluated by numerical simulation. The estimated basic reproduction number was 1.831 ± 0.078, and the greatest contributor was the 5-10 year-old group (0.747 ± 0.042, 40.80%). Sensitivity analysis indicated that there was a strong negative correlation between the second dose vaccination coverage rate and basic reproduction number. In addition, we qualitatively found that the incidence would significantly decrease as the second dose vaccine coverage expands. The results suggest that two-dose varicella vaccination should be mandatory, and the optimal age of second dose vaccination is the 5-10 year-old group. Optimal vaccination time, wide vaccine coverage along with other measures, could enhance the effectiveness of prevention and control of varicella in China.

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.

Enhanced Potency and Persistence of Immunity to Varicella-Zoster Virus Glycoprotein E in Mice by Addition of a Novel BC02 Compound Adjuvant

Herpes zoster (HZ) is one of two distinct syndromes caused by Varicella-zoster virus (VZV). A primary infection with VZV causes varicella in susceptible young children. After resolution of the primary infection, VZV establishes a lifelong latency within the cranial or dorsal root ganglia. With increasing age, family history of shingles, immunosuppression or other risk factors, there is a decline in the virus-specific T-cell-mediated immune (CMI) response which allows reactivation of latent VZV in the root ganglia resulting in HZ. There are currently two vaccines that have been approved to prevent HZ and postherpetic neuralgia (PHN) but one is a live attenuated vaccine, the protective effect of which is considered to decrease significantly with the age of the recipient. However, a recombinant subunit vaccine may provide targeted VZV-specific cellular and humoral immunity, giving it a more potent and longer-lasting protective effect against HZ. The current study reports the development of a novel adjuvant, BC02 (BCG CpG DNA compound adjuvants system 02), composed of Al(OH)₃ inorganic salt adjuvant and BC01 (BCG CpG DNA compound adjuvants system 01), a Toll-like receptor 9 (TLR9) agonist. Immunogenicity and compatibility with recombinant VZV glycoprotein E (gE) in mice were studied. The BC02-adjuvanted gE experimental vaccine was highly effective in eliciting both humoral and cellular immune responses to the recombinant gE glycoprotein and VZV-Oka in a mouse model. The efficient production and long-term persistence of gE and VZV-Oka-specific IFN-γ, IL-2-specific T cells and memory B cells in the early (1W), middle (7W), middle-late (15W), and final (27W) immune stages were established. Results of fluorescent antibody to membrane antigen (FAMA) and serum antibody plaque reduction tests also showed that the BC02 adjuvanted-gE experimental vaccine induced mice to secrete neutralizing antibodies against clinically isolated VZV strains. In combination, the current data suggest that the BC02 compound adjuvant offers a strategy to induce an appropriately strong cellular and humoral immunity against the VZV gE protein subunit to improve vaccine efficacy.

Development and Evaluation of a New Predictive Nomogram for Predicting Risk of Herpes Zoster Infection in a Chinese Population with Type 2 Diabetes Mellitus

Purpose

To identify potential risk factors for herpes zoster infection in type 2 diabetes mellitus in southeast Chinese population.

Patients and Methods

We built a model involving 266 herpes zoster patients collecting data from January 2018 to December 2019. The least absolute shrinkage and selection operator (Lasso) predictive model was used to test herpes zoster virus risk using the patient data. Multivariate regression was conducted to decide which variable would be the strongest to decrease the Lasso penalty. The predictive model was tested using the C-index, a calibration plot, and decision curve study. External validity was verified by bootstrapping by counting probabilities.

Results

In the prediction nomogram, the prediction variables included age, sex, weight, length of hospital stay, infection, and blood pressure. The C-index of 0.844 (0.798–0.896) indicated substantial variability and thus the model was adjusted appropriately. A score of 0.825 was achieved somewhere in the above interval. Examination of the decision curve estimated that herpes zoster nomogram was useful when the intervention was determined at the 16 percent of the herpes zoster infection potential threshold.

Conclusion

The herpes zoster nomogram combines age, weight, position of the rash, 2-hour plasma glucose, glycosuria, serum creatinine, length of the hospital stay, and hypertension. This calculator can be used to assess the individual herpes zoster risks in patients diagnosed with type 2 diabetes mellitus.

Economic Burden and Impact on Quality of Life of Herpes Zoster in Spanish Adults Aged 50 Years or Older: A Prospective Cohort Study

Introduction

The economic burden of herpes zoster (HZ), including its most common complication, postherpetic neuralgia (PHN), and its impact on health-related quality of life (HRQL) is not well described in Spain. The aim of this study was to estimate HZ-related healthcare costs and impact on HRQL in Spanish adults aged 50 years or older.

Methods

A prospective, observational study was performed with patients with HZ recruited through four general practitioner networks in Spain (NCT01521286). HRQL data were collected using the EuroQoL-5 Dimension (EQ-5D) questionnaire; HZ-related pain and associated interference with activities of daily living (ADL) were assessed using the Zoster Brief Pain Inventory (ZBPI) questionnaire at days 0 (HZ rash onset), 15, 30, 60, and 90; patients with PHN were assessed up until day 270. Medical resource utilization was recorded throughout study follow-up. Work loss for patients/caregivers was also assessed. Costs were calculated from both the payer and societal perspectives.

Results

A total of 545 patients with Hz were included, of whom 25 developed PHN. During days 0–30 post HZ diagnosis, the mean EQ-5D utility score was 0.738, equating to a utility loss of 0.138. Sleep was the ADL most affected component. The mean costs for HZ in the overall cohort were €240 and €296 from the payer/societal perspective, respectively; €187/€242 for patients with HZ without any HZ-related complications; and €571/€712 for patients who developed PHN. The majority of costs were incurred during days 0–30.

Conclusions

In Spain, HZ and HZ-related complications such as PHN reduce patient HRQL and increase the economic burden for both payers and society in general.

Trail Registration

ClinicalTrials.gov identifier NCT01521286.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01717-7.

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.

Impact of Reactogenicity After Two Doses of Recombinant Zoster Vaccine Upon Physical Functioning and Quality of Life: An Open Phase III Trial in Older Adults

BACKGROUND

Herpes zoster may significantly impact quality of life (QoL) in older adults. The recombinant zoster vaccine (RZV) is efficacious in adults aged ≥50 and older and is associated with increased reactogenicity compared to placebo. We report here on the impact of reactogenicity of the second RZV dose on the QoL and physical functioning (PF) of vaccine recipients, and summarize findings following both doses.

METHOD

In this single-arm study, 401 adults aged ≥50 and older were enrolled to receive two RZV doses 2 months apart. Change in mean Short Form Survey-36 (SF-36) PF and EuroQol-5 Dimension (EQ-5D) scores, reactogenicity, safety, productivity loss, and healthcare resource utilization were evaluated.

RESULTS

In total, 391 (97.5%) participants received dose 2. Post-dose 2, the most common solicited local symptoms were injection site pain (75.1%), erythema (22.4%), and swelling (13.9%), and the most common systemic symptoms were fatigue (46.3%), headache (37.5%), and myalgia (32.9%). Grade 3 solicited (local and systemic) adverse events were reported by 61 (15.6%) participants and were associated with a transient clinically significant decrease in SF-36 PF score on Days 1-2 post-dose 2 that recovered by Day 3. Overall, no clinically important reduction in mean SF-36 PF scores was observed from baseline to post-dose 2 (mean change -0.4), and no quality-adjusted-life-year loss was recorded.

CONCLUSIONS

Overall, QoL and PF of RZV vaccinees were not affected by vaccine-related reactogenicity. A transient reduction was observed in the first 2 days after RZV vaccination in individuals with Grade 3 adverse events. No safety concerns were identified.

Herpes zoster risk and burden of disease in immunocompromised populations: a population-based study using health system integrated databases, 2009-2014

Background

Estimate the incidence of herpes zoster (HZ), its complications and healthcare utilization rates in adults (≥ 18-years-old) with a wide range of immunocompromised (IC) conditions compared to IC-free cohort.

Method

A population-based retrospective study using the Valencia healthcare Integrated Databases (VID) (2009–2014). HZ and IC were defined using ICD-9 codes in primary care (PC) and hospitalization registers. Incidence rates (IR), risk of HZ, HZ-recurrence, HZ-complications and healthcare utilization rates were estimated in the IC-cohort compared to IC-free.

Results

The study population consisted of 4,382,590 subjects, of which 578,873 were IC (13%). IR (in 1000 persons-year) of HZ overall, in IC and in IC-free cohort was 5.02, 9.15 and 4.65, respectively. IR of HZ increased with age in both cohorts and it was higher for all IC conditions studied, reaching up to twelvefold in subjects with stem cell transplantation. IC subjects had 51% higher risk of developing HZ, 25% higher HZ-recurrence and the risk of HZ-complications was 2.37 times higher than in IC-free. HZ-related healthcare utilization was higher in the IC-cohort than in IC-free (number of hospitalizations 2.93 times greater, hospital stays 12% longer, 66% more HZ-specialist visits, 2% more PC visits, sick leaves 18% longer and 20% higher antiviral dispensation).

Conclusions

Patients suffering from all the IC conditions studied are at higher risk of developing HZ, HZ-recurrence and post-herpetic complications, which implies a substantial morbidity and a high consumption of resources. These results should be considered for vaccine policy implementation.

Decoding the Architecture of the Varicella-Zoster Virus Transcriptome

Varicella-zoster virus (VZV), a double-stranded DNA virus, causes varicella, establishes lifelong latency in ganglionic neurons, and reactivates later in life to cause herpes zoster, commonly associated with chronic pain. The VZV genome is densely packed and produces multitudes of overlapping transcripts deriving from both strands. While 71 distinct open reading frames (ORFs) have thus far been experimentally defined, the full coding potential of VZV remains unknown. Here, we integrated multiple short-read RNA sequencing approaches with long-read direct RNA sequencing on RNA isolated from VZV-infected cells to provide a comprehensive reannotation of the lytic VZV transcriptome architecture. Through precise mapping of transcription start sites, splice junctions, and polyadenylation sites, we identified 136 distinct polyadenylated VZV RNAs that encode canonical ORFs, noncanonical ORFs, and ORF fusions, as well as putative noncoding RNAs (ncRNAs). Furthermore, we determined the kinetic class of all VZV transcripts and observed, unexpectedly, that transcripts encoding the ORF62 protein, previously designated Immediate-Early, were expressed with Late kinetics. Our work showcases the complexity of the VZV transcriptome and provides a comprehensive resource that will facilitate future functional studies of coding RNAs, ncRNAs, and the biological mechanisms underlying the regulation of viral transcription and translation during lytic VZV infection.IMPORTANCE Transcription from herpesviral genomes, executed by the host RNA polymerase II and regulated by viral proteins, results in coordinated viral gene expression to efficiently produce infectious progeny. However, the complete coding potential and regulation of viral gene expression remain ill-defined for the human alphaherpesvirus varicella-zoster virus (VZV), causative agent of both varicella and herpes zoster. Here, we present a comprehensive overview of the VZV transcriptome and the kinetic class of all identified viral transcripts, using two virus strains and two biologically relevant cell types. Additionally, our data provide an overview of how VZV diversifies its transcription from one of the smallest herpesviral genomes. Unexpectedly, the transcript encoding the major viral transactivator protein (pORF62) was expressed with Late kinetics, whereas orthologous transcripts in other alphaherpesviruses are typically expressed during the immediate early phase. Therefore, our work both establishes the architecture of the VZV transcriptome and provides insight into regulation of alphaherpesvirus gene expression.

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.

Botulinum toxin A treatment for post-herpetic neuralgia: A systematic review and meta-analysis

The present meta-analysis study aimed to investigate the safety and efficacy of local administration of botulinum toxin (BTX-A) vs. lidocaine in the treatment of post-herpetic neuralgia. A systematic search of the Cochrane Library, PubMed, Embase, Chinese National Knowledge Infrastructure, Wanfang, Chongqing VIP Information Co. and Chinese Biomedical Literature Database was performed to identify randomized controlled trials (RCTs) comparing BTX-A and lidocaine in the treatment of post-herpetic neuralgia. The primary outcomes were Visual Analogue Scale (VAS) pain scores at 1, 2 and 3 months after treatment and the effective rate. Secondary outcomes were scores on the McGill pain questionnaire and adverse event rate. A total of 7 RCTs comprising 752 patients were included. The VAS pain score was significantly lower at 1 month [mean difference (MD)=-2.31; 95% CI: -3.06, -1.56; P<0.00001)], 2 months (MD=-2.18; 95% CI: -2.24, -2.11; P<0.00001) and 3 months (MD=-1.93; 95% CI: -3.05, -0.82; P=0.0007) after treatment, the effective rate was significantly higher (odds ratio=2.9; 95% CI: 1.71, 4.13; P<0.0001) and scores on the McGill pain questionnaire were significantly lower (MD=-10.93; 95% CI: -21.02, -0.83; Z=2.12; P=0.03) in patients who received BTX-A for post-herpetic neuralgia compared to those who received lidocaine. There was no difference in the adverse event rate between treatments. In conclusion, BTX-A has potential as a safe and effective treatment option for post-herpetic neuralgia. Further large and well-designed RCTs are required to confirm this conclusion.

The burden of herpes zoster disease in Norway

BACKGROUND

No national vaccination program against herpes zoster (HZ) is currently in place in Norway. We aimed to quantify the burden of medically attended HZ to assess the need for a vaccination program.

METHODS

We linked data from several health registries to identify medically attended HZ cases during 2008-2014 and HZ-associated deaths during1996-2012 in the entire population of Norway. We calculated HZ incidences for primary and hospital care by age, sex, type of health encounter, vaccination status, and co-morbidities among hospital patients. We also estimated HZ-associated mortality and case-fatality.

RESULTS

The study included 82,064 HZ patients, of whom none were reported as vaccinated against HZ. The crude annual incidence of HZ was 227.1 cases per 100,000 in primary healthcare and 24.8 cases per 100,000 in hospitals. Incidence rates were higher in adults aged ≥50 years (461 per 100,000 in primary care and 57 per 100,000 in hospitals), and women than in men both in primary healthcare (267 vs 188 per 100,000), and hospitals (28 vs 22 per 100,000). Among hospital patients, 47% had complicated zoster and 25% had comorbidities, according to the Charlson comorbidity index. The duration of hospital stay (median 4 days) increased with the severity of comorbidities. The estimated mortality rate was 0.18 per 100,000; and in-hospital case-fatality rate was 1.04%.

CONCLUSIONS

Medically attended HZ poses a substantial burden in the Norwegian healthcare sector. The majority of the zoster cases occurred among adults aged ≥50 years - the group eligible for zoster vaccination - and increased use of zoster vaccination may be warranted, especially among persons with co-morbidities.

Treatment Patterns and Medication Use in Patients with Postherpetic Neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is a chronic, painful condition characterized by persistent pain following resolution of a herpes zoster (HZ) infection. Epidemiologic data demonstrate that the risks for HZ infections and the development of PHN increase with age.

OBJECTIVE

To characterize prescribing patterns, health care utilization, and treatment costs for adults with PHN based on real-world data.

METHODS

This study analyzed medical and pharmacy claims from 2010 to 2014 in the MarketScan Commercial and Medicare Supplemental databases. PHN patients were identified based on criteria from a published algorithm. PHN treatment patterns were analyzed by age and reported descriptively for patients aged < 65 or ≥ 65 years. Excess incremental health care costs were calculated for PHN patients by comparing expenditures for a cohort of PHN patients to expenditures of a propensity score-matched control group of patients with HZ alone.

RESULTS

Approximately 0.4% of patients aged < 65 years were diagnosed with HZ versus 1.3% of patients aged ≥ 65 years; approximately 15.3% of HZ patients aged < 65 years and 26.4% of patients aged ≥ 65 years were diagnosed with PHN. Overall, opioids remained the most frequently prescribed initial treatment. Approximately 21.6% of PHN patients received an opioid as an initial treatment for PHN, 15.1% received gabapentin; 8.9% received a prescription nonsteroidal anti-inflammatory drug (NSAID); 8.3% received a lidocaine patch; 3.3% received pregabalin; 2.5% received a tricyclic antidepressants (TCAs); 0.8% received other topical lidocaine; and < 1% received capsaicin. Observed first-line use of the lidocaine patch and gabapentin was higher in patients aged ≥ 65 years relative to patients aged < 65 years. When separated by age group, only 24.6% of patients aged < 65 years and 38.5% of patients aged ≥ 65 years were prescribed a recommended first-line treatment for initial PHN therapy (gabapentin, lidocaine patch, pregabalin, and TCAs). Comparisons of treatment costs of PHN patients to matched HZ patients without PHN indicated that PHN patients initiated on opioids had the highest mean additional health care expenditure compared with PHN patients initiated on other medications. On average, PHN patients initiated on opioids had $7,601 additional health care expenditure compared with HZ patients with no PHN; additional expenditures were $6,428 for pregabalin, $4,213 for lidocaine patches, $3,478 for gabapentin, $3,304 for NSAIDs, and $2,797 for TCAs, respectively.

CONCLUSIONS

Management of PHN is associated with substantial utilization of opioid-based therapies across all ages. Medications supported by evidence either as first-line therapies or as part of a multimodal regimen for the management of PHN are underused relative to opioid-based PHN therapies. Improving adherence to evidence-based PHN treatment regimens offers the potential to reduce opioid prescribing first line and reduce overall treatment costs. Given the emphasis to reduce opioid prescribing to minimize the risk of dependence, abuse, and diversion, multimodal analgesic treatments that can avoid or reduce opioid use should be considered.

DISCLOSURES

Research funding was provided by SCILEX Pharmaceuticals. The sponsor reviewed and approved the research plan and provided support for manuscript preparation through Patel's role as a coauthor of this manuscript. The sponsor's product (lidocaine patch) was not used in this study. Patel is a paid employee of SCILEX Pharmaceuticals. Goss is an employee and minority owner of Boston Healthcare Associates, which received a research grant from SCILEX Pharmaceuticals to conduct this study. Gudin reports advisory board fees from AcelRx Pharmaceuticals and BioDelivery Sciences International and consulting fees from Averitas, Daiichi, Hisumitsu, Nektar, Purdue, Quest Diagnostics, SCILEX Pharmaceuticals, and US WorldMeds, unrelated to this study. Fudin reports advisory board fees from AcelRx Pharmaceuticals, Human Half-Cell, Quest Diagnostics, GlaxoSmithKline, SCILEX Pharmaceuticals, BioDelivery Sciences, Daiichi Sankyo, and Salix Pharmaceuticals; speaker fees from Daiichi Sankyo, Salix Pharmaceuticals, Abbott Laboratories, Acutis Diagnostics, and AstraZeneca; and consulting fees from Firstox Laboratories, unrelated to this study. The other authors have nothing to disclose. Parts of this research were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 22, 2016; San Francisco, CA, and at the 35th Annual Scientific Meeting of the American Pain Society; May 11-14, 2016; Austin, TX.

Evaluation of impact of one dose varicella vaccine on the incidence of chickenpox in Argentina

INTRODUCTION

Varicella, also known as chickenpox is one of the most common immunizable diseases. In 1998, the World Health Organization (WHO) recommended to incorporate this vaccine in the national immunization programs, which Argentina did in 2015.

OBJECTIVES

To describe the behavior of the varicella time series for the 2005-2017 period, and to evaluate the impact of the vaccine in Argentina.

METHODOLOGY

An ecological observational study was performed, using the varicella cases reported in the National Health Monitoring System, and the data of the National census as secondary data sources. A model based time series analysis of the notified varicella cases in Argentina was performed, using a Negative Binomial Mixed Model. For the verification of the vaccine impact, the 2005-2014 period was selected, and a prognosis for the following years was performed. Impact was evaluated by comparing the rates and confidence intervals between the predicted and observed values.

RESULTS

Argentina reported 1,775,587 varicella cases for the 2005-2017 period. The series exhibited seasonality, and, a decreasing trend in the number of cases was observed in 2016 and 2017. A reduction of the incidence rate after the implementation of the vaccine was observed. The transmission risk decreased in the country after vaccine implementation.

CONCLUSIONS

This study is the first concrete evidence of the varicella incidence decline after the implementation of a single dose application program in Argentina.

Patient and economic burdens of postherpetic neuralgia in China

Background

Little is known about the patient-reported and economic burdens of postherpetic neuralgia (PHN) among China’s urban population.

Methods

This noninterventional study was conducted among adults ≥40 years with PHN who were seeking medical care at eight urban hospitals in China. At one study site, patients completed a questionnaire evaluating the patient-reported disease burden (N=185). The questionnaire consisted of validated patient-reported outcomes including the Brief Pain Inventory (BPI), 5-dimension, 3-level EuroQol (EQ-5D-3L), Medical Outcomes Study Sleep Scale, and Work Productivity and Activity Impairment Questionnaire for Specific Health Problems. Questions on non-pharmacologic therapy and out-of-pocket (OOP) expenses were also included. At all study sites, physicians (N=100) completed a structured review of patient charts (N=828), which was used to derive health care resource utilization and associated costs from the societal perspective. Annual costs in Chinese Yuan Renminbi (RMB) for the year 2016 were converted to US dollars (US$).

Results

Patients (N=185, mean age 63.0 years, 53.5% female) reported pain of moderate severity (mean BPI score 4.6); poor sleep quantity (average of 5.3 hrs per night) and quality; and poorer health status on the EQ-5D-3L relative to the general Chinese population. Respondents also reported average annual OOP costs of RMB 16,873 (US$2541) per patient, mainly for prescription PHN medications (RMB 8990 [US$1354]). Substantial work impairment among employed individuals resulted in annual indirect costs of RMB 28,025 (US$4221). In the chart review, physicians reported that patients (N=828) had substantial health resource utilization, especially office visits; 98% had all-cause and 95% had PHN-related office visits. Total annual direct medical costs were RMB 10,002 (US$1507), mostly driven by hospitalizations (RMB 8781 [US$1323]).

Conclusion

In urban China, PHN is associated with a patient-reported burden, affecting sleep, quality-of-life, and daily activities including work impairment, and an economic burden resulting from direct medical costs and indirect costs due to lost productivity. These burdens suggest the need for appropriate prevention and management of PHN.

Herpes zoster related healthcare burden and costs in immunocompromised (IC) and IC-free populations in England: an observational retrospective database analysis

OBJECTIVE

Individuals with immunocompromised (IC) conditions are at a higher risk of developing herpes zoster (HZ) than IC-free individuals. This study assessed the healthcare resource utilisation (HCRU) burden and costs, of HZ in IC and IC-free individuals ≥18 years of age (YOA).

METHODS

We conducted an observational retrospective study in a cohort of IC (n=621 588) and IC-free (n=621 588) individuals, matched by age, gender and General Practitioner practice region, contributing to the Clinical Practice Research Datalink database from 2000 to 2012 and linked to the Hospital Episode Statistics inpatient data. HCRU (ie, primary and secondary care consultations, hospital inpatient stays and treatment prescriptions) was analysed from 7 days before to: (1) 30, (2) 365 days after the HZ diagnosis date for individuals with (1) HZ only (no postherpetic neuralgia (PHN)) and (2) individuals with HZ and PHN only. Healthcare costs were computed by multiplying the number of units of resources used by the unit costs, summed across all HCRU categories to obtain a total cost per subject. Values were expressed in 2014 UK pound sterling (£) and presented for HZ cases overall, stratified by age (ie, 18-49, 50-59, 60-69, 70-79 and ≥80 YOA) and IC status.

RESULTS

The percentage of HZ cases requiring hospitalisation was higher in IC individuals (2.7% vs 0.4% in IC and IC-free individuals aged 18-49 YOA, respectively and 9.5% vs 7.5% in IC and IC-free individuals aged ≥80 YOA, respectively). Similarly, HZ-related mean treatment costs per subject were higher in IC individuals (£189 vs £104 in IC and IC-free individuals aged 18-49 YOA, respectively and £557 vs £401 in IC and IC-free individuals aged ≥80 YOA, respectively). Costs varied considerably by IC condition.

CONCLUSIONS

Individuals with IC conditions, have a high burden of HZ, associated with an increased risk of HZ and high HZ-related healthcare costs.

The Impact of Reactogenicity After the First Dose of Recombinant Zoster Vaccine on the Physical Functioning and Quality of Life of Older Adults: An Open-Label, Phase III Trial

BACKGROUND

Herpes zoster and its related complications are associated with significant medical burden, which negatively affects quality of life and daily functioning of the patients. The recently licensed recombinant zoster vaccine (RZV) offers high efficacy but is associated with local and systemic reactions. This study assessed the impact of RZV on the quality of life and daily functioning of participants and implications for caregivers.

METHODS

Four hundred and one adults aged 50 years or older received single RZV doses at 0 and 2 months in this open-label, single-arm, multicenter study (NCT02979639). Change in mean SF-36 Physical Functioning score following first-dose administration, quality of life, reactogenicity, safety, productivity loss, and health care resource utilization was assessed. The current analysis was performed post-vaccine dose-1; safety follow-up will continue until 1 year post-dose-2.

RESULTS

The most common solicited local symptoms were injection-site pain (77.5%), redness (23.0%), and swelling (13.3%); the most frequent solicited systemic reactions were fatigue (33.5%), headache (28.3%), and myalgia (26.8%). Grade 3 reactogenicity occurred in 9.5% of participants and was associated with a transient clinically important decrease in SF-36 Physical Functioning score (affecting activities such as walking, carrying groceries, climbing stairs) on Days 1 and 2 post-first vaccination. No clinically meaningful reductions in mean SF-36 Physical Functioning scale scores from pre- to post-RZV dose-1 were observed (mean +1.9 points, primary end point), and no overall quality-adjusted-life-year loss was recorded post-dose-1. Five participants reported lost workdays; caregiver workload was not increased.

CONCLUSIONS

Overall, the physical functioning and quality of life of older adults were not affected by a first RZV dose. The observed reactogenicity was consistent with previous studies.

Healthcare costs associated with varicella and herpes zoster in Norway

BACKGROUND

Norway does not implement routine vaccination against varicella or herpes zoster. Despite substantial health burden associated with both diseases, their economic impact is not well described. The aim of the present study was to document the healthcare costs associated with both conditions in a Norwegian setting.

METHODS

We used registry data about patients' contacts with primary and specialized healthcare services from 2008 to 2014 to estimate the costs associated with varicella and herpes zoster in the primary and hospital care sector. We calculated the individual costs by treatment facility (general practitioner and emergency primary care clinic) in primary care and by treatment level (inpatient, outpatient or ambulatory treatment) at hospitals.

RESULTS

We estimate that the annual healthcare cost of patients with varicella and herpes zoster are NOK 85 million (approximately € 9 million). Of the annual costs, 73% are associated with herpes zoster and 27% are due to varicella. The majority (54%) of the total annual cost is represented by patients with herpes zoster treated in hospital.

CONCLUSION

Varicella and herpes zoster impose a substantial financial burden on the national healthcare services in Norway. Most of the costs are incurred by herpes zoster, which could be prevented by vaccination.

Development of adjuvanted recombinant zoster vaccine and its implications for shingles prevention

INTRODUCTION

GSK has developed a two-dose adjuvanted recombinant zoster vaccine (Shingrix, RZV) to protect people aged ≥50 years (50+) against herpes zoster (HZ) and its complications. RZV showed >90% efficacy against HZ, sustained over 4 years of follow-up, in all studied age groups.

AREAS COVERED

This article reviews the scientific rationale underlying the design of RZV; the clinical evidence demonstrating immunogenicity, safety, and efficacy in persons 50+; and the public health implications and cost-effectiveness.

EXPERT COMMENTARY

A decline in varicella zoster virus (VZV) immunity is associated with increased risk of HZ in adults 50+ and immunocompromised individuals. RZV was designed to restore levels of anti-VZV cellular and humoral immunity to prevent VZV reactivation. RZV includes the recombinant gE glycoprotein antigen, and Adjuvant System AS01_B which promotes cellular and antibody responses. In two Phase III studies in subjects aged 50+ and 70+ years, RZV efficacy against HZ compared to placebo was >90% and ≥89% against post-herpetic neuralgia (PHN). RZV is expected to dramatically impact HZ morbidity including its complications, and associated health-care costs. In the US population aged 50+ years, vaccination with RZV can be cost-effective compared to no vaccination and cost-saving compared to the currently available live-attenuated HZ vaccine (Zostavax, Merck).

Herpes zoster in frail elderly patients: prevalence, impact, management, and preventive strategies

Population aging is a worldwide phenomenon with significant and manifold impacts on society. Advanced age correlates with the onset of frailty. In this vulnerable state, the immune response is weakened and a higher susceptibility to infectious diseases is observed. The present narrative review aims to cover the topic of herpes zoster (HZ) and its complications in frail populations. The lifetime risk of developing HZ is estimated at about 20-30%, and the risk increases with age. In older people, HZ can lead to the inability to recover the lifestyle, the interests, and the level of activity that existed before its development. Severity of the disease at presentation and depression are the major correlates of pain burden in patients with acute HZ and postherpetic neuralgia (PHN). The frail elderly need careful assessment prior to treatment initiation and could be affected to a greater extent by treatment-related adverse events. In light of the significant burden caused by HZ and its complications in the frail elderly, the adoption of a preventive strategy appears to be promising, particularly using vaccination in appropriate age- and risk-groups. Although very few vaccine studies consider explicitly the frail elderly as their study population, there is evidence that the live, attenuated vaccine induces significant immunological responses. An adjuvanted recombinant subunit vaccine has recently been approved in Canada, in the United States, in the European Union, and in Japan, and will likely provide additional opportunities for prevention.

Impact of Herpes Zoster and Post-Herpetic Neuralgia on Health-Related Quality of Life in Japanese Adults Aged 60 Years or Older: Results from a Prospective, Observational Cohort Study

Background and Objectives

Herpes zoster (HZ) and its most frequent complication, post-herpetic neuralgia (PHN), have been shown to considerably impact quality of life (QoL). This has not yet been demonstrated in Japan.

Methods

QoL in HZ and PHN patients was evaluated using the Zoster Brief Pain Inventory (ZBPI), EuroQoL-5 Dimension (EQ-5D), Short-Form 12 version 2.0, and short-form McGill Pain Questionnaire up to 270 days after rash onset as part of a prospective, observational, cohort study conducted in Kushiro, Hokkaido, Japan.

Results

This study involved 412 adults ≥ 60 years of age diagnosed with HZ, 38 of whom developed PHN. QoL in daily activity performance and emotional and physical functioning was impaired at Day 0 (rash onset) and almost resolved by Day 90. Although the mean ZBPI worst pain score for HZ patients without PHN improved from 4.1 at Day 0 to 0.1 at Day 90, the score for HZ patients with PHN at Day 90 was comparable to that for HZ patients without PHN at Day 0. While the EQ-5D score in HZ without PHN improved, on average, from 0.755 to 0.949, the score for HZ with PHN was dependent on PHN duration and did not improve until PHN disappearance.

Conclusions

HZ impaired QoL in daily activity performance and emotional and physical functioning. The negative impact on QoL was more prevalent in patients with a longer PHN duration compared with HZ without PHN.

ClinicalTrials.gov identifier: NCT01873365.

Impact of postherpetic neuralgia: A six year population-based analysis on people aged 50 years or older

OBJECTIVES

To estimate the incidence and burden of postherpetic neuralgia (PHN) and to investigate risk factors for PHN in the Valencia Region of Spain.

METHODS

Data were extracted from population and healthcare databases from the Valencia Region (2009-2014). Herpes zoster (HZ) and PHN were defined using ICD-9 codes and drug prescriptions in people aged ≥50 years. The risk of HZ patients for developing PHN and potential risk factors (diabetes mellitus, COPD and heart failure) were investigated. A survival analysis was developed to estimate the cumulative hazard of developing HZ and PHN between ages 50-90 years.

RESULTS

From a total of 2,289,485 subjects, 87,086 cases of HZ were registered, 13,658 (15.7%) of whom developed PHN. PHN risk was higher in women and increased sharply with age and comorbidities as diabetes mellitus, COPD and heart failure. The cumulative risk of developing HZ between ages 50-90 years was 31.7% (95% CI: 31.3-32.1) and 6.9 (95% CI: 6.7-7.1) for PHN.

CONCLUSIONS

PHN risk was higher in women and increased with age and comorbidities. At least 32% and 7% of people will develop HZ and PHN, respectively, between ages 50-90 years. These results should be considered for vaccine policy implementation.

Risk and impact of herpes zoster among COPD patients: a population-based study, 2009-2014

Background

The objective of this study was to assess the incidence of Herpes Zoster (HZ) among patients with chronic obstructive pulmonary disease (COPD) and the impact of HZ on the underlying COPD.

Methods

A retrospective cohort of all subjects older than 49 years was followed up between 2009 and 2014 using population and health databases of Valencia Region (Spain). HZ and COPD were identified using ICD-9 codes, differentiating COPD patients with inhaled corticosteroids prescriptions (COPD-ICS). The incidence of HZ was compared among 3 groups [non-COPD, COPD and COPD-ICS populations] and use of healthcare resource due to HZ for 6 months following HZ diagnosis through different statistical generalized linear models (GLM). We also compared resources consumption due to COPD before and after HZ.

Results

The cohort consisted of 2,289,485 subjects, including 161,317 COPD patients of which 29,708 were COPD-ICS. HZ incidence rates were 11 (95% confidence interval [CI]: 10.7–11.4) and 13 (95% CI: 12.3–13.8) cases/1000 persons-year for COPD and COPD-ICS populations respectively. Incidence increased with age in all groups. The risk of HZ rose by 45 and 61% among COPD and COPD-ICS patients respectively compared to non-COPD (95% credible intervals [CrI]: 1.41–1.5 and 1.52–1.71 respectively). COPD patients consumed more resources due to their HZ than non-COPD. There was no statistically significant impact of the HZ on the resources consumed due to COPD during the 6 months post-HZ compared to the 6 months pre-HZ.

Conclusions

The presence of COPD increases the risk, severity and impact of zoster episodes.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3121-x) contains supplementary material, which is available to authorized users.

Efficacy and Safety of Once-Daily Controlled-Release Pregabalin for the Treatment of Patients With Postherpetic Neuralgia: A Double-Blind, Enriched Enrollment Randomized Withdrawal, Placebo-Controlled Trial

OBJECTIVES

To assess efficacy and safety of once-daily controlled-release (CR) formulation of pregabalin in patients with postherpetic neuralgia.

METHODS

An enriched enrollment, randomized withdrawal trial, with 6-week single-blind pregabalin treatment phase and 13-week double-blind phase, where patients with ≥50% decrease in mean pain score at single-blind end point from baseline were randomized (1:1) to pregabalin CR (82.5 to 660 mg/d) or placebo. Primary efficacy outcome was time to loss of therapeutic response (LTR) (<30% decrease in weekly mean pain score from single-blind baseline or discontinuation due to adverse event or lack of efficacy). Secondary efficacy outcomes included change in weekly mean pain score (1-wk recall period) at double-blind end point.

RESULTS

In total, 801 patients were randomized and treated in the single-blind phase, and 413 in the double-blind phase (208, pregabalin CR; 205, placebo). Pregabalin CR significantly increased time to LTR versus placebo (Kaplan-Meier analysis) with significantly fewer LTR events with pregabalin CR than with placebo (29 [13.9%] vs. 63 [30.7%]; P<0.0001). Median time to LTR was not estimable. Pregabalin CR significantly improved weekly mean pain score versus placebo: LS mean difference (95% CI) of -1.11 (-1.47, -0.75) and -1.00 (-1.34, -0.65) (P<0.0001) from single-blind baseline and double-blind baseline, respectively. Most commonly reported adverse events in the single-blind phase were dizziness, somnolence, and peripheral edema. Pregabalin CR was well tolerated.

DISCUSSION

Time to LTR was significantly longer with pregabalin CR than with placebo. Safety profile of pregabalin CR was comparable to that reported for the immediate-release formulation in patients with postherpetic neuralgia.

Incidence and costs of herpes zoster and postherpetic neuralgia in German adults aged ≥50 years: A prospective study

OBJECTIVES

Herpes zoster (HZ) mainly affects elderly people and immunocompromised individuals. HZ is usually characterized by a unilateral painful skin rash. Its most common complication, postherpetic neuralgia (PHN), may cause chronic debilitating pain. This study aimed to estimate the HZ incidence in individuals aged ≥50 years in Germany, the proportion of PHN and the economic burden.

METHODS

From 2010 to 2014, HZ patients were recruited when consulting physicians in physician networks covering about 157,000 persons aged ≥50 years. PHN was defined as "worst pain" rated ≥3 on the zoster brief pain inventory persisting or appearing over 90 days after rash onset. Costs were calculated based on medical resource utilization and lost working time.

RESULTS

HZ incidence was estimated as 6.7/1000 person-years, increasing with age to 9.4/1000 in ≥80 year-olds. Among 513 HZ patients enrolled, the proportion of PHN was 11.9%, rising with age to 14.3% in HZ patients ≥80 years. Estimated total cost per HZ patient was €156 from the healthcare system perspective and €311 from the societal perspective.

CONCLUSIONS

The study confirmed previous findings that HZ causes a substantial clinical and economic burden in older German adults. It also confirmed the age-related increasing risk of HZ and PHN.

Acute herpes zoster and post herpetic neuralgia in primary care: a study of diagnosis, treatment and cost

Acute herpes zoster and its complication post herpetic neuralgia represent a significant challenge to primary care physicians in their care of an ageing population of patients. This was a cross-sectional observational study by means of a quantitative survey of 1,000 general practitioners registered in Ireland exploring the frequency of diagnosis, methods of treatment and cost of AHZ and PHN in primary care. We recorded an 18% response rate (n = 184) with an 83% completion rate (n = 152/184). 80% of cases of AHZ occurred in patients aged 50 years or more with 81% of study participants encountering cases at a rate of 1-3 patients per month. Famciclovir (37%) and valaciclovir (36%) were the most commonly prescribed antiviral agents. Mild opioids (32%) were the most common analgesic agents used for first line AHZ pain, and pregabalin (37%) the most commonly prescribed analgesic agent for second line AHZ pain. Pregabalin was also the most commonly prescribed analgesic for both first and second line PHN pain (29% and 24%, respectively). The mean per-case direct cost (medication and GP visits) of treating AHZ and PHN in primary care was €195 (range €153-€236) and €201 (range €140-€313), respectively. Based on national sentinel data the estimated annual direct costs of treating AHZ and PHN in primary care is €2,278,196 (range €1,793,399-€2, 763,445). The treatment of AHZ and PHN represents both a significant care and cost burden on primary care resources in Ireland in keeping with other European based studies.

Herpes Zoster in the Older Adult

Herpes zoster (HZ) is the result of reactivation of latent varicella zoster virus (VZV) and occurs most frequently in older adults. Classically, HZ presents as a unilateral, selflimited, dermatomal rash. Postherpetic neuralgia (PHN) is a common sequela, presenting as severe pain that persists after the rash has resolved. In the elderly, PHN can be debilitating and requires a prompt diagnosis, treatment with antivirals, and adequate pain control. A longer-term pain management strategy is required if PHN occurs. A modestly effective vaccine exists and is recommended for older individuals.

Risk and impact of herpes zoster on patients with diabetes: A population-based study, 2009-2014

AIMS

This study was designed to assess the impact of diabetes on the risk and severity of herpes zoster (HZ), and the impact of HZ on diabetes. It focused primarily on immunocompetent patients aged ≥ 50 years who would be eligible for preventive vaccination.

METHODS

Using population and healthcare databases of Valencia Region (Spain), a retrospective cohort of all subjects ≥ 50 years was followed up between 2009 and 2014. HZ and diabetes were defined using ICD-9 codes. We compared the incidence of HZ between non-diabetes and diabetes groups and healthcare resource consumption due to HZ in the 6 months following HZ diagnosis using different statistical generalized linear models (GLM). We also compared resources consumption due to diabetes treatment and haemoglobinA1c(HbA1c) levels before and after HZ.

RESULTS

The cohort consisted of 2,289,485 individuals ≥ 50 years old, 397,940 of whom had diabetes. HZ incidence rate was 9.3 cases/1000 persons with diabetes-year (95% CI: 9.1-9.4). Incidence increased with age in all groups. The risk of HZ increased in the diabetes group compared to the non-diabetes group (RR 1.2, 95% credibility interval [CrI] 1.17-1.22). Patients with diabetes utilized more health care resources due to their HZ episodes than patients without diabetes. In 24% of well controlled patients with diabetes (HbA1C levels ≤ 6.5%), HbA1C increased after HZ.

CONCLUSIONS

Diabetes increased by 20% the risk of HZ. HZ contributed to the deterioration of glycaemic control and higher healthcare resource consumption in people with diabetes, becoming a priority population for HZ immunization.

Economic Burden of Herpes Zoster and Post-Herpetic Neuralgia in Adults 60 Years of Age or Older: Results from a Prospective, Physician Practice-Based Cohort Study in Kushiro, Japan

BACKGROUND AND OBJECTIVE

Herpes zoster has a high incidence rate among people aged ≥ 60 years and can lead to serious complications such as post-herpetic neuralgia. There are currently no data on the economic burden of herpes zoster and post-herpetic neuralgia in Japan, and the objective of this study was to address this gap.

METHODS

A total of 412 patients aged ≥ 60 years diagnosed with herpes zoster were recruited. Demographic, clinical, and healthcare resource utilization data on patients with herpes zoster or post-herpetic neuralgia collected via case report forms were used to estimate direct medical cost. Data obtained from a questionnaire survey among patients with herpes zoster/post-herpetic neuralgia were used to estimate transportation cost and productivity loss.

RESULTS

The mean number of outpatient visits was 5.7. Prescription medications were the main cost driver accounting for 60% of the direct medical cost. The mean direct medical and total herpes zoster-related costs per patient were ¥43,925 and ¥57,112, respectively, and were higher in patients with post-herpetic neuralgia than in those with herpes zoster without complications. Direct medical cost represented 77%, productivity loss 19%, and transportation cost 4% of the total.

CONCLUSIONS

This is the first study of the economic burden of herpes zoster and post-herpetic neuralgia in Japan and it demonstrated substantial direct medical cost as a result of the multiple outpatient visits and prescription medications required. These findings provide baseline data for possible future economic evaluations of new herpes zoster/post-herpetic neuralgia interventions.

TRIAL REGISTRATION

This cost analysis is part of a prospective, physician practice-based cohort study conducted between June 2013 and February 2015 in Kushiro, Japan (Clinicaltrials.gov identifier NCT01873365, registered on 6 June, 2013).

Prevention of Herpes Zoster and its complications: From clinical evidence to real life experience

Herpes zoster (HZ) is an acute viral illness characterized by a vesicular rash with unilateral distribution, which can also result in severe complications such as post-herpetic neuralgia (PHN), ophthalmic zoster, stroke or other neurological complications. The estimate incidence in Europe ranges between 2.0 and 4.6 cases per 1,000 person-years, with a sharp increase in >50 year-old subjects. Currently, treatment options for HZ are only partially effective in limiting the acute phase, while the management of complications is complex and often unsatisfactory. The total burden of the disease and the high costs related to its diagnostic and therapeutic management led researchers to develop a new preventive approach through a live attenuated virus vaccine. The currently available vaccine, with a high antigen content, is safe, well tolerated and reduces the incidence of HZ, PHN and the burden of illness. Several countries have introduced this vaccination, albeit with different recommendations and methods of financing. Taking into account the barriers to this immunization registered in some areas (difficulty of vaccine distribution, lack of physician recommendations, the cost of vaccine for patients, etc.), this group of Italian experts advocate that a common strategy able to guarantee a good compliance with this vaccination should be implemented. The same group addresses some practical questions concerning the use of zoster vaccine.

Shingles (Herpes Zoster) Vaccine (Zostavax(®)): A Review in the Prevention of Herpes Zoster and Postherpetic Neuralgia

Zostavax(®) is a live attenuated shingles (herpes zoster) vaccine approved in the EU for the prevention of herpes zoster (HZ) and postherpetic neuralgia (PHN) in adults aged ≥50 years. Zoster vaccine protected against HZ in adults aged 50-59 years (ZEST trial) and ≥60 years [Shingles Prevention Study (SPS)], and also reduced the burden of illness associated with HZ and the risk of PHN in adults aged ≥60 years (SPS). A large amount of real-world data also supports the efficacy of zoster vaccine. Results of the SPS Short- and Long-Term Persistence Substudies and real-world studies indicate that zoster vaccine provided continued benefit in the longer term, albeit with a gradual decline in vaccine efficacy over time; long-term effectiveness studies are ongoing. The need for a booster dose is still unknown, but a study showed that, if necessary, a booster dose administered to adults aged ≥70 years who received their first dose of zoster vaccine ≥10 years previously was immunogenic. Zoster vaccine had a favourable safety and tolerability profile, with the most commonly reported adverse events being non-severe injection-site reactions. In conclusion, zoster vaccine reduces the incidence of HZ and PHN, thereby reducing the burden of illness associated with HZ; improved uptake of zoster vaccine is needed.