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

A systematic review and meta-analysis of herpes zoster risk in adults with immunocompromised conditions and autoimmune diseases in Asia-Pacific

Asia-Pacific (APAC) faces an increasing burden of herpes zoster (HZ) over time. The risk of HZ and its complications are increased in immunocompromised (IC) patients and those with autoimmune diseases (AID). Our study aimed to synthesize evidence on the epidemiological burden of HZ and its complications among the general adult population and patients with IC/AID conditions in APAC. Following a systematic literature review, we performed meta-analyses for outcomes where ≥3 studies met the inclusion criteria. Of the 271 articles identified, 75 were included for meta-analysis. We found a high burden of HZ and its complications (i.e., postherpetic neuralgia, HZ ophthalmicus), particularly among individuals with IC/AID conditions in APAC. Patients with IC/AID conditions had significantly increased HZ risk and a higher proportion of HZ recurrence than the general adult population. These findings may inform clinical practice and public health decisions regarding HZ prevention, including HZ vaccination strategies, among the IC/AID population in APAC.

Inpatient Burden of COVID-19 in Japan: A Retrospective Cohort Study

BACKGROUND

Changing disease dynamics and access to COVID-19 vaccines in Japan warrant a timely description of the burden of severe disease. Here we report inpatient healthcare resource utilization of COVID-19 in Japan and contextualize results with influenza.

METHODS

We selected persons hospitalized for COVID-19 (ICD-10 code U07.1) from April 1, 2020 - January 31, 2024 or influenza (ICD-10 code J09.X - J11.x) from November 1, 2017 - October 31, 2019 from Medical Data Vision, a large hospital-based database in Japan. Outcomes of interest were length of stay, intensive care unit (ICU) admission, receipt of invasive mechanical ventilation (IMV), and inpatient mortality, assessed overall, as well as stratified by age groups and calendar time.

FINDINGS

Among 5,684 hospitalized COVID-19 cases, persons were older (median age 80 vs 64) and had a longer length of stay (median 21 vs 5 days) than the 18,584 influenza cases. The proportions of patients admitted to ICU (3% vs 1%), received IMV (6% vs 3%) and died in hospital (12% vs 3%) were higher in COVID-19 patients than influenza patients. Burden was higher in adult COVID-19 patients than pediatric COVID-19 patients, although for both adults and pediatric patients, COVID-19 burden surpassed influenza. Inpatient burden of COVID-19 between May 2023 and January 2024 remained greater than influenza, with 5-times longer length of stay, more frequent need for ICU care (3-times higher), IMV support (2-times higher) and in-hospital deaths (4-times higher).

INTERPRETATION

These findings underscore the need for continued prevention and treatment of COVID-19 to prevent severe disease.

Herpes Zoster: Risk Factors for Occurrence, Complications, and Recurrence with a Focus on Immunocompromised Patients

BACKGROUND

The varicella-zoster virus is a highly contagious human herpesvirus that primarily causes varicella (chickenpox) as an initial infection, targeting T cells, neurons, as well as skin cells, and can later reactivate to cause herpes zoster (shingles). Following reactivation, the varicella-zoster virus infection can lead to severe complications, the most common of which is postherpetic neuralgia. Risk factors include aging, immunosuppression, chronic diseases such as diabetes, cardiovascular disorders, respiratory conditions, and others.

OBJECTIVE

In this article, we present an analysis of factors increasing the risk of herpes zoster occurrence, complications, and recurrences (in particular in immunocompromised patients).

Immune Dysregulation in Acute Herpes Zoster: Predictive Factors for Postherpetic Neuralgia

BACKGROUND Postherpetic neuralgia (PHN) is closely related to the host immune response. This study explored the cellular and humoral immune functions of acute immunocompetent herpes zoster (HZ) patients and their relationship with PHN. MATERIAL AND METHODS We selected 188 patients with acute HZ admitted to our hospital and 79 individuals who underwent physical examinations during the same period. We measured and compared the levels of peripheral blood lymphocyte subsets (CD3+, CD4+, CD8+, CD4+/CD8+, CD19+, CD56+), serum immunoglobulins (IgA, IgG, IgM), and complement (C3, C4) between the 2 groups. Based on whether they had neuralgia during follow-up, we divided the patients into an HZ-PHN group and an HZ-control group, and compared their differences in immune functions and their relationship with PHN. RESULTS Compared with the control group, the levels of CD3+ and CD4+ and CD4+/CD8+ ratios of HZ patients were significantly lower (P<0.05). Among 188 HZ patients, 91 (48.4%) developed PHN. The patients in the HZ-PHN group were significantly older (P<0.01) and the levels of CD3+, CD4+, and CD8+ and CD4+/CD8+ ratios were significantly lower than those in the HZ-control group (P<0.05, P<0.01). Binary logistic regression analysis showed that age and CD4+/CD8+ ratios are independent risk factors for determining whether HZ patients develop PHN. CONCLUSIONS Acute immunocompetent HZ patients, especially those who are older and more prone to developing PHN, exhibit significant cellular immune dysregulation. Age and CD4+/CD8+ ratios may be useful predictors of PHN in acute HZ patients.

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.

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.

Optimal timing of recombinant herpes zoster virus vaccination for a JAK inhibitor treatment in rheumatoid arthritis: a multicentre, open-label, randomised comparative study (STOP-HZ study): study protocol

INTRODUCTION

Janus kinase (JAK) inhibitors are an important therapeutic option in the treatment of rheumatoid arthritis, but increase the risk of developing herpes zoster. Although a dry recombinant zoster vaccine (RZV) that can be used under immunosuppressive conditions has recently been developed, its optimal use and appropriate timing in patients scheduled to start JAK inhibitors is still unclear. The present study is designed to clarify the appropriate timing of JAK inhibitor initiation to measure varicella zoster virus (VZV)-specific IgG titers and VZV-specific T cell response in patients with rheumatoid arthritis who start tofacitinib at the first RZV vaccination or at the second one.

METHODS AND ANALYSIS

STOP HZ (Effectiveness and S afe T y O f P rophylactic Recombinant H erpes Z oster Virus Vaccination for Rheumatoid Arthritis Patients with Tofacitinib Treatment) study is a multicentre, open-label, randomised, comparative study in patients with rheumatoid arthritis who are scheduled to start tofacitinib. This study enrols 60 study subjects in 12 sites. Enrolled subjects receive RZV two times on day 1 and week 8 and initiate tofacitinib 5 mg two times a day at the time of their first RZV (day 1, group A) or second RZV (week 8, group B) based on randomisation. The random assignment is performed centrally in a 1:1 ratio. Patients in Group B continue the same treatment until the start of tofacitinib treatment. Primary endpoint is VZV-specific IgG antibody titers at week 12 compared with those at baseline in each group. Secondary endpoints include comparison of VZV-specific IgG antibody between the groups, changes in disease activity of rheumatoid arthritis, VZV-specific T cell response and adverse events.

ETHICS AND DISSEMINATION

The study has been approved by the Certified Review Board of Keio (No. 2022008), and conforms to the Declaration of Helsinki and good clinical practice guidelines. Written informed consent is obtained from participants prior to enrolment. The results of this study are planned to be submitted for publishment in relevant peer-review journals.

TRIAL REGISTRATION NUMBER

jRCTs031230329.

Burden of Herpes Zoster in Individuals With Chronic Conditions in the Republic of Korea: A Nationwide Population-Based Database Study

Background

Chronic conditions (CCs) may increase the risk of herpes zoster (HZ) infection, leading to a greater healthcare burden in these individuals compared to those without CCs. It is therefore clinically important to quantify HZ disease burden in individuals with and without CCs, given the rapidly aging population in the Republic of Korea (ROK).

Methods

This retrospective cohort study examines the trends in incidence rates (IRs) and incidence rate ratios (IRRs) in individuals aged ≥18 years with CCs, using the National Health Insurance Service National Sample Cohort (NHIS-NSC) database from 2010 to 2019. These patients were stratified by age group, sex, HZ complications, and CCs. The annual average number of HZ patients, IRs, and IRRs were calculated for individuals with and without CCs.

Results

In total, 729 347 patients with HZ were eligible for the study. HZ IRs were highest in patients with diabetes, followed by chronic obstructive pulmonary disease, chronic kidney disease, asthma, and chronic liver disease, with HZ IRRs following a similar trend. Overall, HZ IRs generally increased with age, typically peaking at 60-64 or 65-69 years, and were similar for females and males. HZ IRs were highest among patients without complications, followed by HZ with other, cutaneous, ocular, and neurologic complications across all CCs. For each of the CCs, HZ IRs were consistently higher than those of the non-CC population regardless of sex.

Conclusions

The findings of this study reiterate the importance of HZ prevention for healthy aging, especially for CC populations at increased risk of HZ in the ROK.

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.

Clinical, Laboratory, and Imaging Characteristics of Tropheryma Whipplei Detection in Bronchoalveolar Lavage Fluid Using Next-Generation Sequencing: A Case-Control Study

Objective

The aim of this study was to assess the prevalence of Tropheryma whipplei (TW) infection in the population and to investigate the clinical symptoms, as well as the laboratory and imaging characteristics of patients testing positive for TW using next-generation sequencing (NGS).

Methods

A retrospective review was conducted on 1346 bronchoalveolar lavage fluid (BALF) samples collected between January 2021 and September 2023. The case group comprised patients with TW detected using NGS while the control group included 65 randomly chosen Gram-positive bacterial infection patients without TW. Comparative analyses were carried out on the basic demographics, laboratory parameters, and imaging findings between the two groups. Additionally, the case group underwent an in-depth examination of underlying diseases, pathogens, final diagnoses, treatment strategies.

Results

The case group comprised of 51 patients with TW, constituting 3.8% of the total. There was no significant difference in gender and age between the case and control groups (P = 0.84, P = 0.07). Symptoms such as coughing, expectoration, wheezing, fever, and hemoptysis are less commonly detected in the case group with a higher incidence of chest pain when compared to the control group (P >0.05). The case group exhibited decreased albumin levels and increased C-reactive protein and D-dimer levels compared to normal levels. Imaging findings in the case group commonly included nodules, patchy images, and interstitial changes, the most common underlying disease is cardiovascular disease, and the most frequently co-occurring pathogen is the human herpesvirus. Among the case group, 27 patients received a final diagnosis of pneumonia, and 3 patients clinically diagnosed with Whipple's disease demonstrated improvement in both symptoms and imaging after treatment.

Conclusion

NGS revealed a relatively low overall detection rate of TW-positive patients using BALF. TW was more prevalent in middle-aged and elderly male patients characterized by symptoms such as cough, expectoration, shortness of breath, and fever. Chest imaging in these cases typically showed nodules and interstitial changes.

Risk factors for herpes zoster infections: a systematic review and meta-analysis unveiling common trends and heterogeneity patterns

PURPOSE

The burden of herpes zoster (HZ) is substantial and numerous chronic underlying conditions are known as predisposing risk factors for HZ onset. Thus, a comprehensive study is needed to synthesize existing evidence. This study aims to comprehensively identify these risk factors.

METHODS

A systematic literature search was done using MEDLINE via PubMed, EMBASE and Web of Science for studies published from January 1, 2003 to January 1, 2023. A random-effects model was used to estimate pooled Odds Ratios (OR). Heterogeneity was assessed using the I2 statistic. For sensitivity analyses basic outlier removal, leave-one-out validation and Graphic Display of Heterogeneity (GOSH) plots with different algorithms were employed to further analyze heterogeneity patterns. Finally, a multiple meta-regression was conducted.

RESULTS

Of 6392 considered records, 80 were included in the meta-analysis. 21 different conditions were identified as potential risk factors for HZ: asthma, autoimmune disorders, cancer, cardiovascular disorders, chronic heart failure (CHF), chronic obstructive pulmonary disorder (COPD), depression, diabetes, digestive disorders, endocrine and metabolic disorders, hematological disorders, HIV, inflammatory bowel disease (IBD), mental health conditions, musculoskeletal disorders, neurological disorders, psoriasis, renal disorders, rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and transplantation. Transplantation was associated with the highest risk of HZ (OR = 4.51 (95% CI [1.9-10.7])). Other risk factors ranged from OR = 1.17-2.87, indicating an increased risk for all underlying conditions. Heterogeneity was substantial in all provided analyses. Sensitivity analyses showed comparable results regarding the pooled effects and heterogeneity.

CONCLUSIONS

This study showed an increased risk of HZ infections for all identified factors.

Burden of narcolepsy in Japan: A health claims database study evaluating direct medical costs and comorbidities

OBJECTIVE

This study aimed to determine the burden of narcolepsy in terms of direct medical costs and comorbidities and compare it with the respective burden of schizophrenia, epilepsy, and ulcerative colitis as controls.

METHODS

Patients diagnosed with narcolepsy (at least once based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, code G47.4) between April 2017 and March 2022 were identified on the health insurance claims database compiled by JMDC Inc. Patients with schizophrenia (F20), epilepsy (G40), and ulcerative colitis (K51) were matched as controls. Direct medical costs (including inpatient, outpatient, and medication costs) and comorbidities were analyzed.

RESULTS

We identified 4,594 patients with narcolepsy (≥18 years), 18,376 with schizophrenia, 18,376 with epilepsy, and 4,594 with ulcerative colitis. The total annual direct medical cost per person with narcolepsy was 349,188 JPY. The cost for narcolepsy was less than that for schizophrenia, epilepsy, and ulcerative colitis. Several comorbidities, such as sleep apnea, attention deficit hyperactivity disorder (ADHD), and obesity were more prevalent in the narcolepsy group.

CONCLUSIONS

The total direct cost for narcolepsy was approximately three times higher than the national medical expense for people aged 15-44 years (122,000 JPY in 2020), but lower than the total cost for all control diseases. The patients with narcolepsy were also likely to have comorbidities that affected their burden. These findings can contribute to future discussions on medical expense assistance programs for patients with narcolepsy.

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.

Associations between income changes and the risk of herpes zoster: LIFE study

Economic stability is thought to be associated with health outcomes. Income changes may affect the occurrence of herpes zoster (HZ), which is a neurocutaneous disease caused by the varicella-zoster virus. This retrospective cohort study aimed to examine the associations between annual income changes and incident HZ in a Japanese population. The analysis was conducted using a database of public health insurance claims data linked with administrative data containing income levels. The study population comprised 48,317 middle-aged persons aged 45-64 years from five municipalities, and participants were followed-up from April 2016 until March 2020. Income changes were categorized as income unchanged (income in the year of interest remained within 50% of income in the previous year), income rise (income increased by more than 50% from the previous year to the year of interest), and income drop (income decreased by more than 50% from the previous year to the year of interest). Cox proportional hazards regression analyses were performed to calculate the hazard ratios of HZ for income drop and income rise (reference: income unchanged) as time-varying variables. Covariates included age, sex, and immune-related conditions. The results showed that income drop was significantly associated with a higher hazard ratio (1.15, 95% confidence interval: 1.00-1.31) for HZ. In contrast, income rise was not associated with HZ. A subgroup analysis revealed that the lowest baseline income group had a significantly higher risk of HZ when experiencing an income drop (HR: 1.56, 95% CI: 1.13-2.15). As zoster vaccination is voluntary and vaccination coverage in middle-aged persons is low in Japan, our findings indicate that it may be advantageous to promote and subsidize voluntary vaccinations for middle-aged people with low baseline income who have experienced substantial income reductions in order to reduce the risk of HZ.

Effectiveness of Live Attenuated Varicella-Zoster Vaccine in Adults Older than 50 Years in Japan: A Retrospective Cohort Study

Background: In Japan, freeze-dried live attenuated varicella-zoster vaccine BIKEN is available for adults aged ≥50 years to prevent herpes zoster (HZ). A prospective cohort study of 1200 healthy adults and 300 patients with underlying illness confirmed vaccine safety between 2016 and 2017. However, evidence of vaccine effectiveness (VE) is limited. Methods: VE against HZ and postherpetic neuralgia (PHN) was evaluated in the vaccinated cohort of the previous safety study in a follow-up study between 2021 and 2022 and compared with unvaccinated family members. Self-administered questionnaires determined retrospective experiences of HZ and PHN diagnosis. Logistic regression estimated the VE by calculating the outcome odds ratio (OR) in vaccinated vs. unvaccinated groups: VE = (1 - OR) × 100(%). Results: Overall, 1098 vaccinated and 518 unvaccinated subjects were analysed. Between 2016 and 2022, 26 vaccinated (2.4%) and 22 unvaccinated (4.2%) subjects reported HZ diagnosis, and 3 vaccinated (0.3%) and 2 unvaccinated (0.4%) subjects reported PHN. Adjusted VE against a clinical diagnosis was 41% for HZ [-6% to 67%], with marginal significance, and 16% [-408% to 86%] for PHN. Stratification by age, sex, or comorbidities had an adjusted VE against HZ of ~40%, which was similar between strata. Conclusion: Freeze-dried live attenuated varicella-zoster vaccine reduces the risk of HZ regardless of age, sex, or comorbidities.

Safety and efficacy of recombinant and live herpes zoster vaccines for prevention in at-risk adults with chronic diseases and immunocompromising conditions

Compared with the general population, older adults with immune senescence and individuals who are immunocompromised (IC) due to disease or immunosuppressive therapy are at increased risk for herpes zoster (HZ) and its associated complications, which can be debilitating and life-threatening. Vaccination can be an effective strategy against HZ and studies have shown that HZ vaccination in IC individuals can elicit immune responses and provide protection from infection. Recently, the first approvals have been granted in the United States and the European Union for the recombinant HZ vaccine (RZV) in adults ≥ 18 years of age at risk of HZ due to immunodeficiency or immunosuppression. Existing systematic reviews have highlighted the risks for HZ in limited immunocompromising conditions and have only examined clinical data for RZV. This review details the risks and burden of HZ in a broad range of clinically relevant IC populations and summarizes key efficacy and safety data for RZV and live HZ vaccine in these individuals. Research has shown IC individuals can benefit from HZ vaccination; however, these insights have yet to be fully incorporated into vaccination guidelines and clinical care. Clinicians should consider HZ vaccination in eligible at-risk populations to protect against HZ and its associated complications and thereby, reduce the burden that HZ poses on the healthcare system. Electronic health records and linked personal health records could be used to identify and contact patients eligible for HZ vaccination and provide clinical decision support-generated alerts for missing or delayed vaccinations. This review will help clinicians identify eligible IC individuals who may benefit from HZ vaccination. A video abstract linked to this article is available on Figshare https://doi.org/10.6084/m9.figshare.21517605.

Incidence rates for hospitalized infections, herpes zoster, and malignancies in patients with ulcerative colitis in Japan: an administrative health claims database analysis

BACKGROUND/AIMS

Patients with ulcerative colitis (UC) are at an increased risk of certain infections and malignancies compared with the general population. Incidence rates (IRs) of hospitalized infections, herpes zoster (HZ), and malignancies in patients with UC, stratified by treatment, in Japan were estimated.

METHODS

This retrospective study identified patients with UC treated with corticosteroids, immunosuppressants, or tumor necrosis factor inhibitors (TNFi) from 2 administrative databases (Japan Medical Data Center [JMDC] and Medical Data Vision [MDV]). IRs (unique patients with events per 100 patient-years) were estimated for hospitalized infections, HZ, and malignancies, between June 2010 and May 2018.

RESULTS

Among 6,033 MDV patients with UC receiving corticosteroids, immunosuppressants, or TNFi, IRs (95% confidence intervals) were: hospitalized infections, 1.73 (1.52-1.93); HZ, 1.00 (0.85-1.16), and malignancies, 1.48 (1.29-1.66). Among 958 JMDC patients with UC receiving corticosteroids, immunosuppressants, or TNFi, IRs (95% confidence intervals) were: HZ, 1.82 (1.27-2.37) and malignancies, 1.35 (0.87-1.82). In both cohorts, IRs of malignancies were generally similar among patients receiving immunosuppressants, TNFi, or combination therapy (immunosuppressants and TNFi); this was also true for IRs of hospitalized infections and HZ in the MDV cohort. IRs of hospitalized infections, HZ, and malignancies were higher in patients receiving calcineurin inhibitors compared with immunosuppressants or TNFi, in both cohorts.

CONCLUSIONS

IRs of hospitalized infections, HZ, and malignancies among patients with UC were generally similar regardless of UC treatment, except for calcineurin inhibitors.

Efficacy, effectiveness, and safety of herpes zoster vaccine in the immunocompetent and immunocompromised subjects: A systematic review and network meta-analysis

Objective

To investigate the efficacy, effectiveness and safety of recombinant zoster vaccine (RZV) and zoster vaccine live (ZVL) in immunocompetent and immunocompromised subjects.

Methods

Data sources: PubMed, EMBASE, Cochrane Library, and Web of Science databases (up to Jan 2022) were searched to identify English articles. Search terms included randomized controlled trials (RCTs), observational studies, herpes zoster, RZV, ZVL. Study Selection: Only randomized controlled trials (RCTs) evaluating vaccine efficacy and safety and observational studies assessing vaccine effectiveness (after a vaccine was approved for marketing) were included. Data Extraction: Two researchers independently screened the literature, extracted the data, and checked the each other results.

Results

Seventeen RCTs and 19 cohort studies were included. Among immunocompetent subjects, RZV was superior to ZVL at wide intervals (relative vaccine efficacy: 84%, 95% CI: 53%–95%; relative vaccine effectiveness: 49%, 95% CI: 21%–67%), across genders and subjects aged ≥ 60 years. Among immunocompromised subjects, RZV was superior to placebo in terms of vaccine efficacy (60%, 95% CI: 49%–69%). There was no difference between ZVL and placebo in those with selected immunosuppressive conditions. RZV was 45% (95% CI: 30%–59%) superior to ZVL in real-world practice. Compared with placebo, adverse events related to RZV were primarily related to injection-site and systemic, and RZV did not increase the risk of serious adverse events (SAEs) or death. There was no difference in the incidence of adverse events between groups with and without immunosuppression.

Conclusions

Both RZV and ZVL can reduce the risk of herpes zoster in both immunocompetent and immunocompromised subjects. RZV was well-tolerated in the study population and demonstrated stronger protection than ZVL.

Systematic review registration

Prospero CRD42022310495.

Drug Utilization and Medical Cost Study Focusing on Moisturizers in Cancer Patients Treated with Molecular Targeted Therapy: A Retrospective Observational Study Using Data from a Japanese Claims Database

Introduction

Molecular targeted therapies (MTTs) cause skin disorders in patients with cancer, and moisturizers are useful treatments; however, their actual use and costs are unknown. Our purpose was to examine the use and costs of moisturizers prescribed for xerosis (asteatosis) in patients with cancer treated with MTTs.

Methods

We used data from a Japanese hospital-based claims database. The index date was the first date of MTT prescription from October 2011 to April 2018 (selection period), and the follow-up period was 1 year from the index date. Patients treated with MTTs during the selection period and who were not prescribed moisturizers in the 6 months before the index date were included as the study cohort. Timing, duration, amount, and costs of the prescribed moisturizers and total medical costs were analyzed.

Results

Among the 78,190 patients in the study cohort, 27,906 patients (35.7%) were prescribed moisturizers during follow-up. Moisturizer prescription timing, duration, and volume were inconsistent. The average annual total medical costs for treating patients with MTT who were prescribed moisturizers was JPY 6.165 million (USD 53,797) per patient, and the moisturizer costs were JPY 6033 (USD 53). The number of patients who used moisturizers showed an increasing trend.

Conclusion

No consistent patterns were observed for the timing or duration of moisturizer use, which suggests various developmental patterns of skin disorders. Furthermore, medical costs for moisturizers accounted for only a small proportion of the total medical costs required for cancer treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00712-2.

Meta-Regression of Herpes Zoster Incidence Worldwide

Introduction

Many studies have been conducted worldwide to estimate herpes zoster (HZ) incidence rates. We synthesized studies of HZ incidence rates in the general population using meta-analysis models.

Methods

A random effects meta-analysis was conducted to estimate HZ incidence from a published worldwide systematic literature review (SLR) including only individuals aged 50 years and older. Meta-regression was used to explore whether variability in incidence rates could be explained by a combination of study-specific characteristics including age, gender, continent and year of study data. The impact of adding additional covariates—case detection method (general practitioner surveillance, healthcare database, sentinel network, etc.), case definition (medical record-based, self-reported), study design (retrospective passive surveillance, retrospective active surveillance, etc.), incidence type (cumulative incidence/1000 persons or incidence rate/1000 person-years), patient type (outpatients or in- and out-patients) and latitude to the base model—was also assessed.

Results

Sixty-one records from 59 studies were included in the analysis: 25, 20, 11 and 5 from Europe, North America, Asia and Oceania, respectively. There was variation in study methodology and outcomes. Heterogeneity of incidence rates was greatest among studies conducted in Asia. Meta-analysis showed that incidence increased with age, was lower in males compared to females, tended to be lower in Europe and North America compared to Asia and Oceania and increased with year of study data. The data-driven meta-regression model included continent, year of study data, gender, age and an age × gender interaction term. The difference in incidence between males and females was greater in younger ages (e.g., 50–59) compared to older age groups (e.g., 80+). None of the additional covariates contributed significantly to the model.

Conclusion

Incidence rates were shown to vary by age, gender, continent and year of study data.

Graphical Plain Language Summary

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00567-8.

Low willingness to vaccinate against herpes zoster in a Chinese metropolis

BACKGROUND

Herpes zoster vaccine (HZV) has been available in China's mainland since June 2020. This study estimated willingness to receive HZV to characterize factors that may influence vaccination willingness.

METHODS

We conducted a face-to-face questionnaire survey in adults aged 50-69 years in 13 communities in Shanghai in late 2020. We explored the relationship between vaccination willingness and independent factors including demographic factors, medical history, knowledge of herpes zoster and HZV, and vaccine hesitancy. Outcomes included participants' willingness to vaccinate themselves, their partners, and their parents, under both the current payment scenario (self-payment) and a hypothetical scenario (payment by basic medical insurance).

RESULTS

A total of 1672 respondents aged 50-69 years were included in this study. The proportion of respondents willing to get vaccinated was 16.57% for themselves, 13.88% for their partners, and 8.49% for their parents. If the vaccine was covered under insurance, these numbers increased to 72.25%, 62.50%, and 29.96%, respectively. Younger age, female gender, higher income, higher educational level, local residents, and lower vaccine hesitancy were associated with increased willingness to vaccinate. Knowledge of herpes zoster and HZV positively influenced the willingness in the hypothetical payment scenario.

CONCLUSION

We determined a very low willingness to vaccinate HZV in adults aged 50-69 years in a Chinese metropolis. Decreasing costs is important to increase coverage. Additionally, strengthening advocacy and health promotion for the vaccine will be particularly important, especially for groups with certain underlying diseases.

A systematic literature review of herpes zoster incidence worldwide

We conducted a systematic review to characterize the incidence rate of herpes zoster (HZ) in the general population, specifically in individuals ≥50 years of age. A total of 69 publications were included in the review. We found a cumulative incidence of HZ ranging from 2.9–19.5 cases per 1,000 population and an incidence rate of HZ ranging from 5.23–10.9 cases per 1,000 person-years. The cumulative incidence (3.22–11.2 versus 2.44–8.0 cases per 1,000 population) and incidence rates (6.05–12.8 versus 4.30–8.5 cases per 1,000 person-years) were higher in females than males. Studies revealed a trend of increasing incidence of HZ with increasing age and over time. Variations in incidence estimates can be attributed to the various study designs, case ascertainments, age distributions of the population and year of the study. HZ is associated with a substantial disease burden and is expected to increase due to population aging.

Inpatient Dermatology Consultations in a General Surgery Ward in a Tertiary Hospital in China: A Retrospective Study of 251 Patients

Introduction

Dermatologists play essential roles in providing dermatology consultations to inpatients admitted to hospital for care in another speciality ward. Data on dermatology consultations provided to inpatients admitted to general surgery wards are limited. The aim of this study was to analyze the reasons for and diagnoses of consultations provided by dermatologists to hospitalized patients in a general surgery ward and compare the provisional diagnoses by surgical residents and the final diagnoses by dermatologists.

Methods

Electronic health records were retrieved for patients admitted to a general surgery ward who received dermatology consultations while inpatients in Peking Union Medical College Hospital between 1 September 2015 and 31 August 2020. Sex, age, surgical diagnosis, reason for dermatology consultation, provisional diagnosis by surgical residents, and final diagnosis by dermatologists were reviewed.

Results

A total of 262 dermatology consultations for 251 patients (n = 251, 123 women and 128 men) were identified, of whom 240 (95.6%) required only one consultation and 11 (4.4%) required two. Dermatology consultations were classified into three categories: preoperative consultation (n = 45, 17.9%), postoperative consultation (n = 65, 25.9%), and consultation unrelated to general surgery diseases or treatments (including surgery) (n = 141, 56.2%). For consultations falling in the category preoperative consultation, common reasons for the consultation were: to evaluate whether the current treatment plan for previously diagnosed skin diseases needed to be changed; to evaluate and manage skin problems that emerged after admission; to evaluate syphilis; and to evaluate whether previously diagnosed skin diseases would affect surgical incision or wound healing. Drug eruption, dermatitis/eczema, infectious skin disorders, and urticaria were the most common skin diseases in the hospitalized general surgery patients. Only 32 (12.7%) provisional diagnoses were made, of which 25 (78.1%) were correct and seven (21.9%) were incorrect. Surgical residents mainly had difficulty distinguishing herpes zoster, drug eruption, and infectious skin disorders from dermatitis/eczema.

Conclusion

Our results facilitate the understanding of inpatient dermatology consultations in general surgery wards and may help in the design of future educational materials and/or management guidelines.

Incidence of Hospitalizations and Emergency Department Visits for Herpes Zoster in Immunocompromised and Immunocompetent Adults in Ontario, Canada, 2002-2016

BACKGROUND

Immunocompromised adults are at .increased risk of herpes zoster (HZ) infection and related complications. We aimed to assess the incidence of hospital-attended HZ (ie, seen in hospital or emergency department) in immunocompromised populations and compare it to immunocompetent populations.

METHODS

We calculated incidence rates (IRs) of hospital-attended HZ in Ontario, Canada, between 1 April 2002 and 31 August 2016 in adults ≥18 years of age categorized as immunocompromised or immunocompetent. We repeated these analyses by type of immunocompromising condition and provided incidence rate ratios (IRRs) comparing to immunocompetent adults. We also calculated IRs and IRRs of HZ complications by immunocompromised status.

RESULTS

There were 135 206 incident cases of hospital-attended HZ during the study period. Immunocompromised adults accounted for 13% of these cases despite representing 3% of the population. The risk of hospital-attended HZ was higher for immunocompromised adults compared with immunocompetent adults (IRR, 2.9 [95% confidence interval {CI}, 2.9-3.0]) and ranged across type of immunocompromising conditions, from 2.6 (95% CI, 2.6-2.7) in those with a solid tumor malignancy to 12.3 (95% CI, 11.3-13.2) in those who had undergone hematopoietic stem cell transplant. The risk of any HZ complication was higher in immunocompromised adults (IRR, 3.6 [95% CI, 3.5-3.7]) and highest for disseminated zoster (IRR, 32.8 [95% CI, 27.8-38.6]).

CONCLUSIONS

The risk of hospital-attended HZ and related complications was higher in immunocompromised populations compared with immunocompetent populations. Our findings underscore the high-risk nature of this population and the potential benefits that may be realized through HZ vaccination.

[Herpes zoster and subunit vaccine]

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

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.

Successful oral treatment of third cranial nerve palsy and optic neuritis from neglected herpes zoster in an immunocompetent patient

Purpose

Herpes zoster (HZ) is an acute viral eruption caused by the reactivation of varicella zoster virus (VZV), a herpes virus causing chicken pox in children. We aimed to report a 3-month neglected case of acute herpes zoster-induced third nerve palsy and optic neuritis, followed by a late-onset keratouveitis in an immunocompetent young adult.

Observations

A 36-year old immunocompetent Egyptian male patient presented with 3-month complaints of blurred vision and drooping of his left upper eyelid that appeared 4 days after a herpetic rash. He had been diagnosed with herpes zoster ophthalmicus (HZO) of the left eye. However, he had not received any systemic antiviral treatment. The patient had an abnormal head posture with post-eruptive scars on the left forehead and the nose tip. Examination revealed weakness of elevation and adduction, partial ptosis, and mid-dilated non-reactive pupil in the left eye. A relative afferent pupillary defect (RAPD) was present in the affected eye. His blood sugar and blood pressure were within normal limits. Contrast magnetic resonance imaging (MRI) showed no space-occupying lesion. However, there were enhancement and enlargement of the left optic nerve on T1-weighted images, denoting optic neuritis. A diagnosis of acute left third nerve palsy with pupil involvement and optic neuritis secondary to HZO was made. Despite late treatment with oral acyclovir and prednisolone, the patient recovered. One and a half months later, he developed a late-onset keratouveitis about 8 months after the rash onset. After the resolution of the episode, oral acyclovir was continued at a prophylactic dose (400 mg BID).

Conclusions and importance

HZ is a rare cause of third nerve palsy with pupil involvement and optic neuritis. Oral acyclovir and steroids were effective in the delayed treatment in this case. Abnormal optic nerve enhancement on MRI 3 months after the appearance of vesicular rash may suggest chronic HZ activity. Concurrent optic neuritis and third cranial nerve palsy in the absence of other signs of orbital apex syndrome can be seen in cases of HZO. Regular follow-up of patients with HZ is important for detecting recurrence and initiating prompt treatment.

Low complication rate in immunocompromised children with varicella-zoster virus infections in a single centre

AIM

Recent studies focusing on morbidity and mortality rates of immunocompromised children with varicella-zoster virus (VZV) infections are scarce. We aimed to summarise our experience.

METHODS

The study was a retrospective analysis of the medical records of children, who were admitted to Hadassah-Hebrew University Medical Centre, Jerusalem, Israel, during the period of 2008-2016. Data regarding baseline characteristics, treatment and outcome were extracted from patient's medical files.

RESULTS

We enrolled 74 patients (43% males) with a mean age of 8 (1-19) years. Most patients (72%) had no reported complications. Clinical outcome was favourable with 73 (99%) patients who had completely recovered and none died. Multivariable analysis identified the presence of fever (P = .005 and 0.02; hazard ratio (HR) 7.72 and 17.61, for total and herpes zoster groups, respectively) and prolonged interval period from clinical presentation to treatment onset (P = .021 and 0.025; HR 1.68 and 2.26, respectively), as associated with higher rates of complications.

CONCLUSION

Our results found low complication rate of VZV-associated infections in immunocompromised children admitted to a single centre. This should encourage conducting further large multicentre studies evaluating management of low-risk patients with oral acyclovir treatment.

Risk of herpes zoster in the Japanese population with immunocompromising and chronic disease conditions: Results from a claims database cohort study, from 2005 to 2014

Older adults, women and patients with immunocompromised (IC) or chronic medical conditions have a higher incidence of herpes zoster (HZ) and are at higher risk of developing HZ-associated complications such as postherpetic neuralgia. The incidence rates of HZ in various IC and chronic conditions have been previously reported in a retrospective cohort study using claims data from Japanese adults. Here, we report further analyses from this cohort using univariate and multivariable Cox regression to estimate crude and adjusted hazard ratios (HRs) associated with different IC and chronic conditions. After adjusting for multiple covariates (age, sex and other coexisting medical conditions), the risk of HZ was higher in women (HR, 1.14 [95% CI, 1.11-1.17]), irrespective of age and increased with increasing age, being substantially higher in patients aged 65 years or older (HR, 3.28 [95% CI, 3.07-3.49]) when compared with those aged 18-29 years. The highest HRs were observed for the following specific IC conditions; hematopoietic stem cell transplant recipients (HR, 9.85 [95% CI, 6.80-14.28]), hematological malignancy (HR, 3.22 [95% CI, 2.54-4.09]), systemic lupus erythematosus (HR, 2.46 [95% CI, 1.45-4.15]) and inflammatory bowel disease (HR, 1.59 [95% CI, 1.14-2.21]). For most other IC and chronic medical conditions, a higher risk was also apparent though of a smaller magnitude (HRs ranging from 1.2 to <1.5). These results corroborate our previous findings and demonstrate an increased risk of HZ associated with different IC and chronic conditions.