Diabetes as a risk factor for herpes zoster infection: results of a population-based study in Israel

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.

Hospitalisation for herpes zoster in people with and without diabetes: A 10-year-observational study

AIMS

This study explores the association between Herpes Zoster (HZ) hospitalizations and diabetes in Piedmont, Italy from 2010 to 2019. Focusing on the burden of HZ hospitalizations in diabetic and non-diabetic groups, it aims to identify risk factors in diabetics to enhance prevention strategies.

METHODS

In a two-phase study, we first compared age-standardized HZ hospitalization rates between diabetic and non-diabetic individuals from 2010 to 2019. We then examined hospitalization risk factors for HZ within a diabetic patient cohort managed by regional diabetes clinics.

RESULTS

Of 3,423 HZ hospitalizations in 2010-2019, 17.9 % (613 cases) were diabetic patients, who exhibited higher hospitalization rates (15.9 to 6.0 per 100,000) compared to non-diabetese individuals. Among diabetics subjects risk factors for HZ hospitalization included age over 65, obesity (BMI > 30), and poor glycemic control (HbA1c > 8.0 %). These patients had a 40 % increased rehospitalization risk and a 25 % higher risk of severe complications, such as stroke and myocardial infarction, post-HZ.

CONCLUSIONS

Diabetes markedly increases HZ hospitalization rates, rehospitalization, and complication risks. These findings underscore the need for preventive strategies, especially improved glycemic control among high-risk diabetic patients, to inform public health policies and clinical practices aimed at mitigating HZ's impact on this population.

Prevalence of intestinal parasitic infections in patients with diabetes: a systematic review and meta-analysis

Patients with diabetes are at an increased risk of intestinal parasitic infections (IPIs). We evaluated the pooled prevalence and OR of IPIs in patients with diabetes through a systematic review and meta-analysis. A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol for studies reporting IPIs in patients with diabetes through 1 August 2022. The collected data were analyzed using comprehensive meta-analysis software version 2. Thirteen case-control studies and nine cross-sectional studies were included in this study. The overall prevalence of IPIs in patients with diabetes was calculated to be 24.4% (95% CI 18.8 to 31%). Considering the case-control design, the prevalence of IPIs in case (25.7%; 95% CI 18.4 to 34.5%) was higher than controls (15.5%; 95% CI 8.4 to 26.9%) and a significant correlation was observed (OR, 1.80; 95% CI 1.08 to 2.97%). Moreover, a significant correlation was seen in the prevalence of Cryptosporidium spp. (OR, 3.30%; 95% CI 1.86 to 5.86%), Blastocystis sp. (OR, 1.57%; 95% CI 1.11 to 2.22%) and hookworm (OR, 6.09%; 95% CI 1.11 to 33.41%) in the cases group. The present results revealed a higher prevalence of IPIs in patients with diabetes than in controls. Therefore, the results of this study suggest a proper health education program to preventing measures for the acquisition of IPIs in patients with diabetes.

Vaccines for preventing herpes zoster in older adults

BACKGROUND

Herpes zoster, commonly known as shingles, is a neurocutaneous disease caused by the reactivation of the virus that causes varicella (chickenpox). After resolution of the varicella episode, the virus can remain latent in the sensitive dorsal ganglia of the spine. Years later, with declining immunity, the varicella zoster virus (VZV) can reactivate and cause herpes zoster, an extremely painful condition that can last many weeks or months and significantly compromise the quality of life of the affected person. The natural process of ageing is associated with a reduction in cellular immunity, and this predisposes older adults to herpes zoster. Vaccination with an attenuated form of the VZV activates specific T-cell production avoiding viral reactivation. Two types of herpes zoster vaccines are currently available. One of them is the single-dose live attenuated zoster vaccine (LZV), which contains the same live attenuated virus used in the chickenpox vaccine, but it has over 14-fold more plaque-forming units of the attenuated virus per dose. The other is the recombinant zoster vaccine (RZV) which does not contain the live attenuated virus, but rather a small fraction of the virus that cannot replicate but can boost immunogenicity. The recommended schedule for the RZV is two doses two months apart. This is an update of a Cochrane Review first published in 2010, and updated in 2012, 2016, and 2019.

OBJECTIVES

To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.

SEARCH METHODS

For this 2022 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2022, Issue 10), MEDLINE (1948 to October 2022), Embase (2010 to October 2022), CINAHL (1981 to October 2022), LILACS (1982 to October 2022), and three trial registries.

SELECTION CRITERIA

We included studies involving healthy older adults (mean age 60 years or older). We included randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine (any dose and potency) versus any other type of intervention (e.g. varicella vaccine, antiviral medication), placebo, or no intervention (no vaccine). Outcomes were cumulative incidence of herpes zoster, adverse events (death, serious adverse events, systemic reactions, or local reaction occurring at any time after vaccination), and dropouts.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included two new studies involving 1736 participants in this update. The review now includes a total of 26 studies involving 90,259 healthy older adults with a mean age of 63.7 years. Only three studies assessed the cumulative incidence of herpes zoster in groups that received vaccines versus placebo. Most studies were conducted in high-income countries in Europe and North America and included healthy Caucasians (understood to be white participants) aged 60 years or over with no immunosuppressive comorbidities. Two studies were conducted in Japan and one study was conducted in the Republic of Korea. Sixteen studies used LZV. Ten studies tested an RZV. The overall certainty of the evidence was moderate, which indicates that the intervention probably works. Most data for the primary outcome (cumulative incidence of herpes zoster) and secondary outcomes (adverse events and dropouts) came from studies that had a low risk of bias and included a large number of participants. The cumulative incidence of herpes zoster at up to three years of follow-up was lower in participants who received the LZV (one dose subcutaneously) than in those who received placebo (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.43 to 0.56; risk difference (RD) 2%; number needed to treat for an additional beneficial outcome (NNTB) 50; moderate-certainty evidence) in the largest study, which included 38,546 participants. There were no differences between the vaccinated and placebo groups for serious adverse events (RR 1.08, 95% CI 0.95 to 1.21) or deaths (RR 1.01, 95% CI 0.92 to 1.11; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of one or more adverse events (RR 1.71, 95% CI 1.38 to 2.11; RD 23%; number needed to treat for an additional harmful outcome (NNTH) 4.3) and injection site adverse events (RR 3.73, 95% CI 1.93 to 7.21; RD 28%; NNTH 3.6; moderate-certainty evidence) of mild to moderate intensity. These data came from four studies with 6980 participants aged 60 years or older. Two studies (29,311 participants for safety evaluation and 22,022 participants for efficacy evaluation) compared RZV (two doses intramuscularly, two months apart) versus placebo. Participants who received the new vaccine had a lower cumulative incidence of herpes zoster at 3.2 years follow-up (RR 0.08, 95% CI 0.03 to 0.23; RD 3%; NNTB 33; moderate-certainty evidence), probably indicating a favourable profile of the intervention. There were no differences between the vaccinated and placebo groups in cumulative incidence of serious adverse events (RR 0.97, 95% CI 0.91 to 1.03) or deaths (RR 0.94, 95% CI 0.84 to 1.04; moderate-certainty evidence). The vaccinated group had a higher cumulative incidence of adverse events, any systemic symptom (RR 2.23, 95% CI 2.12 to 2.34; RD 33%; NNTH 3.0), and any local symptom (RR 6.89, 95% CI 6.37 to 7.45; RD 67%; NNTH 1.5). Although most participants reported that their symptoms were of mild to moderate intensity, the risk of dropouts (participants not returning for the second dose, two months after the first dose) was higher in the vaccine group than in the placebo group (RR 1.25, 95% CI 1.13 to 1.39; RD 1%; NNTH 100, moderate-certainty evidence). Only one study reported funding from a non-commercial source (a university research foundation). All other included studies received funding from pharmaceutical companies. We did not conduct subgroup and sensitivity analyses AUTHORS' CONCLUSIONS: LZV (single dose) and RZV (two doses) are probably effective in preventing shingles disease for at least three years. To date, there are no data to recommend revaccination after receiving the basic schedule for each type of vaccine. Both vaccines produce systemic and injection site adverse events of mild to moderate intensity. The conclusions did not change in relation to the previous version of the systematic review.

Management of Invasive Infections in Diabetes Mellitus: A Comprehensive Review

Patients with diabetes often have more invasive infections, which may lead to an increase in morbidity. The hyperglycaemic environment promotes immune dysfunction (such as the deterioration of neutrophil activity, antioxidant system suppression, and compromised innate immunity), micro- and microangiopathies, and neuropathy. A greater number of medical interventions leads to a higher frequency of infections in diabetic patients. Diabetic individuals are susceptible to certain conditions, such as rhino-cerebral mucormycosis or aspergillosis infection. Infections may either be the primary symptom of diabetes mellitus or act as triggers in the intrinsic effects of the disease, such as diabetic ketoacidosis and hypoglycaemia, in addition to increasing morbidity. A thorough diagnosis of the severity and origin of the infection is necessary for effective treatment, which often entails surgery and extensive antibiotic use. Examining the significant issue of infection in individuals with diabetes is crucial. Comprehensive research should examine why infections are more common amongst diabetics and what the preventive treatment strategies could be.

Prior antibiotics and risk of subsequent Herpes zoster: A population-based case control study

Background

The effect of antibiotics on the human microbiome is now well established, but their indirect effect on the related immune response is less clear. The possible association of Herpes zoster, which involves a reactivation of a previous varicella zoster virus infection, with prior antibiotic exposure might indicate a potential link with the immune response.

Methods

A case-control study was carried out using a clinical database, the UK’s Clinical Practice Research Datalink. A total of 163,754 patients with varicella zoster virus infection and 331,559 age/sex matched controls were identified and their antibiotic exposure over the previous 10 years, and longer when data permitted, was identified. Conditional logistic regression was used to identify the association between antibiotic exposure and subsequent infection in terms of volume and timing.

Results

The study found an association of antibiotic prescription and subsequent risk of varicella zoster virus infection (adjusted odds ratio of 1.50; 95%CIs: 1.42–1.58). The strongest association was with a first antibiotic over 10 years ago (aOR: 1.92; 95%CIs: 1.88–1.96) which was particularly pronounced in the younger age group of 18 to 50 (aOR 2.77; 95%CIs: 1.95–3.92).

Conclusions

By finding an association between prior antibiotics and Herpes zoster this study has shown that antibiotics may be involved in the reactivation of the varicella zoster virus. That effect, moreover, may be relatively long term. This indirect effect of antibiotics on viruses, possibly mediated through their effect on the microbiome and immune system, merits further study.

Varicella zoster virus and cardiovascular diseases

Varicella zoster virus (VZV) is a Herpesviridae family double-stranded DNA virus that only affects humans. The first clinical manifestation appears to be varicella, typical of childhood. VZV, on the other hand, becomes latent in ganglion neurons throughout the neuroaxis after primary infection. The VZV reactivates and travels along peripheral nerve fibers in the elderly and immunocompromised individuals, resulting in Zoster. It can, however, spread centrally and infect cerebral and extracranial arteries, resulting in vasculopathy, which can lead to transient ischemic attacks, strokes, aneurysms, cavernous sinus thrombosis, giant cell arteritis, and granulomatous aortitis. Although the mechanisms of virus-induced pathological vascular remodeling are not fully understood, recent research indicates that inflammation and dysregulation of ligand-1 programmed death play a significant role. Few studies, on the other hand, have looked into the role of VZV in cardiovascular disease. As a result, the purpose of this review is to examine the relationship between VZV and cardiovascular disease, the efficacy of the vaccine as a protective mechanism, and the target population of heart disease patients who could benefit from vaccination.

Prevalence of and factors associated with herpes zoster in England: a cross-sectional analysis of the Health Survey for England

BACKGROUND

Herpes zoster (commonly called shingles) is caused by the reactivation of varicella zoster virus, and results in substantial morbidity. While the risk of zoster increases significantly with age and immunosuppression, relatively little is known about other risk factors for zoster. Moreover, much evidence to date stems from electronic healthcare or administrative data. Hence, the aim of this study was to explore potential risk factors for herpes zoster using survey data from a nationally-representative sample of the general community-dwelling population in England.

METHODS

Data were extracted from the 2015 Health Survey for England, an annual cross-sectional representative survey of households in England. The lifetime prevalence of self-reported herpes zoster was described by age, gender and other socio-demographic factors, health behaviours (physical activity levels, body mass index, smoking status and alcohol consumption) and clinical conditions, including; diabetes, respiratory, digestive and genito-urinary system and mental health disorders. Logistic regression models were then used to identify possible factors associated with shingles, and results were presented as odds ratios with 95% confidence intervals.

RESULTS

The lifetime prevalence of shingles among the sample was 11.5% (12.6% among women, 10.3% among men), which increased with age. After adjusting for a range of covariates, increased age, female gender (odds ratio: 1.21; 95%CI: 1.03, 1.43), White ethnic backgrounds (odds ratio: 2.00; 95%CI: 1.40, 2.88), moderate physical activity 7 days per week (odds ratio: 1.29; 95%CI: 1.01, 1.66) and digestive disorders (odds ratio: 1.51; 95%CI: 1.13, 1.51) were each associated with increased odds of having had herpes zoster.

CONCLUSIONS

Age, gender, ethnicity and digestive disorders may be risk factors for herpes zoster among a nationally representative sample of adults in England. These potential risk factors and possible mechanisms should be further explored using longitudinal studies.

Visceral disseminated varicella zoster infection: a rare cause of acute abdomen in a patient with well-controlled diabetes mellitus-a case report

BACKGROUND

Visceral disseminated varicella zoster virus (VZV) infections frequently affect immunocompromised patients. Diabetes mellitus has been associated with VZV infection, and most cases of disseminated infection involve patients with poorly controlled blood glucose levels. It initially presents as severe abdominal pain, which is evaluated as an acute abdomen, however, the cause is typically unidentified due to unremarkable computed tomography (CT) findings. We report a case of visceral disseminated VZV infection in a patient with well-controlled diabetes mellitus with fat stranding around the celiac and superior mesenteric artery on CT.

CASE PRESENTATION

A 61-year-old Japanese woman with well-controlled diabetes mellitus presented to the emergency department with severe abdominal pain that gradually worsened. She had stable vital signs and skin rashes, suggestive of varicella. Abdominal CT showed fat stranding around the celiac and superior mesenteric arteries. The patient tested positive for the VZV antigen and was diagnosed with a visceral disseminated VZV infection. Acyclovir was administered, and the patient was discharged on the 14th day.

CONCLUSIONS

Visceral disseminated VZV infection may affect patients with well-controlled diabetes mellitus and causes acute abdomen. Periarterial fat stranding on CT is associated with abdominal pain due to visceral disseminated VZV infection.

The Pattern of Hemoglobin A1C Trajectories and Risk of Herpes Zoster Infection: A Follow-Up Study

To investigate the risks of herpes zoster (HZ) infection among heterogeneous HbA1C trajectories of patients with newly diagnosed type 2 diabetes, this cohort study used data from the Chang Gung Research Database (CGRD), from the 10-year period of 1 January 2007 to 31 December 2017. We applied group-based trajectory modeling (GBTM) to identify the patterns of HbA1C trajectories, and multiple Cox proportional hazards regressions were used to estimate the hazard ratio (HR) for the risk of HZ infection with adjustment of age, sex, and comorbidities. This study enrolled 121,999 subjects to perform the analysis. The GBTM identified four HbA1C trajectories: 'good control' (58.4%), 'high decreasing' (8.9%), 'moderate control' (25.1%), and 'poor control' (7.6%) with the mean HbA1C of 6.7% (50 mmol/mol), 7.9% (63 mmol/mol), 8.4% (68 mmol/mol), and 10.7% (93 mmol/mol) respectively. The risk of HZ was significantly higher in the poor control with an HR = 1.44 (95% CI 1.26-1.64) after adjustment for confounders and comorbidities. The risk of HZ infection for the high decreasing group (initially poor then rapidly reaching optimal control) was nonsignificant compared to the good control group. In conclusion, the patients with poor glycemic control (mean HbA1C = 10.7%) had the highest risk of HZ infection. The patients with initial hyperglycemia then reaching optimal control could have a lower risk of HZ infection.

Association Between Diabetes Mellitus and the Risk of Herpes Zoster: A Systematic Review and Meta-analysis

CONTEXT

Individuals with diabetes mellitus (DM) are susceptible to various infections.

OBJECTIVE

We estimated the risk of herpes zoster (HZ) among individuals with DM compared with individuals in the general population.

METHODS

We searched the PubMed, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, and PerioPath databases from their inception to January 30, 2021, for studies on the risk of HZ in individuals with DM. Two authors independently screened all articles identified. The same 2 authors independently extracted the data. Four case-control studies and 12 cohort studies were included.

RESULTS

Meta-analyses were performed using fixed and mixed-effects models. In the pooled analysis, individuals with DM had a higher risk of developing HZ (pooled relative risk [RR]: 1.38; 95% CI, 1.21-1.57) than individuals in the general population. The results were consistent in subgroup analyses stratified by type of diabetes, age, and study design. In individuals with DM, cardiovascular disease had an additive effect on increasing the risk of HZ (pooled RR: 1.19; 95% CI, 1.11-1.28). There was a linear dose-response association between age and the risk of HZ in individuals with DM.

CONCLUSION

Individuals with DM have an increased risk of HZ compared with the general population. Varicella vaccination should be provided to individuals with DM regardless of their age, prioritizing older adults and those with cardiovascular disease. Varicella vaccination policies for individuals with DM should be updated based on the evidence.

The association of family history of herpes zoster and the risk of incident herpes zoster: the SHEZ Study

Background

We investigated whether family histories of herpes zoster (HZ) are associated with the risk of incident HZ in a Japanese population.

Methods

A total of 12,522 Japanese residents aged ≥50 years in Shozu County participated in the baseline survey between December 2008 and November 2009 (the participation rate = 72.3%). They were interviewed at baseline by research physicians regarding the registrants’ history of HZ. A self-administered questionnaire survey was conducted to evaluate the potential confounding factors. 10,530 participants without a history of HZ were followed up to ascertain the incidence of HZ during 3-years follow-up until the end of November 2012 with Japanese nationals. We estimated hazard ratios (HRs) of incident HZ according to first-degree family histories using the Cox proportional hazard regression after adjusting for age, sex, and other potential confounding factors.

Results

Compared to no HZ history of each family member, a history of brother or sister was associated with a higher risk of incident HZ while histories of father and mother were not. The multivariable HR (95%CI) of incident HZ for a history of brother or sister was 1.67 (1.04–2.69). When comparing to no family histories of all first-degree relatives, the multivariable HRs (95%CIs) were 1.34 (0.77–2.34) for a history of brother or sister alone, but 4.81 (1.78–13.00) for a history of mother plus brother or sister. As for the number of family histories, the multivariable HRs (95%CIs) were 1.08 (0.76–1.54) for one relative (father, mother, or brother or sister) and 2.75 (1.13–6.70) for two or more relatives.

Conclusion

Family histories of mother plus brother or sister and two or more first-degree relatives were associated with a higher risk of incident HZ.

Re-evaluating Perinatal Group B Streptococcal screening in Israel - Is it time for a change in policy?

Group B streptococcal early-onset disease (EOGBSD) is a significant cause of morbidity and fatality in newborns. Current policy in Israel is risk-based management. Our aim was to re-evaluate the current screening policy for Group B Streptococcus (GBS), considering colonization and prevalence rates and costs estimates. This was a retrospective cohort study including term pregnancies between 2015 and 2016 insured by Maccabi Healthcare Services (MHS). A costs estimation model was performed comparing three approaches: universal culture-based screening, current policy in Israel and the current clinical scenario. Out of 54,759 pregnancies, 46.3% women undergo GBS culture-based screening. Overall GBS colonization rates in screened women were 21%. Six EOGBSD cases were identified, all offspring of mothers who were not screened. EOGBSD prevalence rate was 11 per 100,000. Universal culture-based screening was found to be 50% less costly than the current risk-based policy, and would have prevented 20.29 per 100,000 cases. Universal GBS culture-based screening was found to be more cost-effective, compared to the current policy and screening behaviors. Due to the clinical and economic benefits, we recommend that a change in policy should be considered.

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.

Burden of Herpes Zoster in Adult Patients with Underlying Conditions: Analysis of German Claims Data, 2007-2018

INTRODUCTION

Several chronic underlying conditions (UCs) are known to be risk factors for developing herpes zoster (HZ) and to increase the severity of HZ and its risk of recurrence. The aim of this study was to investigate the incidence and recurrence of HZ in adult patients with one or multiple UCs.

METHODS

A retrospective cohort study based on claims data representing 13% of the statutory health insurance population from 2007 to 2018 in Germany was performed. Patients aged ≥ 18 years were included when at least one of the following UCs was diagnosed: asthma, chronic heart failure, chronic obstructive pulmonary disease (COPD), coronary heart disease (CHD), depression, diabetes mellitus type 1 or 2, and rheumatoid arthritis (RA). Exact matching was used to account for differences in the distribution of age and sex between the case and matched control cohorts. Multi-morbidity was considered in sensitivity analyses by analyzing patients with only one UC.

RESULTS

Patients with asthma, CHD, COPD, depression, and RA had, on average, a 30% increased risk of developing acute HZ compared to patients without any UC. RA was found to have the highest odds ratio among these conditions, varying from 1.37 to 1.57 for all age groups. Patients with depression also showed a high risk of developing HZ. Analysis of recurrence indicated that patients with at least one UC in the age groups 18-49 years and 50-59 years had the highest risk for a recurrent HZ. After experiencing a first recurrence, patients, regardless of age group, had a two- to threefold higher risk for a second recurrence.

CONCLUSION

This study of representative claims data shows a higher HZ incidence and recurrence frequency in patients with UCs. These results provide relevant information for national health care guidelines and disease management programs.

The incidence of herpes zoster in patients with diabetes mellitus: A meta-analysis of cohort studies

The research has correlated the risk factors of herpes zoster with some chronic diseases. This meta-analysis aimed to assess the incidence of herpes zoster in patients with diabetes mellitus.We conducted a literature search using Web of Science and PubMed for articles published from January 1, 2000 to December 31, 2019. The incidence rate ratio and 95% confidence interval for herpes zoster associated with diabetes mellitus was calculated.We included 5 cohort studies for a meta-analysis. The pooled incidences of herpes zoster in patients with diabetes mellitus and in patients without diabetes mellitus were 7.22 and 4.12 per 1000 person-years. The overall risk of developing herpes zoster was significantly higher in patients with diabetes mellitus when compared to those with no diabetes mellitus (incidence rate ratio = 1.60, 95% confidence interval = 1.33-1.93).Patients with diabetes mellitus are substantially at increased risk for the development of herpes zoster. Patients with diabetes mellitus should take into consideration the vaccination to prevent herpes zoster.

Causal inference concepts applied to three observational studies in the context of vaccine development: from theory to practice

Background

Randomized controlled trials are considered the gold standard to evaluate causal associations, whereas assessing causality in observational studies is challenging.

Methods

We applied Hill’s Criteria, counterfactual reasoning, and causal diagrams to evaluate a potentially causal relationship between an exposure and outcome in three published observational studies: a) one burden of disease cohort study to determine the association between type 2 diabetes and herpes zoster, b) one post-authorization safety cohort study to assess the effect of AS04-HPV-16/18 vaccine on the risk of autoimmune diseases, and c) one matched case-control study to evaluate the effectiveness of a rotavirus vaccine in preventing hospitalization for rotavirus gastroenteritis.

Results

Among the 9 Hill’s criteria, 8 (Strength, Consistency, Specificity, Temporality, Plausibility, Coherence, Analogy, Experiment) were considered as met for study c, 3 (Temporality, Plausibility, Coherence) for study a, and 2 (Temporary, Plausibility) for study b. For counterfactual reasoning criteria, exchangeability, the most critical assumption, could not be tested. Using these tools, we concluded that causality was very unlikely in study b, unlikely in study a, and very likely in study c. Directed acyclic graphs provided complementary visual structures that identified confounding bias and helped determine the most accurate design and analysis to assess causality.

Conclusions

Based on our assessment we found causal Hill’s criteria and counterfactual thinking valuable in determining some level of certainty about causality in observational studies. Application of causal inference frameworks should be considered in designing and interpreting observational studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01220-1.

Study on the related factors of post-herpetic neuralgia in hospitalized patients with herpes zoster in Sichuan Hospital of Traditional Chinese Medicine based on big data analysis

Although various factors were reported to be related to post-herpetic neuralgia (PHN), studies based on adequate and comprehensive data were absent. Data was extracted from cases of hospitalized patients with herpes zoster in dermatology department, Sichuan hospital of traditional Chinese medicine range from December, 2011 to February, 2018, and then cleaned to build prediction model with TREENET algorithms. Following evaluated the prediction model by ROC and confusion matrix, variables importance ranking and variables dependency analysis were performed, resulting in the importance ranking of factors for PHN and the dependency between factors and PHN. Based on strict inclusion and exclusion criteria, 1303 (571 PHN and 732 normal controls) cases and 2958 indicators were selected. Model evaluation showed high ROC value (training sample = 0.985, test samples = 0.752) and high accuracy value (70.27%), which indicated that the model was predictive. After variables importance ranking and variables dependency analysis, 62 variables in the model were associated with the occurrence of PHN. Our study identified 62 variables related to PHN and revealed that various variables were the important risk factors for PHN, including age, MCHC, sodium and UA.

The double burden of diabetes and global infection in low and middle-income countries

Four out of five people in the world with diabetes now live in low- and middle-income countries (LMIC), and the incidence of diabetes is accelerating in poorer communities. Diabetes increases susceptibility to infection and worsens outcomes for some of the world’s major infectious diseases such as tuberculosis, melioidosis and dengue, but the relationship between diabetes and many neglected tropical diseases is yet to be accurately characterised. There is some evidence that chronic viral infections such as hepatitis B and HIV may predispose to the development of type 2 diabetes by chronic inflammatory and immunometabolic mechanisms. Helminth infections such as schistosomiasis may be protective against the development of diabetes, and this finding opens up new territory for discovery of novel therapeutics for the prevention and treatment of diabetes. A greater understanding of the impact of diabetes on risks and outcomes for infections causing significant diseases in LMIC is essential in order to develop vaccines and therapies for the growing number of people with diabetes at risk of infection, and to prioritise research agendas, public health interventions and policy. This review seeks to give an overview of the current international diabetes burden, the evidence for interactions between diabetes and infection, immune mechanisms for the interaction, and potential interventions to tackle the dual burden of diabetes and infection.

Risk Factors for Herpes Zoster Infection: A Meta-Analysis

Background

The burden of herpes zoster (HZ) is significant worldwide, with millions affected and the incidence rising. Current literature has identified some risk factors for this disease; however, there is yet to be a comprehensive study that pools all evidence to provide estimates of risk. Therefore, the purpose of this study is to identify various risk factors, excluding immunosuppressive medication, that may predispose an individual to developing HZ.

Methods

The literature search was conducted in MEDLINE, EMBASE, and Cochrane Central, yielding case control, cohort, and cross-sectional studies that were pooled from January 1966 to September 2017. Search terms included the following: zoster OR herpe* OR postherpe* OR shingle* AND risk OR immunosupp* OR stress OR trauma OR gender OR ethnicity OR race OR age OR diabetes OR asthma OR chronic obstructive pulmonary disease OR diabetes. Risk ratios (RRs) for key risk factors were calculated via natural logarithms and pooled using random-effects modeling.

Results

From a total of 4417 identified studies, 88 were included in analysis (N = 3, 768 691 HZ cases). Immunosuppression through human immunodeficiency virus/acquired immune deficiency syndrome (RR = 3.22; 95% confidence interval [CI], 2.40–4.33) or malignancy (RR = 2.17; 95% CI, 1.86–2.53) significantly increased the risk of HZ compared with controls. Family history was also associated with a greater risk (RR = 2.48; 95% CI, 1.70–3.60), followed by physical trauma (RR = 2.01; 95% CI, 1.39–2.91) and older age (RR = 1.65; 95% CI, 1.37–1.97). A slightly smaller risk was seen those with psychological stress, females, and comorbidities such as diabetes, rheumatoid arthritis, cardiovascular diseases, renal disease, systemic lupus erythematosus, and inflammatory bowel disease compared with controls (RR range, 2.08–1.23). We found that black race had lower rates of HZ development (RR = 0.69; 95% CI, 0.56–0.85).

Conclusions

This study demonstrated a number of risk factors for development of HZ infection. However, many of these characteristics are known well in advance by the patient and clinician and may be used to guide discussions with patients for prevention by vaccination.

Diabetes as a risk factor for herpes zoster in adults: A synthetic literature review

AIM

The objective of this review was to evaluate the role of diabetes as a risk factor for herpes zoster (HZ) and to discuss implications of prevention by vaccination with available HZ vaccines.

METHODS

We reviewed studies that investigated the incidence rates of HZ in patients with diabetes. Papers in English or French published between January 2000 and December 2018 have been selected from PubMed and Google Scholarship by using appropriate key words.

RESULTS

The risk of HZ was significantly higher in patients with diabetes as compared to controls in 11 studies out of 16, although the magnitude of risk associated to diabetes varied across studies from 1.06 to 2.38 (p < 0.05). The incidence of HZ in patients with diabetes increased with age and was higher in women than in men. The incidence of the most common complication of HZ, i.e. post-herpetic neuralgia was also higher in patients with diabetes.

CONCLUSIONS

The presence of HZ adds supplementary complications to the pre-existing comorbidity in patients with diabetes. Investigating the impact of preventive measure by HZ vaccination is therefore of paramount importance in patients with diabetes.

Vaccines for preventing herpes zoster in older adults

BACKGROUND

Herpes zoster, commonly known as shingles, is a neurocutaneous disease caused by the reactivation of the virus that causes varicella (chickenpox). After resolution of the varicella episode, the virus can remain latent in the sensitive dorsal ganglia of the spine. Years later, with declining immunity, the varicella zoster virus (VZV) can reactivate and cause herpes zoster, an extremely painful condition that can last many weeks or months and significantly compromise the quality of life of the affected person. The natural process of aging is associated with a reduction in cellular immunity, and this predisposes older people to herpes zoster. Vaccination with an attenuated form of the VZV activates specific T-cell production avoiding viral reactivation. The USA Food and Drug Administration has approved a herpes zoster vaccine with an attenuated active virus, live zoster vaccine (LZV), for clinical use amongst older adults, which has been tested in large populations. A new adjuvanted recombinant VZV subunit zoster vaccine, recombinant zoster vaccine (RZV), has also been approved. It consists of recombinant VZV glycoprotein E and a liposome-based AS01B adjuvant system. This is an update of a Cochrane Review last updated in 2016.

OBJECTIVES

To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.

SEARCH METHODS

For this 2019 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, January 2019), MEDLINE (1948 to January 2019), Embase (2010 to January 2019), CINAHL (1981 to January 2019), LILACS (1982 to January 2019), WHO ICTRP (on 31 January 2019) and ClinicalTrials.gov (on 31 January 2019).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine (any dose and potency) versus any other type of intervention (e.g. varicella vaccine, antiviral medication), placebo, or no intervention (no vaccine). Outcomes were incidence of herpes zoster, adverse events (death, serious adverse events, systemic reactions, or local reaction occurring at any time after vaccination), and dropouts.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 11 new studies involving 18,615 participants in this update. The review now includes a total of 24 studies involving 88,531 participants. Only three studies assessed the incidence of herpes zoster in groups that received vaccines versus placebo. Most studies were conducted in high-income countries in Europe and North America and included healthy Caucasians (understood to be white participants) aged 60 years or over with no immunosuppressive comorbidities. Two studies were conducted in Japan. Fifteen studies used LZV. Nine studies tested an RZV. The overall quality of the evidence was moderate. Most data for the primary outcome (incidence of herpes zoster) and secondary outcomes (adverse events and dropouts) came from studies that had a low risk of bias and included a large number of participants. The incidence of herpes zoster at up to three years follow-up was lower in participants who received the LZV (one dose subcutaneously) than in those who received placebo (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.43 to 0.56; risk difference (RD) 2%; number needed to treat for an additional beneficial outcome (NNTB) 50; moderate-quality evidence) in the largest study, which included 38,546 participants. There were no differences between the vaccinated and placebo groups for serious adverse events (RR 1.08, 95% CI 0.95 to 1.21) or deaths (RR 1.01, 95% CI 0.92 to 1.11; moderate-quality evidence). The vaccinated group had a higher incidence of one or more adverse events (RR 1.71, 95% CI 1.38 to 2.11; RD 23%; number needed to treat for an additional harmful outcome (NNTH) 4.3) and injection site adverse events (RR 3.73, 95% CI 1.93 to 7.21; RD 28%; NNTH 3.6) of mild to moderate intensity (moderate-quality evidence). These data came from four studies with 6980 participants aged 60 years or over. Two studies (29,311 participants for safety evaluation and 22,022 participants for efficacy evaluation) compared RZV (two doses intramuscularly, two months apart) versus placebo. Participants who received the new vaccine had a lower incidence of herpes zoster at 3.2 years follow-up (RR 0.08, 95% CI 0.03 to 0.23; RD 3%; NNTB 33; moderate-quality evidence). There were no differences between the vaccinated and placebo groups in incidence of serious adverse events (RR 0.97, 95% CI 0.91 to 1.03) or deaths (RR 0.94, 95% CI 0.84 to 1.04; moderate-quality evidence). The vaccinated group had a higher incidence of adverse events, any systemic symptom (RR 2.23, 95% CI 2.12 to 2.34; RD 33%; NNTH 3.0), and any local symptom (RR 6.89, 95% CI 6.37 to 7.45; RD 67%; NNTH 1.5). Although most participants reported that there symptoms were of mild to moderate intensity, the risk of dropouts (participants not returning for the second dose, two months after the first dose) was higher in the vaccine group than in the placebo group (RR 1.25, 95% CI 1.13 to 1.39; RD 1%; NNTH 100, moderate-quality evidence). Only one study reported funding from a non-commercial source (a university research foundation). All of the other included studies received funding from pharmaceutical companies. We did not conduct subgroup and sensitivity analyses AUTHORS' CONCLUSIONS: LZV and RZV are effective in preventing herpes zoster disease for up to three years (the main studies did not follow participants for more than three years). To date, there are no data to recommend revaccination after receiving the basic schedule for each type of vaccine. Both vaccines produce systemic and injection site adverse events of mild to moderate intensity.

Real-world database investigating the association between diabetes mellitus and herpes zoster in Taiwan

Little evidence is available about the correlation between diabetes mellitus and herpes zoster in Taiwan. This study aimed to investigate the correlation between diabetes mellitus and herpes zoster in Taiwan.A population-based cohort study was conducted using the database of Taiwan National Health Insurance Program. There were 27,369 subjects aged 20 to 84 years with newly diagnosed diabetes mellitus from 2000 to 2012 as the diabetes mellitus group and 107,705 sex- and age-matched subjects without diabetes mellitus as the nondiabetes mellitus group. The incidence of herpes zoster at the end of 2013 was estimated. The multivariable Cox proportional hazards regression model was used to calculate the hazard ratio (HR) and 95% confidence interval (CI) of herpes zoster associated with diabetes mellitus.The overall incidence of herpes zoster was 1.16-fold higher in the diabetes mellitus group than the nondiabetes mellitus group (7.85 vs 6.75 per 1000 person-years, 95% CI 1.12-1.20). After adjustment for co-variables, the adjusted HR of herpes zoster was 1.17 for subjects with diabetes mellitus (95% CI 1.10-1.23), compared with subjects without diabetes mellitus.Patients with diabetes mellitus are associated with 1.17-fold increased risk for developing herpes zoster.

Adeno-associated virus neutralising antibodies in type 1 diabetes mellitus

Recombinant Adeno-associated viruses (AAVs) are an attractive vector for gene therapy delivery which may be blocked by AAV neutralising antibodies (NAbs). As Type 1 Diabetes (T1DM) is an endocrine disease of immunological origin, it is likely that NAb profiles are altered in the disease. In this study NAb to AAV2, AAV5, AAV6, and AAV8 in 72 subjects with T1DM and 45 non-diabetic patients were measured over a 4-year follow-up period. AAV2 NAb titres were significantly lower in non-diabetic subjects (P = 0.036). The T1DM group had more AAV8 NAb activity at baseline (P = 0.019), whilst after 4 years follow-up the T1DM group displayed developed increased AAV 5 (P = 0.03), 6 (P = 0.03) and 8 (P = 0.002) activity relative to the control group, however, overall AAV5 and 8 NAb levels were very low in patients <40. AAV NAb titre activity and prevalence generally appears higher in T1DM, however, low levels of AAV 5 and 8, particular in younger adult age groups at which T1DM can be targeted, could make these attractive vectors to target the disease.

Altered immunogenicity of 23-valent pneumococcal polysaccharide vaccine in elderly patients with diabetes who revealed lower responses to concomitant administration of BIKEN varicella zoster vaccine: Results of post hoc analysis of a randomized double-blind trial

AIMS

This double-blind randomized controlled study of 52 elderly patients with diabetes assessed cell-mediated immunity and safety of BIKEN varicella-zoster vaccine (BVZV). Cellular and humoral responses to VZV at 3 months after BVZV and 23-valent polysaccharide pneumococcal vaccine (PPSV23) vaccination elicited poor results. Post-hoc analyses assessed the effects of immunogenicity of PPSV23.

METHODS

Using standardized enzyme-linked immunosorbent assay, pneumococcal 6B and 23F serotype-specific immunoglobulin G (IgG)-binding antibody concentrations were measured in stored samples retrospectively before administration and 3 months after. Responders increased more than twofold in at least one serotype-specific IgG.

RESULTS

The geometric mean concentration ratio (GMCR) of serum anti-pneumococcal 6B IgG was 1.76 (95%C.I.: 0.58, 5.34) in patients receiving concurrent PPSV23 and BVZV, compared to 2.39 (95%C.I.: 0.53, 10.76) in patients receiving PPSV23 and placebo (P = .055). The GMCR of serum anti-pneumococcal 23F IgG was 2.54 (95%C.I.: 0.57, 11.43) in PPSV23/BVZV vaccinees compared to 3.34 (95%C.I.: 0.84, 12.92) in PPSV23/placebo vaccinees (P = .424). Responder rates, those who developed antibodies to either/both serotypes, were 68% in the BVZV group and 85% in the placebo group (P = .007).

CONCLUSIONS

Results suggest that concurrent administration of BVZV influenced humoral responses to PPSV23 in elderly subjects with diabetes.

Risk factors for modified vaccine effectiveness of the live attenuated zoster vaccine among the elderly in England

Background

The United Kingdom introduced routine vaccination with the live-attenuated zoster vaccine for 70 year-olds in 2013, with the vaccine also offered to 79 year-olds as part of a catch-up campaign. In the subsequent years, the catch-up campaign was extended to also include adults aged 78 years. We investigated 14 pre-identified potential risk factors for potential modified vaccine effectiveness.

Methods

This retrospective cohort study in England included subjects born in 1943-1946 (the routine cohort) and in 1934-1937 (the catch-up cohort). We used the Clinical Practice Research Datalink (CPRD) to identify herpes zoster (HZ) cases and the risk factors: age, gender, ethnicity, socio-economic status, asthma, type 2 diabetes, chronic obstructive pulmonary disease, smoking, body mass index, immunosuppression, history of HZ, co-administration with influenza or pneumococcal vaccine. We derived HZ incidence by risk groups, overall vaccine effectiveness (VE) and modified VE expressed as relative differences in VE from Poisson regression models.

Results

Overall VE was 66.8% [95% CI: 62.2; 71.0]. Two out of the 14 investigated risk factors modified the HZ VE. Notably, lower VE was observed in diabetics and in persons with a history of HZ with relative differences in VE of -22·2%, [95% CI: -39·6, -4·5] and -22·5%, [95% CI: -44·9, -0·1].

Conclusions

Live-attenuated zoster vaccine protection against HZ was lower in type 2 diabetics and in subjects with a history of HZ. Contrary to clinical trial results, age did not affect the observed VE. Further study is required to gain insights into why certain risk groups are less protected. Identifying and understanding the effect modifiers of VE is important for future vaccine development as well as vaccine recommendations.

Recurrence Rate of Herpes Zoster and Its Risk Factors: a Population-based Cohort Study

BACKGROUND

Herpes zoster (HZ) is generally thought to occur once in a lifetime and recurrence is considered to be limited to immunocompromised individuals. Although HZ recurrence rates seem to be increasing, there have been few studies exploring these rates in the general population. We investigated the recurrence rate and associated risk factors in the general population.

METHODS

We used the population-based samples of the National Health Insurance Service database to identify cases of initial HZ episodes from January 1, 2002 to December 31, 2013. We also followed up on these cases through December 31, 2013 to identify recurrence.

RESULTS

Overall, the incidence rate of HZ is 5.1 per 1,000 person years and the recurrence rate is 12.0 per 1,000 person years. There were 2,100 recurrent cases out of 39,441 initial episodes with 4.4 years of the mean follow-up period. We identified significant risk factors for recurrence such as old age (51-70 years) (hazard ratio [HR], 1.447; 95% confidence interval [CI], 1.311-1.598), women (1.476; 1.345-1.619), zoster-related pain (ZRP) longer than 30 days (cases of ZRP lasting 31-90 days [1.200; 1.042-1.383], and ZRP lasting longer than 90 days [2.293; 1.990-2.643]). Concurrent hematologic malignancies (2.864; 1.929-4.251), autoimmune diseases (1.466; 1.252-1.715), dyslipidemia (1.390; 1.263-1.530), and hypertension (1.222; 1.107-1.350) were also significant risk factors.

CONCLUSION

Our results suggest that the recurrence of HZ is much more common than generally expected, and that the associated risk factors can play an important role in predicting recurrence.

Epidemiology, treatment and prevention of herpes zoster: A comprehensive review

Herpes zoster is a major health burden that can affect individuals of any age. It is seen more commonly among individuals aged ≥50 years, those with immunocompromised status, and those on immunosuppressant drugs. It is caused by a reactivation of varicella zoster virus infection. Cell-mediated immunity plays a role in this reactivation. Fever, pain, and itch are common symptoms before the onset of rash. Post-herpetic neuralgia is the most common complication associated with herpes zoster. Risk factors and complications associated with herpes zoster depend on the age, immune status, and the time of initializing treatment. Routine vaccination for individuals over 60 years has shown considerable effect in terms of reducing the incidence of herpes zoster and post-herpetic neuralgia. Treatment with antiviral drugs and analgesics within 72 hours of rash onset has been shown to reduce severity and complications associated with herpes zoster and post-herpetic neuralgia. This study mainly focuses on herpes zoster using articles and reviews from PubMed, Embase, Cochrane library, and a manual search from Google Scholar. We cover the incidence of herpes zoster, gender distribution, seasonal and regional distribution of herpes zoster, incidence of herpes zoster among immunocompromised individuals, incidence of post-herpetic neuralgia following a zoster infection, complications, management, and prevention of herpes zoster and post-herpetic neuralgia.

No increased risk of herpes zoster in TNF inhibitor and non-TNF inhibitor users with rheumatoid arthritis: epidemiological study using the Japanese health insurance database

OBJECTIVE

It is controversial whether the use of biological disease-modifying antirheumatic drugs (DMARDs) increases the risk of herpes zoster (HZ). We aimed to evaluate the risks of HZ in tumor necrosis factor inhibitor (TNFI) and non-TNFI users with rheumatoid arthritis (RA) over 3 years in Japan.

METHOD

Using the Japanese health insurance database, we assigned patients with at least one RA diagnostic code and one prescription for any DMARDs (RA cases) recorded between January 2005 and December 2013 to the RA group. We randomly selected five age-, sex-, calendar year- and observation length-matched non-RA cases for each RA case (non-RA group), and assessed associations between RA and HZ. To evaluate the risks of HZ in TNFI and non-TNFI users, we conducted a nested case-control study (NCC) in the RA group.

RESULTS

The RA group (n = 6712) had a significantly higher crude incidence rate of HZ than the non-RA group (n = 33 560) (14.2 vs. 8.3/1000 patient-years), and the adjusted odds ratio (95% confidence interval) of the RA versus non-RA groups was 1.43 (1.17-1.75). The NCC demonstrated that use of TNFI, non-TNFI, methotrexate, or immunosuppressive DMARDs did not increase the risks of HZ. Use of corticosteroid ≥ 5 mg/day conveyed a significant risk of HZ in patients with RA.

CONCLUSIONS

Rheumatoid arthritis was significantly associated with the development of HZ, and use of corticosteroids ≥ 5 mg/day was identified as a significant risk factor, whereas either TNFI or non-TNFI use were not.

Herpes Zoster and Diabetes Mellitus: A Review

Accumulating evidence suggests that diabetes mellitus (DM) represents an important risk factor for both herpes zoster and post-herpetic neuralgia. Moreover, post-herpetic neuralgia appears to be more severe and persistent in diabetic patients. On the other hand, a novel vaccine against varicella-zoster virus (VZV) was recently introduced in clinical practice. Given the increased risk and severity of herpes zoster infection in patients with DM, this vaccine might be useful in this population. However, there are limited data regarding the efficacy and safety of vaccination against herpes zoster in the diabetic population. The aim of the present review is to discuss the incidence and consequences of herpes zoster infection in DM and to comment on the role of vaccination against VZV in these patients.

Associations of Perceived Mental Stress, Sense of Purpose in Life, and Negative Life Events With the Risk of Incident Herpes Zoster and Postherpetic Neuralgia: The SHEZ Study

In the present population-based prospective study, we examined the associations of psychosocial factors with the incidence of herpes zoster (HZ) and postherpetic neuralgia (PHN). Data were collected from 12,359 participants (≥50 years of age) who answered a self-completed health questionnaire in the Shozu County of Kagawa Prefecture in Japan. During a 3-year follow-up between December 2008 and November 2012, HZ and PHN were diagnosed in 400 and 79 subjects, respectively. We used Cox regression analysis to estimate hazard ratios of incident HZ and PHN according to psychosocial factors, adjusting for age, sex, histories of HZ, cancer, and diabetes, smoking and drinking habits, and time from disease onset to treatment. Men with high levels of mental stress were twice as likely to be at risk for incident HZ. The risk of incident HZ was approximately 60% lower among men and women who reported a high sense of purpose in life. Women who experienced negative life events-particularly changes in their work, living environment, and relationships-had a 2- to 3-fold higher risk of incident PHN. Psychosocial factors such as perceived mental stress, sense of purpose in life, and negative life events may contribute to the development of HZ and PHN in the general population.

Risk Factors for Herpes Zoster: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review studies examining risk factors for herpes zoster (HZ).

METHODS

We performed a literature search using PubMed, EMBASE, and Web of Science for articles published from January 1, 2003, to February 1, 2017. A random-effects model was used to summarize the risk ratio (RR) or odds ratio (OR) and 95% CI.

RESULTS

Of the 3450 studies screened, we included 84 studies in the systematic review and conducted meta-analysis in 62 studies. Women were at increased risk of HZ compared with men (pooled adjusted RR, 1.31; 95% CI, 1.27-1.34). Black individuals had almost half the risk of HZ as white individuals (pooled RR, 0.54; 95% CI, 0.47-0.63). Family history was found to be a risk factor for HZ (pooled OR, 3.59; 95% CI, 2.39-5.40). Autoimmune diseases, including rheumatoid arthritis (pooled RR, 1.67; 95% CI, 1.41-1.98) and systemic lupus erythematosus (pooled RR, 2.10; 95% CI, 1.40-3.15), were associated with an elevated risk of HZ. Other comorbidities were associated with an increased risk of HZ, with the pooled RRs ranging from 1.25 (95% CI, 1.13-1.39) for asthma to 1.30 (95% CI, 1.17-1.45) for diabetes mellitus and 1.31 (95% CI, 1.22-1.41) for chronic obstructive pulmonary disease.

CONCLUSION

Our review revealed that female sex, race/ethnicity, family history, and comorbidities are risk factors for HZ. Efforts are needed to increase the uptake of zoster vaccination.

The Prevalence and Risk for Herpes Zoster Infection in Adult Patients With Diabetes Mellitus in the Canadian Primary Care Sentinel Surveillance Network

OBJECTIVES

Herpes zoster (HZ) is a common infection in Canada that can result in serious and long-term complications. People with diabetes may be at an increased risk for HZ. The objectives of this study were to develop and validate a case definition of HZ diagnosis based on electronic medical records; determine a prevalence estimate for HZ in adult patients in the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and assess the association between HZ and diabetes.

METHODS

This was a retrospective cross-sectional study. Patients 18 years of age or older who had made at least 1 visit to their primary health-care providers within the past 2 years in the CPCSSN were included. These data came from a 2015 extract of CPCSSN data, and a subsample of 289 patients was used to validate our case definition. Prevalences were estimated for the overall population and for people with diabetes, chronic obstructive pulmonary disease, cancer or HIV. Risk ratios were modelled for these conditions.

RESULTS

The sensitivity, specificity, positive predictive value and negative predictive values for HZ were 100%, 73.8%, 83.9% and 100%, respectively. The 1-year prevalence of HZ in the CPCSSN data was 0.32%. The prevalence of HZ was higher in females (0.35%) than in males (0.28%). People with diabetes have an increased risk for HZ infection (RR 2.64, 95% CI 2.34, 2.99).

CONCLUSIONS

People with diabetes have an increased risk for the diagnosis of HZ infection in the primary care setting in Canada. Women over the age of 65 years with diabetes and/or other chronic conditions are at greatest risk for developing HZ.

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.

Prevaccination epidemiology of herpes zoster in Denmark: Quantification of occurrence and risk factors

BACKGROUND

Herpes zoster (HZ) is a vaccine-preventable disease caused by reactivation of the varicella-zoster virus. Unfortunately, formulation of recommendations on routine immunization is hampered by a lack of data on disease burden, since most countries do not record cases of HZ in the general population. We developed and validated an algorithm to identify HZ based on routinely collected registry data and used it to quantify HZ occurrence and risk factors in Denmark prior to marketing of the HZ vaccine.

METHODS

We included patients aged ≥40years with a first-time systemic Acyclovir, Valacyclovir, or Famciclovir prescription or a hospital-based HZ diagnosis in the Danish nationwide health registries during 1997-2013. In a validation substudy (n=176), we computed the proportion of persons with HZ among patients who redeemed antiviral prescriptions. In a cohort study, we computed age-specific rates of HZ (45,297,258 person-years). In a case-control study, we then computed odds ratios (ORs) for common chronic diseases and immunosuppressive factors among HZ cases (n=189,025) vs. matched population controls (n=945,111).

RESULTS

Medical record review confirmed HZ in 87% (95% confidence interval: 79-93%) of persons ≥40years who dispensed antivirals at doses recommended for HZ. HZ rates increased from 2.15/1000 person-years in 40-year-olds to 9.45/1000 person-years in 95-year-olds. Rates were highest in women. HZ was diagnosed during hospitalization among 3.5%. As expected, persons with severe immunosuppressive conditions had the highest ORs of HZ (between 1.82 and 4.12), but various autoimmune diseases, asthma, chronic kidney disease, and inhaled glucocorticoids were also associated with increased ORs (between 1.06 and 1.64).

CONCLUSION

This algorithm is a valid tool for identifying HZ in routine healthcare data. It shows that HZ is common in Denmark, especially in patients with certain chronic conditions. Prioritized vaccination of such high-risk patients might be an option in countries considering alternatives to universal vaccination.

Varicella Zoster Virus Infection of the Central Nervous System - 10 Year Experience from a Tertiary Hospital in South India

INTRODUCTION

Varicella zoster virus is an exclusively human neurotrophic virus. The primary infection with the virus causes varicella. The virus remains latent in nervous tissue and upon secondary activation causes a variety of syndromes involving the central nervous system (CNS) including meningoencephalitis and cerebellitis.

MATERIALS AND METHODS

In this study, we looked at the epidemiology, clinical and laboratory features, and outcomes of patients who were admitted with varicella zoster of the CNS from 2005 to 2014.

RESULTS

There were 17 patients. Fever was present in 13 patients, seizures in 9 patients and headache and vomiting in 4 patients each. A generalized varicella rash was present in 8 out of 17 patients. A single dermatomal herpes zoster was present in seven patients. Two patients had no rash. Varicella zoster polymerase chain reaction (PCR) in cerebrospinal fluid (CSF) was done in 5 patients of which 4 were positive and 1 was negative. Nine patients had diabetes with an average glycated hemoglobin of 8.6%. Total number of deaths was five.

CONCLUSIONS

Patients with diabetes who develop varicella or herpes zoster may be at risk for CNS complications. The diagnosis of varicella encephalitis has to rest on a combination of clinical findings and CSF PCR, as neither the rash nor the PCR is sensitive enough to diagnose all the cases with varicella encephalitis.

Herpes zoster risk after 21 specific cancers: population-based case-control study

BACKGROUND

Some malignancies are known to be associated with increased risk of herpes zoster, but little is known about how associations between cancer and subsequent zoster risk vary by cancer site, by time since cancer diagnosis, and by age.

METHODS

An age-, sex-, calendar time-, and practice-matched case-control study, nested in the broadly UK representative Clinical Practice Research Datalink (CPRD) primary care database, was analysed using conditional logistic regression to estimate the association between 21 of the most common specific malignancies and subsequent zoster risk. We adjusted for comorbid conditions and other potential confounders, and investigated effect modification by age and time since malignancy diagnosis.

RESULTS

A total of 192 081 adult zoster patients and 732 035 controls were included. Malignancy overall was positively associated with zoster risk (adjusted OR 1.29, 95% CI 1.27-1.32), and the association was especially strong for haematological malignancies (OR 2.46, 2.33-2.60). Among specific malignancies, there was evidence that oral, oesophageal, stomach, colorectal, lung, breast, ovarian, prostate, kidney, bladder, and CNS cancers, as well as lymphoma, myeloma, and leukaemia were associated with increased zoster odds (P⩽0.05 in each case), but the magnitude of associations varied widely. The association was typically strongest within 2 years of malignancy diagnosis and decreased with older age for both haematological and solid malignancies.

CONCLUSIONS

Several cancers were associated with an increased risk of zoster, particularly within the first 2 years after diagnosis and among younger individuals. Knowledge that patients with a recent diagnosis of cancer are at high risk of zoster may encourage initiation of antiviral therapy earlier in the course of zoster when the benefits are greater. Evaluation of whether patients diagnosed with cancer would benefit from early zoster vaccination is warranted.

Varicella zoster virus vasculopathy: The expanding clinical spectrum and pathogenesis

Varicella zoster virus (VZV) is a ubiquitous, human alphaherpesvirus that produces varicella on primary infection then becomes latent in ganglionic neurons along the entire neuraxis. In elderly and immunocompromised individuals, VZV reactivates and travels along nerve fibers peripherally resulting in zoster. However, VZV can also spread centrally and infect cerebral and extracranial arteries (VZV vasculopathy) to produce transient ischemic attacks, stroke, aneurysm, sinus thrombosis and giant cell arteritis, as well as granulomatous aortitis. The mechanisms of virus-induced pathological vascular remodeling are not fully elucidated; however, recent studies suggest that inflammation and dysregulation of programmed death ligand-1 play a significant role.

Herpes Zoster and Recurrent Herpes Zoster

Background

The incidence of recurrent herpes zoster (HZ) and the relationship between initial and recurrent HZ are not clear.

Methods

The Miyazaki Dermatologist Society has surveyed ~5000 patients with HZ annually since 1997. A questionnaire regarding HZ and its recurrence was completed by the dermatologists.

Results

A total of 34 877 patients with HZ were registered at 43 clinics between June 2009 and November 2015. Among 16 784 patients seen at 10 of the 43 clinics, 1076 patients (6.41%) experienced recurrence. Herpes zoster was more frequent in female than in male patients (5.27 vs 4.25 in 1000 person-years, P < .001), as was HZ recurrence (7.63% vs 4.73%, P < .001). Two and three recurrences were observed in 49 and 3 patients, respectively. Recurrence in the same dermatome was observed in 16.3% of patients, and more frequently this occurred in the left side (P = .027). The number of HZ-experienced persons increased with age, and one third of the population had experienced HZ by the age of 80.

Conclusions

Recurrent HZ was observed in 6.41% of patients, with a higher incidence in women. Moreover, HZ experience reduced the HZ incidence to 31.7% of the incidence in the HZ-naive population.

Association of Herpes Zoster and Type 1 Diabetes Mellitus

OBJECTIVE

The purpose of our study was to determine the association of type 1 diabetes mellitus (T1DM) and the risk of herpes zoster (HZ).

METHODS

In this cohort study, we selected 4736 patients with T1DM registered in the Catastrophic Illness Patient Database who received insulin therapy before 2003 and 18944 participants without DM who were selected by frequency matched based on sex and age. Cox proportional hazard regression analysis was used to measure the hazard ratios (HRs) of HZ in the T1DM group compared with that in the non-T1DM group.

RESULTS

Cox proportional hazard regression analysis showed that the adjusted HR of HZ was 2.38 times higher for patients in the T1DM group (95% CI = 1.77-3.19) than for those in the non-T1DM group. According to diabetes severity, mild and serious T1DM patients were associated with a higher risk of HZ (adjusted HR = 2.26, 95% CI = 1.67-3.05; and adjusted HR = 5.08, 95% CI = 2.66-9.71, respectively) than subjects without T1DM.

CONCLUSION

Patients with T1DM are at a higher risk of HZ than those without T1DM.

Positive Predictive Value of ICD-9 Code for Herpes Zoster Among Children During the Varicella Vaccine Era

We examined the positive predictive value of the herpes zoster ICD-9 diagnosis code 053 in the Kaiser Permanente Northwest integrated health plan. Among children 0-17 years old, the positive predictive value was 87.1% (95% confidence interval: 84.2-89.6) and 96.8% (95% confidence interval: 95.0-98.1) during the years 1997-2002 and 2005-2009, respectively, using chart review of the medical record as the diagnostic standard.

Vaccines for preventing herpes zoster in older adults

BACKGROUND

Herpes zoster, also known as 'shingles', is a neurocutaneous disease characterised by the reactivation of the latent varicella zoster virus (VZV), the virus that causes chickenpox when immunity to VZV declines. It is an extremely painful condition that can last many weeks or months and it can significantly compromise the quality of life of affected individuals. The natural process of aging is associated with a reduction in cellular immunity and this predisposes older people to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production avoiding viral reactivation. The Food and Drug Administration has approved a herpes zoster vaccine with an attenuated active virus for clinical use among older adults, which has been tested in large populations. A new adjuvanted recombinant VZV subunit zoster vaccine has also been tested. It consists of recombinant VZV glycoprotein E and a liposome-based AS01B adjuvant system. This new vaccine is not yet available for clinical use.

OBJECTIVES

To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.

SEARCH METHODS

For this 2015 update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 9), MEDLINE (1948 to the 3rd week of October 2015), EMBASE (2010 to October 2015), CINAHL (1981 to October 2015) and LILACS (1982 to October 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine with placebo or no vaccine, to prevent herpes zoster in older adults (mean age > 60 years).

DATA COLLECTION AND ANALYSIS

Two review authors independently collected and analysed data using a data extraction form. They also performed 'Risk of bias' assessment.

MAIN RESULTS

We identified 13 studies involving 69,916 participants. The largest study included 38,546 participants. All studies were conducted in high-income countries and included only healthy Caucasian individuals ≥ 60 years of age without immunosuppressive comorbidities. Ten studies used live attenuated varicella zoster virus (VZV) vaccines. Three studies tested a new type of vaccine not yet available for clinical use. We judged five of the included studies to be at low risk of bias.The incidence of herpes zoster, at up to three years of follow-up, was lower in participants who received the vaccine than in those who received a placebo: risk ratio (RR) 0.49; 95% confidence interval (CI) 0.43 to 0.56, risk difference (RD) 2%, number needed to treat to benefit (NNTB) 50; GRADE: moderate quality evidence. The vaccinated group had a higher incidence of mild to moderate intensity adverse events. These date came from one large study that included 38,546 people aged 60 years or older.A study including 8122 participants compared the new vaccine (not yet available) to the placebo; the group that received the new vaccine had a lower incidence of herpes zoster at 3.2 years of follow-up: RR 0.04, 95% CI 0.02 to 0.10, RD 3%, NNTB 33; GRADE: moderate quality evidence. The vaccinated group had a higher incidence of adverse events but most them were of mild to moderate intensity.All studies received funding from the pharmaceutical industry.

AUTHORS' CONCLUSIONS

Herpes zoster vaccine is effective in preventing herpes zoster disease and this protection can last three years. In general, zoster vaccine is well tolerated; it produces few systemic adverse events and injection site adverse events of mild to moderate intensity.There are studies of a new vaccine (with a VZV glycoproteic fraction plus adjuvant), which is currently not yet available for clinical use.

The Incidence and Risk of Herpes Zoster in Patients With Sleep Disorders: A Population-Based Cohort Study

Lack of sleep can compromise the immune system, which may reactivate latent varicella-zoster virus. Studies on sleep disorders and the risk of herpes zoster (HZ) are scant.We conducted a population-based cohort study to evaluate the risk of HZ in patients with sleep disorders and potential risk factors for HZ development. We identified patients with sleep disorders without apnea from 2002 to 2005 by using the Taiwan Longitudinal Health Insurance Database. The patients without sleep disorders were randomly selected and frequency matched with patients with sleep disorders according to age, sex, and index year. We estimated the follow-up time in person-years for the patients from the entry date until HZ diagnosis, loss to follow-up, or the end of 2010. We used Cox proportional hazards regression models and a sensitivity analysis to estimate the risk of HZ while controlling for demographic characteristics and comorbidities. A total of 131,001 study participants (follow-up, 948,177 person-years; mean age, 51.2 ± 16.5 years; 62.2% women) were included in the study. Patients with sleep disorders exhibited a higher incidence of HZ compared with a comparison cohort when stratified by age, sex, and comorbidities. After adjustment for covariates, the sleep disorder cohort exhibited a 1.23-fold greater risk of HZ compared with the comparison cohort (95% confidence interval [CI] = 1.17-1.30). The incidence of HZ increased with age. Adults ages 65 years and older exhibited a 6.11-fold greater risk of HZ development compared with their younger counterparts (95% CI = 5.34-7.00). Cancers and autoimmune diseases were independent risk factors of HZ development. The patients with sleep disorders may carry an increased risk of developing HZ.

Short-term dipeptidyl peptidase-4 inhibitor use increases the risk of herpes zoster infection in Asian patients with diabetes

BACKGROUND

We aimed to evaluate whether patients with diabetes who use dipeptidyl peptidase (DPP)-4 inhibitors are at a higher risk of developing a herpes zoster (HZ) infection.

METHODS

We used a subset of the Longitudinal Health Insurance Database 2000 containing all inpatient and outpatient medical claims of ∼1 million people who were randomly sampled from the National Health Insurance Research Database. Patients who were newly diagnosed with Type 2 diabetes International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM 250.x0 and 250.x2) who used antidiabetic medications were divided into two cohorts based on their use of DPP-4 inhibitors between 2009 and 2011. Cox proportion hazard regression models were used to assess the effects of DPP-4 inhibitors on the incidence of HZ compared with the non-DPP-4-inhibitor-exposed cohort.

RESULTS

Patients in DPP-4-inhibitor-exposed cohort with diabetes and HZ infections revealed an incidence density of 4.20 per 1000 person-years compared with 3.50 per 1000 person-years for the non-DPP-4-inhibitor-exposed cohort (adjusted hazard ratio [HR] = 1.19, 95% confidence interval [CI] = 0.70-1.99). Furthermore, high-dose DPP-4-inhibitor treatment was associated with a significantly higher risk of HZ (adjusted HR = 2.46, 95% CI = 1.16-5.19 for a defined daily dose [DDD] ≥ 360). In addition, short-term DPP-4-inhibitor treatment was associated with a significantly higher risk of HZ (adjusted HR = 2.04, 95% CI = 1.03-4.04 for a DDD ≥ 360 days).

CONCLUSION

These results suggest that Asian patients with diabetes who use short-term DPP-4 inhibitors might be at a higher risk of developing HZ.

Zoster vaccination is associated with a reduction of zoster in elderly patients with chronic kidney disease

Background

Growing epidemiological evidence demonstrates increased zoster risks in people with chronic kidney disease (CKD). Study objectives were to determine zoster vaccine effectiveness in individuals with CKD in pragmatic use.

Methods

A population-based cohort study was undertaken in a 5% random sample of US Medicare from 2007 to 2009 involving 766 330 eligible individuals aged ≥65 years who were (29 785) and were not (736 545) exposed to the zoster vaccine. Incidence rates for zoster in vaccinated and unvaccinated individuals and hazard ratios for zoster comparing vaccinated with unvaccinated were determined for individuals with CKD. Time-updated Cox proportional hazards models were used, adjusting for relevant confounders.

Results

CKD was present in 183 762 (24%) of individuals (15% of vaccinees). Adjusted vaccine effectiveness [95% confidence intervals (CIs)] in individuals with CKD was 0.49 (0.36–0.65). The adjusted vaccine effectiveness in participants with both CKD and diabetes mellitus was 0.46 (95% CI 0.09–0.68). Vaccine effectiveness estimates were similar to those previously reported for the general population [vaccine effectiveness 0.48 (95% CI 0.39–0.56)].

Conclusions

Zoster vaccine is effective against incident zoster in older individuals with CKD. Extra efforts are warranted to increase vaccine uptake in individuals with CKD given the known low uptake in these higher risk individuals.