Systematic Literature Review of Herpes Zoster Disease Burden in Southeast Asia

Cost burden and temporal trends of herpes zoster in China: Evidence from Beijing's health records

Objective

Herpes zoster poses a significant health threat to the aging population in China. This study aimed to analyze the cost burden and temporal trends of herpes zoster in China.

Methods

This study encompassed herpes zoster outpatients from 15 hospitals between 2016 and 2023 and herpes zoster inpatients from 175 hospitals between 2013 and 2023. We used descriptive analysis and log-linear model to investigate herpes zoster related cost burden and their temporal trends during the selected period.

Results

Over the past eight years, outpatient visits increased by about 23.8 % across the selected hospitals, while inpatient discharges increased by approximately 124.8 %. About 23.6 % of the outpatient cases were under 45 years of age. The cost per outpatient visit fluctuated at approximately 57 USD, while the cost per hospitalization increased by over 20 %, reaching around 1931 USD in 2023. Older patients and those with post-herpetic neuralgia experienced higher herpes zoster related healthcare costs and utilization.

Conclusions

Our findings suggest that although the average cost per visit or discharge changed little in China, the growing demand for herpes zoster healthcare highlights the necessity of more preventive efforts to reduce the burden on both individuals and the healthcare system.

Cost-Utility and Budget Impact Analyses of Herpes Zoster Vaccines in Patients With Human Immunodeficiency Virus in Thailand

OBJECTIVES

This study aimed to perform cost-utility and budget impact analyses of zoster vaccine live (ZVL) and recombinant zoster vaccine (RZV) compared with no vaccination in patients infected with human immunodeficiency virus (HIV) in Thailand.

METHODS

A Markov model was used to estimate costs and outcomes as a quality-adjusted life year from a societal perspective. Costs and outcomes were discounted at 3% per year. Parameters for herpes zoster prevalence and complications were estimated from previous studies. The target population included patients with HIV infection aged ≥18 years with a CD4 count ≥ 200 cells/mm3. Direct medical and nonmedical costs were included in the analysis. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the results. A 5-year budget impact analysis of the vaccination program was performed.

RESULTS

The incremental cost-effectiveness ratios of ZVL and RZV compared with no vaccination for patients with HIV infection were $2908.70 and $4391.36 per quality-adjusted life year gain, respectively. ZVL was more likely to be cost-effective. Threshold analysis revealed that RZV could be cost-effective if the cost per dose of RZV was reduced by 0.86%. An additional budget of $15 276 033 for ZVL and $43 338 761 for RZV was estimated to be needed over 5 years.

CONCLUSIONS

ZVL is cost-effective at the Thai willingness-to-pay threshold for patients with HIV infection aged ≥18 years with a CD4 count ≥ 200 cells/mm3. RZV needs a 0.86% price reduction to be cost-effective. These findings may be useful in evidence-based policymaking.

Herpes zoster incidence and burden in older Chinese: a systematic review and meta-analysis

BACKGROUND

Previous studies have documented variations in herpes zoster (HZ) incidence across regions and periods. We aimed to synthesize data on HZ incidence, complications, and associated healthcare costs (inpatient and outpatient) in the Chinese population aged 50 years and older over the last two decades.

METHODS

We searched studies published in English between January 1, 2000, and March 31, 2023 in PubMed, Cochrane Library, Embase, EBSCO, OVID, and Web of Science, supplemented by Chinese databases CNKI, Wan Fang, CQVIP, and Yiigle. Main search terms included 'Herpes Zoster', 'Herpesvirus 3, Human', 'Neuralgia Postherpetic', 'incidence', 'morbidity', 'epidemiology', 'complication', 'health care cost', 'expenditure', 'economic', and 'burden'. The Agency for Healthcare Research and Quality tool and Newcastle-Ottawa Scale were used for quality assessment.

RESULTS

Of 6,958 studies, 19 (73,044,981 total population) were included for analysis (1,107,682 HZ cases, mean age 63.03 ± 8.30 years, 47.10% male). The pooled annual HZ incidence from 13 studies (2 with high quality, 11 with medium quality) from 2000 to 2020 was 6.28 per 1000 PYs (95%CI: 5.42, 7.15), with a significant increasing trend over the period (meta-regression coefficient: 0.0031, 95%CI: 0.0027, 0.0036), and more pronounced among females and those with advancing age. Neuralgia system disorders were the most frequently reported complications, followed by ear and eye diseases. Furthermore, HZ-associated inpatient costs showed a 4.4-fold dramatic increases, rising from 3260 RMB in 2010-2012 to 14,303 RMB per patient in 2017-2018, while outpatient costs remained growth from 336 RMB to 1329 RMB.

CONCLUSIONS

Despite the medium overall quality of the studies, our findings highlight an urgent need for effective public health strategies including vaccine aimed at reducing HZ incidence and associated healthcare costs in China.

Expanded spectrum of varicella disease and the need for vaccination in India

Varicella vaccine was first licensed in Japan and South Korea in 1989 for use in healthy children and was introduced in US in 1995. So far, 29 countries have adopted varicella vaccine in their universal immunization program (UIP). No Asian country, India included, has adopted the varicella vaccine as part of their UIP. The extra-cutaneous sites for VZV diseases are central nervous system and gastrointestinal tract, the expanded disease spectrum includes vasculopathy, myelitis, inflammatory bowel disease, perforated ulcers, and gastritis. The actual disease burden of varicella is not known as most of the infected individuals may not visit the physician. The amplifiable VZV DNA will not always be detectable in cerebrospinal fluid (CSF) samples in protracted illnesses such as vasculopathies, but demonstrable anti-VZV IgG in CSF has diagnostic value. The World Health Organization (WHO) position paper 2014 recommends two doses of varicella and zoster vaccines in targeted population. In India, varicella vaccine is not included in the UIP due to the cost and the belief that lifelong immunity occurs following primary infection. The expanded spectrum of VZV disease and the mounting body of evidence, however, suggest the need for both varicella and zoster vaccines in routine immunization schedule.

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.

The Herpes Zoster Patient Pathway and Gaps in Current Vaccination Guidelines in Southeast Asia: Summary of a Zoster Experts' Network Scientific Workshop

The burden of herpes zoster (HZ) is recognized worldwide; however, there is seemingly limited information on incidence and vaccination practices in Southeast Asia (SEA). A scientific workshop was held by the Zoster Experts' Network to exchange and consolidate insights on the burden of HZ and the patient pathway in SEA. The workshop included practicing clinical experts and public health specialists/epidemiologists from Indonesia, Malaysia, the Philippines, Thailand, and Vietnam. It aimed to identify gaps in the literature, outline patient pathways, and evaluate HZ vaccine recommendations among these countries. Consensus was identified on the substantial lack of epidemiological data on HZ in SEA and the need to investigate the impact of age, immunocompromising conditions, and comorbidities on the incidence and severity of HZ in the region. However, available data in SEA did indicate a rising disease and socioeconomic burden of HZ, with concerns that current treatment strategies for HZ are suboptimal. The HZ patient pathways generated by the experts highlighted common themes and differences between the five countries. Furthermore, the experts highlighted the lack of awareness of HZ and its impact on patients' quality of life, among patients and healthcare professionals. Evaluation of the current local HZ vaccine recommendations further showed differences in age and the inclusion of at-risk populations between countries. The workshop outcomes emphasize the need for further HZ surveillance in SEA. Efforts to align and address leakage within the patient pathway and raise awareness on the impact of HZ should be prioritized. Awareness initiatives and alignment on vaccine recommendations are also needed.

Development of a Prediction Model and Corresponding Scoring Table for Postherpetic Neuralgia Using Six Machine Learning Algorithms: A Retrospective Study

INTRODUCTION

Postherpetic neuralgia (PHN), a complication of herpes zoster, significantly impacts the quality of life of affected patients. Research indicates that early intervention for pain can reduce the occurrence or severity of PHN. This study aims to develop a predictive model and scoring table to identify patients at risk of developing PHN following acute herpetic neuralgia, facilitating informed clinical decision-making.

METHODS

We conducted a retrospective review of 524 hospitalized patients with herpes zoster at The First Affiliated Hospital of Zhejiang Chinese Medical University from December 2020 to December 2023 and classified them according to whether they had PHN, collecting a comprehensive set of 30 patient characteristics and disease-related indicators, 5 comorbidity indicators, 2 disease score values, and 10 serological indicators. Relevant features associated with PHN were identified using the least absolute shrinkage and selection operator (LASSO). Then, the patients were divided into a training set and a test set in a 4:1 ratio, with comparability tested using univariate analysis. Six models were established in the training set using machine learning methods: support vector machines, logistic regression, random forest, k-nearest neighbor, gradient boosting, and neural network. The performance of these models was evaluated in the test set, and a nomogram based on logistic regression was used to create a PHN prediction score table.

RESULTS

Eight non-zero characteristic variables selected from the LASSO regression results were included in the model, including age [area under the curve (AUC) = 0.812, p < 0.001], Numerical Rating Scale (NRS) (AUC = 0.792, p < 0.001), receiving treatment time (AUC = 0.612, p < 0.001), rash recovery time (AUC = 0.680, p < 0.001), history of malignant tumor (AUC = 0.539, p < 0.001), history of diabetes (AUC = 0.638, p < 0.001), varicella-zoster virus immunoglobulin M (AUC = 0.620, p < 0.001), and serum nerve-specific enolase (AUC = 0.659, p < 0,001). The gradient boosting model outperformed other classifier models on the test set with an AUC of 0.931, 95% confidence interval (CI) (0.882-0.980), accuracy of 0.886 (95% CI 0.809-0.940). In the test set, our predictive scoring table achieved an AUC of 0.820 (95% CI 0.869-0.970) with accuracy of 0.790 (95% CI 0.700-0.864).

CONCLUSION

This study presents a methodology for predicting the development of postherpetic neuralgia in shingles patients by analyzing historical case data, employing various machine learning techniques, and selecting the optimal model through comparative analysis. In addition, a logistic regression model has been used to create a scoring table for predicting the postherpetic neuralgia.

The Incidence of Herpes Zoster Complications: A Systematic Literature Review

INTRODUCTION

The objective of this work was to summarize the incidence of herpes zoster (HZ) complications in different populations.

METHODS

Systematic literature review of PubMed, Embase, and Virtual Health Library records between January 1, 2002 and October 20, 2022 using search strings for HZ, complications, and frequency measurements.

RESULTS

The review included 124 studies, most conducted in the general population (n = 93) and on individuals with comorbidities (n = 41) ≥ 18 years of age. Most studies were conducted in Europe (n = 44), Asia (n = 40), and North America (n = 36). Postherpetic neuralgia (PHN) was the most studied neurological complication. Variable relative PHN incidence was found in the general population (2.6-46.7%) or based on diagnosis: immunocompromised (3.9-33.8%), depression (0-50%), and human immunodeficiency virus (HIV) (6.1-40.2%). High incidence rates were observed in hematological malignancies (HM) and solid organ malignancies (132.5 and 93.7 per 1000 person-years, respectively). Ocular complications were frequently reported with herpes zoster ophthalmicus (HZO). The relative incidence (incidence rate) of HZO in the general population was reported as 1.4-15.9% (0.31-0.35 per 1000 person-years). High relative incidence was observed in HIV (up to 10.1%) and HM (3.2-11.3%). Disseminated HZ was the most frequently reported cutaneous complication. The relative incidence of disseminated HZ was 0.3-8.2% in the general population, 0-0.5% in the immunocompetent, and 0-20.6% in patients with comorbidities. High relative incidence was reported in HM and solid organ transplant (up to 19.3% and 14.8%, respectively).

DISCUSSION

Most reported complications were neurological (n = 110), ocular (n = 48), and cutaneous (n = 38). Few studies stratified complications by age or gender (or both). Incidence appeared higher in select immunocompromised populations. Higher incidence was associated with older age in several studies; the general association with gender was unclear.

CONCLUSIONS

Variable incidence of HZ complications was reported by population subgroup. Further research is required to quantitatively analyze incidence by age, gender, and location.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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