Predictors of postherpetic neuralgia among patients with herpes zoster: a prospective study

Updated Public Health Impact and Cost Effectiveness of Recombinant Zoster Vaccine in Canadian Adults Aged 50 Years and Older

OBJECTIVES

The aim of this study was to update previously estimated public health impact and cost effectiveness of recombinant zoster vaccine (RZV) for the prevention of herpes zoster (HZ) in Canadians aged ≥50 years using longer-term RZV efficacy and waning data and real-world coverage and completion.

METHODS

A multicohort Markov model was used to conduct a cost-utility analysis comparing RZV with no HZ vaccination among Canadians aged ≥50 years. Real-world data were used for first-dose coverage (17.5%) and second-dose completion (65%). Vaccine efficacy and waning data were applied from up to 8-year follow-up from the ZOE-50 and ZOE-70 clinical trials. Incremental costs and benefits were calculated using a lifetime horizon from the healthcare payer (base case) and societal perspectives. A discount rate of 1.5% was applied to costs and quality-adjusted life-years (QALYs).

RESULTS

The model estimated that RZV would prevent 303,835 HZ cases, 83,256 post-herpetic neuralgia (PHN) cases, 39,653 other complications, and 99 HZ-related deaths compared with no HZ vaccination. Incremental cost-effectiveness ratios (ICERs) were estimated to be $27,486 and $22,097 per QALY (2022 Canadian dollars [CAN$]) from the healthcare payer and societal perspectives, respectively. The base-case ICER was most sensitive to a lower percentage of initial HZ cases with PHN. Almost all probabilistic sensitivity analysis simulations (98.1%) resulted in ICERs

CONCLUSIONS

RZV is expected to remain a cost-effective option for Canadian adults aged ≥50 years when using longer-term RZV efficacy and waning estimates, although the estimated public health impact was smaller than in the previous analysis (due to lower coverage/completion estimates).

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Grants

• GlaxoSmithKline Biologicals

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Affiliation(s)

Sydney George GSK, Mississauga, ON, Canada.
Justin Carrico RTI Health Solutions, Research Triangle Park, NC, USA
Katherine A Hicks RTI Health Solutions, Research Triangle Park, NC, USA
Dessi Loukov GSK, Mississauga, ON, Canada
Cheryl Ng GSK, Singapore, Singapore
Jessica Regan GSK, Mississauga, ON, Canada
Nikolaos Giannelos GSK, Wavre, Belgium

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Public health impact of recombinant zoster vaccine for prevention of herpes zoster in US adults immunocompromised due to cancer

Individuals who are immunocompromised (IC) due to therapy or underlying disease are at increased risk of herpes zoster (HZ). This study evaluates the public health impact of recombinant zoster vaccine (RZV) relative to no HZ vaccination for the prevention of HZ among adults aged ≥18 years diagnosed with selected cancers in the United States (US). A static Markov model was used to simulate three cohorts of individuals who are IC with cancer (time horizon of 30 years; one-year cycle length): hematopoietic stem cell transplant (HSCT) recipients, patients with breast cancer (BC; a solid tumor example), and patients with Hodgkin's lymphoma (HL; a hematological malignancy example). Cohort sizes reflect the estimated annual incidence of each condition in the US population (19,671 HSCT recipients, 279,100 patients with BC, and 8,480 patients with HL). Vaccination with RZV resulted in 2,297; 38,068; and 848 fewer HZ cases for HSCT recipients, patients with BC, and patients with HL, respectively (each versus no vaccine). Vaccination with RZV also resulted in 422; 3,184; and 93 fewer postherpetic neuralgia cases for HSCT, BC, and HL, respectively. Analyses estimated the quality-adjusted life years gained to be 109, 506, and 17 for HSCT, BC, and HL, respectively. To prevent one HZ case, the number needed to vaccinate was 9, 8, and 10, for HSCT, BC, and HL, respectively. These results suggest RZV vaccination may be an effective option to significantly reduce HZ disease burden among patients diagnosed with selected cancers in the US.

How large could the public health impact of introducing recombinant zoster vaccination for people aged ≥50 years in five Latin American countries be?

This study aimed to: (1) estimate the disease burden of herpes zoster (HZ) and (2) assess the potential public health impact of introducing adjuvanted recombinant zoster vaccine (RZV) compared with no vaccination in adults aged ≥50 years in Argentina, Brazil, Mexico, Chile, and Colombia using the ZOster ecoNomic Analysis (ZONA) static multicohort Markov model. The model followed individuals aged ≥50 years from administration of RZV over their remaining lifetime. Inputs were based, most often, on local data. First dose coverage was assumed to be 35%, with 75% second dose compliance. It was predicted that without RZV, there would be 23,558,675 HZ cases, 6,115,981 post-herpetic neuralgia (PHN) cases, and 7,058,779 non-PHN complications in the five countries, but introducing RZV under assumed coverage could avoid 4,583,787 (19%) HZ cases, 1,130,751 (18%) PHN cases, and 1,373,419 (19%) non-PHN complications. Also, 10427,504 (20%) doctor's office visits and 1,630,201 (19%) days of hospitalization could be averted in the three countries (Argentina, Brazil, and Mexico) with available input data. The numbers needed to be vaccinated to avoid one case of HZ were 9-10 across countries, and to avoid one case of PHN, 35-40. One-way sensitivity analyses showed that the input parameters with the largest impact on the estimated number of HZ cases avoided were first dose coverage, initial HZ incidence, and vaccine efficacy waning. In conclusion, the introduction of RZV for older adults in Latin America could greatly reduce the public health burden of HZ and reduce the related doctor visits and hospitalization days.

Comprehensive Bibliometric Analysis of Research Articles on Post-Herpetic Neuralgia and Varicella-Zoster Virus: A 20-Year Review(2003-2022)

Objective

Post-herpetic neuralgia (PHN) is a debilitating condition that has garnered considerable attention from pain physicians due to its association with the or Varicella-Zoster Virus (VZV). In this study, we aimed to conduct a bibliometric analysis to quantitatively assess the research outcomes related to PHN and VZV over the past two decades (2003-2022).

Methods

We conducted a bibliometric analysis by querying the Web of Science database for articles related to PHN published from 2003 to 2022. In this analysis, we collected relevant information from the database including the number of publications, publication year, source, country, institution, and citation data.

Results

A total of 1073 publications were extracted from the database, with 387 articles (36.1%) being authored by individuals from the United States, making it the leading country in terms of article publications. The top ten institutions that made significant contributions to research on PHN and VZV were primarily concentrated within the United States. Notably, the New England Journal of Medicine and Pain claimed the two highest positions in terms of citation count, with 2482 and 1591 citations, respectively. The topics covered in these articles mainly revolved around "Postherpetic Neuralgia", "Herpes Zoster", "Epidemiology", "Vaccine", and "Quality-of-life".

Conclusion

Over the past two decades, there has been a gradual increase in publications on PHN and VZV, demonstrating significant advancements in academic achievements. Vaccines have proven effective in reducing PHN incidence among the elderly, but there is a lack of research on interventional treatments and underlying mechanisms. To elevate evidence-based medicine, researchers should conduct more controlled clinical trials. Additionally, leveraging pathogenesis research findings can lead to the development of better pain relief medications.

Comparison of the Severity of Zoster-Associated Pain and Incidence of Postherpetic Neuralgia in Patients with and without Pre-Existing Spinal Disorders at the Same Spinal Nerve Level: A Retrospective Multicenter Study

The incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are significantly influenced by age. As individuals age, the occurrence of spinal disorders increases, thereby raising the likelihood of HZ and PHN coexistence. Considering this, our study aimed to explore the potential impact of pre-existing spinal disorders at the nerve level where HZ developed, on the severity of zoster-associated pain (ZAP) and the incidence of PHN. For our investigation, we retrospectively analyzed a total of 237 patients who presented with HZ and ZAP at various sensory levels (cervical, thoracic, lumbar, and sacral) with or without pre-existing spinal disorders. The presence or absence of spinal disorders at the sensory level affected by HZ was determined using computed tomography or magnetic resonance imaging. Our study results revealed that the group with spinal disorders at the sensory level where HZ developed did not exhibit an increased incidence of PHN. However, 3-6 months after HZ onset, this same group showed significantly higher ZAP scores compared to the group without spinal disorders. It implies a need for heightened pain management, as the coexistence of these conditions can increase pain severity. This study furnishes an initial standpoint to delve into intricate interactions between two diseases.

Top 100 Most-Cited Papers in Herpes Zoster from 2000 to 2022: A Bibliometric Study

Background

In recent years, the incidence of herpes zoster has risen steeply, the exact pathogenesis of the acute pain and the transformation into postherpetic neuralgia are still obscure, and the absence of effective management remains a major therapeutic challenge. The purpose of this study was to perform a qualitative and quantitative bibliometric analysis of the 100 most cited papers on herpes zoster.

Materials and methods

Related literature were retrieved from the Web of Science Core Collection. Excel and VOSviewer software were applied to quantitatively analyze, and construct the bibliometric network charts.

Results

The Top 100 most-cited papers published between 2000 and 2018 showed a fluctuating downward trend. The most studies were published in the year of 2000 (n = 12). The article entitled "A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults" from Oxman MN, was the most-cited publication. The United States was the most contributing country, followed by the United Kingdom, and Italy. Finland occupied the highest citations per publication (CPP). The University of Colorado topped the list of institutions with the most publications with 18 articles and also had the most citations (average citations: 281.78 per article). Myron J Levin from the University of Colorado School of Medicine is the most published and most cited researcher overall, whereas Duke University's John W Gnann tops the list in terms of average CPP.

Conclusion

In terms of the quantity of T100 articles, researchers, and organizations, the US is the predominant country. The most T100 papers were published in the special journal Clinical Infectious Diseases. The most academic focus remain the remedies for postherpetic neuralgia and vaccine development for individualized groups.

Efficacy of different acupuncture therapies on postherpetic neuralgia: A Bayesian network meta-analysis

Background

Postherpetic neuralgia (PHN) is a common, complex, and refractory type of neuropathic pain. Several systematic reviews support the efficacy of acupuncture and related treatments for PHN. Nevertheless, the efficacy of various acupuncture-related treatments for PHN remains debatable.

Objective

We aimed to assess the efficacy and safety of acupuncture-related treatments for PHN, identify the most effective acupuncture-related treatments, and expound on the current inadequacies and prospects in the applications of acupuncture-related therapies.

Methods

We searched PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Google Scholar, four Chinese databases (China National Knowledge Infrastructure, China Biomedical, Chongqing VIP, and Wan Fang databases), clinical research registration platform (World Health Organization International Clinical Trial Registration platform, China Clinical Trial Registration Center) for relevant studies. We also examined previous meta-analyses; gray literature; and reference lists of the selected studies. We then evaluated the risk of bias in the included studies and performed a Bayesian multiple network meta-analysis.

Results

We included 29 randomized controlled trials comprising 1,973 patients, of which five studies showed a high risk of bias. The pairwise meta-analysis results revealed that the efficacy of all acupuncture-related treatments for pain relief related to PHN was significantly better than antiepileptics. The network meta-analysis results showed that pricking and cupping plus antiepileptics were the most effective treatment, followed by electroacupuncture (EA) plus antiepileptics for pain relief in patients with PHN. EA plus antiepileptics ranked the best regarding reduced Pittsburgh Sleep Quality Index (PSQI) and Self-Rating Depression Scale (SDS) scores in patients with PHN. No results were found regarding the total response rate or quality of life in this study. Acupuncture-related treatments showed a lower incidence of adverse events than that of antiepileptics.

Conclusion

Acupuncture-related therapies are potential treatment options for PHN and are safe. Pricking and cupping plus antiepileptics, are the most effective acupuncture-related techniques for pain relief, while EA plus antiepileptics is the best acupuncture-related technique for improving PHN-related insomnia and depression symptoms. However, owing to the limitations of this study, these conclusions should be cautiously interpreted, and future high-quality studies are needed.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021226422, identifier CRD42021226422.

Interventions for zoster-associated pain: A retrospective study based on the clinical database

Background

Herpes zoster (HZ)-associated pain can lead to severe pain and reduced quality of life. Exploring effective treatment and the risk factors of zoster-associated pain has become important.

Methods

Interventions including nerve block, radiofrequency, and thermocoagulation were used for zoster-associated pain. The data of 131 patients with HZ and 230 patients with postherpetic neuralgia (PHN) were collected at baseline, 2 weeks, 3, 6, and 12 months after the intervention. Visual analog scale (VAS) and Brief Pain Inventory (BPI) scores at different time points were analyzed by two-way repeated measures ANOVA with Group as the between-subject variable (different pain durations and areas), Time as the within-subject variable (baseline, 2 weeks, 3 months, 6 months, and 12 months), and Group × Time as the two-way interaction. Besides, the effective rate, adverse effects, and medication were also recorded. The risk factors of PHN were analyzed by logistic regression.

Results

A total of 25 (19.08%) patients with HZ continued to have pain in the initially affected area after 3 months. The VAS scores and the BPI quality of life scores of patients with HZ-associated pain were significantly reduced from baseline to 2 weeks, 3, 6, and 12 months after the interventions. There was no significant difference in VAS and BPI scores in different pain areas and pain durations. No significant Group × Time interaction was observed. Age, diabetes mellitus, and immune-related diseases were risk factors of PHN.

Conclusion

Interventions could significantly improve the pain degree and life quality of patients with zoster-associated pain, and the positive effect of intervention did not change with pain duration and area. Advanced age, diabetes, and immune-related diseases are risk factors of PHN.

Incidence of complications of herpes zoster in individuals on immunosuppressive therapy: A register-based population study

OBJECTIVES

Herpes zoster (HZ) exposes to alterations of the quality-of-life. HZ is more frequent in immunocompromised individuals, but whether immunosuppression is associated with a higher rate of complications is not well documented. We aimed to assess association between drug-induced immunosuppression and HZ complications.

METHODS

Data from a sample of the French healthcare claims from 01/01/2006 to 12/31/2018 were analyzed. Complicated zoster (CZ) was defined as a hospitalization with a code for HZ or the first-time dispensation of high-dose valacyclovir and specific neuralgia analgesics. Drug-induced immunosuppression was identified through medication dispensation. Risk ratios were calculated to compare incidences in exposed individuals (EI) and non-exposed to immunosuppressive therapy (NEI).

RESULTS

We identified 227 and 2838 CZ, accounting for an incidence of 178 per 100,000 person-year (95%CI[154.9-201.1]) and 51.7 per 100,000 person-year (95%CI[49.8-53.6]), in EI and NEI, respectively (risk ratio: 3.44 (95%CI[3.01-3.94]). Mean age was 66 years in both groups. CZ occurred after a median of 11.7 months (IQR[5.3-49.9]) of immunosuppressive therapy. Post-herpetic neuralgia (PHN) lasted at least 3 months in 32.6% and 22.5% of cases in EI and NEI, respectively (p=.01).

CONCLUSIONS

Drug-induced immunosuppression increases the risk of CZ and exposes to longer-lasting PHN. Figures provided in this study could help guide prophylaxis of HZ.

Immunological mechanism of postherpetic neuralgia and effect of pregabalin treatment on the mechanism: a prospective single-arm observational study

BACKGROUND

Although neuropathic pain is a severe and common pain, its pathophysiology has not been elucidated yet. Studies in recent years have focused on the immune system's role in the pathogenesis of neuropathic pain. The aim of this study was to investigate the role of immunological mechanisms in neuropathic pain and the effect of pregabalin by measuring immunological marker levels in peripheral blood before and after pregabalin treatment in postherpetic neuralgia (PHN) patients with neuropathic pain.

METHODS

Forty patients diagnosed with PHN were included in the study. CD4, T follicular cells (Tfh: CD4+CXCR5+PD1+), Th17 (CD4+CCR6+ and CD4+IL17A+), regulatory T cells (Treg: CD4+ CD25+foxp3+), Th1 (CD4+ CXCR3+ and CD4+ IFN-γ+) and Th2 (CD4+ IL-4+) cell ratios were measured in peripheral blood samples before treatment and after 3 months of treatment.

RESULTS

When immunological marker and inflammation parameter levels were compared before and after treatment, the helper T cell ratio (CD3+, CD4+) was 30.28 ± 12.27% before treatment and 34.93 ± 11.70% after treatment, so there was a statistically significant increase (P = 0.028). Th17 was 4.75 ± 5.02% before treatment and 5.80 ± 3.13% after treatment, and there was a statistically significant increase (P = 0.036).

CONCLUSIONS

Immunological mechanisms play an essential role in the pathogenesis of neuropathic pain, immunologically based treatment approach will be the critical point of treatment.

Effects of Transcutaneous Spinal Direct Current Stimulation (tsDCS) in Patients With Chronic Pain: A Clinical and Neurophysiological Study

Background and Aims: Chronic pain is a complex clinical condition, often devastating for patients and unmanageable with pharmacological treatments. Converging evidence suggests that transcutaneous spinal Direct Current Stimulation (tsDCS) might represent a complementary therapy in managing chronic pain. In this randomized, double-blind and sham-controlled crossover study, we assessed tsDCS effects in chronic pain patients.

Methods: Sixteen patients (aged 65.06 ± 16.16 years, eight women) with chronic pain of different etiology underwent sham and anodal tsDCS (anode over the tenth thoracic vertebra, cathode over the somatosensory cortical area: 2.5 mA, 20 min, 5 days for 1 week). As outcomes, we considered the Visual Analog Scale (VAS), the Neuropathic Pain Symptom Inventory (NPSI), and the components of the lower limb flexion reflex (LLFR), i.e., RIII threshold, RII latency and area, RIII latency and area, and flexion reflex (FR) total area. Assessments were conducted before (T0), immediately at the end of the treatment (T1), after 1 week (T2) and 1 month (T3).

Results: Compared to sham, anodal tsDCS reduced RIII area at T2 (p = 0.0043) and T3 (p = 0.0012); similarly, FR total area was reduced at T3 (p = 0.03). Clinically, anodal tsDCS dampened VAS at T3 (p = 0.015), and NPSI scores at T1 (p = 0.0012), and T3 (p = 0.0015), whereas sham condition left them unchanged. Changes in VAS and NPSI scores linearly correlated with the reduction in LLFR areas (p = 0.0004).

Conclusions: Our findings suggest that tsDCS could modulate nociceptive processing and pain perception in chronic pain syndromes.

Circulating Level of Myelin Basic Protein Predicts Postherpetic Neuralgia: A Prospective Study

OBJECTIVES

Patients with herpes zoster (HZ) would benefit from accurate prediction of whether they are likely to develop postherpetic neuralgia (PHN). We investigated whether a circulating biomarker of neuronal damage could be a predictor of PHN in this nonmatched prospective, nested, case-control study.

MATERIALS AND METHODS

We included patients with HZ who were within 90 days after rash onset. Volunteers without a history of HZ were recruited as controls. We evaluated epidemiologic factors and circulating neuronal damage biomarkers, including cell-free DNA, myelin basic protein (MBP), and soluble protein-100B (S100B). We conducted logistic regression analyses to develop a prediction model of PHN.

RESULTS

We found that cell-free DNA and MBP levels were higher in patients with HZ (n=71) than in controls (n=37). However, only MBP level was higher in patients who developed PHN (n=25), in comparison with those who did not (n=46). MBP level and 3 clinical factors, age, acute pain severity, and response to treatment drugs were identified as independent predictors of PHN. Receiver operating characteristic (ROC) curve analysis showed that the prediction made using a combination of MBP level and clinical factors had an area under ROC curve of 0.853 (95% confidence interval: 0.764 to 0.943), which was better than prediction using clinical factors alone (area under ROC curve: 0.823, 95% confidence interval: 0.728 to 0.917).

DISCUSSION

Our results indicate that circulating MBP level in patients with HZ is a predictor for PHN. The combination of clinical predictors and MBP level enhanced the prediction performance.

Effect of pain neuroscience education and transcutaneous electrical nerve stimulation on trigeminal postherpetic neuralgia. A case report

Introduction: Postherpetic neuralgia (PHN) is a complex neuropathic painful condition in which pain is a direct consequence of the response to peripheral nerve damage experienced during herpes zoster attack. PHN is the most common chronic complication of herpes zoster and it causes considerable suffering, affecting the physical functioning and psychological well-being of patients. Objective: To describe the effect of a conservative treatment using pain neuroscience education (PNE) and transcutaneous electrical nerve stimulation (TENS) in a patient with trigeminal PHN. Case Description: A 67-year-old woman sought care for pain, dysfunction, and sensory loss in the left jaw. The assessment included: 1) pain, using the numerical pain rating scale (NPRS), pressure pain threshold (PPT), Douleur Neuropathique 4 (DN4), McGill Pain Questionnaire (MPQ), Graded Chronic Pain Scale (GCPS), and classic body charts of the cranial region; 2) somatosensory function, by means of mechanical detection threshold (MDT) and pressure pain threshold (PPT); 3) jaw function, using the Jaw Functional Limitation Scale-20 (JFLS-20); and 4) psychosocial features, by means of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorders Questionnaire-7 (GAD-7). Treatment consisted of 12 sessions of PNE and TENS. Outcomes: After treatment, a clinically significant improvement in NPRS, DN4, MDT, GCPS, and PHQ-9 was observed. Conclusion: In this case report, a treatment based on the combination of PNE and TENS seemed to have contributed to improving pain, sensory abnormalities, and jaw function. Psychosocial factors also showed a trend to improve after the treatment.

Recombinant Zoster Vaccine Is Efficacious and Safe in Frail Individuals

BACKGROUND/OBJECTIVES

Frail participants are often under-represented in randomized trials, raising questions about outcomes of interventions in real-world settings. Frailty is strongly associated with vulnerability to illness and adverse health outcomes. We studied the impact of frailty on recombinant zoster vaccine (RZV) clinical outcomes.

DESIGN/SETTING

Data from two previously conducted phase III randomized trials of RZV were pooled. These two parent trials were conducted concurrently at the same study sites using the same methods.

PARTICIPANTS/INTERVENTION

In the two parent studies, participants aged ≥50 years (ZOE-50 study) and ≥70 years (ZOE-70 study), respectively, were randomized 1:1 to receive two doses of RZV or placebo.

MEASUREMENTS

In the current ZOE-Frailty study (NCT03563183), a frailty index was created using previously validated methods. Clinical outcomes assessed by frailty status included vaccine efficacy, immunogenicity, reactogenicity, and safety.

RESULTS

Of 29,305 participants from the pooled ZOE-50 and ZOE-70 total vaccinated cohort, 92% were included in this study. Mean age was 68.8 years; 58.1% were women; 45.6% were pre-frail and 11.3% frail. The percentage of frail participants increased with age from 5.7% aged 50-59 years to 22.7% aged ≥80 years. RZV vaccine efficacy against herpes zoster was >90% for all frailty subgroups (non-frail: 95.8% (95% confidence interval = 91.6-98.2), pre-frail: 90.4% (84.4-94.4), frail: 90.2% (75.4-97.0)). The RZV group demonstrated robust anti-gE antibody and gE-specific CD4²⁺ responses, with mean concentrations remaining above pre-vaccination levels at least 3 years post-dose two, in all frailty subgroups. In the RZV group, the percentage of participants reporting solicited adverse events tended to decrease with increasing frailty.

CONCLUSION

The relatively nonrestrictive inclusion/exclusion criteria in the parent ZOE studies resulted in a range of participants that included frail and pre-frail older adults. RZV significantly reduced the risk of herpes zoster across all frailty subgroups.

Differences in Estimates of Post-Herpetic Neuralgia Between Medical Chart Review and Self-Report

PURPOSE

Post-herpetic neuralgia (PHN) is a common herpes zoster (HZ) complication, where pain persists 90 days after the initial HZ diagnosis. Evaluating PHN risk is essential for determining the burden on patients and health-care systems, but research shows variable estimates. The extent to which these differences are related to the assessment method has not been examined. The purpose of this study is to compare the proportion of PHN among HZ patients measured by medical chart review and self-report surveys.

METHODS

PHN risk was assessed among a sample of Kaiser Permanente Southern California members with HZ. Chart reviews identified lingering pain 90-180 days post-HZ diagnosis and the Zoster Brief Pain Inventory was administered 90 days post-HZ diagnosis by telephone. Frequencies of PHN identified with each approach were cross-tabulated and stratified by sex, age group, and zoster vaccine live vaccination status.

RESULTS

Chart review and self-report were largely concordant (n=875, 89.20%); however, chart review yielded lower PHN risk overall and for the stratified subgroups. PHN from self-report was substantially higher (6.30-8.33%) among patients who were male, ≥70 years, or unvaccinated. Among those who typically seek care more often (female, younger, vaccinated), the discrepancy between each method was notably lower (1.60-2.92%).

CONCLUSION

Our findings suggest that chart review underestimates cases among those less likely to seek health care, including males, the elderly, and unvaccinated individuals. The agreement between the methods indicates that each can provide a reasonable approximation of PHN, but analyses should carefully control for health-care utilization.

Neurological and Ophthalmological Manifestations of Varicella Zoster Virus

BACKGROUND

Approximately 1 million new cases of herpes zoster (HZ) occur in the United States annually, including 10%-20% with herpes zoster ophthalmicus (HZO). Postherpetic neuralgia, a debilitating pain syndrome occurs in 30% HZ, whereas 50% HZO develop ophthalmic complications. Diplopia from cranial nerve palsy occurs in less than 30% HZO, whereas optic neuropathy is seen in less than 1% HZO. We reviewed recent developments in the diagnosis, treatment, and prevention of HZ as well as neurological and ophthalmological complications of relevance to the neuro-ophthalmologist.

EVIDENCE ACQUISITION

We searched the English language literature on Pubmed and Google scholar for articles relevant to the various sections of this review.

RESULTS

Antiviral treatment should be initiated within 48-72 hours of onset of HZ and HZO to decrease pain and reduce complications. We recommend neuroimaging in all patients with neuro-ophthalmic manifestations such as diplopia and acute vision loss. Diagnostic confirmation using polymerase chain reaction and serology on paired serum and cerebrospinal fluid samples should be obtained in those with neurological signs and symptoms or abnormal imaging. Patients with neurological and/or retinal varicella zoster virus (VZV) infection should be treated promptly with intravenous acyclovir. Patients with isolated optic neuropathy or cranial nerve palsy can be managed with oral antivirals. The prognosis for visual recovery is good for patients with isolated optic neuropathy and excellent for patients with isolated ocular motor cranial nerve palsy.

CONCLUSIONS

HZ produces a spectrum of potentially blinding and life-threatening complications that adversely affect quality of life and increase health care costs. Individuals at risk for HZ, such as the elderly and immunocompromised, should be encouraged to receive the highly effective VZV vaccine to prevent HZ and its complications.

Effectiveness and cost-effectiveness of vaccination against herpes zoster in Canada: a modelling study

BACKGROUND

Two vaccines against herpes zoster are currently authorized for use in Canada: the recombinant subunit zoster vaccine and live attenuated zoster vaccine. We compared the effectiveness and cost-effectiveness of these 2 vaccines.

METHODS

We used a decision analytic static cohort model parametrized with Canadian epidemiologic and economic data. We performed the economic analysis from the health care system perspective, using a lifetime horizon and a 3% discount rate for costs and benefits. The primary outcome was the incremental cost per quality-adjusted life-year (QALY) gained, relative to no vaccination. We ran 30 000 simulations varying all model parameters, including vaccine costs, efficacy and waning.

RESULTS

The number needed to vaccinate (NNV) was higher for the live attenuated zoster vaccine than for the recombinant subunit zoster vaccine for all herpes zoster-related events at all ages. For example, in persons exactly 65 years old, for herpes zoster, median NNV was 21 (90% uncertainty interval [UI] 13-31) versus 8 (90% UI 6-18), and for postherpetic neuralgia, NNV was 64 (90% UI 33-93) versus 31 (90% UI 23-73). For the recombinant vaccine, the median cost-effectiveness ratios varied between cost-saving and $25 881 per QALY gained for adults aged 50 years or older. For the live vaccine, the cost-effectiveness ratios varied between cost-saving and $130 587 per QALY gained and were less than $45 000 per QALY gained only for those 65 to 75 years old. Given its higher efficacy, we estimated that the cost for the complete series of the recombinant vaccine could be $150 to $200 more than the cost of the live vaccine and still be considered cost-effective.

INTERPRETATION

Our model predicted that the recombinant subunit zoster vaccine is likely cost-effective in Canada for adults 60 years or older, and is likely more cost-effective than live attenuated zoster vaccine. These results have informed updated national and provincial recommendations on herpes zoster vaccination.

Herpes Zoster Presentation, Management, and Prevention: A Modern Case-Based Review

Herpes zoster (HZ) is a common cutaneous entity with protean clinical presentations, management options, complication rates, and prevention strategies, all of which are rife with dogma. During an inpatient consultation for HZ, have you ever been approached by a frantic staff or family member, worried that a pregnant, elderly, or infant contact will be 'infected' if they get too close? Have your patients ever asked you about their risk of having HZ twice, or claimed that they have frequent 'recurrences'? In what timeline should antiviral therapy be employed? Is there evidence for prednisone or gabapentin in acute HZ treatment? Who should be vaccinated against HZ and what are the benefits and risks? In case-based form, these and other complex but common scenarios will be examined using clinical and viral mechanistic clues, along with updated treatment and prevention guidelines, to provide a modern HZ case management compendium, comprehensive of the diverse age and health populations now presenting with this condition.

Public Health Impact and Cost-Effectiveness of Non-live Adjuvanted Recombinant Zoster Vaccine in Canadian Adults

OBJECTIVES

In Canada, incidences of herpes zoster (HZ) and postherpetic neuralgia (PHN) are increasing, posing a significant burden on the healthcare system. This study aimed to determine the public health impact and cost effectiveness of an adjuvanted recombinant zoster vaccine (RZV) compared to no vaccination and to the live attenuated vaccine (ZVL) in Canadians aged 60 years and older.

METHODS

A multi-cohort Markov model has been adapted to the Canadian context using recent demographic and epidemiologic data. Simulations consisted of age-cohorts annually transitioning between health states. Health outcomes and costs were discounted at 1.5% per year. The perspective of the Canadian healthcare payer was adopted. A coverage of 80% for the first RZV and ZVL dose and a compliance of 75% for the second RZV dose were assumed.

RESULTS

RZV was estimated to be cost effective compared with no vaccination with an incremental cost-effectiveness ratio (ICER) of $28,360 (Canadian dollars) per quality-adjusted life-year (QALY) in persons aged ≥ 60 years, avoiding 554,504 HZ and 166,196 PHN cases. Compared with ZVL, RZV accrued more QALYs through the remaining lifetime and an increase in costs of approximately $50 million resulting in an average ICER of $2396. Results were robust under deterministic and probabilistic sensitivity analyses. HZ incidence rate and persistence of vaccine efficacy had the largest impact on cost effectiveness.

CONCLUSIONS

The cost-utility analysis suggested that RZV would be cost effective in the Canadian population compared with no vaccination and vaccination with ZVL at a willingness-to-pay threshold of $50,000.

Complete resolution of postherpetic neuralgia following pallidotomy: case report

The authors report on a female patient with left-dominant Parkinson's disease with motor fluctuations and levodopa-induced dyskinesias and comorbid postherpetic neuralgia (PHN), who underwent a right-sided pallidotomy. Besides a substantial improvement in her Parkinson's symptoms, she reported an immediate and complete disappearance of PHN. This neuralgia had been long-standing, pharmacologically refractory, and severe (preoperative Brief Pain Inventory [BPI] pain severity score of 8.0, BPI pain interference score of 7.3, short-form McGill Pain Questionnaire sensory pain rating index of 7 and affective pain rating index of 10, Present Pain Intensity rank value of 4, and visual analog scale score of 81 mm; all postoperative scores were 0). She continued to be pain free at 16 months postoperatively.This peculiar finding adds substantially to the largely unrecognized evidence for the role of the pallidum in pain processing, based on previous electrophysiological, metabolic, anatomical, pharmacological, and clinical observations. Therefore, the potential of the pallidum as a neurosurgical target for neuropathic pain warrants further investigation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound Guided Continuous Sciatic Nerve Block for Acute Herpetic Neuralgia

Herpes Zoster (HZ) is the reactivation of a well-known viral disease which manifests itself with painful skin lesions. An effective analgesic method during the acute phase of HZ can contribute to decrease the incidence of postherpetic neuralgia (PHN) by reducing neural sensitization. Sciatic nerve block (SNB) is useful in the management of distal lower extremity pain sustained by the sciatic nerve. We describe our experience with a continuous ultrasound guided subgluteus sciatic nerve block in a patient with herpetic neuralgia- (HN-) related refractory acute left leg pain.

Cross-sectional study on hospitalizations related to herpes zoster in an Italian region, 2008-2016

INTRODUCTION

To assess the burden of herpes zoster (HZ) by analyzing HZ-related hospital admissions.

METHODS

We conducted a population-based descriptive cross-sectional study on all hospitalizations for HZ among the resident population admitted to all public and accredited private hospitals in the Veneto Region (north-east Italy) during the years 2008-2016. HZ hospitalizations were identified from the International Classification of Diseases codes in the hospital discharge records.

RESULTS

During the period considered, we identified 3566 HZ-associated admissions, 194 (5.4%) of which were readmissions within 30 days. A complicated HZ diagnosis was mentioned for 44.4% of the patients admitted once and for 65.9% of those admitted twice. In the sample as a whole, 27.0% of patients had at least one comorbidity. Overall, our analysis revealed a gradual increase in hospitalizations with age for both genders, reaching a hospitalization rate for the population over 80 years old of 51.2 × 100,000 for males and 52.8 × 100,000 for females. The average hospitalization rate for HZ-related conditions during the years 2008-2016 was 7.7 per 100,000 population. Postherpetic neuralgia was diagnosed in 8.2% of hospitalizations, with no difference between the genders. The estimated overall cost of HZ-related conditions was approximately €2.7 million a year.

CONCLUSIONS

This study suggests that the burden of HZ and its impact on quality of life are of critical relevance to public health decision-making.

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.

Acute pain and postherpetic neuralgia related to Varicella zoster virus reactivation: Comparison between typical herpes zoster and zoster sine herpete

Herpes zoster (HZ) is typically characterized by pain involving the area of vesicular eruption. Several patients, however, complain of unilateral radicular pain without rash (zoster sine herpete [ZSH]). To evaluate whether the severity and duration of pain and the use of analgesics are greater in ZSH patients than in typical HZ with rash, 16 consecutive patients with acute unilateral pain, without vesicular eruption (ZSH), were compared with 16 controls suffering from typical HZ eruption. Only patients with laboratory evidence of varicella-zoster virus (VZV) reactivation were selected. Serum samples were obtained from all patients at their initial visit and 1 and 2 months later. Monthly, the administered therapies and the average pain score (visual analog scale [VAS] score) were recorded. VZV DNA persisted statistically higher in ZSH sera than HZ sera 1 month after onset (P = 0.0007). ZSH patients averaged greater pain than HZ patients, scoring VAS 76.88 and 66.88 ( P = 0.0012), respectively. ZSH patients used significantly more opioid therapy than HZ patients ( P = 0.0449; OR, 9.00). This is the first study comparing pain in ZSH and HZ patients: greater severity and duration of pain and more opioid use was detected in patients with ZSH.

The Neuralgias

PURPOSE OF REVIEW

Neuralgias are characterized by pain in the distribution of a cranial or cervical nerve. Typically, they are brief, paroxysmal, painful attacks, although continuous neuropathic pain may occur. The most commonly encountered conditions are trigeminal, postherpetic, and occipital neuralgia. Less common neuralgias include glossopharyngeal, superior laryngeal, auriculotemporal, and nervus intermedius neuralgia, among others. The approach to diagnosis and treatment of this group of disorders is reviewed.

RECENT FINDINGS

Recent guidelines of medication administration, the use of botulinum toxin, and more targeted procedures have improved treatment of neuralgias. Patients who present with neuralgias should have imaging studies to investigate for structural abnormalities unless the etiology is apparent. Management of both common and rare neuralgias can be challenging and is best guided by the most recent available evidence.

Measuring herpes zoster disease burden in São Paulo, Brazil: a clinico-epidemiological single-center study

OBJECTIVES

Herpes zoster is characterized by acute neuritis and post-herpetic neuralgia. Currently, data concerning the zoster-associated impact on quality of life and healthcare resource utilization in Brazil are scarce. This study measured the zoster-associated burden in a Brazilian population.

METHODS

This was a prospective, observational, single-cohort study conducted in a primary hospital's emergency room in São Paulo, Brazil. Patients enrolled at various timepoints during a zoster episode were followed over 180 days. The Zoster Brief Pain Inventory and the Initial Zoster Impact Questionnaire assessed zoster-associated pain. The EuroQoL assessed the impact of herpes zoster and/or zoster-associated pain on quality of life. Healthcare resource utilization was assessed by patient-reported questionnaires.

RESULTS

One-hundred forty-six zoster patients were enrolled [mean (SD) age of 69.9 (10.9) years]. Mean (SD) worst pain scores decreased from 5.3 (3.5) at baseline to 1.9 (3.0) 180 days following rash onset. Mean (SD) EuroQoL scores significantly decreased from 0.9 (0.2) before rash appearance to 0.7 (0.2) after rash onset (p<0.001), followed by gradual improvements in quality of life over 180 days, with pre-herpes zoster quality of life achieved at the end of the observation period. The majority of patients purchased prescription medications (89.7%) and required doctor's office visits (65.8%) for zoster episodes.

CONCLUSIONS

Herpes zoster is associated with a significant disease burden, including zoster-associated pain, impaired quality of life and increased healthcare resource utilization in Brazil. These results support the implementation of early intervention and prevention programs such as vaccinations to reduce the herpes zoster-associated disease burden in Brazil.

Burden of herpes zoster in 16 selected immunocompromised populations in England: a cohort study in the Clinical Practice Research Datalink 2000-2012

OBJECTIVES

Herpes zoster (HZ) is caused by reactivation of varicella-zoster virus which remains latent in individuals after a varicella infection. It is expected that HZ will be more frequent in immunocompromised (IC) individuals than in immunocompetent (IC-free). This study assessed the incidence rate (IR) of HZ in individuals with a wide set of IC conditions and in IC-free individuals.

SETTING

A retrospective cohort study was conducted in England using data (January 2000 to March 2012) from the Clinical Practice Research Datalink with linkage to the Hospital Episodes Statistics.

PARTICIPANTS

A cohort of 621 588 individuals with 16 selected IC conditions and a gender/age-matched cohort of IC-free individuals were identified. The IC conditions included haematopoietic stem cell transplant (HSCT), solid organ transplant, malignancies, autoimmune diseases and users of immunosuppressive medications.

OUTCOMES

IR of HZ per 1000 person-years (PY) was estimated. Proportions of postherpetic neuralgia (PHN) and other HZ complications within 90 days of HZ onset were also estimated among patients with HZ. Risk factors for PHN in IC individuals with HZ were assessed by a multivariate regression model.

RESULTS

The overall IR of HZ in the IC cohort was 7.8/1000 PY (95% CI 7.7 to 7.9), increasing with age from 3.5/1000 PY (3.4-3.7) in individuals aged 18-49 years to 12.6/1000 PY (12.2-13.0) in individuals aged ≥80 years. This IR in the IC-free cohort was 6.2/1000 PY (6.1-6.3). The overall IR of HZ varied across IC conditions, ranging from 5.3 (5.1-5.5) in psoriasis to 41.7/1000 PY (35.7-48.4) in HSCT. The proportions of PHN and other HZ complications were 10.7% (10.2-11.1) and 2.9% (2.7-3.2) in the IC cohort, but 9.1% (8.7-9.5) and 2.3% (2.1-2.6) in the IC-free cohort, respectively.

CONCLUSION

IC population contributes to the public health burden of HZ in England. Vaccination might be the most preferable HZ preventive measure for the IC population.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

FV-100 versus valacyclovir for the prevention of post-herpetic neuralgia and the treatment of acute herpes zoster-associated pain: A randomized-controlled trial

This prospective, parallel-group, randomized, double-blind, multicenter study compared the efficacy and safety of FV-100 with valacyclovir for reducing pain associated with acute herpes zoster (HZ). Patients, ≥50 years of age, diagnosed with HZ within 72 h of lesion appearance who had HZ-associated pain, were randomized 1:1:1 to a 7-day course of either FV-100 200 mg QD (n = 117), FV-100 400 mg QD (n = 116), or valacyclovir 1000 mg TID (n =117). Efficacy was evaluated on the basis of the burden of illness (BOI; Zoster Brief Pain Inventory scores); incidence and duration of clinically significant pain (CSP); pain scores; incidence and severity of post-herpetic neuralgia (PHN); and times to full lesion crusting and to lesion healing. Safety was evaluated on the basis of adverse event (AE)/SAE profiles, changes in laboratory and vital signs values, and results of electrocardiograms. The burden of illness scores for pain through 30 days were 114.5, 110.3, and 118.0 for FV-100 200 mg, FV-100 400 mg, and valacyclovir 3000 mg, respectively. The incidences of PHN at 90 days for FV-100 200 mg, FV-100 400 mg, and valacyclovir 3000 mg were 17.8%, 12.4%, and 20.2%, respectively. Adverse event and SAE profiles of the two FV-100 and the valacyclovir groups were similar and no untoward signals or trends were evident. These results demonstrate a potential for FV-100 as an antiviral for the treatment of shingles that could both reduce the pain burden of the acute episode and reduce the incidence of PHN compared with available treatments.

Herpes zoster - typical and atypical presentations

Varicella- zoster virus infection is an intriguing medical entity that involves many medical specialties including infectious diseases, immunology, dermatology, and neurology. It can affect patients from early childhood to old age. Its treatment requires expertise in pain management and psychological support. While varicella is caused by acute viremia, herpes zoster occurs after the dormant viral infection, involving the cranial nerve or sensory root ganglia, is re-activated and spreads orthodromically from the ganglion, via the sensory nerve root, to the innervated target tissue (skin, cornea, auditory canal, etc.). Typically, a single dermatome is involved, although two or three adjacent dermatomes may be affected. The lesions usually do not cross the midline. Herpes zoster can also present with unique or atypical clinical manifestations, such as glioma, zoster sine herpete and bilateral herpes zoster, which can be a challenging diagnosis even for experienced physicians. We discuss the epidemiology, pathophysiology, diagnosis and management of Herpes Zoster, typical and atypical presentations.

Burden of herpes zoster and postherpetic neuralgia in Japanese adults 60 years of age or older: Results from an observational, prospective, physician practice-based cohort study

Approximately one in three persons will develop herpes zoster during their lifetime, and it can lead to serious complications such as postherpetic neuralgia. However, evidence on burden of herpes zoster and postherpetic neuralgia in Japan is limited. This prospective, observational, multicenter, physician practice-based cohort study was conducted in Kushiro, Hokkaido, Japan (Clinicaltrials.gov identifier NCT01873365) to assess the incidence and hospitalization rates of herpes zoster, and the proportion, clinical burden and risk factors for postherpetic neuralgia in adults aged 60 years or more. Within the study area, 800 subjects developed herpes zoster and 412 were eligible for the study. Herpes zoster incidence was 10.2/1000 person-years and higher among women and older subjects. Subjects with herpes zoster required on average 5.7 outpatient consultations. Herpes zoster-associated hospitalization rate was 3.4% (27/800). The proportion of postherpetic neuralgia and other complications was 9.2% (38/412) and 26.5% (109/412), respectively. Statistically significant association with the development of postherpetic neuralgia was male sex (odds ratio [OR], 2.51; 95% confidence interval [CI], 1.17-5.38), age of 70-74 years (OR, 3.51; 95% CI, 1.09-11.3), immunosuppressive therapy (OR, 6.44; 95% CI, 1.26-32.9), severe herpes zoster pain at first consultation (OR, 3.08; 95% CI, 1.10-8.62) and rash on upper arms (vs no rash on upper arms; OR, 3.46; 95% CI, 1.10-10.9). Considerable herpes zoster and postherpetic neuralgia burden exists among elderly in Japan, and there may be predictive factors at the first visit which could be indicative of the risk of developing postherpetic neuralgia.

Pain, Itch, Quality of Life, and Costs after Herpes Zoster

BACKGROUND

Herpes zoster (HZ) and postherpetic neuralgia are known to have a profound effect on the patient's quality of life, but the incidence and severity of itch and its relation with pain and quality of life in the long term are still relatively unknown.

OBJECTIVE

The aim of this study was to measure the presence and severity of pain and itch and impact on quality of life in patients over 50 years old with HZ.

METHODS

We enrolled 661 patients with HZ in this 12-month observational study. Patient data were collected via a web-based questionnaire. Outcomes were pain, itch, burden of illness, impact on patient's daily life, impact on quality of life, and healthcare costs.

RESULTS

At inclusion, 94% of patients reported any pain, 74.3% significant pain, and 26% severe pain. After 3 months, 18.8% of patients suffered from postherpetic neuralgia. At inclusion, 70.8% of patients had any itch, 39.2% significant itch, and 7.3% severe itch. The occurrence of pain increases costs and has a high impact on the quality of life, lowering EQ-5D scores by an average of 18%. In contrast, itch has little effect on the quality of life.

CONCLUSIONS

Pain and itch are highly prevalent months after HZ. Pain caused by HZ has a large impact on quality of life, burden of illness, impact on daily life, and health care costs for these patients. The impact of itch on quality of life is relatively small.

A systematic review and meta-analysis of risk factors for postherpetic neuralgia

Supplemental Digital Content is Available in the Text.

Patients with herpes zoster can develop persistent pain after rash healing, a complication known as postherpetic neuralgia. By preventing zoster through vaccination, the risk of this common complication is reduced. We searched MEDLINE and Embase for studies assessing risk factors for postherpetic neuralgia, with a view to informing vaccination policy. Nineteen prospective studies were identified. Meta-analysis showed significant increases in the risk of postherpetic neuralgia with clinical features of acute zoster including prodromal pain (summary rate ratio 2.29, 95% confidence interval: 1.42-3.69), severe acute pain (2.23, 1.71-2.92), severe rash (2.63, 1.89-3.66), and ophthalmic involvement (2.51, 1.29-4.86). Older age was significantly associated with postherpetic neuralgia; for individual studies, relative risk estimates per 10-year increase ranged from 1.22 to 3.11. Evidence for differences by gender was conflicting, with considerable between-study heterogeneity. A proportion of studies reported an increased risk of postherpetic neuralgia with severe immunosuppression (studies, n = 3/5) and diabetes mellitus (n = 1/4). Systemic lupus erythematosus, recent trauma, and personality disorder symptoms were associated with postherpetic neuralgia in single studies. No evidence of higher postherpetic neuralgia risk was found with depression (n = 4) or cancer (n = 5). Our review confirms a number of clinical features of acute zoster are risk factors for postherpetic neuralgia. It has also identified a range of possible vaccine-targetable risk factors for postherpetic neuralgia; yet aside from age-associated risks, evidence regarding risk factors to inform zoster vaccination policy is currently limited.

Cost-effectiveness analysis of a vaccination program for the prevention of herpes zoster and post-herpetic neuralgia in adults aged 50 and over in Germany

Herpes zoster (HZ; shingles) is a common viral disease that affects the nerves and surrounding skin causing a painful dermatomal rash and leading to debilitating complications such as, mainly, post-herpetic neuralgia (PHN). Currently, there is no effective treatment for HZ and PHN. The objective of this study was to assess the cost-effectiveness of a HZ vaccination program in Germany. An existing Markov Model was adapted to the German healthcare setting to compare a vaccination policy to no vaccination on a lifetime time-horizon, considering 2 scenarios: vaccinating people starting at the age of 50 or at the age of 60 years, from the perspective of the statutory health insurance (SHI) and the societal perspective. According to the perspective, vaccinating 20% of the 60+ German population resulted in 162,713 to 186,732 HZ and 31,657 to 35,793 PHN cases avoided. Corresponding incremental cost-effectiveness ratios (ICER) were 39,306 €/QALY from the SHI perspective and 37,417 €/QALY from a societal perspective. Results for the 50+ German population ranged from 336,468 to 394,575 HZ and from 48,637 to 56,087 PHN cases avoided from the societal perspective. Corresponding ICER were 39,782 €/QALY from a SHI perspective and 32,848 €/QALY from a societal perspective. Sensitivity analyses showed that results are mainly impacted by discount rates, utility values and use of alternative epidemiological data.The model indicated that a HZ vaccination policy in Germany leads to significant public health benefits and could be a cost-effective intervention. The results were robust and consistent with local and international existing literature.

Efficacy of low dose gabapentin in acute herpes zoster for preventing postherpetic neuralgia: a prospective controlled study

Postherpetic neuralgia (PHN) is a sequela of herpes zoster that adversely affects quality of life seriously. The risk factors for PHN are well known but the effective interventions that reduce the incidence of PHN are less studied. The objective of this study is to evaluate the efficacy of treatment with gabapentin in patients with acute herpes zoster for preventing PHN. We performed a prospective randomized controlled study of 120 participants diagnosed with acute herpes zoster, aged 50 and over and complaining moderate to severe pain. All patients were treated with valacyclovir and acetaminophen. Half of the participants were assigned to the gabapentin group and received gabapentin 300 mg three times a day additionally. The intensity of pain at every visit and the incidence of PHN in both groups were measured. Total 52 and 49 patients in the gabapentin group and the control group, respectively, had completed 12 weeks of follow-up period. Although the incidence of PHN was higher in the control group, the difference was not statistically significant (6.1% vs. 3.8%, p = 0.67). Our results indicate that the use of low-dose gabapentin in acute herpes zoster seems not effective in the prevention of PHN.

Adjuvanted herpes zoster subunit vaccine

This review highlights the characteristics of a candidate herpes zoster (HZ) vaccine (HZ/su, GlaxoSmithKline Vaccines) that consists of 50 μg recombinant glycoprotein E (gE) of varicella zoster virus adjuvanted with AS01B. It is well tolerated and shows a clinically acceptable tolerability profile. It strongly enhances pre-existing gE-specific CD4+ T-cell and anti-gE antibody responses in older adults and immunocompromised persons. Administration of two doses 2 months apart reduces the risk of HZ by 97.2% in adults ≥50 years. This effect does not diminish with increasing age. Long-term persistence of its efficacy still needs to be determined. This candidate HZ vaccine may become an alternative for the high-dose live-attenuated varicella zoster virus vaccine for the prevention of HZ in older persons and in immunocompromised patients in whom the use of live-attenuated vaccines is contraindicated.

Local Injection of Methylcobalamin Combined with Lidocaine for Acute Herpetic Neuralgia

OBJECTIVE

To determine the efficacy of methylcobalamin combined with lidocaine for acute herpetic neuralgia.

DESIGN

Randomized controlled trial with longitudinal analysis.

SUBJECTS

The authors recruited 204 patients (>50 years) with T5-10 dermatomal acute herpetic neuralgia with rash onset within 7 days. Patients were divided into two groups based on the time of onset: immediate-early (IE, 1-3 days) and early stage (ES, 4-7 days) groups and then subdivided randomly into control (IE-Ctl, ES-Ctl) and treatment (IE-Tr, ES-Tr) groups.

METHODS

Control groups received intramuscular methylcobalamin in addition to local lidocaine injection, while treatment groups received local methylcobalamin combined with lidocaine injection for 14 days. Treatment efficacy was assessed based on rash healing time, alteration in pain intensity, and interference with quality of life. Multilevel mixed modeling and survival analysis were employed to examine treatment responses.

RESULTS

There was no significant difference in the rash healing time between IE and ES. The mean pain scores in IE-Tr (2.4 ± 0.7) and ES-Tr (1.3 ± 0.7) decreased significantly compared with those in the control groups. The median satisfactory response time was 6 days in ES-Tr and 11 days in IE-Tr. The benefit ratio for ES-Tr versus IE-Tr was 14.94. The subjects in IE-Tr and ES-Tr had higher quality of life scores (81.2 ± 6.9 vs 88.3 ± 8.6, respectively) than those in the control groups. The incidence of postherpetic neuralgia was 1.1% at 3 months.

CONCLUSIONS

Local methylcobalamin combined with lidocaine, optimally administered within 4-7 days of onset, may be an effective therapeutic option for acute herpetic neuralgia.

Treatment of herpes zoster with ultrasound-guided superficial cervical plexus block

Herpes zoster most commonly occurs in elderly patients, and usually affects sensory neurons. Therefore, its characteristic symptoms are segmental pain, itching, and sensory changes in the affected areas. A 71-yr-old woman experienced painful herpetic rash on the right cervical 2-4 dermatomes for 16 days. Two days after the onset of the rash, she was diagnosed with herpes zoster, and prescribed 250 mg famciclovir three times a day for 7 days, pregabalin 150 mg twice a day, and tramadol 150 mg once a day for 14 days, by a dermatologist. Despite medication, her pain was rated at an intensity of 6/10 on the numeric rating scale. In addition, she complained of severe itching sensation on the affected dermatomes. Superficial cervical plexus block (SCPB) was performed at the right C4 level with 15 ml 0.5% lidocaine plus triamcinolone 30 mg. Five days after the procedure, pain and itching completely disappeared. SCPB may be an effective option for the treatment of acute pain and itching arising from herpes zoster, and for the prevention of postherpetic neuralgia.

Anti-cytokine autoantibodies in postherpetic neuralgia

BACKGROUND

The mechanisms by which varicella zoster virus (VZV) reactivation causes postherpetic neuralgia (PHN), a debilitating chronic pain condition, have not been fully elucidated. Based on previous studies identifying a causative role for anti-cytokine autoantibodies in patients with opportunistic infections, we explored this possibility in PHN.

METHODS

Sera from herpes zoster (HZ) patients without and with PHN (N = 115 and 83, respectively) were examined for the presence of autoantibodies against multiple cytokines, and other known autoantigens. In addition, a cohort of patients with complex regional pain syndrome or neuropathic pain was tested for autoantibodies against selected cytokines. Antibody levels against VZV, Epstein Barr virus, and herpes simplex virus-2 were also measured in the HZ and PHN patients. Patient sera with high levels of anti-cytokine autoantibodies were functionally tested for in vitro neutralizing activity.

RESULTS

Six PHN subjects demonstrated markedly elevated levels of single, autoantibodies against interferon-α, interferon-γ, GM-CSF, or interleukin-6. In contrast, the HZ and the pain control group showed low or no autoantibodies, respectively, against these four cytokines. Further analysis revealed that one PHN patient with high levels of anti-interleukin-6 autoantibodies had a markedly depressed antibody level to VZV, potentially reflecting poor T cell immunity against VZV. In vitro functional testing revealed that three of the five anti-cytokine autoantibody positive PHN subjects had neutralizing autoantibodies against interferon-α, GM-CSF or interleukin-6. In contrast, none of the HZ patients without PHN had neutralizing autoantibodies.

CONCLUSIONS

These results suggest the possibility that sporadic anti-cytokine autoantibodies in some subjects may cause an autoimmune immunodeficiency syndrome leading to uncontrolled VZV reactivation, nerve damage and subsequent PHN.

Functional decline and herpes zoster in older people: an interplay of multiple factors

Herpes zoster is a frequent painful infectious disease whose incidence and severity increase with age. In older people, there is a strong bidirectional link between herpes zoster and functional decline, which refers to a decrement in ability to perform activities of daily living due to ageing and disabilities. However, the exact nature of such link remains poorly established. Based on the opinion from a multidisciplinary group of experts, we here propose a new model to account for the interplay between infection, somatic/psychiatric comorbidity, coping skills, polypharmacy, and age, which may account for the functional decline related to herpes zoster in older patients. This model integrates the risk of decompensation of underlying disease; the risk of pain becoming chronic (e.g. postherpetic neuralgia); the risk of herpes zoster non-pain complications; the detrimental impact of herpes zoster on quality of life, functioning, and mood; the therapeutic difficulties due to multimorbidity, polypharmacy, and ageing; and the role of stressful life events in the infection itself and comorbid depression. This model underlines the importance of early treatment, strengthening coping, and vaccine prevention.

Pain Intensity and Pain Interference in Patients With Lung Cancer: A Pilot Study of Biopsychosocial Predictors

OBJECTIVE

To explore biopsychosocial factors (beliefs, depression, catastrophizing cytokines) in individuals newly diagnosed with lung cancer and no pain to determine their relationship at diagnosis and across time and to determine whether these factors contribute to pain intensity or pain interference with function at pain onset.

MATERIALS AND METHODS

A longitudinal, exploratory, pilot study was implemented in a private medical center and a VA medical center in the southeast. Twelve subjects not experiencing pain related to cancer of the lung or its treatment were recruited. A Karnofsky status of 40% and hemoglobin of 8 g were required. Five questionnaires were completed and 10 mL of blood was drawn at baseline; 4 questionnaires and blood draws were repeated monthly for 5 months. One baseline questionnaire and a pain assessment were added at final. Demographic, clinical, and questionnaire data were summarized; standardized scale scores were calculated.

RESULTS

Biopsychosocial scores that were low at baseline increased from T1-T4 but decreased slightly T5-T6. Individuals with higher pain intensity and higher pain interference at final had higher psychosocial scores at baseline than individuals with lower pain intensity and lower pain interference at final.

CONCLUSIONS

Unrelated to disease stage, metastasis, or treatment, unique levels of biopsychosocial factors are observed in patients newly diagnosed with lung cancer who report higher levels of pain intensity and higher levels of pain interference at the time pain occurs. Replication studies are needed to validate this response pattern and determine the value of repeated individual assessments.

Local Administration of Methylcobalamin and Lidocaine for Acute Ophthalmic Herpetic Neuralgia: A Single-Center Randomized Controlled Trial

OBJECTIVES

To determine the therapeutic efficacy of combined methylcobalamin and lidocaine for acute ophthalmic herpetic neuralgia (AOHN).

METHODS

Based on the onset, patients with AOHN (n = 98) were randomly allocated into groups A (≤ 3 days) and B (4 to 7 days) and then subdivided into control (A0, B0; received intramuscular methylcobalamin in addition to local lidocaine injection) and treatment (A1, B1; received local injection of the methylcobalamin and lidocaine combination for 14 days) groups. Treatment efficacy was assessed based on rash healing time, alteration of pain intensity, and interference with quality of life. Multilevel modeling and survival analysis were performed.

RESULTS

The time (hours) to start and full opening of the affected eye and the time (hours) to start and full crusting were significantly reduced in both treatment groups (P < 0.05 vs. controls). The mean pain scores in A1 (2.6 ± 0.7) and B1 (1.2 ± 0.8) decreased significantly compared with those in A0 (7.0 ± 1.7) and B0 (5.6 ± 1.9), and the difference between the two therapeutic strategies significantly increased over time. The median minimum intervention time was 6 days in B1 and 11 days in A1. The incidence of postherpetic neuralgia (PHN) was 2.04% at 3 months.

CONCLUSIONS

Methylcobalamin combined with lidocaine mediated detumescence and improved cutaneous healing of the affected area, as well as a significant and sustained analgesic effect on AOHN. The incidence of PHN was also significantly decreased. Local methylcobalamin intervention within 4 to 7 days of onset may be an effective therapeutic option for AOHN.

Herpes zoster epidemiology, management, and disease and economic burden in Europe: a multidisciplinary perspective

Herpes zoster (HZ) is primarily a disease of nerve tissue but the acute and longer-term manifestations require multidisciplinary knowledge and involvement in their management. Complications may be dermatological (e.g. secondary bacterial infection), neurological (e.g. long-term pain, segmental paresis, stroke), ophthalmological (e.g. keratitis, iridocyclitis, secondary glaucoma) or visceral (e.g. pneumonia, hepatitis). The age-related increased incidence of HZ and its complications is thought to be a result of the decline in cell-mediated immunity (immunosenescence), higher incidence of comorbidities with age and social-environmental changes. Individuals who are immunocompromised as a result of disease or therapy are also at increased risk, independent of age. HZ and its complications (particularly postherpetic neuralgia) create a significant burden for the patient, carers, healthcare systems and employers. Prevention and treatment of HZ complications remain a therapeutic challenge despite recent advances. This is an overview of the multidisciplinary implications and management of HZ in which the potential contribution of vaccination to reducing the incidence HZ and its complications are also discussed.

Predictors of postherpetic neuralgia in patients with herpes zoster: a pooled analysis of prospective cohort studies from North and Latin America and Asia

OBJECTIVES

The most common complication of herpes zoster (HZ) is postherpetic neuralgia (PHN), a persistent pain that can substantially affect quality of life (QoL). This analysis aimed to evaluate predictors of PHN in HZ patients.

METHODS

A pooled analysis of prospective cohort studies of HZ patients aged ≥ 50 years from North America (Canada), Latin America (Brazil, Mexico, and Argentina), and Asia (Taiwan, South Korea, and Thailand) was performed. Patients within 14 days of rash onset were included. The incidence of PHN was defined as a worst pain score of ≥ 3, persisting/appearing at >90 days after rash onset. Socio-demographics, HZ disease characteristics, treatment, pain-related interference with activities of daily living, and health-related QoL were assessed.

RESULTS

Of 702 patients with HZ, 148 (21.1%) developed PHN. Similar risks of PHN were observed across geographic regions. On multivariate analysis, older age, greater severity of pain at rash onset, employment status, walking problems at enrollment, and pain interference affecting social relationships were significantly associated with the development of PHN.

CONCLUSIONS

In addition to older age and severe acute pain, this study suggests that impaired physical and social functioning from acute zoster pain may play a role in the development of PHN in this prospective cohort study of HZ patients from North and Latin America and Asia.