A systematic literature review to assess the burden of herpes zoster disease in China

Diagnostic ability for common skin diseases among general practitioners working in community health service centers in Shanghai, China: a cross-sectional study

OBJECTIVE

Primary care general practitioners (GPs) play a crucial role in common skin diseases (CSDs) diagnosis and treatment for community residents. This study investigates their clinical diagnostic ability for CSDs and influencing factors among GPs in Shanghai.

METHODS

In 2023, we recruited 5745 GPs in Shanghai, and online survey was conducted among 5745 GPs with written informed consents. Images of ten CSDs was used to evaluate the diagnostic ability among GPs, logistic regression (LR) analysis was applied to explore influencing factors in GPs with a good skin diseases diagnostic ability.

RESULTS

The 5745 GPs included 1740 male (30.3%), the age ranged from 25 to 60 years with an average of age of 40.8 years. The total score for GSDs diagnostic ability ranged from 2 to 10, with a median of 7.5. In this study, GPs who have achieved ≥ 9 scores were identified as GPs with good diagnostic ability, with a prevalence of 26.7%. LR analysis indicated that GPs with 11 to 15 and over 15 years of work experience had a higher prevalence of good diagnostic ability compared with those with <5 years, the OR was 1.23 (95% CI: 1.02-1.48) and 1.25 (95% CI: 1.05-1.49) respectively. GPs with advanced studies [OR = 1.61, 95% CI:1.33-1.95] and work experience [OR = 1.39, 95% CI:1.20-1.61] in dermatology had a higher prevalence of good diagnostic ability.

CONCLUSION

The diagnostic ability for CSDs was good among GPs in Shanghai. GPs with more years of work, advanced studies and work experience in dermatology have better diagnostic abilities CSDs.

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.

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.

The barriers and facilitators of herpes zoster vaccination intentions of urban residents in China: a qualitative study

BACKGROUND

In an aging society, herpes zoster (HZ) increases the health burden on infected patients. While quantitative studies point to a lack of willingness to accept the HZ vaccine in China, there is limited number of studies with in-depth qualitative analysis on HZ vaccination intention. This study undertakes a qualitive study method to identify the barriers and facilitators behind urban residents' HZ vaccination intention in three China cities, and contributes towards some targeted vaccination promotion suggestions to China and other LMICs with similar low coverage of HZ vaccination.

METHODS

We conducted 12 focus group discussions in three cities of China. In each discussion we recruited 3 to 6 participants aged 20 and older to catch the views on the HZ vaccine from residents with a wider age range. Participants were recruited by purposive sampling techniques. Guided by the health belief model, thematic analysis was used to group participants' HZ vaccine attitudes and to identify the barriers and facilitators to HZ vaccination.

RESULTS

The attitude of 59 participants participating in the focus group discussions showed a low-level acceptability of the HZ vaccine with only 27.1% (16/59) displaying a willingness to HZ vaccine uptake. The barriers to HZ vaccination included limited or incorrect conception on HZ prevalence, risk factors, susceptibility, symptoms, prevention and treatment methods, and the high cost of the HZ vaccine. Perceived vulnerability to HZ, fear of HZ pain and individuals' financial capacity were the strongest facilitators to HZ vaccination. In addition, it was found that advocacy of HZ vaccination by health professionals or government financial subsidies to HZ vaccination, could attenuate the above barriers to HZ vaccine uptake.

CONCLUSIONS

Our study revealed a series of barriers and facilitators of HZ vaccination intention. We recommend HZ education and advocacy by health workers and government health officials to address the limited HZ knowledge and HZ misconceptions, and the government (or health insurance providers) to pay or subsidize the high costs of HZ vaccination to increase the HZ vaccination rate.

Are health education effective to improve herpes zoster vaccine willingness in vulnerable elderly

BACKGROUND

Compared to other vaccines recommended for the elderly, the effectiveness of health education in improving the willingness to vaccinate the herpes zoster vaccine (HZV) in low-come residents remains unclear.

METHODS

We recruited elderly participants from villages in Lingcheng District, and assigned each village to one of three health education interventions: oral health education, brochure-based health education, or video health education. The follow-up surveys were conducted immediately after each intervention. Baseline survey and the fifth follow-up were conducted at the beginning and end of the study, respectively. We assessed respondents' willingness to vaccinate the HZV under different pricing scenarios, as well as their reasons for accepting or refusing to vaccinate HVZ. Latent class growth analysis was used to identify potential similar trends in vaccination willingness.

RESULTS

Of 1027 recruited, 946 completed 5 follow-ups. Data shows only when HZV was free, willingness to vaccinate could increase significantly across all interventions. Heterogeneity among population clusters has been identified on intervention effectiveness and comorbidity may be an important cause. Vaccine effectiveness and personal infection risk motivated acceptance, while accessibility and affordability were barriers.

CONCLUSION

Health education improves HZV vaccination willingness, under free pricing scenario. Lowering HZV costs through health insurance or affordable options is necessary for successful education initiatives.

The association between age and acute pain sensitivity in patients with Herpes Zoster

Herpes zoster has a well-established increased incidence in older adults, but the relationship between age and acute pain severity remains less clear. This retrospective study aimed to explore the association between age and pain intensity in Herpes zoster patients. A total of 613 patients treated at the Second Affiliated Hospital of Guangxi Medical University were included. Pain intensity was measured using the Numerical Rating Scale-11, and statistical models were applied to evaluate age-related pain differences while controlling for confounders. While older age was associated with higher pain scores (β = 0.02, p < 0.001), the effect size was small. Other factors, such as pain duration and inflammatory markers (e.g., CRP levels), showed stronger associations with pain severity. These findings suggest that age may not be the dominant factor in Herpes zoster pain severity, and a more comprehensive approach is required for risk assessment and pain management in clinical practice.

Knowledge, attitude, and practice toward herpes zoster (HZ) and HZ vaccination: Concept elicitation findings from a multi-country study in the Asia Pacific

Herpes zoster (HZ) is a prevalent disease characterized by a painful rash. A multi‑country study was conducted to elicit public and physician knowledge, attitude, and practice (KAP) toward HZ disease and vaccination for the assessment of local factors influencing HZ vaccine perceptions in four Asian-Pacific countries/territories One-to-one qualitative interviews were conducted in 2022, among the public (people aged ≥ 50 years, adults with parents aged ≥ 50 years, zoster vaccine live-vaccinated individuals aged ≥ 50 years in Republic of Korea, and HZ patients; n = 78) and physicians (general practitioners and specialists; n = 24). Themes surrounding KAP toward HZ and HZ vaccination were summarized using a thematic analysis. A substantial knowledge gap related to HZ was observed among the public, including its causes, long-term impacts, and the at-risk population. There was a low perceived risk of HZ and low general awareness of HZ vaccine availability, although country/territory-specific differences existed. Fear of HZ-associated pain contributed toward vaccination intent among HZ patients and adults with parents aged ≥ 50 years. HZ-naïve adults who were encouraged to receive the vaccine by others were not motivated to do so due to optimism bias. Physicians were perceived to be a reliable source of information. However, physicians did not always proactively discuss HZ vaccination due to time constraints and a perceived need to prioritize other vaccinations including influenza and pneumococcal vaccines. Initiatives are needed to improve public awareness of HZ and its complications, in terms of overall impact on individuals and society, and highlight the important role of physicians in recommending vaccination.

Efficacy, reactogenicity, and safety of the adjuvanted recombinant zoster vaccine for the prevention of herpes zoster in Chinese adults ≥ 50 years: A randomized, placebo-controlled trial

Phase III multi-country studies (ZOE-50/70) demonstrated that the adjuvanted recombinant zoster vaccine (RZV) was well tolerated and prevented herpes zoster (HZ) in healthy ≥ 50-year-olds, with a vaccine efficacy (VE) > 90% across age groups. These pivotal trials did not enroll participants from mainland China where RZV is licensed, therefore similar clinical data are missing for this population. In this phase IV observer-blind study (NCT04869982) conducted between 2021 and 2023 in China, immunocompetent and medically stable ≥ 50-year-olds were randomized 1:1 to receive two RZV or placebo doses, 2 months apart. This study assessed the VE (overall, as confirmatory objective, and descriptively by age category [50-69-year-olds/≥ 70-year-olds]), reactogenicity, and safety of RZV in this Chinese population. Of the 6138 enrolled participants, 99.2% completed the study. During a mean follow-up period of 15.2 (±1.1) months, 31 HZ episodes were confirmed (RZV = 0; placebo = 31) for an incidence rate of 0.0 vs 8.2 per 1000 person-years and an overall VE of 100% (89.82-100). The descriptive VE was 100% (85.29-100) for 50-69-year-olds and 100% (60.90-100) for ≥ 70-year-olds. Solicited adverse events (AEs) were more frequent in the RZV vs the placebo group (median duration: 1-3 days for both groups). Pain and fatigue were the most frequent local and general AEs (RZV: 72.1% and 43.4%; placebo: 9.2% and 5.3%). The frequencies of unsolicited AEs, serious AEs, potential immune-mediated diseases, and deaths were similar between both groups. RZV is well tolerated and efficacious in preventing HZ in Chinese ≥ 50-year-olds, consistent with efficacy studies including worldwide populations with similar age and medical characteristics.

Real-world effectiveness of recombinant zoster vaccine in self-identified Chinese individuals aged ≥50 years in the United States

We evaluated the vaccine effectiveness (VE) of two doses of recombinant zoster vaccine (RZV) against herpes zoster (HZ) and postherpetic neuralgia (PHN) in Chinese adults at Kaiser Permanente Southern California (KPSC). Chinese KPSC members were identified based on self-reported ethnicity or self-reported preferred spoken/written language. Those aged ≥50 years who received two doses of RZV 4 weeks to ≤ 6 months apart were matched 1:4 to RZV unvaccinated Chinese members and followed through June 2022; second doses were accrued 6/1/2018-12/31/2020. We estimated incidence and adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) comparing outcomes (HZ and PHN). Adjusted VE (%) was calculated as (1-aHR)×100. 3978 RZV vaccinated Chinese members were matched to 15,912 RZV unvaccinated Chinese members. The incidence per 1000 person-years (95% CI) of HZ in the vaccinated group was 1.5 (0.9-2.5) and 10.9 (9.8-12.1) in the unvaccinated group; aHR (95% CI) was 0.12 (0.07-0.21). Adjusted VE (95% CI) was 87.6% (78.9-92.7) against HZ. We identified 0 PHN cases in the vaccinated group and 19 in the unvaccinated group. Among Chinese adults aged ≥50 years, two doses of RZV provided substantial protection against HZ and PHN supporting the real-world effectiveness of the vaccine in this population.

Knowledge, attitudes, and practices of the general population, herpes zoster patients, and dermatologists toward herpes zoster in China: A quantitative cross-sectional survey

The burden of herpes zoster (HZ) is anticipated to increase among the aging population of China over time. The knowledge, attitudes, and practices (KAP) of the population toward HZ can help inform the design of public health strategies. As there is a paucity of KAP data in China, this cross-sectional survey therefore sought to assess KAP related to HZ from the general population, patients with HZ, and dermatologists in China. The total number of respondents from the general population, HZ patients, and dermatologists were 804, 282, and 160, respectively. Notably, some gaps in knowledge regarding the severity, transmission, and prevention of HZ were identified across all groups. For example, less than half of respondents from the general population and HZ patients understood that vaccination does not treat HZ. For dermatologists, not all were aware of adverse reactions following HZ vaccination and some had misconceptions regarding the mode of transmission of HZ. Given the link between an individual's disease knowledge to their attitudes and practices, improved understanding of HZ could underlie positive attitudes and help reinforce healthcare professionals' recommendations in the management and prevention of HZ. In particular, doctors may be well-positioned to support HZ prevention initiatives, as most of the general population and HZ patients found vaccination more acceptable if recommended by a doctor (78.9% and 81.6%, respectively). Therefore, consideration of these KAP attributes may support the development of targeted educational interventions and effective public health strategies against HZ in China.

The relationship between pain duration characteristics and pain intensity in herpes zoster-related pain: a single-center retrospective study

Background

The varicella-zoster virus (VZV) can cause herpes zoster (HZ), which may progress to postherpetic neuralgia (PHN), leading to severe inflammatory responses and pain.

Objective

This study investigates the relationship between pain duration characteristics and pain intensity in patients with herpes zoster-related pain, hypothesizing that persistent pain correlates with higher pain intensity compared to intermittent pain.

Methods

A retrospective study was conducted at the Second Affiliated Hospital of Guangxi Medical University, China. Data from patients treated for herpes zoster-related pain between January 2019 and February 2024 were analyzed. Pain intensity was measured using the Numerical Rating Scale (NRS-11), and pain duration was categorized as intermittent or persistent. Multivariate regression models were used to assess the association between pain duration and intensity, adjusting for potential confounders.

Results

A total of 840 patients were included. Persistent pain was significantly associated with higher NRS-11 scores compared to intermittent pain (β = 0.71, 95% CI 0.50-0.91, p < 0.001). Subgroup analyses showed that persistent pain was associated with higher pain intensity in both acute HZ and PHN patients (HZ: β = 0.71, 95% CI 0.45-0.96, p < 0.001; PHN: β = 0.76, 95% CI 0.40-1.13, p < 0.001). Inflammatory markers, such as C-reactive protein (CRP) and white blood cell count, were positively correlated with pain intensity.

Conclusion

Pain duration significantly impacts pain intensity in HZ patients. Considering pain duration is crucial for effective pain management. Further research should explore the mechanisms underlying persistent pain to develop better treatment strategies.

Abnormal Degree Centrality in Zoster-Associated Pain with or Without Psychiatric Comorbidities: A Resting-State Functional MRI Study

Purpose

Zoster-associated pain (ZAP) is frequently concomitant with psychiatric comorbidities. However, the underlying neuropathological mechanisms of ZAP with psychiatric comorbidities remain poorly understood.

Patients and Methods

Rest-stating functional MRI (rs-fMRI) data from 41 ZAP patients without anxiety or depression (noA/D-ZAP), 11 ZAP patients with anxiety or depression (A/D-ZAP) and 29 healthy controls (HCs) were acquired. Degree centrality (DC) based on rs-fMRI was used to explore the node changes in the brain functional network in these subjects. Moreover, correlations and receiver operating characteristic curve analysis were performed.

Results

One-way analysis of variance revealed abnormal DC values in the right middle frontal gyrus (MFG) and bilateral precuneus among the three groups. Compared with HCs, A/D-ZAP showed increased DC values in the bilateral pons, while noA/D-ZAP showed increased DC values in the right pons, left brainstem and rectal gyrus and decreased DC values in the right cingulate gyrus and bilateral precuneus. A/D-ZAP showed increased DC values in the left MFG and precentral gyrus (PG) compared with noA/D-ZAP. The DC value of the left pons in A/D-ZAP was positively correlated with the self-rating anxiety scale score. Areas under the curve of DC values in the left PG and MFG for distinguishing A/D-ZAP from the noA/D-ZAP group were 0.907 and 1.000, respectively.

Conclusion

This study revealed the node differences in the brain functional network of ZAP patients with or without psychiatric comorbidities. In particular, abnormal DC values of the left MFG and PG may play an important role in the neuropathologic mechanism of the disease.

Cost-Effectiveness Analysis of Herpes Zoster Vaccination in a Chinese Population: Recombinant Subunit Vaccine versus Live Attenuated Vaccine

BACKGROUND

Currently, the recombinant subunit vaccine and live attenuated vaccine in the prevention of herpes zoster are approved for marketing in China. This study aims to evaluate the cost-effectiveness of the recombinant subunit vaccine and the live attenuated vaccine in the Chinese population.

METHODS

A decision tree-Markov analysis model was utilized to estimate expected costs and quality-adjusted life years (QALYs), comparing the lifetime cost-effectiveness of vaccination with the recombinant subunit vaccine (London, United Kingdom, Shingrix, GSK) to that of the live attenuated vaccine (Changchun, China, Ganwei, Changchun Bcht) in the Chinese population, with the primary outcome measure being the incremental cost-effectiveness ratio (ICER).

RESULTS

In the base-case analysis, the ICERs for the recombinant subunit vaccine ranged by age from USD 3428 to USD 5743 per QALY, while the ICERs for the live attenuated vaccine ranged from USD 4017 to USD 18,254 per QALY, compared with no vaccination. Among all age groups, the category of 60 to 69 years was the optimal age for vaccination. The results were most sensitive to changes in herpes zoster incidence, vaccine efficacy, and discount rate. Even with a two-dose compliance rate of 20% for the recombinant subunit vaccine, vaccination remained cost-effective. ZVL would need to reduce costs by at least 12.2% compared to RZV to have a cost-effectiveness advantage.

CONCLUSIONS

The recombinant subunit vaccine and the live attenuated vaccine were both cost-effective in the Chinese population, but, relatively, the recombinant subunit vaccine had a greater advantage in disease prevention and cost-effectiveness in all age groups above 50 years.

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.

Parabolic Changes in Pain Scores Among Partial Herpes Zoster Patients: A Retrospective Study

Background

Herpes zoster (HZ) typically manifests in the acute phase with distinct blisters and severe neuropathic pain. Remarkably, a subset of patients initially presents with only a mild skin rash and moderate pain that gradually intensifies, following a parabolic pattern. Despite being frequently observed in clinical settings, the underlying causes of this trajectory and its potential connection with post-herpetic neuralgia (PHN) remain unclear.

Methods

To investigate this phenomenon in-depth, we conducted a meticulous retrospective study involving 529 eligible HZ patients. All these patients sought medical care at the Third Central Hospital of Tianjin, China, between January 2020 and December 2023.

Results

The research identified that 14.6% of the sample (77 patients) experienced pain scores aligning with a parabolic curve. This trend was significantly more prevalent in patients aged 60 and above, accounting for 90.9% of this group, and demonstrated a positive correlation with age. Moreover, 87.0% of these patients had pre-existing medical conditions, highlighting the potential role of comorbidities in influencing the pain trajectory. A concerning 45.5% of patients sought medical attention more than seven days after the onset of symptoms, a delay that could exacerbate neurological damage. Notably, among those following a parabolic pain pattern, 66.2% eventually developed PHN, a considerably higher rate compared to the broader patient population.

Conclusion

We emphasize that healthcare practitioners meticulously assess patients who initially report lower pain scores for high-risk factors potentially leading to parabolic pain increases, including being over 60 years old, having comorbid conditions, and delaying medical consultation beyond seven days from symptom onset. Early implementation of supplementary pain management therapies may mitigate the risk of PHN development and enhance the quality of life for patients. This study furnishes clinicians with a deeper understanding of the variations in HZ-related pain trajectories, promising to improve treatment approaches and prognoses for HZ patients while paving the way for enriched clinical practice in the future.

Associations between Different Antivirals and Hospital-Acquired Acute Kidney Injury in Adults with Herpes Zoster

Key Points

Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. The risk of hospital-acquired AKI was dose dependent for intravenous nucleoside analogs.

Background

To examine the association of use of different antivirals with hospital-acquired AKI among Chinese adults with herpes zoster.

Methods

This study selected 3273 adult patients who received antiviral therapy for herpes zoster during hospitalization from the China Renal Data System. We identified and staged AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes criteria. We compared the relative risks of hospital-acquired AKI among patients treated with different antivirals using Cox proportional hazards models.

Results

Among 3273 patients, 1480 (45%), 681 (21%), 489 (15%), and 623 (19%) were treated with acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. During the follow-up period, a total of 111 cases of hospital-acquired AKI occurred, predominantly classified as AKI stage 1. The cumulative incidences of hospital-acquired AKI were 5%, 3%, 3%, and 1% in the patients receiving acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. Compared with acyclovir/valacyclovir, penciclovir/famciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI, with an adjusted hazard ratio of 0.59 (95% confidence interval [CI], 0.37 to 0.94) and 0.27 (95% CI, 0.11 to 0.63), respectively. Compared with intravenous acyclovir, intravenous penciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI with an adjusted hazard ratio of 0.53 (95% CI, 0.29 to 0.98) and 0.31 (95% CI, 0.12 to 0.76), respectively. The associations were consistent across various subgroups and sensitivity analyses.

Conclusions

Among antiviral therapies for herpes zoster, we found different risks of hospital-acquired AKI among the patients receiving different antivirals, in particular, those administered intravenously. Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. Confirmation studies with large samples from other populations are warranted.

Perceptions, Attitudes, Beliefs, and Practices Toward Traditional Chinese Medicine Therapies for Herpes Zoster: A Cross-Sectional Study of Healthcare Professionals

Introduction

Traditional Chinese medicine (TCM) holds great potential in promoting healing and relieving pain for herpes zoster (HZ) treatments. Evidence showed that both healthcare professionals' (HCPs) belief and knowledge influence their attitudes, which result in their expression and direct behavior. However, little is known in this area regarding TCM treatments for HZ. This study aimed to understand the HCPs' perceptions, attitudes, beliefs, and practices toward TCM and its services for HZ.

Methods

During July 2021 and October 2022, a cross-sectional study of HCPs querying demographics, perceptions, attitudes, beliefs, and practices toward TCM and TCM services for HZ was conducted. The frequency and percentage or mean and standard deviation were used to present categorical data and continuous data, respectively. A Chi-square analysis compared nurses' and doctors' views on TCM treatments for HZ.

Results

Out of 306 eligible respondents, 66.0% used TCM content in clinical practice less than 40% of the time. Respondents reported that there were three main advantages of TCM for HZ, including better crusting and healing, fewer side effects, and mitigating complications. A total of 41.3% (81/196) of the respondents who had cared for/treated HZ patients applied TCM treatments. The three factors most associated with referrals/providing TCM to patients were postherpetic neuralgia, early erythema or papules, and acute pain. Compared to nurses, doctors showed more endorsement of the efficacy and cost-effectiveness of TCM treatments for HZ patients.

Conclusion

The study found that most healthcare professionals in HZ had a favorable view of TCM, but lacked practical experience administering it to patients. Programs should be developed to provide evidence-based TCM treatments and encourage combining TCM with Western medicine for better patient care.

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

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

Willingness to vaccinate against herpes zoster in Chinese urban population: a mixed-methods study

OBJECTIVE

Although the herpes zoster vaccine has been available in mainland China since June 2020, residents' knowledge of herpes zoster and the herpes zoster vaccine is poor, and vaccination rates are low, especially among the elderly, who are at high risk for herpes zoster. This study assessed willingness to be vaccinated against herpes zoster and factors associated with vaccination among urban residents in China.

METHODS

A mixed-methods study was conducted in community health centres from August 2022 to September 2022. We used convenience sampling to select 2864 residents from 9 Chinese cities for the quantitative study and 67 adults for the qualitative study. A structured questionnaire was used for the quantitative study, and data were collected through face-to-face interviews. Multinomial logistic regression was used to analyse factors associated with willingness to vaccinate. Qualitative data were analysed using thematic analysis of barriers to herpes zoster vaccination.

RESULTS

A total of 2864 eligible respondents were included in the study. Of these, 42.67% intended to receive the herpes zoster vaccine, 21.44% refused and 35.89% were hesitant. The results of the quantitative and qualitative analyses showed that the factors associated with respondents' willingness to be vaccinated against herpes zoster included: personal characteristics such as gender, age and income; knowledge and attitudes about herpes zoster and the vaccine; vaccine characteristics such as efficacy, safety and price; and other factors such as pain tolerance and accessibility to vaccination.

CONCLUSION

The low willingness to vaccinate, especially among the elderly, is mainly related to their poor knowledge and negative attitude towards the infection and vaccination. Therefore, health education about herpes zoster, immunisation promotion, and improvement of accessibility and affordability would be valuable in China.

Aberrant functional and causal connectivity of the amygdala in herpes zoster and post-herpetic neuralgia patients

OBJECTIVE

Resting-state functional magnetic resonance imaging (rs-fMRI) and Granger causality analysis (GCA) were used to observe the characteristics of amygdala and whole-brain effect connections in patients with herpes zoster (HZ) and post-herpetic neuralgia (PHN) and to determine their relationship with clinical features.

METHODS

Rs-fMRI scans were performed on 50 HZ; 50 PHN; and 50 age-, sex- and education-year-matched healthy controls (HCs). Bilateral amygdala subregions were used as seeds for functional connectivity (FC). GCA was used to analyze the effective connection of brain regions that were significantly different among groups. Then, the correlation between FC, and GCA values and clinical indices was investigated.

RESULTS

PHN had impaired FC between the amygdala subregion with the putamen, cortex, anterior cingulate cortex (ACC) to HCs and reduced FC of medial amygdala (MeA) with the parieto-occipital lobe and motor cortex to HZ; HZ had reduced FC of the lateral amygdala (LA) with the insula to HCs. GCA values from the bilateral LA to the bilateral ACC, left MeA to the bilateral ACC and left putamen, and right ACC to the bilateral MeA were reduced in PHN patients compared to HCs. Compared with HCs, the GCA values from the left MeA to the left ACC and right putamen were reduced in HZ. The GCA values from the amygdala subregion to the ACC were positively correlated with HAMA or HAMD scores in PHN.

CONCLUSION

PHN showed reduced FC between the amygdala subregions and cortico-putamen and decreased effective connectivity from the amygdala subregion to the ACC and putamen.

ADVANCES IN KNOWLEDGE

HZ and PHN patients had significant changes in effective connectivity in brain regions, including diverse functional areas emanating from and projecting to the amygdala. The current findings will provide a new perspective for understanding the neuropathophysiological mechanism HZ and PHN.

Cost-Effectiveness of Recombinant Zoster Vaccine for Adults Aged ≥50 Years in China

INTRODUCTION

Adjuvanted recombinant zoster vaccine (RZV) was the first vaccine made available for herpes zoster in China. Authors aimed to evaluate its economic and health impacts on Chinese adults aged ≥50 years.

METHODS

A lifetime Markov model was developed to compare the cost-effectiveness of RZV with that of no vaccination from a societal perspective. Model inputs were derived from published literature and analyzed in 2022. Outcomes included total costs, quality-adjusted life-years, incremental cost-effectiveness ratio, and number of herpes zoster and herpes zoster-related cases. Sensitivity analyses were performed to examine the robustness of the model results.

RESULTS

RZV was more costly than no vaccination by $2.78 billion with an additional 65,008 quality-adjusted life-years gained and could avoid 1,893,530 herpes zoster cases, 295,761 postherpetic neuralgia cases, 51,734 other complications, and 229 herpes zoster-related deaths. Incremental cost-effectiveness ratios of RZV varied in a range of $34,465.5-$51,002.7 per quality-adjusted life-year. RZV for the entire cohort would be cost-effective when discount rate was <2.4%, a waning rate of 2-dose RZV efficacy decreased to <0.8%, the utility of postherpetic neuralgia was <0.496, duration of postherpetic neuralgia was >12.86 months, or the cost of RZV per dose decreased to <$229.6. In a probabilistic sensitivity analysis, the probability of RZV being cost-effective was 43.95%, 59.32%, 45.27%, and 39.50% for people aged 50-59, 60-69, 70-79, and ≥80 years, respectively, with threefold gross domestic product per capita (37,654.5 per quality-adjusted life-year) as the willingness-to-pay threshold.

CONCLUSIONS

RZV was most likely to be cost-effective in people aged 60-69 years. A slight decrease in vaccine cost would result in RZV being cost-effective in all people aged ≥50 years.

Comparison of efficacy of acupuncture-related therapy in the treatment of herpes zoster: A network meta-analysis of randomized controlled trials

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) were conducted to evaluate the efficacy and safety of acupuncture-related therapy in the treatment of herpes zoster (HZ) and to provide a reference for the clinical treatment of herpes zoster.

METHODS

PubMed, Cochrane Library, EMBASE, Web of Science, CNKI, VIP database, Wanfang Database, and SinoMED Chinese and English databases were systematically searched for RCTs on acupuncture-related therapy for HZ until February 2023. Literature screening, data extraction, and risk of bias assessment were performed independently by 2 researchers. R4.2.1 and Stata15.1 software were used for data analysis.

RESULTS

A total of 26 RCTs involving 1929 HZ patients were included, and the network meta-analysis results showed that acupotomy appeared to be most effective in terms of improving VAS scores and the time of incrustation; SUCRA cumulative probability ranking showed the best efficacy of bloodletting in improving efficiency and the time of ceasing new blisters, acupuncture in improving the time of decrustation, and moxibustion in reducing the incidence of postherpetic neuralgia (PHN).

CONCLUSIONS

Through a comprehensive comparison of 9 different acupuncture therapies, acupotomy was the optimal treatment to improve VAS pain scores and the time of incrustation; bloodletting, acupuncture, fire needle, and moxibustion could be effective intervention measures to improve the time of ceasing new blisters and decrustation and reduce the incidence of PHN; Western medicine was closely related to adverse reactions. The conclusions need to be further verified due to the limitations of the study.

The incidence of herpes zoster in China: A meta-analysis and evidence quality assessment

This review aimed to estimate the disease burden of herpes zoster (HZ) in China and explore the application of the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach in studies of disease burden. We searched for the literature of observational studies analyzing HZ incidence in populations of all ages in China. Meta-analysis models were constructed to calculate the pooled incidence of HZ and pooled risks of postherpetic neuralgia (PHN), HZ recurrence, and hospitalization. Subgroup analysis was performed according to gender, age, and quality assessment score. The quality of evidence for incidence was rated using the GRADE system. Twelve studies with a total of 25,928,408 participants were included in this review. The pooled incidence for all ages was 4.28/1000 person years (95% CI 1.22-7.35). It increased with the increasing in age especially for individuals aged ≥60 y, which was 11.69/1000 person years (95% CI 6.56-16.81). The pooled risks of PHN, recurrence, and hospitalization were 12.6% (95% CI 10.1-15.1), 9.7% (95% CI 3.2-16.2), and 6.0/100,000 population (95% CI 2.3-14.2), respectively. The quality of the evidence assessment of the pooled incidence by the GRADE for all ages was 'low'; however, it was 'moderate' for the ≥60 yold subgroup. HZ is a serious public health problem in China and is more significant in individuals older than 60 y. Therefore, an immunization strategy for the zoster vaccine should be considered. The evidence quality assessment by the GRADE approach indicated that we had more confidence in the estimation of aged population.

Lifetime risk of herpes zoster in the population of Beijing, China

Objectives

We aimed to estimate the current and future lifetime risks (LTR) of herpes zoster (HZ) and postherpetic neuralgia (PHN), as well as their respective number of annual incident cases in Beijing, China, if individuals were not vaccinated against HZ.

Study design

Mathematical model built in Microsoft Excel, de novo.

Methods

A hypothetical cohort of 1,000 people was simulated from age 0-100 or until death to generate LTRs of HZ/PHN in Beijing, China. LTR was defined as the risk of developing HZ/PHN at least once in the person's lifetime. The current number of annual incident HZ/PHN cases were also calculated by multiplying up-to-date population data and the annual age-specific incidence of HZ/PHN. For both LTR and annual incident cases, current estimates were projected into the year 2035 to investigate the impact of an aging population. Scenario and deterministic sensitivity analyses (DSA) were conducted to validate the model outcomes.

Results

In Beijing, the current and future LTRs of HZ (PHN) were 32.4% (2.8%) and 34.8% (3.3%), respectively. The current and future annual incident cases of HZ (PHN) of individuals aged ≥50 years were 68,394 (7,801) cases among 7.04 million individuals and 88,676 (9,649) cases among 9.08 million individuals, respectively. The scenario analyses demonstrated that modelled results were likely to underestimate the LTR of HZ. Results were robust under the DSA.

Conclusions

Given an aging population, HZ poses a significant, growing burden on individuals, the society, and healthcare system of China, highlighting the need for preventative measures such as vaccination.

Willingness to accept herpes zoster vaccines and the influencing factors in China

BACKGROUND

Herpes zoster increases the burden on the elderly in an aging society. Although an effective vaccine licensed by China Food and Drug Administration in 2019 was introduced into the market in June 2020, the willingness and influencing factors of herpes zoster vaccines in Chinese adults ≥ 50-years-old during coronavirus disease-2019 pandemic are yet to be elucidated.

METHODS

An online questionnaire survey was conducted using a simple random sampling method in October 2021 for viewers of the broadcast program. A binary logistic regression and multiple response analysis were conducted for herpes zoster vaccine and vaccination willingness. Pareto's graphs were plotted to present the multiple-choice questions of influencing factors.

RESULTS

A total of 3838 eligible participants were included in this study. Among them, 43.02% intended to be vaccinated, including 10.34% self-reported about receiving at least one shot of shingles vaccine, 30.22% declined, and 26.76% were hesitant. This population comprised a large proportion of middle-aged and older people (≥ 50-years-old) who have not experienced an episode of herpes zoster (54.98%) or are unaware of the virus (33.22%). The strongest determinants of vaccine hesitancy among older people were education background of Master's degree or above compared to senior high or equivalent and below, personal monthly income < 3000 RMB compared to 3000-5999 RMB, and living in a rural area.

CONCLUSIONS

The willingness to get shingles vaccines can be improved further. Professional education and credible recommendation might prompt the elderly to improve their willingness and reassure them of the safety and efficacy of the vaccine. Also, accessibility and affordability should also be improved in the future.

Identifying the Optimal Age for Herpes Zoster Vaccination - Yichang City, Hubei Province, China, 2017-2019

What is already known about this topic?

Herpes zoster (shingles) is a common skin condition in older adults, which usually presents as a painful rash with blisters. Vaccination is the most effective method to prevent shingles. However, there is not sufficient population-based epidemiological data in China to optimize the timing of zoster vaccination.

What is added by this report?

Clustering analyses of population-wide epidemiological data from the Healthcare Big Data Platform in Yichang, China showed that the average annual zoster incidence is the highest among people 55 years or older, at 10 cases per thousand persons per year, making this age group the optimal target population for vaccination. Incidence was lower but increased with age among younger adults, 28-54 years old.

What are the implications for public health practice?

With limited vaccination resources, zoster vaccinations should be targeted at adults 55 years or older who are at the greatest risk for shingles. Research should be conducted to understand the risk of shingles among young and middle-aged adults and identify triggers of shingles: potentially leading to preventive measures.

Comparison of lidocaine and ropivacaine stellate ganglion blockade in treating upper limb postherpetic neuralgia

To provide a basis for treating postherpetic neuralgia (PHN), we compared the efficacy of lidocaine and ropivacaine stellate ganglion block (SGB) in PHN treatment in the upper limbs.Data from 252 patients with upper-limb PHN were retrospectively analyzed. The lidocaine group (n = 118) was treated with oral pregabalin capsules 75 mg twice a day, tramadol hydrochloride sustained release tablets 100 mg twice a day, and amitriptyline 25 mg once at night combined with ultrasound-guided lidocaine SGB; the ropivacaine group (n = 134) was orally administered the same medicines combined with ultrasound-guided ropivacaine SGB. The visual analog scale (VAS), self-rating anxiety scale (SAS), and adverse reactions were compared between the groups before treatment and at 1 week, 1 month, and 3 months after treatment.There were no significant differences between the lidocaine and ropivacaine groups in terms of sex, age, height, weight, and pain duration (P > .05). There was no significant difference between the groups in VAS and SAS scores before treatment (P > .05). At 1 week, 1 month, and 3 months after ultrasound-guided SGB treatment, the VAS and SAS scores were significantly lower in the ropivacaine group than in the lidocaine group (P < .05). There were no significant differences between the groups in terms of adverse reactions (P > .05).For ultrasound-guided SGB treatment of upper limb PHN, ropivacaine is superior to lidocaine. Ultrasound-guided ropivacaine SGB is safe and effective for the treatment of upper limb PHN.

Incidence trend and disease burden of seven vaccine-preventable diseases in Shandong province, China, 2013-2017: Findings from a population-based observational study

Introduction

Although vaccines provide a cost-effective solution to vaccine-preventable diseases (VPDs), the disease burden of VPDs is still very high in most parts of the world.

Methods

A population-based observational study was conducted in Shandong province, China, from 2013 to 2017, giving an insight into the epidemiological characteristics and disease burden of seven VPDs. The incidence trend was estimated using the Poisson regression model. The disease burden was calculated using the disability-adjusted life years (DALYs).

Results

Most VPDs included in the China’s National Immunization Program had higher incidence density (ID) in inland cities. The ID of mumps decreased significantly, while herpes zoster increased (both P < 0.05). The top three causes of the disease burden as assessed with DALYs included tuberculosis, herpes zoster, and hepatitis B, with the rates of 72.21, 59.99, and 52.10 DALYs/100 000, respectively. The disease burden of influenza and herpes zoster were relatively high in people aged > 50 years, while highest DALYs of hepatitis B were found in young adults.

Conclusion

Inequalities in the vaccine coverage by geography, socio-economic status, and targeted population contribute to the increasing incidence and high burden of VPDs and call for renewed and sustained immunization strategies in China.

Global herpes zoster incidence, burden of disease, and vaccine availability: a narrative review

Herpes zoster (HZ) is a neurocutaneous disease that causes significant morbidity worldwide. The disease is caused by the reactivation of the varicella-zoster virus (VZV), which leads to the development of a painful, vesicular rash and can cause complications such as post-herpetic neuralgia and vision loss. Globally, the incidence of HZ is increasing, and it incurs billions in cost annually to the healthcare system and to society through loss of productivity. With the advent of effective vaccines such as the live attenuated vaccine, Zostavax®, in 2006, and more recently the adjuvant recombinant subunit vaccine, Shingrix®, in 2017, HZ has become a preventable disease. However, access to the vaccines remains mostly limited to countries with developed economies, such as the United States and Canada. Even among countries with developed economies that license the vaccine, few have implemented HZ vaccination into their national immunization schedules due to cost-effectiveness considerations. In this review, we discuss the currently available HZ vaccines, landscape of HZ vaccine guidelines, and economic burden of disease in countries with developed and developing economies, as well as barriers and considerations in HZ vaccine access on a global scale.

Case Report: Various Clinical Manifestations Caused by Varicella-Zoster Virus in a Family

A family cluster of varicella-zoster virus (VZV) infections was reported. Four family members (two children and their parents) continuously develop varicella after the grandmother's herpes zoster. The unvaccinated 16-month-old infant and his mother developed primary varicella with atypical clinical presentation; however, his 28-year-old father presented with a typical generalized vesicular rash. His vaccinated 4-year-old sister was clinically mild, which could be defined as a breakthrough varicella case. They infected the same virus strain but presented various clinical forms.

Low willingness to vaccinate against herpes zoster in a Chinese metropolis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Potential public health impact of the adjuvanted recombinant zoster vaccine among people aged 50 years and older in Beijing

Herpes zoster (HZ) is a painful, unilateral rash which occurs upon reactivation of latent varicella zoster virus due to age-related immunity decline or immuno-suppression. In 2019, the recombinant zoster vaccine (RZV) was the first vaccine to be approved in China for HZ prevention. This study aimed to estimate the potential public health impact of RZV vaccination, compared with the status quo of no vaccination, in individuals ≥50 years of age (YOA) in Beijing, by adapting the published ZOster ecoNomic Analysis (ZONA) model. We considered 5% and 50% vaccination coverage for the private market (near-term post-launch) and mass vaccination (long-term) settings respectively. In the base-case analysis of both market settings, second-dose compliance was set to 80%. Coverage and second-dose compliance rates were varied under scenario and sensitivity analyses. In the base case, mass vaccination with RZV was estimated to prevent 435,681 HZ cases, 51,558 postherpetic neuralgia (PHN) cases, and 15,703 cases of other HZ-related complications in the overall ≥50 YOA cohort over their remaining lifetime, compared with no vaccination. Under the same base-case scenario, 14,247 hospitalizations and 1,031,387 outpatient visits could be avoided. The 50-59 YOA cohort had the highest contributions to the overall reduction in HZ cases, its complications and related healthcare resource utilization. Results were robust under numerous scenario and sensitivity analyses. This analysis demonstrates the potential of RZV vaccination to substantially reduce the public health burden of HZ among individuals ≥50 YOA, and may inform appropriate vaccination strategies for HZ prevention, particularly in urban settings within China.