A population based study of the epidemiology of Herpes Zoster and its complications

doi:10.1016/j.jinf.2013.06.016

Journal of Infection

Volume 67, Issue 5, November 2013, Pages 463-469

https://doi.org/10.1016/j.jinf.2013.06.016 Get rights and content

Summary

Objectives

To assess the incidence of Herpes Zoster (HZ) and its complications in the Israeli general population and specifically in immune-compromised individuals, and to identify risk factors for developing HZ and post-herpetic neuralgia (PHN).

Methods

A retrospective database search for newly diagnosed cases of HZ and of PHN during 2006–2010 was conducted using the comprehensive longitudinal database of Maccabi Health Services. Cox-proportional hazards models were used to assess associations between risk factors and HZ and PHN.

Results

During 2006–2010 there were 28,977 newly diagnosed cases of HZ and 1508 newly diagnosed cases of PHN. Incidence density rate of HZ was 3.46 per 1000 person-years in the total population and 12.8 per 1000 person-years in immune-compromised patients. HZ and PHN incidence increased sharply with age. 12.4% and 3.1% of elderly HZ patients (≥65 years) developed PHN or ophthalmic complications, respectively. In multivariable analyses, HZ and PHN were associated with female sex, higher socioeconomic status, diabetes mellitus, cancer history, and HIV treatment.

Conclusions

Extrapolating to the entire Israeli population, we estimate over 24,000 new cases of HZ and 1250 new cases of PHN each year. Cost-effectiveness analysis should be performed to determine the threshold age for vaccination against HZ.

Introduction

Herpes Zoster (shingles) is caused by varicella-zoster virus (VZV) reactivation, often several decades after the initial infection, and is characterized by painful dermatological symptoms. According to previous studies from the UK, Canada, and the USA the lifetime risk of developing HZ is 20%–30%.1, 2 Incidence increases markedly with age and is higher among patients with neoplastic diseases (especially lymphoproliferative cancers), organ-transplant recipients, and in those receiving immunosuppressive drugs, due to impaired cell-mediated immunity in these patients. The most common complication of HZ is post-herpetic neuralgia (PHN), a persistent pain that negatively affects the patient's quality of life and ability to function.³ Precise definitions of PHN vary, but most authors use persistent pain for 1–3 months after the outbreak of the HZ rash.4, 5, 6, 7

HZ vaccine has been shown to substantially reduce the risk of HZ and subsequent PHN in immune-competent elderly subjects.⁸ The vaccine is licensed for use in the USA since 2006 and recommended in persons aged 60 years or above with no contraindications, such as primary or acquired immunodeficiency.⁹ Despite lack of updated local data regarding the epidemiology of HZ, an advisory committee to the Israeli Ministry of Health has recently recommended immunization for elderly citizens. We undertook the present study to evaluate the incidence of HZ and its complications in the Israeli general population and among specific high-risk groups, as well as to assess the proportion of under-diagnosed HZ cases in the community. In recent years, use of biological immune-suppressants in Israel has increased due to inclusion of several new indications in the Israeli basket of health services.10, 11 Therefore we divided the analyses into two different time-periods: Incidence rates of HZ and PHN in the general population were derived for the years 2006–2010, whereas high-risk populations and complications other than PHN were studied during 2010.

Section snippets

Data source and case definition

The present retrospective cohort analysis was conducted using the comprehensive longitudinal database of Maccabi Healthcare Services (MHS), the second largest health maintenance organization (HMO) in Israel, covering approximately 2 million individuals, or 25% of the total Israeli population. Since 1995, all Israeli citizens are universally covered under the 1994 National Healthcare Insurance Act that provides a comprehensive basket of services through four national HMOs. The age and sex

Epidemiology of HZ and PHN during 2006–2010

During the study period there were 28,977 newly diagnosed cases of HZ and 1508 newly diagnosed cases of PHN among MHS members (Table 1). The IDR of HZ was 3.46 per 1000 person-years with a sharp increase with age, ranging from 2 per 1000 person-years among children and young adults to 10 per 1000 person-years among the elderly (≥65 years of age). There was little variation in the annual IDR of HZ during the study period (Fig. 1). The mean age at diagnosis increased linearly from 43.3 years in

Discussion

The results of this population based cohort indicate a substantial annual risk of HZ of about 4.5 per 1000, with one in twenty HZ patients further developing PHN. Similar to previous studies, we found a strong association between age and occurrence of HZ2, 4, 5, 6, 7, 16, 17, 18, 19, 20 and of PHN.4, 5, 6, 7, 20 Our analysis provides further evidence of the importance of well-known HZ risk factors such as female sex,6, 7, 16, 17, 21, 22 diabetes,13, 20, 23 and immunocompromised conditions.7, 16

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Cost-Effectiveness of Recombinant Zoster Vaccine for Adults Aged ≥50 Years in China
2023, American Journal of Preventive Medicine
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.
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.
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.
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.
Viral Ocular Infections
2022, Encyclopedia of Infection and Immunity
Herpes simplex virus (HSV), varicella-zoster virus (VZV) and cytomegalovirus (CMV) are double-stranded DNA viruses which belong to the Herpesviridae family. These viruses remain latent in the cranial nerve sensory ganglia after the primary infection. Ocular HSV can cause blepharitis, conjunctivitis, keratitis, uveitis, and retinitis among others. VZV causes varicella (chickenpox) as a primary infection. As cellular immunity declines with age or in immunocompromised patients, VZV can be reactivated and cause herpes zoster. Herpes zoster ophthalmicus results from VZV infection of the ophthalmic branch of the trigeminal nerve and may lead to keratitis, anterior uveitis and retinitis. CMV can cause corneal endotheliitis and anterior uveitis. Anterior CMV uveitis may follow two courses: as a Posner-Schlossman syndrome pattern of recurrent acute attacks or Fuchs uveitis syndrome like pattern of chronic anterior uveitis. Acute retinal necrosis can occur in both normal and immunocompromised patients. CMV retinitis and Progressive Outer Retinal Necrosis occur in immunocompromised patients.
Risk of recurrent herpes zoster in a population-based cohort study of older adults
2021, Journal of the American Academy of Dermatology
There are limited data on zoster recurrence.
To examine in detail zoster recurrence in a population-based cohort.
Using data from a large cohort (The 45 and Up Study) with linked medical data (2004-2015), the incidences of first and recurrent zoster were examined by using survival analysis methods.
Over 1,846,572 person-years of follow-up, of 17,413 participants who had a first zoster episode (incidence, 9.43 per 1000 person-years; 95% confidence interval, 9.29-9.57), 675 (3.9%) experienced a recurrence. The mean time between first and recurrent zoster was 2 years for those aged 45-54 years and 3 years for those aged 55 years and older. Among those with a first zoster, the incidence of recurrence was 11.05 (95% confidence interval, 10.24-11.91) per 1000 person-years, and higher recurrence incidence occurred in women compared to men, in younger compared to older participants, and in immunosuppressed compared to nonimmunosuppressed participants. Recurrence appeared lower in the 12 months after zoster onset but then remained consistent at approximately 12.00 per 1000 person-years in the following 8 years.
Recurrence may be underestimated because of the use of administrative data for case ascertainment. Potential misclassification of nonimmunosuppressed participants.
Our results support the vaccination of people who have already experienced zoster and underpin the need for additional studies on immunogenicity and vaccine efficacy in these populations.
Short-Term Peripheral Nerve Stimulation Relieve Pain for Elder Herpes Zoster Ophthalmicus Patients: A Retrospective Study
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Ophthalmic postherpetic neuralgia (PHN) is the final stage of herpes zoster (HZ) ophthalmicus and a severe refractory neuropathic pain, thus there is no curative treatment that could alleviate pain and reduce the incidence of ophthalmic PHN now. The purpose of this study is to evaluate therapeutic efficacy of short-term peripheral nerve stimulation (PNS) for elder patients with HZ ophthalmicus.
We performed a retrospective study from March 2015 to August 2019 in our pain department. All the HZ ophthalmicus patients underwent supraorbital nerve short-term PNS were included. The patients' data, including numeric rating scale (NRS), 36-Item short form health survey (SF-36), and analgesic consumptions, were retrospectively analyzed. Severe side effects also were recorded.
A total of 68 patients were enrolled in this study. The NRS scores were significantly decreased at different time points after short-term PNS compared to baseline (p < 0.001). The SF-36 scores, including general health, social function, emotional role, mental health, bodily pain, physical functioning, physical role, and vitality, were significantly improved at different time points after treatment (p < 0.001). The average dosages of tramadol and pregabalin administered (mg/d) were both significantly reduced compared to baseline (p < 0.001). There was no bleeding, infection, pain increase, and other side effects after treatment.
Short-term PNS is an effective and safe therapeutic alternative for elder patients with HZ ophthalmicus and could reduce the incidence of ophthalmic PHN.
Diabetes as a risk factor for herpes zoster in adults: A synthetic literature review
2020, Diabetes Research and Clinical Practice
The objective of this review was to evaluate the role of diabetes as a risk factor for herpes zoster (HZ) and to discuss implications of prevention by vaccination with available HZ vaccines.
We reviewed studies that investigated the incidence rates of HZ in patients with diabetes. Papers in English or French published between January 2000 and December 2018 have been selected from PubMed and Google Scholarship by using appropriate key words.
The risk of HZ was significantly higher in patients with diabetes as compared to controls in 11 studies out of 16, although the magnitude of risk associated to diabetes varied across studies from 1.06 to 2.38 (p < 0.05). The incidence of HZ in patients with diabetes increased with age and was higher in women than in men. The incidence of the most common complication of HZ, i.e. post-herpetic neuralgia was also higher in patients with diabetes.
The presence of HZ adds supplementary complications to the pre-existing comorbidity in patients with diabetes. Investigating the impact of preventive measure by HZ vaccination is therefore of paramount importance in patients with diabetes.
Herpes zoster after the third dose of SARS-CoV-2 mRNA-BNT162b2 vaccine in actively treated cancer patients: a prospective study
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View all citing articles on Scopus

View full text

A population based study of the epidemiology of Herpes Zoster and its complications

Summary

Objectives

Methods

Results

Conclusions

Introduction

Section snippets

Data source and case definition

Epidemiology of HZ and PHN during 2006–2010

Discussion

Epidemiology of varicella zoster virus infection in Canada and the United Kingdom

Epidemiol Infect

The incidence of shingles and its implications for vaccination policy

Vaccine

The impact of herpes zoster and post-herpetic neuralgia on quality-of-life

BMC Med

Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database

Fam Pract

A population-based study of the incidence and complication rates of herpes zoster before zoster vaccine introduction

Mayo Clin Proc

Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom

Epidemiol Infect

Epidemiology and economic burden of herpes zoster and post-herpetic neuralgia in Italy: a retrospective, population-based study

BMC Infect Dis

A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults

N Engl J Med

Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Recomm Rep

Health ministry director-general circular no. 21/08: expansion of health services basket for 2009

Health ministry director-general circular no. 02/10: expansion of health services basket for 2010

Membership in sick funds 2010

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

Infection

1995 census of population and housing

The epidemiology of diabetes in a large Israeli HMO

Eur J Epidemiol

The incidence of herpes zoster in a United States administrative database

J Gen Intern Med

What does epidemiology tell us about risk factors for herpes zoster?

Lancet Infect Dis

The incidence of herpes zoster

Arch Intern Med

Epidemiological characteristics and societal burden of varicella zoster virus in the Netherlands

BMC Infect Dis