Vaccines for preventing herpes zoster in older adults

Department of Geriatrics and Gerontology, Universidade Federal de São Paulo, Rua Professor Francisco de Castro 105, São Paulo, São Paulo, Brazil, 04020-050.
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 10/2012; 10(10):CD008858. DOI: 10.1002/14651858.CD008858.pub2
Source: PubMed


Herpes zoster or, as it is commonly called, 'shingles' is a neurocutaneous disease characterised by the reactivation of varicella zoster virus (VZV), the virus that causes chickenpox, which is latent in the dorsal spinal ganglia when immunity to VZV declines. It is an extremely painful condition which can often last for many weeks or months, impairing the patient's quality of life. The natural aging process is associated with a reduction of cellular immunity which predisposes to herpes zoster. Vaccination with an attenuated form of VZV activates specific T cell production, therefore avoiding viral reactivation. A herpes zoster vaccine with an active virus has been approved for clinical use among older adults by the Food and Drug Administration and has been tested in large populations.
To evaluate the effectiveness and safety of vaccination for preventing herpes zoster in older adults.
We searched the following sources for relevant studies: CENTRAL 2012, Issue 7, MEDLINE (1948 to July week 1, 2012), EMBASE (2010 to July 2012), LILACS (1982 to July 2012) and CINAHL (1981 to July 2012). We also reviewed reference lists of identified trials and reviews for additional studies.
Randomised controlled trials (RCTs) or quasi-RCTs comparing zoster vaccine with placebo or no vaccine, to prevent herpes zoster in older adults (mean age > 60 years).
Two review authors independently collected and analysed data using a data extraction form. They also carried out an assessment of risk of bias.
We identified eight RCTs with a total of 52,269 participants. Three studies were classified at low risk of bias. The main outcomes on effectiveness and safety were extracted from one clinical trial with a low risk of bias. Four studies compared zoster vaccine versus placebo; one study compared high-potency zoster vaccine versus low-potency zoster vaccine; one study compared refrigerated zoster vaccine versus frozen zoster vaccine; one study compared live zoster vaccine versus inactivated zoster vaccine and one study compared zoster vaccine versus pneumococcal polysaccharide vaccine (pneumo 23).Confirmed cases of herpes zoster were less frequent in patients who received the vaccine than in those who received a placebo: risk ratio (RR) 0.49 (95% confidence interval (CI) 0.43 to 0.56), with a risk difference (RD) of 2%, and number needed to treat to benefit (NNTB) of 50. Analyses according to age groups indicated a greater benefit in participants aged 60 to 69 years, RR 0.36 (95% CI 0.30 to 0.45) and in participants aged 70 years and over, RR 0.63 (95% CI 0.53 to 0.75). Vaccine-related systemic adverse effects were more frequent in the vaccinated group (RR 1.29, 95% CI 1.05 to 1.57, number needed to treat to harm (NNTH) = 100). The pooled data risk ratio for adverse effects for participants with one or more inoculation site adverse effect was RR 4.51 (95% CI 2.35 to 8.68), and the NNTH was 2.8 (95% CI 2.3 to 3.4). Side effects were more frequent in younger (60 to 69 years) than in older (70 years and over) participants.
Herpes zoster vaccine is effective in preventing herpes zoster disease. Although vaccine benefits are larger in the younger age group (60 to 69 years), this is also the age group with more adverse events. In general, zoster vaccine is well tolerated; it produces few systemic adverse events and injection site adverse effects of mild to moderate intensity.

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    • "Les effets indésirables étaient plus fréquents chez les personnes de 60 à 69 ans. En conclusion les auteurs [19] considéraient que ce vaccin était efficace dans la prévention du zona. Bien que les avantages de la vaccination étaient plus importants dans le groupe d'âge le plus jeune (60 à 69 ans), ce groupe d'âge présentait également les événements indésirables les plus défavorables. "

    NPG Neurologie - Psychiatrie - Gériatrie 07/2015; 15(4). DOI:10.1016/J.NPG.2015.05.004
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    • "With continued widespread use of varicella vaccine (Varivax®; Merck, Whitehouse Station, NJ, USA)38 in childhood, primary medical providers may expect to prevent initial VZV infection (chicken pox) and subsequent HZ (shingles) later in life, but varicella vaccine failed to provide long-term protection from VZV.19 One approach to the prevention of PHN in those already harboring VZV involves the administration of the VZ vaccine (Zostavax®; Merck), which has been approved by the FDA for individuals 50 years of age or older.39 The Zostavax® vaccine, which activates specific T-cell production and thus prevents viral reactivations, was found to be effective in reducing the burden of illness due to HZ, incidence of HZ, and incidence of PHN, and was well tolerated, with minor systemic and injection-site adverse events.20,40,41 However, despite the promising results of immunization, data are still insufficient to support long-term prevention of HZ and PHN, and similarly to varicella vaccine, the zoster vaccine protection my wane over time.18,20,21,42 "
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    ABSTRACT: An estimated one million individuals in the US are diagnosed with herpes zoster (HZ; shingles) each year. Approximately 20% of these patients will develop postherpetic neuralgia (PHN), a complex HZ complication characterized by neuropathic pain isolated to the dermatome that was affected by the HZ virus. PHN is debilitating, altering physical function and quality of life, and commonly affects vulnerable populations, including the elderly and the immunocompromised. Despite the availability of an immunization for HZ prevention and several approved HZ treatments, the incidence of PHN is increasing. Furthermore, management of the neuropathic pain associated with PHN is often suboptimal, and the use of available therapeutics may be complicated by adverse effects and complex, burdensome treatment regimens, as well as by patients' comorbidities and polypharmacy, which may lead to drug-drug interactions. Informed and comprehensive assessments of currently available pharmacological treatment options to achieve effective pain control in the primary care setting are needed. In this article, we discuss the situation in clinical practice, review currently recommended prevention and treatment options for PHN, and outline practical considerations for the management of this neuropathic pain syndrome, with a focus on optimal, individual-based treatment plans for use in the primary care setting.
    Journal of Pain Research 03/2014; 7:125-132. DOI:10.2147/JPR.S57242
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    • "For individuals located in the states ‘Healthy’ and ‘healthy after disease’ we chose 1 as a value for baseline utility in the base-case. To account for vaccine-related adverse reactions on the QoL, we assumed a utility of 0.99 for two days per vaccinee, since the vaccine seems to be generally well tolerated [29,49]. "
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    ABSTRACT: Herpes zoster (HZ) is a self-limiting painful skin rash affecting mostly individuals from 50 years of age. The main complication is postherpetic neuralgia (PHN), a long-lasting pain after rash has resolved. A HZ-vaccine has recently been licensed in Europe for individuals older than 50 years. To support an informed decision-making for a potential vaccination recommendation, we conducted a health economic evaluation to identify the most cost-effective vaccination strategy. We developed a static Markov-cohort model, which compared a vaccine-scenario with no vaccination. The cohort entering the model was 50 years of age, vaccinated at age 60, and stayed over life-time in the model. Transition probabilities were based on HZ/PHN-epidemiology and demographic data from Germany, as well as vaccine efficacy (VE) data from clinical trials. Costs for vaccination and HZ/PHN-treatment (in Euros; 2010), as well as outcomes were discounted equally with 3% p.a. We accounted results from both, payer and societal perspective. We calculated benefit-cost-ratio (BCR), number-needed-to-vaccinate (NNV), and incremental cost-effectiveness ratios (ICERs) for costs per HZ-case avoided, per PHN-case avoided, and per quality-adjusted life-year (QALY) gained. Different target age-groups were compared to identify the most cost-effective vaccination strategy. Base-case-analysis as well as structural, descriptive-, and probabilistic-sensitivity-analyses (DSA, PSA) were performed. When vaccinating 20% of a cohort of 1 million 50 year old individuals at the age of 60 years, approximately 20,000 HZ-cases will be avoided over life-time. The NNV to avoid one HZ (PHN)-case was 10 (144). However, with a BCR of 0.34 this vaccination-strategy did not save costs. The base-case-analysis yielded an ICER of 1,419 (20,809) Euros per avoided HZ (PHN)-case and 28,146 Euros per QALY gained. Vaccination at the age of 60 was identified in most (sensitivity) analyses to be the most cost-effective vaccination strategy. In DSA, vaccine price and VE were shown to be the most critical input-data. According to our evaluation, HZ-vaccination is expected to avoid HZ/PHN-cases and gain QALYs to higher costs. However, the vaccine price had the highest impact on the ICERs. Among different scenarios, targeting individuals aged 60 years seems to represent the most cost-effective vaccination-strategy.
    BMC Health Services Research 09/2013; 13(1):359. DOI:10.1186/1472-6963-13-359 · 1.71 Impact Factor
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