The epidemiology of herpes zoster and potential cost-effectiveness of vaccination in England and Wales

doi:10.1016/S0264-410X(01)00044-5

Vaccine

Volume 19, Issues 23–24, 30 April 2001, Pages 3076-3090

https://doi.org/10.1016/S0264-410X(01)00044-5 Get rights and content

Abstract

The epidemiology of herpes zoster and post-herpetic neuralgia (PHN) was quantified from a variety of data sources and the potential cost-effectiveness of vaccination assessed. The annual incidence and severity of zoster increases sharply with age, as measured by physician consultation and hospitalisation rates, average length of stay, average proportion of cases developing PHN and the age-specific case-fatality ratio. Combining these data with information on health related quality of life results in an estimated loss of 20 000 quality adjusted life years (QALYs) annually in England and Wales from herpes zoster (17 400 due to PHN). The current cost of treating herpes zoster associated disease is estimated to be £47.6m annually. Since both the health and economic burden are high, vaccination of the elderly is expected to be cost-effective under most scenarios, the attractiveness of immunisation increasing with age due to the increased burden of disease in the very elderly.

Introduction

Varicella zoster virus (VZV) is associated with two distinct diseases: varicella (chickenpox) and herpes zoster (shingles). Primary infection with VZV results in varicella, a usually mild infection of children. Following primary infection the virus becomes dormant in dorsal root ganglia, and may reactivate later to cause herpes zoster, a cutaneous eruption commonly associated with pain. Reactivation is thought to follow a decline in cell-mediated immunity, usually occurring in immunocompromised individuals or the elderly. Complications of zoster occur in 13–26% of cases [1], [2], [3], the most common and debilitating being post-herpetic neuralgia (PHN) — persistent pain occurring after the onset of zoster. Around 25% of individuals would be expected to develop herpes zoster at some point in their lives [4], and between 15 and 40% of these will develop PHN [5], [6]. Hence, zoster and PHN are the cause of significant morbidity. Since the probability of developing zoster and PHN both increase significantly with age [5], [6], the overwhelming burden associated with these diseases is borne by the elderly.

A live attenuated VZV vaccine (Oka strain) has been available since the mid 1970s [7], and has been introduced into a number of country's infant immunisation schedules, including that of the United States, with the primary aim of preventing varicella [8]. There is increasing interest as to whether a similar vaccine (either live-attenuated or inactivated) might prevent the development of zoster through boosting cell-mediated immunity to VZV [9], [10], [11], [12]. Follow-up of vaccinated immuno-compromised children suggests that those who had a household exposure to wild varicella were significantly less likely to develop zoster than those who did not [13], suggesting that exposure to the vaccine might provide a similar boost. Safety and immunogenicity studies have shown that adults with a prior history of varicella can be safely immunised with either a live or attenuated varicella vaccine, resulting in a boost to their cell-mediated response [9], [10], [11], [12]. The efficacy of the live vaccine in preventing zoster in the elderly is currently being evaluated in clinical trials.

To enable the impact of mass vaccination to be assessed (whether this be vaccination of children against varicella, or vaccination of adults against herpes zoster) it is necessary to have good, population-based pre-vaccination epidemiological data. Many of the population-based studies of shingles were performed decades ago [2], [5], [6], [14] and the epidemiology of herpes zoster might be expected to have changed over time, particularly in the light of new treatment regimes and an aging population. Hence it is timely to assess the occurrence and characteristics of herpes zoster in the community.

The aims of this paper are to quantify the epidemiology of zoster and post-herpetic neuralgia in a typical industrialised country (England and Wales), to determine if mass adult vaccination against zoster is likely to be cost-effective, and if so, which age group should be targeted for immunisation.

Section snippets

Epidemiological data sources and parameter estimates

The age-specific incidence of zoster in the community was taken from a prospective study of zoster in general practice over the period 1947–1972 [5] and from two sentinel surveillance systems: the fourth morbidity survey in general practice (MSGP4), a survey of general practices covering a 1% sample of England and Wales during 1991–1992 [15]; and the Royal College of general practitioners weekly returns service (RCGP) [16] which also comprises of a representative sample of GP practices in

Epidemiology of zoster

The annual incidence of first episode of herpes zoster in England and Wales by age group as calculated from the different data sets is shown in Fig. 1. It is clear that the incidence of first episode of zoster increases with age from 10 to 20 per 10 000 person years in children to greater than 100 per 10 000 person years in those aged 85 years or greater. There is a high degree of agreement between the different estimates presented here as well as with studies from other industrialised

Discussion

We present here a detailed review of the epidemiology of herpes zoster and post-herpetic neuralgia in England and Wales and the first analysis of the potential cost-effectiveness of vaccination against these conditions.

The collation and analysis of national, population-based data on physician consultations and hospitalisations, as well as the analysis of historical data-sets allowed us to quantify the epidemiology of herpes zoster and PHN. This detailed epidemiological data, combined with

Acknowledgements

The United Kingdom Medical Research Council, Grant number G9818303, provided financial support. We thank Dr Elizabeth Miller for comments on the manuscript and Usha Gungabissoon for obtaining the mortality data.

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A hybrid model of decision tree and Markov models was used to estimate lifetime cost and health outcomes. This open-cohort model was populated based on Utah population statistics and included a population of 50 years and older who were eligible for HZ vaccination between the years 2010 and 2020. Data were derived from the U.S. Bureau of Labor Statistics, the Utah Immunization Coverage Report, the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System, the CDC National Health Interview Survey, and existing literature. The analysis was performed from a societal perspective. A lifetime time horizon was used. The primary outcomes were the number of vaccination cases increased and the number of shingles and postherpetic neuralgia (PHN) cases averted. Total costs and quality-adjusted life-years (QALYs) were also estimated.
Based on a cohort of 853,550 people eligible for HZ vaccination in Utah, an additional 11,576 individuals were vaccinated in the community pharmacy-based scenario compared with the nonpharmacy-based vaccination, resulting in 706 averted cases of shingles and 143 averted cases of PHN. Community pharmacy-based HZ vaccination was less costly (−$131,894) and gained more QALYs (52.2) compared with the nonpharmacy-based vaccination. A series of sensitivity analyses showed that the findings were robust.
Community pharmacy-based HZ vaccination was less costly and gained more QALYs and was associated with improved other clinical outcomes in the State of Utah. This study might be used as a model for future evaluations of other community pharmacy-based vaccination programs in the United States.
Facial nevralgia (including cluster headache)
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Les névralgies faciales sont des causes rares mais invalidantes de douleurs paroxystiques ou chroniques. Leur diagnostic est clinique, basé pour les formes typiques sur des critères diagnostiques consensuels. Il existe cependant des formes de chevauchement ou trompeuses qui peuvent faire errer le diagnostic. La névralgie du trijumeau prédomine chez la femme de 50 ans. Elle se présente sous formes d’éclairs douloureux dans une branche du trijumeau le plus souvent dus à une compression du nerf par une boucle vasculaire. Les douleurs, déclenchées par l’effleurement d’une zone gâchette sont favorisées par de nombreux actes de la vie quotidienne (boire, manger, déglutir…). Elles sont particulièrement invalidantes et parfois confondues avec une douleur dentaire. Les traitements médicamenteux reposent en premier lieu sur la carbamazépine/oxcarbazépine. La décompression microvasculaire et les traitements percutanés locaux sont réservés aux formes résistantes. L’algie vasculaire de la face touche préférentiellement l’homme jeune. Elle se caractérise par des crises très douloureuses orbitotemporales survenant tous les jours à la même heure souvent en réveillant le patient. Les douleurs, associées à des signes végétatifs de la face, durent de 30 minutes à une heure et se répètent régulièrement pendant quelques semaines avant de disparaître temporairement. La physiopathologie est encore mal comprise. L’oxygène à haut débit et les triptans sont les traitements de choix. Le vérapamil et l’isoptine peuvent prévenir la récidive des crises. La névralgie post zostérienne est la persistance au-delà de 3 mois d’une douleur dans le territoire d’un zona. Son incidence augmente avec l’âge. Il s’agit d’une douleur chronique invalidante traitée par les molécules efficaces sur les douleurs neuropathiques. D’autres formes plus rares de névralgies faciales sont décrites comme la névralgie d’Arnold ou la névralgie du glossopharygien. Compte tenu du retentissement important de ces douleurs sur la qualité de vie, leur reconnaissance et prise en charge précoce est indispensable.
Facial nevralgias are rare but debilitating paroxystic or chronic pains. Consensual diagnostic criteria can help to establish the diagnosis, but misleading presentations exist. Trijeminal neuralgia has a pic incidence in women in theirs 1950s. Patients complains of lightning pain in the territory of a branch of the trijeminal nerve. The nerve lesion is most often secondary to a microvascular compression. The pain is triggered by a light sensation on a small area of the face. Pain are severe and sometimes confused with a dental affection. Pharmacotherapy is primarily based on carbamazepine/oxcarbazepine. Microvascular decompression is offered to patients not sufficiently controlled medically. Cluster headache is more common in young men. The pain last 30 minutes to one hour is periorbital. Region and is accompanied by cranial autonomic symptoms. Cluster attacks have a circadian and circumannual rhythmicity. The pathyphysiology is nor fully understood. Intranasal/subcutaneous triptan or high concentration oxygen inhalation are the mainstay of acute treatment. Prevention of cluster recurrence is based on verapamil or lithium administration. Postherpetic neuralgia is defined of the persistence of pain 3 months after a herpes zoster rash. The prevalence of the disease increased with age. It presents as a chronic neuropathic pain that must be treated with appropriate medications. Other facial nevralgias have been described such as occipital or glossopharyngeal nevralgia. Due to their significant impact on quality of life, awareness of the entities is critical an early and to avoid misdiagnosis.
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The epidemiology of herpes zoster and potential cost-effectiveness of vaccination in England and Wales

Abstract

Introduction

Section snippets

Epidemiological data sources and parameter estimates

Epidemiology of zoster

Discussion

Acknowledgements

Antiviral Res.

Infect. Dis. Clin. North Am.

Vaccine

Clin. Epidemiol.

Pain

Herpes zoster and its complications in Italy: an observational survey

J. Infect.

Population-based study of herpes zoster and its sequelae

Medicine

The sequelae of herpes zoster

Arch. Intern. Med.

Epidemiology, outcome and control of varicella-zoster infection

Rev. Med. Micro.

Postherpetic neuralgia

J. R. Coll. Gen. Pract.

The outcome of patients with herpes zoster

AMA Arch. Dermat.

Development of a live attenuated varicella vaccine

Biken J.

Live attenuated varicella vaccine

Pediatrics

Use of a live attenuated varicella vaccine to boost varicella-specific immune responses in seropositive people 55 years of age and older: duration of booster effect

J. Infect. Dis.

The protective effect of immunologic boosting against zoster: an analysis in leukemic children who were vaccinated against chickenpox

J. Infect. Dis.

The nature of herpes zoster: a long-term study and a new hypothesis

Proc. R. Soc. Med.