Crohn's Disease and Herpes Zoster: Being Mindful of Vaccination.

Crohn's disease is a chronic inflammatory disease of the gastrointestinal tract. Immunosuppressive therapy is the main treatment modality in Crohn's disease. Herpes zoster (HZ), caused by Varicella-zoster virus, is a relatively common albeit burdensome clinical picture mainly affecting adult population with immunosuppressive status. In this paper, we aimed to report a Crohn's disease patient with HZ to raise awareness on vaccination. There are commercially available vaccines that are shown to be safe and effective against HZ reactivation. Crohn's disease patients should be evaluated and informed about preventive options against HZ to prevent unwanted HZ-related complications.

Cost-effectiveness of varicella and herpes zoster vaccination in Sweden: An economic evaluation using a dynamic transmission model.

OBJECTIVES: Comprehensive cost-effectiveness analyses of introducing varicella and/or herpes zoster vaccination in the Swedish national vaccination programme. DESIGN: Cost-effectiveness analyses based on epidemiological results from a specifically developed transmission model. SETTING: National vaccination programme in Sweden, over an 85- or 20-year time horizon depending on the vaccination strategy. PARTICIPANTS: Hypothetical cohorts of people aged 12 months and 65-years at baseline. INTERVENTIONS: Four alternative vaccination strategies; 1, not to vaccinate; 2, varicella vaccination with one dose of the live attenuated vaccine at age 12 months and a second dose at age 18 months; 3, herpes zoster vaccination with one dose of the live attenuated vaccine at 65 years of age; and 4, both vaccine against varicella and herpes zoster with the before-mentioned strategies. MAIN OUTCOME MEASURES: Accumulated cost and quality-adjusted life years (QALY) for each strategy, and incremental cost-effectiveness ratios (ICER). RESULTS: It would be cost-effective to vaccinate against varicella (dominant), but not to vaccinate against herpes zoster (ICER of EUR 200,000), assuming a cost-effectiveness threshold of EUR 50,000 per QALY. The incremental analysis between varicella vaccination only and the combined programme results in a cost per gained QALY of almost EUR 1.6 million. CONCLUSIONS: The results from this study are central components for policy-relevant decision-making, and suggest that it was cost-effective to introduce varicella vaccination in Sweden, whereas herpes zoster vaccination with the live attenuated vaccine for the elderly was not cost-effective-the health effects of the latter vaccination cannot be considered reasonable in relation to its costs. Future observational and surveillance studies are needed to make reasonable predictions on how boosting affects the herpes zoster incidence in the population, and thus the cost-effectiveness of a vaccination programme against varicella. Also, the link between herpes zoster and sequelae need to be studied in more detail to include it suitably in health economic evaluations.

Patient characteristics and analgesic efficacy of antiviral therapy in postherpetic neuralgia.

Postherpetic neuralgia (PHN) is the most common complication of shingles caused by reactivation of varicella zoster virus (VZV). Management of PHN is often suboptimal while using current conventional treatments. Antiviral therapy was used to reduce PHN-associated pain in two small trials which showed conflicting results. We hypothesize the analgesic efficacy of antiviral therapy on PHN is affected by patient characteristics including pathophysiology of the participants and serum vitamin D levels. Pathophysiology of PHN includes neuronal excitability and chronic VZV ganglionitis (persistent active VZV infection in ganglions). VZV-DNA positivity or a positive IgG coupled with a positive IgM indicates recent or current VZV infection. Positive VZV-DNA or IgG/IgM tests are used to confirm whether the patients experience chronic VZV ganglionitis. Antiviral therapy decreases pain in PHN patients with chronic VZV ganglionitis; whereas, antiviral therapy shows no effects in PHN patients with negative VZV-DNA or IgM. Vitamin D is a natural antiviral mediator. Studies show a high prevalence of vitamin D deficiency in hepatitis B/C virus-infected patients. Serum vitamin D levels and vitamin D supplementation are factors which affect the antiviral efficacy on hepatitis B/C virus infection. Serum 25-OHD levels of hospitalized patients with shingles were significantly lower compared to healthy controls. Accordingly, PHN patient may have a high prevalence of vitamin D deficiency which negatively affects the antiviral efficacy. Vitamin D supplementation may improve the antiviral efficacy on PHN. Future trials regarding antiviral therapy on PHN should consider patient characteristics and should be conducted among different subgroups of PHN patients.

A critical appraisal of 'Shingrix', a novel herpes zoster subunit vaccine (HZ/Su or GSK1437173A) for varicella zoster virus.

HZ/Su, branded as 'Shingrix', is one of the newest vaccines to be submitted for multi-national regulatory approval. It is targeted to prevent shingles, a global concern with aging populations. A live attenuated vaccine for shingles has been available for over a decade, however it is contraindicated in specific subgroups of people, and there are added concerns regarding long-term immunogenicity. HZ/Su is the first subunit vaccine developed to protect against shingles. This paper provides a critical appraisal of current evidence regarding HZ/Su.

Augmenting immune responses to varicella zoster virus in older adults: a randomized, controlled trial of Tai Chi.

OBJECTIVES: To evaluate the effects of a behavioral intervention, Tai Chi, on resting and vaccine-stimulated levels of cell-mediated immunity (CMI) to varicella zoster virus (VZV) and on health functioning in older adults. DESIGN: A prospective, randomized, controlled trial with allocation to two arms (Tai Chi and health education) for 25 weeks. After 16 weeks of intervention, subjects were vaccinated with VARIVAX, the live attenuated Oka/Merck VZV vaccine licensed to prevent varicella. SETTING: Two urban U.S. communities between 2001 and 2005. PARTICIPANTS: A total of 112 healthy older adults aged 59 to 86. MEASUREMENTS: The primary endpoint was a quantitative measure of VZV-CMI. Secondary outcomes were scores on the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). RESULTS: The Tai Chi group showed higher levels of VZV-CMI than the health education group (P<.05), with a significant rate of increase (P<.001) that was nearly twice that found in the health education group. Tai Chi alone induced an increase in VZV-CMI that was comparable in magnitude with that induced by varicella vaccine, and the two were additive; Tai Chi, together with vaccine, produced a substantially higher level of VZV-CMI than vaccine alone. The Tai Chi group also showed significant improvements in SF-36 scores for physical functioning, bodily pain, vitality, and mental health (P<.05). CONCLUSION: Tai Chi augments resting levels of VZV-specific CMI and boosts VZV-CMI of the varicella vaccine.

Effects of a behavioral intervention, Tai Chi Chih, on varicella-zoster virus specific immunity and health functioning in older adults.

OBJECTIVE: Both the incidence and severity of herpes zoster (shingles) increase markedly with increasing age in association with a decline in varicella-zoster virus (VZV) specific cell-mediated immunity (CMI). This study examined whether a behavioral intervention, Tai Chi Chih (TCC), affects VZV specific immunity and health functioning in older adults who, on average, show impairments of health status and are at risk for shingles. METHODS: Thirty-six men and women (age > or =60 years) were assigned randomly to a 15-week program of TCC instruction (three 45 minute classes per week; N = 18) or a wait list control condition (N = 18). VZV-specific CMI was measured at baseline and at 1-week postintervention. Health functioning (Medical Outcome scale: SF-36) was assessed at baseline, and at 5, 10, and 15 weeks during the intervention, and at 1-week postintervention. RESULTS: In the intent-to-treat sample, VZV-specific CMI increased 50% from baseline to 1-week postintervention in the TCC group (p < 0.05) but was unchanged in the wait list control group. In those who completed the study, 1-week postintervention SF-36 scale scores for role-physical (p < 0.05) and physical functioning (p < 0.05) were higher in the TCC group (N = 14) as compared with controls (N = 17). Older adults who had impairments of physical status at baseline showed the greatest increases of SF-36 role-physical (p < 0.01) and physical functioning (p < 0.001) during the TCC intervention. CONCLUSIONS: Administration of TCC for 15 weeks led to an increase in VZV-specific CMI. Gains in health functioning were found in participants who received TCC and were most marked in those older adults who had the greatest impairments of health status.

Incidence, risk factors and outcome of varicella-zoster virus infection in children after haematopoietic stem cell transplantation.

We report a retrospective analysis of VZV infection after haematopoietic stem cell transplantation (HSCT) in children. Thirty-three (30%) of the total 109 children who were transplanted during a 7 year period developed post-transplant VZV infection. Twenty-four of these 33 (73%) children had VZV infection within 1 year following HSCT. The cumulative incidences of post-transplant VZV infection at 1 and 5 years were 26% and 45%, respectively. The positive and negative predictive values of pretransplant VZV serology in recipients on the development of HZ following HSCT were 39% and 88%, respectively. Pretransplant VZV seropositivity in recipients was the only risk factor for post-transplant herpes zoster (HZ) infection on multivariate analysis. All patients responded to acyclovir. The median duration of VZV infection was 5 days. Three (11%) and one (3%) children with HZ developed visceral dissemination and post-herpetic neuralgia, respectively. No mortality was directly attributed to VZV infection. VZV infection remains a major cause of morbidity in children after HSCT. Further studies are warranted to evaluate the potential use of VZV vaccine in these children. Bone Marrow Transplantation (2000) 25, 167-172.

Psychologic modulation of the human immune response to varicella zoster.

Psychoimmunology, the interrelationship between the brain/mind/psyche and the immune system, is now an established area of scientific research. Based on prior investigations we hypothesized that an experienced meditator could affect her delayed hypersensitivity reaction by a psychological process. A single-case study design was employed in which the subject was skin tested weekly with varicella zoster skin test reagent. After baseline immunologic studies, she was able, as hypothesized, to significantly reduce both the induration of her delayed hypersensitivity skin test reaction and in vitro lymphocyte stimulation to varicella zoster. Then, as predicted, she was able to allow her reaction to return to baseline. As a confirmation of what is to our knowledge this previously undescribed phenomenon, she was able to reproduce the entire sequence nine months later. It appears that this subject can intentionally modulate her immune response by a psychologic mechanism.

Acyclovir in the treatment of simian varicella virus infection of the African green monkey.

Acyclovir (9-(2-hydroxyethoxymethyl)guanine) administered as an intramuscular formulation twice daily at a dosage of 100 mg/kg per day prevented the development of disease in African green monkeys inoculated with simian varicella virus. Viremia, appearance of a vesicular rash, and elevations of serum transaminases, each indicative of infection, were suppressed by acyclovir treatment. Plasma concentrations of acyclovir were measured and showed rising levels after repeated intramuscular injection with a prolonged period of absorption of acyclovir into the plasma circulation. Investigation of antiviral efficacy after either intramuscular or intravenous acyclovir treatment showed both routes of administration to be effective in inhibiting simian varicella virus infection at the 100 mg/kg per day level. However, intravenous acyclovir 50 mg/kg twice daily did result in elevated values of blood urea nitrogen, creatinine, and serum transaminases.