Corticosteroid Use and Risk of Herpes Zoster in a Population-Based Cohort.

OBJECTIVE: To examine the relationship between corticosteroid use and herpes zoster risk. METHODS: With data from a large cohort of adults (the 45 and Up Study) recruited between 2006 and 2009 and linked to health data sets, the effect of corticosteroid use on zoster risk was analyzed by Cox proportional hazards models, adjusting for age, sex, and other characteristics. RESULTS: During 602,152 person-years (median, 7.36 years) of follow-up, there were 20,048 new systemic corticosteroid users and 6294 incident herpes zoster events among 94,677 participants (zoster incidence, 11.0 per 1000 person-years). Compared with nonusers, the risk of zoster was 59% higher in those using systemic corticosteroids (adjusted hazard ratio [aHR], 1.59; 95% CI, 1.48 to 1.71) and greater with higher cumulative doses: aHR of 1.32 (95% CI, 1.17 to 1.48), 1.74 (95% CI, 1.55 to 1.95), and 1.80 (95% CI, 1.61 to 2.02) for use of less than 500 mg, 500 mg to less than 1000 mg, and 1000 mg or more prednisolone equivalents, respectively (P value for trend, <.001). Compared with nonusers, zoster risk increased significantly (aHR, 6.00; 95% CI, 4.85 to 7.42) in the month after a single prescription of systemic corticosteroids and returned to levels similar to those in nonusers by the third month after dispensing (aHR, 0.91; 95% CI, 0.49 to 1.69). CONCLUSION: Practitioners should be alert to the increased risk of zoster among patients taking systemic corticosteroids. Given the significant morbidity from zoster, particularly in older adults, these findings support judicious prescribing of corticosteroids, including using as low a dose and as short a course as possible.

Use of disease-modifying antirheumatic drugs and the subsequent risk of herpes zoster in older adults.

OBJECTIVES: To examine the association between DMARD use and subsequent risk of herpes zoster in a large, heterogeneous and prospective population-based cohort. METHODS: Using data from a cohort of adults (45 and Up Study) recruited between 2006 and 2009 and linked to pharmaceutical, hospital and death data (2004-2015), the effect of DMARD use on zoster risk was analysed using Cox proportional hazards models, adjusting for sociodemographic characteristics, comorbidities and corticosteroid use. RESULTS: Among 254 065 eligible participants, over 1 826 311 person-years follow-up, there were 6295 new DMARD users and 17 024 incident herpes zoster events. Compared with non-users, the risk of zoster was higher in those who used biologic (b)DMARDs, either alone or in combination with conventional synthetic (cs)DMARDs than in those who only used csDMARDs (adjusted hazard ratio [aHR] 2.53 [95% CI: 2.03, 3.16]) for bDMARDs vs 1.48 [95% CI: 1.33, 1.66] for csDMARDs, P-heterogeneity < 0.001; reference: non-users). Among users of csDMARDs, compared with non-users, zoster risks were highest in those using exclusively cyclophosphamide (aHR 2.69 [95% CI: 1.89, 3.83]), more moderate in those using azathioprine (aHR 1.57 [95% CI: 1.07, 2.30]) and hydroxychloroquine (aHR 1.43 [95%CI: 1.11, 1.83]) and not elevated in users of methotrexate (aHR 1.24 [95% CI: 0.98, 1.57]), sulfasalazine (aHR 1.00 [95% CI: 0.71, 1.42]) and leflunomide (aHR 0.41 [95% CI: 0.06, 2.88]). CONCLUSIONS: The risk of zoster was high among bDMARD and cyclophosphamide users. Also, the risk was increased in those using hydroxychloroquine alone and in combination with methotrexate but not methotrexate alone. Preventative strategies such as zoster vaccination or antiviral therapies should be considered in these populations if not contraindicated.

Risk of recurrent herpes zoster in a population-based cohort study of older adults.

BACKGROUND: There are limited data on zoster recurrence. OBJECTIVE: To examine in detail zoster recurrence in a population-based cohort. METHODS: 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. RESULTS: 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. LIMITATIONS: Recurrence may be underestimated because of the use of administrative data for case ascertainment. Potential misclassification of nonimmunosuppressed participants. CONCLUSIONS: 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.

Tracking Australian Hajj Pilgrims' Health Behavior before, during and after Hajj, and the Effective Use of Preventive Measures in Reducing Hajj-Related Illness: A Cohort Study.

This study assessed Australian Hajj pilgrims' knowledge, attitude and practices throughout their Hajj journey to understand their health behaviors, use of preventative measures and development of illness symptoms. A prospective cohort study with data collection at three phases (before, during and after Hajj) was conducted among Australian pilgrims between August and December 2015. Baseline data were collected from 421 pilgrims before Hajj, with 391 providing follow-up data during Hajj and 300 after their home return. Most participants (78% [329/421]) received one or more recommended vaccines; travel agents' advice was the main factor affecting vaccination uptake. Most participants (69% [270/391]) practiced hand hygiene with soap and sanitizers frequently, followed by disposable handkerchief use (36% [139/391]) and washing hands with water only (28% [111/391]). During Hajj 74% (288/391) of participants reported one or more illness symptoms, 86% (248/288) of these symptoms were respiratory. Cough was less often reported among pilgrims who received vaccinations, cleaned their hands with soap or alcoholic hand rubs, while a runny nose was less common among those who frequently washed their hands with plain water but was more common among those who used facemasks. This study reveals that most Australian Hajj pilgrims complied with key preventative measures, and that tour group operators' advice played an important role in compliance. Pilgrims who were vaccinated and practiced hand hygiene were less likely to report infection symptoms.

HIV diagnoses in migrant populations in Australia-A changing epidemiology.

INTRODUCTION: We conducted a detailed analysis of trends in new HIV diagnoses in Australia by country of birth, to understand any changes in epidemiology, relationship to migration patterns and implications for public health programs. METHODS: Poisson regression analyses were performed, comparing the age-standardised HIV diagnosis rates per 100,000 estimated resident population between 2006-2010 and 2011-2015 by region of birth, with stratification by exposure (male-to-male sex, heterosexual sex-males and females). Correlation between the number of permanent and long-term arrivals was also explored using linear regression models. RESULTS: Between 2006 and 2015, there were 6,741 new HIV diagnoses attributed to male-to-male sex and 2,093 attributed to heterosexual sex, with the proportion of diagnoses attributed to male-to-male sex who were Australian-born decreasing from 72.5% to 66.5%. Compared with 2006-2010, the average annual HIV diagnosis rate per 100,000 in 2011-15 attributed to male-to-male sex was significantly higher in men born in South-East Asia (summary rate ratio (SRR) = 1.37, p = 0.001), North-East Asia (SRR = 2.18, p<0.001) and the Americas (SRR = 1.37, p = 0.025), but significantly lower as a result of heterosexual sex in men born in South-East Asia (SRR = 0.49, p = 0.002), Southern and Central Asia (SRR = 0.50, p = 0.014) and Sub-Saharan Africa (SRR = 0.39, p<0.001) and women born in South-East Asia (SRR = 0.61, p = 0.002) and Sub-Saharan Africa (SRR = 0.61, p<0.001). Positive associations were observed between the number of permanent and long-term arrivals and HIV diagnoses particularly in relation to diagnoses associated with male-to-male sex in men from North Africa and the Middle East, North Asia, Southern and Central Asia and the Americas. CONCLUSION: The epidemiology of HIV in Australia is changing, with an increase in HIV diagnosis rates attributed to male-to-male sex amongst men born in Asia and the Americas. Tailored strategies must be developed to increase access to, and uptake of, prevention, testing and treatment in this group.

Risk of Herpes Zoster Prior to and Following Cancer Diagnosis and Treatment: A Population-Based Prospective Cohort Study.

BACKGROUND: Information on the risks of herpes zoster (zoster) preceding a cancer diagnosis and the role of cancer treatment on risk is limited. METHODS: This was a prospective cohort of 241497 adults, with mean age 62.0 years at recruitment (2006-2009), linked to health datasets from 2006 to 2015. The relation between cancer diagnosis, treatment, and zoster risk was analyzed using time-varying proportional hazards models. RESULTS: Over 1760 481 person-years of follow-up, 20286 new cancer diagnoses and 16350 zoster events occurred. Participants with hematological and solid cancer had higher relative risks of zoster than those without cancer (adjusted hazard ratio [aHR], 3.74 [95% confidence interval {CI}, 3.11-4.51] and 1.30 [95% CI, 1.21-1.40], respectively). Compared to those without cancer, zoster risk was also elevated prior to a hematological cancer diagnosis (aHR for 1-2 years prior, 2.01 [95% CI, 1.31-3.09]), but this was not the case for solid cancers (aHR for 1-2 years prior, 0.90 [95% CI, .75-1.07]). Compared to those without cancer, zoster risk among participants with solid cancers receiving chemotherapy was greater than in those without a chemotherapy record (aHR, 1.83 [95% CI, 1.60-2.09] and 1.16 [95% CI, 1.06-1.26], respectively). CONCLUSIONS: For hematological cancer, increases in zoster risk are apparent in the 2 years preceding diagnosis and treatment; for solid organ cancers, the increased risk appears to be largely associated with receipt of chemotherapy.

Adherence to anti-vectorial prevention measures among travellers with chikungunya and malaria returning to Australia: comparative epidemiology.

OBJECTIVE: Compare the adoption and adherence to health protection behaviours prior to and during travel among international Australian travellers who return to Australia with notified chikungunya or malaria infection. This information could inform targeted health promotion and intervention strategies to limit the establishment of these diseases within Australia. RESULTS: Seeking travel advice prior to departure was moderate (46%, N = 21/46) yet compliance with a range of recommended anti-vectorial prevention measures was low among both chikungunya and malaria infected groups (16%, N = 7/45). Reasons for not seeking advice between groups was similar and included 'previous overseas travel with no problems' (45%, N = 9/20) and 'no perceived risk of disease' (20%, N = 4/20). Most chikungunya cases (65%, N = 13/20) travelled to Indonesia and a further 25% (N = 5/20) visited India, however most malaria cases (62%, N = 16/26) travelled to continental Africa with only 12% (N = 3/26) travelling to India. The majority (50%, N = 10/20) of chikungunya cases reported 'holiday' as their primary purpose of travel, compared to malaria cases who most frequently reported travel to visit friends and family (VFR; 42%, N = 11/26). These results provide import data that may be used to support distinct public health promotion and intervention strategies of two important vector-borne infectious diseases of concern for Australia.