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A Twenty-Year Audit of Herpes Zoster in Asia-Pacific

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A Twenty-Year Audit of Herpes Zoster in Asia-Pacific Chen et al. BMC Infectious Diseases (2017) 17:213 DOI 10.1186/s12879-017-2198-y REVIEW Open Access Looking back to move forward: a twenty- year audit of herpes zoster in Asia-Pacific Liang-Kung Chen1,2*, Hidenori Arai3, Liang-Yu Chen1, Ming-Yueh Chou2,4, Samsuridjal Djauzi5, Birong Dong6, Taro Kojima7, Ki Tae Kwon8, Hoe Nam Leong9, Edward M. F. Leung10, Chih-Kuang Liang2,4,11, Xiaohong Liu12, Dilip Mathai13, Jiun Yit Pan14, Li-Ning Peng1,2, Eduardo Rommel S. Poblete15, Philip J. H. Poi16, Stewart Reid17, Terapong Tantawichien18 and Chang Won Won19 Abstract Background: Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region. Methods: We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines. Results: From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand. HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation. Conclusions: Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular. Keywords: Asia-Pacific, Complications, Epidemiology, Healthcare burden, Herpes zoster, Immunisation, Management, Post-herpetic neuralgia, Prevention, Vaccine * Correspondence: [email protected] 1Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei 11217, Taiwan 2Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Chen et al. BMC Infectious Diseases (2017) 17:213 Page 2 of 39 Background Filipino, Malay, combined with the terms herpes zoster, Herpes zoster (HZ) is a prevalent and debilitating viral guidelines, recommendations, adult immunisation, vac- disease that often causes serious complications and cine, vaccination. proves challenging to treat. Consequently, HZ results in substantial morbidity, healthcare expenditure, loss of Data management productivity, and diminished quality of life (QoL). Older PubMed and Scopus results were downloaded in people bear the greatest burden of disease, which is in- Comma Separated Value format then saved to Microsoft creasing as populations age. Despite a strong rationale Excel files. WHO Global Health Library searches were for prevention, availability of an effective vaccine, and exported as text files then imported into Microsoft Excel. guidelines recommending HZ immunisation, vaccination Results from each database were screened to remove du- has not become routine practice. One reason was limited plicates before entering the results for each country into a availability of HZ vaccine after its launch in 2006 [1, 2]. Microsoft Excel workbook. Duplicates between databases Although an ample supply was restored, a fundamental were identified by using conditional formatting to high- barrier in Asia is long-standing neglect of preventive adult light entries with the same title. Duplicates between coun- healthcare. Since Ilina Isahak highlighted this issue in tries were identified similarly, by highlighting entries with 2000 [3], progress been limited and adult immunisation is thesamedatabaseidentitycodes. still not given the priority that it merits [4, 5, 6]. Moreover, existing HZ immunisation guidelines are based on evi- Inclusion and inclusion criteria dence from Western populations, which creates a percep- We included articles about four topics: epidemiology and tual barrier to changing management practices in Asia. burden; complications and comorbidities; management Conversely, more locally-relevant data may promote and prevention; and recommendations/guidelines. We guideline implementation; however, many Asian countries excluded articles about: subjects only younger than lack such data [7]. To address these concerns, we system- 18, or from another country; primary varicella zoster atically reviewed literature on HZ from the Asia-Pacific virus (VZV) infection or not specifying that VZV region. Our objectives were: 1) To provide a comprehen- infection was reactivated; negative disease associations, sive overview of the epidemiology, burden, and current cases of coincidental HZ, or diseases other than HZ; management of HZ; 2) To disseminate best practice in extraneous research topics, eg, basic/molecular/experimental, HZ immunisation; and 3) To provide an up-to-date source diagnosis, technology; or reviews without country-specific of reference and information for stakeholders concerned information. Miscellaneous exclusions were editorials, with reducing the burden of HZ in Asia-Pacific. This re- correspondence or errata concerning included articles; view summarises our key findings and recommendations. study protocols, and articles on terminology, hypotheses, non-human subjects, or knowledge, attitudes and Methodology behaviour relating to HZ and its treatment. Literature search strategy We reviewed literature on HZ published over 21 years Literature search results by authors from 14 Asia-Pacific countries. We searched The database searches returned 4007 articles (Fig. 1a). three databases: PubMed (United States [US] National Having excluded 1493 duplicates and 1264 non-relevant Library of Medicine National Institutes of Health), Scopus articles, 1250 were assigned to four categories: epidemi- (Elsevier), and the World Health Organization (WHO) ology and burden (421); complications and comorbidities Global Health Library Regional Indexes. PubMed and Sco- (538); management and prevention (287); and guidelines pus searches used the search term ‘zoster’ in title, abstract, (4) (Fig. 1b). The separate search for guidelines found rec- and author keywords fields, AND the term ‘country name’ ommendations on adult immunisation from Australia, in the affiliation field. The countries/regions were: India, Indonesia, Malaysia, New Zealand, the Philippines, Australia, China, Hong Kong, India, Indonesia, Japan, South Korea, Taiwan, and Thailand. Korea, Malaysia, New Zealand, the Philippines, Singapore, ‘Grey literature’ included other key studies/data cited Taiwan, Thailand, and Vietnam OR Viet Nam. WHO in retrieved articles or not stored in the searched data- searches used the terms ‘country name’ AND ‘zoster’. bases, eg, national statistics or reports published locally; Searches were limited to articles with abstracts in English 16 such sources were added. published electronically since 1 January 1994 and before 31 December 2014; alerts were set to capture eligible articles Clinicopathology added to PubMed and Scopus after the initial search dates. Herpes zoster is caused by reactivation of VZV dormant We performed separate internet searches for guidelines in nerve root ganglia since a primary varicella infection on HZ immunisation. These used the country names and (Chickenpox). The cardinal symptom is neuropathic also vernacular terms for their inhabitants,
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