Shingles Raises Risk Of Stroke By 30 Percent Or More In Adults, Study Finds

ScienceDaily (Oct. 9, 2009) — Adults with shingles were about 30 percent more likely to have a stroke during a one-year follow-up than adults without shingles, in a study reported in Stroke: Journal of the American Heart Association.

The risk was even greater when the infection involved the eyes.

Shingles, also called herpes zoster, is a painful skin rash caused by the varicella zoster virus (VZV). VZV is the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays in the body. Usually the virus doesn’t cause problems, but it can reappear years later, causing shingles.

Shingles is not caused by the same virus that causes genital herpes, a sexually transmitted disease.

“Many studies have shown that people with herpes zoster infection are more likely to develop stroke. But ours is the first to demonstrate the actual risk of stroke following herpes zoster infection,” said Jiunn-Horng Kang, M.D., M.Sc., lead author of the study and attending physician in the Department of Physical Medicine and Rehabilitation and chair of the Sleep Physiological Lab at Taipei Medical University Hospital.

Kang and his associates studied 7,760 patients 18 years and older who received shingles treatment between 1997 and 2001. These people were matched by age and gender with 23,280 adults who weren’t treated for shingles (controls). Their average age was 47.

During the one-year follow-up, 133 shingles patients (about 1.7 percent) and 306 of the controls (about 1.3 percent) had strokes. After adjusting for general factors for stroke risk, the researchers found:

People treated for a shingles infection were 31 percent more likely to have a stroke, compared with patients without a shingles infection.Patients with shingles infections that involved the skin around the eye and the eye itself (herpes zoster ophthalmicus) were 4.28 times more likely to have a stroke than patients without shingles. When the researchers analyzed the risk of stroke by stroke type, they found:Shingles patients were 31 percent more likely to develop an ischemic stroke during the one-year follow-up than those without shingles.The risk of hemorrhagic (bleeding) stroke was 2.79 times higher for people with shingles infection than for people without shingles.

Ischemic strokes, which are caused by the blockage of an artery, account for 87 percent of the new or recurrent strokes that strike about 780,000 Americans annually, according to the American Heart Association.

“Herpes zoster infection is very easy to diagnose, and antiviral medication can be used to treat the infection in the early stages,” Kang said. “While the mechanism by which shingles increases stroke risk remains unclear, the possibility of developing a stroke after a shingles attack should not be overlooked.

Doctors and patients must pay extra attention to controlling other risk factors for stroke, such as high blood pressure, smoking and diabetes.”

Shingles usually starts as a rash on one side of the face or body. The rash starts as blisters that scab after three to five days and usually clears within two to four weeks. There is often pain, itching or tingling in the area where the rash develops.

Researchers didn’t design the study to determine how shingles infection raises stroke risk. But other research suggests that as the herpes zoster virus replicates and attacks the vessel wall, the vessel wall becomes damaged and inflamed. This in turn can cause the vessel to close up, or occlude, blocking blood flow to the brain. Shingles is also the only recognized human virus able to invade cerebral arteries.

In addition, shingles is also associated with severe pain, and the stress of that chronic pain may raise the risk of cardiovascular disease theoretically, Kang said.

Co-authors are Jau-Der Ho, M.D., Ph.D.; Yi-Hua Chen, Ph.D.; and Herng-Ching Lin, Ph.D. Individual author disclosures are on the manuscript.

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Shingles vaccine is safe, according to new study

ScienceDaily (Apr. 23, 2012) — The herpes zoster vaccine, also known as the shingles vaccine, is generally safe and well tolerated according to a Vaccine Safety Datalink study of 193,083 adults published online in the Journal of Internal Medicine.

More than 1 million people develop shingles every year in the United States. Shingles is a painful contagious rash caused by the dormant chickenpox virus which can reactivate and replicate, damaging the nerve system. The elderly are especially vulnerable because immunity against the virus that causes shingles declines with age.

The VSD project is a collaborative effort between the Centers for Disease Control and Prevention and integrated care organizations, including Kaiser Permanente. The VSD project monitors immunization safety and addresses the gaps in scientific knowledge about any rare and serious events that occur following immunization.

This study examined adverse events after the zoster vaccine was administered to 193,083 adults aged 50 and older from Jan. 1, 2007, to Dec. 31, 2008. Vaccination data were retrieved from electronic health records and collected from eight managed care organizations participating in the VSD project.

Researchers found a small increased risk of local reactions from one to seven days after vaccination. These findings corroborate clinical trials of the vaccine in which there was evidence of a minor local reaction at the injection site in the form of redness and pain.

The study found no increased risk for cerebrovascular diseases; cardiovascular diseases; meningitis, encephalitis, and encephalopathy; Ramsay-Hunt syndrome; or Bell's palsy.

"It's good to know there is no serious adverse reaction to the zoster vaccine. The study supports the CDC's Advisory Committee on Immunization Practices' recommendation and reassures the general public that the vaccine is safe," said study lead author Hung Fu Tseng, PhD, MPH, a research scientist with the Kaiser Permanente Southern California Department of Research & Evaluation in Pasadena, Calif.

The herpes zoster vaccine was licensed in 2006, but few people have been vaccinated, national data shows. The ACIP recommends the vaccine for healthy people age 60 years and older. In 2011, the U.S. Food and Drug Administration approved the use of the herpes zoster vaccine in individuals 50 to 59 years of age. The study results provide important safety data for people in this age group as well as adults 60 and older.

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Journal Reference:

H. F. Tseng, A. Liu, L. Sy, S. M. Marcy, B. Fireman, E. Weintraub, J. Baggs, S. Weinmann, R. Baxter, J. Nordin, M. F. Daley, L. Jackson, S. J. Jacobsen. Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study. Journal of Internal Medicine, 2012; 271 (5): 510 DOI: 10.1111/j.1365-2796.2011.02474.x

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New study alters long-held beliefs about shingles

ScienceDaily (Feb. 1, 2011) — For decades, medical wisdom about shingles has been that it's a once-in-a-lifetime experience. The commonly-held belief is that patients are protected from a recurrence of the herpes zoster virus, which causes shingles, after one episode. But according to a study published in the February issue of Mayo Clinic Proceedings, recurrences of shingles may be significantly more common than doctors have suspected.

"It's been thought that recurrences were limited to people with compromised immune systems, for instance from chemotherapy or bloodborne malignancies, but this is not the case," says lead author Barbara Yawn, M.D., director of research at Olmsted Medical Center in Rochester. "Recurrence was prevalent in the immunocompetent population. We were very surprised by the results."

The research team examined medical records, dating from 1996 to 2001, of nearly 1,700 patients over age 22 who had a documented episode of shingles. The condition causes a specific type of skin rash and severe pain. They then searched area medical records to determine whether those patients had been treated for a second episode at any point, following them up to 12 years (the average follow-up was eight years). The data showed the recurrence rate was over 5 percent, the same rate an age-matched cohort would be expected to experience a first case of shingles. Some patients had experienced as many as three recurrences. "And that's only within eight years," Dr. Yawn notes. "As you continue to follow these patients throughout their lives, it's likely the recurrence rate will be much higher than 5 percent."

The study found that women, who are more likely than men to have shingles, also were more likely to experience a recurrence of the disease. Although the team had suspected that recurrence rates would be higher in older patients, age did not appear to make individuals more susceptible to another round of the disease. Instead, researchers found the most striking determinant for recurrence was patients' pain during the initial episode. Those who had experienced pain lasting more than 30 days after the initial onset of shingles were more likely to face a recurrence, particularly in the first three to four years after the initial episode. This, too, surprised the research team. "We'd thought that suffering a worse case would possibly give patients more resistance to a second occurrence, but our data presented the exact opposite," says Dr. Yawn.

The results suggest that the herpes zoster vaccine, which is known to reduce first-time occurrences of shingles by 50 percent, may help patients avoid a second episode. "Until now, we haven't been able to tell patients their risks of getting zoster a second time," Dr. Yawn says. "This study offers another piece of information for patients and doctors who are discussing the likelihood of recurrence and considering a prevention strategy."

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Journal Reference:

B. P. Yawn, P. C. Wollan, M. J. Kurland, J. L. St. Sauver, P. Saddier. Herpes Zoster Recurrences More Frequent Than Previously Reported. Mayo Clinic Proceedings, 2011; 86 (2): 88 DOI: 10.4065/mcp.2010.0618

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Zoster vaccine associated with lower risk of shingles in older adults

ScienceDaily (Jan. 12, 2011) — Vaccination for herpes zoster, a painful rash commonly known as shingles, among a large group of older adults was associated with a reduced risk of this condition, regardless of age, race or the presence of chronic diseases, according to a study in the January 12 issue of JAMA.

"The pain of herpes zoster is often disabling and can last for months or even years, a complication termed postherpetic neuralgia. Approximately 1 million episodes of herpes zoster occur in the United States annually, but aside from age and immunosuppression, risk factors for this condition are not known," the authors write. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions to show whether benefits of the vaccine can be generalized to conditions of clinical practice, according to background information in the article. The researchers note that this is particularly important for the herpes zoster vaccine, given the medical and physiological diversity in the elderly population for whom the vaccine is indicated.

Hung Fu Tseng, Ph.D., M.P.H., of Southern California Kaiser Permanente, Pasadena, Calif., and colleagues evaluated the risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings. The study included community-dwelling adults, age 60 years or older, who were members of a managed care organization. There were 75,761 members in the vaccinated cohort, who were age matched (1:3) to 227,283 unvaccinated members.

Compared with the unvaccinated cohort, individuals in the vaccinated cohort were more likely to be white, women, and to have had more outpatient visits, and a lower prevalence of chronic diseases. There were 5,434 herpes zoster cases identified in the study (6.4 cases per 1,000 persons per year among vaccinated individuals and 13.0 cases per 1,000 persons per year among unvaccinated individuals). In the fully adjusted analysis, vaccination was associated with reduced risk of herpes zoster. The reduction in risk did not vary by age at vaccination, sex, race, or with presence of chronic diseases. Herpes zoster vaccine recipients had reduced risks of ophthalmic herpes zoster and hospitalizations coded as herpes zoster. Overall, the vaccine was associated with a 55 percent reduction in incidence of herpes zoster.

"Herpes zoster vaccine was licensed recently, which means the durability of its protection needs to be assessed in future studies. Meanwhile, however, this vaccine has the potential to annually prevent tens of thousands of cases of herpes zoster and postherpetic neuralgia nationally. To date, herpes zoster vaccine uptake has been poor due to weaknesses in the adult vaccine infrastructure and also due to serious barriers to the vaccine among clinicians and patients. Solutions to these challenges need to be found so that individuals seeking to receive herpes zoster vaccine will be able to reduce their risk of experiencing this serious condition," the authors conclude.

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H. F. Tseng, N. Smith, R. Harpaz, S. R. Bialek, L. S. Sy, S. J. Jacobsen. Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease. JAMA: The Journal of the American Medical Association, 2011; 305 (2): 160 DOI: 10.1001/jama.2010.1983

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Study challenges concerns on effectiveness of administering pneumococcal, shingles vaccines together

ScienceDaily (May 11, 2011) — Administering both the pneumococcal and the herpes zoster vaccines to patients during the same visit is beneficial and does not appear to compromise the protective effect of the zoster vaccine, according to a Kaiser Permanente study published in the journal Vaccine.

The study's findings challenge information in the zoster vaccine manufacturer's package insert. This new information is important to patients who find it more convenient and less costly to receive both vaccines from their health care providers during the same visit.

A revision to the zoster vaccine package insert, approved in 2009, stated that the zoster vaccine and the pneumococcal vaccine should not be given together because such concurrent use reduced the ability of the zoster vaccine to generate an immune response.

"Our study found no evidence that receiving the zoster vaccine and pneumococcal vaccine on the same day would compromise the immune response necessary to protect against herpes zoster, also known as shingles," noted study lead author Hung Fu Tseng, PhD, MPH, a research scientist with the Kaiser Permanente Department of Research & Evaluation in Pasadena, Calif.

The study was conducted from Jan. 1, 2007, to June 30, 2010, starting from the date of receipt of the zoster vaccine for two groups of Kaiser Permanente Southern California members, 60 years of age and older. The incidence of herpes zoster after vaccination with a zoster vaccine in the population receiving both vaccines on the same day was compared to that in the population receiving a pneumococcal vaccine from one year to 30 days before the zoster vaccine. Vaccinations and the incidence of herpes zoster cases were identified by electronic health records.

Included in the study were two groups or cohorts: 7,187 people who received both vaccines at the same time and 7,179 people who received the two vaccines at different times (nonconcurrently). There were 114 herpes zoster cases identified in the study: 56 cases in the concurrent group, and 58 cases in the nonconcurrent vaccination group. The study found no statistically significant difference in incidence of shingles between the two groups.

Dr. Tseng adds, "Ideally, when a new vaccine is introduced to the public, one should consider giving it at the same time as other vaccines to increase coverage levels and minimize administration costs, if there are no immune response issues or safety concerns."

According to the Centers for Disease Control and Prevention, pneumococcal polysaccharide vaccine protects against 23 types of pneumococcal bacteria, including those most likely to cause serious disease. Pneumococcal disease can result in long-term problems such as like brain damage, hearing loss and limb loss, and in some cases can be fatal. Most healthy adults who get the vaccine develop protection to most or all of these types within two to three weeks of getting the shot.

The risk of developing shingles during a lifetime is about 30 percent, and there are more than 1 million episodes of shingles every year in the United States. Shingles is a painful condition that can last months or years and can seriously impact quality of life. Less than 7 percent of the eligible U.S. population was vaccinated for herpes zoster by the end of 2008.

The CDC continues to recommend that the zoster vaccine and pneumococcal vaccine be administered at the same visit if the person is eligible for both vaccines.

The FDA approved the package label change in 2009 based on a research study by Merck that found antibody levels to the herpes zoster virus were lowered if the vaccine was administered concomitantly with pneumonia vaccine. However that study used the antibody level as the marker of protection, but it is the cell-mediated immunity against the herpes virus, instead of the antibody level that protects against the disease explained Dr. Tseng.

"This new study provides even stronger data because it relies on the measurement of the occurrence of disease rather than intermediate markers of immunity," Tseng said.

This study is the latest in a series of published Kaiser Permanente studies undertaken to better understand vaccine effectiveness and safety:

A study of 300,000 people published in JAMA earlier this year by Dr. Tseng found that receiving the herpes zoster vaccine was associated with a 55 percent reduced risk of developing shingles.Another Tseng study published in JAMA last year found the pneumococcal pneumonia vaccination is not associated with a reduced risk of heart attacks or strokes.Another Kaiser Permanente study found the combination vaccine for measles, mumps, rubella and chickenpox (MMRV) is associated with double the risk of febrile seizures for 1- to 2-year-old children compared to same-day administration of the separate vaccine for MMR (measles, mumps, rubella) and the varicella (V) vaccine for chickenpox.Other recent published Kaiser Permanente studies found children of parents who refuse vaccines are nine times more likely to get chickenpox and 23 times more likely to get whooping cough compared to fully immunized children. A study published last year found that herpes zoster, also known as shingles, is very rare among children who have been vaccinated against chickenpox.

Co-authors of the paper include Hung Fu Tseng, PhD, MPH, Ning Smith, PhD, Lina S. Sy, MPH, and Steven J. Jacobsen, MD, PhD, with Kaiser Permanente Department of Research & Evaluation.

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Journal Reference:

Hung Fu Tseng, Ning Smith, Lina S. Sy, Steven J. Jacobsen. Evaluation of the incidence of herpes zoster after concomitant administration of zoster vaccine and polysaccharide pneumococcal vaccine. Vaccine, 2011; 29 (20): 3628 DOI: 10.1016/j.vaccine.2011.03.018

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Patients with COPD have higher risk of shingles, study finds

ScienceDaily (Feb. 23, 2011) — Patients with chronic obstructive pulmonary disease (COPD) are at greater risk of shingles compared with the general population, according to a study published in CMAJ (Canadian Medical Association Journal). The risk is greatest for patients taking oral steroids to treat COPD.

Shingles, or herpes zoster, is a reactivation of the chicken pox virus resulting in a painful rash with lesions.

People with a compromised immune system are at greater risk of developing shingles although it has not been previously studied in patients with COPD.

There is increasing evidence that COPD is an autoimmune disease. "Given that various immune-mediated diseases, such as rheumatoid arthritis and inflammatory bowel disease, have been reported to be associated with an increased risk of herpes zoster, it is reasonable to hypothesize that immune dysregulation found in COPD may put patients at higher risk of developing herpes zoster," writes Dr. Hui-Wen Lin, Taipei Medical University, Taiwan with coauthors.

This study, using data from the Taiwan Longitudinal Health Insurance Database, included 8486 patients with COPD and 33 944 subjects from the comparison cohort. Of the total sample of 42 430 patients, 1080 had incident of herpes zoster during the follow-up period. There were 321 cases of shingles identified in the COPD cohort, 16.4 per 1000 person years, and 759 cases in the comparison cohort, 8.8 per 1000 person years.

"Our cohort study demonstrated that patients with COPD are at an increased risk of developing herpes zoster compared with the general population, after controlling for other herpes zoster risk factors," write the authors. "The risk of herpes zoster associated with COPD is greater for patients with inhaled or oral corticosteroids therapy than patients without."

The authors conclude it is possible that "increased disease severity further contributes to the increased risk of herpes zoster associated with COPD."

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Journal Reference:

Yang, Ya-Wen, Chen, Yi-Hua, Wang, Kuo-Hsien, Wang, Chen-Yi, Lin, Hui-Wen. Risk of herpes zoster among patients with chronic obstructive pulmonary disease: a population-based study. Canadian Medical Association Journal, 2011; DOI: 10.1503/cmaj.101137

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Pain of shingles (herpes zoster) significantly interferes with daily life

ScienceDaily (Oct. 4, 2010) — Acute herpes zoster, or shingles, interferes with all health areas for people with the condition, including sleep, enjoyment of life and general activities, according to a study published in CMAJ (Canadian Medical Association Journal).

Herpes zoster is a reactivation of the chicken pox (varicella-zoster) virus which results in pain and a rash with small blisters. It occurs in people who have had chicken pox and is most common in people over the age of 50, although younger people can have the condition. The lifetime risk of developing shingles is about 30%, but may increase as life expectancies increase.

Policymakers are being asked to consider implementing vaccination programs for the herpes zoster vaccine which is available as a preventative tool but more information is needed about the impact of shingles.

The MASTER study (Monitoring and Assessing Shingles Through Education and Research) was conducted in Canada to provide an in-depth understanding of the impact of shingles. The multi-centre study involved outpatients recruited through general practitioners or specialists across Canada.

"Acute herpes zoster significantly affected quality-of-life and functional status," writes Dr. Marc Brisson, Laval University, with coauthors. "Sleeping, enjoyment of life, general activities, mood, normal work and quality-of-life domains of pain/discomfort and usual activities were particularly diminished. This was consistently observed across all age groups."

The discomfort of shingles can also persist for months after the acute phase, with 24% of people in the study developing pain (postherpetic neuralgia) after the rash healed. The risk increased for older people.

The researchers conclude that this study reinforces "the need for effective prevention strategies, such as vaccination, and additional early intervention to reduce the burden of herpes zoster and postherpetic neuralgia."

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Shingles may be related to elevated risk of multiple sclerosis

ScienceDaily (June 9, 2011) — Taiwanese investigators have found that there can be a significantly higher risk of multiple sclerosis (MS) occurring in the year following a shingles, or herpes zoster, attack. The findings, which support a long-held view on how MS may develop, are published in The Journal of Infectious Diseases and now available online.

MS is an autoimmune disease that affects the brain and spinal cord, leading to inflammation and nerve damage as the body's immune cells attack the nervous system. Possible causes that may trigger the inflammation include environmental, genetic, and viral factors. One virus that has been associated with MS is varicella zoster virus, the cause of herpes zoster.

In a study conducted by Herng-Ching Lin, PhD, and colleagues at Taipei Medical University in Taiwan, 315,550 adults with herpes zoster and a control group of 946,650 subjects were tracked and then evaluated for MS occurrence during a one-year follow-up period. The control group was selected randomly from a pool of subjects who had not been diagnosed with herpes zoster or other viral diseases. After adjusting for monthly income and geographic region, the authors found that the group with herpes zoster had a 3.96 times higher risk of developing MS than the control group. The authors noted that this risk, although increased, was still low, as is the frequency of MS in general. The study also noted an interval of approximately 100 days between a herpes zoster event and occurrence of MS.

Although the study was limited almost entirely to Han Chinese adults, the large scope of this nationwide case-controlled study, 1.26 million sampled patients, provides strong epidemiological evidence for a possible role for herpes zoster in the development of MS. The authors also point out that MS has a lower prevalence in Asian compared to Western populations and, thus, it may be difficult to project their findings to other populations.

In an accompanying editorial, Teresa Corona, MD, and Jose Flores, MD, of the National Institute of Neurology and Neurosurgery in Mexico noted that "The evidence provided in this study…allows us to better understand the role of these viral factors as an MS risk among certain genetically susceptible individuals," and that the study should be corroborated in other parts of the world to help clarify the role of this and other viruses in MS.

Fast Facts:

There is epidemiological evidence that some herpes viruses may contribute to multiple sclerosis (MS) occurrence.The rate of MS prevalence varies by geographical location and income.In this study, investigators found a significantly higher -- but still low -- risk for MS occurring in the year following a shingles, or herpes zoster, attack compared to a control population.There is evidence that 30 percent of relapses in MS patients may be associated with an infectious disease.Share this story on Facebook, Twitter, and Google:

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Journal References:

Jiunn-Horng Kang, Jau-Jiuan Sheu, Senyeong Kao and Herng-Ching Lin. Increased Risk of Multiple Sclerosis Following Herpes Zoster: A Nationwide, Population-Based Study. Journal of Infectious Diseases, June 7, 2011 DOI: 10.1093/infdis/jir239Teresa Corona and José Flores. Herpes Zoster and Multiple Sclerosis. Journal of Infectious Diseases, June 7, 2011 DOI: 10.1093/infdis/jir243

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Shingles vaccine is safe, according to new study

ScienceDaily (Apr. 23, 2012) — The herpes zoster vaccine, also known as the shingles vaccine, is generally safe and well tolerated according to a Vaccine Safety Datalink study of 193,083 adults published online in the Journal of Internal Medicine.

More than 1 million people develop shingles every year in the United States. Shingles is a painful contagious rash caused by the dormant chickenpox virus which can reactivate and replicate, damaging the nerve system. The elderly are especially vulnerable because immunity against the virus that causes shingles declines with age.

The VSD project is a collaborative effort between the Centers for Disease Control and Prevention and integrated care organizations, including Kaiser Permanente. The VSD project monitors immunization safety and addresses the gaps in scientific knowledge about any rare and serious events that occur following immunization.

This study examined adverse events after the zoster vaccine was administered to 193,083 adults aged 50 and older from Jan. 1, 2007, to Dec. 31, 2008. Vaccination data were retrieved from electronic health records and collected from eight managed care organizations participating in the VSD project.

Researchers found a small increased risk of local reactions from one to seven days after vaccination. These findings corroborate clinical trials of the vaccine in which there was evidence of a minor local reaction at the injection site in the form of redness and pain.

The study found no increased risk for cerebrovascular diseases; cardiovascular diseases; meningitis, encephalitis, and encephalopathy; Ramsay-Hunt syndrome; or Bell's palsy.

"It's good to know there is no serious adverse reaction to the zoster vaccine. The study supports the CDC's Advisory Committee on Immunization Practices' recommendation and reassures the general public that the vaccine is safe," said study lead author Hung Fu Tseng, PhD, MPH, a research scientist with the Kaiser Permanente Southern California Department of Research & Evaluation in Pasadena, Calif.

The herpes zoster vaccine was licensed in 2006, but few people have been vaccinated, national data shows. The ACIP recommends the vaccine for healthy people age 60 years and older. In 2011, the U.S. Food and Drug Administration approved the use of the herpes zoster vaccine in individuals 50 to 59 years of age. The study results provide important safety data for people in this age group as well as adults 60 and older.

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Journal Reference:

H. F. Tseng, A. Liu, L. Sy, S. M. Marcy, B. Fireman, E. Weintraub, J. Baggs, S. Weinmann, R. Baxter, J. Nordin, M. F. Daley, L. Jackson, S. J. Jacobsen. Safety of zoster vaccine in adults from a large managed-care cohort: a Vaccine Safety Datalink study. Journal of Internal Medicine, 2012; 271 (5): 510 DOI: 10.1111/j.1365-2796.2011.02474.x

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Disclaimer: This article is not intended to provide medical advice, diagnosis or treatment. Views expressed here do not necessarily reflect those of ScienceDaily or its staff.

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Study challenges concerns on effectiveness of administering pneumococcal, shingles vaccines together

ScienceDaily (May 11, 2011) — Administering both the pneumococcal and the herpes zoster vaccines to patients during the same visit is beneficial and does not appear to compromise the protective effect of the zoster vaccine, according to a Kaiser Permanente study published in the journal Vaccine.

The study's findings challenge information in the zoster vaccine manufacturer's package insert. This new information is important to patients who find it more convenient and less costly to receive both vaccines from their health care providers during the same visit.

A revision to the zoster vaccine package insert, approved in 2009, stated that the zoster vaccine and the pneumococcal vaccine should not be given together because such concurrent use reduced the ability of the zoster vaccine to generate an immune response.

"Our study found no evidence that receiving the zoster vaccine and pneumococcal vaccine on the same day would compromise the immune response necessary to protect against herpes zoster, also known as shingles," noted study lead author Hung Fu Tseng, PhD, MPH, a research scientist with the Kaiser Permanente Department of Research & Evaluation in Pasadena, Calif.

The study was conducted from Jan. 1, 2007, to June 30, 2010, starting from the date of receipt of the zoster vaccine for two groups of Kaiser Permanente Southern California members, 60 years of age and older. The incidence of herpes zoster after vaccination with a zoster vaccine in the population receiving both vaccines on the same day was compared to that in the population receiving a pneumococcal vaccine from one year to 30 days before the zoster vaccine. Vaccinations and the incidence of herpes zoster cases were identified by electronic health records.

Included in the study were two groups or cohorts: 7,187 people who received both vaccines at the same time and 7,179 people who received the two vaccines at different times (nonconcurrently). There were 114 herpes zoster cases identified in the study: 56 cases in the concurrent group, and 58 cases in the nonconcurrent vaccination group. The study found no statistically significant difference in incidence of shingles between the two groups.

Dr. Tseng adds, "Ideally, when a new vaccine is introduced to the public, one should consider giving it at the same time as other vaccines to increase coverage levels and minimize administration costs, if there are no immune response issues or safety concerns."

According to the Centers for Disease Control and Prevention, pneumococcal polysaccharide vaccine protects against 23 types of pneumococcal bacteria, including those most likely to cause serious disease. Pneumococcal disease can result in long-term problems such as like brain damage, hearing loss and limb loss, and in some cases can be fatal. Most healthy adults who get the vaccine develop protection to most or all of these types within two to three weeks of getting the shot.

The risk of developing shingles during a lifetime is about 30 percent, and there are more than 1 million episodes of shingles every year in the United States. Shingles is a painful condition that can last months or years and can seriously impact quality of life. Less than 7 percent of the eligible U.S. population was vaccinated for herpes zoster by the end of 2008.

The CDC continues to recommend that the zoster vaccine and pneumococcal vaccine be administered at the same visit if the person is eligible for both vaccines.

The FDA approved the package label change in 2009 based on a research study by Merck that found antibody levels to the herpes zoster virus were lowered if the vaccine was administered concomitantly with pneumonia vaccine. However that study used the antibody level as the marker of protection, but it is the cell-mediated immunity against the herpes virus, instead of the antibody level that protects against the disease explained Dr. Tseng.

"This new study provides even stronger data because it relies on the measurement of the occurrence of disease rather than intermediate markers of immunity," Tseng said.

This study is the latest in a series of published Kaiser Permanente studies undertaken to better understand vaccine effectiveness and safety:

A study of 300,000 people published in JAMA earlier this year by Dr. Tseng found that receiving the herpes zoster vaccine was associated with a 55 percent reduced risk of developing shingles.Another Tseng study published in JAMA last year found the pneumococcal pneumonia vaccination is not associated with a reduced risk of heart attacks or strokes.Another Kaiser Permanente study found the combination vaccine for measles, mumps, rubella and chickenpox (MMRV) is associated with double the risk of febrile seizures for 1- to 2-year-old children compared to same-day administration of the separate vaccine for MMR (measles, mumps, rubella) and the varicella (V) vaccine for chickenpox.Other recent published Kaiser Permanente studies found children of parents who refuse vaccines are nine times more likely to get chickenpox and 23 times more likely to get whooping cough compared to fully immunized children. A study published last year found that herpes zoster, also known as shingles, is very rare among children who have been vaccinated against chickenpox.

Co-authors of the paper include Hung Fu Tseng, PhD, MPH, Ning Smith, PhD, Lina S. Sy, MPH, and Steven J. Jacobsen, MD, PhD, with Kaiser Permanente Department of Research & Evaluation.

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Journal Reference:

Hung Fu Tseng, Ning Smith, Lina S. Sy, Steven J. Jacobsen. Evaluation of the incidence of herpes zoster after concomitant administration of zoster vaccine and polysaccharide pneumococcal vaccine. Vaccine, 2011; 29 (20): 3628 DOI: 10.1016/j.vaccine.2011.03.018

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Type Of Rheumatoid Arthritis Medication May Be Associated With Increased Risk For Shingles

ScienceDaily (Feb. 17, 2009) — Use of certain medications known as monoclonal anti– tumor necrosis factor a (TNF-a) antibodies for the treatment of rheumatoid arthritis appears to be associated with an increased risk for herpes zoster (shingles), the painful infection characterized by blisters, according to a new study.

There has been evidence from some studies that patients treated with anti–TNF-a agents are at an increased risk of bacterial infections, but little is known about the risk of viral infections, such as herpes zoster, in patients with rheumatoid arthritis receiving these types of medications. Herpes zoster is one of the most common adverse events reported in clinical trials of anti–TNF-a agents, according to background information in the article. Patients with rheumatoid arthritis are at increased risk of herpes zoster compared with the general population.

Anja Strangfeld, M.D., of the German Rheumatism Research Center, Berlin, and colleagues investigated the association of various rheumatoid arthritis treatments, including anti–TNF-a therapy, with the risk of herpes zoster. The researchers analyzed data from patients who began treatment with adalimumab or infliximab (monoclonal anti–TNF-a antibodies), etanercept (a fusion protein), the monotherapeutic agent anakinra, or when patients changed conventional disease-modifying anti-rheumatic drug (DMARD). Treatment, clinical status and adverse events were assessed by rheumatologists at fixed points during follow-up (of up to three years). A total of 5,040 patients were included in the analysis.

There were 86 cases of herpes zoster among 82 patients. Thirty-nine occurrences could be attributed to treatment with anti–TNF-a antibodies (23 to etanercept, 24 to conventional DMARDs). The researchers found a significant association between herpes zoster and treatment with the monoclonal anti–TNF-a antibodies infliximab and adalimumab, although this risk was lower than the threshold for clinical significance. There was no significant association between herpes zoster and treatment with etanercept, or anti–TNF-a treatment as a class.

A significantly higher risk of developing herpes zoster was found for patients of older age and for treatment with glucocorticoids (steroid hormones that are widely used as anti-inflammatory medications).

"Based on our data, we recommend careful monitoring of patients treated with monoclonal anti–TNF-a antibodies for early signs and symptoms of herpes zoster," the authors conclude.

Editorial: Herpes Zoster in the Age of Focused Immunosuppressive Therapy

In an accompanying editorial, Richard J. Whitley, M.D., and John W. Gnann Jr., M.D., of the University of Alabama at Birmingham, comment on the findings of this study.

"The TNF-a inhibitors provide tremendous benefit to a broad spectrum of patients with systemic inflammatory diseases. As with any therapy, time is required for all of the safety concerns related to these potent medications to become apparent. TNF-a inhibitors have revolutionized the management of a number of difficult diseases, especially inflammatory arthritis, but clinicians must continue to remain aware of the potential for serious infectious complications, which now include herpes zoster."

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Journal Reference:

Anja Strangfeld; Joachim Listing; Peter Herzer; Anke Liebhaber; Karin Rockwitz; Constanze Richter; Angela Zink. Risk of Herpes Zoster in Patients With Rheumatoid Arthritis Treated With Anti%u2013TNF-{alpha} Agents. JAMA, 2009;301(7):737-744 [link]

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Childhood Chicken Pox Can Lead To Shingles Later In Life

ScienceDaily (Feb. 18, 2009) — You may recall as a child catching the itchy red rash, chicken pox. The unsightly infection was caused by the varicella zoster virus and was responsible for nearly 4 million cases each year, according to the Centers for Disease Control (CDC), until a vaccine introduced in 1995 reduced that number by 83 percent.

Yet, if you were among those that suffered from chicken pox, the varicella zoster virus may still be present in your body and could lead to serious (and irreversible) oral health problems such as herpes-type lesions and severe bone damage to the jaws.

 Varicella zoster can lie dormant in the body for decades, and if activated can lead to herpes zoster (HZ), more commonly referred to as shingles, according to a study that appeared in General Dentistry, the Academy of General Dentistry’s (AGD) clinical, peer-reviewed journal.

Affecting nearly 1 million Americans each year, 50 percent of all new cases of herpes zoster occur in individuals over the age of 60.

“Herpes zoster manifests as painful blisters that erupt along the sensory nerves usually on one side of the body or face,” according to co-author of the study, M.A. Pogrel, DDS, MD. “It can be a debilitating disease that can lead to osteonecrosis of the jaw and vision loss in addition to a prolonged painful syndrome.”

Osteonecrosis is a condition in which bone in the lower or upper jaw becomes exposed. As a result, the jaw bone suffers severe damage and/or death, eventually leading to tooth loss.

While the exact reason for tooth loss is unknown, it has been noted that restricted blood flow and inflammation may be a cause.

However, AGD spokesperson, Laura Murcko, DMD, notes that, “Your dentist can help detect early signs of osteonecrosis of the jaw by checking for loose teeth, detached gums as well as taking dental x-rays.”

Dr. Murcko encourages patients who may have signs of or are suffering from osteonecrosis to visit their dentist regularly and practice good oral hygiene. She recommends that patients consume 1,000 to 1,200 milligrams of calcium a day, add vitamin D to their diet, exercise and weight train, quit smoking and decrease caffeine and alcohol intake.

Symptoms of osteonecrosis:

Pain, swelling or infection of the gumsLoosening of teethPoor healing of the gumsNumbness or the feeling of heaviness in the jawShare this story on Facebook, Twitter, and Google:

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Pain of shingles (herpes zoster) significantly interferes with daily life

ScienceDaily (Oct. 4, 2010) — Acute herpes zoster, or shingles, interferes with all health areas for people with the condition, including sleep, enjoyment of life and general activities, according to a study published in CMAJ (Canadian Medical Association Journal).

Herpes zoster is a reactivation of the chicken pox (varicella-zoster) virus which results in pain and a rash with small blisters. It occurs in people who have had chicken pox and is most common in people over the age of 50, although younger people can have the condition. The lifetime risk of developing shingles is about 30%, but may increase as life expectancies increase.

Policymakers are being asked to consider implementing vaccination programs for the herpes zoster vaccine which is available as a preventative tool but more information is needed about the impact of shingles.

The MASTER study (Monitoring and Assessing Shingles Through Education and Research) was conducted in Canada to provide an in-depth understanding of the impact of shingles. The multi-centre study involved outpatients recruited through general practitioners or specialists across Canada.

"Acute herpes zoster significantly affected quality-of-life and functional status," writes Dr. Marc Brisson, Laval University, with coauthors. "Sleeping, enjoyment of life, general activities, mood, normal work and quality-of-life domains of pain/discomfort and usual activities were particularly diminished. This was consistently observed across all age groups."

The discomfort of shingles can also persist for months after the acute phase, with 24% of people in the study developing pain (postherpetic neuralgia) after the rash healed. The risk increased for older people.

The researchers conclude that this study reinforces "the need for effective prevention strategies, such as vaccination, and additional early intervention to reduce the burden of herpes zoster and postherpetic neuralgia."

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Shingles Raises Risk Of Stroke By 30 Percent Or More In Adults, Study Finds

ScienceDaily (Oct. 8, 2009) — Adults with shingles were about 30 percent more likely to have a stroke during a one-year follow-up than adults without shingles, in a study reported in Stroke: Journal of the American Heart Association.

The risk was even greater when the infection involved the eyes.

Shingles, also called herpes zoster, is a painful skin rash caused by the varicella zoster virus (VZV). VZV is the same virus that causes chickenpox. After a person recovers from chickenpox, the virus stays in the body. Usually the virus doesn’t cause problems, but it can reappear years later, causing shingles.

Shingles is not caused by the same virus that causes genital herpes, a sexually transmitted disease.

“Many studies have shown that people with herpes zoster infection are more likely to develop stroke. But ours is the first to demonstrate the actual risk of stroke following herpes zoster infection,” said Jiunn-Horng Kang, M.D., M.Sc., lead author of the study and attending physician in the Department of Physical Medicine and Rehabilitation and chair of the Sleep Physiological Lab at Taipei Medical University Hospital.

Kang and his associates studied 7,760 patients 18 years and older who received shingles treatment between 1997 and 2001. These people were matched by age and gender with 23,280 adults who weren’t treated for shingles (controls). Their average age was 47.

During the one-year follow-up, 133 shingles patients (about 1.7 percent) and 306 of the controls (about 1.3 percent) had strokes. After adjusting for general factors for stroke risk, the researchers found:

People treated for a shingles infection were 31 percent more likely to have a stroke, compared with patients without a shingles infection.Patients with shingles infections that involved the skin around the eye and the eye itself (herpes zoster ophthalmicus) were 4.28 times more likely to have a stroke than patients without shingles. When the researchers analyzed the risk of stroke by stroke type, they found:Shingles patients were 31 percent more likely to develop an ischemic stroke during the one-year follow-up than those without shingles.The risk of hemorrhagic (bleeding) stroke was 2.79 times higher for people with shingles infection than for people without shingles.

Ischemic strokes, which are caused by the blockage of an artery, account for 87 percent of the new or recurrent strokes that strike about 780,000 Americans annually, according to the American Heart Association.

“Herpes zoster infection is very easy to diagnose, and antiviral medication can be used to treat the infection in the early stages,” Kang said. “While the mechanism by which shingles increases stroke risk remains unclear, the possibility of developing a stroke after a shingles attack should not be overlooked.

Doctors and patients must pay extra attention to controlling other risk factors for stroke, such as high blood pressure, smoking and diabetes.”

Shingles usually starts as a rash on one side of the face or body. The rash starts as blisters that scab after three to five days and usually clears within two to four weeks. There is often pain, itching or tingling in the area where the rash develops.

Researchers didn’t design the study to determine how shingles infection raises stroke risk. But other research suggests that as the herpes zoster virus replicates and attacks the vessel wall, the vessel wall becomes damaged and inflamed. This in turn can cause the vessel to close up, or occlude, blocking blood flow to the brain. Shingles is also the only recognized human virus able to invade cerebral arteries.

In addition, shingles is also associated with severe pain, and the stress of that chronic pain may raise the risk of cardiovascular disease theoretically, Kang said.

Co-authors are Jau-Der Ho, M.D., Ph.D.; Yi-Hua Chen, Ph.D.; and Herng-Ching Lin, Ph.D. Individual author disclosures are on the manuscript.

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Patients with COPD have higher risk of shingles, study finds

ScienceDaily (Feb. 22, 2011) — Patients with chronic obstructive pulmonary disease (COPD) are at greater risk of shingles compared with the general population, according to a study published in CMAJ (Canadian Medical Association Journal). The risk is greatest for patients taking oral steroids to treat COPD.

Shingles, or herpes zoster, is a reactivation of the chicken pox virus resulting in a painful rash with lesions.

People with a compromised immune system are at greater risk of developing shingles although it has not been previously studied in patients with COPD.

There is increasing evidence that COPD is an autoimmune disease. "Given that various immune-mediated diseases, such as rheumatoid arthritis and inflammatory bowel disease, have been reported to be associated with an increased risk of herpes zoster, it is reasonable to hypothesize that immune dysregulation found in COPD may put patients at higher risk of developing herpes zoster," writes Dr. Hui-Wen Lin, Taipei Medical University, Taiwan with coauthors.

This study, using data from the Taiwan Longitudinal Health Insurance Database, included 8486 patients with COPD and 33 944 subjects from the comparison cohort. Of the total sample of 42 430 patients, 1080 had incident of herpes zoster during the follow-up period. There were 321 cases of shingles identified in the COPD cohort, 16.4 per 1000 person years, and 759 cases in the comparison cohort, 8.8 per 1000 person years.

"Our cohort study demonstrated that patients with COPD are at an increased risk of developing herpes zoster compared with the general population, after controlling for other herpes zoster risk factors," write the authors. "The risk of herpes zoster associated with COPD is greater for patients with inhaled or oral corticosteroids therapy than patients without."

The authors conclude it is possible that "increased disease severity further contributes to the increased risk of herpes zoster associated with COPD."

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Journal Reference:

Yang, Ya-Wen, Chen, Yi-Hua, Wang, Kuo-Hsien, Wang, Chen-Yi, Lin, Hui-Wen. Risk of herpes zoster among patients with chronic obstructive pulmonary disease: a population-based study. Canadian Medical Association Journal, 2011; DOI: 10.1503/cmaj.101137

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New study alters long-held beliefs about shingles

ScienceDaily (Feb. 1, 2011) — For decades, medical wisdom about shingles has been that it's a once-in-a-lifetime experience. The commonly-held belief is that patients are protected from a recurrence of the herpes zoster virus, which causes shingles, after one episode. But according to a study published in the February issue of Mayo Clinic Proceedings, recurrences of shingles may be significantly more common than doctors have suspected.

"It's been thought that recurrences were limited to people with compromised immune systems, for instance from chemotherapy or bloodborne malignancies, but this is not the case," says lead author Barbara Yawn, M.D., director of research at Olmsted Medical Center in Rochester. "Recurrence was prevalent in the immunocompetent population. We were very surprised by the results."

The research team examined medical records, dating from 1996 to 2001, of nearly 1,700 patients over age 22 who had a documented episode of shingles. The condition causes a specific type of skin rash and severe pain. They then searched area medical records to determine whether those patients had been treated for a second episode at any point, following them up to 12 years (the average follow-up was eight years). The data showed the recurrence rate was over 5 percent, the same rate an age-matched cohort would be expected to experience a first case of shingles. Some patients had experienced as many as three recurrences. "And that's only within eight years," Dr. Yawn notes. "As you continue to follow these patients throughout their lives, it's likely the recurrence rate will be much higher than 5 percent."

The study found that women, who are more likely than men to have shingles, also were more likely to experience a recurrence of the disease. Although the team had suspected that recurrence rates would be higher in older patients, age did not appear to make individuals more susceptible to another round of the disease. Instead, researchers found the most striking determinant for recurrence was patients' pain during the initial episode. Those who had experienced pain lasting more than 30 days after the initial onset of shingles were more likely to face a recurrence, particularly in the first three to four years after the initial episode. This, too, surprised the research team. "We'd thought that suffering a worse case would possibly give patients more resistance to a second occurrence, but our data presented the exact opposite," says Dr. Yawn.

The results suggest that the herpes zoster vaccine, which is known to reduce first-time occurrences of shingles by 50 percent, may help patients avoid a second episode. "Until now, we haven't been able to tell patients their risks of getting zoster a second time," Dr. Yawn says. "This study offers another piece of information for patients and doctors who are discussing the likelihood of recurrence and considering a prevention strategy."

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B. P. Yawn, P. C. Wollan, M. J. Kurland, J. L. St. Sauver, P. Saddier. Herpes Zoster Recurrences More Frequent Than Previously Reported. Mayo Clinic Proceedings, 2011; 86 (2): 88 DOI: 10.4065/mcp.2010.0618

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Zoster vaccine associated with lower risk of shingles in older adults

ScienceDaily (Jan. 11, 2011) — Vaccination for herpes zoster, a painful rash commonly known as shingles, among a large group of older adults was associated with a reduced risk of this condition, regardless of age, race or the presence of chronic diseases, according to a study in the January 12 issue of JAMA.

"The pain of herpes zoster is often disabling and can last for months or even years, a complication termed postherpetic neuralgia. Approximately 1 million episodes of herpes zoster occur in the United States annually, but aside from age and immunosuppression, risk factors for this condition are not known," the authors write. Although prelicensure data provided evidence that herpes zoster vaccine works in a select study population under idealized circumstances, the vaccine needs to be evaluated in field conditions to show whether benefits of the vaccine can be generalized to conditions of clinical practice, according to background information in the article. The researchers note that this is particularly important for the herpes zoster vaccine, given the medical and physiological diversity in the elderly population for whom the vaccine is indicated.

Hung Fu Tseng, Ph.D., M.P.H., of Southern California Kaiser Permanente, Pasadena, Calif., and colleagues evaluated the risk of herpes zoster after receipt of herpes zoster vaccine among individuals in general practice settings. The study included community-dwelling adults, age 60 years or older, who were members of a managed care organization. There were 75,761 members in the vaccinated cohort, who were age matched (1:3) to 227,283 unvaccinated members.

Compared with the unvaccinated cohort, individuals in the vaccinated cohort were more likely to be white, women, and to have had more outpatient visits, and a lower prevalence of chronic diseases. There were 5,434 herpes zoster cases identified in the study (6.4 cases per 1,000 persons per year among vaccinated individuals and 13.0 cases per 1,000 persons per year among unvaccinated individuals). In the fully adjusted analysis, vaccination was associated with reduced risk of herpes zoster. The reduction in risk did not vary by age at vaccination, sex, race, or with presence of chronic diseases. Herpes zoster vaccine recipients had reduced risks of ophthalmic herpes zoster and hospitalizations coded as herpes zoster. Overall, the vaccine was associated with a 55 percent reduction in incidence of herpes zoster.

"Herpes zoster vaccine was licensed recently, which means the durability of its protection needs to be assessed in future studies. Meanwhile, however, this vaccine has the potential to annually prevent tens of thousands of cases of herpes zoster and postherpetic neuralgia nationally. To date, herpes zoster vaccine uptake has been poor due to weaknesses in the adult vaccine infrastructure and also due to serious barriers to the vaccine among clinicians and patients. Solutions to these challenges need to be found so that individuals seeking to receive herpes zoster vaccine will be able to reduce their risk of experiencing this serious condition," the authors conclude.

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Journal Reference:

H. F. Tseng, N. Smith, R. Harpaz, S. R. Bialek, L. S. Sy, S. J. Jacobsen. Herpes Zoster Vaccine in Older Adults and the Risk of Subsequent Herpes Zoster Disease. JAMA: The Journal of the American Medical Association, 2011; 305 (2): 160 DOI: 10.1001/jama.2010.1983

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Chicken pox vaccine reduces shingles risk in kids

ScienceDaily (Dec. 4, 2009) — Herpes zoster, also known as shingles, is very rare among children who have been vaccinated against chicken pox, according to a Kaiser Permanente study in the December issue of the Pediatric Infectious Diseases Journal.

The study, the largest of its kind, used electronic health records to identify more than 170,000 children vaccinated with the varicella (chicken pox) vaccine from 2002 to 2008 in Kaiser Permanente's Southern California region, then followed children for an average of two and a half years to identify the occurrence of herpes zoster.

Researchers found only 122 cases of herpes zoster among the 172,163 vaccinated children, for an estimated incidence of 1 case per 3,700 vaccinated children per year. This is a lower rate compared to what one would expect in the unvaccinated children based on previous experiences.

"The message to parents and pediatricians is: vaccinating your child against the chicken pox is also a good way to reduce their chances of getting herpes zoster," said the study's lead author, HungFu Tseng, Ph.D, MPH, a research scientist and epidemiologist at the Kaiser Permanente Department of Research and Evaluation in Pasadena, Calif. "More research is needed to identify the virus strains that cause herpes zoster."

This study did not look at side effects of the varicella vaccine.

Herpes zoster is an acute skin viral infection caused by reactivation of latent varicella-zoster virus, which remains in certain nerve cells of the body after an infection with either wild-type or the varicella vaccine virus. The wild-type virus is found in the natural infection, in contrast to the virus strain found in vaccine.

Since the vaccine's introduction in 1995, there have been few studies on the incidence of childhood herpes zoster among children vaccinated with the varicella vaccine.

Following licensure in 1995, 1-dose varicella vaccine was recommended for children 12 months to 12 years of age. In 2006, a routine second dose of varicella vaccine for previously vaccinated persons aged 4 years and older was recommended.

Other study authors included: Ning Smith, MS, Lina S. Sy, MPH, S Michael Marcy, MD, and Steven J. Jacobsen, MD, Ph.D., from the Kaiser Permanente Department of Research and Evaluation.

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Shingles may be related to elevated risk of multiple sclerosis

ScienceDaily (June 8, 2011) — Taiwanese investigators have found that there can be a significantly higher risk of multiple sclerosis (MS) occurring in the year following a shingles, or herpes zoster, attack. The findings, which support a long-held view on how MS may develop, are published in The Journal of Infectious Diseases and now available online.

MS is an autoimmune disease that affects the brain and spinal cord, leading to inflammation and nerve damage as the body's immune cells attack the nervous system. Possible causes that may trigger the inflammation include environmental, genetic, and viral factors. One virus that has been associated with MS is varicella zoster virus, the cause of herpes zoster.

In a study conducted by Herng-Ching Lin, PhD, and colleagues at Taipei Medical University in Taiwan, 315,550 adults with herpes zoster and a control group of 946,650 subjects were tracked and then evaluated for MS occurrence during a one-year follow-up period. The control group was selected randomly from a pool of subjects who had not been diagnosed with herpes zoster or other viral diseases. After adjusting for monthly income and geographic region, the authors found that the group with herpes zoster had a 3.96 times higher risk of developing MS than the control group. The authors noted that this risk, although increased, was still low, as is the frequency of MS in general. The study also noted an interval of approximately 100 days between a herpes zoster event and occurrence of MS.

Although the study was limited almost entirely to Han Chinese adults, the large scope of this nationwide case-controlled study, 1.26 million sampled patients, provides strong epidemiological evidence for a possible role for herpes zoster in the development of MS. The authors also point out that MS has a lower prevalence in Asian compared to Western populations and, thus, it may be difficult to project their findings to other populations.

In an accompanying editorial, Teresa Corona, MD, and Jose Flores, MD, of the National Institute of Neurology and Neurosurgery in Mexico noted that "The evidence provided in this study…allows us to better understand the role of these viral factors as an MS risk among certain genetically susceptible individuals," and that the study should be corroborated in other parts of the world to help clarify the role of this and other viruses in MS.

Fast Facts:

There is epidemiological evidence that some herpes viruses may contribute to multiple sclerosis (MS) occurrence.The rate of MS prevalence varies by geographical location and income.In this study, investigators found a significantly higher -- but still low -- risk for MS occurring in the year following a shingles, or herpes zoster, attack compared to a control population.There is evidence that 30 percent of relapses in MS patients may be associated with an infectious disease.Share this story on Facebook, Twitter, and Google:

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Journal References:

Jiunn-Horng Kang, Jau-Jiuan Sheu, Senyeong Kao and Herng-Ching Lin. Increased Risk of Multiple Sclerosis Following Herpes Zoster: A Nationwide, Population-Based Study. Journal of Infectious Diseases, June 7, 2011 DOI: 10.1093/infdis/jir239Teresa Corona and José Flores. Herpes Zoster and Multiple Sclerosis. Journal of Infectious Diseases, June 7, 2011 DOI: 10.1093/infdis/jir243

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Shingles Vaccine Doesn't Increase Short Term Shingles Risk In People Taking Biologics for Autoimmune and Inflammatory ...

Newswise — CHICAGO – The live attenuated shingles (herpes zoster) vaccine (Zostavax®) does not appear to increase the short-term risk of developing shingles infection in people taking biologics for autoimmune and inflammatory diseases, according to research presented this week at the American College of Rheumatology Annual Scientific Meeting in Chicago.

The shingles vaccine is approved in the United States for people over the age of 50 to reduce the risk of developing the infection. This infection is essentially a re-activation of the same virus that causes chickenpox, typically during childhood. The virus remains dormant (or sleeping) in the body from the time someone develops chickenpox and can manifest itself as a painful, blistering rash in later adulthood. It can also have more serious complications that threaten vision and internal organs. For some patients, due to nerve damage, the pain remains persistent at the site of the rash for months or years – long after the rash has resolved. Shingles affects about one in 50 older people with autoimmune diseases (e.g. rheumatoid arthritis and lupus) each year.

“The vaccine has been shown to be very effective to reduce the risk for shingles infection in older adults and is currently recommended for all older patients who are not receiving immunosuppressive medications, explains the study’s lead investigator, Jeffrey Curtis, MD, MPH; assistant professor, Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham. “The concern for people who are taking immunosuppressive medications, such as patients with rheumatoid arthritis taking anti-TNF therapies [e.g. Enbrel®, Humira®, Remicade®, Cimzia®, Simponi®] is that since the vaccine contains a weakened version of the live virus, it could allow the virus to reactivate and cause a short-term increase in the risk for shingles infection – within six weeks of vaccination. Beyond that initial time period, the vaccine would likely decrease the risk for shingles infection by helping the body form natural protective antibodies to prevent the infection.”

Using data from the U.S. Medicare program in 2006 to 2009, Dr. Curtis’ team identified 6,793 patients with autoimmune diseases who were over the age of 60 and who received the live zoster vaccine. The majority were Caucasian women with an average age of 74-and-a-half. Seventy-six vaccinated patients had ankylosing spondylitis; 1,260 had inflammatory bowel disease; 161 had psoriatic arthritis; 1,745 had psoriasis; 3,246 had rheumatoid arthritis; and 305 had two or more of these diseases.

At the time of vaccination, or within the previous 60 days, 580 patients were taking biologics (mostly anti-TNF therapy); 1,825 were taking disease-modifying anti-rheumatic drugs (commonly called DMARDS); and 1,432 were taking steroids (such as prednisone).

There were 387 people vaccinated who were current users of biologic medications and not steroids. Among these people, there were no cases of shingles in the six weeks following vaccination. Another 193 people on biologics and steroids were vaccinated, and their rate of the shingles infection was no higher than that of vaccinated people taking non-biologic DMARDs and steroids, but no biologics.

“In both of these groups taking steroids, only about five out of 1,000 people [less than one percent] developed the infection,” says Dr. Curtis. “Steroids have been previously shown to significantly increase the risk for shingles infection, so this finding was not a surprise.”

These findings led the researchers to conclude that people taking biologics may be able to receive the zoster vaccine safely and may not be at an increased, short-term risk of developing shingles from the vaccine. Dr. Curtis and his team have received funding through the ACR Research and Education Foundation’s Within Our Reach campaign to continue this research as a clinical trial in hopes of demonstrating the safety of the live zoster vaccine in people receiving biologic medications.

The American College of Rheumatology is an international professional medical society that represents more than 8,000 rheumatologists and rheumatology health professionals around the world. Its mission is to advance rheumatology. The ACR/ARHP Annual Scientific Meeting is the premier meeting in rheumatology. For more information about the meeting, visit www.rheumatology.org/education. Follow the meeting on Twitter by using the official hashtag: #ACR2011.

Editor’s Notes: Jeffrey R. Curtis, MD, MPH and his colleagues, including Dr. Sophie (Jie) Zhang, will present this research during the ACR Annual Scientific Meeting at McCormick Place Convention Center at 5:45 PM on Sunday, November 6 in Room W470b. Dr. Curtis will be available for media questions and briefing at 8:30 AM on Tuesday, November 8 in the on-site press conference room, W 175 C.

Learn more about living well with rheumatic disease as well as rheumatologists and the role they play in health care. Also, discover the ACR’s Simple Tasks campaign, which highlights the severity of rheumatic diseases and the importance of early and appropriate referral to a rheumatologist.

Presentation Number: 806

Safety of Zoster Vaccine in Individuals with Rheumatoid Arthritis, Psoriatic Arthritis, Ankylosing Spondylitis, and Inflammatory Bowel Disease

Jeffrey R. Curtis (University of Alabama at Birmingham, Birmingham, AL)
Jie Zhang (University of Alabama at Birmingham, Birmingham, AL)
Fenglong Xie (University of Alabama at Birmingham, Birmingham, AL)
Elizabeth S. Delzell (University of Alabama at Birmingham, Birmingham, AL)
Lang Chen (University of Alabama at Birmingham, Birmingham, AL)
Kenneth G. Saag (University of Alabama at Birmingham, Birmingham, AL)
Kevin L. Winthrop (Oregon Health Science Univ, Portland, OR)

Background/Purpose: The live zoster vaccine is approved in the US for individuals ages 50 and older to reduce risk and severity of Herpes zoster infection, also known as shingles. Based upon limited data, the vaccine is currently considered to be contraindicated in individuals taking biologics. The objective of the study is to examine whether the administration of zoster vaccine is associated with an increased risk of Herpes zoster shortly following vaccination among persons treated with biologics for autoimmune and inflammatory diseases.

Method: From 2006 through 2009, we identified from the 100% Medicare fee for service population individuals who were 60 years of age or older; had rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease; and received zoster vaccine. We classified these individuals according to their concomitant medications (biologics; non-biologic DMARDs, including methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine; oral glucocorticoids) within 60 days prior to or after vaccination. The cumulative incidence of Herpes zoster infection within 42 days following vaccination (the typically-used risk window in zoster vaccine trials) was calculated according to drug exposure.

Result: A total of 6793 subjects were vaccinated; among these, 76 had ankylosing spondylitis, 1,260 had inflammatory bowel disease, 161 had psoriatic arthritis, 1,745 had psoriasis, 3,246 had rheumatoid arthritis, and 305 had two or more diseases; 580 were on biologics, 1825 on non-biologic DMARRDs, and 1432 were on glucocorticoids at the time of or immediately prior (+- 60 days) to vaccination. The mean ± standard deviation (SD) age of vaccinated patients was 74.5 ± 6.3, 72% were women, and 96% were Caucasians.
Within 42 days following vaccination, the overall cumulative incidence of Herpes zoster infection was 2.2 per 1,000 persons. The cumulative incidence of zoster infection was not significantly different between those who were using biologics (1.7 per 1,000) or only non-biologic DMARDs (2.7 per 1,000). Irrespective of biologic or DMARD use, the short term risk of zoster infection was higher for patients receiving oral glucocorticoids compared to those not (p = 0.07) (Table).

Conclusion: Zoster vaccine in current biologic users does not appear to be associated with a short term risk of Herpes zoster infection following vaccination compared to those using only non-biologic DMARDs. In addition, the risks were not different than the rates observed in the general population participating in a large zoster vaccine trial of 38,546 individuals in which the cumulative incidence of Herpes zoster infection within 42 days 1.2 per 1,000 among those who receiving placebo. Vaccination with the live zoster vaccine may be reasonable to consider for patients currently using biologics.

Disclosure: J. Zhang, Amgen, 2 ; F. Xie, None; E. S. Delzell, Amgen, 2 ; L. Chen, None; K. G. Saag, None; K. L. Winthrop, None; J. R. Curtis, Pfizer, BMS, Crescendo, Abbott, Roche, Genetech, UCB, Centacor, Corrona, Amgen, 5

View the full abstract at www.rheumatology.org

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