The burden of illness from herpes zoster (HZ) and postherpetic neuralgia (PHN) in the Australian community is high.
The incidence and severity of HZ and PHN increase with age in association with a progressive decline in cell-mediated immunity to varicella-zoster virus (VZV).
Antiviral medications (valaciclovir, famciclovir, aciclovir) have been shown to be effective in reducing much but not all of the morbidity associated with HZ and PHN, but are consistently underprescribed in Australia.
Zoster-associated pain should be treated early and aggressively, as it is more difficult to treat once established. Clinicians should be proactive in their follow-up of individuals at high risk of developing PHN, and refer patients to a specialist pain clinic earlier, rather than later.
A live, attenuated VZV vaccine (Oka/Merck strain, Zostavax [Merck Sharp & Dohme]) has proven to be efficacious in reducing the incidence of and morbidity associated with HZ and PHN in older adults.
The vaccine’s efficacy has been shown to persist for at least 4 years, but is likely to last a lot longer. Ongoing surveillance will determine the duration of protection and whether a booster dose is required.
Clinicians should consider recommending the vaccine, which can be safely administered at the same time as the inactivated influenza vaccine, to all immunocompetent patients aged 60 years or older.
Clinicians should refer to the Australian immunisation handbook for advice on the use of the live vaccine in immunosuppressed individuals.
- 1. Gnann J Jr, Whitley R. Herpes zoster. N Engl J Med 2002; 347: 340-346.
- 2. International Herpes Management Forum. Johnson RW, Whitely R, editors. Combating varicella zoster virus-related diseases. Herpes 2006; 13 Suppl 1: 1-41.
- 3. Oxman MN, Levin MJ, Johnson GR, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005; 352: 2271-2284.
- 4. Gidding HF, MacIntyre CR, Burgess MA, et al. The seroepidemiology and transmission dynamics of varicella in Australia. Epidemiol Infect 2003; 131: 1085-1089.
- 5. MacIntyre CR, Chu CP, Burgess MA. Use of hospitalisation and pharmaceutical prescribing data to compare the revaccination burden of varicella and herpes zoster in Australia. Epidemiol Infect 2003; 131: 675-682.
- 6. Hope-Simpson RE. The nature of herpes zoster: a long-term study and a new hypothesis. Proc R Soc Med 1965; 58: 1-12.
- 7. Ragozzino MW, Melton LF, Kurland LT. Population based study of herpes zoster and its sequelae. Medicine 1982; 61: 310-316.
- 8. Brisson M, Edmunds W, Law B, et al. Epidemiology of varicella zoster virus infection in Canada and the United Kingdom. Epidemiol Infect 2001; 127: 305-314.
- 9. Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis 2007; 44 Suppl 1: S1-S26.
- 10. Heininger U, Seward JF. Varicella. Lancet 2006; 368: 1365-1376.
- 11. Dwyer DE, Cunningham AL. Herpes simplex and varicella-zoster virus infections. Med J Aust 2002; 177: 267-273.
- 12. Portenay RK, Duma C, Foley KM. Acute herpetic and postherpetic neuralgia: clinical review and current management. Ann Neurol 1986; 20: 651-664.
- 13. Rawlinson WD, Dwyer DE, Gibbons VL, Cunningham AL. Rapid diagnosis of varicella-zoster virus infection with a monoclonal antibody based direct immunofluorescence technique. J Virol Methods 1989; 23: 13-18.
- 14. Wood M, Kay R, Dworkin RH, et al. Oral acyclovir therapy accelerates pain resolution in patients with herpes zoster: a meta-analysis of placebo-controlled trials. Clin Infect Dis 1996; 22: 341-347.
- 15. Beutner K, Friedman D, Forszpaniak C, et al. Valaciclovir compared with aciclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39: 1546-1553.
- 16. Tyring S, Barbarash R, Nahlik J, et al. Famciclovir for the treatment of acute herpes zoster: effects on the acute disease and post herpetic neuralgia: a randomised, double-blind, placebo-controlled trial. Ann Intern Med 1995; 123: 89-96.
- 17. Wood MJ, Shukla S, Fiddian AP, Crooks RJ. Treatment of acute herpes zoster: effect of early (< 48 h) versus late (48–72 h) therapy with acyclovir and valaciclovir on prolonged pain. J Infect Dis 1998; 178 Suppl 1: S81-S84.
- 18. Whitely R, Weiss H, Gnann J Jr, et al. Aciclovir with and without prednisone for the treatment of herpes zoster. A randomised, placebo-controlled trial. The National Institute of Allergy and Infectious Disease Collaborative Antiviral Study Group. Ann Intern Med 1996; 125: 376-383.
- 19. Wood M, Johnson R, McKendrick M, et al. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med 1994; 330: 896-900.
- 20. Board of the Australian Herpes Management Forum. Managing herpes zoster: guidelines for clinicians. 2006. http://www.ahmf.com.au/health_professionals/guidelines/managing_herpes_zoster.htm (accessed Mar 2007).
- 21. International Association for the Study of Pain (IASP) Task Force on Taxonomy. Pain terms: a current list of definitions and notes on usage. In: Merskey H, Bogduk N, editors. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle: IASP Press, 1994: 209-214.
- 22. Neurology Expert Group. Postherpetic neuralgia. In: Therapeutic guidelines: neurology. Version 3. Melbourne: Therapeutic Guidelines Limited, 2007: 163-165.
- 23. National Heath and Medical Research Council. The Australian immunisation handbook. Part 2: Vaccination for special risk groups. 8th ed. Canberra: NHMRC, 2003: 69. http://www9.health.gov.au/immhandbook/ (accessed Aug 2007).
- 24. Kerzner B, Murray AV, Cheng E, et al. Safety and immunogenicity profile of the concomitant administration of ZOSTAVAX and inactivated influenza vaccine in adults aged 50 and older. J Am Geriatr Soc 2007; 55: 1499-1507.
- 25. Lolekha S, Tanthiphabha W, Sornchai P, et al. Effect of climatic factors and population density on VZV epidemiology within a tropical country. Am J Trop Med Hyg 2001; 64: 131-136.
- 26. Macaladad N, Marcano T, Guzman M, et al. Safety and immunogenicity of a zoster vaccine in varicella-zoster virus seronegative and low-seropositive healthy adults. Vaccine 2007; 25: 2139-2144.
- 27. US Advisory Committee on Immunization Practices. Provisional Recommendations. Use of shingles (herpes zoster) vaccine. Atlanta, Ga: ACIP, 2006. http://www.cdc.gov/vaccines/recs/provisional/downloads/zoster-11-20-06.pdf (accessed Aug 2007).
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