SHINGLES TAN MAW PIN, Associate Professor in Geriatric Medicine

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Presentation transcript:

SHINGLES TAN MAW PIN, Associate Professor in Geriatric Medicine Department of Medicine, Faculty of Medicine

CONTENTS How common? Risk Factors What it looks like? Complications eg Postherpetic Neuralgia Psychological Burden Social and Economic Burden

What is Shingles? Herpes Zoster “生蛇” 带状疱疹 Kayap Ular © Dermnet.

Varicella-Zoster Virus

Most Adults Worldwide Are Seropositive For VZV by Age 40 Years Seroprevalence of VZV by Age1–13 Age (years) Seroprevalence (%)

VZV establishes latency sensory nerve dorsal root ganglion Varicella rash Skin

Latent Varicella-Zoster Virus Reactivates to Cause Herpes Zoster Latent VZV reactivates in the dorsal root ganglion, causing intense inflammation and necrosis of nerve cells VZV moves along the sensory nerve from the dorsal root ganglion to the skin Dorsal root ganglion Herpes zoster rash Skin Spinal cord Herpes Zoster (Shingles)

Older Age is Associated With Greater Risk of Developing HZ (Worldwide) Worldwide HZ Incidence by Age1–12 Age (years) Annual Incidence (per 1,000 person-years) Australia1 Israel4 Germany7 Taiwan10 Canada2 Italy5 Netherlands8 UK11 France3 Japan6 Spain9 US12 HZ=herpes zoster. 1. Stein AN et al. Vaccine. 2009;27:520–529. 2. Tanuseputro P et al. Vaccine. 2011;29:8580–8584. 3. Gonzalez Chiappe S et al. Vaccine. 2010;28:7933–7938. 4. Weitzman D et al. J Infect. 2013;67:463–469. 5. Gialloreti LE et al. BMC Infect Dis. 2010;10:230. 6. Toyama N et al. J Med Virol. 2009;81:2053–2058. 7. Ultsch B et al. Eur J Health Econ. 2013;14:1015–1026. 8. de Melker H et al. Vaccine. 2006;24:3946–3952. 9. Esteban-Vasallo MD et al. J Infect. 2014;68:378–386. 10. Lin YH et al. Vaccine. 2010;28:1217–1220. 11. Gauthier A et al. Epidemiol Infect. 2009;137:38–47. 12. Yawn BP et al. Neurology. 2013;81:928–930.

Clinical Presentation of Herpes Zoster Acute Phase1,2 Chronic Phase1 Rash Onset Rash Healed Subacute Herpetic Neuralgia Prodromal Pain Acute Pain Chronic Pain: Postherpetic Neuralgia (PHN) Day 0 2–4 Weeks 3 Months Months/Years

SHINGLES RASH DISTRIBUTION © Bart’s Medical Library / Phototake. © Dr. P. Marazzi / Science Source © Dr. Allan Harris / Phototake. Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved Trigeminal ~13% Cervical ~14% Thoracic ~50% Lumbar ~13% V1 V3 V2

COMPLICATIONS OF SHINGLES Neurologic1,2 Postherpetic neuralgia Cranial and motor neuron palsies Ramsay Hunt syndrome Bell’s palsy Encephalitis Stroke Hearing loss Ophthalmic2,3 Visual loss Pain Facial scarring Keratitis © MedicalRF.com/Getty Images © Ingram Publishing/the Agency Collection/Getty Images Cutaneous2,3 Bacterial superinfection Scarring Visceral (rare)3 Myocarditis Pericarditis Arthritis Hepatitis © Ingram Publishing/the Agency Collection/Getty Images © alexluengo, iStockphoto

Worldwide PHN Incidence by Age1–9 Persons with HZ who develop PHN (%) Age (years) Persons with HZ who develop PHN (%) Australia1 Italy4 Taiwan7 Iceland2 Germany5 UK8 Israel3 Netherlands6 US9 PHN=postherpetic neuralgia. 1. Stein AN et al. Vaccine. 2009;27:520–529. 2. Helgason S et al. BMJ. 2000;321:794–796. 3. Weitzman D et al. J Infect. 2013;67:463–469. 4. Gialloreti LE et al. BMC Infect Dis. 2010;10:230. 5. Ultsch B et al. Eur J Health Econ. 2013;14:1015–1026. 6. Opstelten W et al. Fam Pract. 2002;19:471–475. 7. Jih JS et al. Acta Derm Venereol. 2009;89:612–616. 8. Gauthier A et al. Epidemiol Infect. 2009;137:38–47. 9. Yawn BP et al. Neurology. 2013;81:928–930.

ANTIVIRALS NEED TO BE INITIATED WITHIN 72h HZ PHN Non-narcotic analgesics Antivirals Narcotic analgesics Anticonvulsants for pain management Topical agents Corticosteroids

SPS Study PHN incidence HZ incidence Efficacy 66.5% 65.7% 66.8%

ZEST Study (50-59y) Efficacy 69.8% ZOSTAVAX (n=11,094) Placebo Injection-site reaction, % 63.9 14.4 Solicited,a % Pain 53.9 9.0 Erythema 48.1 4.3 Swelling 40.4 2.8 Unsolicited, % Pruritus 11.3 0.7 Warmth 3.7 0.2 Hematoma 1.6 Induration 1.1 0.0 Number of HZ cases

Malaysian Society of Infectious Diseases and Chemotherapy’s Recommendation

Malaysian Society of Geriatric Medicine Position Statement on Vaccination against HZ in Older Adults