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

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

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

4. Varicella-Zoster Virus

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

6. VZV establishes latency
sensory nerve
dorsal root ganglion
Varicella rash
Skin

7. 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)

8. 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– Tanuseputro P et al. Vaccine. 2011;29:8580– Gonzalez Chiappe S et al. Vaccine. 2010;28:7933– Weitzman D et al. J Infect. 2013;67:463– Gialloreti LE et al. BMC Infect Dis. 2010;10: Toyama N et al. J Med Virol. 2009;81:2053– Ultsch B et al. Eur J Health Econ. 2013;14:1015– de Melker H et al. Vaccine. 2006;24:3946– Esteban-Vasallo MD et al. J Infect. 2014;68:378– Lin YH et al. Vaccine. 2010;28:1217– Gauthier A et al. Epidemiol Infect. 2009;137:38– Yawn BP et al. Neurology. 2013;81:928–930.

9. 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

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

11. 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

12. 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– Helgason S et al. BMJ. 2000;321:794– Weitzman D et al. J Infect. 2013;67:463– Gialloreti LE et al. BMC Infect Dis. 2010;10: Ultsch B et al. Eur J Health Econ. 2013;14:1015– Opstelten W et al. Fam Pract. 2002;19:471– Jih JS et al. Acta Derm Venereol. 2009;89:612– Gauthier A et al. Epidemiol Infect. 2009;137:38– Yawn BP et al. Neurology. 2013;81:928–930.

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

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

15. 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

16. Malaysian Society of Infectious Diseases and Chemotherapy’s Recommendation

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