UK experience of herpes zoster vaccination can inform varicella zoster virus policies
Authors: Benson Ogunjimi, Philippe Beutels
Journal: The Lancet Public Health (2017)

Reactivation of latent varicella zoster virus (VZV) can lead to herpes zoster (also known as shingles). Herpes zoster is generally a painful disease associated with substantial morbidity, including a long-term neuropathic pain syndrome called postherpetic neuralgia. Substantial costs and health-related quality-of-life impairments are incurred by both ambulatory and hospitalised patients with herpes zoster.1Bilcke J Ogunjimi B Marais C et al.The health and economic burden of chickenpox and herpes zoster in Belgium.Epidemiol Infect. 2012; 140: 2096-2109Crossref PubMed Scopus (53) Google Scholar The Shingles Prevention Study2Oxman 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: 2271-2284Crossref PubMed Scopus (2010) Google Scholar—the first clinical trial of a live-attenuated VZV vaccine against herpes zoster (Zostavax; Merck & Co, Kenilworth, NJ, USA)—showed that in the 3 years after vaccination, Zostavax reduced herpes zoster and postherpetic neuralgia incidence by 37·6% (95% CI not shown) and 66·8%, (43·3–81·3%), respectively, in vaccine recipients aged 70 years or older.2Oxman 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: 2271-2284Crossref PubMed Scopus (2010) Google Scholar Vaccine efficacy, however, waned substantially with time, down to 22·4% (6·0–36·6) against herpes zoster and 49·7% (15·6–72·5) against postherpetic neuralgia 7–11 years after vaccination.3Morrison VA Johnson GR Schmader KE et al.Long-term persistence of zoster vaccine efficacy.Clin Infect Dis. 2015; 60: 900-909Crossref PubMed Scopus (216) Google Scholar, 4Bilcke J Ogunjimi B Hulstaert F Van Damme P Hens N Beutels P Estimating the age-specific duration of herpes zoster vaccine protection: a matter of model choice?.Vaccine. 2012; 30: 2795-2800Crossref PubMed Scopus (22) Google Scholar In The Lancet Public Health, Gayatri Amirthalingam and colleagues5Amirthalingam G Andrews N Keel P et al.Evaluation of the impact of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study.Lancet Public Health. 2017; (published online Dec 21.)http://dx.doi.org/10.1016/S2468-2667(17)30234-7Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar show that over the 3 years after the introduction of herpes zoster vaccination in the UK, incidence of herpes zoster and postherpetic neuralgia decreased in routine cohorts (individuals aged 70–71 years at time of vaccination) and catch-up cohorts (individuals aged 78–80 years at time of vaccination). Incidence of herpes zoster decreased by 35% (95% CI 28–40) in the routine cohorts and 33% (26–39) in the catch-up cohorts. Incidence of postherpetic neuralgia decreased by 50% (33–62) in the routine cohorts and 38% (21–50) in the catch-up cohorts. Vaccine uptake was relatively high—varying between 58% and 72% between cohorts—possibly due to the encouragement of concomitant administration during seasonal flu vaccination. Vaccine effectiveness during the 3 years after vaccination was estimated to be 62% (50–71) against herpes zoster and 88% (59–100) against postherpetic neuralgia in the routine cohorts and 62% (48–72) against herpes zoster and 70% (39–93) against postherpetic neuralgia in catch-up cohorts. The VZV exogenous boosting hypothesis proposes that re-exposure to chickenpox boosts VZV-specific immunity and thereby reduces the risk of herpes zoster.6Hope-Simpson RE The nature of herpes zoster: a long-term study and a new hypothesis.Proc R Soc Med. 1965; 58: 9-20PubMed Google Scholar, 7Ogunjimi B Van Damme P Beutels P Herpes zoster risk reduction through exposure to chickenpox patients: a systematic multidisciplinary review.PLoS One. 2013; 8: e66485Crossref PubMed Scopus (90) Google Scholar If true, this hypothesis implies that the potential effect of herpes zoster vaccination in older adults would be greater in the USA than in the UK, because the USA has had universal childhood chickenpox vaccination since 1995, whereas the UK has no such programme. However, Amirthalingam and colleagues' vaccine effectiveness estimates for the UK are similar—and even a bit higher—than those reported in earlier papers for the USA: 48% (95% CI 39–56) against herpes zoster and 59% (21–79) against postherpetic neuralgia in individuals aged 65 years or older;8Langan SM Smeeth L Margolis DJ Thomas SL Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study.PLoS Med. 2013; 10: e1001420Crossref PubMed Scopus (174) Google Scholar and 32·9% (23·1–41·5) against herpes zoster in individuals aged 60 years or older over 3–6 years after vaccination.9Tseng HF Harpaz R Luo Y et al.Declining effectiveness of herpes zoster vaccine in adults aged ≥60 years.J Infect Dis. 2016; 213: 1872-1875Crossref PubMed Scopus (111) Google Scholar Nevertheless, a different distribution of risk factors for herpes zoster might have affected herpes zoster occurrences in the two countries, thereby preventing major conclusions regarding exogenous boosting. Finally, the novel VZV gE subunit vaccine (Shingrix; GlaxoSmithKline, Brentford, UK) has a two-dose vaccine efficacy of 91·3% (95% CI 86·8–94·5) against herpes zoster and 88·8% (68·7–97·1), against postherpetic neuralgia 3·7 years after vaccination in individuals aged 70 years or older.10Cunningham AL Lal H Kovac M et al.Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older.N Engl J Med. 2016; 375: 1019-1032Crossref PubMed Scopus (588) Google Scholar Shingrix's superior efficacy data by age and over time were decisive for the US Advisory Committee on Immunization Practices, who recommended on Oct 25, 2017, the switch from Zostavax to Shingrix in all healthy adults aged 50 years or older, including those who had already received Zostavax.11CDCShingles (herpes zoster) vaccination information for healthcare providers.https://www.cdc.gov/vaccines/vpd/shingles/hcp/index.htmlGoogle Scholar In Europe, cost-effectiveness considerations are central to policy making; European policy makers will probably also consider quantitative and practical differences in costs, health-related quality of life, and implementation (one vs two doses) as well as safety and effectiveness by age and over time. Such considerations have previously led to diverse programme choices across Europe for rotavirus, pneumococcal, and human papillomavirus vaccines. For countries introducing VZV vaccination in childhood, integrated models of both policy choices (on chickenpox and herpes zoster) are likely to be adapted yet again to compare adult strategies using vaccines such as Zostavax versus Shingrix. Amirthalingam and colleagues' work5Amirthalingam G Andrews N Keel P et al.Evaluation of the impact of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based study.Lancet Public Health. 2017; (published online Dec 21.)http://dx.doi.org/10.1016/S2468-2667(17)30234-7Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar provides useful information for such models. We declare no competing interests. Evaluation of the effect of the herpes zoster vaccination programme 3 years after its introduction in England: a population-based studyThe herpes zoster vaccination programme in England has had a population impact equivalent to about 17 000 fewer episodes of herpes zoster and 3300 fewer episodes of postherpetic neuralgia among 5·5 million eligible individuals in the first 3 years of the programme. Communication of the public health impact of this programme will be important to reverse the recent trend of declining vaccine coverage. Full-Text PDF Open Access