Prevention strategies for herpes zoster and post-herpetic neuralgia

Abstract

Impairment of varicella zoster virus (VZV)-specific cell-mediated immunity, including impairment due to immunosenescence, is associated with an increased risk of developing herpes zoster (HZ), whereas levels of anti-VZV antibodies do not correlate with HZ risk. This crucial role of VZV-specific cell-mediated immunity suggests that boosting these responses by vaccination will be an effective strategy for reducing the burden of HZ. Other strategies focus on preventing the major complication of HZ--post-herpetic neuralgia. These strategies include pre-emptive treatment with drugs such as tricyclic antidepressants, anticonvulsants and analgesics.

Fig. 1

Kaplan–Meier estimates of the effect of HZ vaccine on the cumulative incidence of (A) PHN and (B) HZ.

Fig. 2

RCF value, number of responding cells per 10⁵ peripheral blood mononuclear cells (PBMCs); ELISPOT counts, number of spot-forming cells per million PBMCs; gpELISA titre, gpELISA units/mL. Reproduced with permission of The University of Chicago Press from Levin MJ et al, J Infect Dis 2008;197:825–35. © The Infectious Diseases Society of America.

Fig. 3

Varicella incidence, hospitalization and mortality rates: USA, 1990–2005. (A) Varicella incidence: incidence of reported varicella cases from four states (Illinois, Michigan, Texas and West Virginia) that maintained consistent and adequate surveillance during 1990–1995. (B) Hospitalization: varicella was the primary diagnosis code; data are for individuals aged <50 years. (C) Mortality rates: varicella was the underlying cause of death. Reproduced with permission from Pediatrics, Vol. 122, Page e744–e751, © 2008 by the AAP.

Fig. 4

Duration of zoster-associated pain according to pain severity at presentation in patients who were aged (A) ≥50 or (B) <50 years. (A) For very mild vs. severe pain, hazard ratio (HR) = 3.00 (CI, 2.26–3.99; p = 0.0001); for mild vs. severe pain, HR = 2.23 (CI, 1.69–2.95; p = 0.0001); for moderate vs. severe pain, HR = 1.58 (CI, 1.21–2.06; p = 0.0007). (B) For mild vs. severe pain, HR = 1.69 (CI, 1.34–2.13; p = 0.0001). Reproduced with permission of The University of Chicago Press from Whitley RJ, J Infect Dis 1998;178(Suppl 1):S71–5. © The Infectious Diseases Society of America.

Fig. 5

Combination of antivirals with tricyclic antidepressants reduces the incidence of PHN at 6 months. Reprinted from The Lancet Volume 353. Dworkin RH. Prevention of postherpetic neuralgia. Pages 1636–7, © 1999, with permission from Elsevier.

Fig. 6

A hypothesized model for attenuating nerve damage and acute pain during HZ and thereby preventing the development of PHN. This model proposes that combined antiviral and analgesic treatment in patients with HZ might decrease the risk of developing PHN by both inhibiting viral replication and reducing the acute afferent barrage of nociceptive and neuropathic pain. Reprinted with permission from Dworkin RH, Perkins FM, Nagasako EM. Prospects for the prevention of postherpetic neuralgia in herpes zoster patients. Clin J Pain 2000;16(2 Suppl):S90–100.