Measuring herpes zoster disease burden in São Paulo, Brazil: a clinico-epidemiological single-center study

OBJECTIVES: Herpes zoster is characterized by acute neuritis and post-herpetic neuralgia. Currently, data concerning the zoster-associated impact on quality of life and healthcare resource utilization in Brazil are scarce. This study measured the zoster-associated burden in a Brazilian population. METHODS: This was a prospective, observational, single-cohort study conducted in a primary hospital's emergency room in São Paulo, Brazil. Patients enrolled at various timepoints during a zoster episode were followed over 180 days. The Zoster Brief Pain Inventory and the Initial Zoster Impact Questionnaire assessed zoster-associated pain. The EuroQoL assessed the impact of herpes zoster and/or zoster-associated pain on quality of life. Healthcare resource utilization was assessed by patient-reported questionnaires. RESULTS: One-hundred forty-six zoster patients were enrolled [mean (SD) age of 69.9 (10.9) years]. Mean (SD) worst pain scores decreased from 5.3 (3.5) at baseline to 1.9 (3.0) 180 days following rash onset. Mean (SD) EuroQoL scores significantly decreased from 0.9 (0.2) before rash appearance to 0.7 (0.2) after rash onset (p<0.001), followed by gradual improvements in quality of life over 180 days, with pre-herpes zoster quality of life achieved at the end of the observation period. The majority of patients purchased prescription medications (89.7%) and required doctor's office visits (65.8%) for zoster episodes. CONCLUSIONS: Herpes zoster is associated with a significant disease burden, including zoster-associated pain, impaired quality of life and increased healthcare resource utilization in Brazil. These results support the implementation of early intervention and prevention programs such as vaccinations to reduce the herpes zoster-associated disease burden in Brazil.

Dolor, calidad de vida relacionada con la salud y utilización de servicios médicos asociados al herpes zoster en Argentina / Herpes zoster-associated pain, health-related quality of life, and healthcare utilization in Argentina

El herpes zoster (HZ) es causado por reactivación del virus varicela-zoster latente. Se caracteriza por exantema vesicular unilateral, neuri-tis aguda y neuralgia posherpética. Aún hay escasos datos sobre el do-lor asociado al HZ (DAZ), su repercusión en la calidad de vida (CdV) y la utilización de recursos sanitarios (URS) asociada en Argentina. En este estudio prospectivo, observacio-nal, de una cohorte, realizado en 3 centros argenti-nos se valuó la carga de morbilidad asociada al HZ en Argentina en contextos clínicos reales. Los pa-cientes fueron enrolados en diversos momentos du-rante un episodio herpético, y seguidos activamen-te los días 14, 21, 30, 60, 90, 120, 150 y 180. Hubo 96 enrolados(edad 70±10,7 años; tiempo desde el inicio del exantema 16±16,9 días[media±DE]). El puntaje del peor dolor (media±DE) disminuyó de 5,5±3,1 en el enrolamiento a 0,2±0,7 a los 180 días de seguimiento. El puntaje del cuestionario de cali-dad de vida EQ-5D (media±DE) disminuyó significa-tivamente de 0,8±0,1 antes del inicio del exantema a 0,6±0,2 tras su inicio (P<0,001), con mejoría gra-dual de la CdV durante 180 días (0,9±0,1), hasta un puntaje similar al previo al inicio del exantema. La URS más frecuente fueron visitas al consultorio mé-dico (96,9%). La gran mayoría de pacientes compró medicamentos recetados (95,8%) y de venta sin receta (83,3%) para los episodios herpéticos. El DAZ estuvo asociado a gran carga de morbili-dad, deterioro de CdV, aumento de URS y costos asociados en Argenti-na. Esto subraya la importancia de estrategias de intervención precoz o prevención para disminuir la carga de morbilidad asociada al HZ

Herpes zoster (HZ) is caused by re-activation of latent varicella zoster virus and is characterized by unilateral, vesicular cutaneous eruptions, acute neuritis, and post-herpetic neuralgia. To date, data on HZ associated pain (ZAP) and its impact on quality of life (QoL) and associated healthcare resource utilization use (HCRU) in Argentina is scarce. This study assessed the burden of illness associated with HZ in Argentina in a real-life clinical setting. This was a prospective, observational, single-cohort study conducted in 3 sites across Argentina. Patients were enrolled at various time points during the course of a zoster episode and were actively followed on days 14, 21, 30, 60, 90, 120, 150, and 180. There were 96 HZ patients enrolled with a mean±SD age and time since rash onset of 70±10. 7 years and 16±16. 9 days, respectively. Mean±SD worst pain score decreased from 5. 5±3. 1 at enrollment to 0. 2±0.7 at 180 days of follow-up. The mean±SD EQ-5D score significantly decreased from 0. 8±0. 1 before rash onset to 0. 6±0. 2 after rash onset (P <0.001) followed by gradual improvement in QoL over 180 days (0. 9±0.) reaching a similar score to that prior to rash onset. The most common HCRU was visits to the doctor's office with 96.9%. The vast majority of patients purchased prescription medications (95.8%) and over-the-counter medications (83.3%) for HZ episodes. ZAP was found to be associated with severe burden of illness, impaired QoL, increased HCRU, and associated cost in Argentina; highlighting the importance of early intervention or prevention strategies to reduce HZ-associated disease burden

The feasibility of a school-based VI polysaccharide vaccine mass immunization campaign in Hue City, central Vietnam: streamlining a typhoid fever preventive strategy.

We report the coverage, safety, and logistics of a school-based typhoid fever immunization campaign that took place in Hue City, central Vietnam; a typhoid fever endemic area. A cluster-randomized evaluation-blinded controlled trial was designed where 68 schools (cluster) were randomly allocated the single dose Vi polysaccharide vaccine (Typherix) or the active control hepatitis A vaccine (Havrix). A safety surveillance system was implemented. A total of 32,267 children were immunized with a coverage of 57.5%. Strong predictors for vaccination were attending primary schools, peri-urban location of the school, and low family income. Human resources were mainly schoolteachers and the campaign was completed in about 1 month. Most adverse events reported were mild. Safe injection and safe sharp-waste disposal practices were followed. A typhoid fever school-based immunization campaign was safe and logistically possible. Coverage was moderate and can be interpreted as the minimum that could have been achievable because individual written informed consent procedures were sought for the first time in Hue City and the trial nature of the campaign. The lessons learned, together with cost-effectiveness results to be obtained by the end of follow-up period, will hopefully accelerate the introduction of Vi typhoid fever vaccine in Vietnam.

A cost-benefit analysis of typhoid fever immunization programmes in an Indian urban slum community.

Many economic analyses of immunization programmes focus on the benefits in terms of public-sector cost savings, but do not incorporate estimates of the private cost savings that individuals receive from vaccination. This paper considers the implications of Bahl et al.'s cost-of-illness estimates for typhoid immunization policy by examining how community-level incidence estimates and information on distribution of costs of illness among patients and the public-health sector can be used in the economic analysis of vaccination-programme options. The findings illustrate why typhoid vaccination programmes may often appear to be unattractive to public-health officials who adopt a public budgetary perspective. Under many plausible sets of assumptions, public-sector expenditure on typhoid vaccination does not yield comparable public-sector cost savings. If public-health officials adopt a societal perspective on the economic benefits of vaccination, there are many situations in which different vaccination programmes will make economic sense. The findings show that this is especially true when public decision-makers recognize that (a) the incidence of typhoid fever is underestimated by blood culture-positive cases and (b) avoided costs of illness represent a significant underestimate of the actual economic benefits to individuals of vaccination.

The role of epidemiology in the introduction of vi polysaccharide typhoid fever vaccines in Asia.

Despite the availability of at least two licensed typhoid fever vaccines--injectable sub-unit Vi polysaccharide vaccine and live, oral Ty21a vaccine--for the last decade, these vaccines have not been widely introduced in public-health programmes in countries endemic for typhoid fever. The goal of the multidisciplinary DOMI (Diseases of the Most Impoverished) typhoid fever programme is to generate policy-relevant data to support public decision-making regarding the introduction of Vi polysaccharide typhoid fever immunization programmes in China, Viet Nam, Pakistan, India, Bangladesh, and Indonesia. Through epidemiological studies, the DOMI Programme is generating these data and is offering a model for the accelerated, rational introduction of new vaccines into health programmes in low-income countries. Practical and specific examples of the role of epidemiology are described in this paper. These examples cover: (a) selection of available typhoid fever vaccines to be introduced in the programme, (b) generation of policy-relevant data, (c) providing the 'backbone' for the implementation of other multidisciplinary projects, and (d) generation of unexpected but useful information relevant for the introduction of vaccines. Epidemiological studies contribute to all stages of development of vaccine evaluation and introduction.

Costs of illness due to typhoid fever in an Indian urban slum community: implications for vaccination policy.

Data on the burden of disease, costs of illness, and cost-effectiveness of vaccines are needed to facilitate the use of available anti-typhoid vaccines in developing countries. This one-year prospective surveillance was carried out in an urban slum community in Delhi, India, to estimate the costs of illness for cases of typhoid fever. Ninety-eight culture-positive typhoid, 31 culture-positive paratyphoid, and 94 culture-negative cases with clinical typhoid syndrome were identified during the surveillance. Estimates of costs of illness were based on data collected through weekly interviews conducted at home for three months following diagnosis. Private costs included the sum of direct medical, direct non-medical, and indirect costs. Non-patient (public) costs included costs of outpatient visits, hospitalizations, laboratory tests, and medicines provided free of charge to the families. The mean cost per episode of blood culture-confirmed typhoid fever was 3,597 Indian Rupees (US$ 1=INR 35.5) (SD 5,833); hospitalization increased the costs by several folds (INR 18,131, SD 11,218, p<0.0001). The private and non-patient costs of illness were similar (INR 1,732, SD 1,589, and INR 1,865, SD 5,154 respectively, p=0.8095). The total private and non-patient ex-ante costs, i.e. expected annual losses for each individual, were higher for children aged 2-5 years (INR 154) than for those aged 5-19 years (INR 32), 0-2 year(s) (INR 25), and 19-40 years (INR 2). The study highlights the need for affordable typhoid vaccines efficacious at 2-5 years of age. Currently-available Vi vaccine is affordable but is unlikely to be efficacious in the first two years of life. Ways must be found to make Vi-conjugate vaccine, which is efficacious at this age, available to children of developing-countries.

Coverage and costs of mass immunization of an oral cholera vaccine in Vietnam.

The objective of this study was to describe a mass-immunization campaign of a locally-produced oral, killed whole-cell cholera vaccine in Hue city, Vietnam. Mass immunization with a 2-dose regimen of the vaccine was conducted in 13 communes in early 1998. The total, age- and sex-specific vaccine coverage was calculated using data from the vaccination records and the government census. The number of vaccine doses procured, administered, wasted, and left over, and the human and other resources required to prepare and conduct the vaccination campaign were systematically recorded. Government expenditure for planning, procurement, and delivery of the vaccine were documented. In total, 118,555 (79%) of the 49,557 targeted population were fully vaccinated during the mass-vaccination campaign. The total expenditure for the project was US dollar 105,447, resulting in a cost per fully-vaccinated person of US dollar 0.89. Mass immunization with this locally-produced oral, killed cholera vaccine was found to be feasible and affordable with attainment of high vaccination coverage.