Letter to the Editor
Should we promote vaccination against the herpes zoster virus?
¿Deberíamos promover la vacunación contra el virus herpes zóster?
C. Rocha-de-Lossadaa,b,c,d,
, G. Rocha-de-Lossadae, M. Rocha-de-Lossadaf, A. Rocha-Bogasg,h
Corresponding author
a Qvision, VITHAS Hospital, Almería, Spain
b Hospital VITHAS Málaga, Málaga, Spain
c Hospital Regional Universitario de Málaga, Málaga, Spain
d Universidad de Sevilla, Departamento de Cirugía, Área de Oftalmología, Sevilla, Spain
e Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
f Hospital Infanta Margarita, Cabra, Córdoba, Spain
g Hospital Universitario de Ceuta, Ceuta, Spain
h Ceuta Medical Center, Ceuta, Spain
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"apellidos" => "Rocha-Bogas" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Qvision, VITHAS Hospital, Almería, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Hospital VITHAS Málaga, Málaga, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Regional Universitario de Málaga, Málaga, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidad de Sevilla, Departamento de Cirugía, Área de Oftalmología, Sevilla, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Hospital Universitario Virgen de la Arrixaca, Murcia, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Infanta Margarita, Cabra, Córdoba, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Universitario de Ceuta, Ceuta, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Ceuta Medical Center, Ceuta, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Deberíamos promover la vacunación contra el virus herpes zóster?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Varicella zoster virus is a ubiquitous microorganism that causes varicella as a primary infection and herpes zoster (HZ) as a reactivation of its latent state.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> It is known that HZ can cause ocular manifestations, known as herpes zoster ophthalmicus (HZO) that include corneal, scleral or retinal involvement in some cases which can become chronic,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> as well as potentially severe systemic neurological manifestations,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> particularly among young adults.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">According to the literature, the incidence of HZ and HZO infection increases with age.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The lifetime risk of developing HZ and HZO is approximately 30% and 15%, respectively.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> HZ infection is considered a cause of global health problem.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> HZ is a frequent diagnosis in Spain, with an estimated annual incidence of 351.6 cases/100,000 inhabitants.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Furthermore, it is observed that the incidence is increasing globally,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> especially in the young population.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Among the theories supporting this increase is that vaccination against varicella in the childhood population has led to a lower exposure of small amounts of live virus, causing those immunized today who are older to have a weaker immunity compared to the population that suffered the primary infection during childhood. In addition, immunocompromised individuals are known to be at increased risk of disease reactivation.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Vaccines may be the key to preventing HZ and its complications.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Two vaccines are available: Zostavax® (Merck & Co, Inc, USA), a single-dose live attenuated virus vaccine, and Shingrix® (GlaxoSmithKline, NC, USA), a recombinant vaccine whose subunit is a component of the recombinant HZ surface glycoprotein E antigen, vital for viral replication and transmission. Administration consists of two doses, generally separated by two months.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Both are effective in reducing the incidence and complications of HZ (51.3% and 96.2%, respectively), and are also safe,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> with the latter being used in the United States of America (USA) and available in Spain.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Nowadays, vaccination is recommended in Spain for the population over 50 years of age with autologous hematopoietic progenitor transplantation,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> certain cases of systemic immunosuppression,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> infection by the human immunodeficiency virus or patients under treatment with anti-Jak drugs. However, the HZ vaccine is not included in the vaccination schedule recommended by the inter-territorial council of the Spanish national health system<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and, in fact, vaccination of healthy adults is not currently recommended, unlike in the USA.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Recently, Lu et al.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> demonstrated the efficacy of recombinant HZ vaccine in preventing HZO in the US population, observing that the vaccinated cohort had 30 cases of HZO with a total follow-up time of 117,517 person-years, while the unvaccinated group had 5,655 cases of HZO. The vaccinated cohort had 30 cases of HZO with a total follow-up time of 117,517 person-years, while the unvaccinated group of patients had 5,654 cases of HZO with a total follow-up time of 7,374,053 person-years. The incidence rate of HZO was 25.5 cases (95% CI, 17.4-35.8 cases) in the vaccinated group, and 76.7 cases (95% CI, 74.7-78.7 cases) in the unvaccinated group.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However, they noted that the vaccination rate was low and insisted on the need to promote its administration to the target population in order to decrease the incidence of HZ.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> They consider that ophthalmologists can play an important role when recommending vaccination,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> a fact shared by others.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> On the other hand, it is estimated that 65% of adults who are recommended to have this vaccine remain unvaccinated today,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> thus having a low overall vaccination rate. According to Gibbons et al., potential barriers to vaccination include cost, potential side effects, concerns about effectiveness, lack of strong recommendation by the medical community, and confusion regarding indications.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Given the potential complications of HZ and HZO, their increasing incidence, and the effectiveness and safety of the recombinant vaccine,<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8,9</span></a> public health proposals to encourage vaccination in the global population seem to make sense.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In Spain, despite the availability of the recombinant vaccine, the vaccination rate is low and in fact it is not currently indicated in healthy persons over 50 years of age.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In a Spanish survey-based study of the general population to determine the knowledge and perception of HZ in people with and without contact with HZ cases, Álvarez-Pasquín et al. observed that approximately 10% of those surveyed were aware of the HZ vaccine, although 70% of them agreed on the need for its existence. More than 80% would like to receive this vaccine and 62%-78% would be vaccinated if it were offered.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Recently, in another Spanish study by Sánchez-Mellado et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> based on surveys and whose main objective was to determine the current knowledge among Spanish ophthalmologists about the efficacy of available vaccines, it was observed that 27% of the ophthalmologists who participated were unaware of the existence of vaccines against HZ and 71% of them did not know in which cases it might be indicated. Only 4% of the respondents had ever suggested vaccination to their patients, and less than 10% would know how to request the vaccine.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Despite this, 93% of respondents considered it important to recommend HZ vaccination if it is shown to be safe and effective, a fact that has been demonstrated as mentioned above.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,8,9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore, the healthcare community in general at the hospital and primary care level, as well as Ophthalmology in particular, is in an ideal position to support initiatives that encourage proposals that lead campaigns against the prevention of HZ and its potential complications, recommending vaccination of the target population.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">There has been no funding for the preparation of the manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">There is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neuro-ophthalmic complications of varicella-zoster virus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T.O. 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