Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data

H. J. Forbes*, K. Bhaskaran, D. Grint, V. H. Hu, S. M. Langan, H. I. McDonald, C. Morton, L. Smeeth, J. L. Walker, C. Warren-Gash

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

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Abstract

Background: Herpes zoster can cause rare but serious complications; the frequency of these complications has not been well described. Objectives: To quantify the risks of acute non-postherpetic neuralgia (PHN) zoster complications, to inform vaccination policy. 

Methods: We conducted a cohort study among unvaccinated immunocompetent adults with incident zoster, and age-, sex- and practice-matched control adults without zoster, using routinely collected health data from the UK Clinical Practice Research Datalink (years 2001 to 2018). Crude attributable risks of complications were estimated as the difference between Kaplan–Meier-estimated 3-month cumulative incidences in patients with zoster vs. controls. We used Cox models to obtain hazard ratios for our primary outcomes in patients with and without zoster. Primary outcomes were ocular, neurological, cutaneous, visceral and zoster-specific complications. We also assessed whether antivirals during acute zoster protected against the complications. 

Results: In total 178 964 incident cases of zoster and 1 799 380 controls were included. The absolute risks of zoster-specific complications within 3 months of zoster diagnosis were 0·37% [95% confidence interval (CI) 0·34–0·39] for Ramsay Hunt syndrome, 0·01% (95% CI 0·0–0·01) for disseminated zoster, 0·04% (95% CI 0·03–0·05) for zoster death and 0·97% (95% CI 0·92–1·00) for zoster hospitalization. For other complications, attributable risks were 0·48% (95% CI 0·44–0·51) for neurological complications, 1·33% (95% CI 1·28–1·39) for ocular complications, 0·29% (95% CI 0·26–0·32) for cutaneous complications and 0·78% (95% CI 0·73–0·84) for visceral complications. Attributable risks were higher among patients > 50 years old. Patients with zoster had raised risks of all primary outcomes relative to controls. Antiviral prescription was associated with reduced risk of neurological complications (hazard ratio 0·61, 95% CI 0·53–0·70). 

Conclusions: Non-PHN complications of zoster were relatively common, which may affect cost-effectiveness calculations for zoster vaccination. Clinicians should be aware that zoster can lead to various complications, besides PHN.

Original languageEnglish
Pages (from-to)1077-1084
Number of pages8
JournalBritish Journal of Dermatology
Volume184
Issue number6
Early online date4 Jan 2021
DOIs
Publication statusPublished - 6 Jun 2021

Bibliographical note

Funding Information: This study was funded by an HDR-UK Fellowship to H.J.F. All authors carried out this research independently of the funding bodies. C.W-G. is supported by a Wellcome Intermediate Clinical Fellowship (201440/Z/16/Z).

Open Access: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Publisher Copyright: © 2020 The Authors. British Journal of Dermatology published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.

Citation: Forbes, H., Bhaskaran, K., Grint, D., Hu, V., Langan, S., McDonald, H., Morton, C., Smeeth, L., Walker, J. and Warren-Gash, C. (2021), Incidence of acute complications of herpes zoster among immunocompetent adults in England: a matched cohort study using routine health data*. Br J Dermatol, 184: 1077-1084.

DOI: https://doi.org/10.1111/bjd.19687

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