17. 帶狀皰疹的發生率與年齡增加相關
澳洲1
以色列4
德國7
法國3
台灣10 英國11
荷蘭8
義大利5
加拿大2
韓國13
西班牙9
日本6
美國12
年齡
帶狀疱疹發生率(每千人-年)
全球各年齡帶狀疱疹發生率1-13
1.MacIntyreCR et al. PLoSOne. 2015;10:e0125025. 2.Tanuseputro P et al. Vaccine. 2011;29:8580–8584. 3. Gonzalez Chiappe S et al.
Vaccine.2010;28:7933–7938. 4. Weitzman D et al. J Infect.2013;67:463–469.5.Gialloreti LE et al. BMC Infect Dis.2010;10:230. 6. Toyama N et al.
J Med Virol. 2009;81:2053–2058. 7. UltschB et al. Eur J Health Econ. 2013;14:1015–1026.8. de Melker H et al. Vaccine.2006;24:3946–3952. 9.
Esteban-Vasallo MD et al. J Infect.2014;68:378–386. 10. Lin YH et al. Vaccine.2010;28:1217–1220. 11. Gauthier A et al. Epidemiol Infect.
2009;137:38–47. 12. Johnson BH et al. BMC Infect Dis. 2015;15:502. 13.Kim YJ et al. J Korean Med Sci.2014;29:1706–1710.
22. 1. CDC. MMWR. Prevention of Herpes Zoster: Recommendations of the Advisory Committee on Immunization Practices. 2008; 57:1-30. 2. Shinglesinfo.com. FAQ.
www.shinglesinfo.com/shinglesinfo/shingles-in-depth/questions-about-shingles.jsp Accessed 28 May 2013 3. Schmader, K. Herpes Zoster in Older Adults. Aging and Infectious Diseases. CID.
2001:32 1481-1486 4. Oxman, M.N. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med 2005 352:22, 2271-84. 5. National Institute of Aging. Age Page:
Shingles. www.nia.nih.gov/health/publication/shingles. accessed 14 Feb 2013. 6. Population Division, DESA, United Nations. World Population Ageing: 1950-2050. Chapter II:11. 7. WHO. Ageing
and Life Course. 2013 http://www.who.int/ageing/en/ Accessed on 29 May 2013.
帶狀疱疹的小結
隨著年齡增長,罹患帶狀疱疹的風險越高
95%以上的成人暴露在帶狀疱疹的風險中,50歲以後風險更明顯增加
免疫衰退 (Immunosenescence )- 免疫力會隨著年齡增長而降低
每3人就有1人會於一生當中罹患帶狀疱疹
每4位帶狀疱疹患者就有1人會留下至少一種的後遺症
因疾病或藥物導致免疫功能變差時,罹患帶狀風險的機會也會增加
37. 37
接種兩劑水痘疫苗保護力比單劑好
CI = confidence interval; PCR=polymerase chain reaction.
Number
of Doses
Vaccine
Effectiveness 95% CI P-Value
1 86.0% -44.5–99 0.124
2 98.3% 83.5–100 <0.001
95% lower risk of varicella development for 2-dose recipients.
Effectiveness of VARIVAX in 247 Children Aged >4 Years
(2006-2010), by Number of Doses
1. Shapiro ED et al. J Infect Dis. 2011;203:312–315.
Odds of developing varicella for 2-dose recipients who had not
had varicella were 95% lower than for 1-dose recipients.
41. 41
41
Several Worldwide Organizations Recognize the
Benefits of Varicella Vaccination1,2
CDC = Centers for Disease Control and Prevention; WHO = World Health Organization.
1. World Health Organization. Wkly Epidemiol Rec. 2014;89:265–287. 2. About the vaccine. Centers for Disease Control and Prevention Web site.
www.cdc.gov/vaccines/vpd/varicella/hcp/about-vaccine.html. Accessed April 3, 2019.
WHO1
One dose reduces mortality and
severe morbidity, not outbreaks
Two doses have higher
effectiveness and may reduce outbreaks
CDC2
Two doses of vaccines for children,
adolescents, and adults
98% effective in preventing varicella
100% effective against severe varicella
42. 42
Varicella Vaccine Recommendations Worldwide
1. WHO vaccine-preventable diseases: monitoring system. 2019 global summary. World Health Organization Web site.
apps.who.int/immunization_monitoring/globalsummary/schedules. Accessed August 13, 2019. 2. Varicella vaccination in the European Union. European Centre
for Disease Prevention and Control. vaccine-schedule.ecdc.europa.eu/. Accessed July 15, 2019. 3. Free chickenpox vaccine arrives in Colombia. Colombia
Ministry of Health and Social Protection Web site. https://www.minsalud.gov.co/English/Paginas/Free-chickenpox-vaccine-arrives-in-Colombia.aspx. Accessed
July 15, 2019. 4. Child health – immunisation. Family Health Service Web site. fhs.gov.hk/english/main_ser/child_health/child_health_recommend.html.
Accessed July 15, 2019. 5. Ministry of Health, Israel. health.gov.il/Subjects/pregnancy/Childbirth/Vaccination_of_Infants/pages/vaccines_babies.aspx. Accessed
July 15, 2019. 6. Recommended immunization schedule for healthy infants, children and adolescents – Bermuda, 2017. Government of Bermuda Web site.
www.gov.bm/sites/default/files/IMMUNIZATION% 20SCHEDULE%202017%20%28CHILD%29.pdf. Accessed July 15, 2019.
40 countries now have nationwide varicella vaccination recommendations.1-6
1 Dose
2 Dose
National Program for
Varicella Vaccination
44. 44
Age-specific annual incidence of varicella
before and after the nationwide immunization
Chang et al. BMC Infectious Diseases 2011, 11:352
Before NIP
Vaccine coverage rate:
•87% in 2004
•95% in 2006
•95%–99% after 2007
After NIP
3-4y/o 5-6y/o
5-6歲為水痘突破感染的高峰期
45. 各國的疫苗接種建議:台灣跟隨先進國家腳步
台灣預防接種諮詢委員會(ACIP)建
議接種2劑水痘疫苗3:
第一劑:滿12個月大
第二劑:4-6歲大
美國預防接種諮詢委員會(ACIP)建
議接種2劑水痘疫苗1:
第一劑:滿12個月大
第二劑:4-6歲大
德國預防接種諮詢委員會(STIKO)建
議接種2劑水痘疫苗2:
第一劑:11-14個月大
第二劑:15個月-23個月大
45
1. US ACIP.MMWR, June 22, 2007, Vol 56, #RR-04(Accessed on 2018.6.20) https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm
2. Robert Koch Institut. EpidemiologischesBulletin. 24 of August 2015 /No. 34. (Accessed on 2018.06.20)
https://www.rki.de/EN/Content/infections/Vaccination/recommandations/34_2015_engl.pdf?__blob=publicationFile
3. 衛生福利部傳染病防治諮詢會預防接種組106年第1次會議紀錄
47. 47
47
Take Home Messages:
CDC = Centers for Disease Control and Prevention; WHO = World Health Organization.
1. World Health Organization. Wkly Epidemiol Rec. 2014;89:265–287. 2. About the vaccine. Centers for Disease Control and Prevention Web site.
www.cdc.gov/vaccines/vpd/varicella/hcp/about-vaccine.html. Accessed April 3, 2019.
1 dose reduces mortality and severe morbidity, not outbreaks
2 doses have higher effectiveness and may reduce outbreaks
2 dosesof vaccines for children, adolescents, and adults:
98% effective in preventing varicella
100% effective against severe varicella
Varicella can cause complications that affect
multiple organ systems and can be severe
Groups at higher risk for severe complications are
neonates, infants, pregnant women, adults, and
immunocompromised persons
58. 施打帶狀疱疹疫苗目的
提高VZV特異性免疫能力
1. Arvin A. N EnglJ Med. 2005;352(22):2266–2267.
herpes zoster(HZ)=帶狀疱疹
varicella-zoster virus (VZV) =水痘帶狀疱疹病毒
ZOSTAVAX
vaccination
Cell-mediated (T-cell) immunity
- is required to maintain the balance between host and latent VZV
- is more important than humoral immunity in recovery from varicella.1
**
預防/降低帶狀疱疹的發生
61. 帶狀疱疹疫苗的重要研究1
1. Oxman MN et al. N Engl J Med.
2005;352:2271–2284.
2. Schmader KE et al. Clin Infect Dis.
2012;54:922–928
SPS=Shingles Prevention Study, herpes zoster(HZ)=帶狀疱疹, burden of illness
(BOI)=疾病負擔, postherpetic neuralgia(PHN)=帶狀疱疹後神經痛, ZEST= ZOSTAVAX
Efficacy and Safety Trial, AEMS=Adverse Event Management System
兩項重要研究評估帶狀疱疹疫苗的功效、 安
全性、 預防性及減輕疼痛的效果:
帶狀疱疹預防研究
(SPS - Shingles Prevention Study )1
38,546位 60歲以上 (19,270 ZOSTAVAX vs.
19,276 安慰劑) 含男性及女性,無帶狀疱疹病史
子研究:免疫生成性(1,395); 藥物不良反應
(AEMS) (6,616)
主要臨床試驗終點:降低HZ疾病負擔
(BOI)
HZ皮疹發作,
6個月內HZ疼痛的發生率、嚴重程度
和持續時間
次要臨床試驗終點:降低PHN發生
疼痛評分≥3(10分制)並持續≥90天
SPS
62. 帶狀疱疹疫苗的重要研究2
1. Oxman MN et al. N Engl J Med. 2005;352:2271–2284.
2. Schmader KE et al. Clin Infect Dis. 2012;54:922–928
兩項重要研究評估帶狀疱疹疫苗的功效、 安
全性、 預防性及減輕疼痛的效果:
效果及安全性) 2
5個國家進行的隨機、多中心、雙盲、安慰劑對照
研究,22,439位曾得過水痘但無帶狀疱疹病史的
男性及女性
年齡介於50 至 59 歲之間 (11,211 ZOSTAVAX vs.
11,228 安慰劑)
主要臨床試驗終點:降低HZ發生
次要臨床試驗終點:HZ的急性期疼痛持續
時間評分、整體安全性和耐受性
SPS=Shingles Prevention Study, herpes zoster(HZ)=帶狀疱疹, burden of illness (BOI)=疾病負擔, postherpetic neuralgia(PHN)=
帶狀疱疹後神經痛, ZEST= ZOSTAVAX Efficacy and Safety Trial, AEMS=Adverse Event Management System
ZEST
Zostavax Efficacy and Safety Trial
(ZEST)
63. 60-69歲可預防帶狀疱疹(HZ)發生效果達64%
Reduced HZ Incidence in Adults Aged ≥60 Years in SPS
SPS=Shingles Prevention
Study
herpes zoster(HZ)=帶狀疱疹
CI=confidence interval; HZ=herpes zoster.
1. Oxman MN et al. N Engl J Med. 2005;352:2271–2284. 2. Oxman MN et al. J Infect Dis.
2008;197(Suppl 2):S228–S236.
.
642
334
308315
122
193
0
100
200
300
400
500
600
700
All Subjects Aged 60–69 Years Aged ≥70 Years
Placebo
NumberofHZcases
Efficacy 51.3% 63.9% 37.6%
(95% CI) (44.2%–57.6%) (55.5%–70.9%) (25.0%–48.1%)
(n=10,356) (n=10,370) (n=8,891) (n=8,884)(n=19,247) (n=19,254)
1 1,2 1,2
SPS
64. CI=CONFIDENCE INTERVAL; HZ=HERPES ZOSTER; PHN=POSTHERPETIC NEURALGIA.
aPHN WAS DEFINED AS HZ-ASSOCIATED PAIN RATED AS ≥3 ON A 10-POINT SCALE AND PERSISTING OR
APPEARING AT LEAST 90 DAYS AFTER RASH ONSET.
1. OXMAN MN ET AL. N ENGL J MED. 2005;352:2271–2284.
80
23
57
27
8
19
0
20
40
60
80
100
All Subjects Aged 60–69 Years Aged ≥70 Years
Placebo
NumberofHZcaseswithPHN
Efficacy 66.5% 65.7% 66.8%
(95% CI) (47.5%–79.2%) (20.4%–86.7%) (43.3%–81.3%)
(n=10,356) (n=10,370) (n=8,891) (n=8,884)(n=19,247) (n=19,254)
整體60歲以上可預防PHN發生效果達67%
Reduced PHN Incidence in Adults Aged ≥60 Years in SPS1,a
SPS
65. NumberofPHNCases
Placebo
(n=19,247)
ZOSTAVAX
(n=19,254)
99
30
0
20
40
60
80
100
NumberofHZCases
Placebo
(n=11,228)
ZOSTAVAX
(n=11,211)
Placebo
(n=19,247)
ZOSTAVAX
(n=19,254)
Overall Incidence of
Postherpetic Neuralgia
(PHN)
In patients > 60 y/o.
Overall Incidence of
Herpes Zoster (HZ) In
patients > 60 y/o.
Overall Incidence of
Herpes Zoster (HZ) In
patients 50-59 y/o.
70%
Reductio
n
(95% CI:54-
80)
NumberofHZCases
ZEST SPS SPS
51%
Reductio
n
67%
Reductio
n
(95%CI: 44-58)
(95%CI: 48-79)
最常見的藥物不良反應為注射部位過敏反應
接種疫苗者有48%出現注射部位反應-
紅斑、疼痛、腫脹、發癢、溫熱和血腫
herpes zoster(HZ)=帶狀疱疹
postherpetic neuralgia(PHN) =帶狀疱疹後神經痛
SPS=Shingles Prevention Study
ZEST= ZOSTAVAX Efficacy and Safety
Trial
AEMS=Adverse Event Management
System
1. Oxman MN et al. N Engl J Med. 2005;352:2271–2284.
2. Schmader KE et al. Clin Infect Dis. 2012;54:922–928
50-59歲 可預防帶狀疱疹(HZ)發生效果達70%
60歲以上 可預防帶狀疱疹後神經痛(PHN)的發生率達67%
SPS
ZEST
68. NCHS Data Brief. 2016 Dec;(265):1-8.
62
%
38%
influenza vaccine a
53
%
47%
pneumococcal
vaccine b
27
%73%
shingles vaccine c
a. Influenza vaccine統計年紀為18歲以上族群
b. b. pneumococcal vaccine統計年紀為18歲以上族群
c. c. shingles vaccine統計為60歲以上族群NCHS Data Brief. 2016 Dec;(265):1-8
>1/4
有幾種疫苗建議為糖尿病的成人接種,來避免因糖尿病共病導致高風險併發症發生,像是年度
的流感疫苗、肺炎鏈球菌疫苗與帶狀疱疹疫苗等,此研究描述美國糖尿病患者接種疫苗情況。
糖尿病患者>18歲族群中
流感疫苗接種率比起肺炎球菌疫苗接種率來
的更高(疫苗接種率各為61.6%、52.6%)
在診斷糖尿病的≥60歲族群
超過四分之一(27.2%)
曾接種帶狀疱疹疫苗。
美國60歲以上糖尿病患者
超過四分之一曾接種帶狀疱疹疫苗c
美國糖尿病族群疫苗接種率-2015
71. 小結
終其一生,每3個就有1人會得
到帶狀疱疹(HZ)1
許多慢性疾病會增加罹患帶
狀疱疹的風險,像糖尿病、
慢性腎臟疾病2
美國CDC, AADE 成人疫苗施
打建議,建議糖尿病患者施打
帶狀疱疹疫苗7,8
帶狀疱疹後神經痛(PHN)是
帶狀疱疹最常見的併發症3,4
帶狀疱疹水泡內含有大量
VZV病毒,須將病兆處覆
蓋以避免傳播5,6
帶狀疱疹須避免接觸孕婦
與早產兒與低體重嬰兒 6
1.Centers of Disease Control and Prevention (CDC).Prevention of herpes zoster: recommendations of the advisory committee on Immunization Practices(ACIP). MMWR Recomm Rep.2008;57(RR-5):1-30. 2. Forbes HJ et al. BMJ. 2014;348;g2911. 3. O'Connor
KM et al. Med Clin North Am. 2013;97:503–522. 4. Kawai K et al. IntJ Infect DIs.2015;34:126–131. 5. .MMWR June 6, 2008 / Vol. 57 / 6.CDC Shingles
(Herpes Zoster) Transmission. Retrieved from http://www.cdc.gov/shingles/about/transmission-sp.html (Mar,29,2019)
7. CDC, Adults with Health Conditions, Retrieved from https://www.cdc.gov/vaccines/adults/rec-vac/health-conditions/diabetes.html
(Sep,27,2019)
8. AADE, American Association of Diabetes Educators, 5 Vaccines for People with Diabetes, retrieved from
https://www.diabeteseducator.org/news/aade-blog/aade-blog-details/aade/2018/08/21/5-vaccines-for-people-with-diabetes
Oct,3,2019)
73. 73
73
1 Dose
2 Dose
National Program for
Varicella Vaccination
Baxter R et al. Pediatrics. 2013;131:e1389–1396.
Long term study shows that VARIVAX® retains
its effectiveness over 14 years1