1. Implementation of Adult Herpes Zoster (HZ) Surveillance in West Philadelphia, 2006 Niya Spells, BA (niya.spells@phila.gov), Priya Abraham, BS, Dana Perella, MSPH, Mia Renwick, MPH, Barbara Watson, MbChB Varicella Active Surveillance Project (VASP) Philadelphia Department of Public Health This research was supported by cooperative agreement U66/CUU 311179-2-02, National Immunization Program, Centers for Disease Control and Prevention. The presenter has no conflicts of interest to disclose.

2. The Incidence of Herpes Zoster Up to 1,000,000 cases/year in the United States. 1 Up to 1,000,000 cases/year in the United States. 1 >67% of cases occur in people >50 years. 2 >67% of cases occur in people >50 years. 2 Lifetime incidence: 20%- 30%. 1 Lifetime incidence: 20%- 30%. 1 ~ 50% of persons >85 experience zoster ~ 50% of persons >85 experience zoster 1. Schmader KE. Clin Geriatr Med 2007 23:615-632. 2. Strauss SE, Oxman MN. In: Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. Vol 2. New York, NY: McGraw-Hill; 1999:2427-2450. 3. Arvin AM. In: Knipe DM, Howley PM, eds. Field Virology. 4th ed. Vol 2. New York, NY: Lippencott Williams & Wilkins; 2001:2731-2767.

3. Objective To describe Adult Herpes Zoster (HZ) and Post Herpetic Neuralgia (PHN) surveillance in West Philadelphia, and present initial results on: To describe Adult Herpes Zoster (HZ) and Post Herpetic Neuralgia (PHN) surveillance in West Philadelphia, and present initial results on:   Surveillance Methods and Expansion Process   Baseline Incidence   Baseline Clinical Characteristics

4. Why is Adult Herpes Zoster Surveillance Needed? To evaluate the shingles vaccination program’s impact on HZ incidence and disease severity among adults.

5. West Philadelphia Active Surveillance Area West Philadelphia Active Surveillance Area Area: 7 zip codes/ 26 square miles Area: 7 zip codes/ 26 square miles Population: ~269,000 residents Population: ~269,000 residents –~1/5 of the population of Philadelphia –~27% age 50+ –Higher Proportion of Female Adults aged > 50 years –Majority African American/Non-Hispanic (~77%) VASP West Philadelphia Surveillance Area

7. The Process, 2005 The Expansion Process, 2005 Traditional Sources Contacted state and local professional organizations to obtain comprehensive HCP lists to identify potential sites. Contacted state and local professional organizations to obtain comprehensive HCP lists to identify potential sites. Cross-referenced these sites with current MS- Access database. Cross-referenced these sites with current MS- Access database. Performed on-site orientation with new sites Performed on-site orientation with new sites Electronic Sources Monthly Hospital Billing Reports for residents city- wide with HZ Diagnosis (053.X) Monthly Hospital Billing Reports for residents city- wide with HZ Diagnosis (053.X) Daily Reports from Hospital ERs for residents city-wide with HZ Chief Complaints and/or Discharge Diagnoses Daily Reports from Hospital ERs for residents city-wide with HZ Chief Complaints and/or Discharge Diagnoses

8. West Philadelphia Active Surveillance Sites Site Type Before Expansion 2004 n (%) (n = 325) After Expansion 2006 n (%) (n = 339) Healthcare Providers Family Medicine / Internists Family Medicine / Internists 84 (26) 52 (16) 96 (29) 46 (14) Hospitals* Hospitals* 8 (2) Pediatrics Pediatrics 13 (4) 12 (4) Student Health Centers Student Health Centers 5 (2) 5 (1) Public Health Clinics Public Health Clinics 4 (1) Long-Term Care Facilities Long-Term Care Facilities0 14 (4) Other Specialties** Other Specialties** 2 (<1) 7 (2) Non-healthcare providers*** 241 (74) 243 (72) *Represent different departments within each facility: ER, Infection Control, Oncology, Medical Records, Internists /Outpatient clinics **Includes dermatologists, family planning clinics, pain clinics, and infectious disease specialists. ***Schools, daycares, homeless shelters, recreation centers, prisons

9. Active Surveillance Identify contacts, establish and maintain relationships with sites Identify contacts, establish and maintain relationships with sites Send bi-monthly reminders to report cases via fax and email Send bi-monthly reminders to report cases via fax and email Call non-reporting sites Call non-reporting sites Conduct site visits to collect reports and assess problems Conduct site visits to collect reports and assess problems

10. Case Investigation HZ Case Definition: Vesicular rash in a dermatomal distribution with healthcare provider diagnosis OR diagnosis verification by medical record review. HZ Case Definition: Vesicular rash in a dermatomal distribution with healthcare provider diagnosis OR diagnosis verification by medical record review. Assessment of Post Herpetic Neuralgia (PHN) conducted 4 months after rash healed for those with ongoing pain. Assessment of Post Herpetic Neuralgia (PHN) conducted 4 months after rash healed for those with ongoing pain. PHN Case Definition: Ongoing pain at site of rash more than 90 days after rash onset. PHN Case Definition: Ongoing pain at site of rash more than 90 days after rash onset. Acute information collected : Acute information collected : –Rash description –Pain severity, including impact on activities of daily living (ADL) –Complications –Healthcare sought –Treatment HZ –Household VZV transmission links −Underlying conditions −VZV disease / vaccination history −Demographics

11. 2006 HZ Surveillance Results 154 Confirmed Adult HZ Cases – –68% Unilateral Rash Along Single Dermatome – –Majority (90%) with positive or uncertain history of varicella – –1 case developed rash 16 days after vaccination – –23% Immuno-compromised All Diagnosed by a Health Care Professional – –88% Received Anti-Viral Medication Dermatomal Distribution of Zoster Among Confirmed Cases, 2006

12. Total Number of Cases = 154 Adult Herpes Zoster Cases and Rates by Age Group, West Philadelphia, 2006 Number of Cases Rate per 100,000 population

13. HZ Cases and Rates by Age Group and Gender in West Philadelphia, 2006

14. Medical Facilities Visited For HZ, 2006 3% Eye Specialist 8% Hospital 8% Long Term Care 3% Other Specialty 13% Primary Care Provider 7% Health Center 58% ER 18% Immunocompromised 72% Other Chronic Conditions 51% Severe Pain N=152

15. Pain Severity by Age Group in West Philadelphia, 2006 Percentage of Cases

16. Prescription Pain Medications by HZ Pain Severity, 2006 Percentage of Cases

17. PHN by Age Group, 2006 Percentage of Cases

18. Other HZ-Related Complications by Immune Status, 2006 Immunocompromisedp-value* Yes n = 35 n (%) No n = 119 n (%) Segmental Motor Paralysis4 (11)8 (7)NS Bacterial Superinfection7 (20)3 (3)0.001 Cutaneous Dissemination4 (11)1 (1)0.01 Visceral Dissemination0 (0)1 (1)NS Hospitalizations8 (23)7 (6)0.007 Deaths0 (0) NS *Fisher’s Exact test. NS: No significant difference detected (p-value≥0.05)

19. Transmission of VZV to Household Members 117 HZ cases with household member information obtained 117 HZ cases with household member information obtained 46 (39%) lived alone 46 (39%) lived alone 46 (39%) lived with one household member 46 (39%) lived with one household member –Nearly all adults ≥20 years of age (43, 93%) Secondary transmission of VZV only occurred in one household Secondary transmission of VZV only occurred in one household

20. Key Findings from the 1 st Year of Active Adult HZ Surveillance New surveillance sites provided additional HZ case reports among West Philadelphia residents aged ≥70 years. New surveillance sites provided additional HZ case reports among West Philadelphia residents aged ≥70 years. Over one-half of HZ cases reported to VASP in 2006 sought care at an ER. Over one-half of HZ cases reported to VASP in 2006 sought care at an ER. –Majority (77%) reported having a condition requiring regular healthcare provider visits and likely have a primary care provider. Household transmission of VZV from HZ cases aged ≥50 years was rare. Household transmission of VZV from HZ cases aged ≥50 years was rare.

21. Strengths and Limitations of HZ Surveillance in West Philadelphia Strengths HZ is reportable by City Ordinance HZ is reportable by City Ordinance Existing sites have been educated to report HZ for several years Existing sites have been educated to report HZ for several years City-wide electronic surveillance captures West Philadelphia residents seeking care outside of the surveillance area City-wide electronic surveillance captures West Philadelphia residents seeking care outside of the surveillance area Limitations Limitations Surveillance relies primarily on HZ cases who seek care Surveillance relies primarily on HZ cases who seek care Ensuring reporting completeness will be harder to achieve among adults Ensuring reporting completeness will be harder to achieve among adults Accuracy of reporting may vary by site type Accuracy of reporting may vary by site type Obtaining clinical information from the elderly is difficult Obtaining clinical information from the elderly is difficult

22. Future Implications Provide baseline clinical characterization of HZ for the evaluation of the shingles vaccination program Provide baseline clinical characterization of HZ for the evaluation of the shingles vaccination program Establish role of Adult HZ in VZV transmission Establish role of Adult HZ in VZV transmission

23. Acknowledgements CDC VASP Staff CDC VASP Staff –Aisha Jumaan, PhD, MPH –Jessica Leung, MPH –Riduan –Riduan Joesoef, MD, PhD – –Meredith Reynolds, PhD – –Sandra Dos Santos Chaves, MD, MSc Participating Active Surveillance Sites in West Philadelphia Participating Active Surveillance Sites in West Philadelphia

24. QUESTIONS