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BACKGROUND: There are limited population-based data regarding pediatric herpes zoster (HZ). abstract
METHODS:Children aged ,12 years with varicella infections between 2000 and 2006 were
identied from a national population-based database and followed-up for a diagnosis of HZ until
December 2008. Since a routine varicella vaccination program was started in 2004, vaccinated
children without medically attended varicella were identied between 2004 and 2006, and
followed-up for a diagnosis of HZ until December 2008.
RESULTS: Of27 517 children with medically attended varicella, 428 developed HZ. The incidence
of HZ was 262.1 per 100 000 person-years. Of 25 132 vaccinated children without medically
attended varicella, 106 developed HZ. The incidence of HZ was 93.3 per 100 000 person-years.
The mean duration from varicella to HZ was 4.12 years. Children diagnosed with varicella at
aged ,2 years had a higher incidence (P , .001) and shorter duration (P = .04) than those
diagnosed aged 2 years. Children diagnosed with varicella aged $2 but ,8 years had
a signicantly increased incidence of HZ after than before the vaccination program (relative
risk = 1.85 at 3 years of follow-up, P = .03). Children with varicella infections had
a signicantly greater risk of HZ than vaccinated children without a history of varicella
(relative risk = 2.31 at 4 years of follow-up, P , .001).
This study demonstrates the population-based epidemiologic characteristics of
CONCLUSIONS:
pediatric HZ among those who contracted varicella. In the early postvaricella vaccination period,
an increased HZ incidence was observed among children with varicella infection aged $2 years.
a
Department of Dermatology, Taipei City Hospital, Renai Branch, Taipei, Taiwan; bCenter for General Education, WHATS KNOWN ON THIS SUBJECT: This is the
Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; cInstitute of Clinical Research and
Training, Taipei City Hospital, Taipei, Taiwan and dDepartment of Nursing, National Taipei University of Nursing and rst population-based study regarding the
Health Sciences, Taipei, Taiwan epidemiologic characteristics of pediatric zoster
Dr Wen conceptualized and designed the study and drafted and revised the manuscript; Dr Liu carried out the among only those who had contracted varicella.
initial analysis and reviewed the manuscript; and all authors approved the nal manuscript as submitted.
WHAT THIS STUDY ADDS: The herpes zoster (HZ)
www.pediatrics.org/cgi/doi/10.1542/peds.2013-4037 incidence among only children with varicella
DOI: 10.1542/peds.2013-4037 infection is higher than previously reported. The
Accepted for publication Dec 17, 2014 HZ incidence increased for children contracting
Address correspondence to Wen-Liang Liu, PhD, Institute of Clinical Research and Training, Taipei varicella aged ,2 years. After a vaccination
City Hospital, Taipei, Taiwan, No. 10, Sec. 4, Renai Rd, Da-An District, Taipei City 106, Taiwan. E-mail: program, the HZ risk increased for those
suyinwen@ms15.hinet.net
contracting varicella aged $2 years.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to
this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of
interest to disclose.
7.18707.6
335.7966.0
180.1565.0
186.8501.6
200.4455.9
175.2368.8
133.3322.0
168.7453.0
79.4480.6
78.8480.6
89.9844.3
289.9627.5
218.8319.2
83.1339.9
95% CI
which was signicantly younger than
N/A
the children in group A (P , .001).
At 8 y of Follow-up In group A, the incidence of pediatric
589.7
332.3
315.6
308.7
258.6
212.2
285.1
216.8
248.0
310.2
143.5
434.5
265.4
179.0
HZ was 262.1 per 100 000 person-
IR
0
years for the whole observation
No. HZ
5
4
0
3
1
108
8
14
12
16
23
28
20
16
26
diagnosed with varicella when they
were younger than 1 year of age had
No. of Varicella
658
269
189
138
113
712
520
1270
1105
80
4776
(P , .001), with incidence rates of
518.4, 855.5, and 589.7 per 100 000
person-years at 2, 5, and 8 years of
follow-up. The incidence rates of HZ
450.1819.7
186.4409.9
156.3324.7
151.2281.5
94.3201.2
99.1239.4
94.2311.2
75.8342.8
11.7229.8
35.0374.4
24.8488.0
561.8873.8
164.1225.6
76.3219.4
608.21172
95% CI
855.5
614.2
281.8
229.1
208.8
140.2
157.8
179.1
173.3
137.6
147.7
704.9
193.0
134.0
69.5
79
14
7
2
3
2
152
728
517
391
244
14 204
1277
1596
2288
3461
3473
2279
1107
2048
1880
82.2309.2
261.8571.3
132.6201.0
47.5178.7
N/A
immunocompromised diseases
(7 lymphoma/leukemia, 5 other
malignancies, and 1 polyarteritis
At 2 y of Follow-up
84.3
97.4
518.4
318.5
168.5
208.3
167.7
170.9
131.0
120.2
160.7
168.5
398.2
164.1
IR
17
22
23
12
27
89
9
6
3
4
0
2
2660
3613
978
749
499
21 244
diseases.
The risk of developing HZ in the
children diagnosed with varicella
531.2942.3
371.9644.8
197.6377.2
195.8337.6
189.6298.3
170.9275.2
173.4305.7
139.9318.1
78.1258.0
35.36213.9
92.8379.5
29.1311.2
473.5703.9
212.5266.2
94.5201.6
199.8
114.4
580.2
238.2
140.5
IR
Year 20002008
303
47
51
37
52
75
68
48
23
11
98
27
2660
3613
978
749
499
21 244
27
,1
,2
$8
10-
11
1
2
3
4
5
6
7
8
9
group A was 2.31-fold higher than in respectively. Insinga et al5 reported (P = .04). These ndings are similar to
group B at 4 years of follow-up an incidence of 110 per 100 000 those of Stein et al10 but different
(Table 4). person-years in children aged 0 to from the reports by Petursson et al3
14 years, and Weinmann et al11 and and Takayama et al12 in that there
DISCUSSION Civen et al9 reported rates of 230 per were no signicant correlations
100 000 and 238.5 per 100 000 between age at the diagnosis of
To the best of our knowledge, this is
person-years respectively, which are varicella and the time interval to
the rst population-based study to
similar to the ndings of the current develop pediatric HZ.
report the epidemiologic
study. The higher incidence in this This study adds robust additional
characteristics of pediatric HZ among
study may be because pediatric HZ data to existing literature that
only those who contracted varicella.
was measured in a cohort of children contracting varicella in the rst year
Weinmann et al11 reported
who were all infected with varicella of life greatly increases the risk for
a population-based study of HZ in
children, in which the incidence rate rather than including individuals free pediatric HZ.1620 The children who
was calculated by the number of of varicella infection in the contracted varicella aged ,2 years
laboratory-conrmed HZ cases denominator. had a signicantly higher risk of
divided by the total person-years of In the current study, the mean age at developing childhood zoster than
observation in patients aged younger the diagnosis of zoster was 8.4 years, those contracting varicella aged $2
than 18 years, which differs from the which is similar to the ndings of years (P , .001). This may be
current study cohort. Takayama et al12 and Wootton et al,6 explained by a decreased level of
but younger than that reported by immunity to VZV when varicella
The reported incidence rates of
Petursson et al3 (11.8 years). The occurs at a much younger age.17
pediatric HZ vary widely, and are
drawn from different populations and mean duration from varicella to HZ In this study, the children who
based on different methodologies. was 4.12 years in the current study, received systemic antiviral therapy
Guess et al1 reported an incidence which is shorter than in previous for varicella had a higher risk of
rate of 42 per 100 000 person-years studies (range, 58.8 years).3,4,6,18 developing HZ than those who did not
for those aged 0 to 19 years, We also found that the mean duration receive antiviral therapy.
compared with rates of 160 and 220 (3.75 6 1.94 years) among the Immunocompromised children are
per 100 000 person-years among the children who contracted varicella prone to contract pediatric HZ, and
same age group reported by aged ,2 years was signicantly this may have led to the higher
Petursson et al3 and Chidiac et al,8 shorter than those aged $2 years incidence of HZ in the cases receiving
TABLE 4 Incidence of Pediatric HZ in Children With Medical Attended Varicella (Group A) and Those Without a Medical History of Varicella but Who
Received the Varicella Vaccine (Group B)
Follow-up Period, y Group A Group B Group A Versus Group B
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