key: cord-0713129-vovlbygh
authors: Marques, Nelson Pereira; Maia, Célia Márcia Fernandes; Marques, Nádia Carolina Teixeira; de Lucena, Edson Hilan Gomes; Martelli, Daniella R. Barbosa; Oliveira, Eduardo A.; Martelli-Júnior, Hercílio
title: The continuous increase of herpes zoster cases in Brazil during the COVID-19 pandemic Herpes Zoster and COVID-19
date: 2022-01-04
journal: Oral Surg Oral Med Oral Pathol Oral Radiol
DOI: 10.1016/j.oooo.2021.12.133
sha: ace0baa4faa1c4be7d63f5a823a0decadc3a49c1
doc_id: 713129
cord_uid: vovlbygh

nan

With the continuation of the Coronavirus 2019 (COVID-19) pandemic throughout the world, clinical and epidemiological evidence of the occurrence and increase in the number of other diseases, such as herpes zoster (HZ), continue to be discussed, but the real association between HZ and COVID-19 is not well stablished.

An important narrative review identified 27 cases of HZ following 1-2 weeks of COVID-19 in non-vaccinated patients. Most patients showed a typical manifestation of HZ, clinically characterized by painful unilateral rash, compromising the patients' quality of life. Other cases, including patients with lymphopenia, exhibited atypical presentations of HZ, with necrotic tissue injuries and severe neurological involvement. The authors suggest that T cell dysfunction, such as lymphopenia and lymphocyte exhaustion, reactivates the varicella zoster virus (VZV), which causes the HZ disease 1 .

Conversely, recent studies reported cases of VZV reactivation in patients who were vaccinated with mRNA or inactivated COVID-19 vaccines [2] [3] [4] [5] . The COVID-19 vaccines most common adverse reactions are pain, local redness and swelling, fatigue, headache, fever, chills, nauseas and vomiting 3,5,6 , which does not include the main clinical findings of VZV reactivation, that were painful multiple grouped vesicles on an erythematous base and pruritic lesions, which are manifested in patients from 4-14 days after vaccination. These clinical manifestations of HZ may ensue spontaneously, following activation by a trigger, as fever and immunosuppression [2] [3] [4] .

In order to ascertain this issue further, this study aims to compare the data from the Brazilian Unified Health System (SUS) on the number of diagnoses of HZ from the prepandemic period with the pandemic period, as well as compare the first 6 months of the COVID-19 pandemic in Brazil with the last 6 months, so as to update the data and verify if HZ disease control measures were effective in the following months.

The analyzed data were extracted from the public database (DATASUS) (http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sia/cnv/qauf.def) of the Ministry of Health of Brazil. 7 and shows an increase in the number of HZ diagnoses in all Brazilian regions in the months March-August from 2020, compared to the mean number of same months in 2017-2019. The growth increase ranged from +24% in the Northwest to +77% in Midwest Region. The overall Brazilian average increase reached +35%, corresponding to an average of over 2,274 cases in excess. Table 2 shows the comparison of the second half of the pandemic period (September 2020-February 2021) initially with the first half of the COVID-19 pandemic (March-August 2020) and after with the same months of the pre-pandemic. There was a trend towards an increase in the number of HZ cases in the second half of the pandemic throughout Brazil (+11%), with attention to the Northeast region, the least affected in the first study and now the one with the biggest increase (+15%) during the pandemic. When comparing the following period of the pandemic (September 2020-February 2021) with the same months in the prepandemic, the increase in the number of HZ cases was similar to the previous study, keeping the Midwest region as the most impacted (+82%) and an increase of 3,350 cases throughout Brazil (+53%). Table 3 shows the comparison of the incidence rate adjusted per million population for the five geographic Regions of Brazil and throughout the whole country. There was a consistent and significant increase in the incidence rate all over Brazil, between first and second pandemic periods and between the pre pandemic and the second pandemic periods. Limitations of this article include lack of information regarding the criteria for confirmation of HZ diagnoses in the public database from the SUS, and the unavailability of larger clinical COVID-19 vs HZ studies.

The relation between the manifestation of HZ disease and COVID-19 remains to be established. Only case reports and case series have been published showing this coexistence until now, and this evidence is not sufficient to assert this association. However, we observed in this study a continued increase in HZ cases during the COVID-19 pandemic, with a tendency towards an increase in subsequent months, which may suggest a correlation among these diseases, as demonstrated in the previous study 7 . Furthermore, this new data suggests that measures to control the increase in HZ cases in the first period of the pandemic were not effective, including the assessment of access to medicines, healthcare-seeking behavior, telemedicine consultations, aware of practitioners about possible increased risk of HZ during the pandemic period and the application of timely preventive and therapeutic measures against HZ.

Thus, it is necessary to have larger clinical studies with different populations to better understand the relationship between these two conditions and find measures to raise the control of this disease. 

Can COVID-19 Increase the Risk of Herpes Zoster? A Narrative Review

Herpes zoster emergence following mRNA COVID-19 vaccine

Herpes zoster after inactivated COVID-19 vaccine: a cutaneous adverse effect of the vaccine Zoster after COVID-19 vaccine

Herpes zoster following inactivated COVID-19 vaccine: A coexistence or coincidence?

Herpes zoster following BNT162b2 mRNA Covid-19 vaccination in patients with autoimmune inflammatory rheumatic diseases: a case series

Safety and efficacy of the BNT162b2 mMRNA COVID-19 vaccine

Increased number of Herpes Zoster cases in Brazil related to the COVID-19 pandemic