The herpes zoster (HZ) virus is associated with significant morbidity. Its incidence and severity are higher among older adults and immunocompromised individuals. This systematic review assessed the clinical efficacy and effectiveness of recombinant zoster vaccine (RZV) for the prevention of HZ and associated complications in adults at least 50 years of age and in adults (≥18 years) at increased risk of HZ.

Electronic searches restricted to between 2008 and July 2023 were conducted in Embase, MEDLINE, the Cochrane Library, and clinical trial registries. Two reviewers independently screened articles and extracted data. The review adhered to the PRISMA reporting guidelines. Quality appraisal was assessed using version two of the Cochrane risk-of-bias tool for randomized trials tool and the Risk of Bias in Non-Randomized Studies - of Interventions tool. Meta-analysis was undertaken using Cochrane methodology, with preference given to random effects meta-analysis because of study heterogeneity.

Twelve RCTs and five cohort studies were identified. Vaccine efficacy was defined as one minus the incidence rate ratio, multiplied by 100. For the general population, vaccine efficacy was 92 percent (n=29,311 individuals) and vaccine effectiveness was 70 percent (n=43,990,671 individuals). Based on one trial, vaccine efficacy in the general population (aged ≥50 years) waned from an initial 97.7 percent to 73.2 percent by year 10. Two RCTs reported vaccine efficacy for those at increased risk: 68.2 percent in hematopoietic stem cell transplant recipients and 87.2 percent in those with hematological malignancies. Secondary analyses were limited by sample size.

There is clear, consistent evidence that RZV is effective in reducing HZ incidence. Although the vaccine is effective in those who are least 18 years of age and are at increased risk of HZ, efficacy may be lower compared with a general population aged at least 50 years. Secondary analyses (age subgroups, HZ complications, and HZ-related hospitalizations) were limited by small sample size, leading to inconclusive results.

Herpes zoster (HZ), also known as shingles, is characterized by a vesicular skin rash, often associated with acute pain and itching. The safety profile of the recombinant zoster vaccine (RZV) in adults aged 50 years and older and in adults aged 18 and older who are at increased risk of HZ was assessed in this systematic review.

A comprehensive electronic search was performed in Embase, MEDLINE, the Cochrane Library, and clinical trials registries. Searches were limited to the period from 2008 to July 2023. Article screening and data extraction were carried out by two independent reviewers. Risk of bias was assessed using the Cochrane revised Risk of Bias 2 (RoB2) tool for randomized controlled trials (RCTs). The Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) tool was used to assess the quality of non-randomized studies. An adapted version of the Newcastle–Ottawa Scale was used for the appraisal of quality of non-comparative studies.

Eighteen RCTs, four observational cohort studies, seven single-arm trials, and 11 single-arm observational studies were identified. Compared with placebo, solicited local (RZV: 74.1 to 84.0%; placebo: 7.9 to 11.9%) and systemic reactions (RZV: 53.0 to 66.1%; placebo: 6 to 11.4%) were more common in the vaccinated cohorts. Reactions were generally transient and mild to moderate in intensity. The most frequent reactions reported were pain at the reaction site, fatigue, and myalgia. The incidence of potential immune-mediated diseases (pIMDS), serious adverse events (SAEs), and fatalities was similar in vaccine and placebo groups. No SAEs, pIMDs, or deaths were reported as vaccine related.

The available data on RZV shows that while local and systemic adverse events are common with RZV, these are typically transient, and SAEs are uncommon in both the general population and those at increased risk of HZ.

Patients refusing transportation is common EMS practice with potentially fatal outcomes. Determining which patients are at high risk for poor outcomes is poorly defined. This study described patients who experienced an out-of-hospital cardiac arrest (OHCA) within 24 hours of refusing transportation.

This is a retrospective, descriptive study of patients who had an OHCA within 24 hours of refusing EMS transportation between 2019 to 2021. Data was obtained from a large, urban medical control authority seeing 175,000 EMS calls annually. We reviewed patient demographics, EMS events when transportation was refused, and cardiac arrest outcome.

There were 6, 30, and 28 EMS refusals resulting in OHCA in 2019, 2020, and 2021. Patients who had OHCA were 65.7 (range 28-103) years old, and African American (54/64). Patients had HTN (36/64), diabetes (19/64), COPD (11/64), and CHF (7/64). Common complaints included breathing problems (17/64), near syncope (8/64) however chest pain was uncommon (4/64). One (28/64) or two (13/64) abnormal vital signs were present and missing vital signs (28/64) were common. Tachycardia (32.8%, 21/64), HTN (29.7%, 19/64), and hypotension (17.2%, 11/64) were more prevalent in the OHCA population compared to all refusal patients (Tachycardia 0.33% [1,978/598,416], HTN 2.27% [13,601/598,416], and hypotension 0.04% [218/598,416]). Patients were seen by both ALS (29/64) and BLS (35/64) providers. Most providers documented risk including death (38/64) though few contacted medical control (14/64). Return encounter for OHCA resulted in obvious deaths (23/64) or field termination (20/64). Few patients achieved ROSC (7/64).

Patients who had an OHCA within 24 hours of refusing transport had underlying comorbidities and abnormal or missing vital signs. The patients experienced tachycardia, hypertension, and hypotension at a higher rate than the overall refusal population. Few patients obtained ROSC. Further research is needed to determine methods to mitigate poor outcomes and decrease refusals.