Skip to main content

Risk factors for herpes zoster in a large cohort of unvaccinated older adults: a prospective cohort study

  • B. LIU (a1) (a2), A. E. HEYWOOD (a1), J. REEKIE (a3), E. BANKS (a2) (a4), J. M. KALDOR (a3), P. McINTYRE (a5), A. T. NEWALL (a1) and C. R. MACINTYRE (a1)...

We analysed data from a prospective cohort of 255024 adults aged ⩾45 years recruited from 2006–2009 to identify characteristics associated with a zoster diagnosis. Diagnoses were identified by linkage to pharmaceutical treatment and hospitalization records specific for zoster and hazard ratios were estimated. Over 940583 person-years, 7771 participants had a zoster diagnosis; 253 (3·3%) were hospitalized. After adjusting for age and other factors, characteristics associated with zoster diagnoses included: having a recent immunosuppressive condition [adjusted hazard ratio (aHR) 1·58, 95% confidence interval (CI) 1·32–1·88], female sex (aHR 1·36, 95% CI 1·30–1·43), recent cancer diagnosis (aHR 1·35, 95% CI 1·24–1·46), and severe physical limitation vs. none (aHR 1·33, 95% CI 1·23–1·43). The relative risk of hospitalization for zoster was higher for those with an immunosuppressive condition (aHR 3·78, 95% CI 2·18–6·55), those with cancer (aHR 1·78, 95% CI 1·24–2·56) or with severe physical limitations (aHR 2·50, 95% CI 1·56–4·01). The novel finding of an increased risk of zoster diagnoses and hospitalizations in those with physical limitations should prompt evaluation of the use of zoster vaccine in this population.

Corresponding author
* Author for correspondence: Dr B. Liu, School of Public Health and Community Medicine, University of New South Wales, Sydney NSW 2052, Australia. (Email:
Hide All
1. Hope-Simpson, R. The nature of herpes zoster: a long-term study and a new hypothesis. Proceedings of the Royal Society of Medicine 1965; 58: 920.
2. Thomas, S, Hall, A. What does epidemiology tell us about risk factors for herpes zoster? Lancet Infectious Diseases 2004; 4: 2633.
3. Langan, S, et al. Herpes zoster vaccine effectiveness against incident herpes zoster and post-herpetic neuralgia in an older US population: a cohort study. PLoS Medicine 2013; 10: e1001420.
4. Buchbinder, S, et al. Herpes zoster and human immunodeficiency virus infection. Journal of Infectious Diseases 1992; 166: 11531156.
5. Fleming, D, et al. Gender differences in the incidence of shingles. Epidemiology and Infection 2003; 132: 15.
6. Schmader, KE, et al. Race and stress in the incidence of herpes zoster in older adults. Journal of the American Geriatrics Society 1998; 46: 973977.
7. Zhang, J, et al. Association between vaccination for herpes zoster and risk of herpes zoster infection among older patients with selected immune-mediated diseases. Journal of the American Medical Association 2012; 308: 4349.
8. Thomas, S, Wheeler, J, Hall, A. Contacts with varicella or with children and protection against herpes zoster in adults: a case-control study. Lancet 2002; 360: 678682.
9. Irwin, M, et al. Cellular immunity to varicella-zoster virus in patients with major depression. Journal of Infectious Diseases 1998; 178: S104108.
10. Weitzman, D, et al. A population based study of the epidemiology of Herpes Zoster and its complications. Journal of Infection 2013; 67: 463469.
11. Oxman, M, et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. New England Journal of Medicine 2005; 352: 22712284.
12. Schmader, K, et al. Persistence of the efficacy of zoster vaccine in the Shingles Prevention Study and the Short-Term Persistence Substudy. Clinical Infectious Diseases 2012; 55: 13201328.
13. 45 and Up Study Collaborators, Banks, E, Redman, S, et al. Cohort profile: the 45 and up study. International Journal of Epidemiology 2008; 37: 941947.
14. Centre for Health Record Linkage. (
15. National Centre for Classification in Health (Sydney). The international statistical classification of diseases and related health problems, 10th revision, Australian Modification (ICD-10-AM), 2nd edn. Lidcombe, NSW: National Centre for Classification in Health Sydney, 2000.
16. Dworkins, R, et al. Recommendations for the management of herpes zoster. Clinical Infectious Diseases 2007; 44: S126.
17. Centers for Disease Control and Prevention. Prevention of herpes zoster. Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report 2008; 57: RR-5.
18. Stein, A, et al. Herpes zoster burden of illness and health care resource utilisation in the Australian population aged 50 years and older. Vaccine 2009; 27: 520529.
19. MacIntyre, C, Chu, C, Burgess, M. Use of hospitalization and pharmaceutical prescribing data to compare the prevaccination burden of varicella and herpes zoster in Australia. Epidemiology and Infection 2003; 131: 675682.
20. Yawn, B, Wollan, P, Sauver, J. Comparing shingles incidence and complication rates from medical record review and administrative database estimates: how close are they? American Journal of Epidemiology 2011; 174: 10541061.
21. Jackson, LA, Reynolds, M, Harpaz, R. Hospitalizations to treat herpes zoster in older adults: causes and validated rates. Clinical Infectious Diseases 2008; 47: 754–9.
22. Ultsch, B, et al. Herpes zoster in Germany: quantifying the burden of disease. BMC Infectious Diseases 2011; 11: 173.
23. Australian Institute of Health and Welfare. Rural, regional and remote health: a guide to remoteness classifications. Canberra: AIHW Catalogue, PHE 53, 2004.
24. Hays, R, et al. Item response theory analyses of physical functioning items in the Medical Outcomes Study. Medical Care 2007; 45: S32–S8.
25. Opstelten, W, et al. Gender as an independent risk factor for herpes zoster: a population-based prospective study. Annals of Epidemiology 2006; 16: 692695.
26. Tseng, HF, et al. Herpes zoster vaccine in older adults and the risk of subsequent herpes zoster disease. Journal of the American Medical Association 2011; 305: 160166.
27. Habel, L, et al. The epidemiology of herpes zoster in patient with newly diagnosed cancer. Cancer Epidemiology Biomarkers and Prevention 2013; 22: 8290.
28. Forbes, H, et al. Quantification of risk factors for herpes zoster: population based case-control study. British Medical Journal 2014; 348: g2911.
29. Chiappe, S, et al. Herpes zoster: burden of disease in France. Vaccine 2010; 28: 79337938.
30. Insinga, R, et al. The incidence of herpes zoster in a United States administrative database. Journal of General Internal Medicine 2005; 20: 748753.
31. Ogunjimi, B, Van Damme, P, Beutels, P. Herpes zoster risk reduction through exposure to chickenpox patients: a systematic multidisciplinary review. PLoS ONE 2013; 8: e66485.
32. Castle, S. Clinical relevance of age-related immune dysfunction. Clinical Infectious Diseases 2000; 31: 578585.
34. Morrison, V, et al. Safety of zoster vaccine in elderly adults following documented herpes zoster. Journal of Infectious Diseases 2013; 208: 559563.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Epidemiology & Infection
  • ISSN: 0950-2688
  • EISSN: 1469-4409
  • URL: /core/journals/epidemiology-and-infection
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Type Description Title
Supplementary materials

Liu Supplementary Material

 Word (20 KB)
20 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed