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Epidemiology and risk factors

Herpes zoster is caused by the reactivation of the varicella zoster virus.

photograph showing the back of a child with chickenpox

Primary varicella infection: Chickenpox1

Varicella zoster virus infection usually occurs in childhood and often manifests as a generalised vesicular rash.

Latency

Latency2-5

Varicella zoster virus establishes latency and the primary infection induces cell-mediated immunity, which may prevent subsequent infection and reactivation.

photograph showing the herpes zoster rash with distinctive lesions caused by reactivation of varicella zoster virus

Reactivation: Herpes zoster1,3,6

Varicella zoster virus can reactivate later in life, causing the distinctive dermatomal rash and pain.

Varicella zoster virus latency and reaction

After primary infection, the virus remains latent in the dorsal root ganglion.1,3,7,8 However, usually in adults greater than 50 years of age, varicella zoster virus can reactivate due to waning immune response and cause herpes zoster.4,9-13

Age-related decline in immunity and a compromised immune system increase the risk of herpes zoster10,14

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Older age (greater than 50 years of age)

Age is the most important risk factor for herpes zoster.15 Cell-mediated immune response decreases with age due to immunosenescence.10 Herpes zoster risk increases dramatically after 50 years of age,14 with over two-thirds of cases occurring in this age group.15

icon depicting a shield with a virus particle

Compromised immune system

Patients with immunodeficient conditions10 and those on immunosuppressive drugs.16

A pooled analysis identified risk factors for herpes zoster.10

Meta-analysis: selected risk factors for herpes zoster
Risk factor Odds ratio (95% CI)†
Family history of herpes zoster 2.48 (1.70, 3.60)
Female 1.19 (1.14, 1.24)
Older age* 1.65 (1.37, 1.97)
HIV/AIDS 3.22 (2.40, 4.33)
Malignancy 2.17 (1.86, 2.53)
SLE 2.08 (1.56, 2.78)
Rheumatoid arthritis 1.51 (1.31, 1.75)
COPD 1.41 (1.28, 1.55)
CV conditions 1.34 (1.17, 1.54)
IBD 1.32 (1.24, 1.40)
CRD 1.29 (1.10, 1.52)
Asthma 1.24 (1.16, 1.31)
Diabetes 1.24 (1.14, 1.35)
Depression 1.23 (1.11, 1.36)

Figure adapted with permission from Marra F, et al. Open Forum Infect Dis. 2020;7:ofaa005.

*Studies reported herpes zoster risk within the following age groups: ≥60 years (36 studies), ≥50 years (2 studies), ≥40 years (1 study)10. †p<0.0001

COPD, chronic obstructive pulmonary disease; CRD, chronic renal disease; CV, cardiovascular; HIV/AIDS, human immunodeficiency virus/acquired immune deficiency syndrome; IBD, inflammatory bowel disease; SLE, systemic lupus erythematosus.

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Disease burden and complications

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Patient management

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Prevention through vaccination: The ZOE programme

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Abbreviations

CI, confidence interval; COPD, chronic obstructive pulmonary disease; CRD, chronic renal disease; CV, cardiovascular; HIV/AIDS, human immunodeficiency virus/acquired immune deficiency syndrome; IBD, inflammatory bowel disease; SLE, systemic lupus erythematosus.

References

  1. Puchhammer-Stöckl E, et al. Manual of Clinical Microbiology. 2015;1704-1717.
  2. Arvin AM. J Infect Dis. 2008;197 Suppl 2:S58-60.
  3. Cohen JI. N Engl J Med. 2013;369:255-263.
  4. Dworkin RH, et al. Clin Infect Dis. 2007;44 Suppl 1:S1-26.
  5. Oxman MN. Clin Infect Dis. 2010;51:197-213.
  6. Sampathkumar P, et al. Mayo Clin Proc. 2009;84:274-280.
  7. Kleinschmidt-DeMasters BK, et al. Arch Pathol Lab Med. 2001;125:770-780.
  8. Kimberlin DW, et al. N Engl J Med. 2007;356:1338-1343.
  9. Arvin A. N Engl J Med. 2005;352:2266-2267.
  10. Marra F, et al. Open Forum Infect Dis. 2020;7:ofaa005.
  11. Boutry C, et al. Clin Infect Dis. 2022;74:1459-1467.
  12. Kawai K, et al. BMJ Open. 2014;4:e004833.
  13. Yawn BP, et al. Neurology. 2013;81:928-930.
  14. John AR, et al. Infect Dis Clin North Am. 2017;31:811-826
  15. Government of Canada Herpes zoster (shingles) vaccine: Canadian Immunization Guide 2018; available at: www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-8-herpes-zoster-(shingles)-vaccine.html
    (accessed August 2022).
  16. Kennedy PGE, et al. Viruses. 2018;10:609.

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