The effect of shingles vaccination at different stages of the dementia disease course.

The varicella zoster virus, a neurotropic herpesvirus, has been hypothesized to play a role in the pathophysiology of dementia, such as through neuroinflammatory processes or intracerebral vasculopathy. Using unique natural experiments, our group has previously found that live-attenuated herpes zoster (HZ) vaccination reduced the incidence of new diagnoses of dementia in both Wales and Australia. To inform further research and ultimately clinical care, it is crucial to understand at which stage of the disease course of dementia the HZ vaccine has its effect. Representing the two opposing ends of the dementia disease course as it can be ascertained from electronic health record data, the aims of this study were twofold: to determine the effect of HZ vaccination on i) new diagnoses of mild cognitive impairment (MCI) among individuals without any record of cognitive impairment, and ii) deaths due to dementia among individuals living with dementia. Our approach took advantage of the fact that at the time of the start date (September 1 2013) of the HZ vaccination program in Wales, individuals who had their eightieth birthday just after this date were eligible for HZ vaccination for one year whereas those who had their eightieth birthday just before were ineligible and remained ineligible for life. This eligibility rule created comparison groups just on either side of the September 2 1933 date-of-birth eligibility threshold who differed in their age by merely a week but had a large difference in their probability of receiving HZ vaccination. The key strength of our study is that these comparison groups should be similar in their health characteristics and behaviors except for a minute difference in age. We used regression discontinuity analysis to estimate the difference in our outcomes between individuals born just on either side of the date-of-birth eligibility threshold for HZ vaccination. Our dataset consisted of detailed country-wide electronic health record data from primary care in Wales, linked to hospital records and death certificates. We restricted our dataset to individuals born between September 1 1925 and September 1 1942. Among our study cohort of 282,557 without any record of cognitive impairment at baseline, HZ vaccination eligibility and receipt reduced the incidence of a new MCI diagnosis by 1.5 (95% CI: 0.5 - 2.9, p=0.006) and 3.1 (95% CI: 1.0 - 6.2, p=0.007) percentage points over nine years, respectively. Similarly, among our study cohort of 14,350 individuals who were living with dementia at baseline, being eligible for and receiving HZ vaccination reduced deaths due to dementia by 8.5 (95% CI: 0.6 - 18.5, p=0.036) and 29.5 (95% CI: 0.6 - 62.9, p=0.046) percentage points over nine years, respectively. Except for dementia, HZ vaccination did not have an effect on any of the ten most common causes of morbidity and mortality among adults aged 70 years and older in Wales in either of our two study cohorts. The protective effects of HZ vaccination for both MCI and deaths due to dementia were larger among women than men. Our findings suggest that the live-attenuated HZ vaccine has benefits for the dementia disease process at both ends of the disease course of dementia.

Background:The United Kingdom (UK) has used date of birth-based eligibility rules for live-attenuated herpes zoster (HZ) vaccination that have led to large differences in HZ vaccination coverage between individuals who differed in their age by merely a few days. Using this unique natural randomization, we have recently provided evidence from Welsh electronic health record data that HZ vaccination caused a reduction in new dementia diagnoses over a seven-year period. Based on this, we hypothesized that HZ vaccination may have slowed the dementia disease process more generally and, thus, already reduced deaths with dementia as their underlying cause even though the UK’s HZ vaccination program commenced as recently as September 2013. Using country-wide death certificate data for England and Wales, this study, therefore, aimed to determine whether eligibility for HZ vaccination caused a reduction in deaths due to dementia over a nine-year follow-up period.Methods:Adults who had their 80th birthday shortly before September 1 2013 were ineligible for HZ vaccination in the UK’s National Health Service and remained ineligible for life, whereas those who had their 80th birthday shortly after September 1 2013 (i.e., born on or after September 2 1933) were eligible for one year. Akin to a randomized trial, this date-of-birth threshold generated birth cohorts who are likely exchangeable in observed and unobserved characteristics except for a small difference in age and a large difference in HZ vaccination uptake. We used country-wide data from death certificates in England and Wales on underlying causes of death from September 1 2004 to August 31 2022 by ICD-10 code and month of birth. Our analysis compared the percentage of the population with a death due to dementia among the month-of-birth cohorts around the September 2 1933 eligibility threshold using a regression discontinuity design. The primary analyses used the maximal available follow-up period of nine years.Results:The study population included 5,077,426 adults born between September 1 1925 and August 31 1941 who were alive at the start of the HZ vaccination program. The month-of-birth cohorts around the September 2 1933 eligibility cutoff were well balanced in their occurrence of all-cause and cause-specific deaths (including deaths due to dementia) prior to the start of the vaccination program. We estimated that over a nine-year follow-up period, eligibility for HZ vaccination reduced the percentage of the population with a death due to dementia by 0.38 (95% CI: 0.08 to 0.68, p=0.012) percentage points, corresponding to a relative reduction of 4.8%. As in our prior analysis, this effect was stronger among women (−0.62 [95% CI: −1.06 to −0.19] percentage points, p=0.004) than among men (−0.11 [95% CI: −0.51 to 0.28] percentage points, p=0.574). The reduction in deaths due to dementia likely resulted in an increase in remaining life expectancy because we found that HZ vaccination eligibility reduced all-cause mortality but had no effect on deaths not due to dementia. An effect on deaths due to dementia at the September 2 date-of-birth eligibility threshold existed only since the year in which the HZ vaccination program was implemented.Conclusions:Our findings indicate that HZ vaccination improved cognitive function at a fairly advanced stage of the dementia disease process because most individuals whose underlying cause of death was dementia during our nine-year follow-up period were likely already living with dementia at the start of the HZ vaccination program. By using a different population, type of data, and outcome than our prior study in Welsh electronic health record data, this analysis adds to the evidence base that HZ vaccination slows, or potentially even prevents, the natural history of dementia.

Importance:Taking advantage of a natural experiment in Wales, our group has recently provided evidence that herpes zoster (HZ) vaccination appears to prevent or delay dementia. Exploiting a similar natural experiment in Australia, this present study investigated the effect of HZ vaccination on dementia occurrence in a different population and health system setting.Objective:To determine the effect of HZ vaccination on the probability of receiving a new diagnosis of dementia in the future.Design, Setting, and Participants:In Australia, starting on November 1 2016, live-attenuated HZ vaccination was provided for free to individuals aged 70 to 79 years of age through primary care providers. Thus, those whose 80th birthday was just a few weeks prior to November 1 2016 never became eligible, whereas those whose 80th birthday was just a few weeks later were eligible. The key strength of our approach is that one would not expect that these comparison groups who differ in their age by only a minute degree would, on average, differ in any of their health characteristics and behaviors. We analyzed primary healthcare records with week-of-birth information from 65 general practices across Australia using regression discontinuity.Exposure:Eligibility for HZ vaccination based on one’s date of birth.Main outcome:New diagnoses of dementia as recorded in primary care electronic health record data.Results:As expected, in our sample of 101,219 patients, individuals born just before versus shortly after the date-of-birth eligibility threshold (November 2 1936) for HZ vaccination were well-balanced in their past preventive health services uptake and chronic disease diagnoses. There was an abrupt increase of 16.4 (95% CI: [13.2 – 19.5], p < 0.001) percentage points in the probability of ever receiving HZ vaccination between patients born shortly before versus shortly after the date-of-birth eligibility threshold. The eligibility rules of the HZ vaccination program, thus, created comparison groups just on either side of the date-of-birth eligibility threshold who were likely similar to each other, except for a large difference in their probability of receiving the intervention (HZ vaccination) of interest. Drawing on a sample of 18,402 patients, we find that eligibility for HZ vaccination (i.e., being born shortly after versus shortly before November 2 1936) decreased the probability of receiving a new dementia diagnosis over 7.4 years by 1.8 percentage points (95% CI: [0.4 – 3.3], p = 0.013). Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations), nor the probability of being diagnosed with other common chronic conditions than dementia.Conclusions and Relevance:Corroborating our quasi-experimental findings from Wales in a different population, this study provides important evidence on the potential benefits of HZ vaccination for dementia because its quasi-experimental design allows for conclusions that are more likely to be causal than those of more commonly conducted associational studies.

Based on limited data, the live attenuated herpes zoster (HZ) vaccine is contraindicated in patients taking anti-tumor necrosis factor (anti-TNF) therapies or other biologics commonly used to treat immune-mediated diseases. The safety and effectiveness of the vaccine are unclear for these patients. To examine the association between HZ vaccination and HZ incidence within and beyond 42 days after vaccination in patients with selected immune-mediated diseases and in relation to biologics and other therapies used to treat these conditions. Retrospective cohort study of 463,541 Medicare beneficiaries 60 years and older with rheumatoid arthritis, psoriasis, psoriatic arthritis, ankylosing spondylitis, or inflammatory bowel disease using Medicare claims data from January 1, 2006, through December 31, 2009. Herpes zoster incidence rate within 42 days after vaccination (a safety concern) and beyond 42 days; hazard ratios estimated using Cox proportional hazards models for HZ comparing vaccinated vs unvaccinated patients. Median duration of follow-up was 2.0 years (interquartile range, 0.8-3.0); 4.0% of patients received HZ vaccine. The overall crude HZ incidence rate was 7.8 cases per 1000 person-years (95% CI, 3.7-16.5) within 42 days after vaccination. The rate among the unvaccinated was 11.6 cases per 1000 person-years (95% CI, 11.4-11.9). Among 633 patients exposed to biologics at the time of vaccination or within the subsequent 42 days, no case of HZ or varicella occurred. After multivariable adjustment, HZ vaccination was associated with a hazard ratio of 0.61 (95% CI, 0.52-0.71) for HZ risk after 42 days. Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence among Medicare beneficiaries with selected immune-mediated diseases, including those exposed to biologics. The vaccine was associated with a lower HZ incidence over a median of 2 years of follow-up.

Background We have recently provided evidence from a quasi-randomized study in Wales that herpes zoster (HZ) vaccination reduced the incidence of new dementia diagnoses. This study used a similar quasi-randomization in Australia to determine the effect of HZ vaccination on new dementia diagnoses over 7.5 years.Figure 1:Eligibility for a free herpes zoster (HZ) vaccine reduces dementia diagnosesIn panel (a), a regression discontinuity is plotted, where the forcing variable is the number of weeks from the cutoff (November 2, 1936) and the outcome is dementia diagnoses (in percentages). The triangular dots indicate dementia diagnoses for the comparison group, scaled up by the intercept for the main cohort. Panel (b) describes this effect for different follow-up periods, and panel (c) shows the effect for different grace periods. Methods In Australia, starting on November 1 2016, live-attenuated HZ vaccination was provided for free to individuals aged 70 to 79 years of age. Thus, those whose 80th birthday was just a few days prior to November 1 2016 never became eligible, whereas those whose 80th birthday was a few days later were eligible for one year. There is no reason to expect that these population groups who differ in their age by only a minute degree should differ in any of their dementia-related characteristics. We used detailed primary healthcare records (provided by PenCS) with week-of-birth information from 65 general practices across Australia. We analyzed our data using a comparative regression discontinuity design, with dementia diagnoses from older birth cohorts serving as a comparison group. Results Of 108,670 patients in our data, 15,297 were born between November 2 1928 and November 2 1944. At baseline, patients were well-balanced across the date-of-birth eligibility threshold (November 2 1936) for HZ vaccination in their preventive health services uptake and chronic disease diagnoses. There was an abrupt increase of 13.2 (95% CI: [8.7, 17.6], p = 0.001) percentage points in the probability of ever receiving HZ vaccination between patients born shortly before versus shortly after the eligibility threshold. Eligibility for a free HZ vaccination caused a 3.9 percentage point (95% CI: [1.7, 6.1], p = 0.001) decrease in the probability of receiving a new dementia diagnosis over 7.5 years. Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations) nor do we find consistent evidence that it affected the probability of receiving any of the twenty most common disease diagnoses in our data. Conclusion In conjunction with our findings from Wales, these results from Australia constitute robust evidence that live-attenuated HZ vaccination may delay or prevent dementia. Disclosures All Authors: No reported disclosures

This study aimed to assess knowledge, attitudes, and practices toward herpes zoster (HZ) disease and vaccination and identify factors influencing HZ vaccination perceptions and behavior in adults ≥50 y of age (YOA) among the public and physicians in Hong Kong (HK), Singapore (SG), Republic of Korea (KR), and Taiwan (TW). A two-phase cross-sectional study was conducted in January–September 2022, including concept elicitation interviews (first phase, previously published) and a quantitative online survey (second phase, current article). The second phase involved a larger sample from the same target populations with different individuals. Participants in the second phase included: 1,970 adults ≥50 YOA, 203 adults aged 30–49 YOA with parents ≥50 YOA, and 220 physicians. Substantial knowledge gaps existed among the public about the causes, long-term impact, and risk factors for HZ. Awareness of HZ vaccine availability varied across locales (highest in KR [76%]; lowest in TW [35%]), and higher among individuals with a history of HZ (73%) than HZ-naïve individuals ≥50 YOA (49%). Key drivers of HZ vaccination included preventing disease/recurrence (44%) and long-term complications (41%), and physician recommendations (36%). Two-in-five individuals ≥50 YOA were recommended HZ vaccination. Most physicians agreed that recommending HZ vaccines to patients ≥50 YOA was important but reported initiating HZ vaccination conversations with 27.8% of their patients ≥50 YOA. Knowledge gaps surrounding HZ and HZ vaccination remain. Initiatives are needed to improve public awareness regarding the importance of HZ prevention. Physicians also play an important role in having proactive discussions about HZ prevention with their patients.

Recent evidence from a quasi-experiment in Wales showed that herpes zoster (HZ) vaccination appears to prevent or delay dementia. Exploiting a similar quasi-experiment in Australia, this study investigated the effect of HZ vaccination on dementia occurrence in a different population and health system setting. To determine the effect of HZ vaccination on the probability of receiving a new diagnosis of dementia. In Australia, starting November 1, 2016, live attenuated HZ vaccination was provided free to individuals aged 70 to 79 years through primary care clinicians. Thus, individuals whose 80th birthday was just a few weeks before November 1, 2016, never became eligible, whereas those whose 80th birthday was just a few weeks later were eligible. The key strength of this quasi-experiment is that one would not expect that these comparison groups who differ in age only minutely would, on average, differ in any health characteristics and behaviors. Primary health care records were analyzed with week-of-birth information from 65 general practices across Australia, using a regression discontinuity design. Eligibility for HZ vaccination based on date of birth. New diagnoses of dementia as recorded in primary care electronic health record data. In this sample of 101 219 patients, 52.7% were women and mean age was 62.6 years (SD, 9.3 years) as of November 1, 2016. Individuals born just before vs just after the date-of-birth eligibility threshold (November 2, 1936) for HZ vaccination were well balanced in their past preventive health services uptake and past chronic disease diagnoses. There was an abrupt increase of 16.4 percentage points (95% CI, 13.2-19.5; P < .001) in the probability of ever receiving HZ vaccination between patients born shortly before vs shortly after the date-of-birth eligibility threshold. The eligibility rules of the HZ vaccination program thus created comparison groups born just on either side of the date-of-birth eligibility threshold who were likely similar to each other, except for a large difference in their probability of receiving the intervention (HZ vaccination) of interest. This study found that eligibility for HZ vaccination (ie, being born shortly after vs shortly before November 2, 1936) decreased the probability of receiving a new dementia diagnosis during 7.4 years by 1.8 percentage points (95% CI, 0.4-3.3 percentage points; P = .01). Being eligible for HZ vaccination did not affect the probability of taking up other preventive health services (including other vaccinations) or the probability of receiving a diagnosis of common chronic conditions other than dementia. By taking advantage of a quasi-experiment and corroborating findings from Wales in a different population, this study provides evidence of the potential benefits of HZ vaccination for dementia that is more likely to be causal than that of more commonly conducted associational studies.

Herpes zoster (HZ) is a prevalent disease characterized by a painful rash. A multi‑country study was conducted to elicit public and physician knowledge, attitude, and practice (KAP) toward HZ disease and vaccination for the assessment of local factors influencing HZ vaccine perceptions in four Asian-Pacific countries/territories One-to-one qualitative interviews were conducted in 2022, among the public (people aged ≥ 50 years, adults with parents aged ≥ 50 years, zoster vaccine live-vaccinated individuals aged ≥ 50 years in Republic of Korea, and HZ patients; n = 78) and physicians (general practitioners and specialists; n = 24). Themes surrounding KAP toward HZ and HZ vaccination were summarized using a thematic analysis. A substantial knowledge gap related to HZ was observed among the public, including its causes, long-term impacts, and the at-risk population. There was a low perceived risk of HZ and low general awareness of HZ vaccine availability, although country/territory-specific differences existed. Fear of HZ-associated pain contributed toward vaccination intent among HZ patients and adults with parents aged ≥ 50 years. HZ-naïve adults who were encouraged to receive the vaccine by others were not motivated to do so due to optimism bias. Physicians were perceived to be a reliable source of information. However, physicians did not always proactively discuss HZ vaccination due to time constraints and a perceived need to prioritize other vaccinations including influenza and pneumococcal vaccines. Initiatives are needed to improve public awareness of HZ and its complications, in terms of overall impact on individuals and society, and highlight the important role of physicians in recommending vaccination.

UK experience of herpes zoster vaccination can inform varicella zoster virus policies

A life-course immunization approach would enhance the quality of life across all age groups and improve societal well-being. The herpes zoster (HZ) vaccine is highly recommended for older adults to prevent HZ infection and related complications. The proportions of willingness to receive the HZ vaccine varies across countries, and various kinds of factors, including sociodemographics and individual perceptions, influence the willingness to vaccinate. We aim to estimate the HZ vaccination willingness rate and identify factors associated with vaccine uptake willingness across all World Health Organization (WHO) regions. A global systematic search was performed on PubMed, Web of Science, and the Cochrane Library for all papers related to the HZ vaccine published until June 20, 2022. Study characteristics were extracted for each included study. Using double arcsine transformation, vaccination willingness rates with 95% CIs were pooled and reported. The willingness rate and associated factors were analyzed by geographical context. Associated factors were also summarized based on Health Belief Model (HBM) constructs. Of the 26,942 identified records, 13 (0.05%) papers were included, covering 14,066 individuals from 8 countries in 4 WHO regions (Eastern Mediterranean Region, European Region, Region of the Americas, and Western Pacific Region). The pooled vaccination willingness rate was 55.74% (95% CI 40.85%-70.13%). Of adults aged ≥50 years, 56.06% were willing to receive the HZ vaccine. After receiving health care workers' (HCWs) recommendations, 75.19% of individuals were willing to get the HZ vaccine; without HCWs' recommendations, the willingness rate was only 49.39%. The willingness rate was more than 70% in the Eastern Mediterranean Region and approximately 55% in the Western Pacific Region. The willingness rate was the highest in the United Arab Emirates and the lowest in China and the United Kingdom. The perception of HZ severity and susceptibility was positively associated with vaccination willingness. The perceived barriers to vaccination willingness (main reasons for unwillingness) included low trust in the effectiveness of the HZ vaccine, concerns about safety, financial concerns, and being unaware of the HZ vaccine's availability. Older individuals, those having lower education, or those having lower income levels were less likely to willing to be vaccinated. Only 1 in 2 individuals showed a willingness to be vaccinated against HZ. The willingness rate was the highest in the Eastern Mediterranean Region. Our findings show the critical role HCWs play in promoting HZ vaccination. Monitoring HZ vaccination willingness is necessary to inform public health decision-making. These findings provide critical insights for designing future life-course immunization programs.

BackgroundUsing a unique natural randomization, we have recently provided evidence from Welsh electronic health record data that herpes zoster (HZ) vaccination caused a reduction in new dementia diagnoses over a seven‐year period. This study aimed to determine whether eligibility for HZ vaccination also caused a reduction in deaths due to dementia in England and Wales over a nine‐year follow‐up period.MethodsAdults who had their 80th birthday shortly before September 1 2013 were ineligible for free HZ vaccination and remained ineligible for life, whereas those who had their 80th birthday shortly after September 1 2013 (i.e., born on or after September 2 1933) were eligible for one year. This date‐of‐birth threshold generated birth cohorts who are likely exchangeable in observed and unobserved characteristics except for a small difference in age and a large difference in HZ vaccination uptake. We used country‐wide data from death certificates in England and Wales on underlying causes of death from September 1 2004 to August 31 2022 by ICD‐10 code and month of birth. Our analysis compared the percentage of the population with a death due to dementia among the month‐of‐birth cohorts around the September 2 1933 eligibility threshold using a regression discontinuity design.ResultsThe study population included 5,077,426 adults born between September 1 1925 and August 31 1941 who were alive at the start of the HZ vaccination program. We estimated that over a nine‐year follow‐up period, eligibility for HZ vaccination reduced the percentage of the population with a death due to dementia by 0.38 (95% CI: 0.08 to 0.68, p = 0.012) percentage points, corresponding to a relative reduction of 4.8%. As in our prior analysis, this effect was stronger among women (‐0.62 [95% CI: ‐1.06 to ‐0.19] percentage points, p = 0.004) than among men (‐0.11 [95% CI: ‐0.51 to 0.28] percentage points, p = 0.574).ConclusionsOur findings indicate that HZ vaccination reduced cognitive decline at a fairly advanced stage of the dementia disease process because most individuals whose underlying cause of death was dementia during our nine‐year follow‐up period were likely already living with dementia at the start of the HZ vaccination program.

BackgroundEfficacy of the live-attenuated herpes zoster (HZ) vaccine (ZVL) wanes substantially over time. We evaluated immunogenicity and safety of the adjuvanted recombinant zoster vaccine (RZV) in previous ZVL recipients.MethodsAdults aged ≥65 years who were previously vaccinated with ZVL ≥5 years earlier (n = 215) were group-matched with ZVL-naive individuals (n = 215) and vaccinated with RZV. Glycoprotein E (gE)–specific humoral and cell-mediated immune responses and the correlation between them, polyfunctional gE-specific CD4 T-cell responses, safety, and confirmed HZ cases were assessed.ResultsThrough 12 months after dose 2, anti-gE antibody concentrations, gE-specific CD4 T-cell frequencies, and activation marker profiles were similar between groups. Safety outcomes were also similar. No HZ episodes were confirmed.ConclusionsRZV induced strong humoral and polyfunctional cell-mediated immune responses that persisted above prevaccination levels through 1 year after dose 2 in adults aged ≥65 years irrespective of previous ZVL vaccination. The RZV safety profile was not affected.Clinical Trials RegistrationNCT02581410.

To examine humoral and cellular immune responses induced by a live attenuated herpes zoster (HZ) vaccine in patients with rheumatoid arthritis (RA) compared with osteoarthritis (OA) patients. This was an observational study of a live attenuated HZ vaccine in 41 patients with RA receiving conventional disease-modifying antirheumatic drugs (cDMARD) and/or low-dose glucocorticoids (GC) and in 28 patients with OA. Blood samples were obtained before and at 12 weeks after HZ vaccination. Immunogenicity was assessed using varicella zoster virus (VZV)-specific interferon gamma ELISA and an in-house ELISA. Clinical outcomes, including adverse events, HZ occurrence, and RA flares, were analyzed. No patients developed vaccination-induced HZ during the followup period (median = 1.6 yrs). The HZ vaccine induced a significant increase in the VZV-specific enzyme-linked immunospot spot-forming units and anti-VZV immunoglobulin G antibodies in patients with RA and OA. The number of spot-forming units was lower in patients with RA than in patients with OA both at baseline and at 12 weeks after vaccination. The disease activity index for patients with RA was similar at baseline and at 12 weeks after vaccination. However, 6 patients with RA (14.6%) experienced a flare during the 12 weeks. Overall, 17 (24.6%) participants reported a mild adverse event such as an injection site reaction (11.6%). The HZ vaccine induced VZV-specific cellular and humoral responses in patients with RA. Although patients with RA showed a weaker vaccine-induced VZV-specific cellular immune response than patients with OA, the vaccine may be considered in patients with RA receiving cDMARD and/or low dose GC.

Unlike in a healthy population, the protection of herpes zoster (HZ) vaccine in end-stage renal disease (ESRD) patients might be insufficient, considering data demonstrating suboptimal response to other vaccines. The study evaluates the association between HZ vaccination and the subsequent HZ risk among ESRD patients. This cohort study included ESRD patients age ≥60 years who were enrolled in Kaiser Permanente Southern California. The vaccinated cohort included 582 patients who received HZ vaccine during 01/01/2007 through 12/31/2013. Each vaccinated patient was matched to five unvaccinated patients on age, sex, and dialysis duration. Subjects were passively followed through their electronic health records to identify HZ incidence. Cox regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) associated with vaccination. Kaplan-Meier estimates of the cumulative incidence were generated. The number of HZ cases was 16 in 1373 person-years (11.7 per 1000 person-years; 95% CI, 7.1-19.0) among the vaccinated and 126 in 5644 person-years (22.3 per 1000 person-years; 95% CI, 18.7-26.6) among the unvaccinated. The 36-month cumulative risk of incident HZ was 4.1% and 6.6%, respectively. HZ vaccination was associated with a reduced risk of HZ (adjusted HR = 0.49; 95% CI, .29-.85). The reduced risk seems more prominent if the vaccine is given within two years of dialysis initiation. Among ESRD patients age ≥60 years, receipt of HZ vaccine was associated with a lower incidence of HZ. In addition, HZ vaccination soon after the initiation of dialysis may provide greater protection.

Vaccine-preventable herpes zoster (HZ) poses substantial burden among Australian adults ≥50 years of age (YOA) despite available vaccination. This study aimed to understand the HZ vaccine-related preferences of adults paying out-of-pocket for HZ vaccination, to facilitate targeted recommendations by physicians and ultimately reduce disease burden. A discrete choice experiment was conducted (March–May 2023) to quantify preferences for HZ vaccine attributes among adults 50–64 YOA: HZ-naïve with selected self-reported comorbidities (n = 525; each comorbidity: n = 75), HZ-naïve without comorbidities (n = 150), and current/former HZ patients (n = 150). Each choice task comprised a “no vaccine” option and three hypothetical HZ vaccine profiles characterized by five attributes with varying levels. Attributes and levels were identified through literature review/concept elicitation/cognitive interviews/expert opinion. The attributes that most influenced HZ vaccine choice (measured by relative importance [RI]) were recommendation by government guidelines/medical societies, then HZ lifetime risk reduction, and protection duration. HZ-naïve adults with comorbidities indicated lower RI of recommendation by government guidelines/medical societies and higher RI of HZ lifetime risk reduction than other respondents. Between HZ-naïve adults without comorbidities and HZ patients, there were no significant differences in RI of each attribute. Respondents with comorbidities, whether overall or grouped by comorbidity, shared identical top three attributes. Between HZ-naïve, HZ-vaccinated adults (n = 146) and those without vaccination (n = 529), each top three attribute (recommendation by government guidelines/medical societies, HZ lifetime risk reduction, and protection duration) showed significantly different RI (p <.001). Findings elucidate the motivations underlying HZ vaccine preferences among Australian adults 50–64 YOA, guiding physician-patient conversations about HZ vaccines.