Survey Identifies Factors in Herpes Zoster Vaccine Hesitancy Among Older Adults


An effective shingles vaccine has been available in China since 2020, but vaccine hesitancy persists in at-risk populations.

Although an effective vaccine for herpes zoster (HZ) was approved by the Chinese Food and Drug Administration in 2019 and went to market in 2020, a recent study found that there is still HZ vaccine hesitancy among this population.

HZ, also known as shingles, is caused by reactivation of the varicella-zoster virus (VZV), which manifests as chickenpox upon initial infection. Primary infection with VZV and subsequent chickenpox generally happens in childhood, but the virus remains dormant in the body for an extended period of time. HZ occurs when the body’s immune response to chickenpox subsides, causing the virus to reactivate later in life. Symptoms include a painful rash, blistering on the skin, and often neuropathic pain (PHN).

HZ incidence is more common in older populations, with the mean age of onset being 59.4 years. The majority of HZ cases affect individuals 50 years of age or older, and HZ can significantly impact quality of life for those affected. PHN especially can significantly affect self-care ability and quality of life for patients, and morbidity, hospitalization rates, and mortality associated with HZ increase with age.

The study, published in BMC Infectious Diseases, used an online questionnaire to gain insight into the willingness of Chinese adults aged 50 years or older to receive the HZ vaccine, as well as factors influencing their willingness or hesitance.

The questionnaire was promoted to viewers of a live health broadcast program about vaccines that was available on various online platforms simultaneously. A total of 2.77 million people viewed the program, and 3988 elderly adults responded to the survey, which was in Chinese. A total of 3838 respondents were included in the analysis after 150 were excluded during quality control. Of the overall cohort, 453 respondents (11.8%) reported a history of HZ, and 68 of those patients (15.01%) had been vaccinated against HZ.

A total of 1651 respondents in the overall cohort (43.02%) indicated that they intended to be vaccinated, 1027 respondents (26.76%) were unsure whether they would be vaccinated, and 1160 (30.22%) did not intend on receiving an HZ vaccination.

Vaccine hesitancy (answering “no” or “not sure”) was most associated with an education background of a master’s degree or above versus senior high school or below; a personal monthly income of less than 3000 RMB compared with 3000-5999 RMB; and living in a rural area versus an urban area.

“As expected, participants from rural areas showed strong unwillingness largely due to access and affordability issues concerning HZ vaccination,” the authors wrote. “We also found that low personal income has a strong influence on vaccination hesitancy since the HZ vaccine is a self-paid vaccine in China.”

Notably, those with monthly incomes of less than 3000 RMB reported a strong willingness to receive the vaccine in the survey, suggesting that multipronged social support strategies such as introducing the vaccine to insurance or cost-sharing may improve uptake, the authors noted. Further studies on willingness to pay for the HZ vaccination could provide additional insight into this finding.

Overall, the most common reasons affecting either vaccine acceptance or denial were recommendations from other people, believing in the vaccine’s safety, and being worried about the potential health and quality-of-life impact of HZ. Recommendations were the most influential factor for promoting willingness to be vaccinated. Efficacy and adverse reactions were the 2 most prominent concerns slowing HZ vaccine uptake in the overall population. Another contributing factor to hesitancy was unawareness of HZ overall.

Considering a main factor in willingness to be vaccinated was recommendation from others, the authors emphasize the importance of community education, informing elderly individuals’ adult children about the vaccine, and prioritizing immunization information and recommendations by health care practitioners.

The findings overall show that HZ vaccine hesitancy persists in a significant portion of at-risk populations. Several factors play into vaccine hesitancy, but strategies to recommend the vaccine and address public concerns could help improve HZ vaccine uptake in this population.


Jiang B, Wang Q, Wang Z, et al. Willingness to accept herpes zoster vaccines and the influencing factors in China. BMC Infect Dis. Published online November 26, 2022.

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