¹Universitätsklinikum, Universität zu Köln, PMV forschungsgruppe, Köln, Germany
²Klinikum Saarbrücken gGmbH, Klinik für Innere Medizin I, Saarbrücken, Germany

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Background: Herpes zoster is caused by the reactivation of the varicella-zoster virus after a primary infection, which manifests itself as chickenpox. The disease causes a painful rash. Complications include potentially long-lasting nerve pain, postherpetic neuralgia (PHN), and zoster ophthalmicus, which can lead to blindness. An inactivated vaccine has been available on the German market since May 2018. Following its recommendation as a standard vaccination for people aged 60 and over by the Standing Committee on Vaccination (STIKO) [1], it has been reimbursed by statutory health insurance funds since May 2019. Two vaccinations at intervals of two to six months are required for complete vaccination protection. The aim of the study was to investigate the incidence of the disease, the frequency of inpatient treatment, the rate of complete vaccination, and differences in vaccination rates between medical practices.

Materials and Methods: Database: data from adult BARMER insurees from 2017 to 2023 [2]. Definition of the incidence of herpes zoster (ICD-10 code B02), zoster ophthalmicus (B02.3) and postherpetic neuralgia (G03.0) observed in the period 2022–2023 in persons with continuous insurance coverage: inpatient main diagnosis and/or outpatient diagnosis marked as “confirmed,” without any of these diagnoses (including inpatient secondary diagnosis) having been present in the previous year (standardized to the population of Germany (December 31, 2023)). The herpes zoster vaccination was studied in a cohort that was continuously insured from 2019 to 2023. Outpatient billing codes (89128, 89129) and special codes from the Association of Statutory Health Insurance Physicians (KV) were taken into account, as were vaccinations billed as voluntary benefits. Two vaccinations at least one month apart or at least three vaccinations were considered complete vaccination. Vaccination activity in general practices was determined for practices that were active as general practices from 2019 to 2023 and treated at least 50 BARMER-insured patients aged 60 and older who were treated at only one general practice. Insured persons who were vaccinated in non-general practitioner practices or for whom no information on the vaccinating practice was available were excluded.

Results: The incidence of herpes zoster increased by 3.4% among 18- to 59-year-olds between 2018 and 2023, while it decreased by 11.2% among those over 60 (zoster ophthalmicus 0.0% vs. -7.0%, PHN 25.0% vs. 0.0%). 3.9% of all adult insurees with herpes zoster were admitted to hospital for herpes zoster (ICD-10 code B02/G03.0) (main diagnosis), compared with 4.8% of those aged 60 and over. People aged 60 and older who were fully vaccinated by the end of 2022 had a 64% lower risk of developing herpes zoster (B02) in 2023 than unvaccinated individuals.

21.3% of people aged 60 and older were fully vaccinated between 2019 and 2023, including 19.4% of men and 22.4% of women. In the 5-year age groups 65–69 to 80–84, the full vaccination rate was around 25 percent, while only 14.9 percent of 60- to 64-year-olds, 17.8 percent of 85- to 89-year-olds, and 9.7 percent of those over 90 were fully vaccinated. The vaccination rate varied between the different federal states, ranging from 15.2% in Baden-Württemberg to 29.3% in Saxony-Anhalt. Vaccination rates were lowest in southern Germany and highest in the eastern federal states. After receiving their first vaccination, 20% of those over 60 did not receive a second vaccination within six months, and 13.7% did not receive a second vaccination within a year.

Around 96% of herpes zoster vaccinations were administered by general practitioners. Vaccination activity varied greatly between GP practices: the lowest 10% vaccinated only up to 7% of patients aged 60 and older, while the top 10% vaccinated 41% or more.

Conclusion: Herpes zoster is a painful condition with potentially serious complications that, according to studies, can increase the risk of stroke [3] or the development of dementia [4]. Against this backdrop, a vaccination rate of 21.3% is completely inadequate. Significant differences in vaccination rates between general practitioners' practices have been identified, indicating that strategies focused on medical practices (e.g., vaccination management systems, training on vaccination counselling and management) could increase vaccination rates. These should be supplemented by patient-focused strategies (e.g., electronic vaccination records) and the introduction of a preventive care appointment at age 60 to assess vaccination status and provide advice on recommended vaccinations. The opportunity to avoid herpes zoster and its complications and consequences should therefore be made more accessible to patients.

References

[1] Siedler A, Koch J, Garbe E, Hengel H, von Kries R, Ledig T, Mertens T, Zepp F, Überla K. Background paper to the decision to recommend the vaccination with the inactivated herpes zoster subunit vaccine : Statement of the German Standing Committee on Vaccination (STIKO) at the Robert Koch Institute. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2019 Mar;62(3):352-376. DOI: 10.1007/s00103-019-02882-5
[2] Grandt D, Lappe V, Schubert I. BARMER Arzneimittelreport 2025. Herpes zoster – Analysen zu Impfungen und Erkrankungen. Berlin: BARMER Institut für Gesundheitssystemforschung (bifg); 2025. DOI: 10.30433/arzneimittel.2025.01
[3] Yahav A, Naftali J, Ryan D, Arbel A, Najjar-Debbiny R, Stein N, Barnett-Griness O, Saliba W, Auriel E. Association between herpes zoster infection and the risk of stroke: A population-based nested case-control study. Int J Stroke. 2025 Apr 16:17474930251338202. DOI: 10.1177/17474930251338202
[4] Blandi L, Bertuccio P, Signorelli C, Brand H, Clemens T, Renzi C, Odone A. Herpes zoster as risk factor for dementia: a matched cohort study over 20 years in a 10-million population in Italy. J Prev Alzheimers Dis. 2025 Jun;12(6):100167. DOI: 10.1016/j.tjpad.2025.100167