Incremental Net Monetary Benefit of Herpes Zoster Vaccination: A Systematic Review and Meta-Analysis of Cost-Effectiveness Evidence

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Incremental Net Monetary Benefit of Herpes Zoster Vaccination: A Systematic Review and Meta-Analysis of Cost-effectiveness Evidence


Objectives: Herpes zoster (HZ) vaccines have been evaluated through a number of cost-effectiveness analyses. We aim to perform a systematic review and meta-analysis to pool the incremental net benefit of each option.

Methods: We identified a systematic review of economic evaluation of HZ vaccines and performed an updated search till June 9, 2020. Study characteristics, costs, and outcomes were extracted. Risk of bias was assessed using the biases in the economic studies (ECOBIAS) checklist. Monetary units were converted to 2019 US dollars and the incremental net benefit (INB) was calculated and pooled by meta-analysis.

Results: A total of 37 studies were pooled for meta-analysis. Analyses were stratified by perspectives (i.e., societal (SP) and third-party payer (TPP)) and vaccine types (i.e., Zoster Vaccine Live (ZVL) and Recombinant Zoster Vaccine (RZV)) resulting in 42 SP-ZVL, 26 SP-RZV, 19 TPP-ZVL, and 4 TPP-RZV.  In SP, ZVL was cost-effective compared to no vaccine when vaccinated at ages of 50-59 and 70-79 years with INBs (95% CI) of $0.61 (0.37, 0.85) and $9.67 (5.20, 14.14), respectively, while RZV was cost-effective for those aged 60-69 and 70-79 years with INBs of $75.61 (17.98, 133.23) and $85.01 (30.02, 140.01), respectively. The cost-effectiveness of RZV was robust across series of sensitivity analyses, but ZVL differs on different vaccination ages.

Conclusion: RZV may be cost-effective for vaccination in ages of 60-79 years for both SP and TPP perspectives, while ZVL might be cost-effective in some age groups, but results are not robust.

Keywords: herpes zoster, vaccination, cost-effectiveness, meta-analysis

Poster References

  1. Chiyaka ET, Nghiem VT, Zhang L, Deshpande A, Mullen PD, Le P. Cost-Effectiveness of Herpes Zoster Vaccination: A Systematic Review. Pharmacoeconomics 2019; 37(2): 169-200.
  2. Crespo C, Monleon A, Díaz W, Ríos M. Comparative efficiency research (COMER): metaanalysis of cost-effectiveness studies. BMC Medical Research Methodology 2014; 14(1): 139.
  3. Haider S, Chaikledkaew U, Thavorncharoensap M, Youngkong S, Islam MA, Thakkinstian A. Systematic Review and Meta-Analysis of Cost-effectiveness of Rotavirus Vaccine in LowIncome and Lower-Middle-Income Countries. Open Forum Infect Dis 2019; 6(4): ofz117.
  4. Bagepally BS, Gurav YK, Anothaisintawee T, Youngkong S, Chaikledkaew U, Thakkinstian A. Cost Utility of Sodium-Glucose Cotransporter 2 Inhibitors in the Treatment of Metformin Monotherapy Failed Type 2 Diabetes Patients: A Systematic Review and Meta-Analysis. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research 2019; 22(12): 1458-69.
  5. Bagepally BS, Chaikledkaew U, Gurav YK, et al. Glucagon-like peptide 1 agonists for treatment of patients with type 2 diabetes who fail metformin monotherapy: systematic review and meta-analysis of economic evaluation studies. BMJ Open Diabetes Res Care 2020; 8(1).
  6. de Boer PT, Pouwels KB, Cox JM, Hak E, Wilschut JC, Postma MJ. Cost-effectiveness of vaccination of the elderly against herpes zoster in The Netherlands. Vaccine 2013; 31(9): 1276- 83.
Recommend0 recommendationsPublished in College of Pharmacy, Virtual Poster Session Spring 2021


  1. Congratulations for the nice presentation of your research work!!!

    1. Thank you Dr. Nui, I could not have done it without your guidance and expertise!

  2. Great work, Maranda! Who do you think might be the audience most interested in your results (e.g., third-party payors, governmental agencies, etc.)?

    1. Thank you Dr. Witt, that is a great question! Zostavax has become unavailable in the US (discontinued June 2020, unavailable a few months later) so I actually believe that the most interested audience may come more from governmental agencies and policy decision makers outside of the US. Specifically, those within countries where both vaccines are available and they may still be determining which to include as the preferred option on formulary, whether it be a national formulary or otherwise.

  3. One of the biggest issues I see is that patients are willing to get this vaccine, but medicare copays are too high for them to actually be willing to PAY for the vaccine. Patients don’t seem to care as much about cost effectiveness (for the most part). How would you design a study to get at patient willingness to pay?

    1. Dr. Gunning, what a relevant question – I see the same issue where I work. I would hope that the cost-effectiveness evidence is used as a basis for covering Shingrix as a preventive therapy under the ACA mandate even in patients with grandfathered in plans, however I admit that may be idealistic thinking. It would be interesting to see how somewhat standardized patient education regarding the negative effects on patient quality of life from the long-term consequences of shingles may impact patient willingness to pay thresholds (compared to those that do not receive counseling). Education could focus on getting the vaccine earlier rather than later since cost-sharing may not be as dramatic before 65 and it is more effective when received at an early age, the risk of infection in a predominantly VZV infected population, and of course efficacy of preventing disease but also decreasing nerve pain if it is contracted. Since the decision to pay more upfront may be centered around a patients risk preference which can vary greatly depending on education, it may prove beneficial. I find this to be a particularly difficult question though as it sounds like I may be assuming that current education is subpar and that instilling fear may encourage the patient to bite the bullet and pay the price. That is, of course, not my intention. I do believe, however, that the negative experiences of patients that have unfortunately suffered from HZ or PHN can serve as perspective or motivation to receive this preventive care.

      1. I’ve just been trying to get people to get it before they get Medicare so that it will be covered – since Medicare is conveniently exempt from the ACA requirements for coverage 🙁 But hopefully in the future – both the price/copays will come down, and more patients will be vaccinated before age 65!

  4. Nice work Maranda! I find the age question intriguing (probably because I’m in that age). Overall, what is the incidence of HZ in individuals 50-59 vs. the older groups and do you think that incidence is low enough to safely move the vaccination recommendation to ≥60?

    1. From: Yawn BP, Gilden D. The global epidemiology of herpes zoster. Neurology. 2013;81(10):928-930. doi:10.1212/WNL.0b013e3182a3516e
      The annual incidence of HZ in the US for patients 50-59 is estimated at 4.7 per 1,000 person years and 7.1 for patients 60-69 years of age. The same study stated the mean age of onset at 59.4 years with 68% of cases in those 50 and older.

      It of course depends on the patient population of interest. I do not believe that moving the vaccination recommendation to over 60 in those that are immunosuppressed or otherwise at higher risk for shingles would be safe. While Shingrix does indeed hold efficacy longer than Zostavax over time, this question is still also complicated by the decreased response to vaccination with aging.

      I have a hard time answering this question because in my own experience I find that one of the biggest barriers to vaccination is cost. This can sometimes contribute to low reuptake rates and decreased vaccine efficacy. If insurances are able to decrease the cost of vaccination (particularly for Medicare patients) by delaying vaccination, I would venture to guess this may increase second dose compliance, and consequently efficacy may also be positively affected.

      There is a need for more research to say definitively, but I would say that it could be safely moved in select low risk patients that may otherwise never receive the vaccine due to unaffordability.

  5. Maranda – congratulations on a wonderful project!! In view of zoster being something that is being discussed following COVID vaccine, what type of future work would you envision in this area?

    1. Thank you, and what an interesting question! I think its also interesting since I have spoken with many patients that are delaying their first or second shingles shot in order to receive the COVID vaccine 14 days separated from any other immunization.

      I do see more research going into how much of a coincidence shingles with vaccination may or may not be since there have been reports of VZV reactivation after receiving vaccines besides those for COVID.

      From the 6 reported cases half of them were above the age of recommended vaccination and the others were not, but none of them reportedly received the any doses of the shingles vaccine. All of the patients were immunosuppressed as well. So if nothing else, I feel like it could be a good counseling point for patients that they should receive the shingles vaccine if they are eligible. Especially since it seems like there may need to be yearly COVID vaccine boosters.

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