A Cost-Effectiveness Analysis of Vaccination for Prevention of Herpes Zoster and Related Complications: Input for National Recommendations

Ann Intern Med. 2019 Mar 19;170(6):380-388. doi: 10.7326/M18-2347. Epub 2019 Feb 19.


Background: The U.S. Advisory Committee on Immunization Practices recently developed recommendations for use of a new recombinant zoster vaccine (RZV).

Objective: To evaluate the cost-effectiveness of vaccination with RZV compared with zoster vaccine live (ZVL) and no vaccination, the cost-effectiveness of vaccination with RZV for persons who have previously received ZVL, and the cost-effectiveness of preferential vaccination with RZV over ZVL.

Design: Simulation (state-transition) model using U.S. epidemiologic, clinical, and cost data.

Data sources: Published data.

Target population: Hypothetical cohort of immunocompetent U.S. adults aged 50 years or older.

Time horizon: Lifetime.

Perspective: Societal and health care sector.

Intervention: Vaccination with RZV (recommended 2-dose regimen), vaccination with ZVL, and no vaccination.

Outcome measures: The primary outcome measure was the incremental cost-effectiveness ratio (ICER).

Results of base-case analysis: For vaccination with RZV compared with no vaccination, ICERs ranged by age from $10 000 to $47 000 per quality-adjusted life-year (QALY), using a societal perspective and assuming 100% completion of the 2-dose RZV regimen. For persons aged 60 years or older, ICERs were less than $60 000 per QALY. Vaccination with ZVL was dominated by vaccination with RZV for all age groups 60 years or older.

Results of sensitivity analysis: Results were most sensitive to changes in vaccine effectiveness, duration of protection, herpes zoster incidence, and probability of postherpetic neuralgia. Vaccination with RZV after previous administration of ZVL yielded an ICER of less than $60 000 per QALY for persons aged 60 years or older. In probabilistic sensitivity analyses, RZV remained the preferred strategy in at least 95% of simulations, including those with 50% completion of the second dose.

Limitation: Few data were available on risk for serious adverse events, adherence to the recommended 2-dose regimen, and probability of recurrent zoster.

Conclusion: Vaccination with RZV yields cost-effectiveness ratios lower than those for many recommended adult vaccines, including ZVL. Results are robust over a wide range of plausible values.

Primary funding source: Centers for Disease Control and Prevention.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Cost-Benefit Analysis
  • Epidemiologic Research Design
  • Health Policy
  • Herpes Zoster / prevention & control*
  • Herpes Zoster Vaccine / adverse effects
  • Herpes Zoster Vaccine / economics*
  • Humans
  • Medication Adherence
  • Middle Aged
  • Neuralgia, Postherpetic / prevention & control*
  • Practice Guidelines as Topic
  • Quality-Adjusted Life Years
  • Secondary Prevention
  • Sensitivity and Specificity
  • Vaccination / adverse effects
  • Vaccination / economics*
  • Vaccines, Synthetic / adverse effects
  • Vaccines, Synthetic / economics


  • Herpes Zoster Vaccine
  • Vaccines, Synthetic