Diabetes a Serious Risk Factor for Herpes Zoster

Jan 15, 2020

Shingles vaccination recommended by CDC and ADCES.

It’s an established fact that people with diabetes (PWD) are more susceptible to numerous infections. Of particular concern are common vaccine-preventable diseases like influenza, pneumonia, hepatitis B, and herpes zoster (HZ), which is why both the CDC and the Association of Diabetes Care & Education Specialists (ADCES) recommend vaccinations against them.

Melissa Young, PharmD, CDCES and ADCES spokesperson noted that individuals with diabetes typically have co-morbid conditions like kidney disease, heart disease, and vascular disease that make them frailer. “When they catch some type of infections, it puts more stress on the body and they’re more susceptible to going downhill quicker,” she told Drug Topics®. Additionally, diabetes and high blood sugar affect their immune systems and cell-mediated immunity.

Despite their increased vulnerability, the CDC reported in 2016 that just 27% of adults aged 60 years of age and older with diagnosed diabetes had ever been vaccinated against shingles.1

A newly published literature review that evaluates the role of diabetes as an independent risk factor for HZ and postherpetic neuralgia (PHN) concluded that the risk is significantly higher than in those without diabetes, and advocates the use of vaccination to reduce the risk of infection.

The review looked at 16 studies worldwide published between January 2000 and December 2018 that investigated the incidence rates (IR) of HZ in PWD. “Retrospective analysis of medical and pharmacy claims from adults in 3 national US database showed that of the 1.2 million HZ annual cases identified from 2005 to 2009, 13.5% occurred in patients with diabetes,” it reported. “The IR of HZ was 87% higher in these patients compared to other patients (7.96 vs 4.48 cases/1000 persons-year).”2

The researchers also noted that not only were PWD at significantly greater risk of HZ than control group members in a majority of the studies, but the incidence increased with age and was higher in women than in men. Additionally, the incidence of PHN - the most common complication of HZ - was also higher in PWD.2

“The presence of HZ adds supplementary complications to the pre-existing comorbidity in patients with diabetes,” the review’s authors noted.2 “Investigating the impact of preventive measure by HZ vaccination is therefore of paramount importance in patients with diabetes.”

Two earlier studies support the findings. The first, conducted in Spain, concluded that diabetes increased the risk of HZ by 20%, and that it contributed to the deterioration of glycemic control and higher healthcare resource consumption in PWD.3 A review published by Greek researchers found that herpes zoster neuralgia is more severe and persistent and the incidence of postherpetic neuralgia is higher in PWD. It concluded that the introduction of the adjuvanted vaccine against herpes zoster Shingrix “appears to be a useful tool for reducing the burden of herpes zoster” in PWD.4

Today, vaccine education is part of the core curriculum content of the National Standards for Diabetes Self-Management Education and Support, and for good reason. “We know that people with diabetes, in most cases, do respond very well to vaccines because that part of their immune system works,” Young pointed out. “So you get real bang for the buck when you give a vaccine.”

She concluded that pharmacists are in a perfect position to educate their patients about the importance of the shingles vaccine because they can discuss its benefits and the risks of vaccination versus infection.


  • Saadatian-Elahi M, Bauduceau B, Del-Signore C, et al. Diabetes as a risk factor for herpes zoster in adults: A synthetic literature review. Diabetes Research and Clinical Practice. 2020. https://doi.org/10.1016/j.diabres.2019.107983

  • Muñoz-Quiles C, López-Lacort M, Ampudia-Blasco FJ, et al. Risk and impact of herpes zoster on patients with diabetes: A population-based study, 2009-2014. Human Vaccines & Immunotherapeutics. 2017. https://doi.org/10.1080/21645515.2017.1368600

  • Papagianni M, Metalldis S, Tziomalos K. Herpes zoster and diabetes mellitus: a review. Diabetes Ther. 2018. https://doi.org/10.1007/s13300-018-0394-4