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Similar herpes zoster incidence across Europe: results from a systematic literature review



Herpes zoster (HZ) is caused by reactivation of the varicella-zoster virus (VZV) and mainly affects individuals aged ≥50 years. The forthcoming European launch of a vaccine against HZ (Zostavax®) prompts the need for a better understanding of the epidemiology of HZ in Europe. Therefore the aim of this systematic review was to summarize the available data on HZ incidence in Europe and to describe age-specific incidence.


The Medline database of the National Library of Medicine was used to conduct a comprehensive literature search of population-based studies of HZ incidence published between 1960 and 2010 carried out in the 27 member countries of the European Union, Iceland, Norway and Switzerland. The identified articles were reviewed and scored according to a reading grid including various quality criteria, and HZ incidence data were extracted and presented by country.


The search identified 21 studies, and revealed a similar annual HZ incidence throughout Europe, varying by country from 2.0 to 4.6/1 000 person-years with no clearly observed geographic trend. Despite the fact that age groups differed from one study to another, age-specific HZ incidence rates seemed to hold steady during the review period, at around 1/1 000 children <10 years, around 2/1 000 adults aged <40 years, and around 1–4/1 000 adults aged 40–50 years. They then increased rapidly after age 50 years to around 7–8/1 000, up to 10/1 000 after 80 years of age. Our review confirms that in Europe HZ incidence increases with age, and quite drastically after 50 years of age. In all of the 21 studies included in the present review, incidence rates were higher among women than men, and this difference increased with age. This review also highlights the need to identify standardized surveillance methods to improve the comparability of data within European Union Member States and to monitor the impact of VZV immunization on the epidemiology of HZ.


Available data in Europe have shortcomings which make an accurate assessment of HZ incidence and change over time impossible. However, data are indicative that HZ incidence is comparable, and increases with age in the same proportion across Europe.

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Varicella-zoster virus (VZV) is a herpes virus that infects nearly all humans and causes two distinct diseases: varicella, the primary infection which usually occurs in childhood, and herpes zoster (HZ), a result of reactivation of VZV which remains latent in the sensory ganglia following varicella. This reactivation occurs when VZV-specific cellular-mediated immunity decreases, mainly due to age-related immunosenescence and immunosuppressive conditions.

HZ is characterized by a vesicular skin rash localized in the sensory region of the affected ganglia, and is often preceded, or accompanied by acute pain or itching. The individual lifetime risk of developing HZ is between 23.8% and 30%, or approximately 1 in 4 people [15]. However, for individuals aged 85 and over, this risk increases to 1 in 2 people [6]. Indeed, HZ incidence increases markedly after 50 years of age, with two-thirds of HZ cases occurring in individuals aged 50 years or over [7]. Anyone who has had varicella is at risk of HZ, and in Europe varicella affects over 90% of children before the age of 15 years [8].

HZ is painful during the acute phase, but pain may persist for months or even years. Post-herpetic neuralgia, defined as chronic pain persisting after rash onset, occurs in 20% to 50% of patients, and can lead to several months of treatment and loss of quality of life [9, 10]. After 1 year, almost 10% of patients, mainly older people, still have persistent pain [11, 12].

The forthcoming European launch of a vaccine against HZ (Zostavax®) prompts the need for a better understanding of the epidemiology of HZ in Europe. Therefore the aim of this review was to summarize the available data on HZ incidence in Europe and to describe age-specific incidence, notably among individuals aged over 50 years.


Literature search

The Medline database of the National Library of Medicine was used to conduct a comprehensive literature search of population-based studies of HZ incidence published between 1960 and 2010. Articles had to include the MeSH term “herpes zoster” or “shingles”, as well as the keyword “incidence” or “age-specific incidence”. Only articles reporting on studies carried out in the 27 European Union Member States, Iceland, Norway, or Switzerland (complete list can be found at end of this paper) were considered. Publications in Dutch, English, French, German, Italian or Spanish were considered.

References lists from retrieved publications were also checked manually for any additional studies or review articles on the epidemiology of HZ, and if necessary the authors were contacted to obtain data on age-specific HZ incidence rates. National surveillance data, the websites of the National Institutes of Health of the United Kingdom (UK), sentinel networks and data from the World Health Organization were also consulted, especially for countries where no publications were found. However, no additional data were identified.

Selection criteria

Included articles had to have HZ incidence data available, a population-based study design and information on the quality criteria used to score the studies in this review. Any study that did not contain this information was excluded.

All studies limited to immunocompromised populations/populations with primary or acquired immunodeficiency status, patients with hematological malignancies (acute and chronic leukemia, lymphoma or other malignant neoplasm affecting the bone marrow or lymphatic system, solid tumors receiving cytotoxic chemotherapy, hematopoietic stem cell transplantation), persons with AIDS, patients on immunosuppressive therapy (i.e., treatment with agents, such as x-rays, corticosteroids, or cytotoxic chemicals, etc.) were excluded. A few articles were also excluded due to duplicate publication, or lack of study dates.

Quality assessment and scoring of articles

In order to provide a methodological classification of the studies, a reading grid was created specifically for this review based on set quality criteria. According to these criteria, each selected article was scored by two independent readers. The reading grid allowed for a total of 30 possible points:

  1. 1)

    Representativeness of the sample of patients (12 points): number of practitioners or specialists, sampling method description and validation—if any, geographic distribution, population covered.

  2. 2)

    Incidence calculation (12 points): estimation of the denominator used to calculate incidence, presence of confidence intervals, estimation of age- or sex-specific incidence, size of the study, diagnostic criteria of HZ.

  3. 3)

    Study design (4 points):

    1. a)

      Prospective inclusion of patients (considered high-quality data) suffering from HZ in health care facilities during a defined study period, either during an ad-hoc study or through a sentinel surveillance network.

    2. b)

      b)) Retrospective identification of HZ cases either through the review of medical files in a sample of practitioners, or through the analysis of large databases (national registries, health insurance databases, etc.). In the first case, potential issues could arise from the quality of files and missing data. Database studies are less time- and cost-consuming for assessing incidence rates; however these studies are subject to bias related to the completeness of the database and inference to the general population.

  4. 4)

    Discussion of the study limitations and study results put in perspective with the data from the literature (2 points).

Papers with a quality score of less than 15 out of the 30 possible points were excluded from the literature review. For the selected articles, pertinent information was extracted, including study dates, setting, study population, sample size, diagnostic criteria used for HZ, overall HZ incidence with 95% confidence intervals (when available), and incidence data by age, and by sex (when available).

The present systematic review is following the PRISMA guidelines [13].


The Medline search identified 1 644 articles, of which 1 563 were immediately excluded based on their abstracts. A review of the reference lists of the 81 remaining articles identified 23 additional articles, making a total of 104. Of these, 77 were excluded due to the inclusion and exclusion criteria: four hospital-based studies, six cost-effectiveness studies (some epidemiological data, but obtained or derived from several community-based studies), 34 general reviews, 18 studies in countries not included in this review, and 15 with no exploitable incidence data or that lacked information on the quality criteria necessary to score the publication.

The 27 remaining articles that corresponded to the inclusion criteria were scored using the reading grid. After the reading grid was applied, six of the 27 studies were further excluded as they did not meet the threshold for inclusion (i.e., 15 points) [1419]. Therefore, 21 articles were finally included in this review (Figure 1).

Figure 1
figure 1

Flow diagram.

The 21 reports of HZ incidence from European countries included one from Belgium, four from France, two from Germany, two from Iceland, two from Italy, three from the Netherlands, two from Spain, one from Switzerland, and four from the UK (Table 1). No relevant data were found for the other 21 countries considered in this review (Austria, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, Greece, Hungary, Ireland, Latvia, Lithuania, Luxembourg, Malta, Poland, Portugal, Romania, Slovenia, Slovakia, Sweden and Norway).

Table 1 Selected details of included studies

Table 1 shows the main features of the included studies and HZ incidence by country. Annual HZ incidence varied by country from 2.0 to 4.57 per 1 000 person-years (PY). The HZ incidence rates in the studies with a score inferior to 15 were in the same range (from 3.2 and 4.14 per 1000 person-years) [15, 16]. The overall incidence was lower in Iceland, Germany and Switzerland (around 2/1 000 PY), medium in the UK, the Netherlands and France (around 3/1 000 PY), and higher in Belgium, Spain and Italy (around 4/1 000 PY) (Table 1). However, no geographic trend of overall incidence was clearly observed (Figure 2).

Figure 2
figure 2

Overall annual herpes zoster (HZ) incidence rates in Europe (/1 000 person-years). Notes: The confidence interval is presented when available in the original publication. In case of several publications per country, the publication with the most recent data and that reported the overall HZ incidence rate is depicted.

It was estimated that in England and Wales alone there are approximately 225 000 new cases of HZ each year [40]. In 2009, the French sentinel network estimated that there were around 350 000 cases of HZ across all age groups [21]. Another study performed in France reported around 182 500 incident cases among immunocompetent people aged 50 years or over [23].

Using the nine most recent studies, which had the highest quality score for their country and were performed without age criteria [20, 22, 26, 29, 31, 35, 36, 40],[41], we estimated an average HZ incidence rate of 3.4 ± 0.2/1 000 for all age groups combined. If this is applied to the total European population of 512 million inhabitants [42], a rough estimate of 1.7 ± 0.1 million new HZ cases can be expected each year in Europe.

Eleven publications from seven countries presented both overall and specific incidence rates by sex and/or by age group (See Additional file 1). In spite of the age groups, which differed from one study to another, age-specific HZ incidence rates appeared to hold steady during the review period at around 1/1 000 children <10 years, around 2/1 000 adults aged < 40 years, around 1–4/1 000 adults aged 40–50 years, and then increased rapidly after 50 years to around 7–8/1 000, up to 10/1 000 at 80 years of age and older (Figure 3). Figure 3 illustrates that in many countries in Europe, HZ incidence increases with age, and quite steeply so after 50 years of age. In all studies included in this review, incidence rates were consistently higher among women than men (male/female ratio range: 1.13–1.56), and this difference also increased with age.

Figure 3
figure 3

Herpes zoster incidence by age in Europe. Note: These studies were the most recent with available HZ incidence data by age group per country.

Studies performed among immunocompetent people and among the general population (including both immunocompetent and immunocompromised people), showed that the risk of HZ was higher in the general population (9.80/1 000 in Germany and 4.31/1 000 in Italy) than among immunocompetent people (9.50/1 000 (Germany) and 4.07/1 000 (Italy)) [25, 29].


The present literature review of HZ incidence in Europe showed similar HZ incidence across the included countries for which data was available. Overall annual HZ incidence varied from 2.0–4.6/1 000 PY depending on the country, which is consistent with previous published estimates [43], and similar to those published in North America (1.25–3.7/1 000 PY [44, 45]).

Our review confirms that HZ incidence increases sharply with age, from around 1/1 000 children <10 years up to 10/1 000 people over 80 years of age. These results are consistent with recent published estimates by Volpi et al. [43]. Annual HZ incidence in Europe has been reported as 0.3–0.74/1 000 children <10 years, 1.6/1 000 adults aged <40 years, 2.5/1 000 adults aged 20–50 years, 7.8/1 000 adults aged 60 years or over, and 10/1 000 in elderly adults over 80 years of age [43].

As expected, the same increase in incidence rates with age was observed in the studies included in this review that reported age-specific incidence (Figure 3). The correlation between age and HZ incidence may be related to a decreased cellular-mediated immune response to VZV as result of immunosenescence [44, 46]. It has been suggested that exposure to varicella reduces the risk of VZV reactivation by boosting specific immunity to the virus [38, 47]. This hypothesis is supported by some studies which showed that repeated familial or occupational exposure is associated with a reduced risk of HZ [4851], but others did not confirm this [46, 52].

This review showed that incidence rates are systematically higher among women than men (male/female ratio around 1.4), and this difference increases with age, which has also been found in other studies [41, 53]. Women over 50 years of age seem to be particularly at risk. However, it is unclear whether the risk of HZ is increased in all women. Women might simply be more likely to seek medical advice, thereby causing a higher reporting rate, or there may be some biological mechanism by which women are more susceptible to VZV reactivation [54].

Our review excluded studies limited to immunocompromised populations, or individuals with primary or acquired immunodeficiency status. Nevertheless, as included studies were population-based, some of them made a distinction between the total study population and the immunocompetent population [25, 29]. This review confirms that immunocompetent patients are at lower risk of developing HZ than the general population [25, 29]. The control of VZV reactivation depends on the maintenance of adequate levels of cellular-mediated immunity to VZV, which explains why cellular-mediated immune deficiency is a risk factor for developing HZ [54].

In Europe, not all countries have some form of surveillance in place for HZ [55, 56] and there is marked heterogeneity in the type of HZ surveillance systems that do exist (national mandatory or sentinel), the type of data collected (case-based or aggregated) and the reported case classification (clinical and/or laboratory) [57]. Most surveillance systems operate using reports of clinical cases [57].

This review highlights the need to identify standardized surveillance methods in order to improve data comparability within European Union Member States and, in the framework of introducing HZ vaccination, to monitor the impact of immunization on the epidemiology of HZ.

Since most of the European studies in this review were performed and published in the last 10 years, it was difficult to look at a time trend variation in the risk of HZ. The only country (the UK) with two incidence rate estimates, which were about 30 years apart, provided two close figures: 3.40/1 000 people in 1975 vs. 3.73/1 000 people in 2000 [38, 40]. However, this comparison is delicate since the first study was retrospective [38] and the second prospective [40].

In the literature, there are conflicting data with regard to whether age-adjusted HZ incidence is changing over time [7, 58]. Indeed, the literature fails to show evidence of any change of HZ incidence over time, notably in relation to varicella vaccination. Longitudinal data, including a few years of baseline before possible routine use of the varicella vaccine in children or adolescents, and a sufficient number of years of data to detect a trend (at least 3, preferably more) after the implementation of the vaccine will be needed to assess the impact of varicella vaccination on HZ incidence [59]. Such data are available from the US where varicella vaccination has been used routinely since 1995; however no clear conclusions were drawn on the impact on HZ incidence. Some authors did not observe any impact of varicella vaccination on HZ incidence [7, 58] and others observed an increase [60]. Moreover, looking at a potential HZ incidence trend overtime is challenging and depends on the availability of baseline data collected using comparable study methods in populations with comparable health care behavior. Comparing results across studies and time periods must take into account different study methods and must adjust for changes in the age structure of the population over time. As the proportion of older people grows in Europe [61], HZ is likely to become a more important public health issue in the future. The apparently increasing proportion of immunocompromised persons due to medical conditions or medication in the population, and the effect this may have on HZ, must also be considered.

This literature review has various limitations. First of all, this review included studies with different designs: direct prospective recruitment of patients with HZ in health care settings during a defined study period, and retrospective identification through medical files from a number of practitioners. In general, prospective recruitment methods are considered to be preferable, whereas retrospective recruitment poses some methodological problems regarding data quality and missing data. However, this was taken into account in the reading grid, which assigned a higher quality score to prospective studies than retrospective studies.

Moreover, in spite of their potential shortcomings, some studies based on large databases (UK, Italy, Spain, Germany) were included in this review. It is true that in the past the methods used in population-based studies, such as those used to extrapolate results obtained from a single database to the entire North American population, have been criticized [62]. Indeed, in this case the fact that the denominator used was the total number of persons registered in the national health care system and was presented as exhaustive raised a methodological problem linked to the calculation of the HZ incidence rate. This was questionable since no information was given on the number of persons who were not registered, compared to the national census. In that case, the denominator was a surrogate for the true number and the calculated rate could have been over-estimated. Recently, Yawn et al. showed that administrative data use alone appears to overestimate the number of HZ cases [53], and the potential coding error of HZ diagnosis in administrative data has also been investigated [63].


Available European epidemiological data on HZ have shortcomings which make accurate assessment of HZ incidence and change over time impossible. However, data are indicative that HZ incidence across Europe is comparable (about 3.4 ± 0.2/1 000 when considering all age groups) and increases with age, especially after 50 years of age. This equates to a total of 1.7 +/− 0.1 million new HZ cases each year in Europe.

Complete list of countries

Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom.



Herpes zoster




United Kingdom


Varicella-zoster virus


  1. Thiry N, Beutels P, Shkedy Z, Vranckx R, Vandermeulen C, Van Der Wielen M, Van Damme P: The seroepidemiology of primary varicella-zoster virus infection in Flanders (Belgium). Eur J Pediatr. 2002, 161: 588-593. 10.1007/s00431-002-1053-2.

    Article  PubMed  Google Scholar 

  2. British Society for the Study of Infection: Guidelines for the management of shingles: report of a working group of the British Society for the Study Infection. J Infect. 1995, 30: 193-200.

    Article  Google Scholar 

  3. Gross G, Schöfer H, Wassilew SW, Friese K, Timm A, Guthoff R, Pau HW, Malin JP, Wutzler P, Doerr HW: Herpes zoster guideline of the German Dermatology Society (DDG). J Clin Virol. 2003, 26: 277-289. 10.1016/S1386-6532(03)00005-2.

    Article  CAS  PubMed  Google Scholar 

  4. Lee VK, Simpkins L: Herpes Zoster and Postherpetic Neuralgia in the Elderly. Geriatr Nurs. 2000, 21: 132-136. 10.1067/mgn.2000.108260.

    Article  CAS  PubMed  Google Scholar 

  5. Edmunds WJ, Brisson M, Rose JD: The epidemiology of herpes zoster and potential cost-effectiveness of vaccination in England and Wales. Vaccine. 2001, 19: 3076-3090. 10.1016/S0264-410X(01)00044-5.

    Article  CAS  PubMed  Google Scholar 

  6. Schmader K: Herpes Zoster in Older Adults. Clin Infect Dis. 2001, 32: 1481-1486. 10.1086/320169.

    Article  CAS  PubMed  Google Scholar 

  7. Yawn BP, Saddier P, Wollan PC, Sauver JL, Kurland MJ, SY LS: A Population-Based Study of the Incidence and Complication Rates of Herpes Zoster Before Zoster Vaccine Introduction. Mayo Clin Proc. 2007, 82: 1341-1349. 10.4065/82.11.1341.

    Article  PubMed  Google Scholar 

  8. Sengupta N, Breuer J: A Global Perspective of the Epidemiology and Burden of Varicella-Zoster Virus. Curr Ped Rev. 2009, 5: 207-228. 10.2174/157339609791317315.

    Article  Google Scholar 

  9. Hannouche D, Alfandari S, Bouhour D, Fouchard N, Geffray L, Quinet B: Prise en charge des infections à VZV. Med Mal Infect. 1998, 28: 1-8. Article in French

    Article  Google Scholar 

  10. Johnson RW, Wasner G, Saddier P, Baron R: Postherpetic neuralgia: epidemiology, pathophysiology and management. Expert Rev Neurother. 2007, 7: 1581-1595. 10.1586/14737175.7.11.1581.

    Article  CAS  PubMed  Google Scholar 

  11. Scott FT, Leedham-Green ME, Barrett-Muir WY, Hawrami K, Gallagher WJ, Johnson R, Breuer J: A Study of Shingles and the Development of Postherpetic Neuralgia in East London. J Medl Virol. 2003, 70: S24-S30. 10.1002/jmv.10316.

    Article  Google Scholar 

  12. Scott FT, Johnson RW, Leedham-Green ME, Davies E, Edmunds WJ, Breuer J: The burden of Herpes Zoster: A prospective population based study. Vaccine. 2006, 24: 1308-1314. 10.1016/j.vaccine.2005.09.026.

    Article  PubMed  Google Scholar 

  13. Moher D, Liberati A, Tetzlaff J, Altman DG: Reprint–preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther. 2009, 89: 873-880.

    PubMed  Google Scholar 

  14. Meister W, Neiss A, Gross G, Doerr HW, Höbel W, Malin JP, Von Essen J, Reimann BY, Witke C, Wutzler P: Demography, Symptomatology, and Course of Disease in Ambulatory Zoster Patients. Intervirol. 1998, 41: 272-277. 10.1159/000024949.

    Article  CAS  Google Scholar 

  15. Chidiac C, Bruxelle J, Daurès J-P, Hoang-Xuan T, Morel P, Leplège A, El Hasnaoui A, De Labaryere C: Characteristics of Patients with Herpes Zoster on Presentation to Practitioners in France. Clin Infect Dis. 2001, 33: 62-69. 10.1086/320884.

    Article  CAS  PubMed  Google Scholar 

  16. di Luzio PU, Arpinelli F, Visonà G: Herpes Zoster and its Complications in Italy: An Observational Survey. J Infect. 1999, 38: 116-120. 10.1016/S0163-4453(99)90079-8.

    Article  Google Scholar 

  17. Gabutti G, Serenelli C, Sarno O, Marconi S, Corazza M, Virgili A: Epidemiologic features of patients affected by herpes zoster: database analysis of the Ferrara University Dermatology Unit, Italy. Méd Maladies Infect. 2010, 40: 268-272. 10.1016/j.medmal.2009.09.005.

    Article  CAS  Google Scholar 

  18. Parlato A, Spica VR, Ciccozzi M, Farchi F, Gallè F, Di Onofrio V, Franco E, Liguori G: Compliance with herpes zoster vaccination in young and adult individuals in two regions of Italy. BMC Public Health. 2010, 10: 1-5. 10.1186/1471-2458-10-1.

    Article  Google Scholar 

  19. Pérez-Faérinos N, Ordobas M, Garcia-Fernandez C, Garcia-Comas L, Canellas S, Rodero I, Gutiérrez-Rodriguez A, Garcia-Gutiérrez J, Ramirez R: Varicella and Herpes Zoster in Madrid, based on the Sentinel General Practitioner Network: 1997–2004. BMC Infect Dis. 2007, 7: 1-5. 10.1186/1471-2334-7-1.

    Article  Google Scholar 

  20. Truyers C, Bartholomeeusen S, Buntinx F, De Loof J: Incidentie van herpes zoster. Huisarts Onderzoek. 2005, 34: 260-262. Article in Flemish

    Google Scholar 

  21. Réseau Sentinelles Coordination nationale: Bilan annuel du réseau Sentinelles Janvier-Décembre 2009. Rapport d’activité. 2009, Paris:

    Google Scholar 

  22. Gonzalez Chiappe S, Sarazin M, Turbelin C, Lasserre A, Pelat C, Bonmarin I, Chosidow O, Blanchon T, Hanslik T: Herpes zoster: Burden of disease in France. Vaccine. 2010, 28: 7933-7938. 10.1016/j.vaccine.2010.09.074.

    Article  CAS  PubMed  Google Scholar 

  23. Mick G, Gallais JL, Simon F, Pinchinat S, Bloch K, Beillat M, Serradell L, Derrough T: Burden of Herpes Zoster and postherpetic neuralgia: incidence, proportion, and associated costs in the French population aged 50 or over. Rev Epidemiol Sante Publique. 2010, 58: 393-401. 10.1016/j.respe.2010.06.166. Article in French

    Article  CAS  PubMed  Google Scholar 

  24. Czernichow S, Dupuy A, Flahault A, Chosidow O: Zona: enquête d’incidence chez les médecins généralistes du réseau “Sentinelles”. Ann Dermatol Venereol. 2001, 128: 497-501. Article in French

    CAS  PubMed  Google Scholar 

  25. Schiffner-Rohe VJ, Jow S, Lilie HM, Köster I, Schubert I: Herpes Zoster in Germany. A retrospective analyse of SHL data. MMW Fortschr Med. 2010, 151 (4): 193-197. Article in German

    PubMed  Google Scholar 

  26. Paul E, Thiel T: Epidemiology of varicella zoster infection. Results of a prospective study in the Ansbach area. Hautarzt. 1996, 47: 604-609. 10.1007/s001050050476. Article in German

    Article  CAS  PubMed  Google Scholar 

  27. Helgason S, Sigurdsson JA, Gudmundsson S: The Clinical Course of Herpes Zoster: a Prospective Study in Primary Care. Eur J Gen Pract. 1996, 2: 12-16. 10.3109/13814789609161651.

    Article  Google Scholar 

  28. Petursson G, Helgason S, Gudmundsson S, Sigurdsson JA: Herpes zoster in children and adolescents. Pediatr Infect Dis J. 1998, 17: 905-908. 10.1097/00006454-199810000-00011.

    Article  CAS  PubMed  Google Scholar 

  29. Emberti Gialloreti L, Merito M, Pezzotti P, Naldi L, Gatti A, Beillat M, Serradell L, Di Marzo R, Volpi A: Epidemiology and economic burden of herpes zoster and post-herpetic neuralgia in Italy: A retrospective, population-based study. BMC Infect Dis. 2010, 10: 1-11. 10.1186/1471-2334-10-1.

    Article  Google Scholar 

  30. Di Legami V, Gianino MM, Ciofi Degli Atti M, Massari M, Migliardi A, Scalia Tomba G, Zotti C: Epidemiology and costs of herpes zoster: Background data to estimate the impact of vaccination. Vaccine. 2007, 25: 7598-7604. 10.1016/j.vaccine.2007.07.049.

    Article  PubMed  Google Scholar 

  31. Opstelten W, Van Essen GA, Schellevis FG, Verheij TJM, Moons KGM: Gender as an Independent Risk Factor for Herpes Zoster: A Population-Based Prospective Study. Ann Epidemiol. 2006, 16: 692-695. 10.1016/j.annepidem.2005.12.002.

    Article  PubMed  Google Scholar 

  32. de Melker H, Berbers G, Hahné S, Rümke H, van den Hof S, de Wit A, Boot H: The epidemiology of varicella and herpes zoster in The Netherlands: implications for varicella zoster virus vaccination. Vaccine. 2006, 24: 3946-3952. 10.1016/j.vaccine.2006.02.017.

    Article  PubMed  Google Scholar 

  33. Opstelten W, Mauritz JW, De Wit NJ, Van Wijck AJM, Stalman WAB, Van Essen GA: Herpes zoster and postherpetic neuralgia: incidence and risk indicators using a general practice research database. Fam Pract. 2002, 19: 471-475. 10.1093/fampra/19.5.471.

    Article  PubMed  Google Scholar 

  34. Cebrian-Cuenca AM, Diez-Domingo J, Puig-Barbera J, Navarro-Perez J, Sanmartin-Rodriguez M: Epidemiology of Herpes Zoster Infection among Patients Treated in Primary Care Centres in the Valencian Community (Spain). BMC Fam Pract. 2010, 11: 1-23. 10.1186/1471-2296-11-1.

    Article  Google Scholar 

  35. Garcia Cenoz M, Castilla J, Montes Y, Moran J, Salaberri A, Elia F, Floristan Y, Rodrigo I, Irisarri F, Arriazu M, Zabala A, Barricarte A: Varicella and herpes zoster incidence prior to the introduction of systematic child vaccination in Navarre, 2005–2006. An Sist Sanit Navar. 2011, 30: 71-80.

    Google Scholar 

  36. Richard J-L, Zimmermann H: Herpès zoster 1998 – 2001. 2001, : Sentinella-Jahresbericht, 6. Article in French

    Google Scholar 

  37. Gauthier A, Breuer J, Carrington D, Martin M, Rémy V: Epidemiology and cost of herpes zoster and post-herpetic neuralgia in the United Kingdom. Epidemiol Infect. 2009, 137: 38-47. 10.1017/S0950268808000678.

    Article  CAS  PubMed  Google Scholar 

  38. Hope-Simpson RE: The Nature of Herpes Zoster: A Long-term Study and a New Hypothesis. Proc R Soc Med. 1965, 58: 9-20.

    CAS  PubMed  PubMed Central  Google Scholar 

  39. Fleming DM, Cross KW, Cobb WA, Chapman RS: Gender difference in the incidence of shingles. Epidemiol Infect. 2003, 132: 1-5.

    Article  Google Scholar 

  40. Brisson M, Edmunds WJ: Epidemiology of Varicella-Zoster Virus in England and Wales. J Med Virol. 2003, 70: S9-S14. 10.1002/jmv.10313.

    Article  PubMed  Google Scholar 

  41. Glynn C, Crockford G, Gavaghan D, Cardno P, Price D, Miller J: Epidemiology of shingles. J Roy Soc Med. 1990, 83: 617-619.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Eurostat: Population at 1 January.,

  43. Volpi A, Gross G, Hercogova J, Johnson RW: Current Management of Herpes Zoster: The European View. Am J Clin Dermatol. 2005, 6: 317-325. 10.2165/00128071-200506050-00005.

    Article  PubMed  Google Scholar 

  44. Donahue JG, Choo PW, Manson JE, Platt R: The Incidence of Herpes Zoster. Arch Intern Med. 1995, 155: 1605-1609. 10.1001/archinte.1995.00430150071008.

    Article  CAS  PubMed  Google Scholar 

  45. Ragozzino MW, Melton LJ, Kurland LT, Chu CP, Perry HO: Population-based study of herpes zoster and its sequelae. Medicine. 1982, 61: 310-316.

    Article  CAS  PubMed  Google Scholar 

  46. Gaillat J, Gajdos V, Launay O, Malvy D, Demoures B, Lewden L, Pinchinat S, Derrough T, Sana C, Caulin E, Soubeyrand B: Does monastic life predispose to the risk of Saint Anthony’s fire (herpes zoster)?. Clin Infect Dis. 2011, 53: 405-410. 10.1093/cid/cir436.

    Article  PubMed  Google Scholar 

  47. Floret D: Immunisation against varicella. Therapie. 2005, 60: 275-282. 10.2515/therapie:2005036.

    Article  PubMed  Google Scholar 

  48. Terada K, Yoshihiro K, Kawano S, Morita T: Incidence of herpes zoster in pediatricians and family practitioners. Estimation of efficacy of varicella vaccine for protection against herpes zoster in the elderly. Kawasaki Med J. 1994, 20: 99-102.

    Google Scholar 

  49. Brisson M, Gay NJ, Edmunds WJ, Andrews NJ: Exposure to varicella boosts immunity to herpes-zoster: implications for mass vaccination against chickenpox. Vaccine. 2002, 20: 2500-2507. 10.1016/S0264-410X(02)00180-9.

    Article  CAS  PubMed  Google Scholar 

  50. Thomas SL, Wheeler JG, Hall AJ: Contacts with varicella or with children and protection against herpers zoster in adults:a case-control study. Lancet. 2002, 360: 678-682. 10.1016/S0140-6736(02)09837-9.

    Article  PubMed  Google Scholar 

  51. Salleras M, Dominguez A, Soldevila N, Prat A, Garrido P, Torner N, Borras E, Salleras L: Contacts with children and young people and adult risk of suffering herpes zoster. Vaccine. 2011, 29: 7602-7605. 10.1016/j.vaccine.2011.08.023.

    Article  CAS  PubMed  Google Scholar 

  52. Garnett GP, Grenfell BT: The epidemiology of varicella-zoster virus infections: the influence of varicella on the prevalence of herpes zoster. Epidemiol Infect. 1992, 108: 513-528. 10.1017/S0950268800050019.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  53. Yawn BP, Wollan P, St Sauver J: Comparing shingles incidence and complication rates from medical record review and administrative database estimates: how close are they?. Am J Epidemiol. 2011, 174: 1054-1061. 10.1093/aje/kwr206.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Thomas SL, Hall AJ: What does epidemiology tell us about risk factors for herpes zoster?. Lancet Infect Dis. 2004, 1: 26-33.

    Article  Google Scholar 

  55. Pinot de Moira A, Nardone A: Varicella zoster virus vaccination policies and surveillance strategies in Europe. Euro Surveill. 2005, 10: 43-45.

    CAS  PubMed  Google Scholar 

  56. Report Venice II: Varicella and herpes Zoster surveillance and vaccination recommandations 2010–11. 2010, Stockholm: ECDC

    Google Scholar 

  57. Report Statens Serum Institut: Surveillance of Varicella and Herpes Zoster in Europe. 2010, Copenhagen:

    Google Scholar 

  58. Jumaan AO, Yu O, Jackson LA, Bohlke K, Galil K, Seward JF: Incidence of herpes-zoster, before and after varicella vaccination associated decreases in the incidence of varicella, 1992–2002. J Infect Dis. 2005, 191: 2002-2007. 10.1086/430325.

    Article  PubMed  Google Scholar 

  59. Alain S, Paccalin M, Larnaudie S, Perreaux F, Launay O: Impact of routine pediatric varicella vaccination on the epidemiology of herpes zoster. Med Mal Infect. 2009, 39: 698-706. 10.1016/j.medmal.2009.04.009. Article in French

    Article  CAS  PubMed  Google Scholar 

  60. Yih WK, Brooks DR, Lett SM, Jumaan AO, Zhang Z, Clements KM, Seward JF: The incidence of varicella and herpes zoster in Massachusetts as measured by the Behavioral Risk Factor Surveillance System (BRFSS) during a period of increasing varicella vaccine coverage, 1998–2003. BMC Public Health. 2005, 5 (68): 1-9.

    Google Scholar 

  61. Eurostat: Active ageing and solidarity between generations. A statistical portrait of the European Union 2012. 2012, Luxembourg: Luxembourg, 2012

    Google Scholar 

  62. Jumaan A, Schmid DS, Gargiullo P, Seward J: Letter to the Editor. Vaccine. 2004, 22: 3228-3231. 10.1016/j.vaccine.2004.03.064.

    Article  PubMed  Google Scholar 

  63. Joesoef MR: Potential coding error of herpes zoster (HZ) vaccination and HZ diagnosis in administrative data. Vaccine. 2011, 29: 2008-2009. 10.1016/j.vaccine.2010.12.093.

    Article  CAS  PubMed  Google Scholar 

  64. Brisson M, Edmunds WJ, Law B, Gay NJ, Wall R, Brownell M, Roos L, De Serres G: Epidemiology of varicella zoster virus infection in Canada and the United Kingdom. Epidemiol Infect. 2001, 127: 305-314.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

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We would like to acknowledge Florence Baron-Papillon and Laurence Serradell-Vallejo (Sanofi Pasteur MSD, Lyon, France) for their contributions in reviewing the draft versions of this manuscript. The authors thank Ms Trudy Perdrix-Thoma for editorial assistance. SP received a funding from SPMSD to perform the literature search, the results analysis and the draft of the manuscript.

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Correspondence to Hélène Bricout.

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Competing interests

This study was funded by SPMSD.

SP is an employee of Biostatem, Castries, France. She had specified relationships with Sanofi Pasteur MSD that might have an interest in the submitted work in the previous 6 years.

HB is an employee of SPMSD, Lyon, France.

AC declares that she has no competing interests.

RJ has received honoraria for consultancy, lectures and scientific meeting attendance from Sanofi Pasteur MSD, Merck Inc., Merck Frosst, Novartis and Astellas.

Authors’ contributions

SP carried out the literature search, the selection of the articles, the scoring of the selected papers, and the extraction of the data and drafted the manuscript. HB performed the scoring of the selected papers, the extraction of the data and participated in drafting the manuscript. AC and RJ helped to interpret the results of the review and to draft the manuscript. All authors read and approved the final manuscript.

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Additional file 1: Incidence rates of herpes zoster (HZ) by age group and by sex when available (/1 000) [20, 22, 23, 25, 2932, 34, 35, 37],[39, 40, 64]. (DOC 92 KB)

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Pinchinat, S., Cebrián-Cuenca, A.M., Bricout, H. et al. Similar herpes zoster incidence across Europe: results from a systematic literature review. BMC Infect Dis 13, 170 (2013).

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