Herpes zoster knowledge, attitudes, and herpes zoster vaccine acceptability among patients in a tertiary hospital and dermatologists in the Philippines: A cross-sectional study

ABSTRACT

As life expectancy increases, age-related diseases become more frequent and severe, making vaccination a key strategy for disease prevention. To assess the knowledge and attitudes toward herpes zoster and to determine associations with acceptability of vaccination among patients and dermatologists, a descriptive and quantitative analytic cross-sectional survey-based study was conducted among patients aged ≥50 y in a tertiary hospital, and dermatologists in the Philippines. Majority of dermatologists had good knowledge (97.5%) and attitudes (99.7%) toward vaccination. Reported barriers were vaccine cost, procurement, and storage. Only 32.8% of patients were aware of herpes zoster, of which 61.7% had good knowledge and 99.2% had positive attitudes toward vaccination. Majority (87.0%) were willing to be vaccinated. Fear of side effects and unwillingness to pay limited acceptance. Knowledge did not impact vaccine acceptance, but favorable attitudes were associated with acceptance in both groups. Recall and social desirability bias cannot be ruled out, and sampling of patients was limited to a single outpatient clinic. Overall, Filipino dermatologists exhibit high levels of knowledge, positive attitudes, and vaccine acceptability. While patient awareness was limited, vaccine acceptability is high, particularly when recommended by a physician, highlighting their critical role in primary care.

Introduction

The global trend of increasing longevity and declining fertility rates is reshaping population demographics, with one in five individuals projected to be aged 60 y or older by 2050.¹ Although this demographic transition is more prominent in developed countries, it is also impacting developing nations like the Philippines, where the number of elderly has been steadily increasing. In 2020, 8.5% of Filipinos, or roughly 9.2 million people, were senior citizens aged 60 and above, compared to just 7.5% in 2015.^2,3 While life expectancy is increasing, many of the added years are lived in poor health as infectious diseases, even vaccine-preventable ones, become more frequent and more severe with age. Promoting life-course immunization is therefore critical, not only to extend lifespan but also to enhance healthy aging.²

Life-course vaccination is a key preventive strategy to protect individuals from birth through old age. However, historically, adult immunization programs have been deprioritized in favor of childhood vaccination initiatives, resulting in lower vaccine coverage among older adults.^2,4 Dermatologists, as advocates for disease prevention, are well-suited to contribute to this effort. In addition to promoting sun protection and early detection of skin cancers, they can play a proactive role in preventing cutaneous infections such as herpes zoster (HZ).⁵

HZ, also known as shingles, is caused by the reactivation of dormant varicella zoster virus (VZV) in the sensory dorsal root ganglia following primary varicella infection.⁶ It predominantly affects the elderly as well as immunocompromised patients due to the decline in immunity in these populations.^7-9 In the Asia-Pacific region, the incidence ranges from 3 to 10 per 1000 person-years, with a female predominance. However, local epidemiologic data on the burden of HZ in the Philippines remain scarce.^10,11 Clinically, HZ presents as painful, dermatomal vesicular eruptions, often accompanied by pruritus or paresthesia. Pain persisting beyond the resolution of skin lesions, known as postherpetic neuralgia, along with cutaneous, neurologic, and visceral complications, further contributes to morbidity that significantly impairs quality of life, underscoring the importance of prevention.^4,6,12

Currently, the adjuvanted recombinant glycoprotein E subunit herpes zoster vaccine (RZV) is available in the Philippines, approved by the Philippine Food and Drug Administration for initial monitored release. The live attenuated VZV herpes zoster vaccine (ZVL) was available locally until 2020.⁴

The study aimed to assess the knowledge and attitudes toward HZ and HZ vaccines to determine how these factors are associated with acceptance of HZ vaccination among patients and dermatologists. Additionally, the study aimed to identify barriers and facilitators and assess the association of specific determinants influencing both the offering of HZ vaccination by dermatologists and the uptake of the vaccine among patients.

Materials and methods

Study design

This non-interventional, descriptive, and quantitative analytic, cross-sectional, survey-based research study was conducted from August 2024 to June 2025. Eligible participants included dermatology fellows, diplomates, and trainees from the Philippine Dermatological Society (PDS), recruited through convenience sampling. In parallel, Filipino patients aged ≥50 y consulting at the outpatient dermatology clinic of a tertiary hospital were recruited using systematic sampling. Survey instruments were developed based on the study objectives and were reviewed by a panel of subject-matter experts to establish content validity and reliability.^13-15 The questionnaire for dermatologists consisted of 22 items, while the questionnaire for patients was composed of 25 items, which assessed baseline socio-demographics, knowledge about HZ and its vaccine, as well as attitudes toward and acceptability of vaccination. The sample size requirement was calculated with Epi Info 7.0 software; a total of 335 dermatologists and 417 patients were included, with an additional 10% to accommodate potential incomplete responses.

Data analysis

The data were analyzed using JASP 0.19.3.0. Categorical variables were presented as frequencies and percentages, while quantitative variables were presented as means and standard deviations. Normality of continuous variables was assessed using the Shapiro–Wilk test, and the Mann-Whitney U test was used to examine the association of knowledge and attitudes of dermatologists and patients with vaccine acceptability. For patients, the association of specific determinants with vaccine acceptability was further analyzed through simple logistic regression, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). A p-value < .05 was considered statistically significant.

Results

Dermatologists

A total of 317 responses were obtained from dermatologists. Sociodemographic and practice characteristics are summarized in Table 1. Nearly all (92.7%) reported diagnosing at least 1 case of herpes zoster in the past month.

Table 1.

Baseline demographic characteristics and practice characteristics of participating dermatologists (n = 317).

Sociodemographic Characteristics	Mean (SD)
Age (y)	38.11 ± 11.40
	N (%)
Sex Male Female	54 (17.04%) 263 (82.96%)
Dermatology Training Level Resident Diplomate Fellow	154 (48.58%) 47 (14.83%) 116 (36.59%)
Approximate time spent in outpatient care (hours/week) 0 1–4 5–9 10–14 15–19 20–24 25–29 30–34 35–39 ≥40	2 (0.63%) 10 (3.15%) 37 (11.67%) 29 (9.15%) 20 (6.31%) 33 (10.41%) 16 (5.05%) 17 (5.36%) 18 (5.68%) 135 (42.59%)
Approximate number of outpatients at least 50 y old per month 0 1–9 10–19 20–29 30–39 40–49 50–59 60–69 70–79 80–89 90–99 ≥100	2 (0.63%) 16 (5.05%) 50 (15.77%) 53 (16.72%) 41 (12.93%) 39 (12.30%) 39 (12.30%) 15 (4.73%) 11 (3.47%) 11 (3.47%) 3 (0.95%) 37 (11.67%)
Number of patients diagnosed with herpes zoster in the past month 0 1–4 5–9 10–14 15–19 20–24 25–29 ≥30	23 (7.26%) 150 (47.32%) 105 (33.12%) 25 (7.89%) 6 (1.89%) 6 (1.89%) 1 (0.31%) 1 (0.31%)

Among dermatologists surveyed, 309 (97.5%) demonstrated good knowledge of HZ and its vaccination, while 316 (99.7%) expressed positive attitudes toward vaccination. However, specific knowledge gaps were noted. Only 22 (6.9%) correctly identified that RZV is indicated for adults aged ≥50 y regardless of prior varicella infection, and just 10 (3.2%) knew that RZV is also recommended for adults aged ≥50 y who previously received ZVL. Nearly all (99.1%) respondents agreed that vaccine administration could be integrated into dermatologic practice, with vaccines against human papillomavirus (94.3%), VZV (88.6%), and HZ (97.5%) considered within scope. Reported barriers to vaccination included high cost (79.8%), limited availability (59.9%), and challenges in maintaining cold-chain storage (70.4%). Despite these barriers, 311 (98.1%) stated they would offer HZ vaccination, and 306 (96.5%) were willing to administer RZV to eligible patients. Notably, all eight (2.5%) dermatologists with poor knowledge still expressed vaccine acceptability, while 11 (3.5%) of those with good knowledge did not. Knowledge and attitude scores were non-normally distributed (Shapiro – Wilk, p < .001). Median knowledge scores did not statistically significantly differ between dermatologists who accepted and those who rejected the vaccine (p = .340). In contrast, attitudes were significantly more positive among those who accepted the vaccine (p < .001) (Table 2).

Table 2.

Association of knowledge, attitudes, and vaccine acceptability among dermatologists (n = 317).

	RZV accepted (Median, IQR)	RZV not accepted (Median, IQR)	p-value
Knowledge	4.0 (3.5–4.5)	4.0 (3.25–5.0)	.340
Attitude	29.0 (27.0–31.0)	25.0 (22.5–30.0)	<.001

Patients

A total of 402 patients were interviewed. Sociodemographic characteristics are summarized in Table 3. Although 393 patients (97.76%) were aware of varicella, the questionnaire was interrupted in 270 (67.16%) patients upon declaration that they had no awareness of HZ. Among those aware of HZ, 34 (25.76%) had the disease prior, and 70 (53.03%) knew at least one individual who had previously contracted it.

Table 3.

Baseline demographic characteristics of participating patients (n = 402).

Sociodemographic Characteristics	N (%)
Age (y), mean (SD) 50–60 >60	63.02 ± 8.03 170 (42.29%) 232 (57.71%)
Sex Male Female	148 (36.82%) 254 (63.18%)
Education Elementary graduate High school graduate College graduate Post-graduate (Master’s/Doctorate/MD) No formal education	61 (15.17%) 204 (50.75%) 117 (29.10%) 5 (1.24%) 15 (3.73%)
Employment status Employed/Self-employed Unemployed	133 (33.08%) 269 (66.92%)
Personal monthly Income (Philippine peso) <5,000 5,000– 14,999 15,000– 29,000 30,000– 44,000 > 45,000	300 (74.63%) 55 (13.68%) 28 (6.97%) 13 (3.23%) 6 (1.49%)
Comorbidities Hypertension Diabetes Asthma Hypercholesterolemia Malignancy Kidney disease Liver disease HIV infection Solid organ transplant recipient Others	252 (62.69%) 94 (23.38%) 25 (12.37%) 79 (19.65%) 37 (9.20%) 27 (6.72%) 9 (2.23%) 1 (0.25%) 0 56 (13.93%)
Aware of varicella Yes No	393 (97.76%) 9 (2.24%)
Personal History of Varicella Yes No Cannot recall	257 (63.93%) 91 (22.64%) 54 (13.43%)
Vaccination against varicella Yes No Cannot recall	148 (36.82%) 83 (20.65%) 171 (42.54%)
Aware of HZ Yes No	132 (32.84%) 270 (67.16%)
Personal History of HZ (n = 132) Yes No Cannot recall	34 (25.76%) 94 (71.21%) 4 (3.03%)
Knows someone who had HZ (n = 132) Yes No	70 (53.03%) 62 (46.97%)

Among the 132 (32.84%) patients who were aware of HZ, 71 (61.74%) demonstrated good knowledge of HZ and its vaccination, and 131 (99.24%) expressed positive attitudes toward vaccination. Only 22 (16.67%) patients knew that HZ could have prolonged sequelae, while 63 (47.73%) knew that those who had varicella were at a high risk of contracting HZ, and over half (72, 54.55%) knew that the elderly age group is more likely to contract HZ compared to the younger population. Participants identified rash (68.94%) and pain (60.61%) as the main symptoms associated with the disease, followed by ocular involvement (16.67%) and hearing loss (12.88%). On the other hand, 26 (19.70%) were unaware of any associated symptoms with HZ.

Vaccine awareness was relatively high, with 89 (67.4%) patients knowing of HZ vaccines, and 107 (81.1%) were aware that vaccination is recommended for adults aged 50 y and older. Most patients (125, 94.7%) believed vaccination is an effective preventive measure and 115 (87.0%) expressed willingness to receive RZV. Willingness rose to 96.9% when vaccination was recommended by a physician.

Factors supporting vaccine acceptance included perceived health benefits (66.1%), belief in efficacy (49.6%), personal risk perception (40.9%), and prior awareness of someone with HZ (25.2%). Only 17 (12.88%) declined vaccination, citing fear of adverse effects (52.9%), perceptions of low personal risk (41.2%), difficulty accessing care (11.8%), or general opposition to vaccination (11.8%). Out-of-pocket cost posed a major barrier, with only 15 (11.4%) patients willing to pay for RZV.

Among patients with good knowledge, 61.7% demonstrated vaccine acceptability, while 38.3% of those with poor knowledge also accepted vaccination. All patients with positive attitudes accepted vaccination. Knowledge and attitude scores were non-normally distributed (Shapiro – Wilk, p < .001). Knowledge scores did not statistically significantly differ by vaccine acceptance (p = .756), whereas more positive attitudes were associated with acceptance (p = .002) (Table 4).

Table 4.

Association of knowledge, attitudes, and vaccine acceptability among patients (n = 132).

	RZV accepted (Median, IQR)	RZV not accepted (Median, IQR)	p-value
Knowledge	3.0 (2.25–3.75)	3.0 (2.0–4.0)	.756
Attitude	12.0 (11.5–12.5)	10.0 (8.5–13.0)	.002

Determinants of vaccine acceptability among patients

Eighty-seven percent (87.02%) were willing to get the vaccine. According to the simple logistic regression (Table 5), the odds of accepting the vaccine were 55% reduced in high school (OR = 0.453, 95% CI [0.053–3.873], p = .470) and college graduates (OR = 0.450, 95% CI [0.051–3.972], p = .472). Employed individuals were more likely to get vaccinated against HZ (OR = 1.733, 95% CI [0.530–5.666], p = 0.363). A prior history of HZ reduced the odds of accepting the vaccine by 23% (OR = 0.769, 95% CI [0.246–2.400]; p = .651), while knowing someone who had HZ increased the odds of getting vaccinated by 150% (OR = 2.496, 95% CI [0.862–7.232], p = .092). In summary, there is insufficient evidence to conclude that these variables have a statistically significant association with vaccine acceptability.

Table 5.

Patient determinants of being in favor of vaccination against HZ.

	Odds Ratio (OR) (95% CI)	p-value
Educational level* High school graduate College graduate	0.453 (0.053–3.873) 0.450 (0.051–3.972)	.470 .472
Employment status	1.733 (0.530–5.666)	.363
Personal history of HZ	0.769 (0.246–2.400)	.651
Knowing someone who has/had HZ	2.496 (0.862–7.232)	.092

*Reference used was “No formal education/Elementary graduate.”.

Discussion

By 2035, the Asian population aged ≥60 y is projected to reach 924.5 million, with an estimated 30,395 new daily HZ cases.¹⁰ Despite the availability of effective vaccines, most Asia – Pacific immunization programs continue to prioritize childhood vaccination, leaving adult vaccination relatively underemphasized.⁴ Currently, HZ vaccination is not part of the Philippine National Immunization Program. Local recommendations still endorse ZVL for immunocompetent adults ≥60 y old, even though it has been unavailable since 2020. Guidelines have yet to be updated to address the availability of RZV, which was introduced locally in 2022.⁴

Our findings demonstrate that nearly all dermatologists surveyed had good knowledge (97.48%) and favorable attitudes (99.68%) toward HZ and HZ vaccination. These rates are notably higher than those reported among primary care physicians in Saudi Arabia (62.6%),¹⁶ though comparisons are limited by differing thresholds used to define ‘good knowledge.’ Most dermatologists acknowledged vaccination as part of their practice, identifying HZ as the leading indication (97.48%), followed by human papilloma virus infection and varicella. Reported barriers were cost (79.81%) followed by procurement and storage challenges, consistent with previous studies.^13,17 In contrast to one study,¹⁶ logistical issues were not a major obstacle to HZ vaccination. The absence of updated national guidelines was also cited as a barrier, underscoring the need for stronger recommendations, education, and infrastructure to support vaccination efforts.^4,17 Notably, nearly all dermatologists indicated willingness to offer (98.11%) and administer (96.53%) RZV. While there were no significant statistical differences in knowledge scores observed between dermatologists who accepted RZV and those who did not (Median, IQR: 4.0 (1.0) vs. 4.00 (1.5), p = .340), attitude scores were significantly higher among those who accepted the vaccine (Median, IQR: 29.0 (4.0) vs. 25 (5.0), p < .001), indicating that while knowledge was not associated with RZV acceptability, more favorable attitudes were linked to acceptance.

Similarly, among patients, knowledge was not associated with RZV acceptance (Median, IQR: 3.0 (1.5) vs. 3.00 (2.0), p = .756), but more favorable attitudes (Median, IQR: 12.0 (1.0) vs. 10.00 (3.0), p = .002) were linked to acceptance. Awareness of HZ was low (32.8%), far below the 80–95% reported elsewhere. Awareness of HZ vaccination was also limited, but within the range (9–57.2%) reported internationally.^15,18–22

Encouragingly, the majority of patients were willing to get vaccinated (87.02%), which increased to 96.97% with physician recommendation, suggesting the crucial role of healthcare workers in advocating for vaccination.^{7,14,20,22,23} This is also supported by Teeter et al.²⁴ who reported a fivefold increase in vaccine uptake when recommended by physicians. While there were no statistically significant predictors of vaccine acceptance determined in the data, the cost of the vaccine is a major barrier to vaccination. Unlike in other countries, such as Saudi Arabia, where RZV is offered for free,¹⁵ the vaccine in the Philippines is not routine and is not subsidized by the government. Thus, patients shoulder the full costs amounting to approximately 8,000– 10,000 Philippine pesos per dose. The majority (88.64%) of patients were unwilling to pay out-of-pocket for the vaccine, given that most had no or low income. While the cost of vaccination may seem prohibitive, it is considerably lower than the estimated expenses of treating complicated HZ (50,000 Philippine pesos in public hospitals and 171,000 Philippine pesos in private hospitals).⁴

Conclusions and recommendations

Most dermatologists expressed willingness to offer and administer vaccines, yet high costs and inadequate infrastructure remain significant barriers. Among patients, employment status and personal connections to someone who had HZ facilitated vaccine acceptance; however, limited awareness, insufficient knowledge, and financial constraints hinder uptake. These findings highlight the need to improve awareness and knowledge of herpes zoster and its prevention among adult patients. Policy efforts should prioritize the inclusion of RZV in the national immunization program to reduce cost-related barriers. In addition, integrating vaccination training into dermatology curricula would strengthen the role of dermatologists in primary care and preventive health services in the country.

This study has several limitations such as reliance on self-reported data, as it is difficult to verify information about the personal history of VZV and HZ, and knowing another individual who was afflicted with HZ. Recall bias and social desirability bias cannot be ruled out. In addition, sampling was limited to a single charity outpatient clinic, thus selection bias may be substantial. Despite these limitations, the findings of this study offer valuable insights into dermatologists’ and patients’ knowledge, attitudes toward HZ and HZ vaccination, and vaccine acceptability.

Biography

Krisha K. Lim earned her Doctor of Medicine degree from the University of the Philippines College of Medicine, Class of 2022. She completed her internship at the Philippine General Hospital, where she later continued her training as a resident in the Department of Dermatology. Her research interests include genodermatoses and preventive medicine.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

Dr. Batac is an occasional lecturer for GlaxoSmithKline (GSK), the manufacturer of the vaccine of interest in the study. The other authors declare no conflicts of interest.

Informed consent statement

Online Informed Consent was obtained from all subjects involved in the study.

Institutional review board statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the University of the Philippines Manila Research Ethics Board (UPMREB) (Protocol code: 2024–0016–01; Date of approval: 11 April 2024).

Abbreviations

CI

Confidence interval

HZ

Herpes zoster

IQR

Interquartile range

OR

Odds ratio

PSD

Philippine Dermatological Society

RZV

Adjuvanted recombinant glycoprotein [2]E subunit herpes zoster vaccine

VZV

Varicella zoster virus

ZVL

Live attenuated varicella zoster virus vaccine