ABSTRACT
Background
The global burden of herpes zoster (HZ) is rising, posing a major public health challenge, especially among aging populations with high chronic disease prevalence. Although chronic conditions are known risk factors, population‐based evidence from China remains scarce.
Objective
The aim of the study is to examine the association between chronic diseases and HZ using nationally representative data from China, considering demographic and lifestyle factors.
Methods
We conducted a national population‐based survey using data from the 2024 China Family Panel Survey. A probability proportional to size sampling method was employed, covering 25 provincial‐level administrative divisions and representing 95% of the population in Chinese mainland. A structured questionnaire collected data on HZ diagnosis, chronic disease status, and demographics. Incidence rates were calculated, and multivariable logistic regression was used to estimate adjusted odds ratio (aOR).
Results
Among 27,868 participants (21,496 adults; 6372 minors), 809 adult HZ cases were identified, with 64.40% (n = 521) having at least one chronic condition. Female adults with chronic diseases had a higher incidence (12.94/1000 person‐years [PY]; 95% confidence intervals [CI]: 11.45–14.56) than males (8.78/1000 PY; 95% CI: 7.55–10.12). Incidence increased with age, from 8.07/1000 PY (95% CI: 4.45–13.10) in those aged 18–29 to 13.36/1000 PY (95% CI: 11.08–15.96) in those ≥ 70. Chronic disease was associated with elevated HZ risk (aOR = 1.84; 95% CI: 1.51–2.24). Among 14 chronic conditions, heart disease showed the strongest association (aOR = 2.91; 95% CI: 2.07–4.10), followed by diabetes (aOR = 2.04; 95% CI: 1.48–2.80) and hypertension (aOR = 1.89; 95% CI: 1.47–2.42).
Conclusions
Chronic diseases, particularly cardiovascular and metabolic conditions, are significantly associated with increased HZ risk. These findings highlight the need for targeted HZ prevention strategies, including vaccination, among high‐risk groups in China.
Keywords: chronic disease, epidemiology, herpes zoster, nationwide survey
Chronic disease was associated with elevated herpes zoster risk (aOR = 1.84, 95% CI: 1.51–2.24). Among 14 chronic conditions, heart disease showed the strongest association (aOR = 2.91, 95% CI: 2.07–4.10), followed by diabetes (aOR = 2.04, 95% CI: 1.48–2.80) and hypertension (aOR = 1.89, 95% CI: 1.47–2.42).
Abbreviations
- aOR
adjusted odds ratio
- CFPS
China Family Panel Survey
- CI
confidence interval
- CNY
Chinese Yuan
- HZ
herpes zoster
- PY
person‐year
- VZV
varicella‐zoster virus
1. Background
Herpes zoster (HZ), also termed shingles, is caused by varicella‐zoster virus (VZV) reactivation, which typically manifests as a dermatomal, vesicular, painful rash [1], imposing significant disease burden for HZ patients. In prior studies, the risk of HZ progressively increases with advancing age, with approximately 25% of adults aged ≥ 50 years developing HZ during their lifetime, imposing a substantial burden both globally and in China [2, 3]. The HZ incidence reported in 2013 indicated a global incidence ranging from 3 to 5 cases per 1000 person‐years and an annual increase of 2.5%–5.0% [4]. In China, the HZ‐related cost reached US$1931 per inpatient in 2023 in Beijing [5].
Accumulating studies demonstrate that chronic diseases are key risk factors for HZ. Studies from European and Republic of Korea's cohorts have found that various chronic diseases are associated with differing magnitudes of HZ risk [6, 7, 8, 9]. Notably, despite China's implementation of comprehensive chronic disease prevention strategies—including surveillance, interventions, and targeted screening—non‐communicable diseases have represented 91% of all‐cause mortality in the Chinese population [10, 11].
In particular, after the COVID‐19 pandemic, older adults with chronic diseases emerged as highly vulnerable to SARS‐CoV‐2 infection and faced elevated mortality risks [12, 13]. The reciprocal relationship between chronic diseases and infections may accelerate disease progression in both conditions [14, 15]. This highlights the need to prioritize immune‐related conditions in the context of long COVID, aiming to optimize synergies between population health gains and economic sustainability [16, 17].
However, HZ has received comparatively limited research attention, particularly in developing countries where public health resources are largely directed toward high‐mortality conditions such as infectious and other major chronic diseases. Moreover, HZ disease burden estimates are primarily derived from non‐Asian databases, with most originating from North American and European populations [4]. Meanwhile, existing research predominantly focuses on individual chronic diseases, with limited studies investigating the association between chronic diseases and HZ in articles published between 2003 and 2022 [18]. Chronic diseases are highly heterogeneous and exert varying impacts on the risk of HZ, highlighting the importance of evaluating specific disease types rather than treating them as a homogeneous group when assessing HZ risk [6, 7, 8, 9]. As one of the countries with the largest aging populations in the world, China faces an urgent need to reduce the burden of chronic diseases and HZ. However, the absence of systematic HZ surveillance in Chinese mainland has resulted in a critical knowledge gap, making it difficult to estimate the disease burden, develop vaccination strategies, and allocate healthcare resources [19]. For example, a survey conducted in 2024 reported that among people aged ≥ 40 years in China, the overall HZ vaccine coverage was only 0.79% [20].
To address this critical research gap and respond to China's expanding aging population and increasing burden of chronic disease, we conducted a nationally representative, population‐based cross‐sectional survey to examine the epidemiological associations between 14 specific chronic diseases and HZ. These findings aim to provide epidemiological evidence that may inform future prevention strategies for high‐risk populations.
2. Methods
2.1. Study Design
We designed the questionnaire and conducted a population‐based survey as part of the 2024 China Family Panel Survey (CFPS), which was administered to CFPS respondents between July and September 2024 by well‐trained investigators through in‐person one‐on‐one questionnaire‐based interviews. The CFPS encompasses three levels: individual, household, and community. CFPS employed systematic probability proportional to size sampling, which implicitly incorporated stratification by administrative boundaries and socioeconomic status, as measured by a composite socioeconomic indicator [21]. After applying weights and standardizing for age, gender, and education to match the national population, the CFPS sample is widely regarded as nationally representative.
Comprehensive quality assurance protocols were systematically implemented throughout the research process to ensure data accuracy and reliability. Pre‐survey preparations included mandatory standardized training for all field investigators. To ensure data integrity, a multi‐stage quality control process was implemented throughout and following the survey period. Daily statistical evaluations of submitted questionnaires were conducted to monitor response intervals and determine daily non‐participation rates. Interviews were audio‐recorded following participant authorization, with a randomly sampled subset undergoing procedural audits to validate adherence to standardized protocols, particularly focusing on outliers such as surveys with abbreviated completion times or elevated item non‐response. Post‐data collection, telephone‐based authenticity checks were performed on a randomly selected respondent cohort to corroborate interview veracity. All identified cases of incomplete entries or inconsistencies were methodically removed from the final dataset.
2.2. Population
The target population includes all household members from sampled families across 25 provincial‐level administrative divisions (excluding Xinjiang, Xizang, Qinghai, Inner Mongolia, Ningxia, and Hainan), representing 95% of the total population of the Chinese mainland [21, 22].
2.3. Measures
2.3.1. HZ Status and Onset Time
A specialized cross‐sectional survey on HZ was conducted as part of the 2024 wave of the CFPS. The primary outcome was HZ, defined as a categorical variable. Our questionnaire included HZ‐related questions, including history of HZ infection, onset and duration of symptoms, occurrence and duration of post‐herpetic neuralgia, duration of rash and zoster‐associated pain, economic burden, etc. We conducted semi‐structured interviews with clinical experts and referenced clinical guidelines to establish criteria for identifying HZ [23, 24, 25, 26]. Participants were shown photographic examples of HZ‐related symptoms and rash locations to help determine whether they had experienced similar manifestations. Participants were asked whether they had received a diagnosis of HZ within the past 5 years (from 2019 to 2024), as well as the specific year and month of diagnosis. Confirmation of HZ cases required meeting at least one of the following criteria: (1) physician‐diagnosed HZ; (2) presence of clinical signs or symptoms consistent with HZ; or (3) dermatological verification of HZ through review of documented case responses [27]. For participants with uncertain HZ status, audio recordings of their responses were captured and subsequently evaluated by dermatologists' post‐survey.
2.3.2. Chronic Disease Assessment
We surveyed adults (aged ≥ 18 years) regarding their history of chronic diseases, defined as physician‐diagnosed conditions that met at least one of the following criteria: (1) a diagnosis made within the 6 months prior to the survey, or (2) a prior diagnosis with disease recurrence or ongoing treatment within the past 6 months. Participants were asked to self‐report based on medical history recall; no documentation or medical records were required during the interview. The 14 chronic conditions were categorized into seven etiological groups: metabolic disorders (hypertension, dyslipidemia, diabetes), immune‐related diseases (rheumatism, asthma), neurodegenerative disorders (memory disorders), neoplastic conditions (malignant tumors), infection/inflammatory diseases (lung, liver, stomach, and kidney diseases), vascular events (stroke, heart disease), and psychiatric disorders (mental disorders).
2.3.3. Sociodemographic Characteristics
For all participants, we also collected demographic characteristics, including gender, age, ethnicity, marital status, education level, residency, and annual household income.
2.4. Follow‐Up
The CFPS conducted its baseline survey in 2010, followed by biennial follow‐up waves that collected data from the same respondents. Information on HZ and chronic disease history was obtained from the 2024 wave of the CFPS, while other variables were collected in each wave. This study used data exclusively from the 2024 wave.
2.5. Statistical Analysis
We conducted analyses on the adult subpopulation to evaluate associations between chronic diseases and HZ based on the 2024 wave of the CFPS. There were no missing values for the variables included in this study. The 5‐year incidence rates of HZ were calculated per 1000 person‐years (PY) by dividing the number of HZ cases (numerator) by the total person‐time at risk (denominator), which was the sum of person‐years contributed by all adult participants during the 5‐year recall period; 95% confidence intervals (CI) were derived using the Poisson distribution. Categorical variables were presented as frequencies and analyzed using χ 2 tests or Fisher's exact tests. A multivariate logistic regression model was employed to assess the association between chronic diseases and HZ occurrence. All models shared the same dependent variable but differed in the covariates adjusted for. To ensure national representativeness of the findings, we applied survey weights that were age‐, gender‐, and education‐standardized to the population structure reported in the Seventh National Population Census of China (2020) [28]. All analyses were carried out in R 4.2.3 (The R Foundation for Statistical Computing, Vienna, Austria) [29].
2.6. Ethical Considerations
Both the CFPS and this HZ‐related sub‐study received ethical approval (IRB00001052‐14010; IRB000001052‐24022) from the Institutional Review Board at Peking University. This study was registered with the Chinese Clinical Trial Registry (ChiCTR2400085891). Additionally, all participants were required to sign informed consent forms, and personal information was anonymized through ID codes to ensure confidentiality.
3. Results
3.1. Incidence Rate of HZ by Chronic Diseases
Our study surveyed 27,868 participants, comprising 21,496 adults (≥ 18 years) and 6372 minors (< 18 years). The characteristics of the sample are presented in Table 1. Among adults in the past 5 years, we identified 809 HZ cases, of whom 521 had documented diagnoses of at least one of the 14 specified chronic diseases. Table 2 presented the case distribution, incidence rates (per 1000 PY), and intergroup comparative analyses stratified by chronic disease status. Among individuals with a history of HZ and at least one chronic disease, the average number of chronic conditions was 2.44 (SD = 1.66).
Table 1.
Sample characteristics (n = 21,496).
| Variables | Participants (n, %) |
|---|---|
| Gender | |
| Male | 10,480 (48.75) |
| Female | 11,016 (51.25) |
| Age group (years) | |
| 18–29 | 3196 (14.87) |
| 30–39 | 3949 (18.37) |
| 40–49 | 2976 (13.84) |
| 50–59 | 4526 (21.06) |
| 60–69 | 3722 (17.31) |
| ≥ 70 | 3127 (14.55) |
| Ethnicity | |
| Han | 19,744 (91.85) |
| Ethnic Minority | 1752 (8.15) |
| Marital Status | |
| Single | 5050 (23.49) |
| Married | 16,446 (76.51) |
| Education Level | |
| Illiterate | 3993 (18.58) |
| Primary school | 3885 (18.07) |
| Middle school | 6047 (28.13) |
| High school and above | 7571 (35.22) |
| Residency | |
| Urban | 11,133 (51.79) |
| Rural | 10,363 (48.21) |
| Household Income (CNY) | |
| 0–120,000 | 14,584 (67.85) |
| ≥ 120,000 | 6912 (32.15) |
| Chronic disease | |
| Without chronic diseases | 12,090 (56.24) |
| With chronic diseases | 9406 (43.76) |
Abbreviation: CNY, Chinese Yuan.
Table 2.
Incidence rate of herpes zoster among adults in China, stratified by chronic diseases status (n = 21,496).
| With chronic diseases | Without chronic diseases | |||||||
|---|---|---|---|---|---|---|---|---|
| Variables | Cases (n, %) | Incidence rate/per 1000 PYa (95% CI) | PYa | p | Cases (n, %) | Incidence rate/per 1000 PYa (95% CI) | PYa | p |
| Gender | 0.0002 | 0.4130 | ||||||
| Male | 213 (40.88) | 8.78 (7.55, 10.12) | 21,225.46 | 132 (45.83) | 4.33 (3.67, 5.06) | 35,857.10 | ||
| Female | 308 (59.12) | 12.94 (11.45, 14.56) | 21335.92 | 156 (54.17) | 4.83 (4.14, 5.64) | 34,263.30 | ||
| Age group (years) | 0.0017 | 0.0051 | ||||||
| 18–29 | 11 (2.11) | 8.07 (4.45, 13.10) | 1888.31 | 54 (18.75) | 3.60 (2.82, 4.54) | 19,974.41 | ||
| 30–39 | 27 (5.18) | 7.56 (4.95, 10.94) | 3591.77 | 68 (23.61) | 3.95 (3.09, 4.96) | 18,523.13 | ||
| 40–49 | 39 (7.49) | 6.70 (4.91, 8.94) | 6865.80 | 45 (15.63) | 4.58 (3.54, 5.90) | 13,657.49 | ||
| 50–59 | 124 (23.80) | 11.02 (9.13, 13.12) | 11,101.34 | 55 (19.10) | 5.61 (4.27, 7.17) | 10,929.78 | ||
| 60–69 | 168 (32.25) | 12.98 (10.89, 15.46) | 10,054.83 | 38 (13.19) | 6.57 (4.46, 9.44) | 4534.85 | ||
| ≥ 70 | 152 (29.17) | 13.36 (11.08, 15.96) | 9059.32 | 28 (9.72) | 8.92 (5.51, 13.32) | 2500.73 | ||
| Ethnicity | 0.1780 | 0.9600 | ||||||
| Han | 491 (94.24) | 11.04 (10.05, 12.14) | 39,896.51 | 260 (90.28) | 4.57 (4.07, 5.14) | 63,769.93 | ||
| Ethnic Minority | 30 (5.76) | 8.16 (5.17, 12.50) | 2664.87 | 28 (9.72) | 4.63 (3.06, 6.56) | 6350.47 | ||
| Marital Status | 0.2930 | 0.1560 | ||||||
| Single | 87 (16.70) | 9.58 (7.53, 12.04) | 7715.92 | 68 (23.61) | 3.91 (3.12, 4.84) | 21,499.84 | ||
| Married | 434 (83.30) | 11.15 (10.05, 12.30) | 34,845.46 | 220 (76.39) | 4.87 (4.27, 5.54) | 48,620.56 | ||
| Education level | 0.4720 | 0.6310 | ||||||
| Illiterate | 151 (28.98) | 12.89 (9.09, 17.79) | 2866.31 | 31 (10.76) | 5.29 (2.15, 11.03) | 1308.15 | ||
| Primary school | 115 (22.07) | 11.41 (9.71, 13.37) | 13,650.15 | 40 (13.89) | 4.61 (3.37, 6.13) | 10,007.01 | ||
| Middle school | 151 (28.98) | 10.76 (9.20, 12.53) | 15,511.08 | 77 (26.74) | 4.17 (3.45, 5.03) | 27,227.19 | ||
| High school and above | 104 (19.96) | 9.75 (7.98, 11.86) | 10,533.83 | 140 (48.61) | 4.89 (4.14, 5.71) | 31,578.05 | ||
| Residency | 0.0883 | 0.0050 | ||||||
| Urban | 270 (51.82) | 11.73 (10.38, 13.21) | 23,184.00 | 170 (59.03) | 5.36 (4.64, 6.14) | 37,741.26 | ||
| Rural | 251 (48.18) | 9.83 (8.46, 11.30) | 19,377.38 | 118 (40.97) | 3.67 (3.04, 4.40) | 32,379.14 | ||
| Household Income/CNY | 0.5000 | 0.0091 | ||||||
| 0–120,000 | 383 (73.51) | 11.11 (9.96, 12.39) | 29,745.73 | 164 (56.94) | 3.99 (3.44, 4.63) | 45,206.65 | ||
| ≥ 120,000 | 138 (26.49) | 10.28 (8.62, 12.21) | 12,815.65 | 124 (43.06) | 5.64 (4.73, 6.63) | 24,913.75 | ||
Note: The columns “With chronic diseases” and “Without chronic diseases” present the number of HZ cases and incidence rates across stratified variables for individuals with and without chronic diseases, respectively.
Abbreviations: CI, confidence interval; CNY, Chinese Yuan; PY, person year.
The incidence rate and person years were calculated using weighted data.
A significant gender‐based disparity in HZ incidence was observed among individuals with chronic diseases (p = 0.0002), whereas no such difference emerged in the non‐chronic disease group. Within the chronic disease group, females exhibited a higher incidence rate (12.94 per 1000 PY; 95% CI: 11.45–14.56) compared to males (8.78 per 1000 PY; 95% CI: 7.55–10.12). Furthermore, HZ incidence revealed significant age‐stratified variation across both groups (p < 0.05). Advancing age exhibited a progressive escalation in HZ risk, with this age‐dependent association demonstrating heightened magnitude within the chronic disease subpopulation. Urban‐rural disparities showed differential significance across subgroups: urban residents exhibited elevated HZ risk relative to rural counterparts, achieving statistical significance exclusively within the non‐chronic disease subpopulation (p = 0.0050).
Supporting Information S1: Table S1 reports the incidence rate of HZ among 21,496 adults without stratification by chronic disease status. The incidence rate varied significantly across subgroups defined by gender, age, marital status, education level, residency, and chronic disease status. Females exhibited a higher incidence rate (7.94 per 1000 PY; 95% CI: 7.23–8.73) compared to males (5.99 per 1000 PY; 95% CI: 5.37–6.66).
3.2. Association Between Chronic Diseases and HZ
Table 3 presented the multivariable logistic regression analyses evaluating associations between chronic diseases and HZ. Model 1 adjusted for gender, age, educational attainment, and annual household income. Model 2 further adjusted for ethnicity, marital status, and urban/rural residency. Individuals with chronic diseases demonstrated significantly elevated adjusted odds ratio of HZ infection across both models, with adjusted odds ratio (aOR) of 1.85 (95% CI: 1.52–2.26) in Model 1 and 1.84 (95% CI: 1.51–2.24) in Model 2 compared to those without chronic conditions. A higher aOR was observed in females compared to males (aOR = 1.31, 95% CI: 1.11–1.55). A strong age‐dependent association was observed, with adults aged ≥ 70 years demonstrating an aOR of 2.23 (95% CI: 1.43–3.48) relative to the 18–29‐year reference group. HZ was significantly associated with urban residency (aOR = 1.26, 95% CI: 1.05–1.51).
Table 3.
Association between chronic diseases and herpes zoster among adults.
| Model 1 aOR (95% CI) | Model 2 aOR (95% CI) | |
|---|---|---|
| Chronic disease (Ref: Without chronic disease) | ||
| With chronic diseases | 1.85 (1.52, 2.26)*** | 1.84 (1.51, 2.24)*** |
| Gender (Ref: Male) | ||
| Female | 1.33 (1.12, 1.57)** | 1.31 (1.11, 1.55)** |
| Age group (Refs. [18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29]:) | ||
| 30–39 | 1.11 (0.77, 1.60) | 0.98 (0.65, 1.50) |
| 40–49 | 1.20 (0.81, 1.78) | 1.06 (0.68, 1.65) |
| 50–59 | 1.81 (1.25, 2.61)** | 1.58 (1.02, 2.42) |
| 60–69 | 2.25 (1.54, 3.30)*** | 1.98 (1.27, 3.09)** |
| ≥ 70 | 2.52 (1.67, 3.80)*** | 2.23 (1.43, 3.48)** |
| Ethnicity (Ref: Ethnic Minority) | ||
| Han | — | 1.03 (0.74, 1.43) |
| Marital status (Ref: Single) | ||
| Married | — | 1.18 (0.90, 1.55) |
| Education level (Ref: Illiterate) | ||
| Primary school | 1.01 (0.74, 1.37) | 0.97 (0.71, 1.33) |
| Middle school | 1.15 (0.85, 1.54) | 1.06 (0.79, 1.44) |
| High school and above | 1.32 (0.96, 1.83) | 1.20 (0.86, 1.68) |
| Residency (Ref: Rural) | ||
| Urban | — | 1.26 (1.05, 1.51)* |
| Household income per year (Ref: 0–120,000) | ||
| ≥ 120,000 | 1.17 (0.98, 1.40) | 1.13 (0.94, 1.35) |
Note: Model 1 and Model 2 shared the same dependent variable but differed in the covariates adjusted for. Model 2 adjusts for all covariates listed in the table; Model 1 does not adjust for the covariates marked with “–”
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval.
p < 0.05
p < 0.01
p < 0.001
We further investigated the impact of health insurance coverage and lifestyle risk factors, including smoking and alcohol consumption on HZ. Detailed results are presented in Supporting Information S1: Table S2. Notably, the aOR for non‐smokers versus smokers and non‐drinkers versus drinkers were both greater than 1, though these associations were not statistically significant.
We further examined associations between specific chronic diseases and HZ, as illustrated in Figure 1. Each evaluated chronic condition, except stroke, showed a significant association with HZ, with aOR ranging from 1.84 (95% CI: 1.03–3.27) for asthma to 2.91 (95% CI: 2.07–4.10) for heart disease.
Figure 1.
Adjusted odds ratio for herpes zoster stratified by specific chronic disease. *p < 0.05, **p < 0.01, ***p < 0.001. OR, odds ratio.
To address potential confounding from mental health disorders—with depression exemplifying a condition that can act as both an outcome and a confounder—we conducted an additional analysis controlling for mental disorders as confounders. As shown in Supporting Information S1: Figure S1, the results were largely consistent with those presented in Figure 1. However, the association with asthma no longer reached statistical significance. The strongest association was observed for heart disease, with an aOR of 2.86 (95% CI: 2.02–4.06).
4. Discussion
Our analysis of chronic diseases and HZ associations through a nationally representative population‐based survey revealed that chronic diseases were associated with HZ risk (aOR = 1.84, 95% CI: 1.51–2.24). Notably, among the 14 categories of chronic diseases, cardiovascular disease demonstrated the strongest association (aOR = 2.91, 95% CI: 2.07–4.10).
The biological mechanism underlying most HZ risk factors is primarily attributable to impaired cell‐mediated immunity [30, 31]. Patients with autoimmune diseases exhibit elevated HZ susceptibility due to both immunity and medication [18, 32]. Diabetes is characterized by diminished VZV‐specific cellular immunity, while depression induces systemic inflammation that further attenuates VZV‐specific immune responses [33, 34, 35]. In asthma patients, concurrent deficiencies in innate and adaptive immunity—both critical for suppressing VZV reactivation—create a permissive environment for viral resurgence, culminating in clinical HZ manifestations [36].
To interpret the strong association between cardiovascular disease and HZ with caution is essential due to the potential reverse causality. Previous studies have shown that HZ carries an increased risk of stroke and transient ischemic attack, featuring acute elevations in ischemic stroke and myocardial infarction following HZ episodes [37, 38]. One possible hypothesis posits that inflammation triggered by HZ may promote arterial thrombosis in individuals with underlying atherosclerosis [38]. However, emerging evidence suggests that systemic inflammation, autoimmune responses, or hemodynamic disturbances related to HZ may independently contribute to cardiovascular events [39, 40]. Additionally, reverse causality may exist between HZ and psychological stress [41]. This bidirectional relationship complicates causal inference, particularly in cross‐sectional studies such as ours, where the temporal order of disease onset cannot be clearly established. Future longitudinal studies are needed to better determine the directionality and underlying mechanisms of this association.
The association between chronic diseases and an increased risk of HZ is evidenced by prior studies. A recent systematic meta‐analysis (studies published 2003–2022) investigates risk factors for HZ, demonstrating associations across all analyzed comorbidities, with pooled OR ranging from 1.17 (95% CI: 0.93–1.48) for renal disorders to 2.87 (95% CI: 1.99–4.13) for systemic lupus erythematosus [18]. While our results ranged from an aOR of 1.64 (95% CI: 0.84–3.18) for malignant tumors to 2.91 (95% CI: 2.07–4.10) for cardiovascular disease, we identified notably stronger associations for certain conditions. Another systematic meta‐analysis (studies published 2003–2024) focused on adults with asthma, which reported an overall aOR for HZ development in adults with asthma ranging between 1.11 and 1.67 [36, 42, 43, 44, 45] (based on studies from the United Kingdom, Germany, Spain, and Republic of Korea). Notably, our study estimated a higher aOR of 1.84 (95% CI: 1.03–3.27) for adults with asthma compared to these prior studies. The United States retrospective database analysis has also revealed that individuals with diabetes are nearly twice as likely to be diagnosed with HZ, showing an adjusted incidence rate ratio of 1.84 (95% CI: 1.82–1.85) [46]. Our findings exceeded the prior aOR, demonstrating that individuals with diabetes were associated with HZ (aOR = 2.04, 95% CI: 1.48–2.80), potentially reflecting population‐specific risk profiles. The elevated aOR in our study could also be partially attributed to limitations in prior United States research that relied on administrative claims data. Additionally, the high burden of chronic diseases in China may contribute to the stronger association observed in our population. However, this association might also stem from reverse causality. Persistent hyperglycemia in diabetic individuals activates the polyol pathway, inducing cellular dysfunction and increasing susceptibility to VZV reactivation [47]. Moreover, some studies have reported that among diabetic patients with well‐controlled blood glucose, HbA1c levels demonstrate an upward trend following HZ infection, further suggesting a bidirectional relationship [48].
We further identified that gender acts as a significant factor linked to HZ occurrence. Consistent with global epidemiological evidence, numerous studies have demonstrated that females are at a higher risk of HZ compared to males [6, 49, 50, 51]. Our analysis further revealed this gender disparity across both chronic disease and non‐chronic disease groups. Among individuals with chronic diseases, females exhibited a higher incidence rate of HZ (12.94 per 1000 PY; 95% CI: 11.45–14.56) than males (8.78 per 1000 PY; 95% CI: 7.55–10.12). Similarly, in the non‐chronic disease group, the incidence rate was elevated in females (4.83 per 1000 PY; 95% CI: 4.14–5.64) compared to males (4.33 per 1000 PY; 95% CI: 3.67–5.06). This difference may be attributed to immunologic or hormonal mechanisms, such as estrogen's immunomodulatory effects or gender‐specific immune aging patterns [33]. We also observed an interesting phenomenon: the risk of HZ increases with higher levels of education. Individuals with higher education may have greater health awareness and be more likely to recall or report HZ, which could induce potential reporting bias.
Furthermore, the incidence of HZ is rising with increasing age in adults [52]. Our analysis revealed that adults aged ≥ 70 years (with chronic diseases: 13.36 per 1000 PY, 95% CI: 11.08–15.96; without chronic diseases: 8.92 per 1000 PY, 95% CI: 5.51–13.32) exhibited nearly double the incidence rate compared to the 18–29‐year‐old group (with chronic diseases: 8.07 per 1000 PY, 95% CI: 4.45–13.10; without chronic diseases: 3.60 per 1000 PY, 95% CI: 2.82–4.54). Over recent decades, global population aging has accelerated across nearly every country, driving an inevitable surge in HZ infections through demographic transition [53]. China exemplifies this trend, with people ≥ 50 years comprising 37.80% of its population in 2023 [54]. This demographic shift predicts a substantial healthcare burden from HZ and its complications, particularly affecting elderly patients managing pre‐existing comorbidities [52]. Given that HZ vaccination demonstrates substantial positive impacts on quality‐of‐life metrics and complication mitigation, it offers critical protection for aging populations vulnerable to postherpetic neuralgia and other sequelae [55]. Hence, sustained surveillance of HZ epidemiology and prioritized vaccination of eligible populations become imperative to mitigate disease burden and improve individuals' healthcare conditions.
Nevertheless, our study may have several limitations. As a nationwide, population‐based cross‐sectional survey, it was designed to explore epidemiological associations between chronic diseases and HZ, rather than to investigate mechanistic pathways underlying HZ pathogenesis. While we acknowledge the limitations inherent in using retrospective survey data to estimate annual incidence rates, efforts were made to minimize potential bias. The cross‐sectional nature of the data limits our capacity to establish the temporal sequence between HZ onset and chronic disease development, thereby precluding definitive causal inference. Some observed associations may have been affected by reverse causality or reporting bias. Additionally, several potential confounders—including immunosuppressive therapies and prior HZ vaccination history—were not assessed. The lack of these variables may have introduced residual confounding, as immunosuppressive therapies are known to elevate HZ risk, while prior vaccination can lower susceptibility. Moreover, self‐reported data on HZ and chronic diseases may be subject to bias, although we implemented multiple measures to minimize such risks. However, this research still makes significant contribution to HZ fields and fills the gap of limited evidence of the incidence of HZ in China, providing unprecedented value as the first nationally representative study systematically examining HZ‐chronic disease associations across multiple chronic conditions simultaneously. The identification of disease interactions offers critical evidence to inform targeted vaccination policies and chronic disease management strategies within China's aging population framework.
5. Conclusions
The presence of chronic comorbidities is significantly associated with an increased risk of HZ. These findings highlight the importance of prioritizing HZ prevention strategies—including vaccination—among high‐risk populations with chronic diseases in China.
Author Contributions
Wenhui Zhu: methodology, writing – original draft, writing – review and editing; software, investigation, formal analysis. Yiqi Xia: writing – review and editing, investigation, formal analysis. Yanran Wang: writing – review and editing, formal analysis, validation. Zhenyu Shi: writing – review and editing, investigation, formal analysis. Yang Shen: writing – review and editing, investigation. Chengsen Cui: writing – review and editing, investigation. Jinxu Ai: writing – review and editing, investigation. Yemin Yuan: writing – review and editing, investigation. Xin Ye: writing – review and editing, investigation, validation, methodology. Dawei Zhu: validation; writing – review and editing, methodology, project administration. Ping He: validation, supervision, writing – review and editing, methodology, resources, project administration, conceptualization.
Funding
The authors have nothing to report.
Ethics Statement
Both the CFPS and this HZ‐related sub‐study received ethical approval (IRB00001052‐14010; IRB000001052‐24022) from the Institutional Review Board at Peking University. This study was formally registered with the Chinese Clinical Trial Registry (ChiCTR2400085891).
Consent
All participants provided written informed consent at the time of enrollment in this study. Participants aged ≥ 15 years signed the consent form themselves, whereas written informed consent for participants aged ≤ 15 years was obtained from their legal guardians.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Figure S1: Adjusted odds ratio of herpes zoster stratified by specific chronic diseases with mental disorders considered as a confounder. Table S1: Incidence rate of herpes zoster among adults in China (n = 21496). Table S2: Association between chronic diseases and herpes zoster among adults.
Acknowledgments
We gratefully acknowledge the Institute of Social Science Survey, Peking University and all those who participated in this project and the 2024 CFPS. During the preparation of this work, the authors used Deepseek AI to improve the manuscript's readability and language. The authors reviewed and edited the content as needed and take full responsibility for the final version.
Data Availability Statement
Anonymized individual‐level data and datasets generated or analyzed during the current study are available from the CFPS portal (https://www.isss.pku.edu.cn/cfps/) on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1: Adjusted odds ratio of herpes zoster stratified by specific chronic diseases with mental disorders considered as a confounder. Table S1: Incidence rate of herpes zoster among adults in China (n = 21496). Table S2: Association between chronic diseases and herpes zoster among adults.
Data Availability Statement
Anonymized individual‐level data and datasets generated or analyzed during the current study are available from the CFPS portal (https://www.isss.pku.edu.cn/cfps/) on reasonable request.