From awareness to action: Overcoming knowledge gaps and enhancing herpes zoster vaccination counseling among Chinese rheumatologists – Results from a nationwide survey

ABSTRACT

To assess the knowledge, attitudes, and practices (KAP) regarding herpes zoster (HZ) and its vaccination among rheumatologists in China. A nationwide cross-sectional survey was conducted between April 1 and May 31, 2025, using the Questionnaire Star online platform. The questionnaire assessed sociodemographic characteristics, knowledge of HZ and its vaccine (via a 13-item scale), attitudes and behaviors regarding vaccination, and willingness to disseminate information. Ordinal logistic regression was applied to identify associated factors of knowledge scores, while subgroup analyses were conducted to evaluate attitude-related factors. A total of 1,772 rheumatologists from a wide range of provinces participated (mean age: 41.4 y; 67.3% female). Regarding professional background, most held a master’s degree (44.1%), followed by a bachelor’s (38.9%) and doctoral degree (17.0%). Clinical titles were distributed as associate chief (31.3%), chief (26.4%), attending (26.2%), and junior physicians (16.0%). The median knowledge score was 7 (IQR: 6–9). Multivariable analysis revealed that higher regional GDP per capita (β = 0.020, p = .040), advanced education (β = 0.234, p < .001), and greater clinical seniority (β = 0.296, p < .001) were independently associated with higher knowledge scores. Clinically, physicians expressed significant concern primarily in three areas: HZ‘s potential to interfere with the underlying autoimmune inflammatory rheumatic diseases (AIIRDs) (89.0%), HZ-related complications (81.5%), and deterioration of patient quality of life (73.0%). Notably, 65.6% of respondents were concerned about all three aspects simultaneously. Regarding vaccination attitudes, 96.4% of respondents reported conditional support for vaccinating patients with AIIRDs, contingent upon pre-vaccination risk assessment and adherence to recommended protocols. Additionally, 80.0% favored prioritizing recombinant vaccines. Subgroup analyses indicated that higher clinical seniority was significantly associated with more supportive attitudes (p < .001). In clinical practice, 76.5% of physicians reported actively recommending HZ vaccination, although several barriers remained. The main reasons for not recommending included limited consultation time (52.2%), perception of low HZ incidence (42.8%), and lack of patient concern (31.3%). Targeted education and strengthened rheumatologist-led counseling may help address existing barriers, particularly among junior physicians in under-resourced settings. Such measures could contribute to improving HZ vaccination uptake and protection in patients with AIIRDs.

Introduction

Clinically manifested as shingles, Herpes Zoster (HZ) arises from the resurgence of the varicella-zoster virus (VZV), which persists indefinitely in sensory ganglia after the initial varicella (chickenpox) episode.¹ Subsequent to the primary infection, the virus retreats into a state of permanent dormancy within the dorsal root or cranial nerve ganglia.^2–5 Globally, more than 90% of adults harbor latent VZV, placing them at risk of developing HZ later in life.⁶ When host immunity declines – often due to aging, immunosuppressive therapy, or systemic illness – the latent virus can reactivate, replicate, and migrate along sensory nerves to the skin, causing unilateral vesicular eruptions accompanied by neuropathic pain.^3,7,8 Beyond its cutaneous presentation, HZ is fundamentally a neurological pathology capable of causing severe morbidity. Its predominant sequela, postherpetic neuralgia (PHN), is characterized by enduring neuropathic pain that continues for extended periods after the resolution of skin lesions, substantially degrading the patient’s quality of life.⁸ The pivotal importance of cell-mediated immunity in suppressing latent VZV is underscored by the observation that HZ susceptibility escalates significantly with both aging and immunocompromised states.⁶

In the general Chinese population, the background incidence of HZ has been reported as 4.28 per 1,000 person-years based on recent epidemiological data.⁹ Conversely, adult patients (aged ≥18 y) afflicted with rheumatic and immune pathologies face a substantially heightened vulnerability, with incidence rates climbing to 16–17 per 1,000 person-years.¹⁰ This trend is starkly exemplified by major autoimmune conditions; specifically, HZ incidence is 2.3 times greater in rheumatoid arthritis (RA) and quadrupled in systemic lupus erythematosus (SLE) relative to the general public.¹¹ Similarly, elevated figures are observed in psoriasis (PsO) and psoriatic arthritis (PsA), standing at 13.3 and 15.9 per 1,000 person-years, respectively,¹² followed by ankylosing spondylitis (AS), which demonstrates an incidence of 11.0 per 1,000 person-years.¹³ Such vulnerability stems from a confluence of risk factors, notably senescence, high neutrophil-to-lymphocyte ratios, and treatment regimens involving glucocorticoids (GC) or immunosuppressants.¹⁴ Regarding clinical outcomes, data reveal a 2.85-fold surge in complication rates for RA patients and a 1.76-fold elevated risk of PHN in the SLE cohort, trends that are significantly compounded by immunosuppressive therapies.^15,16 Furthermore, a higher frequency of recurrent episodes is observed within the patient with autoimmune inflammatory rheumatic diseases (AIIRDs).¹⁷ Surpassing direct physical harm, the burden of HZ is twofold: it incurs substantial costs and necessitates interruptions in the standard care of the patient’s autoimmune disorder. In RA patients, 42.8% temporarily discontinued tofacitinib,¹⁸ and 9.1% permanently ceased treatment following an HZ episode.¹⁹ In SLE patients, VZV infection significantly increases the risk of disease flare-ups, with higher SLE disease activity index (SLEDAI) scores observed in those with HZ compared to those without.^20,21

AIIRDs patients constitute a high-risk population for infections,^22,23 particularly those with advanced age and those receiving immunosuppressive therapies such as GCs, conventional immunosuppressants, and Janus kinase (JAK) inhibitors. A population-based study demonstrated that RA patients treated with JAK inhibitors (tofacitinib, baricitinib, and upadacitinib) had a significantly higher risk of HZ compared to those on conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), underscoring the need for targeted preventive measures.²⁴ Vaccination is an effective strategy to mitigate this risk. Currently, two types of vaccines exist: the live-attenuated zoster vaccine (ZVL) and the recombinant zoster vaccine (RZV). In the United States, ZVL was discontinued following RZV’s FDA approval in 2017 and Advisory Committee on Immunization Practices (ACIP) prioritization in 2018,²⁵ with RZV’s indication expanded in 2021 to include immunodeficient or immunosuppressed adults aged ≥19 y.²⁶ In China, RZV was approved in 2019, followed by the introduction of a domestic live-attenuated vaccine in 2023²⁷; notably, in October 2025, RZV was further indicated for adults aged ≥18 y at increased risk of herpes zoster due to immunodeficiency or immunosuppression. RZV demonstrates high and durable efficacy (≈97% in adults ≥50 y; ≈91% in ≥70 y), sustained for approximately 10 y.^28,29 Based on these evidences, the 2023 Chinese expert consensus recommends RZV for individuals aged ≥50 y and immunocompromised patients aged ≥18 y.³⁰ Similarly, the 2022 American College of Rheumatology (ACR) guidelines strongly advocate RZV for patients aged >18 y undergoing immunosuppressive treatment.³¹ These recommendations align with international guidance from the ACIP,²⁶ the Swiss Federal Vaccination Commission,³² the New Zealand Ministry of Health, and health authorities in Spain, Italy, and Canada,^33,34 all of which support RZV use in immunocompromised adults. Collectively, these guidelines emphasize that vaccination provides essential protection for this vulnerable population.

However, a recent nationwide survey revealed that HZ vaccine coverage among Chinese adults aged ≥40 y is extremely low (0.79%), a situation primarily driven by insufficient public understanding and barriers to vaccine availability.³⁵ In addition to limited awareness and vaccine availability, affordability is also likely to be an important barrier to HZ vaccine uptake in China. In particular, the recombinant zoster vaccine (RZV) is not included in the free National Immunization Program, which means that out-of-pocket cost may further constrain vaccination, especially among older adults and other high-risk groups. Therefore, vaccination uptake in routine practice is likely shaped not only by physician recommendation, but also by broader structural factors such as cost, access, and policy support. Physicians are the primary source of information regarding HZ and vaccination.³⁶ For AIIRDs patients, decisions concerning infection risk and vaccine eligibility require specialist consultation. Given that clinicians’ knowledge and attitudes significantly influence prevention strategies – especially in immunocompromised populations – understanding rheumatologists’ perspectives is crucial. Their awareness of disease burden, familiarity with guidelines, and views on vaccine safety directly shape clinical decision-making and patient outcomes. Therefore, the aim of this study was to investigate the KAP of Chinese rheumatologists regarding HZ vaccination through a nationwide cross-sectional survey.

Methods

Study design

A nationwide questionnaire survey was conducted among rheumatologists via the Questionnaire Star platform from 1 April to 31 May 2025. The survey utilized convenience sampling to recruit eligible rheumatologists practicing in geographically diverse regions nationwide. To establish the necessary participant count, we set a precision threshold (E) of 0.05 alongside a confidence coefficient of 1.96 (95% level). This baseline calculation was adjusted with a design effect (DE) of 2 to mitigate the limitations of convenience sampling and clustering, supplemented by a 10% buffer for invalid data. These parameters dictated a minimum recruitment target of 856. Ultimately, the survey yielded 1,772 valid responses – surpassing the estimate by twofold – which bolstered statistical power and refined the precision of subgroup comparisons. Ethical clearance was secured from the Ethics Committee of Peking University First Hospital. Prior to participation, all respondents were apprised of the research objectives. Digital consent was mandatory, confirming their understanding of the voluntary nature of the study, the right to withdraw at any stage, and strict data anonymity.

Questionnaire design

The questionnaire was designed to assess rheumatologists’ knowledge, attitudes, and practices regarding HZ and HZ vaccination. It consisted of four sections: (1) demographic and professional characteristics, including gender, age, academic degree, years of practice, hospital level, and clinical seniority; (2) knowledge of HZ and HZ vaccines, assessed using 13 items covering etiology, risk factors, clinical manifestations, complications, diagnosis, treatment, vaccine availability, efficacy, and adverse reactions; (3) attitudes toward HZ vaccination in patients with rheumatic and immune diseases; and (4) practice patterns, including willingness to share HZ-related knowledge and recommend vaccination.

To account for regional economic disparities, the province or municipality of each respondent’s hospital was matched with the corresponding 2024 per capita GDP based on official statistics from the National Bureau of Statistics of China. The regional per capita GDP varied substantially, ranging from approximately 80,000 to 220,000 CNY, providing a basis for analyzing the influence of regional economic context on physicians’ knowledge and attitudes.

The initial questionnaire was drafted by two investigators (Y.G. and Z.Z.) based on the study objectives and relevant clinical and public health considerations. A pilot test was conducted before formal distribution, and the questionnaire was subsequently reviewed and refined by an expert panel from Peking University with expertise in epidemiology and biostatistics to improve its clarity, content relevance, and alignment with the study aims. The full questionnaire is provided in the Supplementary Material.

Data analysis

Data were analyzed using the SPSS software (V.27). Independent variables included gender, age, education background, clinical seniority, hospital levels, and regional per capita GDP. The GDP data were obtained from the 2024 report of the National Bureau of Statistics of China. Knowledge of HZ and its vaccine was assessed with 13 items, each correct answer scored as 1 point (total score range: 0–13). An ordinal logistic regression model was used to identify factors associated with knowledge scores. Further subgroup analysis was conducted on cognition-related attitude items, stratified by gender, age, education background, clinical seniority, hospital levels, and per capita GDP levels. For subgroup comparisons, provinces were grouped into low, medium, and high GDP categories determined by the national data. We expressed categorical variables as absolute numbers (n) and relative frequencies (%). A χ² test was used to examine differences between categorical variables. Statistical significance was determined based on two-tailed tests with a threshold of P < .05.

Results

Demographic and professional characteristics of the participants

A total of 1,772 rheumatologists participated in this nationwide survey. Respondents were recruited from 30 provincial-level administrative regions across China, representing broad geographic coverage. The largest respondent cohorts originated from Beijing (n = 194, 10.9%) and Henan Province (n = 166, 9.4%), followed by Zhejiang Province (n = 84, 4.7%) and Shandong Province (n = 84, 4.7%). Complete provincial-level distribution data are provided in Supplementary Table S1.

The mean age of respondents was 41.4 y, and 67.3% were female. The distribution of professional titles was as follows: 16.0% resident physicians or below, 26.2% attending physicians, 31.3% associate chief physicians, and 26.4% chief physicians. Regarding clinical experience, the majority (68.5%) reported over 10 y of practice, specifically 33.8% with 11–20 y, 22.6% with 21–30 y, and 12.1% with more than 30 y (Table 1, Figure 1).

Table 1.

Sociodemographic and professional characteristics of the participants.

Demographic data	Number (%)
Age (years)	41.4 ± 9.5
Gender (female)	1193 (67.3)
Clinical Seniority
Resident physician or below	285 (16.0)
Attending physician	464 (26.2)
Associate chief physician	555 (31.3)
Chief physician	468 (26.4)
Education Level
Bachelor	689 (38.9)
Master	782 (44.1)
Doctor	301 (17.0)
Years of Practice
1–10	559 (31.5)
11–20	598 (33.8)
>20	615 (34.7)
Hospital Level
Grade A tertiary	1341 (75.7)
Non-grade A tertiary	431 (24.3)

Figure 1.

Sociodemographic and professional characteristics of the study participants. (A) Education level (including bachelor’s, master’s, and doctorate degrees). (B) Clinical seniority (resident physician or below, attending physician, associate chief physician, and chief physician). (C) Age group (≤40 y, 41–50 y, and >50 y). (D) Years of practice (1–10 y, 11–20 y, and >20 y).

In this survey, systemic lupus erythematosus (89.5%), rheumatoid arthritis (75.9%), and sjögren’s syndrome (39.0%) were perceived as the three conditions most strongly associated with an elevated risk of HZ.

Knowledge of and factors associated with HZ and HZ vaccine

The median knowledge score among the 1,772 respondents was 7 (IQR: 6–9), with scores spanning the full range (0–13). The distribution was right-skewed, with most scores (78.0%) falling between 5 and 10. A cumulative 21.0% scored ≤5, while 14.3% achieved a high score (≥10). Notably, scores showed a bimodal clustering around 8 (18.4%), 7 (17.1%), and 9 (14.4%), indicating moderate overall knowledge with considerable individual variation.

Performance on specific items varied: only 41.3% correctly identified the causative virus of HZ, whereas 70.3% answered correctly on diagnostic criteria, and 67.2% were aware of the approved vaccine in China.

An ordinal logistic regression analysis was performed to identify factors associated with HZ knowledge. As shown in Table 2, a higher regional per capita GDP was significantly associated with higher knowledge scores (β = 0.020, 95% CI: 0.001–0.039, P = .040 for each 10,000 CNY increase). Additionally, both greater clinical seniority (β = 0.296, 95% CI: 0.158–0.435, P < .001) and advanced education levels (β = 0.234, 95% CI: 0.097–0.372, P < .001) were positively correlated with knowledge scores.

Table 2.

Factor associated with knowledge score regarding HZ and vaccination (Ordinal Logistic Regression).

	β-value (95%CI)	P-values
Per capita GDPa (10,000 CNY)	0.020 (0.001, 0.039)	.040
Age	−0.004 (−0.019–0.012)	.646
Gender (Ref. Male)	0.054 (−0.119–0.233)	.551
Educational level (Ref. Bachelor)	0.234 (0.097–0.372)	<.001
Clinical seniority (Ref. Resident physician or below)	0.296 (0.158–0.435)	<.001
Hospital level (Ref. Non-grade A tertiary hospital)	0.132 (−0.080–0.344)	.222

^aGDP: Gross Domestic Product; CNY: China Yuan.

Concerns and attitudes toward HZ vaccination

Rheumatologists recognized multiple clinically relevant consequences of HZ in patients with rheumatic and immune diseases. Specifically, 89.0% expressed concern about interference with the underlying autoimmune inflammatory rheumatic diseases (AIIRDs), 81.5% about HZ-related complications, and 73.0% about deterioration in patients’ quality of life. Overall, 65.6% of respondents reported concern across all three dimensions simultaneously, whereas only 9.4% were concerned about a single aspect. Regarding vaccination, 96.4% of respondents reported conditional support for vaccine use for infectious disease prevention in patients with rheumatic diseases. When recommending a specific HZ vaccine for patients in a stable condition, 80.0% preferred the recombinant type, 18.8% favored the live attenuated vaccine, and 1.1% advised against vaccination (Figure 2).

Figure 2.

Concerns and attitudes toward herpes zoster (HZ) vaccination. (A) Key aspects of HZ impact on patients with rheumatic and immune diseases (three categories). (B) Attitudes toward the use of vaccines for preventing infectious diseases in patients with rheumatic immune diseases (two categories). (C) Vaccine preference for patients with rheumatic immune diseases in a stable stage (three categories).

To explore factors associated with concerns and attitudes toward HZ vaccination, subgroup analyses were conducted across three dimensions: concern level, preventive attitude, and vaccine preference. Regarding the perceived impact of HZ, participants were categorized into those concerned about “all three dimensions” (65.6%), “two dimensions” (25.0%), and “one dimension” (9.4%) (Figure 2(A)). Subgroup analyses revealed no significant differences across demographic characteristics (Figure 3(A)). In terms of attitudes toward preventing HZ in patients with rheumatic diseases, 96.4% of respondents were “conditionally supportive,” while 3.6% were “opposed” (Figure 2(B)). In subgroup analyses, supportive attitudes toward vaccination differed by clinical seniority (P < .001)(Figure 3(B)). Regarding vaccine preference for patients in a stable disease stage, the majority preferred “recombinant vaccines” (80.0%), followed by “live attenuated vaccines” (18.8%), with only 1.1% opposing vaccination (Figure 2(C)). In addition, vaccine preference differed by gender (P = .002) and clinical seniority (P < .001), with female rheumatologists and those with higher clinical seniority more frequently preferring recombinant vaccines (Figure 3(C)). No other significant differences were observed across the remaining subgroups.

Figure 3.

Subgroup analyses of concerns and attitudes toward HZ vaccination. (A) Subgroup analyses of concerns about the impact of HZ on patients with AIIRDs (three categories). (B) Subgroup analyses of attitudes toward the use of HZ vaccines for preventing HZ in patients with AIIRDs (two categories). (C) Subgroup analyses of vaccine preference for patients with AIIRDs in a stable stage (three categories).

Behavioral to share HZ knowledge and recommend the HZ vaccine

Among the 1,772 physicians, the vast majority (92.0%) reported a willingness to disseminate HZ knowledge, primarily to patients (93.8%) and clients (90.1%), and less commonly to family or friends, reflecting a clinically oriented communication pattern (Figure 4(A)). Among the 143 physicians unwilling to share knowledge, limited consultation time was the leading barrier (72.0%), substantially more common than patient disinterest (30.1%) or a low perceived incidence of HZ (29.4%), suggesting that time constraints may be an important barrier in clinical practice.(Figure 4(B)). Similarly, 76.5% (n = 1356) indicated a willingness to actively recommend HZ vaccination, primarily to patients (93.9%) and clients (85.1%), with lower rates for family (70.8%) and friends (69.7%) (Figure 5(A)). Recommendations were age-specific, favoring individuals aged over 50 y: 50–59 y (76.0%), 60–69 y (82.3%), and ≥70 y (72.3%). In contrast, the <40 age group received the least attention (23.3%) (Figure 5(A)). The most effective educational approaches, as rated by the surveyed rheumatologists, were medical science brochures (87.0%), videos (79.8%), and lectures (71.4%). (Figure 5(B)). Among the 416 physicians who were unwilling to recommend HZ vaccination, the most frequently reported reasons were limited consultation time (52.2%), perceived low HZ incidence (42.8%), and lack of patient concern (31.3%) (Figure 5(C)).

Figure 4.

Key patterns in physicians’ knowledge-sharing behaviors regarding HZ. Bar graphs depict (A) target groups for active HZ knowledge sharing among willing physicians (n = 1630) and (B) barriers among unwilling physicians (n = 143). Each bar represents a specific target group or circumstance, with percentages indicating the proportion of physicians selecting that option.

Figure 5.

Key patterns in HZ vaccine-related practices among rheumatologists. Bar graphs depict rheumatologists’ practices and perceptions regarding HZ vaccination: (A) Recommendation preferences toward different target groups and age groups, based on responses from participants willing to recommend vaccination (N = 1356). (B) Preferred methods for conducting HZ-related patient education among physicians (N = 1356). (C) Reasons for physicians’ reluctance to recommend HZ vaccination (N = 416). Each bar indicates the percentage of participants who selected each corresponding option.

Discussion

HZ represents a significant clinical challenge in immunocompromised populations, with the potential for severe complications, including postherpetic neuralgia. Patients with AIIRDs constitute a particularly vulnerable cohort, experiencing substantially elevated HZ incidence attributed to intrinsic immune dysregulation and concurrent immunosuppressive therapy.³⁷ Accumulating evidence demonstrates that HZ vaccination effectively reduces disease incidence and severity while maintaining an acceptable safety profile in immunocompromised individuals.³⁸ Consequently, current clinical guidelines advocate prioritizing HZ vaccination not only for patients aged ≥50 y with AIIRDs but also for all adults aged ≥18 y with AIIRDs receiving immunosuppressive treatment.¹¹ Despite these guidelines, successful vaccine implementation depends critically on healthcare providers’ willingness to recommend vaccination. Although the internet is the most ubiquitous source of health information, physician recommendation remains the cornerstone of vaccine acceptance.³⁶ Patients view clinician-led counseling as significantly more accurate and trustworthy, making it the most effective driver of behavioral change. Nevertheless, data on rheumatologists’ perspectives regarding HZ prevention in China remain limited. The present study sought to address this knowledge gap by evaluating Chinese rheumatologists’ awareness of HZ risk, interpretation of guideline recommendations, and incorporation of vaccination into routine care.

Knowledge regarding HZ and HZ vaccination among rheumatologists is important for clinical decision-making and patient counseling.In this survey, respondents showed moderate levels of HZ-related knowledge, with variation according to educational attainment, professional title, and regional economic context.These findings align with international reports, which similarly demonstrate heterogeneity in clinicians’ understanding of HZ and its vaccination across different specialties, levels of seniority, and regions.^39–41 These findings suggest that both individual qualifications and broader healthcare resources may influence vaccine literacy.The observed association between regional GDP and knowledge scores may reflect the disparity in medical resources and continuing education opportunities across China. Economically developed regions typically host more tertiary hospitals and academic conferences, providing rheumatologists with greater exposure to updated vaccine guidelines. The implementation of structured CME(Continuing Medical Education) programs, the integration of vaccine education into rheumatology training curricula, and the development of accessible clinical decision support tools may help address these knowledge gaps and support more consistent vaccine counseling in patients with AIIRDs.

This survey provides additional insights into Chinese rheumatologists’ concerns and attitudes toward HZ vaccination. The majority of participants demonstrated awareness of the multifaceted concerns of HZ, acknowledging its potential to interfere with the treatment of AIIRDs, cause severe complications, and impair quality of life. These patterns are consistent with the substantial clinical burden of HZ, particularly among patients with AIIRDs.^42,43 Attitudes toward HZ vaccination were largely favorable, with nearly all respondents expressing conditional support. The high level of conditional support suggests general acceptance of vaccination in principle; however, the conditional nature of this support may reflect persistent uncertainties regarding vaccine efficacy, safety, and cost-effectiveness in AIIRDs.⁴⁴ With respect to vaccine preference, most respondents favored the recombinant zoster vaccine (RZV), while only a minority preferred the live attenuated vaccine.

This trend mirrors current guideline recommendations, which endorse RZV as the preferred option for immunocompromised individuals due to its superior efficacy and safety.⁴⁵ The observed differences in RZV preference by seniority and gender may reflect differences in familiarity with updated evidence or engagement with vaccination guidelines.This finding aligns with international evidence indicating that physicians with higher educational attainment consistently exhibit more favorable attitudes toward HZ and its vaccination, including RZV.⁴⁰ Through the dissemination of updated guidelines and the systematic integration of vaccination discussions into routine rheumatology practice, rheumatologists’ confidence in vaccine counseling may be strengthened. Such efforts may support more consistent vaccine counseling and could potentially contribute to improved HZ vaccination uptake among high-risk patients with AIIRDs.

The majority of respondents expressed readiness to share HZ-related information, particularly with patients and clients, reflecting a clinically oriented pattern of communication. Barriers to sharing knowledge were most commonly attributed to limited consultation time. This suggests that structural constraints in clinical practice may limit preventive counseling, where time pressures often compete with preventive health counseling. Previous studies have similarly identified inadequate consultation time as a key barrier to effective vaccine communication.⁴⁶ Interventions that streamline patient education, such as providing standardized educational materials or integrating digital communication tools, may help address these limitations and support more consistent dissemination. Medical science brochures, videos, and lectures were most frequently endorsed as effective tools. These modalities offer scalable means of reaching diverse patient populations, while also mitigating time constraints during clinic visits.

Encouragingly, a large proportion of rheumatologists expressed willingness to recommend HZ vaccination, particularly for patients over 50 y of age. This aligns with international guideline recommendations prioritizing older adults as a high-risk population.^25,30 Nevertheless, comparatively fewer physicians recommended vaccination for younger adults, despite evidence that immunosuppressed individuals under 50 y also face an elevated risk of HZ.¹¹ It is important to note that at the time of this survey, the expanded indication of RZV for adults aged ≥18 y at increased risk had not yet been officially approved in China. Consequently, the observed caution regarding younger patients likely reflects physicians’ adherence to the then-current approved indications rather than a lack of awareness. With the subsequent approval of this new indication, recommendation rates for this younger vulnerable group may become more aligned with clinical guidelines.

Improving HZ vaccine uptake requires coordinated action across multiple levels, with vaccine cost representing the primary structural barrier. Although physician counseling may enhance patient understanding and acceptance, the recombinant zoster vaccine’s exclusion from China’s National Immunization Program – requiring ~3,200 RMB out-of-pocket – remains prohibitive for many AIIRD patients facing ongoing medication expenses. Without policies addressing affordability through NIP inclusion for high-risk populations, insurance reimbursement, or subsidies, even optimal physician knowledge and recommendation will achieve limited population-level impact. The clinician-level barriers identified in our study warrant educational intervention as essential preparation, but successful implementation ultimately depends on parallel policy efforts to improve vaccine accessibility for the vulnerable populations who would benefit most.

This study provides the first large-scale, multi-regional assessment of HZ vaccination knowledge, attitudes, and practices among Chinese rheumatologists caring for patients with AIIRDs. We identify a substantial knowledge-practice gap that persists despite high awareness of HZ risks, and demonstrate that vaccination counseling varies significantly by physician seniority, educational background, and regional economic context. Specific knowledge deficits regarding vaccine timing, contraindications, and vaccine selection are characterized, establishing an empirical foundation for targeted educational interventions and implementation strategies.

This study has several important limitations. First, our scientific contribution is incremental, focused on implementation science rather than clinical discovery. The cross-sectional design precludes causal inference and does not generate new clinical evidence regarding vaccine efficacy. Rather, we provide methodologically rigorous, adequately powered, geographically representative baseline data that fills an implementation evidence gap in China’s rheumatology community. Second, the knowledge assessment lacked formal psychometric validation, and self-reported data may be subject to social desirability bias. Third, convenience sampling and predominant recruitment from tertiary hospitals may have introduced selection bias and underrepresented perspectives from secondary or community settings, limiting national representativeness. But this exactly reflect the current landscape of rheumatology in China which is characterized by a severe geographical and hierarchical imbalance, with the overwhelming majority of specialists and resources concentrated in tertiary hospitals within major cities. Besides that, physicians with a greater interest in HZ and vaccination were more likely to respond to the questionnaire, introducing a potential direction of bias. Our findings may overestimate the true level of HZ vaccination counseling practices. Conversely, if non‑responders were primarily those with lower awareness or greater time constraints, the true knowledge gaps could be even larger than reported. Fourth, we did not assess vaccine affordability, National Immunization Program inclusion, or clinicians’ support for the recombinant zoster vaccine’s inclusion – important policy-related implementation barriers. Future research should employ probability-based sampling across diverse settings and professional groups, utilize validated instruments, and assess policy-related barriers.

Conclusions

Chinese rheumatologists currently demonstrate suboptimal knowledge of HZ and its vaccination. Targeted education is essential to improve vaccine literacy, particularly for junior physicians and those practicing in economically underdeveloped regions. Moreover, strengthening rheumatologist-led patient education across multiple channels and fostering collaboration with community healthcare providers may help improve uptake. These measures are important for translating professional recommendations into effective preventive action, thereby strengthening protection for patients with AIIRDs.

Biography

Zhuoli Zhang, MD, PhD, is a Chief Physician and Second-Class Professor and doctoral supervisor at the Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China, where she serves as Department Chair and leads the National Clinical Key Specialty Program. She is also Head of the Rheumatology Group at the National Health Commission Examination Center, Vice Chair of the Rheumatic Disease Prevention Committee of the Chinese Preventive Medicine Association, Vice Chair of the Rheumatology and Immunology Committee of the Chinese Hospital Association, and Vice President of the Chronic Disease Branch of the National Health Industry Enterprise Management Association. Prof. Zhang has long been engaged in the clinical management, prevention, and translational research of major rheumatic and immune-mediated diseases. She has led eight National Natural Science Foundation of China (NSFC) projects and nearly 40 national and provincial/ministerial research programs, and has published more than 554 papers, including over 230 SCI-indexed articles in leading journals. She has spearheaded over 50 clinical practice guidelines and Chinese expert consensuses, edited multiple monographs, and founded China’s first rheumatology imaging training base. Her contributions have been recognized by several national and regional medical science and technology awards.

Funding Statement

This work was supported by the National High Level Hospital Clinical Research Funding (Interdisciplinary Clinical Research Project of Peking University First Hospital) [2024IR37], Research Foundation of Immune-Mediated Inflammatory Diseases [J202301E036] and the Beijing Natural Science Foundation [L259070], the National Natural Science Foundation of China [92474201].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The dataset(s) supporting the conclusions of this article are included within the article (and its additional file(s)). Further anonymized data are available from the corresponding authors on reasonable request.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Peking University First Hospital (approved code: 2023-619, date: 29 Jan 2024). All participants provided informed consent electronically prior to participation.

Supplemental material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2678679