Brief report: Effectiveness and safety of recombinant zoster vaccine in inflammatory bowel disease patients aged 18 years and older: A matched cohort and self-controlled case series study

Maheen Humayun; Lina S Sy; Emily Rayens; Lei Qian; Jun Wu; Bradley K Ackerson; Yi Luo; Yanjun Cheng; Avanish R Patel; Zendi Solano; Britta Amundsen; Justine De Jesus; Jennifer H Ku; Elizabeth Chmielewski-Yee; Driss Oraichi; Harry Seifert; Huifeng Yun; Hung Fu Tseng

doi:10.1080/21645515.2026.2730840

. 2026 Sep 28;22(1):2730840. doi: 10.1080/21645515.2026.2730840

Brief report: Effectiveness and safety of recombinant zoster vaccine in inflammatory bowel disease patients aged 18 years and older: A matched cohort and self-controlled case series study

Maheen Humayun ^a,^✉, Lina S Sy ^a, Emily Rayens ^a, Lei Qian ^a, Jun Wu ^a, Bradley K Ackerson ^a, Yi Luo ^a, Yanjun Cheng ^a, Avanish R Patel ^a, Zendi Solano ^a, Britta Amundsen ^a, Justine De Jesus ^a, Jennifer H Ku ^a, Elizabeth Chmielewski-Yee ^b, Driss Oraichi ^b, Harry Seifert ^b, Huifeng Yun ^b, Hung Fu Tseng ^a,^c

^aKaiser Permanente Southern California, Pasadena, CA, USA

^bGSK, Rockville, MD, USA

^cKaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, USA

^✉

CONTACT Maheen Humayun Maheen.X.Humayun@kp.org Kaiser Permanente Southern California, 100 S Los Robles Ave., Pasadena, CA 91101, USA.

Roles

Maheen Humayun: Writing – original draft

Lina S Sy: Conceptualization, Methodology, Supervision, Writing – review & editing

Emily Rayens: Conceptualization, Writing – review & editing

Lei Qian: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Writing – review & editing

Jun Wu: Conceptualization, Data curation, Formal analysis, Investigation, Software, Validation, Writing – review & editing

Bradley K Ackerson: Conceptualization, Investigation, Methodology, Validation, Writing – review & editing

Yi Luo: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Supervision, Validation, Writing – review & editing

Yanjun Cheng: Conceptualization, Data curation, Formal analysis, Investigation, Software, Validation, Writing – review & editing

Avanish R Patel: Conceptualization, Investigation, Methodology, Validation, Writing – review & editing

Zendi Solano: Conceptualization, Investigation, Methodology, Project administration, Supervision, Validation, Writing – review & editing

Britta Amundsen: Investigation, Project administration, Validation, Writing – review & editing

Justine De Jesus: Investigation, Validation, Writing – review & editing

Jennifer H Ku: Conceptualization, Methodology, Writing – review & editing

Elizabeth Chmielewski-Yee: Conceptualization, Methodology, Project administration, Writing – review & editing

Driss Oraichi: Writing – review & editing

Harry Seifert: Conceptualization, Methodology, Writing – review & editing

Huifeng Yun: Conceptualization, Methodology, Writing – review & editing

Hung Fu Tseng: Conceptualization, Funding acquisition, Methodology, Project administration, Supervision, Writing – review & editing

PMCID: PMC13625710 PMID: 42804491

ABSTRACT

Individuals with inflammatory bowel disease (IBD) are at increased risk of herpes zoster (HZ). Using a matched cohort design, we evaluated the vaccine effectiveness (VE) of recombinant zoster vaccine (RZV) against HZ among IBD patients aged ≥18 years. Within the Kaiser Permanente Southern California population, individuals who received 2 RZV doses were matched up to 1:3 to RZV-unvaccinated individuals. Individuals were followed from 31 days after the receipt of the 2^nd RZV dose until the occurrence of a censoring event. VE was calculated using Cox proportional hazards regression. A self-controlled case series analysis was used to compare the rate of flares in the 30‑day risk window following vaccination with the comparison window among RZV recipients using conditional Poisson regression. The adjusted VE of 2 RZV doses (≥4 weeks apart) against HZ was 65.4% (95% confidence interval [CI]: 40.6%–79.9%) in all IBD patients, 62.7% (17.2%–83.2%) in ulcerative colitis patients, and 70.2% (34.5%–86.4%) in Crohn’s disease patients. The VE of 2 doses administered 4 weeks-6 months apart in IBD patients was 62.9% (34.3%–79.1%). The rate ratio for IBD flares was 0.80 (95% CI: 0.58–1.12). In conclusion, RZV provided protection against HZ in IBD patients with no increased risk of IBD flares observed.

KEYWORDS: Inflammatory bowel disease, ulcerative colitis, Crohn’s disease, recombinant zoster vaccine, vaccine effectiveness, flare

Plain Language Summary

Herpes zoster, commonly known as shingles, is a painful skin rash that develops from reactivation of the virus that causes chickenpox. People with inflammatory bowel disease (IBD), including ulcerative colitis or Crohn’s disease, have a higher risk of developing shingles, especially if they receive medications that lower their immune response. A vaccine against shingles, known as RZV for “recombinant zoster vaccine,” is available. In this study, we looked at the health records of adults aged 18 years or older with IBD who had received RZV to see how often they developed shingles compared with adults with IBD who had not received the vaccine. We also looked to see if there was a higher risk of a person’s IBD symptoms suddenly getting worse in the 30 days after RZV vaccination. For our study, we used electronic health records of people who received healthcare services with Kaiser Permanente Southern California between 2018 and 2024. We found that adults with IBD who received 2 doses of RZV given at least 4 weeks apart were 65% less likely to develop shingles than adults with IBD who didn’t receive the vaccine. In adults with IBD who received at least 1 dose of RZV, we found that vaccination did not increase the risk of IBD symptoms suddenly getting worse. Overall, our results show that RZV provides some protection against developing shingles in adults with IBD and does not increase the risk of a flare-up of IBD symptoms.

Introduction

Immunocompromising conditions and use of immunosuppressive medications are recognized as risk factors for herpes zoster (HZ).¹ HZ typically presents as a painful rash and can result in more serious complications including postherpetic neuralgia (PHN) which is characterized by severe and persistent pain.² Individuals with inflammatory bowel disease (IBD) (including ulcerative colitis [UC] and Crohn’s disease [CD]), especially those on immunosuppressive medication, are at increased risk of HZ.^3–5 Following the approval of recombinant zoster vaccine (RZV) for prevention of HZ in adults ≥50 years of age (YOA) in 2017, the United States Food and Drug Administration expanded the indication for RZV to include adults ≥18 YOA who are or will be at increased risk of HZ due to immunodeficiency or immunosuppression caused by known disease or therapy in 2021.^6,7

A pooled post-hoc analysis of 2 pivotal, randomized clinical trials demonstrated robust efficacy of RZV against HZ with no increased risk of serious adverse events among individuals ≥50 YOA with preexisting potential immune-mediated diseases.⁸ However, these clinical trials did not include participants with immunosuppressive conditions, and the post-hoc analysis was not stratified by condition, thus limiting generalizability.^9,10 A few observational studies, focused on older adults, have addressed these concerns by demonstrating that RZV was effective against HZ without increased risk of IBD flares among IBD patients on a variety of medication regimens in real-world settings.^11–15 In a previously published interim analysis of this study, we reported that 2 doses of RZV were effective in preventing HZ with no increased risk of IBD flares post-vaccination among IBD patients ≥50 YOA.¹⁶ In this final analysis, we evaluate the effectiveness and safety of RZV in IBD patients ≥18 YOA, using a larger sample size and extended follow-up.

Methods

Study setting

Methods for the final analysis were similar to the interim analysis and were previously described in detail.¹⁶ This study was conducted among members of Kaiser Permanente Southern California (KPSC), a large integrated pre-paid healthcare system with 4.9 million members.¹⁷ The KPSC member population reflects the racial and socioeconomic diversity of Southern California.^18,19 About 93% of its members remained with KPSC for more than 1 year and 75% remained for at least 5 years.¹⁷ This study was approved by the KPSC Institutional Review Board (IRB number 13192), which waived the requirement for informed consent due to minimal risk to participants.

Vaccine effectiveness

Briefly, a matched cohort design was used to create 2-dose and 1-dose RZV cohorts to assess the effectiveness of RZV among IBD patients ≥18 YOA. The vaccine accrual period spanned from April 2018 to August 2023 with follow-up through August 2024. For individuals ≥50 YOA, the vaccine accrual period ended in November 2022 as the target sample size was met sooner. Those with an index date between March 2020 and December 2020 were excluded due to the potential impact of the coronavirus disease 2019 (COVID-19) pandemic on healthcare seeking behavior and healthcare delivery.

For the 2-dose RZV cohort, those who received 2 doses of RZV ≥4 weeks apart were matched up to 1:3 to RZV-unvaccinated individuals on age group (18–29 years, 30–39 years, 40–49 years, 50–59 years, 60–69 years, 70–79 years and 80+ years), sex, race and ethnicity (White, Black, Hispanic, Asian, and other), IBD condition (UC or CD), and IBD medication category (Table S1) at index date. Vaccinated individuals with both UC and CD were matched to unvaccinated individuals with both conditions if sufficient matches were found. Otherwise, they were matched to unvaccinated individuals with CD (which had a smaller sample size) and were included only in the CD analysis. Medication categories captured the use of medications for IBD management ranging from no treatment in category 1 to highly immunosuppressive medications in category 5 (Table S1). The date of receipt of the 2^nd dose of RZV was the index date for vaccinated individuals and their matched unvaccinated counterparts. The inclusion and exclusion criteria for the 2-dose RZV cohort of IBD patients ≥18 YOA were described previously and detailed in Figure S1.¹⁶

Individuals were followed through electronic health records (EHR) from 31 days after the index date until the occurrence of HZ, termination of KPSC membership, death, receipt of a dose of zoster vaccine (receipt of a 3^rd dose of RZV for 2-dose vaccinated individuals, receipt of a 1^st dose of RZV for unvaccinated individuals, or another zoster vaccine), or end of study period, whichever came first. For PHN analysis among IBD patients, PHN cases contributed person-time until the occurrence of PHN, while HZ cases without PHN were followed until HZ diagnosis date plus 180 days, death, disenrollment, or receipt of a dose of zoster vaccine, whichever came first.

The 2-dose RZV cohort was used to estimate the effectiveness of 2 doses of RZV against HZ and PHN. The cumulative incidence of HZ was estimated by the Kaplan–Meier method, and the difference between vaccinated and unvaccinated groups was tested by the log-rank test. Cox proportional hazards regression was used to calculate the hazard ratio (HR) with 95% confidence interval (CI) comparing incidence rates in RZV vaccinated and unvaccinated individuals. Estimates of vaccine effectiveness (VE) (%) were calculated as (1 – HR) × 100 when the HR was less than or equal to 1, and ([1/HR] −1) × 100 when the HR was greater than 1. VE analysis against HZ was stratified by IBD condition (UC or CD), age group, timing of 2^nd dose (4 weeks-6 months or >6 months after the receipt of 1^st dose), and IBD medication category, while maintaining matched sets. A matched set with both UC and CD was included in both the UC and CD analyses. Following the approach used in the interim analysis, we combined categories 1 and 2 to capture the use of mild or no immunosuppressive medication and categories 3–5 to capture immunosuppressive medications associated with higher HZ risk in a post-hoc analysis (Table S1).¹⁶ To evaluate VE against HZ by time since vaccination, time-varying Cox regression models which model the risk of HZ by time interval were used to estimate VE for each follow-up year. Years since vaccination were combined due to small sample size in a post-hoc analysis. For all analyses, when the number of cases was <5 in the vaccinated group, only incidence estimates were presented.

The 1-dose RZV cohort was used to estimate the VE of 1 dose of RZV against HZ. Vaccinated individuals in this cohort received 1 dose of RZV and did not receive a 2^nd dose within 6 months of the 1^st dose, but could have received the 2^nd RZV dose more than 6 months after the 1^st RZV dose or no subsequent RZV dose by the end of the accrual period. The eligibility criteria for the 1-dose RZV cohort of IBD patients ≥18 YOA are provided in Figure S2. Using the matching algorithm described for the 2-dose RZV cohort, 1-dose RZV-vaccinated individuals were matched to RZV-unvaccinated individuals. An unvaccinated individual was allowed to be matched to both a vaccinated individual in the 2-dose RZV cohort and a vaccinated individual in the 1-dose RZV cohort. The index date was the vaccination date of the 1^st dose of RZV. Individuals were followed from 31 days after the index date until the occurrence of HZ, or occurrence of a censoring event (termination of KPSC membership, death, receipt of a dose of zoster vaccine in unvaccinated individuals and receipt of 2^nd dose of RZV or another zoster vaccine in 1-dose vaccinated individuals), or end of study period, whichever came first. Unvaccinated individuals stopped contributing person-time upon their matched vaccinated individuals’ receipt of the 2^nd RZV dose. VE of 1 dose of RZV was calculated using the methods described for VE of 2 doses of RZV.

Details related to the identification of the IBD study population, HZ using International Classification of Diseases, 10^th Revision diagnosis codes and antiviral prescription, PHN through chart review, and timing and number of doses of RZV using Centers for Disease Control and Prevention vaccine administered (CVX) codes were described previously.¹⁶

Safety

The safety cohort of IBD patients ≥18 YOA, described in Figure S3, was used to conduct a self-controlled case series analysis (SCCS) similar to the interim publication.¹⁶ The vaccine accrual period for this cohort spanned from April 2018 to August 2023 with follow-up through August 2024. For individuals ≥50 YOA, the vaccine accrual period ended in September 2022 as the target sample size was met sooner. Rate ratio (RR) comparing the rate of IBD flares in the 30day risk window following the receipt of RZV to the rate of IBD flares in the comparison window was calculated using conditional Poisson regression. For individuals who received 1 RZV dose, the comparison window included a 30day period between 61–90 days pre-vaccination and a 30day period immediately after the risk window. The comparison windows relative to the timing of the 2^nd dose were previously described in detail.¹⁶ RR was stratified by IBD condition (UC or CD), IBD medication category, and dose of RZV (1^st or 2^nd dose). In a post-hoc analysis, medication categories were combined similar to the VE analysis.

Results

Vaccine effectiveness

The 2-dose RZV cohort of IBD patients had 1,811 vaccinated and 4,880 matched unvaccinated individuals with a mean age of 66.0 years (standard deviation [SD] 11.9) (Table 1). The cohort consisted of 54.0% females, and 65.6% identified as White (Table 1). About 40.7% of the cohort was on medication category 1 (no IBD treatment), and 55.7% of the cohort members had UC (without CD) (Table 1). After matching, age, sex, race and ethnicity, and medication category were well-balanced between vaccinated and unvaccinated individuals (absolute standardized difference [ASD]<0.1, Table 1). Compared to matched unvaccinated individuals, the frequency of outpatient visits was higher (≥11 visits, 88.6% vs. 80.8%, Table 1) and the frequency of emergency department (ED) visits was lower (≥2 visits, 13.3% vs. 16.6%, Table 1) among vaccinated individuals in the year prior to the index date. A higher percentage of vaccinated individuals had previously received zoster vaccine live (ZVL)/varicella vaccination, compared to unvaccinated individuals (36.2% vs. 25.7%, Table 1). The frequencies of baseline comorbidities and immunocompromised status were similar across vaccinated and unvaccinated groups (ASD <0.1) (Table 1). The length of continuous KPSC membership was longer for vaccinated individuals compared to unvaccinated individuals (≥11 years, 63.4% vs. 57.2%, Table 1).

Table 1.

Comparison of baseline characteristics between 2-dose RZV-vaccinated and matched unvaccinated individuals with inflammatory bowel disease included in the 2-dose RZV cohort.

	Vaccinated	Unvaccinated	Total	p-value	ASD
	N = 1811	N = 4880	N = 6691	p-value	ASD
Age at index date, years				.004	0.065
mean (standard deviation)	66.51 (11.59)	65.74 (11.99)	65.95 (11.88)
median	67	66	67
quartile 1, quartile 3	60, 74	60, 73	60, 74
range	18, 98	19, 99	18, 99
Age at index date, years, n (%)				.723	0.040
18—49	85 (4.7%)	251 (5.1%)	336 (5.0%)
50—59	330 (18.2%)	941 (19.3%)	1271 (19.0%)
60—69	656 (36.2%)	1767 (36.2%)	2423 (36.2%)
70—79	548 (30.3%)	1419 (29.1%)	1967 (29.4%)
≥80	192 (10.6%)	502 (10.3%)	694 (10.4%)
Sex, n (%)				.928	0.002
Female	976 (53.9%)	2636 (54.0%)	3612 (54.0%)
Male	835 (46.1%)	2244 (46.0%)	3079 (46.0%)
Race and ethnicity, n (%)				.255	0.062
White	1167 (64.4%)	3223 (66.0%)	4390 (65.6%)
Black	122 (6.7%)	304 (6.2%)	426 (6.4%)
Hispanic	365 (20.2%)	1002 (20.5%)	1367 (20.4%)
Asian	122 (6.7%)	281 (5.8%)	403 (6.0%)
Other	35 (1.9%)	70 (1.4%)	105 (1.6%)
IBD^a, n (%)				.108	0.054
UC	984 (54.3%)	2745 (56.3%)	3729 (55.7%)
CD^b	822 (45.4%)	2130 (43.6%)	2952 (44.1%)
UC+CD	5 (0.3%)	5 (0.1%)	10 (0.1%)
Medication category^c, n (%)				.150	0.075
Category 1	719 (39.7%)	2006 (41.1%)	2725 (40.7%)
Category 2	622 (34.3%)	1690 (34.6%)	2312 (34.6%)
Category 3	316 (17.4%)	811 (16.6%)	1127 (16.8%)
Category 4	152 (8.4%)	354 (7.3%)	506 (7.6%)
Category 5	2 (0.1%)	19 (0.4%)	21 (0.3%)
Number of outpatient visits^a, n (%)				<.001	0.227
0—4	12 (0.7%)	97 (2.0%)	109 (1.6%)
5—10	194 (10.7%)	841 (17.2%)	1035 (15.5%)
≥11	1605 (88.6%)	3942 (80.8%)	5547 (82.9%)
Number of ED visits^a, n (%)				.001	0.102
0	1250 (69.0%)	3165 (64.9%)	4415 (66.0%)
1	321 (17.7%)	905 (18.5%)	1226 (18.3%)
≥2	240 (13.3%)	810 (16.6%)	1050 (15.7%)
Number of hospitalizations^a, n (%)				.048	0.069
0	1540 (85.0%)	4032 (82.6%)	5572 (83.3%)
1	185 (10.2%)	557 (11.4%)	742 (11.1%)
≥2	86 (4.7%)	291 (6.0%)	377 (5.6%)
Baseline comorbidities^a, n (%)
Kidney disease	329 (18.2%)	779 (16.0%)	1108 (16.6%)	.031	0.059
Heart disease	175 (9.7%)	489 (10.0%)	664 (9.9%)	.664	0.012
Lung disease	403 (22.3%)	1044 (21.4%)	1447 (21.6%)	.448	0.021
Liver disease	166 (9.2%)	427 (8.8%)	593 (8.9%)	.595	0.015
Diabetes	439 (24.2%)	1111 (22.8%)	1550 (23.2%)	.204	0.035
Other autoimmune diseases^d	133 (7.3%)	350 (7.2%)	483 (7.2%)	.809	0.007
SARS-CoV-2 infection/COVID- 19 diagnosis	205 (11.3%)	514 (10.5%)	719 (10.7%)	.356	0.025
Immunocompromised status^e at index date, n (%)				.006	0.074
Yes	481 (26.6%)	1139 (23.3%)	1620 (24.2%)
No	1330 (73.4%)	3741 (76.7%)	5071 (75.8%)
History of ZVL/varicella vaccination^f, n (%)				<.001	0.275
No	1155 (63.8%)	3627 (74.3%)	4782 (71.5%)
Yes, ≤5 years	63 (3.5%)	238 (4.9%)	301 (4.5%)
Yes, >5 years	593 (32.7%)	1015 (20.8%)	1608 (24.0%)
History of herpes zoster^f, n (%)				.027	0.060
Yes	273 (15.1%)	634 (13.0%)	907 (13.6%)
No	1538 (84.9%)	4246 (87.0%)	5784 (86.4%)
Length of continuous KPSC membership^f, years, n (%)				<.001	0.142
0—5	335 (18.5%)	1160 (23.8%)	1495 (22.3%)
6—10	327 (18.1%)	927 (19.0%)	1254 (18.7%)
≥11	1149 (63.4%)	2793 (57.2%)	3942 (58.9%)
Concomitant vaccination^g, n (%)				N/A	N/A
Yes	785 (43.3%)	N/A	N/A
No	1026 (56.7%)	N/A	N/A
Time between first and second doses, n (%)				N/A	N/A
4 weeks—6 months	1509 (83.3%)	N/A	N/A
>6 months^h	302 (16.7%)	N/A	N/A

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^aDefined in the 1 year prior to index date.

^b14 of the vaccinated individuals in the CD category also had UC but could only be matched to other unvaccinated individuals with CD.

^cMedication categories are defined in Supplementary Table S1.

^dPsoriasis/psoriatic arthritis, multiple sclerosis, systemic lupus erythematosus, and rheumatoid arthritis.

^eHIV/AIDS, leukemia/lymphoma, congenital/other immunodeficiencies, asplenia/hyposplenia, hematopoietic stem cell transplant/solid organ transplant, and receipt of immunosuppressive medications.

^fDefined based on all available medical records prior to index date.

^gIndividuals with concomitant vaccines on the same day as RZV received: influenza vaccine (47%), COVID-19 vaccine (10%), PCV13/PCV20/PPSV23 (30%), Tdap (26%), and other (14%); 70% concomitant with 1^st dose and 47% concomitant with 2^nd dose.

^hAmong individuals who received the 2^nd dose more than 6 months after the 1^st dose, the range of time between 2 doses was from 6 to 58 months with a median of 11 months.

AIDS, acquired immunodeficiency syndrome; ASD, absolute standardized difference; CD, Crohn’s disease; COVID-19, coronavirus disease 2019; ED, emergency department; HIV, human immunodeficiency virus; IBD, inflammatory bowel disease; KPSC, Kaiser Permanente Southern California; N/A, not applicable; PCV, pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine; RZV, recombinant zoster vaccine; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; Tdap, tetanus, diphtheria, and acellular pertussis vaccine; UC, ulcerative colitis; ZVL, zoster vaccine live.

In the 2-dose RZV cohort of IBD patients who received the 2^nd dose ≥4 weeks after the 1^st dose, 27 HZ cases were identified with an incidence rate of 5.4 (95% CI: 3.7–7.8) per 1,000 person-years compared to 103 HZ cases with an incidence rate of 11.9 (95% CI: 9.8–14.4) per 1,000 person-years among matched unvaccinated IBD patients (Table S2). The mean follow-up times were 2.8 years and 1.8 years for the vaccinated and unvaccinated groups, respectively. The cumulative incidence of HZ was significantly higher among the unvaccinated group compared to the vaccinated group (p-value <.0001, Figure S4). The adjusted VE of 2 RZV doses, administered ≥4 weeks apart, against HZ was 65.4% (95% CI: 40.6%–79.9%) (Figure 1, Table S2).

A forest plot of adjusted vaccine effectiveness against herpes zoster among individuals with inflammatory bowel disease. A forest plot showing adjusted vaccine effectiveness against HZ across subgroups of individuals with inflammatory bowel disease. The heading above the forest plot states Adjusted VE percent, 95 percent CI (Adjusted has a superscript a and VE has a superscript b). The x-axis label is not shown; tick labels run from minus 100 to 100. The y-axis lists subgroup rows. A vertical reference line is at 0. There is a diamond marker (point estimate) with a horizontal 95 percent confidence interval of the following values: Overall: 65.4, 40.6 to 79.9. Time between first and second doses, 4 weeks to 6 months: 62.9, 34.3 to 79.1. Age at index date, years: greater than or equal to 50 is 67.0, 42.2 to 81.2; 60 to 69 is 72.6, 19.0 to 90.7; greater than or equal to 70 is 50.4, minus 7.5 to 77.2. Year after index date with a superscript c: 0 to less than 1 is 73.1, 32.5 to 89.3; 1 to less than 3 is 92.2, 61.5 to 98.4; 3 to less than 7 is minus 30.0, minus 80.8 to 60.9. IBD condition: UC including UC plus CD with a superscript d is 62.7, 17.2 to 83.2; CD including UC plus CD is 70.2, 34.5 to 86.4. Medication category: Category 1 to 2 is 73.1, 44.5 to 87.0; Category 3 to 5 is 51.6, minus 16.2 to 80.4. — Vaccine effectiveness of 2 doses of RZV in preventing herpes zoster among individuals with inflammatory bowel disease.

^aAdjusted for covariates: immunocompromised status, history of HZ, number of outpatient visits, number of ED visits, history of ZVL/varicella vaccination, and length of continuous KPSC membership.

^bVE (%) = (1 – HR) ×100 if HR ≤ 1, and VE (%) = ([1/HR] – 1) ×100 if HR > 1.

^cMedication categories (Table S1) and years after index date combined in post hoc analyses.

^dNot including 14 vaccinated individuals with UC+CD who could only be matched to unvaccinated individuals with CD alone.

CD, Crohn’s disease; CI, confidence interval; ED, emergency department; HR, hazard ratio; HZ, herpes zoster; IBD, inflammatory bowel disease; KPSC, Kaiser Permanente Southern California; RZV, recombinant zoster vaccine; UC, ulcerative colitis; VE, vaccine effectiveness; ZVL, zoster vaccine live.

The adjusted VE estimates of 2 doses of RZV (≥4 weeks apart) against HZ for patients with UC and CD were 62.7% (95% CI: 17.2%–83.2%) and 70.2% (95% CI: 34.5%–86.4%), respectively (Figure 1, Table S2). VE varied by age group, years since index date, and medication category (Figure 1, Table S2). For some categories, the CI was wide potentially due to the small number of cases (Table S2). For individuals who received the 2^nd dose between 4 weeks and 6 months after the 1^st dose, the adjusted VE was 62.9% (95% CI: 34.3%–79.1%) (Figure 1, Table S2). The adjusted VE estimates of 2 doses of RZV (≥4 weeks apart) for 0-<1 years and 1-<3 years since index date (date of receipt of 2^nd dose) were 73.1% (95% CI: 32.5%–89.3%) and 92.2% (95% CI: 61.5%–98.4%), respectively (Figure 1, Table S2). For 3-<7 years since index date, the VE results were inconclusive (−30.0%, 95% CI: −80.8%–60.9%).

The incidence rate of PHN was 0.8 (95% CI: 0.3–2.1) per 1,000 person-years among individuals vaccinated with 2 doses of RZV administered ≥4 weeks apart compared to an incidence rate of 1.1 (95% CI: 0.6–2.1) per 1,000 person-years among unvaccinated individuals (Table S3).

In the 1-dose RZV cohort of IBD patients, 801 vaccinated and 2,340 matched unvaccinated individuals were included (Table S4). Most baseline characteristics were well-balanced (ASD <0.1) between the vaccinated and unvaccinated groups except number of outpatient visits and history of ZVL/varicella vaccination (Table S4). Among those vaccinated with 1 dose of RZV, 8 HZ cases were identified with an incidence rate of 8.1 (95% CI: 4.0–16.1) per 1,000 person-years compared to 37 HZ cases with an incidence rate of 14.7 (95% CI: 10.6–20.2) per 1,000 person-years in matched unvaccinated individuals (Table S5). The adjusted VE of 1 dose of RZV against HZ was 28.9% (95% CI: −41.5%–70.4%) (Table S5).

Safety

The safety cohort comprised 2,600 RZV recipients with IBD (Table 2, Figure S3). The mean age of this cohort was 65.7 years (SD 12.9), 53.4% were female, 61.0% identified as White, 56.0% had UC, and 38.3% were on medication category 1 (Table 2). In the safety cohort, 57 IBD flare cases were identified with an incidence rate of 149.8 (95% CI: 115.6–194.2) per 1,000 person-years during the risk window compared to 95 IBD flare cases with an incidence rate of 181.3 (95% CI: 148.3–221.7) per 1,000 person-years during the comparison window (Table S6). For those who received ≥1 dose of RZV, the RR for IBD flares was 0.80 (95% CI: 0.58–1.12) (Figure 2, Table S6). Compared to the comparison window, the rate of IBD flares was not significantly higher in the risk window following the 1^st (RR = 1.03, 95% CI: 0.72–1.47) and 2^nd dose (RR = 0.45, 95% CI: 0.25–0.81) of RZV (Figure 2, Table S6). The rate of IBD flares was comparable across the risk and comparison windows for both UC (RR = 0.91, 95% CI: 0.59–1.40) and CD (RR = 0.69, 95% CI: 0.41–1.14) (Figure 2, Table S6). The RR for medication category 1–2 was 0.90 (95% CI: 0.57–1.43) and 0.71 (95% CI: 0.44–1.14) for medication category 3–5 (Figure 2, Table S6).

Table 2.

Baseline characteristics of recombinant zoster vaccine recipients with inflammatory bowel disease included in the safety cohort.

	Vaccinated^a
	N = 2600
Age at index date, years
mean (standard deviation)	65.66 (12.91)
median	67
quartile 1, quartile 3	59, 74
range	18, 97
Age at index date, years, n (%)
18—49	201 (7.7%)
50—59	492 (18.9%)
60—69	855 (32.9%)
70—79	751 (28.9%)
≥80	301 (11.6%)
Sex, n (%)
Female	1388 (53.4%)
Male	1212 (46.6%)
Race and ethnicity, n (%)
White	1587 (61.0%)
Black	216 (8.3%)
Hispanic	543 (20.9%)
Asian	195 (7.5%)
Other	59 (2.3%)
IBD condition, n (%)
UC	1456 (56.0%)
CD	1122 (43.2%)
UC+CD	22 (0.8%)
Medication category^b, n (%)
Category 1	996 (38.3%)
Category 2	860 (33.1%)
Category 3	473 (18.2%)
Category 4	198 (7.6%)
Category 5	73 (2.8%)
Number of RZV doses, n (%)
1 dose	558 (21.5%)
2 doses	2042 (78.5%)
Concomitant vaccination^c, n (%)
Yes	1125 (43.3%)
No	1475 (56.7%)

Open in a new tab

^aSupplementary Figure S3 provides the selection criteria for this safety cohort.

^bMedication categories are defined in Supplementary Table S1.

^cIndividuals with concomitant vaccines on the same day as RZV received: influenza vaccine (47%), COVID-19 vaccine (10%), PCV13/PCV20/PPSV23 (32%), Tdap (23%), and other (14%); 79% concomitant with 1^st dose and 34% concomitant with 2^nd dose.

CD, Crohn’s disease; COVID-19, coronavirus disease 2019; IBD, inflammatory bowel disease; PCV, pneumococcal conjugate vaccine; PPSV, pneumococcal polysaccharide vaccine; RZV, recombinant zoster vaccine; Tdap, tetanus, diphtheria, and acellular pertussis vaccine; UC, ulcerative colitis.

A forest plot of inflammatory bowel disease flare rate ratios by dose, condition and medication category. A forest plot titled, Rate Ratio 95 percent CI. The x-axis is unlabeled, with tick labels 0, 0.5, 1 and 1.5. The y-axis lists groups: Overall; RZV dose with First and Second; IBD condition with UC (including UC plus CD) and CD (including UC plus CD); Medication category with Category 1 to 2 and Category 3 to 5 (Medication category has superscript a). A vertical reference line is at 1. Each row shows a diamond marker with a horizontal 95 percent confidence interval and a numeric value at right. Overall: 0.80 with 95 percent confidence interval 0.58 to 1.12. RZV dose, First: 1.03 with 0.72 to 1.47. RZV dose, Second: 0.45 with 0.25 to 0.81. IBD condition, UC (including UC plus CD): 0.91 with 0.59 to 1.40. IBD condition, CD (including UC plus CD): 0.69 with 0.41 to 1.14. Medication category, Category 1 to 2: 0.90 with 0.57 to 1.43. Medication category, Category 3 to 5: 0.71 with 0.44 to 1.14. — Rate ratio of inflammatory bowel disease flare after RZV among individuals with inflammatory bowel disease.

^aMedication categories (Table S1) combined in post hoc analysis.

CD, Crohn’s disease; CI, confidence interval; IBD, inflammatory bowel disease; RZV, recombinant zoster vaccine; UC, ulcerative colitis.

Discussion

Our results demonstrate that 2 doses of RZV were effective in preventing HZ with no increased rate of IBD flares among IBD patients ≥18 YOA. The adjusted VE of 2 RZV doses (≥4 weeks apart) against HZ was 65.4% (95% CI: 40.6%–79.9%) in all IBD patients, 62.7% (95% CI: 17.2%–83.2%) in UC patients, and 70.2% (34.5%–86.4%) in CD patients. The rates of IBD flares were comparable in the risk and comparison windows in IBD (RR = 0.80, 95% CI: 0.58–1.12), UC (RR = 0.91, 95% CI: 0.59–1.40), and CD (RR = 0.69, 95% CI: 0.41–1.14) patients, demonstrating that RZV was not associated with increased rate of flares in these patient populations.

Previously published interim analyses of this study reported that the VE of 2 doses (≥4 weeks apart) of RZV against HZ was 65.1% among IBD patients ≥50 YOA.¹⁶: For UC, the VE of 2 doses was 83.2% (95% CI: 26.3%–96.2%) but results for CD (VE = 43.6%, 95% CI: −39.5%–80.8%) were inconclusive with a wide CI in the interim analysis.¹⁶ With a larger sample size and longer follow-up time in this final analysis, we provide more robust VE estimates addressing some of the limitations of the interim analyses.

Several observational studies, focused on older IBD patients, have found RZV to be associated with a lower risk of HZ.^11,12,15 A retrospective matched cohort study of adults ≥50 YOA found the VE of 2 RZV doses (≥28 days apart) to be 73.4% (95% CI: 60.8%–82.0%) in IBD, 63.5% (95% CI: 43.0%–76.6%) in UC, and 85.7% (95% CI: 69.5%–93.3%) in CD patients.¹¹ In a propensity score matched analysis of ≥50 years olds, the incidence rate of HZ was lower in 2-dose vaccinated IBD (10.9 per 1000 person-years vs. 24.2 per 1000 person-years), UC (10.5 per 1000 person-years vs. 25 per 1000 person-years), and CD (9.4 per 1000 person-years vs. 20.6 per 1000 person-years) patients compared to their unvaccinated counterparts.¹²

There is a lack of studies evaluating the durability of protection offered by RZV in IBD patients. Our results suggest that RZV was effective against HZ for up to 3 years since vaccination, with 2 doses of RZV (≥4 weeks apart) being 73.1% (95% CI: 32.5%–89.3%) effective during 0-<1 years and 92.2% (95% CI: 61.5%–98.4%) effective during 1-<3 years since vaccination. VE results were inconclusive beyond ≥3 years post-vaccination due to small sample size. Constenla et al. reported a VE of 66.7% (95% CI: 45.1 %–79.9%) in 0-<1 years, 77.3% (95% CI: 53.3%–89.0%) in 1-<2 years, and 79.3% (95% CI: 32.7%–93.6%) in 2-<3 years since vaccination among IBD patients ≥50 YOA.¹¹

The rates of IBD flares were comparable in the risk and comparison windows for IBD patients, including UC and CD, across medication categories and following 1^st or 2^nd RZV dose. These results are consistent with the findings of the interim analysis which reported a RR of 0.80 (95% CI: 0.47–1.35) among IBD patients ≥50 YOA.¹⁶ Findings from a previously published SCCS analysis showed that the risk of flares was comparable in the 42day risk window following vaccination compared to the 42day control window (98–140 days prior to vaccination) among ≥50-year-old IBD, CD, and UC patients receiving a 1^st or 2^nd RZV dose.¹⁴ However, this study relied on administrative data alone to ascertain flares, while our study captured clinically relevant flares through chart review as previously described.¹⁶ Another cohort study reported that the 90day cumulative incidence of IBD flare was similar across RZV vaccinated and unvaccinated groups.¹³

This study had several strengths including the use of KPSC’s comprehensive EHR data which accurately captures exposure, outcome, and covariates. The KPSC member population is stable with a high retention rate allowing for longitudinal assessment of outcomes. However, this study had a few limitations. For some outcomes such as PHN and for group categories such as ≥3 years since vaccination and the 18–49 years age group, we could not draw definitive conclusions potentially due to small numbers of cases. While we controlled for confounding at the design stage and through multivariable modeling at the analytical stage, residual confounding could still impact study results. Misclassification of exposure was possible and mild HZ cases not requiring clinical evaluation could have been missed, but this potential misclassification was likely non-differential.

In conclusion, 2 doses of RZV were effective in preventing HZ for up to 3 years post-vaccination with no increased rate of IBD flares observed among IBD patients ≥18 YOA. These results are helpful in addressing theoretical concerns related to possible flares resulting from the administration of an adjuvanted vaccine.

Supplementary Material

EPI_ZOSTER_044_final analysis_IBD_MS_Revised Supplement_2026_07_22.docx

KHVI_A_2730840_SM5289.docx^{(287.9KB, docx)}

Acknowledgments

The authors would also like to thank the following Kaiser Permanente Southern California research associates who were employed by KPSC and provided research support: Rossy Perez, Ashley McDaniel, Abraelle Shirley, Bernice Batres, Charanjot Singh, Elizabeth Sanchez, Isabella Chavez, Laura Gomez-Merchan, Katy Taylor, Samantha Baluyot, Samantha Quinones, Talia Begi, Leticia Vega Daily, Jeannie Song, Ruby Aguayo, Candice Beissel, Savannah Acosta, Maricela Esqueda, Travis Macaraeg, Maria Navarro, Samuel Payan, and Christina Santana. The authors would like to thank Jose Forero (GSK) for study management. The authors also thank Enovalife Medical Communication Service Center for editorial assistance, publication coordination, and writing support (Julia Cope [independent medical writer]), on behalf of GSK.

Biography

Dr. Maheen Humayun is an infectious disease epidemiologist and postdoctoral research fellow in the Department of Research & Evaluation at Kaiser Permanente Southern California. Her research interests include infectious diseases, molecular epidemiology, health equity, and vaccine effectiveness.

Funding Statement

GlaxoSmithKline funded this study [GlaxoSmithKline study identifier: 213825].

Disclosure statement

Maheen Humayun, Lina S. Sy, Emily Rayens, Lei Qian, Jun Wu, Bradley K. Ackerson, Yi Luo, Yanjun Cheng, Avanish R. Patel, Zendi Solano, Britta Amundsen, Justine De Jesus, Jennifer H. Ku, and Hung Fu Tseng report payments made by GSK to their institution for the present work. Maheen Humayun, Lina S. Sy, Emily Rayens, Lei Qian, Jun Wu, Bradley K. Ackerson, Yi Luo, Yanjun Cheng, Zendi Solano, Britta Amundsen, Justine De Jesus, Jennifer H. Ku, and Hung Fu Tseng report payments made by GSK to their institution for studies unrelated to this paper. Maheen Humayun, Lina S. Sy, Emily Rayens, Lei Qian, Bradley K. Ackerson, Yi Luo, Jennifer H. Ku, and Hung Fu Tseng report payments made by Moderna to their institution for studies unrelated to this paper. Lina S. Sy, Emily Rayens, Lei Qian, Bradley K. Ackerson, Yi Luo, Jennifer H. Ku, and Hung Fu Tseng report payments made by AstraZeneca to their institution for studies unrelated to this paper. Lina S. Sy, Lei Qian, Bradley K. Ackerson, and Zendi Solano report payments made by Dynavax to their institution for studies unrelated to this paper. Emily Rayens and Bradley K. Ackerson report payments made by F2G to their institution for studies unrelated to this paper. Jun Wu reports payments made by VoxelCloud to her institution for studies unrelated to this paper. Bradley K. Ackerson and Justine De Jesus report payments made by Pfizer to their institution for studies unrelated to this paper. Elizabeth Chmielewski-Yee, Driss Oraichi, Harry Seifert, and Huifeng Yun are employed by GSK and hold financial equities in GSK. The authors declare no other financial and non-financial relationships and activities.

Data availability statement

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2730840

References

1.Kawai K, Yawn BP.. Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clin Proc. 2017;92(12):1806–10. doi: 10.1016/j.mayocp.2017.10.009. [DOI] [PubMed] [Google Scholar]
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14.Leung J, Anderson TC, Dooling K, Xie F, Curtis JR. Recombinant zoster vaccine uptake and risk of flares among older adults with immune-mediated inflammatory diseases in the US. Arthritis Rheumatol. 2022;74(11):1833–1841. doi: 10.1002/art.42261. [DOI] [PubMed] [Google Scholar]
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17.Kaiser Permanente Southern California Department of Research and Evaluation . Fast facts. 2025. Dec 31. [accessed 2024 Jan 31].https://www.kp-scalresearch.org/aboutus/fast-facts/.
18.Koebnick C, Langer-Gould AM, Gould MK, Chao CR, Iyer RL, Smith N, Chen W, Jacobsen SJ. Sociodemographic characteristics of members of a large, integrated health care system: comparison with US census bureau data. Perm J. 2012;16(3):37–41. doi: 10.7812/TPP/12-031. [DOI] [PMC free article] [PubMed] [Google Scholar]
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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

EPI_ZOSTER_044_final analysis_IBD_MS_Revised Supplement_2026_07_22.docx

KHVI_A_2730840_SM5289.docx^{(287.9KB, docx)}

Data Availability Statement

The datasets generated and/or analyzed during the current study are not publicly available due to privacy concerns.

[cit0001] 1.Kawai K, Yawn BP.. Risk factors for herpes zoster: a systematic review and meta-analysis. Mayo Clin Proc. 2017;92(12):1806–10. doi: 10.1016/j.mayocp.2017.10.009. [DOI] [PubMed] [Google Scholar]

[cit0002] 2.Kawai K, Gebremeskel BG, Acosta CJ. Systematic review of incidence and complications of herpes zoster: towards a global perspective. BMJ Open. 2014;4(6):e004833. doi: 10.1136/bmjopen-2014-004833. [DOI] [PMC free article] [PubMed] [Google Scholar]

[cit0003] 3.Gupta G, Lautenbach E, Lewis JD. Incidence and risk factors for herpes zoster among patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2006;4(12):1483–1490. doi: 10.1016/j.cgh.2006.09.019. [DOI] [PubMed] [Google Scholar]

[cit0004] 4.Khan N, Patel D, Trivedi C, Shah Y, Lichtenstein G, Lewis J, Yang YX. Overall and comparative risk of herpes zoster with pharmacotherapy for inflammatory bowel diseases: a nationwide cohort study. Clin Gastroenterol Hepatol. 2018;16(12):1919.e3–1927.e3. doi: 10.1016/j.cgh.2017.12.052. [DOI] [PubMed] [Google Scholar]

[cit0005] 5.Long MD, Martin C, Sandler RS, Kappelman MD. Increased risk of herpes zoster among 108 604 patients with inflammatory bowel disease. Aliment Pharmacol Ther. 2013;37(4):420–429. doi: 10.1111/apt.12182. [DOI] [PMC free article] [PubMed] [Google Scholar]

[cit0006] 6.U.S. Food and Drug Aministration (FDA) . Approval letter. SHINGRIX. 2017. Oct 20 [accessed 2024 Feb 28]. https://www.fda.gov/media/108274/download?attachment.

[cit0007] 7.U.S. Food and Drug Administration (FDA) . Shingrix Package Insert. 2026. Feb [accessed 2024 Oct 14]. https://www.fda.gov/media/108597/download?attachment.

[cit0008] 8.Dagnew AF, Rausch D, Hervé C, Zahaf T, Levin MJ, Schuind A. ZOE-50/70 study group. Efficacy and serious adverse events profile of the adjuvanted recombinant zoster vaccine in adults with pre-existing potential immune-mediated diseases: a pooled post hoc analysis on two parallel randomized trials. Rheumatology (Oxford). 2021;60(3):1226–1233. doi: 10.1093/rheumatology/keaa424. [DOI] [PMC free article] [PubMed] [Google Scholar]

[cit0009] 9.Cunningham AL, Lal H, Kovac M, Chlibek R, Hwang SJ, Diez-Domingo J, Godeaux O, Levin MJ, McElhaney JE, Puig-Barberà J, et al. Efficacy of the herpes zoster subunit vaccine in adults 70 years of age or older. N Engl J Med. 2016;375(11):1019–1032. doi: 10.1056/NEJMoa1603800. [DOI] [PubMed] [Google Scholar]

[cit0010] 10.Lal H, Cunningham AL, Godeaux O, Chlibek R, Diez-Domingo J, Hwang SJ, Levin MJ, McElhaney JE, Poder A, Puig-Barberà J, et al. Efficacy of an adjuvanted herpes zoster subunit vaccine in older adults. N Engl J Med. 2015;372(22):2087–2096. doi: 10.1056/NEJMoa1501184. [DOI] [PubMed] [Google Scholar]

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[cit0012] 12.Desai A, Hashash JG, Kochhar GS, Hayney MS, Caldera F, Farraye FA. Recombinant Zoster Vaccine [RZV] is effective in patients with inflammatory bowel disease: a US propensity matched cohort study. J Crohns Colitis. 2024;18(6):828–835. doi: 10.1093/ecco-jcc/jjae008. [DOI] [PubMed] [Google Scholar]

[cit0013] 13.Khan N, Trivedi C, Aberra F, Pernes T, Yang YX. Safety of recombinant zoster vaccine in patients with inflammatory bowel disease. J Crohns Colitis. 2022;16(9):1505–1507. doi: 10.1093/ecco-jcc/jjac040. [DOI] [PubMed] [Google Scholar]

[cit0014] 14.Leung J, Anderson TC, Dooling K, Xie F, Curtis JR. Recombinant zoster vaccine uptake and risk of flares among older adults with immune-mediated inflammatory diseases in the US. Arthritis Rheumatol. 2022;74(11):1833–1841. doi: 10.1002/art.42261. [DOI] [PubMed] [Google Scholar]

[cit0015] 15.Khan N, Wang L, Trivedi C, Pernes T, Patel M, Xie D, Yang YX. Efficacy of recombinant zoster vaccine in patients with inflammatory bowel disease. Clin Gastroenterol Hepatol. 2022;20(7):1570.e1–1578.e1. doi: 10.1016/j.cgh.2021.07.023. [DOI] [PubMed] [Google Scholar]

[cit0016] 16.Tseng HF, Sy LS, Rayens E, Ackerson BK, Ku JH, Wu J, Luo Y, Cheng Y, Patel AR, Solano Z, et al. Effectiveness and safety of the recombinant zoster vaccine in adults aged ≥50 years with inflammatory bowel disease. Hum Vaccin Immunother. 2025;21(1):2576981. doi: 10.1080/21645515.2025.2576981. [DOI] [PMC free article] [PubMed] [Google Scholar]

[cit0017] 17.Kaiser Permanente Southern California Department of Research and Evaluation . Fast facts. 2025. Dec 31. [accessed 2024 Jan 31].https://www.kp-scalresearch.org/aboutus/fast-facts/.

[cit0018] 18.Koebnick C, Langer-Gould AM, Gould MK, Chao CR, Iyer RL, Smith N, Chen W, Jacobsen SJ. Sociodemographic characteristics of members of a large, integrated health care system: comparison with US census bureau data. Perm J. 2012;16(3):37–41. doi: 10.7812/TPP/12-031. [DOI] [PMC free article] [PubMed] [Google Scholar]

[cit0019] 19.Davis AC, Voelkel JL, Remmers CL, Adams JL, McGlynn EA. Comparing Kaiser Permanente members to the general population: implications for generalizability of research. Perm J. 2023;27(2):87–98. doi: 10.7812/TPP/22.172. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Brief report: Effectiveness and safety of recombinant zoster vaccine in inflammatory bowel disease patients aged 18 years and older: A matched cohort and self-controlled case series study

Maheen Humayun

Lina S Sy

Emily Rayens

Lei Qian

Jun Wu

Bradley K Ackerson

Yi Luo

Yanjun Cheng

Avanish R Patel

Zendi Solano

Britta Amundsen

Justine De Jesus

Jennifer H Ku

Elizabeth Chmielewski-Yee

Driss Oraichi

Harry Seifert

Huifeng Yun

Hung Fu Tseng

Roles

ABSTRACT

Plain Language Summary

Introduction

Methods

Study setting

Vaccine effectiveness

Safety

Results

Vaccine effectiveness

Table 1.

Figure 1.

Safety

Table 2.

Figure 2.

Discussion

Supplementary Material

Acknowledgments

Biography

Funding Statement

Disclosure statement

Data availability statement

Supplementary material

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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