Burden of herpes zoster and recombinant zoster vaccine willingness in systemic lupus erythematosus: A single-center cohort study

Objective To characterize the burden of herpes zoster (HZ) in systemic lupus erythematosus (SLE) and to examine clinical correlates of HZ and patients’ attitudes toward the recombinant zoster vaccine (RZV). Methods We conducted a single-center retrospective cohort study combined with a cross-sectional survey among consecutive adult outpatients with SLE between December 2024 and June 2025. HZ episodes after SLE diagnosis were ascertained via structured interviews. Incidence rates were calculated as the number of HZ episodes per 1000 person-years from SLE diagnosis to enrollment. Participants were classified into three groups according to the number of HZ episodes: HZ 0 , HZ 1 , and HZ ≥2 groups. Factors associated with HZ development were assessed using multivariable logistic regression. Patients were asked about willingness to receive RZV (“yes”, “no”, or “not sure”) and reasons for the response. Results Among 170 patients with SLE, 73 (43%) reported at least one HZ episode after SLE diagnosis, and 29 (40% of those with HZ) reported recurrent HZ. During 3138 person-years of follow-up, at least 102 HZ episodes were reported, yielding a minimum incidence of 32.5 per 1000 person-years. In multivariable analysis, ever use of azathioprine (OR 2.74, 95% CI 1.03–7.29) and renal dysfunction (OR 2.59, 95% CI 1.04–6.48) were associated with HZ development. Attitude data were available for 159 patients: 31 (20%) were willing to receive RZV, 47 (30%) were unwilling, and 81 (50%) were unsure. Conclusions HZ was common and frequently recurrent in this Japanese SLE cohort. Ever use of azathioprine and renal dysfunction were associated with HZ development, while willingness to receive RZV was low. Risk-stratified clinician counselling and shared decision-making may improve acceptance of HZ prevention strategies in high-risk patients with SLE.