Real-World Evaluation of Recombinant Zoster Vaccine Uptake and Outcomes in Solid Organ Transplant Recipients: A Retrospective Cohort Study

Herpes zoster incidence is increased after solid organ transplantation. We analyzed adult recipients of liver, heart, lung, kidney, pancreas or dual-organ transplants between January 2018 and December 2025. We assessed recombinant zoster vaccine uptake and the association between pre-transplant vaccination and post-transplant herpes zoster in 2595 patients. Median follow-up was 2.8 years [IQR 1.6-4.8]. Thirty-two percent of patients completed the two-dose recombinant zoster vaccine series before transplant. A total of 110 herpes zoster cases occurred. By vaccine status, incidence rates (per 1,000 person-years) were 15.4 [95%CI 12.1-19.5] in unvaccinated pre-transplant, 12.3 [95%CI 7.4-19.2] in those with one dose pre-transplant, and 8.1 [95%CI 4.9-12.7] in those with >2 doses pre-transplant. Among patients who received any post-transplant dose, 83% of herpes zoster cases occurred before vaccination. Compared with under-vaccinated patients, those who completed >2 pre-transplant doses had a 49% lower rate of herpes zoster in the post-transplant period (unadjusted HR=0.51 (0.31-0.85) p=0.009) and a 52% lower adjusted hazard in multivariable analysis (aHR 0.48 95% CI 0.29-0.81, p=0.006). Twenty-four cases of postherpetic neuralgia occurred, none in the fully vaccinated group. Recombinant zoster vaccine uptake remains suboptimal and pre-transplant series completion was associated with lower post-transplant herpes zoster incidence.