Do Vaccines Cause Herpes Zoster?

Updated November 9, 2023



Varicella vaccines can rarely cause herpes zoster due to vaccine-strain viral reactivation. Other vaccines currently routinely recommended to the general population in the U.S.* do not cause vaccine-strain viral reactivation.

Epidemiological Evidence

 The 2012 report by the Institute of Medicine (IOM), now called the National Academy of Medicine (NAM), described one study assessing varicella vaccination with vaccine-strain viral reactivation 1; however, it did not provide convincing evidence due to a lack of validity and precision 2.

One large randomized controlled trial published since the 2012 IOM report and conducted in ten European countries found one unconfirmed case of herpes zoster infection and one papular rash out of 4976 recipients of either the MMR vaccine PriorixTM and the varicella vaccine Varilrix® or the combination MMRV vaccine Priorix-Tetra®, all vaccines not used in the U.S. Both of these serious adverse events ** were reported as recovered or resolved 3.

One Israeli study found no association between Comirnaty, the Pfizer-BioNTech COVID-19 vaccine, and herpes zoster 4; however, another larger Israeli study found an excess risk of 15.8 cases of herpes zoster per 100,000 persons vaccinated with Comirnaty 5, though this is not due to vaccine-strain viral reactivation.

Proposed Biological Mechanism

Varicella vaccines are live attenuated viral vaccines, and are therefore able to replicate in the body. Generalized rash is reported in 4-6% of recipients. Systemic reactions are uncommon but possible. Mild zoster illness (shingles) resulting from a latent infection with varicella vaccine virus has been reported. Some cases of herpes zoster after vaccination are due to reactivation of wild type varicella virus from a prior (usually unrecognized) primary varicella infection 6. Immunodeficiency is a contraindication for most live vaccines, including varicella vaccine. For more information, see the Varicella summary.

The 2012 IOM report described cases of vaccine-strain viral reactivation after varicella vaccination 6-25, and concluded that these cases together presented strong mechanistic evidence supporting an association 2. A laboratory-documented case of herpes zoster caused by the vaccine-strain varicella zoster virus in an immunocompetent recipient of zoster vaccine was reported in 2014 26. In immunodeficient persons, vaccine-strain viral reactivation can result in meningitis 6,11,23-25 or encephalitis 13,22.

* These conclusions do not necessarily consider vaccines recommended only for special populations in the United States such as Yellow Fever vaccine (international travelers) or Smallpox vaccine (military personnel), or vaccines no longer recommended to the public such as the Janssen (J&J) COVID-19 vaccine.

[**] A serious adverse event is defined by the Food and Drug Administration (FDA) as resulting “in any of the following outcomes: Death, a life-threatening adverse event, inpatient hospitalization or prolongation of existing hospitalization, a persistent or significant incapacity or substantial disruption of the ability to conduct normal life functions, or a congenital anomaly/birth defect. Important medical events that may not result in death, be life-threatening, or require hospitalization may be considered serious when, based upon appropriate medical judgment, they may jeopardize the patient or subject and may require medical or surgical intervention to prevent one of the outcomes listed in this definition.” This definition is found in Title 21, §312.32 of the Electronic Code of Federal Regulations.


1.         Donahue JG, Kieke BA, Yih WK, Berger NR, McCauley JS, Baggs J, Zangwill KM, Baxter R, Eriksen EM, Glanz JM, Hambidge SJ, Klein NP, Lewis EM, Marcy SM, Naleway AL, Nordin JD, Ray P, Belongia EA. Varicella vaccination and ischemic stroke in children: is there an association? Pediatrics 2009; 123(2): e228-34.

2.         Institute of Medicine. In: Stratton K, Ford A, Rusch E, Clayton EW, eds. Adverse Effects of Vaccines: Evidence and Causality. Washington (DC): National Academies Press (US); 2012.

3.         Prymula R, Bergsaker MR, Esposito S, Gothefors L, Man S, Snegova N, Stefkovicova M, Usonis V, Wysocki J, Douha M, Vassilev V, Nicholson O, Innis BL, Willems P. Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine versus one dose of monovalent varicella vaccine: a multicentre, observer-blind, randomised, controlled trial. Lancet 2014; 383(9925): 1313-24.

4.         Shasha D, Bareket R, Sikron FH, Gertel O, Tsamir J, Dvir D, Mossinson D, Heymann AD, Zacay G. Real-world safety data for the Pfizer BNT162b2 SARS-CoV-2 vaccine: historical cohort study. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases 2022; 28(1): 130-4.

5.         Barda N, Dagan N, Ben-Shlomo Y, Kepten E, Waxman J, Ohana R, Hernan MA, Lipsitch M, Kohane I, Netzer D, Reis BY, Balicer RD. Safety of the BNT162b2 mRNA Covid-19 Vaccine in a Nationwide Setting. N Engl J Med 2021; 385(12): 1078-90.

6.         Galea SA, Sweet A, Beninger P, Steinberg SP, Larussa PS, Gershon AA, Sharrar RG. The safety profile of varicella vaccine: a 10-year review. J Infect Dis 2008; 197 Suppl 2: S165-9.

7.         Sharrar RG, LaRussa P, Galea SA, Steinberg SP, Sweet AR, Keatley RM, Wells ME, Stephenson WP, Gershon AA. The postmarketing safety profile of varicella vaccine. Vaccine 2000; 19(7-8): 916-23.

8.         Wise RP, Salive ME, Braun MM, Mootrey GT, Seward JF, Rider LG, Krause PR. Postlicensure safety surveillance for varicella vaccine. Jama 2000; 284(10): 1271-9.

9.         Angelini P, Kavadas F, Sharma N, Richardson SE, Tipples G, Roifman C, Dror Y, Nofech-Mozes Y. Aplastic anemia following varicella vaccine. The Pediatric infectious disease journal 2009; 28(8): 746-8.

10.       Bryan CJ, Prichard MN, Daily S, Jefferson G, Hartline C, Cassady KA, Hilliard L, Shimamura M. Acyclovir-resistant chronic verrucous vaccine strain varicella in a patient with neuroblastoma. The Pediatric infectious disease journal 2008; 27(10): 946-8.

11.       Chaves SS, Haber P, Walton K, Wise RP, Izurieta HS, Schmid DS, Seward JF. Safety of varicella vaccine after licensure in the United States: experience from reports to the vaccine adverse event reporting system, 1995-2005. J Infect Dis 2008; 197 Suppl 2: S170-7.

12.       Ghaffar F, Carrick K, Rogers BB, Margraf LR, Krisher K, Ramilo O. Disseminated infection with varicella-zoster virus vaccine strain presenting as hepatitis in a child with adenosine deaminase deficiency. The Pediatric infectious disease journal 2000; 19(8): 764-6.

13.       Goulleret N, Mauvisseau E, Essevaz-Roulet M, Quinlivan M, Breuer J. Safety profile of live varicella virus vaccine (Oka/Merck): five-year results of the European Varicella Zoster Virus Identification Program (EU VZVIP). Vaccine 2010; 28(36): 5878-82.

14.       Ihara T, Kamiya H, Torigoe S, Sakurai M, Takahashi M. Viremic phase in a leukemic child after live varicella vaccination. Pediatrics 1992; 89(1): 147-9.

15.       Jean-Philippe P, Freedman A, Chang MW, Steinberg SP, Gershon AA, LaRussa PS, Borkowsky W. Severe varicella caused by varicella-vaccine strain in a child with significant T-cell dysfunction. Pediatrics 2007; 120(5): e1345-9.

16.       Kraft JN, Shaw JC. Varicella infection caused by Oka strain vaccine in a heart transplant recipient. Arch Dermatol 2006; 142(7): 943-5.

17.       Kramer JM, LaRussa P, Tsai WC, Carney P, Leber SM, Gahagan S, Steinberg S, Blackwood RA. Disseminated vaccine strain varicella as the acquired immunodeficiency syndrome-defining illness in a previously undiagnosed child. Pediatrics 2001; 108(2): E39.

18.       Levy O, Orange JS, Hibberd P, Steinberg S, LaRussa P, Weinberg A, Wilson SB, Shaulov A, Fleisher G, Geha RS, Bonilla FA, Exley M. Disseminated varicella infection due to the vaccine strain of varicella-zoster virus, in a patient with a novel deficiency in natural killer T cells. J Infect Dis 2003; 188(7): 948-53.

19.       Waters V, Peterson KS, LaRussa P. Live viral vaccines in a DiGeorge syndrome patient. Arch Dis Child 2007; 92(6): 519-20.

20.       Chan Y, Smith D, Sadlon T, Scott JX, Goldwater PN. Herpes zoster due to Oka vaccine strain of varicella zoster virus in an immunosuppressed child post cord blood transplant. J Paediatr Child Health 2007; 43(10): 713-5.

21.       Ota K, Kim V, Lavi S, Ford-Jones EL, Tipples G, Scolnik D, Tellier R. Vaccine-strain varicella zoster virus causing recurrent herpes zoster in an immunocompetent 2-year-old. The Pediatric infectious disease journal 2008; 27(9): 847-8.

22.       Chouliaras G, Spoulou V, Quinlivan M, Breuer J, Theodoridou M. Vaccine-associated herpes zoster ophthalmicus [correction of opthalmicus] and encephalitis in an immunocompetent child. Pediatrics 2010; 125(4): e969-72.

23.       Iyer S, Mittal MK, Hodinka RL. Herpes zoster and meningitis resulting from reactivation of varicella vaccine virus in an immunocompetent child. Annals of emergency medicine 2009; 53(6): 792-5.

24.       Levin MJ, Dahl KM, Weinberg A, Giller R, Patel A, Krause PR. Development of resistance to acyclovir during chronic infection with the Oka vaccine strain of varicella-zoster virus, in an immunosuppressed child. J Infect Dis 2003; 188(7): 954-9.

25.       Levin MJ, DeBiasi RL, Bostik V, Schmid DS. Herpes zoster with skin lesions and meningitis caused by 2 different genotypes of the Oka varicella-zoster virus vaccine. J Infect Dis 2008; 198(10): 1444-7. 26.       Tseng HF, Schmid DS, Harpaz R, LaRussa P, Jensen NJ, Rivailler P, Radford K, Folster J, Jacobsen SJ. Herpes zoster caused by vaccine-strain varicella zoster virus in an immunocompetent recipient of zoster vaccine. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2014; 58(8): 1125-8.

Talking Points

Step 1: Establish empathy and credibility
·         As your doctor, I know that you want to make the best choices about vaccines for you and your family.

·         I also know there is a lot of information out there, and it is difficult to figure out who to trust.

·         Would it be okay if I share with you what I have learned from my experience, and what I share with my patients, my family and my friends about vaccine-strain viral reactivation?

Step 2: Briefly address specific concerns, if any
·         The varicella vaccine, the vaccine that protects against chicken pox, can cause zoster due to vaccine-strain viral reactivation, but this is very rare.
Step 3: Pivot to disease risk
·         Vaccine-preventable diseases are real and have very real dangers associated with them, including illness, and even death. They are also equal opportunity diseases, as they can infect anyone at any time.

·         Varicella can cause skin lesions, pneumonia, and inflammation of the brain and spinal cord membranes. Individuals under the age of 1 are particularly at risk.

Step 4: Convey vaccine effectiveness
·         Vaccines are highly effective at protecting you and your family from vaccine-preventable diseases.

·         The two-dose series of varicella vaccine is 94% effective against varicella disease.

Step 5: Give a strong and personalized recommendation
·         You and I have the same goal: to keep you and your family healthy.


·         You have the power to protect yourself and your family from these diseases through vaccination.

·         I strongly recommend vaccination to my patients, my family, and my friends.