Varicella-zoster virus seroprevalence among reproductive-age women in Iran: a meta-analysis and implications for targeted immunization.

BACKGROUND

Primary varicella-zoster virus (VZV) infection during pregnancy poses significant risks to both mother and fetus, including congenital varicella syndrome (CVS) and serious maternal complications. In Iran, the absence of varicella vaccination in the national immunization program leaves many women susceptible. This systematic review and meta-analysis aimed to determine the overall seroprevalence of VZV antibodies among reproductive-age women in Iran.

METHODS

A comprehensive search was conducted in both international and Iranian databases for studies published up to November 15, 2024. Eligible studies reporting VZV seroprevalence among Iranian women aged 15-49 years were identified. Screening, data extraction, and risk of bias assessment were independently performed by two reviewers. Pooled seroprevalence was estimated using a random-effects meta-analysis in STATA version 18. Heterogeneity was evaluated with the Cochrane Q test and I² statistic. Subgroup analyses and meta-regression explored sources of heterogeneity. Sensitivity analyses (leave-one-out) and publication bias (Doi plot, LFK index) were also performed. The protocol was registered in PROSPERO (CRD42025647813).

RESULTS

Data from 20 studies, including 5,629 participants, were analyzed. A pooled VZV seroprevalence of 81% (95% CI: 77-85%) was found, indicating that approximately 19% of reproductive-age women in Iran remain susceptible. Higher seroprevalence was observed in pregnant women (88%) compared with non-pregnant women (79%), with the lowest rates among medical students (74%). Despite subgroup and meta-regression analyses, substantial heterogeneity remained unexplained. Sensitivity analyses supported the robustness of the results, while possible publication bias was suggested.

CONCLUSIONS

Nearly one in five reproductive-age women in Iran lack immunity to VZV. Targeted vaccination, especially among non-pregnant women and students, may reduce susceptibility. Preconception screening for VZV immunity could help prevent maternal and fetal complications. However, given the high unexplained heterogeneity, results should be interpreted with caution.