From Neglected to Soaring: The Shingles Vaccine Sector's Remarkable Comeback

Time can falsify many things, such as earlier investment decisions.

Recently, the market performance of the shingles vaccine has left many investors in awe. According to the 2023 financial report released by Changchun Bcht Biotechnology Co., its live attenuated shingles vaccine generated 882 million yuan in sales in just the first eight months after its launch. This is merely the market performance of the fastest-selling domestically produced shingles vaccine. As more promising shingles vaccines with better efficacy and safety data enter the late stages of clinical development, ZF Bio, which once popularized the HPV9 vaccine, placed an order worth several times the amount for GSK’s star product, Shingrix. The hundred-billion-yuan market potential of the shingles vaccine seems to be coming into clearer focus.

"How do you feel now that countless investors in China previously denied the clinical and market significance of this product?" one investor lamented on social media. He himself was among those who missed the opportunity. Four years ago, he reviewed several projects related to shingles, "but I didn’t invest because I was worried the product wouldn’t sell." As for why he made that judgment, he did not elaborate.

The missed opportunity in the shingles vaccine market has become the first regret for many investors in 2024. As the saying goes, those who don’t know how to use money heat up a hot stove, while those who do heat up a cold one. A few years ago, China’s shingles vaccine market was undoubtedly a very cold stove, but waiting for that cold stove to heat up requires not only courage but also a bit of luck.

The process of innovation is to establish a new order in chaos.

In China, there has been ongoing debate about whether the shingles vaccine is worth getting. Initially, many people were concerned that it would be too late if they didn’t get the shingles vaccine soon. Subsequently, another perspective emerged, accusing vaccine manufacturers of over-marketing. Both viewpoints have their own arguments and data to support them. As a result, many people have chosen to get vaccinated. With the development of clinical medicine and public health to date, the idea that prevention is better than treatment has been accepted by many.

It is undeniable that the manufacturers of the shingles vaccine have put great effort into promotion. Shingrix, GSK's recombinant shingles vaccine, is the second shingles vaccine to be approved for marketing globally. From the outset of its launch, it followed the route of becoming an internet-famous vaccine, using extensive science popularization campaigns to help users quickly build awareness. In March 2022, GSK faced criticism for its commercial promotion of Shingrix in the UK. Some media outlets pointed out that GSK used the creation of a publicity week as an excuse, but in reality, it was to aggressively promote and boost the sales of Shingrix. In response, GSK immediately clarified that disease awareness campaigns are valuable and legitimate sources of information for the public about diseases and conditions, aiming to raise public awareness of the disease and provide educational information about the condition.

Behind the strong promotional efforts lies a 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However, the negative reviews brought by the overwhelming science popularization did not stop people from getting vaccinated. The shingles vaccine took off amidst controversies. In 2017, Shingrix was launched and quickly replaced another attenuated shingles vaccine on the market. Its sales soared, becoming a new growth driver for GSK.

Data shows that between 2018 and 2022, the global sales of Shingrix were £784 million, £1.8 billion, £1.989 billion, £1.721 billion, and £2.958 billion respectively. By 2023, Shingrix sales reached £3.446 billion. Correspondingly, between 2018 and 2023, with an average vaccination cost of £350 per person, Shingrix achieved vaccinations for 2.14 million, 5.15 million, 5.69 million, 4.924 million, 8.4635 million, and 9.8597 million people globally. In the 2022 list of the top 10 global vaccine sales (excluding the impact of COVID-19 vaccines), Shingrix ranked third, being one of the major products only after Merck's Gardasil 9 HPV vaccine and Pfizer's Prevnar series vaccines.

In China, the shingles vaccine has also taken off amid controversy. When Shingrix first entered the Chinese market, a large-scale public education campaign about the shingles vaccine was launched. There was filial anxiety over taking parents to get the shingles vaccine, which trended on Weibo's hot search, knowledge sharing by clinical doctors at all levels, and user experience sharing on social platforms like Xiaohongshu and Douyin. Coincidentally, the promotion of the shingles vaccine in China also sparked criticism.

At first, the sales of Shingrix in China were quite sluggish. In 2019, Shingrix was approved for marketing in China and began entering preventive immunization clinics across the country in 2020. According to data published by Shingrix's former agent, Shanghai Pharmaceuticals, between 2020 and 2022, Shingrix achieved sales of 487 million yuan, 600 million yuan, and 1.2 billion yuan respectively in China, corresponding to vaccination numbers of 152,000, 187,000, and 375,000 people. The penetration scope and speed were much lower than those in the global market.

The reason for Shingrix's sluggish sales in China does not lie in a lack of market awareness. On the contrary, thanks to intensive science popularization efforts, people’s understanding of the shingles vaccine has rapidly improved. Previously, a set of data disclosed by the media showed that between May and June 2020, the Shanghai Center for Disease Control and Prevention conducted a survey on the willingness of people aged 50 and above to get vaccinated against shingles. The results revealed that out of 562 respondents, only 30.07% were aware of the shingles vaccine, and less than 50% of those were willing to get vaccinated. However, in another survey two years later, 61.8% of respondents at the Songjiang District Maogang Town Community Health Service Center in Shanghai said they would choose the shingles vaccine if it were offered for free.

In fact, the sales data of Changchun Bcht Biotechnology Co. most intuitively reflects the market potential of herpes zoster vaccines in China. As one of the main producers of varicella vaccines in China, Bcht Biotechnology has a mature sales network for Category II vaccines. Relying on vaccination sites embedded in the grassroots healthcare system, the herpes zoster vaccine quickly expanded its reach soon after its launch. With a unit price of 1,398 yuan per dose, approximately 640,000 people completed vaccination within eight months of its market release.

Notably, in October 2023, GSK changed the Chinese distributor of Shingrix to ZF Bio, increasing the number of end-point vaccination sites from over 6,500 to more than 30,000. According to ZF Bio's orders, in 2024, purchases of Shingrix will amount to 3.44 billion yuan, corresponding to an additional vaccinated population of 1.0763 million people, which is several times higher than the previous annual vaccination numbers.

Of course, whether Changchun Bcht Biotechnology Co. or GSK, they are very special participants in the vaccine market, and their commercialization experience and capabilities are difficult for start-up vaccine companies to replicate. However, the shingles vaccine has already shown the potential to become a phenomenal product, and in such a situation, many traditional commercialization concepts may often be overturned.

For a long time, symptomatic treatment was considered the optimal solution for herpes zoster. Objectively speaking, symptomatic treatment can also basically meet the clinical needs of herpes zoster.

This is a skin disease that predominantly affects the elderly. A study published in China CDC Weekly, conducted jointly by the Chinese Center for Disease Control and Prevention, Hainan Provincial Center for Disease Control and Prevention, and other institutions, indicates that the incidence of herpes zoster is highest among people aged 55 and above. As age increases, the probability of developing herpes zoster and experiencing postherpetic neuralgia rises significantly. Additionally, critically ill patients are also a high-risk group for herpes zoster.

But in fact, the varicella-zoster virus does not only trouble the elderly and seriously ill patients; the vast majority of people are carriers of this virus. After entering the human body, the varicella-zoster virus lurks in the neurons of the dorsal root ganglia of the spinal cord. However, for most of one’s life, the virus remains dormant. It is only when the body's immunity declines that the varicella-zoster virus becomes activated, causing shingles.

Clinical Treatment of Herpes Zoster: No Specific Drug Yet, but Both Western and Traditional Chinese Medicine Offer Extensive Symptomatic SolutionsIn clinical practice, there is still no specific drug for the treatment of herpes zoster. However, both Western medicine and Traditional Chinese Medicine (TCM) have rich symptomatic treatment options. Typically, Western medicine recommends patients to use antiviral drugs such as acyclovir or apply local anesthetic lidocaine ointment on the skin to reduce nerve pain. The treatment of herpes zoster is one of the strengths of TCM. Taking prescriptions that clear heat, detoxify, and constrict, or using acupuncture, bloodletting, and cupping therapies, may quickly alleviate pain or even lead to complete recovery.

But even with significant symptomatic treatment, herpes zoster remains a nightmare for patients. If afflicted with herpes zoster, aside from unbearable itching, there is often accompanying burning, electric shock-like, or cutting pain. Pain lasting more than one month can be defined as postherpetic neuralgia, the most common complication of herpes zoster. Some individuals may experience neuropathic pain for as long as ten years or more.

Today, people yearn for a healthier lifestyle, and their attitude towards diseases has shifted from passive treatment to proactive prevention. This change in mindset has also driven a leap in the underlying logic of medical innovation. It is against this backdrop that the shingles vaccine has emerged.

Based on the clinical research and real-world data obtained so far, the shingles vaccine has proven to be highly effective in preventing this disease. Taking Shingrix as an example, according to data released by GSK, in the pivotal Phase III clinical trial, Shingrix reduced the risk of shingles infection by 97.2% in adults aged 50 and above compared to the placebo group, and by 91.3% in adults aged 70 and above. Four years after vaccination, the protective efficacy of Shingrix did not show a significant decline, but it dropped notably after eight years. In other words, Shingrix can provide long-term protection for the target population.

In terms of safety, based on current real-world data, there is no clear risk of triggering other diseases after receiving the shingles vaccine, aside from some common side effects. Taking Shingrix as an example, it faced a safety crisis shortly after its launch, but it was quickly resolved. In March 2021, the FDA alerted the public that Shingrix had been associated with an increased risk of Guillain-Barré Syndrome (GBS), a rare neurological autoimmune disorder. However, according to reports from Medicare beneficiaries in the CDC's Vaccine Safety Datalink system, between October 2017 and February 2020, among nearly 3.73 million vaccinated individuals, there were six additional cases of GBS per one million people aged 65 and older within 42 days after receiving Shingrix, compared to the traditional shingles vaccine.

Compared with the strong publicity offensive, the clear health defense function is undoubtedly the core reason for the phased success of the commercialization of the shingles vaccine. It is not that the shingles vaccine has created additional immune needs for people, but rather that the shingles vaccine appeared at the right time when people were looking for better disease response solutions. In other words, what people are willing to pay for is often upgraded health needs. The investment logic of medical innovation should also be based on this changed underlying logic.

As mentioned earlier, the reason why the shingles vaccine is gaining attention is that it provides a better solution for disease management. In this sense, any exploration to optimize the current status of shingles vaccination may give rise to venture capital opportunities.

First is the exploration of enhancing the protective efficacy of the vaccine itself. At present, multiple shingles vaccines are still in the research and development process in China. According to publicly available data, in addition to Changchun Bcht Biotechnology Co., domestic companies such as Luzhu Bio, Wantai Bio, Walvax Bio, Zhifei Bio, Shanghai Institute of Biological Products, Jiangsu Zhonghui Yuantong, Dalian Yalifeng, Chengdu Maikang, Changchun Qikang, CanSino, and Bowei Bio have all made strategic arrangements. Besides attenuated live vaccines, there are also a significant number of recombinant protein vaccines directly competing with GSK's Shingrix. Moreover, companies like Recbio and Luzhu Bio have openly declared competition against GSK by conducting "head-to-head" clinical studies with Shingrix. Meanwhile, Walvax Bio is even attempting to develop an mRNA-based shingles vaccine.

Secondly, there is the exploration of providing differentiated solutions. The primary recipients of the shingles vaccine are elderly individuals who are highly price-sensitive. A previous survey conducted in Chongming District, Shanghai, and reported by the media showed that among 845 respondents, 475 were unwilling to receive the shingles vaccine, with 211 of them citing high cost as the reason. This indicates that developers of future shingles vaccines do not necessarily have to compete directly with existing products on protective efficacy. There remains market potential for a shingles vaccine offering slightly lower protection efficiency but at a more affordable price, creating opportunities for many domestically produced vaccines.

Finally, the optimization of the vaccination process. The decision-making for herpes zoster vaccination and the timing of vaccination need to be combined with the user's physical condition to make a professional judgment. For instance, when the body experiences a particular special condition or is in the process of receiving other vaccines, whether the herpes zoster vaccine can be administered is not something the average user possesses professional knowledge about. Excessive decision-making costs often lead people to give up vaccination. A U.S. vaccine expert once found in a study that the unsatisfactory vaccination rate among American adults might be more significantly attributed to their difficulty in knowing what vaccines to get, when and where to get vaccinated, and how to use insurance to pay for various vaccines. In future herpes zoster vaccinations, how to leverage cutting-edge technology to customize personalized vaccination plans and form a service loop from vaccination awareness to vaccination practice will undoubtedly be a direction worth exploring.

2023 is widely regarded as a turning point for the herpes zoster vaccine market in China. According to forecasts, starting from this year, both the supply and demand for the herpes zoster vaccine in China are expected to grow more robustly. However, the plotlines of medical innovation are often unpredictable, and only through continuous and meticulous observation of changes in clinical demand can one identify traces of investment opportunities.