From 1 September 2023, the eligibility criteria for the free NHS shingles vaccine will expand. But what is the impact of shingles on people living with Addison's and adrenal insufficiency? We speak with Professor John Wass and explain more.

What is shingles?

Shingles is the infection of a nerve and the skin around it. Shingles has some quite obvious symptoms including a tingling or painful feeling in an area of skin. It can affect you if you’ve had chickenpox, even if you had chickenpox a long time ago, as it’s caused by the same virus. To read more about the symptoms of shingles please visit the NHS shingles website.

Shingles vaccine

In the UK, there is a national vaccine programme to protect older people against shingles. From 1 September 2023, the eligibility criteria for the free NHS shingles vaccine will expand - you can read more about this on the NHS website.

Anyone turning 65 will now be eligible for the vaccine, with no upper age limit. Those over 50 with a severely weakened immune system will also be eligible. We understand this applies across the UK (England, Wales, Scotland and Northern Ireland). The vaccine was previously available to those aged 70 to 79.

Are people with Addison’s and adrenal insufficiency eligible?

People with Addison’s and adrenal insufficiency are only eligible for the shingles vaccine when offered by age. They are not eligible to have the shingles vaccination on the grounds of immunosuppression. People with Addison’s and adrenal insufficiency are not classified as having a severely weakened immune system or being immunosuppressed, unlike for example, those with conditions such as blood cancer. 

This can be an area of confusion for many. So the current Green Book (information from Public Health England which contains the latest evidence, guidance and recommendations on all vaccinations) specifically mentions adrenal insufficiency to clarify that a replacement steroid dose does not fall under the definition of being severely immunosuppressed.

The Green Book states in Chapter 28a page 6 that the vaccine: “should not be offered earlier to those on replacement corticosteroids for adrenal insufficiency, or to those taking topical or inhaled corticosteroids or corticosteroid replacement therapy.”

People with Addison’s and adrenal insufficiency are on a low dose of replacement steroids – rather than on a high dose of steroids for immune suppressive purposes. Therefore the replacement steroids do not make the individual immunosuppressed as the steroids are replacing what the body would naturally produce.

However, it is important to remember that those with Addison’s and adrenal insufficiency are unable to mount a response to infection without extra steroid medication. This is why, for vaccines where the eligibility criteria is wider, such as with an annual flu vaccine, people with Addison’s and adrenal insufficiency benefit hugely from this protection. If you are eligible for the shingles vaccine due to your age, we strongly recommend you receive the vaccine. 

We understand some people may be disappointed to not be eligible for the free shingles vaccine until they are eligible by age. If you have multiple health conditions, please speak directly to your GP who has access to your full medical history and can advise if you may be eligible for other reasons. If you need more support please visit our Sanctuary of Support page

Different vaccines – is one better for our community than another?

There are 2 types of shingles vaccine given in the UK: Shingrix® and Zostavax®. You can check the ingredients in the patient leaflets from the NHS shingles website.

The current Zostavax® vaccination is gradually being phased out and it will be used until supplies deplete to avoid vaccine wastage. The newer and more effective Shingrix® vaccine will then be given as standard. If you are given the option between vaccines, we recommend you ask to receive the Shingrix® vaccine.

Should I increase my steroid dose for the vaccine? 

Our Addison's Clinical Advisory Panel (CAP) advises you to increase your steroid dose for the vaccination for 24 hours as a precaution. There are not likely to be major effects.

Remember vaccines are different for everyone, as everybody is different - so please listen to your body and do what is right for you. Those who are particularly anxious/ stressed before a vaccination for example will "use up" more cortisol so find they have to up-dose further in response to how they feel. 

If you were to feel unwell after vaccination, check if you have an allergy to any ingredients in the vaccine, increase your glucocorticoid (sick day rules), take paracetamol to help reduce your symptoms making them easier to manage, rest and drink plenty of fluids. Visit the NHS website to find out more about reactions to vaccines and the Yellow Card scheme for reporting.

What should I do if I become unwell with shingles? 

Sick Day Rules. As with all illnesses, you should follow the Sick Day Rules and increase your steroid replacement medication.

Contact your GP so they can confirm the shingles diagnosis and prescribe antivirals to help speed up your recovery and avoid longer-lasting problems. This works best if taken within 3 days of your symptoms starting. Another useful tip is to ask about prescribing Gabapentin if you are experiencing neuropathic pain. 

Don’t waste time. Leaving things until they get worse might lead to more serious infections. Read more about shingles on the NHS website.

How can I prepare in case I become unwell with shingles? 

It is important to be prepared with sufficient extra medication and a hydrocortisone emergency injection kit, so you are able to follow Sick Day Rules guidance should you become unwell. Here are our recommended steps to follow.

• Sufficient steroid supplies - make sure you have enough of your replacement steroid medication in the house to take into account the need to increase your replacement dose in response to shingles (Sick Day Rules). If not, contact your GP or endocrinologist immediately to ensure you have extra medication available. Read our GP article for step-by-step instructions and more support if you need it. Remember, 3 months provision of essential steroid medication is standard practice and is the advice given by the ADSHG Clinical Advisory Panel, Society for Endocrinology and on the NHS page for Addison's disease.
• Steroid Emergency Card – have a copy of the NHS Steroid card or ADSHG steroid card to hand, ready to show healthcare professionals should you need medical support or have an adrenal crisis. Learn more about steroid cards.
• Have your own hydrocortisone injection kit - visit our injection kit page to learn more about the importance of kits and how to get a kit if you don't already have one. If you're nervous about using your kit or unsure how to store it, check out our #ShareYourKit campaign for more support.

Myth busting 

1. What is the relationship between chickenpox and shingles? Chickenpox and shingles are caused by the same virus.
2. If I've already had chickenpox, can I still get shingles? Yes, you can have shingles even if you had chickenpox many years ago. This is because it is caused by the same virus which can lie dormant in your body for years.
3. Is shingles contagious? Shingles itself is not contagious, but the virus is. Shingles and chickenpox are caused by the same virus. Therefore you can pass the virus to another person, which could cause them to develop chickenpox, if they have not had chickenpox before. A person can transmit the virus when the shingles rash is in the blister phase. To prevent transmitting the virus, keep shingles rashes covered. Cover the rash from when the blisters appear to when they crust and scab over.
4. Young children and chickenpox. If you have been in contact with any young children with chickenpox in recent years, this will have primed your immune system to keep your resistance to shingles up.

Visit the NHS shingles page for more information

If you want to learn more about vaccines for those with Addison's and adrenal insufficiency, please visit our main vaccine page.

Vaccines, Addison's & adrenal insufficiency

Thank you Professor John Wass, Chair of the Addison's Clinical Advisory Panel (CAP) and Professor of Endocrinology, Oxford University. Read our interview with Professor John Wass on the ADSHG blog.

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