Coronavirus (COVID-19) – health advice for people with liver disease and liver transplant patients

Posted on: 4th December 2020

If you or a loved one has a liver condition, or you’ve had a liver transplant, you are likely to be very worried about the impact of COVID-19.

Here you’ll find all information and links to help you if you live with a liver condition.

Latest update

Questions about the new vaccine? We have been in touch with the Department of Health and Social Care to ask questions on behalf of people with liver disease. Read our blog here: https://britishlivertrust.org.uk/update-for-people-with-liver-disease-on-the-covid-19-vaccine/

The British Liver Trust has also created some FAQs for people who were previously asked to shield.

On 2nd December, the government will reintroduce local restriction tiers in England which will be in the following areas.

In tier 1:

  • you must not socialise in groups larger than 6 people, indoors or outdoors, other than where a legal exemption applies.  This is called the ‘rule of 6’
  • businesses and venues can remain open, in a COVID secure manner, other than those which remain closed by law, such as nightclubs
  • hospitality businesses selling food or drink for consumption on their premises are required to:
    • provide table service only, for premises that serve alcohol
    • close between 11pm and 5am (hospitality venues in airports, ports, on transport services and in motorway service areas are exempt)
    • stop taking orders after 10pm
  • hospitality businesses and venues selling food and drink for consumption off the premises can continue to do so after 10pm as long as this is through delivery service, click-and-collect or drive-through
  • early closure (11pm) applies to casinos, cinemas, theatres, concert halls, museums, bowling alleys, amusement arcades, funfairs, theme parks, adventure parks and activities and bingo halls. Cinemas, theatres and concert halls can stay open beyond 11pm in order to conclude performances that start before 10pm
  • public attendance at outdoor and indoor events (performances and shows) is permitted, limited to whichever is lower: 50% capacity, or either 4,000 people outdoors or 1,000 people indoors
  • public attendance at spectator sport and business events can resume inside and outside, subject to social contact rules and limited to whichever is lower: 50% capacity, or either 4,000 people outdoors or 1,000 people indoors
  • places of worship remain open, but you must not attend or socialise in groups of more than 6 people while there, unless a legal exemption applies
  • weddings and funerals can go ahead with restrictions on numbers of attendees – 15 people can attend wedding ceremonies and receptions, 30 people can attend funeral ceremonies, and 15 people can attend linked commemorative events
  • organised outdoor sport, physical activity and exercise classes can continue
  • organised indoor sport, physical activity and exercise classes can continue to take place, if the rule of 6 is followed. There are exceptions for indoor disability sport, sport for educational purposes, and supervised sport and physical activity for under-18s, which can take place with larger groups mixing
  • if you live in a tier 1 area and travel to an area in a higher tier you should follow the rules for that area while you are there. Avoid travel to or overnight stays in tier 3 areas other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities. You can travel through a tier 3 area as part of a longer journey
  • for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

Tier 2: High alert

This is for areas with a higher or rapidly rising level of  infections, where some additional restrictions need to be in place.

In tier 2:

  • you must not socialise with anyone you do not live with or who is not in your support bubble in any indoor setting, whether at home or in a public place
  • you must not socialise in a group of more than 6 people outside, including in a garden or a public space – this is called the ‘rule of 6’
  • businesses and venues can continue to operate, in a COVID-Secure manner, other than those which remain closed by law, such as nightclubs
  • pubs and bars must close, unless operating as restaurants. Hospitality venues can only serve alcohol with substantial meals
  • hospitality businesses selling food or drink for consumption on their premises are required to:
    • provide table service only, in premises which sell alcohol
    • close between 11pm and 5am (hospitality venues in airports, ports, transport services and motorway service areas are exempt)
    • stop taking orders after 10pm
  • hospitality businesses and venues selling food and drink for consumption off the premises can continue to do so after 10pm as long as this is through delivery service, click-and-collect or drive-through
  • early closure (11pm) applies to casinos, cinemas, theatres, museums, bowling alleys, amusement arcades, funfairs, theme parks, adventure parks and activities, and bingo halls. Cinemas, theatres and concert halls can stay open beyond 11pm in order to conclude performances  that start before 10pm
  • public attendance at outdoor and indoor events (performances and shows) is permitted, limited to whichever is lower: 50% capacity, or either 2,000 people outdoors or 1,000 people indoors
  • public attendance at spectator sport and business events can resume inside and outside, subject to social contact rules and limited to whichever is lower: 50% capacity, or either 2,000 people outdoors or 1,000 people indoors
  • places of worship remain open but you must not socialise with people from outside of your household or support bubble while you are indoors there, unless a legal exemption applies
  • weddings and funerals can go ahead with restrictions on numbers of attendees – 15 people can attend wedding ceremonies and receptions, 30 people can attend funeral ceremonies, and 15 people can attend linked commemorative events such as wakes  or stonesettings.
  • organised outdoor sport, and physical activity and exercise classes can continue
  • organised indoor sport, physical activity and exercise classes will only be permitted if it is possible for people to avoid mixing with people they do not live with (or share a support bubble with). There are exceptions for indoor disability sport, sport for educational purposes and supervised sport and physical activity for under-18s, which can take place with larger groups mixing
  • you can continue to travel to venues or amenities which are open, but should aim to reduce the number of journeys you make where possible
  • if you live in a tier 2 area, you must continue to follow tier 2 rules when you travel to a tier 1 area. Avoid travel to or overnight stays in tier 3 areas other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities.You can travel through a tier 3 area as a part of a longer journey
  • for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

This is for areas with a very high or very rapidly rising level of infections, where tighter restrictions are in place.

In tier 3:

  • you must not meet socially indoors or in most outdoor places with anybody you do not live with, or who is not in your support bubble, this includes in any private garden or at most outdoor venues
  • you must not socialise in a group of more than 6 in some other outdoor public spaces, including parks, beaches, countryside accessible to the public, a public garden, grounds of a heritage site or castle, or a sports facility – this is called the ‘rule of 6’
  • hospitality settings, such as bars (including shisha venues), pubs, cafes and restaurants are closed – they are permitted to continue sales by takeaway, click-and-collect, drive-through or delivery services.
  • accommodation such as hotels, B&Bs, campsites, and guest houses must close. There are several exemptions, such as for those who use these venues as their main residence, and those requiring the venues where it is reasonably necessary for work or education and training
  • indoor entertainment and tourist venues must close. This includes:
    • indoor play centres and areas, including trampolining parks and soft play
    • casinos
    • bingo halls
    • bowling alleys
    • skating rinks
    • amusement arcades and adult gaming centres
    • laser quests and escape rooms
    • cinemas, theatres and concert halls
    • snooker halls
  • indoor attractions at mostly outdoor entertainment venues must also close (indoor shops, through-ways and public toilets at such attractions can remain open). This includes indoor attractions within:
    • zoos, safari parks, and wildlife reserves
    • aquariums, visitor attractions at farms, and other animal attractions
    • model villages
    • museums, galleries and sculpture parks
    • botanical gardens, biomes or greenhouses
    • theme parks, circuses, fairgrounds and funfairs
    • visitor attractions at film studios, heritage sites such as castles and stately homes
    • landmarks including observation decks and viewing platforms
  • leisure and sports facilities may continue to stay open, but group exercise classes (including fitness and dance) should not go ahead. Saunas and steam rooms should close
  • there should be no public attendance at spectator sport or indoor performances and large business events should not be taking place. Elite sport events may continue to take place without spectators
  • large outdoor events (performances and shows) should not take place, with the exception of drive-in events
  • places of worship remain open, but you must not attend with or socialise with  anyone outside of your household or support bubble while you are there, unless a legal exemption applies
  • weddings and funerals can go ahead with restrictions on the number of attendees – 15 people can attend wedding ceremonies, wedding receptions are not allowed, 30 people can attend funeral ceremonies, 15 people can attend linked commemorative events
  • organised outdoor sport, and physical activity and exercise classes can continue, however higher-risk contact activity should not take place
  • organised indoor sport, physical activity and exercise classes cannot take place indoors. There are exceptions for indoor disability sport, sport for educational purposes and supervised sport and physical activity for under-18s
  • you can continue to travel to venues or amenities which are open, but should aim to reduce the number of journeys you make where possible
  • avoid travelling to other parts of the UK, including for overnight stays other than where necessary, such as for work, education, youth services, to receive medical treatment, or because of caring responsibilities. You can travel through other areas as part of a longer journey
  • for international travel see the Foreign, Commonwealth and Development Office travel advice for your destination and the travel corridors list

The advice is different in each of the devolved nations:

Scotland – https://www.gov.scot/publications/covid-shielding/

Northern Ireland – https://www.nidirect.gov.uk/articles/coronavirus-covid-19-pausing-shielding-extremely-vulnerable-people

Wales –  https://gov.wales/shielding-extremely-vulnerable-people

‘Clinically extremely vulnerable’ liver disease patients include the following:

1. Patients who are actively on the liver transplant waiting list or who have received a liver transplant.

Data: This is supported by data from NHSBT that indicates that patients who have had liver transplant have an unadjusted mortality rate of 25%. Patients who are on the transplant list could be called in any time and will not be transplanted if coronavirus positive.

2. Patients with chronic liver disease who are on immunosuppressants.

Data: There are as yet no large enough datasets to support/refute this approach and thus this is based on clinical judgement.

3. Other people who have also been classed as clinically extremely vulnerable by professional bodies including the British Association for the Study of the Liver, British Transplantation Society and NHS Blood & Transplant. This is based on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions. If you fall into this group, please follow the advice for clinically extremely vulnerable group and contact your supervising clinician/GP to clarify and to ensure you have been added to the CEV list when appropriate and includes:

  •  Any patient with liver cirrhosis and decompensation or complication as defined by presence/recent history (within 12 months) of ascites, hepatic encephalopathy, hepatocellular carcinoma, variceal bleed or synthetic liver dysfunction.

Data: This is supported by data from the COVID-HEP registry that indicates that patients with decompensated liver cirrhosis have an unadjusted mortality rate 5-28 times higher than patients with liver disease without cirrhosis.

All liver patients should follow the guidelines set by the government for clinically vulnerable (different to extremely vulnerable) people to minimise their chance of exposure to COVID-19:

  • stay at home as much as possible
  • work from home if you can
  • limit contact with other people
  • keep your distance if you go out (2 metres apart where possible)
  • wash your hands regularly

Do not leave home if you or anyone in your household has symptoms.

If you are worried about your own personal risk, it is important that you discuss this with your doctor. New evidence about how the virus behaves is emerging all of the time.

There are three main elements to consider:

1.What would happen to me if I contracted the coronavirus?

If you were on the shielding list before, you have been identified you as highly vulnerable.  You may also be vulnerable (but to a lesser extent) if you have other types of liver disease.

2. How likely am I to catch the virus?

The recommended response to the ‘shielding category’ is nationally set, remains under review and will change in response to updated guidance from the Chief Medical Officers and the UK government. It is based on the latest scientific evidence on how the pandemic is behaving and includes disease prevalence, R rates, mortality, etc.

The government will also look at figures at a local level and adjust advice regionally if needed.

3. My own personal situation

Everyone is different and has different circumstances. Ultimately it is up to each patient to decide how they respond to the advice. Based on the above, with support from clinical teams, each patient will need to make personal decisions about what they will then do.

Issues to weigh up will include looking at other risk factors (such as age; any other pre-existing medical conditions, morbidities and concurrent medication; ethnicity, sex, BMI; smoking, alcohol etc); home and family circumstances including age range of others at home and nature of accommodation, the person’s mental health, overall wellbeing, employment status and financial position.

As you are aware, COVID-19 is spreading rapidly across the UK. As a result there are now severe restrictions on the number of liver transplants that can be carried out. The Clinical Directors from the seven UK liver transplant centres are working together to ensure that transplants can go ahead whenever possible. Please be reassured that your care is their top priority and this situation is under constant review. Specialists will also discuss with patients whether it’s riskier for them to have their treatment now or delay until a safer time.  NHS staff have been holding appointments via telephone, email or video appointments to minimise risk and only seeing patients face to face when absolutely necessary.

This web page shows the current status of each transplant centre and is updated regularly.

The coronavirus outbreak is a very worrying time for everyone. This anxiety is even more acute for those patients and their families who are anxiously waiting for a liver transplant. Whilst we are concerned that some people who need a transplant may have this delayed because of this unprecedented crisis, the balance of risk needs to be assessed and vulnerable patients need to be protected from contracting the virus.

 We are urging the public to help relieve

As you are aware, COVID-19 is spreading rapidly across the UK. As a result there are now severe restrictions on the number of liver transplants that can be carried out. The Clinical Directors from the seven UK liver transplant centres are working together to ensure that transplants can go ahead whenever possible. Please be reassured that your care is their top priority and this situation is under constant review. Specialists will also discuss with patients whether it’s riskier for them to have their treatment now or delay until a safer time.  NHS staff have been holding appointments via telephone, email or video appointments to minimise risk and only seeing patients face to face when absolutely necessary.

This web page shows the current status of each transplant centre and is updated regularly.

The coronavirus outbreak is a very worrying time for everyone. This anxiety is even more acute for those patients and their families who are anxiously waiting for a liver transplant. Whilst we are concerned that some people who need a transplant may have this delayed because of this unprecedented crisis, the balance of risk needs to be assessed and vulnerable patients need to be protected from contracting the virus.

 We are urging the public to help relieve the pressure on our NHS by following the Government’s guidelines on social distancing and shielding to reduce the spread of Coronavirus so that normal transplant services can be resumed as soon as possible.

If you have any concerns about your health during this time, please make sure to contact your team in the usual way. If you’re looking for further support, please don’t hesitate to reach out to us

the pressure on our NHS by following the Government’s guidelines on social distancing and shielding to reduce the spread of Coronavirus so that normal transplant services can be resumed as soon as possible.

If you have any concerns about your health during this time, please make sure to contact your team in the usual way. If you’re looking for further support, please don’t hesitate to reach out to us

Coronavirus is a new disease and we are still learning every day about the risks it poses. There is very little published data relating to chronic liver disease, however an international collaborative registry has been set up to monitor what happens to patients with chronic liver disease who develop coronavirus. The analysis of this data is being undertaken by teams at the University of Oxford (UK) and University of North Carolina (USA).

The initial preliminary results show that sadly that the more advanced your liver disease is when you contract coronavirus, the worse your outcomes are likely to be. People with advanced liver cirrhosis who are admitted into hospital with coronavirus have very poor outcomes. The worldwide data shows 27% of people with advanced or decompensated cirrhosis who contract coronavirus are admitted into intensive care, 31% sadly die (combined weekly update dated 25 August 2020).

The rates of death in patients with liver disease are much higher than those observed in the general population where studies predict between 3-4% of people who have tested positive for COVID-19, die.

These results do sound very alarming. However, it’s important to remember that this data is subject to bias – doctors often only submit data to the registry for the most serious cases they see and more than 90% of patients in the study were admitted into hospital. Many other people who have contracted the virus at home, may have recovered and will not be in these records.

The same study has also looked at outcomes for people who have had a liver transplant. The initial results from this study indicate that, assuming no other risk factors or comorbidities, people who have had a liver transplant who contract coronavirus are not at an increased risk of death compared with the general population.

As the UK begins to relax lockdown, this new data does suggests that we need to make sure that everyone with liver disease continues to protect themselves from this virus by strictly following social distancing measures and that those with ‘decompensated liver disease’ follow the stricter shielding advice. The British Liver Trust is taking this issue up with the different UK Governments to seek further clarification. In the meantime, if patients are concerned about their own situation, they should contact their own liver specialist to obtain specific advice from them.

The European Association for the Study of the Liver (EASL) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) have issued a Position Paper, providing recommendations for clinicians caring for patients with liver diseases during the current pandemic.

Read more: EASL and ESCMID Position Paper

You should continue to work from home if you can. If this is not possible, your employer should take steps to make your workplace Covid-secure. You can find out more about safety measures in your workplace by searching here, (https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19) for example if you work in a supermarket, you can read the ‘Shops and branches’ guidance.

If you are concerned about your safety at work, talk to your employer and look to come to an agreement. For example, you could discuss staggered working times or taking on a different role. You can get advice on your specific situation and employment rights by visiting the Acas website or calling the Acas helpline, 0300 123 1100.

 

If you have liver disease or liver cancer, you might be particularly worried about how to access treatment, medication and appointments. It is really important that you contact your medical team to find out how this affects you.

Some medical appointments have been postponed or they may be delivered in a different way. This is to help stop the spread of coronavirus and to protect the NHS.

You may be asked to have your appointment over the phone or by online video consultation. Other patients will find their appointment has been rearranged.

Patients who need to have their appointments face-to-face will be asked not to bring a friend or relative with them, unless completely necessary. When you visit the hospital, you'll need to wear a face covering that covers your nose and mouth, unless you have a medical reason which prevents you from doing so.

Cancer treatment and clinically urgent care will still be treated as a priority, but your treatment plan might be reviewed. They'll consider whether the risks of your treatment have changed as a result of coronavirus. Your clinical team will talk to you and answer questions you may have about any changes to your treatment or appointments.

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