How is it decided who is extremely vulnerable and should shield? How do I know how to assess my personal risk?

Posted on: 9th July 2020

Following a request by the British Liver Trust and patients, the British Society of Gastroenterology has worked closely with other professional bodies including the British Association for the Study of the Liver, British Transplantation Society and NHS Blood & Transplant to agree who should be on this ‘shielding list’. 

Professor Phil Newsome, Hepatology Vice-President for the British Society of Gastroenterology explains

While everyone in the UK has been impacted by the COVID-19 pandemic, people who are considered ‘extremely clinically vulnerable’ are amongst those who have felt the impact more than most.  For more than three months, 2.2 million people with underlying health conditions have had to ‘shield. We know this has had a significant impact on their mental wellbeing and quality of life.

The shielding guidance has started to ease and shielding patients are now able to go outside and meet small number of loved ones.  From 1st August (15th August in Wales), the advice to shield will be completely ‘paused’. This means those who have previously been asked to shield will be advised to follow strict social distancing measures and agree a plan with their employers to return to work.

We are aware that this is causing anxiety for this extremely vulnerable group and many people are worried about whether it will be safe for them to stop shielding as the Government is advising.

In this blog, I have tried to explain the rationale for who is in this ‘shielding group’ and some of the points that you may wish to consider when applying the advice and guidance to your personal situation.

Who should shield?

Deciding who should shield has been challenging for the NHS.  The first case of COVID-19 in the UK was just a month after the first case in China so the NHS had to decide on who should shield based on how other viruses have previously impacted people with underlying health conditions.

As we learn more about the virus from studies taking place across the world and emerging datasets, we now have a growing amount of evidence to support this guidance.

Shielding guidance
Shielding is for a patient’s protection rather than a legal obligation. The need for shielding can be flexed further on a case by case basis in consultation with your healthcare team.

Following a request by the British Liver Trust and patients, the British Society of Gastroenterology has worked closely with other professional bodies including the British Association for the Study of the Liver, British Transplantation Society and NHS Blood & Transplant to agree who should be on this ‘shielding list’. These groups are:

Liver patients on the shielding list
  1. 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.

  1. 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.

  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.

Why is this still relevant if shielding is being stopped?

Everyone who has been identified in the above groups should remain on the ‘shielding list’. The virus will be monitored continuously over the coming months and if it spreads too much, you may be advised to shield again. This may happen nationally, or more likely will happen in particular regions if there are isolated areas of high prevalence. It may also mean that if a vaccine is created, the government will prioritise the shielding patients to be vaccinated.

How can I assess my personal risk?

The need for shielding can be changed further on a case by case basis in consultation with your healthcare team.

Shielding guidance is advisory – it is ultimately up to you to decide what to do and there is a need to balance the risk of the disease with the benefits of gradually returning to a normal life. There are three main elements to consider:

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

If you fall into the categories above, we have identified you as highly vulnerable.  You may also be vulnerable (but to a lesser extent) if you have other types of liver disease.

  1. 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.

One reason the government has changed the advice for example, is that four weeks ago around one person in 500 had the virus. Whereas last week less than one in 1700 people had the virus.

The government will also look at figures at a local level and adjust advice regionally if needed as is currently the case in Leicester.

  1. 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.

To find out more about exactly what shielding means look at the FAQs on the website : https://britishlivertrust.org.uk/shielding/

The current guidance for the four nations can be found:

Shielding guidance in England

Shielding guidance in Wales

Shielding guidance in Scotland

Shielding guidance in Northern Ireland

If you are worried about what the ‘pausing’ of shielding means for you, have a discussion with your doctor or healthcare team.

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