Advice for liver patients including those classed as clinically extremely vulnerable (CEV) people during coronavirus (COVID-19) pandemic

• On 4 January 2021, the Prime Minister announced a new National Lockdown to help tackle the high and rising cases of COVID-19. From 5 January, everyone is required to follow the new restrictions set out in the National Lockdown guidance.
• As part of the lockdown, the Government is also advising all clinically extremely vulnerable people to take extra measures to protect themselves during this period.
• These additional measures apply to everyone in England who has been identified as clinically extremely vulnerable , meaning that they face the highest risk of serious illness if they contract COVID-19. If you are in this group, you may have received a letter from the NHS or from your GP telling you this, and you may have been advised to shield in the past. See the guidance on Definition of clinically extremely vulnerable groups for more details.
• If you are in this group, you will soon receive a formal shielding letter that will set out the new guidance and act as evidence for your employer and the Department of Work and Pensions that you are advised to shield and may be eligible for Statutory Sick Pay (SSP) or Employment Support Allowance (ESA) or Universal Credit (UC). This letter will replace any previous shielding letters you will have received.

If you believe you are in one of the categories below and have not been notified, please follow the 'clinically extremely vulnerable' advice and contact your supervising clinician/GP to clarify to ensure you have been added to the list if appropriate.

‘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.

• We are advising clinically extremely vulnerable people to stay at home as much as possible.
• You should still go outside carefully to exercise or to attend health appointments.
• You may wish to meet up with one other person from outside your household or support bubble outdoors, for example to exercise in an outdoor public place, but we suggest that you always try to do so as safely as possible.
• Over this period, we are advising the clinically extremely vulnerable to work from home. If you cannot work from home, you are advised not to go to work and may be eligible for the Coronavirus Job Retention Scheme (CJRS), Statutory Sick Pay (SSP), Employment Support Allowance (ESA), or Universal Credit.
• Clinically extremely vulnerable people are advised not to form childcare bubbles during the period of national lockdown.

The advice will be in place initially from 5 January until 21 February 2021. If the advice is to continue beyond that date, we will write out to clinically extremely vulnerable people to provide further information.

The guidance offers additional advice to the clinically extremely vulnerable over and above the National Lockdown restrictions, which apply to everyone. As before, the guidance for the clinically extremely vulnerable is advisory, although you are strongly advised to follow the advice in order to keep yourself safe

• Yes, we will write to everyone on the shielded patient list in England advising them of these changes. Emails and text messages are being sent where we have those contact details. Guidance is also available on the GOV.UK website, here: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19
• The new letters will replace any shielding letters clinically extremely vulnerable people may have received previously.

• It is important that you continue to receive the care and support you need to help you stay safe and well.
• You should continue to seek support from the NHS for any health
• You can access a range of NHS services from home, including ordering repeat prescriptions or contacting your health professional through an online consultation. To find out more visit nhs.uk/health-at-home, or download the NHS App. If you have an urgent medical need, call NHS 111 or, for a medical emergency, dial 999.
• Any carers or visitors who support you with your everyday needs can continue to visit. They should follow social distancing guidance where close or personal contact is not required.

• People who are living with someone who is clinically extremely vulnerable do not need to follow shielding guidance themselves but do need to follow the National Lockdown rules, as well as guidance on social distancing, which can be found here:

https://www.gov.uk/government/publications/coronavirus-covid-19-meeting-with-others-safely-social-distancing/coronavirus-covid-19-meeting-with-others-safely-social-distancing.

• This means someone who is living with someone who is clinically extremely vulnerable should attend work as normal if they are unable to work from home.
• Clinically extremely vulnerable people are advised not to form childcare bubbles during the period of national lockdown.

Everyone is advised to stay at home as much as possible, but you are still encouraged to go outside for exercise or to attend health appointments.

If you do go out, you should keep all contact with others to a minimum and avoid busy areas. You should also follow the guidance of ‘Hands. Face. Space’

The shielded patient list is monitored regularly. If, following a consultation with your GP or clinician, a clinical decision is made that you face a very high risk of severe illness from COVID-19 then you would be added to the shielded patient list and informed of this.

• The latest data show the virus is spreading rapidly across the country, driven by the new variant of COVID-19.
• The Government has introduced National Lockdown restrictions which apply to everyone to help slow down the rapid spread, and as part of that we are advising clinically extremely vulnerable people to take additional measures to protect themselves.

• Each nation has a slightly different health system and this information only applies to those living in England.
• Chief Medical Officers monitor the scientific evidence in their nation and will change their advice based on risk levels in each nation.

• We understand how hard these measures can be for individuals to follow, but we are confident that this advice strikes the best balance between preventing exposure to the virus with the potential negative physical and mental health consequences of asking people to isolate themselves.
• The advice will be in place initially from 5 January until 21 February 2021. If the advice is to continue beyond that date, we will write out to clinically extremely vulnerable people to provide further information.

• Clinically extremely vulnerable adults will get priority access to vaccination against COVID-19 before the general population and in line with the priority ordering set by the Joint Committee on Vaccination and Immunisation (JCVI).
• You will be contacted again by the NHS with more information on when and how you will be invited to get the vaccine. Your local NHS will ensure that you can receive the vaccine as safely as possible, as well as any care and support needed.

• Even if you have had both doses of the vaccine, you should continue to follow this shielding advice until further notice as we continue to assess the impact of vaccination among all groups.
• The people you live with should continue to follow the public health rules and guidance as long as they are in place, including if you have received the vaccine and if they have received the vaccine.

• If you are clinically extremely vulnerable and you need support to access food, or you have other support needs, you will be able to request support from your local council to help you to stay at home as much as possible.
• Councils are being given funding to provide support to those clinically extremely vulnerable people who need it. This can include help with shopping or requesting priority access to supermarket deliveries or signposting you to local support or befriending services.
• If friends and family are not able to collect your prescriptions or medicines for you, then you will also be eligible for free medicines delivery from your community pharmacy.
• If you cannot work from home, you are advised not to go to work and may be eligible for the Coronavirus Job Retention Scheme (furlough scheme), Statutory Sick Pay (SSP), Employment Support Allowance (ESA), or Universal Credit.
• CEV employees or workers should talk to their employer as soon as they can about the new guidance.

• Clinically extremely vulnerable people can use the Government’s ‘National Shielding Service’ website to register themselves, or on behalf of someone else, to:
• Request priority access to supermarket delivery slots (if you already have access to supermarket deliveries, that will continue - you don’t need to do anything further ).
• Tell your council if you need support in order to follow this guidance that cannot be provided by friends, family or other support networks.
• Update your details, for example your address.
• This service can be found at: https://www.gov.uk/coronavirus-shielding-support. You’ll be asked for your NHS number. You can find it on any letter the NHS has sent you, or on a prescription.
• It is helpful if you register even if you do not have any support needs at this time.
• If you have already used the service to register support needs but your circumstances or needs have changed, you can submit a new registration or set up an NHS log in account and change your details using the same link.
• If you need to register your needs by phone, or have an urgent need, you should contact your local council directly.

• You are advised not to go to the shops. Use online shopping if you can, or ask friends, family or local charities to collect and deliver shopping for you.
• 7 of the UK’s largest supermarkets (Asda, Sainsburys, Tesco, Morrisons, Iceland, Waitrose and Ocado) are continuing to offer priority access to supermarket delivery slots to those clinically extremely vulnerable people who need them.
• If you cannot access food, your local council can offer support. This may include helping you to request priority access to supermarket delivery slots (if you do not already have these) or help with shopping. There is no longer a national food box scheme.
• If you need to register for help getting access to food, you can go to:

https://www.gov.uk/coronavirus-shielding-support.

• NHS Volunteer Respondersmay also be able to help deliver your food shopping. To arrange support for yourself or someone else, please call 0808 196 3646.

• 7 of the UK’s largest supermarkets (Asda, Sainsburys, Tesco, Morrisons, Iceland, Waitrose and Ocado) are continuing to offer priority supermarket slots to clinically extremely vulnerable people who need them.
• If you are already receiving priority access to supermarket delivery slots this will continue, you do not need to do anything further.
• You can use our online service to register yourself, or on behalf of another CEV individual, to request priority access to a supermarket delivery slot at

https://www.gov.uk/coronavirus-shielding-support.

• If you are clinically extremely vulnerable and you need support to access food, or you have other support needs, you can request support from your local council to help you to stay at home as much as possible.

If you urgently need access to food and are not able to get support from friends or family, then please contact your local council who will support you to access food. Find out what help you might be able to get from your local council at: https://www.gov.uk/coronavirus-local-help

• Government will not be re-introducing nationally provided food parcels. We have moved to a locally led support model which recognises that councils are best placed to assess and meet clinically extremely vulnerable people’s food access needs, with a focus on providing support in a way that encourages independence and choice.
• Use online shopping if you can, or ask friends, family or local charities to collect and deliver shopping for you.
• If you cannot access food, your local council can offer support. Local councils are now being funded to provide support to those clinically extremely vulnerable people who need help to access food. This may include helping you to request priority access to a supermarket delivery slot (if you do not already have one) or help with shopping.

• The Government is extending the offer of a free 4-month supply of vitamin D supplements for all adults who are clinically extremely vulnerable to support general health.
• If you have not already applied, you can register at www.nhs.uk/get-vitamin-d. Further guidance on how to safely take vitamin D supplements will be provided during the opt in process.
• You do not need to opt in to receive the vitamin D supplements if: You are already taking, or are prescribed, a vitamin D supplement by your GP or healthcare professional. You are currently living in a nursing or residential care home, as we will provide these direct to the home where you live.

• Local councils are being given funding to provide support to those clinically extremely vulnerable people who need it because they are shielding. This may include signposting you to local support or befriending services or linking you up with volunteers who can help collect essential supplies for you.
• If you need to register your needs by phone, or have an urgent need, you should contact your local council directly. Find out what help you might be able to get from your local council at https://www.gov.uk/coronavirus-local-help.
• NHS Volunteer Respondersmay also be able to help, including via their ‘check in and chat’ and ‘check in and chat plus’ services. To arrange support for yourself or someone else call 0808 196 3646.
• You may also be able to get support from other local voluntary services in your area.

• We issued the Local Authority Shielding Framework during October 2020, to help Councils prepare to stand up support for clinically extremely vulnerable people if they are advised to follow more restrictive health guidance. Since then, we have issued updated versions of the Framework to ensure it reflects the latest guidance and information.
• The Framework sets out that Councils will be responsible for contacting clinically extremely vulnerable individuals in their area, assessing their needs, and providing support to access food and to meet basic needs.
• There will be no national food box scheme: we are in a different position now to March – with priority supermarket delivery slots and volunteers organised, so we expect that Councils will only need to provide food only in exceptional circumstances.
• Councils will continue to have access to data from an improved registration website, and the Shielded Patient List (SPL) from the NHS.

• Clinically extremely vulnerable people can register their support needs online using the National Shielding Service System (NSSS) which is available at

https://www.gov.uk/coronavirus-shielding-support. CEVs will be able to register for priority access to supermarket deliveries and additional support.

• MHCLG have issued technical guidance to councils on the use of this system.
• The technical guidance details the data-feeds that Councils will receive from the registration system, as well as information on how Councils can support clinically extremely vulnerable peopleand register for them by proxy, and where Councils can go for further technical support.
• Data hub leads will continue to be able to access daily files from the system through the data transfer tool.
• The data fields remain unchanged but, given the national advice to shield, councils can expect all data fields to be populated.

• MHCLG will be providing funding to local Councils to enable them to continue to provide support to clinically extremely vulnerable people who need it for the period that the restrictions are in force.
• MHCLG will be providing Councils with over £32 million for shielding in January to support CEV individuals, based on current numbers of CEVs. .
• The decision to reintroduce shielding in any other areas will be made by Ministers on the advice of the Deputy Chief Medical Officer.
• Funding is calculated per CEV individual on the SPL within the local authority boundaries, irrespective of whether they require support. The latest SPL is published online by NHS Digital. Exact funding levels received by the council will depend on the geography and length of the introduction of restrictive guidance.
• The funding level is based on experience to date, where in practice only a minority of CEV individuals have required active support. Councils are well placed to support people’s independence where possible and to minimise dependency on these services going forward.
• Funding is to enable councils to provide support to clinically extremely vulnerable people, as outlined in the local Shielding Framework. This includes funding to cover set-up and overhead costs of contacting clinically extremely vulnerable people, assessing their food and basic support needs, and facilitating access to support where needed. Funding accounts for the direct provision of food on an exception-only basis.
• The funding will be an un-ringfenced section 31 grant to provide maximum flexibility, but we expect councils to use the funding to deliver the activities and outcomes outlined in the Shielding Framework.
• Funding will be provided to upper tier authorities, and it is essential that they provide sufficient resources to lower tier authorities to carry out any responsibilities that they are asked to undertake to support CEV individuals.
• We will confirm the allocation of funding for this period of restrictive guidance to each local authority, and we will make payments in arrears once the restrictions have come to an end. By exception, if the number of Clinically extremely vulnerable people within the local authority increases significantly whilst restrictions are in force, funding will be adjusted accordingly.

• Councils are sent the latest Shielded Patient List (SPL) by NHS Digital on a weekly basis through their SEFT tool. This contains the latest available data on Clinically extremely vulnerable people in their area.
• Data hub leads continue to receive daily files from the NSSS with registration information for their area.

• Councils are able to direct clinically extremely vulnerable people to the government’s online service to request priority access to supermarket delivery slots at: https://www.gov.uk/coronavirus-shielding-support.
• Councils are also able to fill out the registration form on behalf of clinically extremely vulnerable people who may need additional support in accessing the system (e.g. those who are not digitally enabled). To do this they will need permission from the CEV individual and their NHS number.

• extremely vulnerable people have been helped and how, in line with the LA Framework, in the same manner as November 2020.
• This data will help provide a national picture of how clinically extremely vulnerable people are being supported, where this support is required, and to pinpoint any areas of where further support to councils might be needed, either geographically or by theme.
• We expect all Data Hub Leads to complete this information for Unitary and Upper Tier Councils. The return dates are as follows:

Areas where Shielding guidance was re-introduced on 20 or 26 December 2020

1. First return by 8 January 2021 for the reporting period of 20 or 26 December 2020 to 7 January 2021
2. Second return by 22 January 2021 for the reporting period of 8 to 21 January 2021.

Areas where Shielding guidance was re-introduced on 31 December 2020

1. First return by 22 January 2021 for the reporting period of 31 December 2020 to 21 January 2021.
2. Second return by 3 February 2021 for the reporting period of 19 January to 1 February 2021.

• The data submitted should only include those CEVs supported (and the associated financial values) since the reintroduction of Shielding guidance. The data should not include numbers of CEVs supported during the previous period of national restrictions between 5 November and 2 December 2020.

• To help with their planning, local authorities can look at the aggregated data sets on the NHS Futures platform which indicates numbers of volunteers across local areas.
• If local authorities do not have access, they can request access by emailing NHSVolunteerRespondersCOVID-manager@future.nhs.uk.
• For support with referrals and other queries, the NHS Volunteer Responders Support Team are available on: 0808 196 3382 and at: COVID-communities@nhs.net.

• If you are clinically extremely vulnerable, you should not work outside the home while shielding guidance is in place. Your employer is expected to help you to work from home. CEV employees or workers should talk to their employer as soon as they can about the new guidance.
• If you need support to work at home you can apply for Access to Work. Access to Work will provide support for the disability-related extra costs of working at home that are beyond the standard reasonable adjustments that an employer must provide. Further information can be found at: https://www.gov.uk/access-to-work
• CEV employees or workers should talk to their employer as soon as they can about the new guidance.
• If you are unable to work in your normal role or do all of your usual tasks from home, you should discuss whether there are any alternative arrangements that can be made with your employer, including considering using the Coronavirus Job Retention Scheme (furlough).
• The letter clinically extremely vulnerable people receive will act as a shielding notification for their employer and Department for Work and Pensions.

• Everyone is currently being advised to work from home where they can.
• Where it is not possible to work from home, household members who themselves are not classified as clinically extremely vulnerable can still go to work if they cannot work from home.
• Household members who live with clinically extremely vulnerable people should take extra care to follow the public health guidance on hand washing, social distancing, and complying with any Covid-secure workplace guidance.
• You should try to remain two metres apart from each other, especially if household members display symptoms of the virus or have been advised to self-isolate.

• The Government has extended the Coronavirus Job Retention Scheme (furlough) until 30 April 2021. Please speak to your employer if you think you are eligible. More information is available here: https://www.gov.uk/guidance/check-if-you-could-be-covered-by-the-coronavirus-job-retention-scheme
• If you cannot work, you may be eligible for Statutory Sick Pay (SSP) or Employment and Support Allowance (ESA). And Universal Credit (UC) is available both in and out of work. Eligibility criteria apply.
• The letter you will receive will act as evidence for your employer or the Department of Work and Pensions that you are advised to shield and may be eligible for SSP or ESA.
• SSP is payable for up to 28 weeks per sickness absence. If an individual has used up their SSP entitlement, they may be able to claim UC and/or ESA when their SSP ends, depending on individual circumstances.
• SSP is intended as a safety net for individuals who are clinically extremely vulnerable, in cases where their employer chooses not to furlough them under the Coronavirus Job Retention Scheme and or does not have other suitable policies in place (e.g. the ability to work from home, or the provision of special leave).

• In this situation you should direct your employer to the ‘Protecting people more at risk from coronavirus’ section on the National Lockdown webpage at: https://www.gov.uk/guidance/national-lockdown-stay-at-home  while you wait to receive your letter.
• Some CEVs may also have received the letter by email; however, others will not. Employers should be aware that their CEV employees will be waiting for their letter, but in the meantime, they should follow the guidance set out online in the above link and not go into the workplace. We would encourage employers to support their CEV employees to stay at home while they are waiting for their letter.
• Those eligible for SSP and/or ESA will be eligible for the full period that the shielding guidance is in place, no matter when the CEV individual receives their letter. Eligibility conditions still apply.

• The Government recognises the continued impact that coronavirus (COVID-19) has had on the self-employed and has extended the Self-Employment Income Support Scheme (SEISS) until 30 April 2021.
• Further information is available here: https://www.gov.uk/government/publications/self-employment-income-support-scheme-grant-extension/self-employment-income-support-scheme-grant-extension.
• Self-employed CEVs may also be eligible for ESA and/or Universal Credit. Eligibility criteria apply.

• If friends and family are not able to collect medicines for you and you and/or the pharmacy are unable to arrange for a volunteer, then you will be eligible for free medicines delivery.
• Please contact your pharmacy to inform them that you are clinically extremely vulnerable and need your medicines to be delivered, and they will arrange this free of charge.

You can continue to go outside, including to exercise, but you should try to keep all contact with others outside of your household to a minimum, and avoid busy areas. Generally, you are advised to stay at home as much as possible.

• If you have a routine appointment, make sure you keep it, unless recommended otherwise by your doctor. If you are told to go to hospital for a routine appointment, then the NHS has measures in place to make sure that it safe for you to do so.
• If you have a symptom that could be cancer (such as unexplained blood that doesn’t come from an obvious injury, an unexplained lump, weight loss which feels significant to you, or an unexplained pain that doesn’t go away), or a maternity concern, you should seek medical help. The NHS is here to help you and can see you safely.
• No staff who have COVID-19 symptoms or who have come into contact with someone with symptoms are allowed to work in the hospital, meaning the NHS can see you in a safe environment.
• If you are pregnant, it is crucial that you still attend your antenatal appointments and continue to seek advice from your midwife or maternity team to ensure you have a safe and healthy pregnancy. Maternity services have been asked to take extra precautions to keep women at greatest risk safe and everyone should seek advice without delay if they are concerned about their or their baby’s health.

• The Every Mind Matters website is available to everyone, with advice and practical steps that you can take to support your wellbeing and manage your mental health during this pandemic.
• Anyone concerned about their mental health should speak to their GP or existing care team, or can access further advice via NHS.UK. Online self-referral options are commonly available for some services including children and young people’s mental health services, and psychological therapies services for adults with common mental health problems such as anxiety and depression.
• All mental health providers, including providers of psychological therapies, have been issued with guidance to encourage them to deliver care remotely so that vulnerable groups can receive care safely.
• You may also find helpful resources, including information on how to access counselling and psychotherapy, on the British Association for Counselling and Psychotherapy’s website.
• Mental health trusts in England have been instructed to put in place 24/7 crisis lines for all ages so people can get urgent help whenever they need it. A national service finder for local urgent mental health telephone lines is now available on the NHS.UK website.
• If you or someone you care for are experiencing a mental health crisis, we urge you to make contact with a local health professional

• Helpful information and resources are available on the Let’s Talk Loneliness
• NHS Volunteer Respondersmay also be able to help via their ‘check in and chat plus’ service, which offers regular check-ins with a volunteer by telephone over a period of 10 weeks. To arrange support for yourself or someone else call 0808 196 3646.
• You may also be able to get support from other local voluntary services in your area.

• The mortgage holiday has been extended, with applications open to 31 March 2021. Borrowers who have been impacted by coronavirus and have not yet had a mortgage payment holiday will be entitled to a six-month holiday, and those that have already started a mortgage payment holiday will be able to top up to six months without this being recorded on their credit file.
• For borrowers who have taken six months’ holiday and continue to face ongoing financial difficulties, lenders should continue to provide support through tailored forbearance options. This could include granting new mortgage payment holidays. Homeowners in this situation should speak to their lender to discuss their options.
• Further information on mortgages and the support available during the coronavirus outbreak is available from the Money Advice Serviceand UK Finance.

• The stay on possession proceedings expired on 20 September 2020 and landlords are now able to progress their possession claims through the courts. However, measures to protect tenants remain in place.
• Longer notice periods and new court rules apply.. Courts will carefully prioritise the most egregious cases, such as those involving anti-social behaviour and other crimes.
• Landlords must provide a 6-month notice before starting possession proceedings in the courts for all but the most serious cases such as rent arrears of more than 6 months and anti-social behaviour.
• In addition, no bailiff enforcement of evictions will occur until 11 January at the earliest and, given the 14-day notice period required, no evictions are expected to be enforced until 25 January 2021 at the earliest, except in the most serious circumstances. We are reviewing the measures currently in place and will provide more detail shortly, taking into account public health advice.
• Guidance to support landlords and tenants is available at COVID-19 and renting: guidance for landlords and tenants

• Yes, those who identify as clinically extremely vulnerable are able to move home. However, they should consider their personal situation and the circumstances of their own move and may wish to seek medical advice before deciding whether to commit to, or go ahead with a move. Some moves are likely to be lower risk - for instance if the home is empty, all travel can take place in their own transport and they can avoid contact with others.
• Where people decide to move home they should pay particular attention to maintaining hygiene and social distancing measures to protect themselves and reduce the risk presented by the virus. People in this category should:
• Only take part in property viewings if they are not showing symptoms of coronavirus.
• Where possible, vacate their property when it is being shown to prospective buyers. Ensure all rooms are well ventilated, and clean surfaces before and after viewings, following the general principles of cleaning during the COVID-19 pandemic.
• Let the agent and other parties involved in the move know that they are clinically vulnerable.
• Carefully consider what physical contact they have with any party assisting with the home move and consider how they can either reduce this contact or appropriately protect themselves.
• Seek advice from their GP should they have any immediate concerns around the time of any home move.
• Follow the general guidance for CEVs.

• You do not have to stay in your home if you need to leave to escape domestic abuse.
• Any individual in danger and who is unable to talk on the phone, should call 999 and then either press 55 on a mobile when prompted or wait on a landline and you will be connected to a police call handler who will be able to assist you without you having to speak.

‘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

Please see our guidance here for a full list of Q & As if you are clinically extremely vulnerable in England: https://britishlivertrust.org.uk/new-advice-for-clinically-extrememly-vulnerable-people-during-lockdown-updated-3-november-2020/

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

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.

Everyone must stay at home to help stop the spread of coronavirus.

You should only leave the house for 1 of 4 reasons:

• shopping for basic necessities, for example food and medicine, which must be as infrequent as possible
• one form of exercise a day, for example a run, walk, or cycle – alone or with members of your household
• any medical need, or to provide care or to help a vulnerable person
• travelling to and from work, but only where this absolutely cannot be done from home

Follow these steps to avoid catching or spreading germs:

• wash your hands with soap and water often – use hand sanitiser gel if soap and water are not available
• try to avoid close contact with people who are unwell, cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze.
• Throw used tissues in the bin and always wash your hands afterwards.

• This is a new virus, so no one has immunity through prior exposure
• So far:
  • The majority of cases are in adults and have been mild
  • There are examples, including of people over 80 and with transplant who have recovered
• At this point in most countries, we can assume community spread; that means it is wise to treat any person as a potential carrier. We know that asymptomatic spread can occur during the incubation period with viral shedding when symptoms begin.
• Coronavirus is mostly understood to be spread by droplets (i.e. sneeze or cough which spread about 6 feet)
  •  May be aerosolized
  •  Fecal-oral transmission is possible
  • As people with suppressed immune systems due to medication, age, or as a component of our illnesses, we may be at elevated risk of both contracting the infection and having a more severe reaction. Some early reports from Italy, indicate however, that our weaker immune response may lead to lower reaction and less lung damage
  • Also concurrent conditions such as diabetes (high HbA1C), obesity, heart disease, kidney disease and anemia may increase susceptibility

Social distancing is about ways to avoid catching and spreading coronavirus.

This is about significantly limiting face-to-face contact if you can and making sure that essential visitors (such as health care services, carers or family members) follow handwashing and hygiene advice scrupulously. They should not visit you if you are unwell but make other arrangements for your care.

You can go outside for a walk to the park or into your garden if you stay more than 3 steps (2 metres) from others.

Shielding is a way to protect people who are extremely vulnerable from coming into contact with coronavirus by minimising all interaction between them and other people.

If identified as highly vulnerable, they are strongly advised to stay at home at all times and avoid any face-to-face contact for at least 12 weeks.

They should self-isolate. People who provide essential support, such as health care, personal support for daily needs and social care should continue to visit. If someone cares for a highly vulnerable person, must stay away if they have any symptoms of coronavirus.

People in this group who think they’ve developed coronavirus symptoms of coronavirus should call NHS 111 as soon as they get symptoms.

At the moment, the Government advice is that people who are in the community with a fever or cough do not usually need testing. Instead, tests will primarily be given to:

• all patients in critical care for pneumonia, acute respiratory distress syndrome (ARDS) or flu like illness
• all other patients requiring admission to hospital for pneumonia, ARDS or flu like illness
• where an outbreak has occurred in a residential or care setting, for example long-term care facility or prisons

All other individuals with a high temperature or new, continuous cough should stay at home for 7 days. People do not need to call NHS 111 to go into self-isolation.

If you are at high risk or vulnerable (Government guidance for high-risk and vulnerable people) and develop symptoms of COVID-19 (high temperature above 37.8 °C and/or new and continuous cough), you should seek clinical advice as soon as you get symptoms using the NHS 111 online coronavirus service or call NHS 111 if you don’t have internet access.

If you are not at high risk, you should contact NHS 111 online  if your symptoms worsen during home isolation or are no better after 7 days.  If you have no internet access, you should call NHS 111.

For a medical emergency dial 999.

The Government is aiming to increase the number of tests – however the priority will be the patients listed above, critical workers and  frontline NHS staff. It is aiming to deliver 100,000 tests for COVID-19 per day by the end of April 2020.

The Government is also looking at developing effective antibody tests - to detect if people have had the virus and are now immune. Once proven in a laboratory setting, these tests could potentially be done at home with quick results. They will then be able to work out  what proportion of the population of the population have had the disease

If you are an autoimmune patient on steroids, you are immunosuppressed and are therefore be considered ‘high risk’.

However, small doses of steroids alone are very unlikely to increase the risk of developing a severe form of Covid 19.  All hospitals have been asked to assess people on immuno-suppressive treatment for autoimmune hepatitis and if your consultant believes you are at high risk you will receive a letter.  The risk is probably higher if you are taking certain immunosuppressive drugs combined with steroids.

If you are taking such medicines and do not receive a letter in the next week you should check with your consultant or nurse specialist.

All patients should continue to take their medication unless directed otherwise by their consultant. Please also follow the social distancing advice in full.

You should get in touch with your transplant co-ordinator if you have specific questions about your treatment plan as each transplant unit is able to provide information that is relevant and specific to their own patients. However, please bear in mind that the transplant units are extremely busy and may take some time to get back to you. In the meantime, follow the guidance for social distancing and keep taking any medication.

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.

The outbreak means that unfortunately many Intensive Care Unit beds across the United Kingdom are now being used to care for those affected by this pandemic.

NHS Blood and Transplant along with the medical team and organ advisory group doctors, have agreed that the donor acceptance criteria be reduced on a temporary basis. The reason for this is to reduce the strain on the wider NHS. This in effect will mean that there is a reduction in the numbers of available organs.

The British Liver Trust understands that at the moment liver transplant centres will remain open and urgent transplants are still taking place. However, transplant recipients are considered to be an extremely high-risk group should they develop coronavirus. 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.

Many people are telling us that they feel very worried and anxious with the sudden outbreak of COVID-19. It is quite possibly one of the most important health issues we have seen and we are facing unprecedented challenges.

It’s normal to have these sorts of feelings at a time like this especially if you’re living with an underlying health condition. Protecting your mental health is just as important as your physical health. Here are some ways you can do that:

Avoid information overload

Only look at reliable sources of information about coronavirus that are updated regularly.  Sources like the NHS, Gov.uk, Health Protection Scotland  and Public Health Wales can provide you with up-to-date information.

Try to stay connected

At times of stress, we work better in company and with support. Try and keep regular contact with your friends and family and friends.

It’s good to connect with people on social media but avoid reading or engaging with content that might cause unnecessary stress to you or others.  Only share content from reliable sources.

If you are feeling isolated or lonely and need someone else to talk to, contact one of these helplines:

• Samaritans: 116 123 (for anyone at any time for any reason)
• Mind: 0300 123 3393

Keep a routine

It is a good idea to stick to your daily routine as much as you can. You may also like to focus on the things you can do if you feel able to including partaking in activities and hobbies that you enjoy.

Keep healthy

Try to lead a healthy lifestyle - eating a diet including plenty of fruit and vegetables, taking regular exercise and getting a good night’s sleep will help your immune system to deal with any infection.