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

Posted on: 19th July 2021

If you or a loved one has a liver condition, or you’ve had a liver transplant, you will find out the current information along with links to further information about the coronavirus (COVID-19) pandemic on this page.

People with liver disease or liver cancer have been taking extra precautions to avoid coronavirus (COVID-19) since March 2020.

From 19th July 2021, all legal coronavirus (COVID-19) restrictions and guidelines have ceased in England but we understand patients continue to be concerned about their risk of catching COVID-19 and how to keep safe.

COVID-19 remains a part of our lives and we will all have to keep living lives differently to how we did pre-pandemic.  As a society, post-lockdown, we need to continue wash our hands, wearing a face mask and social distancing where appropriate.

Below you will find answers to the questions you may have if you or your loved one has a liver condition.

These have been agreed by senior hepatologists, BASL and the BSG.

COVID-19 advice for liver disease patients

'Clinically extremely vulnerable’ (CEV) liver disease patients include the following:

  1. Any patient with liver cirrhosis and decompensation or complication as defined by the presence or recent history (within 12 months) of ascites, hepatic encephalopathy, hepatocellular carcinoma, variceal bleed or fluid retention.
  2. Other people who have also been classed as clinically extremely vulnerable by their clinician based on clinical judgement and an assessment of their needs. GPs and hospital clinicians have been provided with guidance to support these decisions.
  3. Patients who are actively on the liver transplant waiting list or who have received a liver transplant.
  4. Patients with chronic liver disease who are on immunosuppressants.

Whilst all these patients remain in the official ‘clinically vulnerable group’ there is now a growing body of evidence that suggests that those with liver disease who are immunosuppressed and those who have had a liver transplant are protected by the vaccine and not as vulnerable as previously thought. People may wish to take this into consideration when considering the guidance below.

People who have had a transplant can read more here

It is recommended that everyone with liver disease is fully vaccinated for covid and also obtains the flu jab. The latest evidence suggests that the vaccine is effective in the majority of people with underlying health conditions. Read more here (link How effective is the Covid-19 vaccine in at-risk groups? - British Liver Trust)

Liver disease patients over the age of 16 who are considered clinically extremely vulnerable and/or immunosuppressed may be offered a third booster jab from September. More information can be found here:  Potential COVID-19 booster vaccine programme

You should continue to consider the risks of close contact with others, particularly if you are clinically extremely vulnerable or not yet fully vaccinated, as the risk of catching or passing on COVID-19 is generally higher:

  • in crowded spaces, where there are more people who might transmit the infection
  • in enclosed indoor spaces where there is limited fresh air
  • when COVID-19 disease levels are high in the general community

you may wish to think particularly carefully about taking precautions when meeting others you do not usually meet with in order to reduce the risk of catching or spreading COVID-19. For example, you could:

  • meet outside if possible – the particles containing the virus that causes COVID-19 are quickly blown away which makes it less likely that they will be breathed in by another person
  • make sure the space is well ventilated if you meet inside; open windows and doors or take other action to let in plenty of fresh air – please see the COVID-19: ventilation of indoor spaces guidance for more information
  • consider whether you and those you are meeting have been vaccinated – you might want to wait until 14 days after your second dose of a COVID-19 vaccine before being in close contact with others
  • wash your hands regularly and avoid touching your face
  • consider continuing to practice social distancing if that feels right for you and your friends
  • asking friends and family to take a lateral flow test before visiting you

You are encouraged to go outside for exercise and can do so freely now. You can find tips and advice on staying active and eating healthily at NHS Better Health.

From 19 July, social distancing measures will end in the workplace and it will no longer be necessary for the government to instruct people to work from home.

However, employers still have a legal responsibility to protect their employees and others from risks to their health and safety. Your employer should be able to explain to you the measures they have in place to keep you safe at work. Some employers may request employees to undertake regular testing for COVID-19 to identify people who are asymptomatic.

The Health and Safety Executive (HSE) has published guidance on protecting vulnerable workers, including advice for employers and employees on how to talk about reducing risks in the workplace.

 

If you need support to work at home or in the workplace you can apply for Access to Work. Access to Work may provide support for the disability-related extra costs of working that are beyond standard reasonable adjustments an employer must provide. Access to Work will prioritise Access to Work applications from disabled people who are in the clinically extremely vulnerable Group.

If you have access to occupational health and employee assistance programmes in the workplace, these services can also provide you with a range of health support and advice for your physical and mental health needs.

Whilst the legal requirement to wear a face covering is being lifted from 19 July, the government expects and recommends that people wear face coverings in crowded areas, such as public transport.

Wearing a face covering, especially when there is close contact between people in enclosed and crowded spaces will still help to reduce the risk of spreading COVID-19, especially. It may also ensure those who are clinically extremely vulnerable feel more relaxed. It is important that face coverings fit securely around the face so as to safely cover the mouth and the nose.

Clinically extremely vulnerable people are now advised to follow the guidance that applies to the rest of the population. You may still wish to consider going to the shops and pharmacy at quieter times of the day.

Priority access to supermarket delivery slots using the Shielding Support website ended on 21 June. After 21 June, you can continue to book delivery slots in the usual manner from a supermarket.

The NHS Volunteer Responders programme is still available to help support those who need it. Call 0808 196 3646 between 8am and 8pm, 7 days a week to self-refer or visit NHS Volunteer Responders for further information. There may also be other voluntary or community services in your local area that you can access for support.

It is important that you continue to receive the care and support you need to help you stay safe and well. Providers of social care and medical services are making every effort to ensure services remain open and as safe as possible.

You should continue to seek support from the NHS for your existing health conditions. 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 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.

The vaccine rollout has significantly reduced transmission of COVID-19 yet no vaccine is 100% effective so you may feel anxiety about catching COVID-19 even after having both doses of the vaccine.

It’s important to remember that the majority of patients with liver disease are not at significantly greater risk than the general public.

Everyone is different and has different circumstances. Ultimately it is up to you how you deal with keeping safe once social distancing, face masks and other restrictions are removed on 19th July.

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.

If you still feel at risk even after having both doses of vaccine, there are steps you can continue to take to reduce your risk.

Ways that you can keep yourself safe are summarised below:

  • You should keep the number of social interactions that you have low and try to reduce the amount of time you spend in settings where you are unable to maintain social distancing.
  • Working from home is strongly advised where possible, but if you have to go to your workplace, your employer should take steps, and share with you what they are doing, to reduce the risk of exposure to COVID-19 in the workplace.
  • If you do go out to the shops or pharmacy, you should consider going at quieter times of the day or using collection or home delivery services.

Many people are telling us that they feel very worried and anxious about lockdown ending.  Assessing your personal risk and knowing how to keep safe will help (see below) and if you are clinically extremely vulnerable, read the advice above.

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 NHSGov.ukHealth 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.

We are aware that if you or a loved one is immunosuppressed you have particular worries about the coronavirus (COVID-19) and the effectiveness of the vaccine.

We continue seek and request the most up to date information on the COVID-19 virus and vaccine efficacy among immunosuppressed patients from DHSC and clinicians. Below you will find answers to some of the questions that you may have.

study by researchers at Oxford University Hospitals into the effects of the Covid-19 virus on patients with auto-immune hepatitis (AIH) suggests that patients with AIH using immunosuppression medication have similar outcomes to people with other forms of liver disease.

This suggests that the use of immunosuppression is not a risk factor for death from COVID-19.

Researchers collected data between March 2020 and October 2020 for nearly 1,000 patients with chronic liver disease and Covid-19 infection, including 70 with AIH.

The results showed that there were no differences in rates of hospitalization, intensive care unit (ICU) admission, and death between AIH patients and those with other types of liver disease.

When compared to patients without liver disease, patients with AIH had higher rates of hospitalisation but no increased risk of intensive care admission or death.

There is a spectrum of immunosuppression among patients with liver disease and only a very small proportion are considered severely immunosuppressed.  This includes but is not limited to:

  • Individuals who are receiving immunosuppressive or immunomodulating biological therapy and individuals treated with steroid sparing agent
  • Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day for adults.
  • Anyone with a history of haematological malignancy, and those who may require long term immunosuppressive treatments.

Patients identified as severely immunosuppressed should be contacted by their medical team as advised by JCVI.   They are advising that household contacts aged over 16 of severely immunosuppressed people are vaccinated as a priority.

For more information contact your consultant or visit: Coronavirus » Vaccination of permanent adult household contacts of severely immunosuppressed individuals alongside JCVI priority cohort 6 (england.nhs.uk)

All three of the COVID-19 vaccines - Pfizer/BioNTech,  AstraZeneca/Oxford, Moderna - that have been approved for use in the UK are considered safe for patients who are immunosuppressed.

While the vaccine might provide a lower level of protection in people who are immunosuppressed compared with the rest of the population, it is still very important to have it as will provide with significant protection against catching COVID-19.   It is also important that you receive two doses of the vaccine to maximise the protection that vaccination offers you.

Data from the NHS Blood and Transplant registry supports the recommendation that people who have had an organ transplant or are on the waiting list should have both their vaccinations.

Research into the effectiveness of the vaccine in people who are immunosuppressed is currently taking place and we received the following update from the DHSC in June 2021.

"We are largely awaiting results of the OCTAVE study for this. As part of the National Core Studies Immunity Programme, UK Research and Innovation (UKRI) is providing initial funding of £1.8 million for 12 months towards the OCTAVE study.

The OCTAVE study will examine the effectiveness of COVID-19 vaccines in clinically at-risk groups. This includes COVID-19 vaccine responses in patients with certain immunosuppressed conditions, including those with inflammatory disorders, high risk cancer patient groups, and patients with severe kidney and liver disease. Cancer patient groups include those with blood cancer (leukaemia, myeloma, and bone marrow (stem cell) transplants).

Key sample timings include 28 days and 6 months post vaccine boost. Results will be available within 3 months of sampling date. It is estimated that that initial results for the immediate response to vaccine (28 days post vaccine) will be available across the majority of the cohort by the middle of June.

This will provide us with a more accurate picture of how effective the vaccine is if you are immunosuppressed."

Antibody tests are used to detect antibodies to the COVID-19 virus to see if it’s likely that you have had the virus before.

The test works by taking a blood sample and testing for the presence of antibodies to see if you have developed an immune response to the virus.

Antibody tests differ to virus swab tests, which test to see if you currently have the virus. An antibody test cannot test if you currently have the virus.

At the moment antibody tests cannot tell you:

  • if you’re immune to COVID-19
  • if you can or cannot spread the virus to other people

Antibody testing in the general population is not being proposed, in part, because clinicians are not able to calibrate what a ‘good’ level of immune response is for COVID.

The JCVI has advised the government that all clinically extremely vulnerable people should be offered a vaccine booster in September.

The final JCVI advice will be published before September and will consider the latest epidemiological situation, additional scientific data from trials such as Cov-Boost, real-time surveillance of the effectiveness of the vaccines over time and emerging variants. The final advice could change from the interim advice as further data is analysed.

Dependent on final advice, the booster programme will be designed to offer further protection against COVID-19 transmission during the winter months.

We will let people know about the final advice via our website, helpline and social media pages once it is announced.

 

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