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

• From 1 April, clinically extremely vulnerable people are no longer advised to shield but should still work from home if they can, but if that is not possible, they can return to the workplace.
• They are advised that if they do go out to the shops or pharmacy, they should consider going at quieter times of the day.
• Children and young people on the shielding list are advised they should return to school or college.
• People on the shielding list should continue to take extra precautions set out in the guidance. This is set out in the letter we are issuing to people on the shielding list, and from 1 April will also be available here: https://www.gov.uk/government/publications/guidance-on-shielding-and-protecting-extremely-vulnerable-persons-from-covid-19

• Everyone is currently required to follow the new restrictions set out in the National Lockdown guidance.
• From 1 April, clinically extremely vulnerable people are no longer advised to shield but must continue to follow the rules in place for everyone.
• The Government is also advising all clinically extremely vulnerable people to continue taking extra measures to protect themselves.
• 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.
• The Government will write to everyone on the Shielded Patient List in England advising them of these changes. Emails are also being sent where these individuals have registered their email address with their GP. The letters will be available online here and the main guidance page will be updated from 1 April.

• The decision to pause shielding has been taken based upon the latest scientific data and on the recommendation of the Chief Medical Officer.
• Since the national restrictions and shielding measures were introduced in January, cases of COVID-19 have fallen considerably across all parts of the country. Prevalence rates are now low enough that the Government can relax shielding advice.
• In addition, the majority of CEV people have now received their first dose of the vaccine. Whilst no vaccine can be 100% effective, this means CEV people are in general better protected against the virus.

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.

From 1 April 2021 you are no longer advised to shield but we recommend you follow the guidance for clinically extremely vulnerable people.

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, the Government will write to everyone on the Shielded Patient List in England advising them of these changes. Emails are also being sent where CEV individuals have registered their email address with their GP. The letter and guidance will be available online here and the main guidance page will be updated from 1 April.

• 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’

• 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.

• 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.

• Yes. Even if you have had both doses of a vaccine, there is still no guarantee that they will not become ill from COVID-19 if you catch the virus. Therefore, they should continue to follow the extra precautions set out by the Government, to help reduce your likelihood of infection.
• The guidance to shield is only advisory. It is not mandatory that you follow this advice, although you should be aware that not doing so may increase your risk of catching COVID-19.
• Everyone must continue to follow the regulations in place at each stage of the roadmap.

• Councils will continue to support those in their communities in need and have systems and relationships in place with other organisations to provide that.
• Councils will be able to provide ad hoc discretionary support to those that need it from existing COMF funding. They should use their judgement in assessing eligibility for further support, ensuring individuals are supported to be as self-sufficient as possible.
• The NHS Volunteer Responders Programme will continue providing support with food, prescriptions and essential items to those who are self-isolating for any reason. This also includes anyone that is clinically extremely vulnerable, or anyone that is vulnerable for another reason.
• Clinically extremely vulnerable people can contact NHSVR on 0808 196 3646 and ask for help. More information is available here: https://volunteering.royalvoluntaryservice.org.uk/nhs-volunteer-responders-portal/isolating

• 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.

From 1st April, whilst you are not advised to avoid going to the shops, you may wish to continue using online delivery for food and essential shopping, or to rely on family and friends. If you do go out to the shops or pharmacy, you should consider going at quieter times of the day. Individuals must wear face coverings in all shops unless they are exempt.

• All major supermarkets have committed to continuing priority access to supermarket
  delivery slots until 21 June (step 4 of the roadmap) for those clinically extremely vulnerable individuals who have already signed up for support. Some supermarkets may choose to extend their offer beyond 21 June but will be in touch to explain the terms of any offer. Even where supermarkets end priority access on 21 June, individuals can continue to book deliveries from a supermarket.
• Clinically extremely vulnerable people without friends, family, or other support networks to rely on can continue to register to request priority access to a supermarket delivery slot up until 31 March via the Shielding Support website, www.gov.uk/coronavirus-shielding-support. You will not be able to register using this website after midnight on the 31 March.

• 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.

• Those supported by the Medicines Delivery Service will continue to receive this support until the end of March.
• After this date, if it is not possible for someone to attend their pharmacy, and friends and family are not able to collect medicine for them, then the NHS Volunteer Responders will continue to offer medicines deliveries. If someone is vulnerable or at risk and needs help with shopping, medication or other essential supplies, they should call 0808 196 3646 (8am to 8pm).

• Everyone is currently advised to work from home where possible. If individuals cannot work from home, they can still go to work.
• Employers are required to take steps to reduce the risk of exposure to COVID-19 in the workplace and should be able to explain to the measures they have put in place to keep people safe at work. Employers and CEV employees should have a conversation as early as possible about their return to work.
• Where employers are not managing the risk of COVID-19, the Health and Safety Executive (HSE) and local authorities will take action which can range from the provision of specific advice, issuing enforcement notices, stopping certain work practices until they are made safe and, where businesses fail to comply with enforcement notices, this could lead to prosecution.

• Employers are required to take steps to reduce the risk of exposure to COVID-19 in the workplace and should be able to explain the measures they have put in place to keep people safe at work.
• Workplace specific safer working guides set out how different workplaces should be made COVID-secure, including how to maintain social distancing and a system of risk management in the workplace: https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19.
• The Health and Safety Executive also provides information to employers on making workplaces COVID-secure and on protecting vulnerable workers:
  https://www.hse.gov.uk/coronavirus/working-safely/protect-people.htm
• The Government is asking employers to work with us to ease the transition back to a
  more normal way of life for their clinically extremely vulnerable employees. It is important that this group continue to take careful precautions, and employers should do all they can to enable them to work from home where this is possible, including moving them to another role if required.
• Where working from home is not possible, those who have been shielding should be provided with the safest onsite roles that enable them to maintain social distancing from others.
• The Coronavirus Job Retention Scheme (furlough) has been extended until 30
  September and clinically extremely vulnerable people remain eligible for this even whilst shielding guidance is not in place.
• Employees and their employers should have conversations as early as possible about their return to work, and on how best to support them to manage their risk and work safely. The Health and Safety Executive has published resources to support employers in having conversations about preventing the spread of coronavirus in the workplace with their employees: https://www.hse.gov.uk/coronavirus/working-safely/talking-to-your-workers/index.htm. This includes specific information and guidance for employers on stress, wellbeing and providing mental health support.

• In this situation you should direct your employer to the ‘Protecting people more at risk from coronavirus’ section on the National Lockdown webpage at: COVID-19: guidance on shielding and protecting people defined on medical grounds as extremely vulnerable - GOV.UK (www.gov.uk) 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.

• The Coronavirus Job Retention Scheme (furlough) has been extended until 30 September. Clinically extremely vulnerable employees can be furloughed throughout this period, provided their employer agrees. https://www.gov.uk/government/collections/coronavirus-job-retention-scheme.
• For self-employed clinically extremely vulnerable people, the Self-Employment Income Support Scheme (SEISS) has also been extended until September:
  https://www.gov.uk/government/publications/self-employment-income-support-scheme-grant-extension
• Clinically extremely vulnerable people who need support to work at home or in the workplace may be able to apply for Access to Work, which provides support for the disability-related extra costs of working that are beyond standard reasonable adjustments an employer must provide: https://www.gov.uk/access-to-work
• There is a wide range of support available for people who are affected by coronavirus or its effect on the economy, including Universal Credit (UC), which is available to people who are in and out of work, including those who are on furlough. The £20 per week increase to UC will remain in place until September. More information about employment and benefits support can be found here: https://www.understandinguniversalcredit.gov.uk/employment-and-benefits-support/
• The Health and Safety Executive has published resources to support employers and employees in having conversations about preventing the spread of coronavirus in the workplace: https://www.hse.gov.uk/coronavirus/working-safely/talking-to-your-workers/index.htm
• The Citizens Advice Bureau has information about workers’ rights and how to solve
  problems in the workplace: https://www.citizensadvice.org.uk/work/. Employees can
  also get advice on their specific situation and their employment rights by visiting the
  Acas website https://www.acas.org.uk/contact or calling the Acas helpline on 0300
  123 1100.

• 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.

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

• Employers are required to take steps to reduce the risk of exposure to COVID-19 in the workplace and should be able to explain the measures they have put in place to keep people safe at work.
• If clinically extremely vulnerable people have concerns about their health and safety at work they can raise them with their workplace union, the Health and Safety Executive (HSE) https://web.archive.org/web/20201018050420/https:/www.hse.gov.uk/contact/concerns.htm or their local council.
• Where some employers are not managing the risk of coronavirus, HSE and local authorities will take action which can range from the provision of specific advice, issuing enforcement notices, stopping certain work practices until they are made safe and, where businesses fail to comply with enforcement notices, this could lead to prosecution.
• The existing employment rights framework also provides protections against discrimination, unfair dismissal and detriment. Further information for employers and workers on work absences due to coronavirus (COVID-19) can be found here: https://www.gov.uk/guidance/if-you-need-to-self-isolate-or-cannot-attend-work-due-to-coronavirus.
• The Citizens Advice Bureau also has information about workers’ rights and how to solve problems in the workplace: https://www.citizensadvice.org.uk/work/.
• Employees can get advice on their specific situation and their employment rights by visiting the Acas website https://www.acas.org.uk/contact or calling the Acas helpline on 0300 123 1100.

• The Department for Transport (DfT) has worked with the Health & Safety Executive (HSE), Public Health England (PHE) and the Department for Business Enterprise and Industrial Strategy (BEIS) to develop Safer Guidance for Transport Operators in order to protect transport workers and passengers: https://www.gov.uk/government/publications/coronavirus-covid-19-safer-transport-guidance-for-operators/coronavirus-covid-19-safer-transport-guidance-for-operators#social-contact
• Operators are also ensuring they implement the Safe Workplace guidance. These actions ensure that operators are keeping their workers and passengers safe.
• DfT has also consulted industry stakeholders and trade unions throughout the pandemic in order to ensure best practice approaches are followed and the transport sector operates safely.
• Since the start of the pandemic, the public has been advised to follow mitigations, introducing requirements for mandatory face coverings on all public transport
• DfT has also provided emergency support to public transport operators to ensure the continuity of essential services during pandemic. This has included express provision for measures to protect transport workers and the public including PPE, passenger spacing, screens, barriers, additional cleaning services.

• 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.

• Where clinically extremely vulnerable individuals are no longer required to shield, and they are unable to work from home but can work on site, they should do so. Shielding guidance must be in place in order for employees to be eligible for SSP on the basis of shielding.
• Employees will be remain eligible for SSP if they are unable to work and are sick, or required to self-isolate, provided they meet all eligibility conditions.
• People who are unable to work due to their health condition or disability will remain eligible for ESA provided they meet the eligibility conditions (ESA as per business as normal).

• Guidance around shielding will be continually reviewed and informed by the latest scientific evidence and advice. The Government will continue to assess the support in place should advice to shield be reinstated.
• Where home working is not possible, employers will be able to access the Coronavirus Job Retention Scheme (furlough) until 30th September 2021.
• For those who have not been furloughed, clinically extremely vulnerable employees who are notified to shield again should again be eligible for Statutory Sick Pay (SSP) or Employment and Support Allowance (ESA) for the period they are advised to shield themselves, if all other SSP or ESA eligibility conditions are met.

• 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.

We encourage you to go outside for exercise. 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. You can find tips and advice on staying active and eating healthily here: https://www.nhs.uk/better-health/

It is also important that you attend any health appointments and continue to access the services you need.

• 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

• 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.

• 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 is 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.

• 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.

• 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.

‘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.

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.