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

• At the start of the COVID-19 pandemic, shielding was introduced as one of the few ways to support those who, at the time, were considered clinically extremely vulnerable (CEV).
• It was the right decision at the time, but we know that shielding advice is extremely restrictive and can have a significant impact on people’s lives and their mental and physical wellbeing.
• We have not advised people to shield since 1 April 2021, and since 19 July, people previously identified as clinically extremely vulnerable have been advised to follow the same guidance as the rest of the population.
• The situation is now very different to when shielding was first introduced. We know a lot more about the virus and what makes someone more or less vulnerable to COVID-19, the vaccine continues to be successfully rolled out, and other treatments and interventions are becoming available.
• We therefore no longer think it is appropriate to advise people to follow restrictive, centralised guidance.
• Instead, people should consider their own risk, supported by their NHS clinician where necessary.

• Based on what we now know about COVID-19, the success of the vaccine programme and with new treatments becoming available, we no longer think shielding is the best way to keep people safe.
• Shielding is very restrictive and can have a significant impact on people’s lives and their mental and physical wellbeing.
• As a result, we do not anticipate needing shielding again in the future.
• However, we have learnt a lot from setting up the shielding programme and will use that knowledge to help us in our planning for any future pandemic or emergency.

• Most people, including those previously considered CEV will be well protected by the vaccine.
• A recent study by Public Health England (PHE)[1] showed that the vaccine is almost as effective for the majority of people previously considered CEV as for the rest of the population.
• In fact, the COVID-19 vaccines are as good at preventing serious illness and death in the majority of people with underlying health conditions as in the rest of the population.
• That’s why people previously identified as CEV are no longer considered to be at very high risk.
• The PHE study was supported by the preliminary findings of the OCTAVE trial which showed that the majority (60%) of clinically at-risk people have a strong immune response following two doses of a vaccine.
• The PHE study did find however that those who were immunosuppressed may not respond as well to COVID-19 vaccines as others. Protection against symptomatic disease for those who are immunosuppressed of all ages was 4% after one dose, however this increased to 74% after two doses.
• There are many reasons that cause immunosuppression and they affect the immune system in differing ways and amounts, so vaccine effectiveness may vary by specific condition and severity of that condition.
• The vaccine continues to be the best way to prevent serious illness and the spread of COVID-19 so we strongly urge you to take up the vaccination offer if you have not already done so.

[1] PHE monitoring of the effectiveness of COVID-19 vaccination - GOV.UK (www.gov.uk)

• If you are immunosuppressed due to underlying health conditions or medical treatment, you may not have a full immune response to the vaccine and so might be less well protected than everyone else.
• As a result, you may want to take extra precautions to protect yourself and then discuss your risk with your NHS specialist at your next routine consultation.
• Third doses of the vaccine are being offered as part of the primary vaccination course to those over 12 years old who were severely immunosuppressed at the time of their first or second dose and may not have had a full response to vaccination – this includes those with leukaemia, advanced HIV and recent organ transplants.[1]
• If you fall into this category, you will be identified and invited for a vaccination by the hospital where you receive care under a consultant and/or your GP.
• If you already receive advice from your clinician on infection risk, you may wish to discuss your risk from COVID-19 at your next routine appointment.

[1] https://www.gov.uk/government/news/jcvi-issues-advice-on-third-dose-vaccination-for-severely-immunosuppressed

• Shielding advice has not been in place since 1^st April 2021, when it was paused.
• Since 19^th July, people previously identified as CEV have been advised to follow the same guidance as everyone else.
• The decision to end shielding is based on the knowledge that for the majority of the CEV group, the risk of developing serious illness was reduced.
• We recognise that, despite advances in vaccination and treatments, there are people who remain at higher risk from COVID-19 and the decision has been taken because advising people to stay at home and limit all contact is no longer the best or most proportionate way of keeping them safe.
• A one-size fits all approach is no longer appropriate given that people can respond differently to the vaccine.
• Those who remain at higher risk after being vaccinated should discuss any necessary precautions with their NHS clinician as part of their routine engagement.

• As a minimum, you should continue to follow the same guidance as everyone else, which can be found at gov.uk/coronavirus. However, people who are less well-protected by the vaccine may wish to consider taking extra precautions and discuss their risk with their NHS specialist at their next routine appointment. Extra precautions could include:
  • considering whether you and those you are meeting have been vaccinated – you might want to wait until 14 days after everyone’s second dose of a COVID-19 vaccine before being in close contact with others
  • considering continuing to practise social distancing if that feels right for you and your friends
  • asking friends and family to take a rapid lateral flow antigen test before visiting you
  • asking home visitors to wear face coverings
  • avoiding crowded spaces

• The Government is no longer telling anyone 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. For example, some employers may ask employees to get tested regularly to identify people who are asymptomatic.
• Anyone who is worried about their risk and is unable to work from home should talk to their employer about their concerns.
• 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.
• Access to Work can offer practical support to people who have a health condition that affects the way they work. The scheme can offer support including mental health support for people returning to work after a period of furlough or shielding, and travel-to-work support for those who may no longer be able to safely travel by public transport. For more information, please visit: gov.uk/access-to-work.

If you are struggling financially, you may also be eligible to apply for Universal Credit or Employment Support Allowance. For more information on benefits, please visit: www.gov.uk/financial-help-disabled.

• The PHE study was supported by the preliminary findings of the OCTAVE trial which showed that the majority (60%) of clinically at-risk people have a strong immune response following two doses of a vaccine.
• The PHE study did find however that those who were immunosuppressed may not respond as well to COVID-19 vaccines as others. Protection against symptomatic disease for those who are immunosuppressed of all ages was 4% after one dose, however this increased to 74% after two doses.
• There are many reasons that cause immunosuppression and they affect the immune system in differing ways and amounts, so vaccine effectiveness may vary by specific condition and severity of that condition.
• The vaccine continues to be the best way to prevent serious illness and the spread of COVID-19 so we strongly urge you to take up the vaccination offer if you have not already done so.

• If you are immunosuppressed due to underlying health conditions or medical treatment, you may not have a full immune response to the vaccine and so might be less well protected than everyone else.
• As a result, you may want to take extra precautions to protect yourself and then discuss your risk with your NHS specialist at your next routine consultation.
• Third doses of the vaccine are being offered as part of the primary vaccination course to those over 12 years old who were severely immunosuppressed at the time of their first or second dose and may not have had a full response to vaccination – this includes those with leukaemia, advanced HIV and recent organ transplants.[1]
• If you fall into this category, you will be identified and invited for a vaccination by the hospital where you receive care under a consultant and/or your GP.
• If you already receive advice from your clinician on infection risk, you may wish to discuss your risk from COVID-19 at your next routine appointment.

[1] https://www.gov.uk/government/news/jcvi-issues-advice-on-third-dose-vaccination-for-severely-immunosuppressed

• Shielding advice has not been in place since 1^st April 2021, when it was paused.
• Since 19^th July, people previously identified as CEV have been advised to follow the same guidance as everyone else.
• The decision to end shielding is based on the knowledge that for the majority of the CEV group, the risk of developing serious illness was reduced.
• We recognise that, despite advances in vaccination and treatments, there are people who remain at higher risk from COVID-19 and the decision has been taken because advising people to stay at home and limit all contact is no longer the best or most proportionate way of keeping them safe.
• A one-size fits all approach is no longer appropriate given that people can respond differently to the vaccine.
• Those who remain at higher risk after being vaccinated should discuss any necessary precautions with their NHS clinician as part of their routine engagement.

• As a minimum, you should continue to follow the same guidance as everyone else, which can be found at gov.uk/coronavirus. However, people who are less well-protected by the vaccine may wish to consider taking extra precautions and discuss their risk with their NHS specialist at their next routine appointment. Extra precautions could include:
  • considering whether you and those you are meeting have been vaccinated – you might want to wait until 14 days after everyone’s second dose of a COVID-19 vaccine before being in close contact with others
  • considering continuing to practise social distancing if that feels right for you and your friends
  • asking friends and family to take a rapid lateral flow antigen test before visiting you
  • asking home visitors to wear face coverings
  • avoiding crowded spaces

• The Government is no longer telling anyone 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. For example, some employers may ask employees to get tested regularly to identify people who are asymptomatic.
• Anyone who is worried about their risk and is unable to work from home should talk to their employer about their concerns.
• 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.
• Access to Work can offer practical support to people who have a health condition that affects the way they work. The scheme can offer support including mental health support for people returning to work after a period of furlough or shielding, and travel-to-work support for those who may no longer be able to safely travel by public transport. For more information, please visit: gov.uk/access-to-work.
• If you are struggling financially, you may also be eligible to apply for Universal Credit or Employment Support Allowance. For more information on benefits, please visit: gov.uk/financial-help-disabled.

• Supermarkets stopped providing priority access to supermarket slots for people previously identified as CEV on the advice of government on 21^st
• Different supermarkets may have their own policies on priority access to supermarket slots.

• The NHS Volunteer Responders programme is still available to offer short-term help to those who need it. The NHS Volunteer Responders scheme can provide telephone support if people are feeling lonely, or help with collecting shopping, medication or other essential supplies. Patients can 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.
• All patients also can access a range of NHS services from home, including ordering repeat prescriptions or contacting their health professional through an online consultation. To find out more visit NHS Health at Home, or download the NHS App.
• The Every Mind Matters website offers advice and practical steps that people can take to support their wellbeing and manage their mental health. If they are feeling lonely, the Let’s Talk Loneliness website also has a variety of tips, advice and further resources that they may find helpful. The Hub of Hope can also be accessed to find local sources of mental health support and services, both from the NHS and from other organisations.

• The aim of the 2021 booster programme is to maintain protection against severe COVID-19 in those most vulnerable, and to protect the NHS.
• Whilst the Shielding Patient List (SPL) was created to help keep the most vulnerable safe at the start of the COVID-19 pandemic, we now have a better definition of the wide range of factors that may put someone at increased risk of serious illness from COVID-19.
• The effectiveness of the vaccine, the availability of evidence based effective treatments, and the reduction in transmission risk in those vaccinated mean that far fewer people are at serious risk of becoming seriously ill or being admitted to hospital with COVID-19.
• JCVI advises that for the 2021 COVID-19 booster vaccine programme, individuals who were vaccinated in Phase 1 of the COVID-19 vaccination programme (priority groups 1-9) should be offered a COVID-19 booster vaccine. This includes all adults over 50, and those aged 16-49 with underlying health conditions putting them at higher risk of severe COVID-19, as outlined in the Green Book.
• The vast majority of people who were on the SPL will therefore be eligible for a booster vaccine.
• Anyone who was on the SPL previously but no longer has a condition listed in the Green Book, is unlikely to need a booster.

• Third dose vaccinations are different to booster vaccinations as their aim is to increase protection levels for people who may not have had a strong vaccine response first time round.
• As per the preliminary results of the OCTAVE trial, most people previously considered CEV will be well protected by the vaccine.
• A third dose is therefore only being offered to people over 12 who were severely immunosuppressed at the time of their first or second dose, including those with leukaemia, advanced HIV and recent organ transplants.
• These people may not have had a full response to vaccination and so might be less protected than everyone else – offering a third dose may increase their protection levels.

• The Shielded Patient List will be maintained in its current form for some time as the information about those who were previously identified as CEV is used by health and social care services to provide care and treatment, to plan health and social care services and to carry out medical research.
• NHS Digital maintains the Shielded Patient List and information about how your personal data is used is available on their website here.

• During periods of shielding, patients may have registered their details with the National Shielding Service System to get support.
• The system has been closed to new registrations since 1^st April 2021.
• To find out more about your data, please see the privacy notice, which can be found here.

'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

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 19^th 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 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.

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.