Coronavirus: Information for shielded patients and those with long-term conditions

The shielded patient list (formerly known as the vulnerable patient list) means that the NHS can identify and contact a group of patients who need specific advice about their circumstances.

Shielded patients are strongly advised to stay at home at all times and avoid any face-to-face contact for a period of at least 12 weeks. Please note that this period of time could change.

Visits from people who provide essential support to you such as healthcare, personal support with your daily needs or social care should continue, but carers and care workers must stay away if they have any of the symptoms of coronavirus (Covid-19).

You may find this guidance on home care provision useful. All people coming to your home should wash their hands with soap and water for at least 20 seconds on arrival to your house and often while they are there.

You should have an alternative list of people who can help you with your care if your main carer becomes unwell. You can also contact your local council for advice on how to access care.

Shielded patients include

People who have had an organ transplant who remain on long term immune suppression therapy

People with specific cancers –

  • with cancer who are undergoing active chemotherapy or radical radiotherapy for lung cancer
  • with cancers of the blood or bone marrow such as leukaemia, lymphoma or myeloma who are at any stage of treatment
  • having immunotherapy or other continuing antibody treatments for cancer
  • having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
  • who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs

People with severe respiratory conditions including all cystic fibrosis, severe asthma and severe COPD. Severe asthmatics are those who are frequently prescribed high dose steroid tablets.

People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID, homozygous sickle cell)

People on immunosuppression therapies sufficient to significantly increase risk of infection

People who are pregnant with significant congenital heart disease

Although not included on national guidance, we would advise that anybody over the age of 80 should shield. We would also advise anybody over the age of 75 to strongly consider shielding.

If you have not received a text or letter but think that you should be in the shielded patient list – the practice has identified several hundred patients that we believe should be on the list and we are currently (31st March 2020) working our way through these medical records. We will send letters to these individuals very shortly.

Asthma

Up to date medical advice for those with severe asthma is available in the ‘Advice for Healthcare Professionals Treating People with Asthma (adults) in relation to COVID-19’ document from the British Thoracic Society.

There is also advice from Asthma UK on the ‘Health advice for people with asthma’ page.

Severe asthma is defined as asthma that requires treatment with high dose inhaled steroids plus a second controller and/or long term steroids to prevent it from becoming ‘uncontrolled’ (or that remains ‘uncontrolled’ despite therapy). Patients with severe asthma are usually under the care of specialist centres and may be on biological therapy.

Currently, there is no published evidence that patients with severe asthma are at higher risk of developing more serious complications from COVID‐19. People who have severe asthma and become unwell due to COVID‐19 should be encouraged to inform their hospital asthma team.

Patients who are receiving biological therapies for their asthma should not stop their biologics as there is no evidence these suppress immunity. Most centres are rapidly organising for patients to receive their biologics via home‐care or similar schemes.

Patients should be advised to continue to attend for their biological treatment until
they are transitioned to home care or if they receive their treatment intravenously.

COPD and other lung conditions

Who is regarded as extremely vulnerable?

People with severe long-term lung conditions in this group include people with:

People are also extremely vulnerable if they have multiple long-term health problems. This group will include people with any long-term lung condition which they are treated for (including asthma, COPD, lung cancer, bronchiectasis, pulmonary fibrosis and others who are offered an annual flu jab) who also have diabetes or heart disease. If you’re not sure ask your respiratory team or GP for further advice.

This is because they are at very high risk of severe illness as a result of coronavirus (COVID-19), and may need be admitted to hospital.

Severe COPD

This includes:

Everyone who has severe or very severe airflow obstruction. This is measured using a breathing test called spirometry where you blow out as hard as you can. If the amount of air you can blow out in one second is less than 50% of the normal range of values, it is classed as severe. Severe or very severe airflow obstruction is sometimes described as GOLD grade 3 or GOLD grade 4.

People who are limited by breathlessness – this means that you can’t walk as fast as other people of your age because of breathlessness. This may be described in clinic letters as an MRC breathlessness score of 3, 4 or 5.

People who have had to be admitted to hospital in the past because of an acute attack of the lung condition.

People who have had 2 or more exacerbations or flare-ups in the past year that needed emergency treatment with steroids or antibiotics from the GP or hospital.

People who are on regular steroid tablets, called prednisolone to treat their condition

People who have oxygen therapy at home

People who use non-invasive ventilation at home – using a mask connected to a ventilator, sometimes called BiPAP, to support their breathing at night

Lung cancer and mesothelioma

This applies to people who are undergoing chemotherapy or radiotherapy for their lung cancer or mesothelioma or if they meet any of the criteria that are on the list under COPD.

Severe bronchiectasis

This includes people with bronchiectasis who:

  • meet any of the criteria that are on the list under COPD
  • use nebulised treatments

Interstitial lung disease, including pulmonary fibrosis

Guidance on ILD has been updated. Hospital clinics will be writing to all patients with interstitial lung disease to advise them to practise social shielding. If you have one of these conditions we would advise you to practise social shielding now and not wait to receive the letter.

Sarcoidosis

Guidance on sarcoidosis has been updated and clinics will be writing to all patients with sarcoidosis who have lung involvement or are on immunosuppressive drugs to advise them to practise social shielding. If you are in this group we would advise you to practise social shielding now and not wait to receive the letter.

Pulmonary hypertension

People with a diagnosis of pulmonary hypertension are advised to practise social shielding.

Your specialist team may be able to give you specific advice. Please visit PHA UK for more information.

Other lung conditions

The groups listed above cover most lung conditions. If your condition is not included or you are not sure, have a look at these criteria:

  • you need to use oxygen at home
  • you use non-invasive ventilation
  • you have to stop walking after 100m or so because of breathlessness, even at your own pace
  • you have had to be admitted to hospital in the last year because of an acute attack of the lung condition
  • you are taking immunosuppressive drugs

If you meet any of these then it is likely your condition makes you especially vulnerable to coronavirus. You should practise social shielding now and seek advice from your health care team about whether you need to continue this.

British Lung Foundation -Information for people with a lung condition
British Thoracic Society -information for people with sarcoidosis, TB, pulmonary fibrosis and mesothelioma

Heart Disease

Up to date medical advice for those with heart disease can be found here

Some heart patients are considered at extremely high risk and should be shielded. This applies to you if:

  • you have had a transplant at any time, including a heart transplant.
  • you are pregnant and have significant heart disease – defined by experts as any of the following: coronary heart disease (if you have symptoms), hypertrophic cardiomyopathy (if it affects your heart function), thickening of the heart muscle (left ventricular hypertrophy) caused by high blood pressure, pulmonary arterial hypertension, a narrowed or leaking heart valve if this is moderate or severe, heart failure that affects your left ventricular function, significant congenital heart disease.

If you are in one of these above groups, you should protect yourself by staying at home, and minimising contact with people you live with, for the next 12 weeks

Even if you are not at extremely high risk, you may still be at particularly high risk because of your heart condition if:

  • You have heart disease and you’re over 70
  • You have heart disease and lung disease or chronic kidney disease
  • You have angina that restricts your daily life or means you have to use your GTN frequently
  • Heart failure, especially if it restricts your daily life or you’ve been admitted to hospital to treat your heart failure in the past year
  • Heart valve disease that is severe and associated with symptoms (such as if you regularly feel breathless, or you have symptoms from your heart valve problem despite medication, or if you are waiting for valve surgery). A heart murmur that does not cause you symptoms doesn’t put you at high risk.
  • You’re recovering from recent open-heart surgery in the last three months (including heart bypass surgery)
  • Cardiomyopathy (any type) if you have symptoms such as breathlessness, or it limits your daily life, or you’ve been told you have problems with your heart function
  • Congenital heart disease (any type) if you also have any of the following: lung disease, pulmonary hypertension, heart failure, you’re over 70, you are pregnant, or if you have complex congenital heart disease (such as Fontan, single ventricle or cyanosis).

If you are in one of these groups, the advice is the same as for everyone in the UK): stay at home apart from essential needs.

If you don’t fall into one of the groups above, having a heart condition or any of these issues means you are at high risk – again, you should stay at home, apart from essential needs:

Diabetes

Diabetes UK – information for people with diabetes

Pregnancy

Information for pregnant women

Cancer

Information for people with cancer

HIV

Up to date advice for those with HIV is available here

Covid-19 infection is likely to be worse in those with a ‘weakened immune system’. This does not mean that all people with HIV are considered at increased risk. Those on HIV treatment with a good CD4 count and an undetectable viral load are not considered to have weakened immune systems. A ‘good’ CD4 count means anything over 200. If your CD4 count is less than 200, if you’re not on treatment or if you have a detectable viral load, then it’s particularly important that you follow the guidance to reduce the risk of catching the virus.

Public Health England has now identified people who are extremely vulnerable to Covid-19. They are being advised to ‘shield’ themselves from the virus, which means staying at home at all times and avoiding face-to-face contact for at least 12 weeks (although this time may change). Although people living with HIV are not included in this list, the British HIV Association (BHIVA) is advising that those with a CD4 count less than 50 or those diagnosed with an opportunistic infection in the last six months should also follow this advice

Effective treatment means that the vast majority of people living with HIV have an undetectable viral and a good CD4 count. We usually don’t do the CD4 count test anymore because we know that, as long as you remain undetectable, your CD4 count won’t fall. As a result, it may be a number of years since you last had your CD4 count checked. Don’t worry about this: you don’t need to have a CD4 count done now. As long as your viral load remains undetectable, your CD4 count will be as good as it was when it was last tested – and probably better.

What is certainly changing is that HIV clinics are reducing their face-to-face appointments. This is to reduce risk of infection and to support people to stay at home as well as freeing up time for doctors and nurses to be redeployed into hospitals if they are needed to support the extra workload on the NHS.

Rest assured that our priority is, and will always be, your health, but be aware that we will have to do things differently over the coming months. Different clinics may take slightly different approaches, but where I work we are stopping all routine appointments and only seeing urgent or emergency cases.

If you’re well and have an undetectable viral load, we’ll do blood tests less frequently but always ensure that you have enough medication (which, at the end of the day, is the most important thing). There’s no need to stockpile medication – in fact this could put unnecessary strain on the system. We have no concerns about the supply of medication, so just ensure that you always have at least a month’s worth of medication at home. Your clinic will be in touch with you about what is happening.

Try to avoid contacting the clinic unless really necessary as things are really busy at the moment – but if you need to contact your clinic, be patient and we will sort out your problem. If you need to be seen then we will see you.

Immunosuppressive treatment

Definite High risk – to be advised to self-isolate

  • Corticosteroid dose of more than 20mg prednisolone (or equivalent) per day for more than four weeks
  • Cyclophosphamide at any dose orally (or intravenous within last six months)
  • Corticosteroid dose of more than 5mg prednisolone (or equivalent) per day for more than four weeks plus at least one other immunosuppressive medication
  • Biologic/monoclonal** or small molecule immunosuppressant (eg JAK inhibitors)***
  • Any two agents among immunosuppressive medications, biologics/monoclonals** or small molecule immunosuppressants with any co-morbidity****
  • Immunosuppressive medications include: Azathioprine, Leflunomide, Methotrexate, Mycophenolate, Ciclosporin, Cyclophosphamide, Tacrolimus, Sirolimus. These do NOT include Hydroxychloroquine or Sulphasalazine.Biologic/monocolonal includes: Rituximab within last 12 months; all anti-TNF drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab and biosimilar variants of all of these); Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab; Sarilumumab; canakinumab
  • Small molecules includes: all JAK inhibitors – baracitinib, tofacitinib etc
  • Co-morbidity includes: age >70, Diabetes Mellitus, any pre-existing lung disease, renal impairment, any history of Ischaemic Heart Disease or hypertension NB This advice applies to both adults, children and young people with rheumatic disease.

We do NOT advise that patients increase steroid dose if they become unwell

Moderate risk – self-isolation only if other concerns or high-risk circumstances

Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication, biologic/monoclonal** or small molecule immunosuppressant

  • Well-controlled patients with minimal disease activity and no co-morbidities on single agent broad spectrum immunosuppressive medication plus Sulphasalazine and/or hydroxychloroquine
  • Well-controlled patients with minimal disease activity and no co-morbidities on a single agent broad spectrum immunosuppressive medication* at standard dose (eg Methotrexate up to 25mg per week) plus single biologic (eg anti-TNF or JAKi)** or ***

Low risk – no additional need to self-isolate

  • Single agent 5-ASA medications (such as mesalazine)
  • Single agent 6-mercaptopurine
  • Only inhaled or rectally administered immunosuppressant medication
  • Hydroxychloroquine
  • Sulphasalazine