GPs to start vaccinating immunosuppressed patients with third Covid jab by 13 September

GPs should start identifying severely immunosuppressed patients who are eligible for a third Covid jab immediately, for a 13 September start, NHS England has said today.

NHS England has said that practices that aren’t delivering the vaccination programme should hand over details about their patients by 17 September, but it said that local searches it is providing to support this may not be available until the ‘end of September’.

Earlier this week, it was announced that around 500,000 people with ‘severely weakened immune systems’ would be offered a third dose of the Covid vaccine, following new JCVI advice.

The JCVI recommended that this should include patients 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’. 

In a letter sent to GPs yesterday, NHS England said delivery of a third vaccine dose to the group should start by 13 September as part of a ‘coordinated approach’ between primary and secondary care.

It added: ‘We are asking all GP practices to identify individuals on their registered list against the eligibility definition provided by the JCVI. 

‘This will be supported by provision of searches (we expect these to be available by the end of September), but where practices can identify individuals themselves in advance of this, they should.’

It adds: ‘Practices that are not delivering the Covid-19 vaccination enhanced service should share a list of eligible patients with their local commissioner so they can arrange for these patients to be offered an appointment at another provider (eg, another PCN-led vaccination site or Hospital Hub) by 17 September. This request is necessary for the reasons of public interest).’

Once eligible patients have been identified, practices ‘should offer them a third primary dose through their PCN with consideration to the optimal timing and interaction with any treatment as set out by the JCVI’, NHS England said.

PCNs can call those on ‘regular immunosuppressive medication’ or who have ‘relatively stable’ immunosuppression for vaccination from eight weeks after their second dose, it added.

GPs may also be asked to vaccinate patients on behalf of hospital colleagues, NHS England said.

The letter said: ‘If it is not possible to offer the individual a vaccine on-site, consultants should write clear advice to the individual’s GP specifying the optimal timing and any interaction with their current treatment. The individual should then receive their vaccination through a PCN grouping-led site.’

NHS England confirmed that no changes to the GP phase one and two Covid vaccination enhanced service specifications are needed for PCN groupings to start delivering third doses to the group.

It added that it is ‘working on a solution to be able to capture third doses in point of care systems’ and expects this will be in place by 13 September, with further information to follow next week.

Meanwhile, the letter recommended that GPs ‘maximise the opportunity’ to vaccinate household contacts of the immunosuppressed who are aged 12 and over.

It said: ‘It is also recommended that individuals are reminded that household contacts of those who are immunosuppressed are advised to be vaccinated. 

‘The JCVI updated their advice in July to include children aged 12-15 as household contacts and we ask that systems endeavour to vaccinate this cohort as soon as possible in line with this advice.’

On Wednesday, the JCVI said that while doses should start being delivered as soon as possible, the exact timing should be determined by specialists and GPs based on when the patient’s immunosuppression is at its lowest point.

It advised that eligible adults over 18 should be given the Moderna or Pfizer vaccine for their third jab, while the Pfizer jab is ‘preferred’ for those aged 12-17.

The JCVI stressed that this third ‘top-up’ dose is part of their primary vaccination schedule and is ‘separate to any potential booster programme’ – details of which will be published soon.

The health secretary said on Wednesday that the Government is ‘continuing to plan for [the booster programme] to begin in September’, which will prioritise the most vulnerable, including those eligible for the third primary vaccine.

JCVI guidance 

Severe immunosuppression at the time of vaccination is defined using the guidance and timings stated below:

1. Individuals with primary or acquired immunodeficiency states at the time of vaccination due to conditions including:

• acute and chronic leukaemias, and clinically aggressive lymphomas (including Hodgkin’s lymphoma) who were under treatment or within 12 months of achieving cure
• individuals under follow up for a chronic lymphoproliferative disorders including haematological malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma, Waldenstrom’s macroglobulinemia and other plasma cell dyscrasias (Note: this list is not exhaustive)
• immunosuppression due to HIV/AIDS with a current CD4 count of <200 cells/µl for adults Primary or acquired cellular and combined immune deficiencies – those with lymphopaenia (<1,000 lymphocytes/ul) or with a functional lymphocyte disorder.
• those who had received an allogeneic (cells from a donor) or an autologous (using their own cells) stem cell transplant in the previous 24 months
• those who had received a stem cell transplant more than 24 months ago but had ongoing immunosuppression or graft versus host disease (GVHD)
• persistent agammaglobulinaemia (IgG < 3g/L) due to primary immunodeficiency (e.g. common variable immunodeficiency) or secondary to disease / therapy

2. Individuals on immunosuppressive or immunomodulating therapy at the time of vaccination including:

• those who were receiving or had received immunosuppressive therapy for a solid organ transplant in the previous 6 months.
• those who were receiving or had received in the previous 3 months targeted therapy for autoimmune disease, such as JAK inhibitors or biologic immune modulators including B-cell targeted therapies (including rituximab but in this case the recipient would be considered immunosuppressed for a 6 month period), T-cell co-stimulation modulators, monoclonal tumour necrosis factor inhibitors (TNFi), soluble TNF receptors, interleukin (IL)-6 receptor inhibitors., IL-17 inhibitors, IL 12/23 inhibitors, IL 23 inhibitors. (N.B: this list is not exhaustive)
• those who were receiving or had received in the previous 6 months immunosuppressive chemotherapy or radiotherapy for any indication.

3. Individuals with chronic immune-mediated inflammatory disease who were receiving or had received immunosuppressive therapy prior to vaccination including:

• high dose corticosteroids (equivalent ≥ 20mg prednisolone per day) for more than 10 days in the previous month
• long term moderate dose corticosteroids (equivalent to ≥10mg prednisolone per day for more than 4 weeks) in the previous 3 months
• non-biological oral immune-modulating drugs e.g. methotrexate >20mg per week (oral and subcutaneous), azathioprine >3.0mg/kg/day; 6-mercaptopurine >1.5mg/kg/day, mycophenolate >1g/day) in the previous 3 months
• certain combination therapies at individual doses lower than above, including those on ≥5mg prednisolone per day in combination with other immunosuppressants (other than hydroxychloroquine or sulfasalazine) and those receiving methotrexate (any dose) with leflunomide in the previous 3 months

4. Individuals who had received high dose steroids (equivalent to >40mg prednisolone per day for more than a week) for any reason in the month before vaccination

Individuals who had received brief immunosuppression (≤40mg prednisolone per day) for an acute episode (e.g. asthma / COPD / COVID-19) and individuals on replacement corticosteroids for adrenal insufficiency are not considered severely immunosuppressed sufficient to have prevented response to the primary vaccination.

Source: JCVI