GPs to help identify up to 500k immunosuppressed patients for third Covid vaccine dose

GPs will be asked to help identify up to 500,000 severely immunosuppressed patients for a third Covid vaccine dose, the Government has said.

The Joint Committee on Vaccination and Immunisation (JCVI) today issued a new recommendation that people with ‘severely weakened immune systems’ should be offered a third dose of the Covid vaccine.

The health secretary has said that the Government has accepted the JCVI’s advice, which is expected to cover around 400-500,000 people across the UK.

In a statement published today, the JCVI said that those who should have a third vaccine dose 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’.

These patients ‘may not mount a full response to vaccination and therefore may be less protected than the wider population’, it added.

It stressed that this third ‘top-up’ dose is part of their ‘primary Covid-19 vaccination schedule’ because they ‘may not have generated a full immune response to the first two doses’ and is ‘separate to any potential booster programme’, which is designed to extend the duration of protection from the primary course.

The JCVI said: ‘Studies are ongoing to see how effective a third dose is for immunosuppressed people, but it is very unlikely to cause any harm. Therefore, on balance, the JCVI’s view is that a third dose can be safely offered as it may increase their protection.’

JCVI chair of Covid-19 immunisation Professor Wei Shen Lim added: ‘We want people with severely suppressed immune systems to have the best chance of gaining protection from Covid-19 via vaccination.

‘Therefore, we are advising they have a third vaccine dose on top of their initial two doses, as we hope this will reduce their risk of severe outcomes such as hospitalisation and death.’

At a background briefing attended by Pulse, Professor Lim said that the JCVI estimates that around 400-500,000 people will be eligible for the top-up jab.

A spokesperson for NHS England’s vaccine deployment programme confirmed at the briefing that GPs will be responsible for identifying and reaching out to eligible patients alongside hospital colleagues.

The vaccines will be delivered in both by GP-led sites and opportunistically in hospital settings where Covid vaccination is available, with further details to follow, they added.

Deputy chief medical officer Professor Jonathan Van Tam and Professor Lim stressed 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.

The JCVI statement said that ‘as a general guide, the third dose should usually be at least 8 weeks after the second dose but with flexibility to adjust the timing so that, where possible, immunosuppression is at a minimum when the vaccine dose is given’.

It advised that eligible adults over 18 should be given the Moderna or Pfizer vaccine for their third jab, as studies suggest that some immunosuppressed people have an ‘increased’ immune response following a third dose of an mRNA vaccine.

The Pfizer jab is ‘preferred’ for those aged 12-17, it added.

Meanwhile, Professor Van Tam and Professor Lim added that further information on booster vaccinations will be published soon and that today’s announcement does not indicate a delay in deliberations about the booster programme.

The JCVI statement said it is ‘still deliberating the potential benefits of booster vaccines for the rest of the population and is awaiting further evidence to inform this decision’.

It added that severely immunosuppressed people are ‘expected’ to be offered a booster dose at a ‘suitable interval’ after their third dose ‘in the event of a booster programme’.

Health secretary Sajid Javid said: ‘Today I have accepted the expert recommendations from the independent JCVI to offer a third vaccine dose to people aged 12 and over with severely weakened immune systems as part of their primary schedule following data from trials of those who are immunosuppressed.

‘We know people with specific conditions that make them particularly vulnerable to Covid-19 may have received less protection against the virus from two vaccine doses. I am determined to ensure we are doing all we can to protect people in this group and a third dose will help deliver that.’

He added: ‘The NHS will contact people as soon as possible to discuss their needs and arrange an appointment for a third dose where clinically appropriate.’

Mr Javid said 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:

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

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.

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

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