Specialty guide to severely immunocompromised patients requiring a third primary dose vaccination

The RCP has produced guidance on the identification of patients aged 12 years and above who are severely immunocompromised and require a third primary dose vaccination. This is supplemented by a dermatology-specific guidance (updated November 2021) produced by the BAD in collaboration with the RCP. Additionally, a letter has been circulated to primary and secondary care providers which contains further information and templates in Annexes A, B, C.

COVID-19 vaccines and immunosuppression FAQ

The BAD has updated the frequently asked questions document addressing COVID-19 vaccination for immunosuppressed patients based on provisional guidance issued in Chapter 14a of the Green Book and the MHRA. (Updated August 2021)

Dermatology Update on the Clinically Extremely Vulnerable

The BAD has updated its dermatology-specific recommendations covering the principles for continued care during the second wave of the COVID-19 pandemic to support clinically extremely vulnerable (CEV) patients, which can be found here. (Updated November 2020)

Recommencing immunosuppressive therapy following COVID-19 infection

The BAD has produced a short guidance on recommencing immunosuppressive therapy post-COVID-19 infection, which can be found here. (November 2020)

Risk Stratification Grid (updated November 2020)

Dermatology departments need to identify those patients for whom, due to their disease and treatment, Covid-19 poses a higher risk. This grid has been created in conjunction with other medical specialties to avoid confusion where patients are being treated with the same drug for a number of different conditions.

You can view the grid here.

FAQs For Dermatology:

How do I select the patients who need to self-isolate?

The BAD has been working with other relevant specialties at the RCP to provide a grid for each specialty which facilitates patient selection.

The link for this can be found at the top of this page and should be read in conjunction with the RCP grid for other specialties (www.rcplondon.ac.uk). We are aware that some of our patients are under care from more than one medical specialty which is why these grids have been harmonised as much as possible to avoid confusion.  We realise that there are some differences between the grids, which is due to differences in how drugs are used and patient groups between specialties.

How will I identify these patients in my own hospital?

The CMO has announced this national directive and advises all hospitals to make available the necessary resources to identify these patients. It is likely that lists from hospital pharmacists will be the main source of information.

Notes – paper or online – will be needed to identify the relevant co-morbidities and, as the grid suggests, this will sometimes require clinical judgement on a case-by-case basis. Just make the best informed clinical decision you can and, if necessary, discuss with your colleagues locally.

What is the timeframe for action?

No definite timeframe has been set yet.  The first step is to produce a list of patients, along with their NHS numbers, who need to be advised to self-isolate for 3 months. We, as clinicians, are expected to start this process immediately. The BAD advises that the list of numbers should be completed by Friday 27th March, as this may be required by the NHS to identify patients.

How will the patients be notified?*

Patients identified using the above process should be notified by dermatology departments by sending them the “template letter to high-risk dermatology patients” available on the link above. We understand that some hospitals are organising this centrally, but in others there is no central process and this is being left to individual departments.

How do I interpret the Dermatology Grid?

There are three columns:

 Column 1 describes those who definitely need to self-isolate.

 Column 2 describes those who may need to self-isolate depending on the clinical circumstances (the patient, disease and drug being used).  This will require clinical judgement.

 Column 3 describes systemic agents used in dermatology where self-isolation is not considered necessary (this is not a comprehensive list but includes treatments that we have had queries about from clinicians and patients).

Examples of the type of patient who would NOT be advised to self-isolate are:

 A patient with hidradenitis on adalimumab who is 45 and has none of the described co-morbidities.

 A patient who is 50 on methotrexate up to 25mg per week and adalimumab.

 A patient who is 57 on hydroxychloroquine and mycophenolate mofetil and no other co-morbidities.

Examples of the type of patient who WOULD be advised to self-isolate

 Patient on any single agent biologic at a standard dose who is >70 years.

 Patient on any single agent biologic at a standard dose who is on medication for hypertension or diabetes or asthma or IHD or who is pregnant.

 Patient on a single agent biologic at a standard dose with any renal impairment.

 Patient on a single agent biologic agent at a standard dose and up to 25mg weekly of methotrexate who develops any medical problems described in the above three points

What happens if my patient wishes to pause therapy?

To date, the BAD is not aware of any good evidence that people taking drugs that target the immune system are at a greater risk of getting COVID-19 or of having a more severe form of the illness to inform this decision.

When providing advice take the following into consideration:

The views and concerns of the patient

The baseline risk of the person for developing significant COVID infection (for example age >70, co-morbidities)

The need for the drug (or drugs) and likely outcome if stopped (including how easily the treatment could be re-started, alternative options that may be acceptable to the person in this context e.g. topicals, and the clinical impact of a disease flare)

What does this mean in terms of future treatment choices for my patients?

Whenever possible:

Avoid starting immunosuppressive agents, particularly in vulnerable patients
Avoid using more than one immunosuppressive agent