Third primary COVID-19 vaccine dose for eligible cancer patients



Classification: Official

Publication approval reference: C1457


  • Cancer Alliances:
    • chairs
    • clinical chairs
    • managing directors
  • NHS England and NHS Improvement regions:
    • Cancer senior responsible officers
    • Cancer deputy senior responsible officers
    • Vaccination operational leads

17 November 2021

Dear colleagues

We are writing to ask for your support in ensuring that all eligible cancer patients receive a third primary COVID-19 vaccine dose.

As you will be aware, on 2 September the Joint Committee on Vaccination and Immunisation (JCVI) published guidance on third doses of COVID-19 vaccinations for individuals aged 12 years and over with severe immunosuppression. The JCVI guidance states that:

“The specialist involved should advise on whether the patient fulfils the eligibility criteria and on the timing of any third primary dose. In general, vaccines administered during periods of minimum immunosuppression (where possible) are more likely to generate better immune responses. The third primary dose should ideally be given at least eight weeks after the second dose, with special attention paid to current or planned immunosuppressive therapies guided by the following principles:

    • “where possible, the third primary dose should be delayed until two weeks after the period of immunosuppression, in addition to the time period for clearance of the therapeutic agent
    • “if not possible, consideration should be given to vaccination during a treatment ‘holiday’ or at a nadir of immunosuppression between doses of treatment.”

Advice from national clinical leaders for cancer highlights that the majority of individuals in this cohort are likely to benefit from receiving a third primary dose as soon as possible. However, at present, just under 30% of eligible people have yet to receive a third dose. There will be some who will need to time vaccination around treatment, and this is made clear in patient facing FAQs (see below).

Next steps

To ensure that we are able to reach all eligible individuals, we are asking you to undertake the following steps:

  • Unless you are aware that a trust has already made contact with all eligible patients, please contact the lead cancer manager in each of the trusts in your area and share this letter, highlighting in particular the steps under ‘Immediate action required.’We are aware that some trusts have had difficulties in identifying the relevant patient cohort. To assist trusts, we would recommend that, when contacting them, you:
    • ask that letters are sent to all patients who have received radiotherapy or systemic anti-cancer treatment since June 2020, and all who have undergone stem cell transplants since June 2019; and
    • enclose the template letter (Annex A) and the FAQs (Appendix A) that trusts can use to send to patients. It is critical that trusts send this letter to eligible patients, as this will act as a referral letter to ensure that vaccination centres can administer the vaccine to these individuals.It is important to recognise, however, that an additional search will need to be done to capture people with chronic lymphoproliferative disorders who received treatment longer ago or who have not yet started treatment, or patients who have ongoing immunosuppression from stem cell transplants performed more than two years ago.
  • In working with your trusts, please highlight that trusts should vaccinate patients eligible for a third primary COVID-19 vaccine dose within their hospital hub, or, where the local hospital hub is not available, put collaborative arrangements in place with an external local vaccination site, eg vaccination centre, to see the patient at that site. Additionally, some systems are locally advertising sites and details of clinic times where patients could be directed.Where these options are not possible, patients should be encouraged to find a walk-in vaccination centre or community pharmacy using this website:

If trusts already have an effective process in place to support the vaccination of this group, then they should continue to implement it.

If you have any questions, please contact your regional vaccination operations centre.

Many thanks in advance for your support with this very important matter.

Yours sincerely

Professor Stephen Powis | National Medical Director | NHS England and NHS Improvement

Dame Cally Palmer | National Cancer Director | NHS England and NHS Improvement

Dr Nikita Kanani | Deputy SRO, COVID-19 Vaccination Deployment Programme, Medical Director for Primary Care | NHS England & NHS Improvement

Annex A: Template letter to patients who require a third primary COVID-19 vaccine dose

Dear [insert name of patient]

RE: Third dose COVID-19 vaccine

We are writing to you because you are eligible for an extra dose of the COVID-19 vaccine. This is because of the latest advice from the Joint Committee on Vaccination and Immunisation (JCVI). If you have already received your third dose, no action is needed.

The advice recommends that a third dose is given for individuals aged 12 and over with immunosuppression, eight weeks after their second dose. This is being delivered as a precautionary measure to increase levels of immunity and provide a better vaccination response based on studies and previous experience of other vaccines. You are eligible within this category given your diagnosis of cancer and/or treatment.

Please find below a Clinical Authorisation Letter enabling you to attend [insert name of {vaccination site identified by clinician} / {any COVID-19 vaccination site which is offering walk-ins for your vaccination which you can find here: } (delete as appropriate)]. You should take this letter with you in order to receive your third dose of the vaccine. We have also included answers to some frequently asked questions at the end of this letter, in Appendix A. Please read this to ensure that you are clear on the next steps, in particular, if you are in active treatment as this contains some important information about the timing of your third dose.

Yours sincerely

[Signatory on behalf of NHS trust]


Dear COVID-19 vaccination centre/unit

RE: Clinical authorisation letter

I am the specialist involved and responsible for the treatment of [insert name of patient here]. This patient meets the criteria set out in the latest JCVI advice on vaccinated individuals with severe immunosuppression and the Green Book due to having a diagnosis of cancer and/or concurrent treatment.

The recommendation is that this individual should be offered an extra third dose of the COVID-19 vaccine as part of their primary vaccination course. They have been advised to self-present to a COVID-19 vaccination site offering walk-in vaccinations to ensure optimal interaction with their treatment.

JCVI have advised a preference for mRNA vaccines (full dose Pfizer or Moderna) for the third dose, with the option of the AstraZeneca Vaxzevria vaccine for individuals who have received this vaccine previously where this would facilitate delivery.

Please accept this letter as clinical authorisation for this patient to receive a third dose due to their immunosuppressed status. The recommendation on the timing of this third dose is that it should be administered on the day that they present to the vaccination site.

Yours sincerely

[Signatory on behalf of NHS trust]

Appendix A: Frequently asked questions

What is the third dose?

This is an extra dose of your main COVID-19 vaccinations. You may hear this referred to as the third primary dose of the vaccine. The third vaccine should be delivered a minimum of eight weeks following the second vaccination. If you are currently receiving treatment it’s important to consider the optimal timing of the vaccine (see relevant questions below). This is advised to help boost your immunity to COVID-19 and ensure the best possible vaccine response. This is based on research and experience with other vaccines.

The JCVI advises giving either the Moderna or Pfizer-BioNTech COVID-19 vaccines for the third dose for adults aged 18 and older. A number of studies have reported an increased immune response in some immunosuppressed people after a third dose of these vaccines. We recommend you should receive a full dose of either vaccine.

Is the third dose the same as a “booster” dose?

No, the third dose is not the same as a booster vaccination. Based on current recommendations, we anticipate you will also be offered a booster vaccination six months after your third dose.

What happens now?

This clinical authorisation letter will act as authorisation to a COVID vaccination site that you require a third dose of the COVID-19 vaccine. You can self-present either to the centre which your clinician has highlighted or, if they have not specified, to any COVID vaccination centre offering walk-in vaccinations. You can find a walk in COVID vaccination centre here: You do not need to call your GP surgery or contact the hospital about this.

If it has been six months or more since you have had your second vaccine, you may book your third dose via this link:

Please ensure that you show your clinical authorisation letter when you attend for your vaccination. This will ensure that you get the correct dose of the vaccine offered.

What do I need to show at the vaccination centre?

Please bring this clinical authorisation letter confirming your eligibility. The vaccination team may also ask you for proof of identification. This will also enable the vaccination team to confirm your eligibility on the vaccine record system (National Immunisation Management System [NIMS]).

The vaccination centre should record this as your third primary dose (not a booster). This will ensure that you are still eligible for a further booster dose.

How can I access antibody testing to assess response to vaccination?

The NHS has launched a national COVID-19 cancer antibody survey for individuals who are on cancer treatment or been diagnosed in the last year. The survey will enable you to find out your COVID antibody responses following vaccination or infection. If you choose to participate in this survey, a finger prick blood kit will be dispatched to your home and testing will be done through the antibody testing program. Individuals may self-enrol at

I am having chemotherapy treatment currently, when should I have my third vaccine?

If you are currently receiving chemotherapy you need to plan your vaccination around your treatment cycles. The best time to have the vaccination is in the week before your next cycle of chemotherapy, when your blood count is likely to be highest; ie if you are on a three-weekly (21 day) cycle, the best day to have the vaccination is days 14-20.

I am having continuous oral chemotherapy treatment currently, when can I have my third vaccine?

If you are having continuous or daily, oral treatment you can have your vaccination at any time.

I am having immunotherapy treatment currently, when can I have my third vaccine?

If you are having single agent immunotherapy you need to plan your vaccination around your treatment cycles. The best time to have the vaccination is in the week before your next treatment cycle is due; ie if you are on a three-weekly (21 day) cycle, the best day to have the vaccination is days 14-20.

If you are receiving dual agent immunotherapy you should contact your consultant for individual advice. If you are unsure about the type of treatment you’re having, please contact your treatment unit for advice.

I have completed my cancer treatment. When should I have my third COVID-19 vaccine?

If you are not currently undergoing treatment and it has been at least eight weeks since your last COVID-19 vaccination, you can have your vaccination at any time. We would recommend that you have it at the earliest convenient opportunity.

I am receiving other treatment under the care of the consultant haematologists, when should I have my third COVID-19 vaccine?

If it has been at least eight weeks since your second COVID-19 vaccination you can have your vaccination at any time. We would recommend that you have it at the earliest convenient opportunity.

I have had a stem cell transplant or CAR-T therapy, should I have a third vaccine?

Please contact the centre where you had your transplant or Car-T therapy for their advice regarding a third vaccine.

Will I still need a booster COVID-19 vaccine?

A separate booster vaccination may be required in approximately six months’ time, pending further advice.

I have already had a third dose of the COVID-19 vaccine, this was referred to as a ‘booster’, what should I do now?

You do not need to take any further action at this point in time.

For more information about the COVID-19 vaccine visit