Vaccination of adult household contacts of severely immunosuppressed individuals alongside JCVI priority Cohort 6 and completion of Cohorts 1-9

Contents

 

Classification: Official

Publications approval reference: C1228

To:

  • All GP practices
  • All CCGs

Cc:

  • All CCG Chairs
  • All ICS and STP leads
  • All Local Authority CEOs
  • All Directors of Adult Social Care
  • All NHS Trust Chief Executives
  • NHS Regional Directors
  • NHS Regional Directors of Commissioning

31 March 2021

Dear GP colleagues

The JCVI has recently advised that adult household contacts of adults (over 16 years of age) with severe immunosuppression should be offered COVID-19 vaccination alongside priority group 6. This is in response to regular monitoring of data on vaccine effectiveness and impact, which indicates lower protection in vaccinated adults who are immunosuppressed. Those with severe immunosuppression are therefore more likely to suffer poor outcomes following infection and are less likely to benefit from the vaccines offered. The JCVI’s recommendation to vaccinate adult household contacts aims therefore to reduce the risk of infection in the immunosuppressed by vaccinating those most likely to transmit to them. A full definition is set out in Annex A.

Next steps

  • We are asking all GP practices to identify individuals on their registered patient lists who fall into the Green Book definition of severely immunosuppressed.
  • GP practices should write to inform these individuals that their adult household contacts are eligible to receive the COVID-19 vaccination. A template letter for this purpose is attached at Annex B.
  • The template letter asks severely immunosuppressed individuals to let their household contacts know that they are eligible for vaccination and that they should contact their registered GP practice.
  • Please adapt the template letter (Annex B) and send it on your GP practice’s headed paper to any severely immunosuppressed individuals that you identify.
  • Household contacts will use the letter, together with their own proof of address, which must match that of the immunosuppressed individual, to provide evidence of eligibility for vaccination. This will be requested on arrival for their vaccination appointment.
  • Please inform staff in your GP practice that household contacts of people who are severely immunosuppressed may call the GP practice asking to book a vaccination appointment, and they should then be invited to attend the PCN-led Local Vaccination Services (LVS) site.
  • There may be a small number of individuals supporting an immunosuppressed person through a period of treatment – eg daily care for the majority of the week – who are unable to provide matching proof of address. Local operational flexibility should be applied in this situation.

We have written separately to all medical directors of acute trusts to inform them of the JCVI advice. Medical directors are asked to cascade this information to the relevant departments and clinical teams so that they are aware and the specialist team can organise vaccination at the acute trust if possible, or inform the immunosuppressed individual’s GP that their household contacts are eligible for the vaccination, and advise them to contact their registered GP.

Completion of Cohorts 1-9

As you know, we are committed to ensuring that everyone in JCVI Cohorts 1-9 has been offered the opportunity to be vaccinated before we are able to open vaccination to Cohort 10. We have also asked sites to confirm, by return of a survey, progress on offering Cohorts 1-9 a vaccination. Please ensure that your response is up-to-date.

Please continue to do all you can to minimise any inequalities in vaccine uptake within JCVI Cohorts 1-9 between different groups wherever possible, working with your CCG, local authority and community partners, mindful of deprivation, ethnicity and factors impacting COVID-19 risk.

This means our focus must remain on doing everything we can to ensure as many people as possible in Cohorts 1-9 receive their first dose, as well as maintaining an unrelenting focus on second dose delivery throughout April.
In response to the supply profile over April, changes to the National Booking System will also be introduced from 1 April. This means that from now eligible frontline health and social care workers and carers who are unknown to the system will need to use alternative routes, including PCN-led local vaccination services.

We are therefore asking each PCN site to continue to work with their local partners to ensure that plans are in place to be able to offer vaccinations to eligible health and social care workers in Cohorts 1 and 2 and unpaid carers from Cohort 6 who have yet to take up the offer.

For Cohort 1 (older persons in care homes) it is important that all PCNs routinely offer opportunistic vaccination using Oxford/AstraZeneca through second, third and any subsequent visits to care homes, as well as other residential settings, for staff who may now want to take up the offer and new starters. Primary care teams are asked to help improve and maintain uptake for this staff group. To help this, please take additional vaccine over the known requirements to each care home visit.

To ensure comprehensive access, we are now asking PCNs to action the following:

  • Record unpaid carers who have not already been called for vaccination, and who care for those with CEV or those ‘at risk’, as carers on their primary care record and offer a vaccination. For new approaches from unpaid carers currently not known to the system, the normal process for identifying and recording eligibility should be applied.
  • Ensure arrangements are in place to offer vaccination to eligible health and social care workers, who will be encouraged to contact their GP. We expect CCGs to support local practices to organise and deliver this process, ensuring it can be handled consistently, in line with existing eligibility criteria, and that we continue to increase uptake for this priority group.
  • Work with local partners, including local authority and CCG vaccination leads, to ensure local provision for domiciliary care workers, including personal assistants, live-in carers and agency workers. Local systems will be asked to ensure that this group can continue to access vaccination.
  • Consider offering practical options working with local partners that might help optimise uptake, such as offering mid-afternoon, midweek, dedicated vaccination clinics in local communities for eligible social care workers.
  • Extend vaccination offers to the carers and care staff who support those who are housebound when vaccinating people in their own homes.

This week national, regional and local communications will start to encourage all of those eligible in Cohorts 1-9 who have yet to receive a vaccination or without an existing appointment, to get in touch with their GP practice.

If, and by exception, you have vaccine at the end of a clinic which may be wasted (as short-life Oxford/AstraZeneca stock or Pfizer/BioNTech), you may bring forward Cohort 1-9 second doses (as per Green Book) as a first step.

Please do not waste vaccine. However, this should be as close to 12 weeks as possible and as a minimum at least 8 weeks after the first dose as recommended by JCVI.

Over the next few weeks, we must maintain focus on ensuring those who are most vulnerable to COVID-19 are protected, before moving to Cohort 10. This is particularly important as we move towards further easing of lockdown restrictions in the coming weeks. We will write to you in due course to identify when it is appropriate to invite Cohort 10.

Thank you in advance for all your efforts to identify this vulnerable population and your help vaccinating their permanent adult household contacts.

Best wishes

Dr Nikita Kanani | Medical Director for Primary Care | NHS England and NHS Improvement

Ed Waller | Director of Primary Care | NHS England and NHS Improvement

Annex A: Definition of severely immunosuppressed individuals

The JCVI definition of severely immunosuppressed individuals is those currently included in either priority group 4 and 6 using the definition set out in the Immunosuppression section of Table 3 ‘Clinical risk groups 16 years of age and over who should receive COVID-19 immunisation’ in the Greenbook Chapter 14A. This section covers immunosuppression due to disease or treatment. This includes but is not limited to:

  • individuals who are receiving immunosuppressive or immunomodulating biological therapy and individuals treated with steroid sparing agents
  • individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day for adults
  • anyone with a history of haematological malignancy, and those who may require long term immunosuppressive treatments.

Most of the more severely immunosuppressed individuals in this category should already be flagged as clinically extremely vulnerable (CEV) and therefore in priority group 4, but some will be in priority group 6. Existing SNOMED codes will capture a proportion, but not all of this group as some individuals will have been added to the CEV list via other routes, including through secondary care.

Immunosuppressed children are not included in the definition, in that their adult household contacts are not being advised for vaccination as part of the JCVI guidance.

Definition of adult household contacts

We are using the same principles to define household contacts in this context as those used in the Greenbook Chapter 19: Influenza: “individuals who expect to share living accommodation on most days…. and therefore, for whom continuing close contact is unavoidable.”

The advice covers individuals aged 16 years or over only. Those household contacts aged 16-17 years old will need to receive the Pfizer/BioNTech vaccine.

Children are excluded. Given that there is still no data on the safety, reactogenicity or efficacy of COVID-19 vaccines in children and that children are much less likely to have poor outcomes from COVID-19, the JCVI is not currently advising vaccination of household contacts of immunosuppressed children, or household contacts of immunosuppressed adults who are themselves children.

Members of ‘bubbles’ that do not live with an immunosuppressed person for the majority of the week (frequent visitors and other non-carers who might visit the house often but not for the majority of the week, including overnight stays) are excluded from the definition.

Those living in long-stay residential care homes or other long-stay care facilities will already be eligible for a vaccine in priority Cohorts 1 and 6, in line with JCVI recommendation. As with the influenza vaccine, this does not include prisons, young offender institutions, university halls of residence etc.

Annex B: Template letter to severely immunosuppressed individuals for GP practices to adapt

Your adult household contacts are now eligible to receive the COVID-19 vaccination

Dear [NAME]

We are writing to let you know that your adult household contacts are now eligible to receive the COVID-19 vaccination. This is because the Joint Committee on Vaccination and Immunisation (JCVI) has recently advised that adult household contacts of adults, over 16 years of age, with severe immunosuppression should be offered COVID-19 vaccination. This aims to reduce the risk of infection to you by vaccinating those most likely to transmit to you, as even though you may have received your COVID-19 vaccination, you may have lower protection from the vaccine given that you are immunosuppressed.

The JCVI advice applies to adult household contacts who are 16 years and above with whom you “expect to share living accommodation on most days…. and therefore, for whom continuing close contact is unavoidable.”

Please let your adult household contacts know that they can now book a vaccination appointment via their registered GP practice, who will then invite them to attend their GP-led Local Vaccination Service.

Your household contacts will need to use this letter, together with their own valid proof of address, which should match your address, to provide evidence of eligibility for vaccination. This should happen on arrival for their vaccination appointment. If an adult is supporting you through a period of treatment – eg chemotherapy – and they are unable to provide a valid proof of address, they should contact their registered GP, who will be able to advise them.

Members of ‘bubbles’ that do not live with an immunosuppressed person for the majority of the week (frequent visitors and other non-carers who might visit the house often but not for the majority of the week, including overnight stays) are excluded from the definition.

This link on the government website outlines what is a valid proof of address: Proof of identity checklist – GOV.UK (www.gov.uk) and includes the following:

  • utility bill (gas, electric, satellite television, landline phone bill) issued within the last three months
  • local authority council tax bill for the current council tax year
  • current UK driving licence (but only if not used for the name evidence)
  • bank, building society or credit union statement or passbook dated within the last three months
  • original mortgage statement from a recognised lender issued for the last full year
  • solicitor’s letter within the last three months confirming recent house purchase or land registry confirmation of address
  • council or housing association rent card or tenancy agreement for the current year
  • benefit book or original notification letter from Benefits Agency (but not if used as proof of name)
  • HMRC self-assessment letters or tax demand dated within the current financial year
  • electoral register entry or NHS medical card or letter of confirmation from GP’s practice of registration with the surgery.

Note that any household contacts aged 16-17 years old will need to receive the Pfizer/BioNTech vaccine as the Oxford/AstraZeneca vaccine has only been authorised for use in people aged 18 years and over.

For more information about the coronavirus vaccine, read the leaflet that came with this letter, or visit www.nhs.uk/covid-vaccination

Yours sincerely,

[Signatory]