Who needs to shield to protect themselves from COVID-19?

The UK government recommends that extremely vulnerable people follow rigorous shielding measures to keep them safe from COVID-19.  According to the gov.uk website, people falling into the extremely vulnerable group include:

  1. Solid organ transplant recipients.
  2. People with specific cancers:
  • people with cancer who are undergoing active chemotherapy
  • people with lung cancer who are undergoing radical radiotherapy people with cancers of the blood or bone marrow, such as leukaemia, lymphoma or myeloma, who are at any stage of treatment
  • people having immunotherapy or other continuing antibody treatments for cancer
  • people having other targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
  • people who have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs.

3.  People with severe respiratory conditions, including all cystic fibrosis, severe asthma and severe COPD (chronic obstructive pulmonary disease).
4.  People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as SCID and homozygous sickle cell).
5.  People on immunosuppression therapies sufficient to significantly increase risk of infection.
6.  Women who are pregnant with significant heart disease, congenital or acquired.

I have a PID, how do I understand my risk in relation to COVID-19?

The response to COVID-19 has been created at speed and things done in a hurry are not always perfect.  NHS patients are identified by GPs and hospitals by a coded system and, if that isn’t translated accurately in the many NHS systems in use, then some patients have been told they are at risk when they are not and some not told to shield when they should.  An example is that many patients with HAE (hereditary angioedema) have been told they should shield, when that is not necessary for these patients who have no other health problems.

The advice$ to date is for medical professionals and contains a lot of jargon. Most people will know from their doctors’ appointments and letters what their diagnosis is, even if they don’t understand the detail of it. For rarer conditions, our patient information sheets on individual disorders usually state whether a condition is a CVID (common variable immune deficiency), a combined immune deficiency or a mild immune deficiency.

If you are uncertain about the specific nature of your condition, please visit the ‘Resources for patients, carers and professionals’ section of our website. Download the appropriate leaflet to identify your condition then use the table below to find out your level of risk.

The most common single major immune deficiency in adults is CVID. If you have a CVID, then you will either be in either the Moderate Risk group or the Extremely Vulnerable groups.

Combined immune deficiencies are disorders, which significantly affect T- and B-lymphocyte function. They include disorders such as Hyper IgE syndrome, Hyper IgM syndrome and APDS, but this list is not exhaustive. If you don’t identify yourself in the Minimal Increased Risk group or the Moderate Risk group, then you should assume you may be vulnerable. Contact your GP or immunology centre for clarification if you haven’t received a letter from the government providing advice.

For many people, it may not be the PID but co-morbidities that define their risk.

What are co-morbidities?

A co-morbidity is any other diagnosis that reduces the overall wellbeing of an individual.

What are the important co-morbidities in COVID-19?

  • Over 70 years of age
  • Diabetes mellitus
  • Any ‘significant’ pre-existing lung disease
  • Impaired kidney function
  • History of heart disease (heart failure, angina or heart attack)
  • Uncontrolled hypertension
  • Chronic liver disease

What is ‘significant’ lung disease’?

Significant or severe lung disease (bronchiectasis or COPD) encompasses:

  • People who use nebulised treatments.
  • Everyone who has severe or very severe airflow obstruction. This is measured using a breathing test called spirometry, where you blow out as hard as you can. If the amount of air you can blow out in one second is less than 50% of the normal range of values, then airflow obstruction is classed as severe. Severe or very severe airflow obstruction is sometimes described as GOLD grade 3 or GOLD grade 4.
  • People who are limited by breathlessness – this means that you can’t walk as fast as other people of your age owing to breathlessness. This may be described in clinic letters as an MRC breathlessness score of 3, 4 or 5.

  • People who have had to be admitted to hospital in the past because of an acute attack of the lung condition.

  • People who are on regular steroid tablets, called prednisolone, to treat their condition.

  • People who have oxygen therapy at home.

  • People who use non-invasive ventilation at home – using a mask connected to a ventilator, sometimes called BiPAP, to support their breathing at night.

If I have a co-morbidity, do I need to shield?

Based on the UKPIN professional advice table (below), if you have a PID and are on regular antibiotic prophylaxis or immunoglobulin, or take other regular medicines (see below) to prevent infection because of your PID, AND you have a listed co-morbidity, then you should be shielding.

It is important to remember that this is guidance. People may fall between categories. If you are unsure, ask your team. However, we encourage everyone to be sensible in protecting themselves as much as is reasonably possible.

* Immunosuppressive medications include: Azathioprine, Leflunomide, methotrexate, Mycophenolate (mycophenolate mofetil or mycophenolic acid), ciclosporin, cyclophosphamide, tacrolimus, sirolimus. It does NOT include Hydroxychloroquine or Sulphasalazine either alone or in combination. Steroids (e.g. prednisolone) are considered immunosuppressive if the dose is above 5mg per day for more than 4 weeks.

** Biologics are treatments that suppress the immune system by targeting immune molecules. They are usually antibody-based and given either subcutaneously or intravenously. They include Rituximab within last 12 months; all anti-TNF drugs (etanercept, adalimumab, infliximab, golimumab, certolizumab and variants of all of these); Tociluzimab; Abatacept; Belimumab; Anakinra; Seukinumab; Ixekizumab; Ustekinumab; Sarilumumab; Canakinumab. The list is very long and not all are listed here, but you should be aware if you are on one of these agents.

*** Small molecule agents are not widely used yet, but include medicines like baricitinib, tofacitinib, Ruxolitinib and Ibrutinib and are tablet immunosuppressives that target immune molecules, but in a different way to the groups above. If you have been put on a new special medicine for your PID or to treat a lymphoma or other cancer, then you should be aware of it from the discussions you have had with your doctor.

$This advice has been produced in accordance with the guidelines published by UKPIN, the professional group representing Clinical Immunologists and immunology nurses, www.ukpin.org.uk/news-item/2020/03/24/covid-19-uk-pin-update

This article has been approved by the Chair of the PID UK Medical Advisory Panel. Posted 8th April 2020