April 17th: Guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19

HM governments latest update for people who may be extremely vulnerable. You can find the full guidelines here.

In particular NOTE: guidelines on registering as a highly vulnerable patient.

Background and scope of guidance

This guidance is for people who are clinically extremely vulnerable, including children. It’s also for their family, friends and carers.

People who are clinically extremely vulnerable should have received a letter telling them they’re in this group or been told by their GP.

It’s for situations where a clinically extremely vulnerable person is living at home, with or without additional support. This includes clinically extremely vulnerable people living in long-term care facilities for the elderly or people with special needs.

If you have been told that you’re clinically extremely vulnerable, you should:

  • follow the advice in this guidance
  • register online even if you do not need additional support now

Who is ‘clinically extremely vulnerable’?

Expert doctors in England have identified specific medical conditions that, based on what we know about the virus so far, place someone at greatest risk of severe illness from COVID-19.

Clinically extremely vulnerable people may include the following people. Disease severity, history or treatment levels will also affect who is in the group.

  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 chronic obstructive pulmonary (COPD).
  4. People with rare diseases and inborn errors of metabolism that significantly increase the risk of infections (such as Severe combined immunodeficiency (SCID), 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.

People who fall in this group should have been contacted to tell them they are clinically extremely vulnerable.

If you’re still concerned, you should discuss your concerns with your GP or hospital clinician.

Check this is the right guidance for you

There’s different guidance if you are not clinically extremely vulnerable.

Follow the different guidance if any of the following apply to you:

  • you do not have any of the conditions that makes you clinically extremely vulnerable
  • you have not been told by your GP or specialist that you’re clinically extremely vulnerable or received a letter

Staying at home and shielding

You’re strongly advised to stay at home at all times and avoid any face-to-face contact if you’re clinically extremely vulnerable to protect yourself.

This is called ‘shielding’.

Shielding means:

  1. Do not leave your house.
  2. Do not attend any gatherings. This includes gatherings of friends and families in private spaces, for example, family homes, weddings and religious services.
  3. Strictly avoid contact with someone who is displaying symptoms of coronavirus (COVID-19). These symptoms include high temperature and/or new and continuous cough.

The Government is currently advising people to shield until the end of June and is regularly monitoring this position.

Handwashing and respiratory hygiene

There are general principles you should follow to help prevent the spread of airway and chest infections caused by respiratory viruses, including:

  • wash your hands more often with soap and water for at least 20 seconds or use a hand sanitiser. Do this after you blow your nose, sneeze or cough, and after you eat or handle food
  • avoid touching your eyes, nose, and mouth with unwashed hands
  • avoid close contact with people who have symptoms
  • cover your cough or sneeze with a tissue, then throw the tissue in a bin
  • clean and disinfect frequently touched objects and surfaces in the home

Note

Register for support

 

Everyone who has received a letter advising that they are clinically extremely vulnerable should register online if you need any extra support, for example, essential groceries delivered to your home.

Please register even if:

  • you do not need support now
  • you’ve received your letter from the NHS

Register for support

Please have your NHS number with you when you register. This will at the top of the letter you have received letting you know you are clinically extremely vulnerable, or on any prescriptions.

Letters to clinically extremely vulnerable people

The NHS in England has contacted clinically extremely vulnerable people with the conditions listed above to provide further advice.

If you have not received a letter or you have not been contacted by your GP but you’re still concerned, you should discuss your concerns with your GP or hospital clinician.

Help with food and medicines if you’re shielding

Ask family, friends and neighbours to support you and use online services.

If you cannot get the help you need, the government can help by delivering essential groceries and support. It may take time for support offered through this service to arrive. If you have not received a letter from the NHS then you may not be able to receive the support offered through this service. If you need urgent food or care, please contact your local council.

Getting your prescriptions

Prescriptions will continue to cover the same length of time as usual.

If you do not currently have your prescriptions collected or delivered, you can arrange this by:

  1. Asking someone who can pick up your prescription from the local pharmacy (this is the best option, if possible).
  2. Contacting your pharmacy to ask them to help you find a volunteer (who will have been ID checked) or deliver it to you.

You may also need to arrange for collection or delivery of hospital specialist medication that is prescribed to you by your hospital care team.

If you receive support from health and social care organisations, for example, if you have care provided for you through the local authority or health care system, this will continue as normal.

Your health or social care provider will be asked to take additional precautions to make sure that you are protected. The advice for formal carers is included in the home care provision.

Visits from essential carers

Any essential carers or visitors who support you with your everyday needs can continue to visit unless they have any of the symptoms of coronavirus. Everyone coming to your home should wash their hands with soap and water for at least 20 seconds on arrival to your house and often while they are there.

If your main carer becomes unwell

Speak to your carers about back-up plans for your care in case your main carer is unwell and needs to self-isolate.

You should have an alternative list of people who can help you with your care if your main carer becomes unwell. You can also contact your local council for advice on how to access care.

Living with other people

The rest of your household do not need to start shielding themselves, but they should do what they can to support you in shielding and to carefully follow guidance on social distancing.

At home you should:

  1. Minimise the time other people living with you spend in shared spaces such as kitchens, bathrooms and sitting areas, and keep shared spaces well ventilated.
  2. Keep 2 metres (3 steps) away from people you live with and encourage them to sleep in a different bed where possible. If you can, use a separate bathroom from the rest of the household. Use separate towels from the other people in your house, both for drying themselves after bathing or showering and for hand-hygiene purposes.
  3. If you share a toilet and bathroom with others, it’s important that they are cleaned every time after use (for example, wiping surfaces you have come into contact with). Consider drawing up a rota for bathing, with you using the facilities first.
  4. If you share a kitchen with others, avoid using it while they’re present. If you can, take your meals back to your room to eat. If you have one, use a dishwasher to clean and dry the family’s used crockery and cutlery. If this is not possible, wash them using your usual washing-up liquid and warm water and dry them thoroughly. If you are using your own utensils, remember to use a separate tea towel for drying these.
  5. Everyone in your household should regularly wash their hands, avoid touching their face, and clean frequently touched surfaces.

If the rest of your household are able to follow this guidance, there is no need for them to take the full protective measures to keep you safe.

If you do not want to be shielded

Shielding is for your personal protection. It’s your choice to decide whether to follow the measures we advise.

For example, if you have a terminal illness, or have been given a prognosis of less than 6 months to live, or have some other special circumstances, you may decide not to undertake shielding.

This will be a deeply personal decision. We advise calling your GP or specialist to discuss this.

Symptoms of coronavirus (COVID-19)

The most common symptoms of coronavirus (COVID-19) are recent onset of one or both of the following:

  • new continuous cough
  • high temperature (above 37.8°C)

If you develop symptoms

If you think you have developed symptoms of COVID-19 such as a new, continuous cough or fever, seek clinical advice using the NHS 111 online coronavirus service or call NHS 111. Do this as soon as you get symptoms.

In an emergency, call 999 if you’re seriously ill. Do this as soon as you get symptoms.

Do not visit the GP, pharmacy, urgent care centre or a hospital.

Prepare a single hospital bag. This will help the NHS provide you with the best care if you need to go to hospital as a result of catching coronavirus. Your bag should include:

  • your emergency contact
  • a list of the medications you take (including dose and frequency)
  • any information on your planned care appointments
  • things you would need for an overnight stay (for example, snacks, pyjamas, toothbrush, medication)
  • your advanced care plan (only if you have one)

Hospital and GP appointments if you’re shielding

Everyone should access medical assistance online or by phone wherever possible.

However, if you have a scheduled hospital or other medical appointment during this period, talk to your GP or specialist to ensure you continue to receive the care you need and determine which of these appointments are absolutely essential.

Your hospital may need to cancel or postpone some clinics and appointments. You should contact your hospital or clinic to confirm appointments.

Looking after your mental wellbeing

Social isolation, reduction in physical activity, unpredictability and changes in routine can all contribute to increasing stress.

Many people, including those without existing mental health needs, may feel anxious. For example, how it could affect support with daily living, ongoing care arrangements with health providers, support with medication and changes in their daily routines.

If you’re receiving services for your mental health, learning disability or autism and are worried about the impact of isolation, please contact your key worker or care coordinator or provider to review your care plan. If you have additional needs, please contact your key worker or care coordinator to develop a safety or crisis plan.

Understandably, you may find that shielding and distancing can be boring or frustrating. You may find your mood and feelings are affected and you may feel low, worried or have problems sleeping and you might miss being outside with other people.

At times like these, it can be easy to fall into unhealthy patterns of behaviour which in turn can make you feel worse.

Constantly watching the news can make you feel more worried. If you think it is affecting you, try to limit the time you spend watching, reading, or listening to media coverage of the outbreak. It may help to only check the news at set times or limit this to a couple of times a day.

Try to focus on the things you can control, such as your behaviour, who you speak to and who you get information from. Every Mind Matters provides simple tips and advice to start taking better care of your mental health.

If you’re struggling with your mental health, please see the NHS mental health and wellbeing advice website for self-assessment, audio guides and tools that you can use.

If you’re still struggling after several weeks and it’s affecting your daily life, please contact NHS 111 online. If you have no internet access, you should call NHS 111.

Staying mentally and physically active

There are simple things you can do that may help, to stay mentally and physically active during this time such as:

  • look for ideas of exercises you can do at home on the NHS website
  • spend time doing things you enjoy such as reading, cooking, other indoor hobbies or listening to favourite radio programmes or watching TV
  • try to eat healthy, well-balanced meals, drink enough water, exercise regularly, and try to avoid smoking, alcohol and drugs
  • try spending time with the windows open to let in the fresh air, arranging space to sit and see a nice view (if possible) and get some natural sunlight, or get out into any private space, keeping at least 2 metres away from your neighbours and household members if you are sitting on your doorstep

Staying connected with family and friends

Use support you might have through your friends, family and other networks during this time. Try to stay in touch with those around you over the phone, by post or online.

Let people know how you would like to stay in touch and build that into your routine. This is also important in looking after your mental wellbeing and you may find it helpful to talk to them about how you are feeling if you want to.

Remember, it is OK to share your concerns with others you trust and in doing so you may end up providing support to them, too. Or you might want to try an NHS recommended helpline.

Unpaid carers who provide care for someone who is clinically extremely vulnerable

If you’re caring for someone who is clinically extremely vulnerable, there are some simple steps that you can take to protect them and to reduce their risk.

Ensure you follow advice on good hygiene:

  • only provide care that is essential
  • wash your hands when you arrive and often, using soap and water for at least 20 seconds or use hand sanitiser
  • cover your mouth and nose with a tissue or your sleeve (not your hands) when you cough or sneeze
  • put used tissues in the bin immediately and wash your hands afterwards
  • do not visit or provide care if you are unwell and make alternative arrangements for their care
  • provide information on who they should call if they feel unwell, how to use NHS 111 online coronavirus service and leave the number for NHS 111 prominently displayed
  • find out about different sources of support that could be used and accessing further advice on creating a contingency plan is available from Carers UK
  • look after your own wellbeing and physical health during this time. See further information from Every Mind Matters

More information on providing unpaid care is available.

People living in long-term care facilities, for the elderly or people with special needs

This guidance also applies to clinically extremely vulnerable people living in long-term care facilities. Care providers should carefully discuss this advice with the families, carers and specialist doctors caring for such people to ensure this guidance is strictly adhered to.

Parents and schools with clinically extremely vulnerable children

This guidance also applies to clinically extremely vulnerable children in mainstream and special schools. If you live with a child who is clinically extremely vulnerable you should try to follow the advice on living with other people, you should continue to have physical contact to provide essential care.

NICE Guidance for Respiratory Patients with regard to COVID-19

The National Institute for Health and Clinical Excellence (NICE) guides the UK NHS and its clinicians as well a social care professionals when good, balanced and well-researched opinions are needed for a new situation, or an update is needed for an existing medical condition. Consequently NICE has brought out a series of guidelines for SARS-CoV-2 (COVID-19) coronavirus infections as the epidemic has developed and doctors may refer to those guidelines for the best way to treat their infected patients who also have a respiratory disease.

NICE can also respond to specific questions from clinicians and some questions relate to people with respiratory disease. We know that some steroid medication can leave patients slightly more vulnerable to some types of infection, so the question was posed “is it better to stop taking steroid medication to help prevent a COVID-19 infection or shall we advise patients to continue taking steroid medication to control their symptoms”.

  1. The first set of guidelines were designed for doctors treating patients with asthma and importantly defines exactly what they mean by severe asthma which is

    “severe asthma is defined by the European Respiratory Society and American Thoracic Society as asthma that requires treatment with high-dose inhaled corticosteroids plus a second controller, and/or systemic corticosteroids to prevent it from becoming or remaining ‘uncontrolled’ despite this therapy”

    As you might expect much of the document is quite technical, but it is clear that severe asthma patients who get a COVID-19 infection are to continue to use their normal medication including corticosteroid just as they did before infection.

  2. The second set of relevant guidelines refers to people who have Chronic Obstructive Pulmonary Disease (COPD).

    “The new guidance on community-based care of patients with COPD says all patients, including those with suspected or confirmed COVID-19, should continue taking their regular inhaled and oral medicines in line with their individualised self-management plan“.

NICE says there is no evidence that treatment with inhaled corticosteroids for COPD increases the risk associated with COVID-19, so patients established on these drugs should continue to use them, and delay any planned trials of withdrawal. Patients on long-term oral corticosteroids should also be told to continue taking them at the prescribed dose.

Coronavirus Outbreak 2020 ANNOUNCEMENT: A notice for all patients that attend the National Aspergillosis Centre, Manchester, UK, 10th April.

NAC CARES

A plea to all NAC patients

As you will be aware the NHS faces unprecedented times due to the Coronavirus pandemic. The National Aspergillosis Centre (NAC) team are extremely busy working on the frontline.

We are currently still trying to offer telephone consultations in place of face to face appointments. However, we are currently overwhelmed with the numbers of calls still required. May we politely request again that you call us to postpone all non-urgent telephone appointments.

Chronic Pulmonary Aspergillosis (CPA) Patients

Many patients have also been in contact with us regarding NHS social shielding letters and support. The National Aspergillosis Centre (NAC) has now sent letters to all NAC registered patients (and their GPs) who have a diagnosis of chronic pulmonary aspergillosis (CPA) advising that they are extremely vulnerable and should follow social shielding advice.

For further details on shielding and protecting highly vulnerable people click here.

All patients living in England will be added to the government’s list of extremely vulnerable people and can register for support at https://www.gov.uk/coronavirus-extremely-vulnerable

NOTE: There is separate advice for patients living in Scotland, Northern Ireland and Wales. For country-specific information regarding social shielding please follow these web links or contact you GP:

Allergic Bronchopulmonary Aspergillosis (ABPA) Patients

Patients with Allergic Bronchopulmonary Aspergillosis (ABPA) and Severe Asthma with Fungal Sensitisation (SAFS) requiring to shield should have been identified by the NHS database searches across the UK. These searches were based on the medication you take to control your asthma. If you have not received a letter and you believe you have severe asthma you should first contact your local respiratory consultant or GP for advice. Please note that the National Institute for Health and Care Excellence (NICE) have defined severe asthma for the purposes of COVID-19 as follows:

“asthma that requires treatment with high-dose inhaled corticosteroids (see inhaled corticosteroid doses for NICE’s asthma guideline) plus a second controller and/or systemic corticosteroids to prevent it from becoming ‘uncontrolled’, or which remains ‘uncontrolled’ despite this therapy.”

Aspergillus bronchitis and Aspergillus sinusitis Patients

Aspergillus bronchitis and Aspergillus sinusitis have not been identified as risk factors for serious complications from COVID-19. If you have one of these conditions alone, you should not follow shielding advice. Instead, you should follow social distancing guidelines.

For further guidance on social distancing click here

Why is social distancing so important?

There has been much discussion around how the novel coronavirus, SARS-CoV-2, which causes COVID-19, is transmitted from person to person. How does it spread? How can we monitor, isolate and control the spread of COVID-19? Why is social distancing so important?

A recently published paper, provides new evidence which adds to our understanding of transition dynamics.

The study looked at viral loads in upper respiratory tracts of 18 people from Zhuhai in Guangdong, China. 14 of these people had recently returned to Zhuhai from Wuhan and 4 were ‘secondary infections’ i.e. they had not been to Wuhan. Swabs were taken at regular intervals as the infection progressed.

  • 13 had signs of pneumonia on CT scans
  • 3 required admission to intensive care
  • 15 had mild to moderate illness
  • 1 had no symptoms
  • None had visited the Huanan Seafood Wholesale Market

The paper describes the relationships between the people in the study. For example, one patient worked in Wuhan. He visited his wife, mother and a friend on January 17th. His wife and mother developed symptoms 3 and 5 days later and had virus detected soon after symptoms started. The friend had no symptoms but he too had positive swabs on days 7, 10 and 11 after contact.

The team also looked at viral load in the nose and throat of the patients who had symptoms from the day that their symptoms started. High viral loads were detected very soon after symptom onset, with more in the nose than the throat. There was similarity in the viral load of the symptomatic and asymptomatic patients. This suggests that asymptomatic carries can spread the virus too.

This is different to SARS, which caused a global epidemic in 2002-2003 with over 8000 cases in 25 countries, and suggests that very different case detection and isolation strategies are required to manage and control SARS-CoV-2.

For COVID-19, even people who have mild to moderate symptoms can be highly infectious, and they are very infectious very quickly, perhaps even before symptoms develop or very soon afterwards. This is why social distancing is so important.

Please follow official advice for social distancing, self-isolation or shielding depending on your circumstances.

  • Social distancing is something we should all do to reduce social interaction between people in order to reduce the transmission of coronavirus (COVID-19)
  • Self-isolation is what people should do if they, or someone they live with, develop symptoms that may be caused by coronavirus.
  • Shielding is a measure to protect people who are clinically extremely vulnerable by minimising all interaction between those who are extremely vulnerable and others.

Coronavirus COVID-19 (SARS-CoV-2): Precautions if you have Aspergillosis (April 4th)

Coronavirus precautions

Over the last few weeks, many of us in the UK have been careful to socially distance ourselves from others in order to slow down the spread of the SARS-CoV-2 (COVID-19) viral outbreak. The requirements are as follows:

Stay at home

  • Only go outside for food, health reasons or work (but only if you cannot work from home)
  • If you go out, stay 2 metres (6ft) away from other people at all times
  • Wash your hands as soon as you get home

Do not meet others, even friends or family.

You can spread the virus even if you don’t have symptoms.

See UK Gov link for full details

These precautions are effective and appropriate for almost everyone, however, there are a few people who are more vulnerable due to age or a specific health condition and may need to take further precautions. Some, but certainly not all patients with aspergillosis will fall into that category, and in some cases will have to be individually considered by your doctor.

If you fall into the extremely vulnerable category you will be informed by a letter from UKgov, your GP, you local hospital doctor or for some (those with CPA) from the National Aspergillosis Centre. This is known as the shielding letter.

If you are extremely vulnerable

The UK government have severe asthma and severe COPD as conditions that put people at high risk from the coronavirus COVID-19 outbreak. The full document published by Public Health England(March 24th) which also contains links to a large number of other relevant documents can be accessed here. Aspergillosis refers to a range of diseases and individual cases, some of which may fall into the high-risk category but some will not. 

The main points (in addition to maintaining good handwashing, cough into tissues) are:

  1. Strictly avoid contact with someone who is displaying symptoms of coronavirus (COVID-19). These symptoms include high temperature and/or new and continuous cough.
  2. Do not leave your house.
  3. Do not attend any gatherings. This includes gatherings of friends and families in private spaces for example family homes, weddings and religious services.
  4. Do not go out for shopping, leisure or travel and, when arranging food or medication deliveries, these should be left at the door to minimise contact.
  5. Keep in touch using remote technology such as phone, internet, and social media.

All people at high risk are being informed of this by text/email/letter over the next week so that they are fully aware of what they must do to protect themselves.

In our discussions with aspergillosis patients, a few more points relating to social isolating that are not fully covered by the above document have been raised, so we will try to answer them here – if you have more questions please join our Facebook group and discuss it there.

Can I use my garden?

If you have a private garden and can maintain social distancing from neighbours and other people living in your home the answer is yes.

Deliveries: can I catch the virus?

There is a specific research paper that answers some of these questions. COVID-19 survival on a variety of surfaces was measured under one set of conditions:

 

SARS-CoV-2 is the current virus (2020 outbreak) which appears as red markers in each graph. We can see that the length of time it takes for the virus to lose half of its infectious particles (ie the half-life) is shortest for cardboard(3-4hrs) and copper (1 hr), so any virus on cardboard packaging should last the least amount of time, whereas the half-life was 6-7 hours for plastic, or roughly twice as long.

Given that someone who is infected by SARS-CoV-2 (COVID-19) can produce over a million viruses in their throat, we can see that a single cough could contain hundreds of thousands. If that number landed in cardboard it would take over 2 days for the virus to ‘die-off’, twice as long as that for plastic. Clearly it is sensible to take precautions with deliveries depending on what they are wrapped in and wipe them down with sanitiser containing more than 60% alcohol or bleach, or this US EPA document is very useful describing a large choice of disinfectants.

How easy is it to be infected if someone is coughing?

The paper above shows that the half-life of the virus under standard conditions as an aerosol ie after a cough or sneeze is similar to copper and can stay in the air for at least an hour, though the majority are thought to sink to the floor within 2-metre area in minutes. It will take 12-24 hours to die-off in air, perhaps longer under non-standard conditions (e.g. warmer temperature or higher humidity) but perhaps longer when it lands depending on the surface it lands on. This is why thorough hand washing is vital to prevent the settled virus from being passed on, and 2-metre spacing keeps us away from direct aerosols in the event of someone coughing.

Should I be cleaning my phone?

The figures given above for the survival of the virus on plastic are helpful when you realise that we all carry around a plastic screen, hold it in our hands, put it up against our faces. If any viruses land on our phones they can remain viable for over 4 days. For that reason, we should be cleaning our phones regularly, at least daily. Use alcohol-based wipes – this article gives more detail.

Disinfecting surfaces: What should I use?

Confusingly different disinfectants need to be used in different ways, and different surfaces may need different disinfectants. The best disinfectants for your hands & skin are preferably soap & running water as the soap unsticks & disables the virus and the water washed it off and dilutes the virus in your skin very efficiently – hot water with soap best of all. If you cannot access running water then hand sanitisers containing at least 60% alcohol (NOT just soap & surfactants) are effective until you can wash your hands properly.

NOTE that most wet wipes/baby wipes are designed to clean and NOT kill coronavirus.

For other surfaces, there are a range of useful disinfectants but some are no good for disinfecting surfaces covered in virus and many need to be left on the surface for longer than you think! Thankfully this document from the US Environmental Protection Agency is very informative.

Cleaning & disinfecting in a home with confirmed or suspected SARS-CoV-2

Cleaning an area that has been exposed to SARS-CoV-2 eg after someone in a house has been diagnosed as Coronavirus positive and has left

COVID-19 monitoring

Help researchers monitor the coronavirus spread using this simple App.

Myths to ignore

World Health Authority on Myths

Live Science (US-based) myths

BBC part 1

  • Garlic
  • Drink water
  • Ice cream
  • Drinkable silver (colloidal silver)

and part 2

  • Holding your breath
  • Home-made hand sanitizer
  • The virus can survive on surfaces for a month
  • Cow urine

I haven’t received a shielding letter, what do I do?

Letters are still being sent out, you may yet receive one and until then the general advice is to socially distance yourself from everyone (see above) rather than shield yourself. For people with asthma who have not received a letter Asthma UK have released some guidelines suggesting further action

For people with chronic lung disease, the British Lung Foundation have released some helpful guidelines.