Information about Coronavirus (COVID-19)

• At the start of the COVID-19 pandemic, shielding was introduced as one of the few ways to support those who, at the time, were considered clinically extremely vulnerable (CEV).
• It was the right decision at the time, but we know that shielding advice is extremely restrictive and can have a significant impact on people’s lives and their mental and physical wellbeing.
• We have not advised people to shield since 1 April 2021, and since 19 July, people previously identified as clinically extremely vulnerable have been advised to follow the same guidance as the rest of the population.
• The situation is now very different to when shielding was first introduced. We know a lot more about the virus and what makes someone more or less vulnerable to COVID-19, the vaccine continues to be successfully rolled out, and other treatments and interventions are becoming available.
• We therefore no longer think it is appropriate to advise people to follow restrictive, centralised guidance.
• Instead, people should consider their own risk, supported by their NHS clinician where necessary.

• Based on what we now know about COVID-19, the success of the vaccine programme and with new treatments becoming available, we no longer think shielding is the best way to keep people safe.
• Shielding is very restrictive and can have a significant impact on people’s lives and their mental and physical wellbeing.
• As a result, we do not anticipate needing shielding again in the future.
• However, we have learnt a lot from setting up the shielding programme and will use that knowledge to help us in our planning for any future pandemic or emergency.

• Most people, including those previously considered CEV will be well protected by the vaccine.
• A recent study by Public Health England (PHE) showed that the vaccine is almost as effective for the majority of people previously considered CEV as for the rest of the population.
• In fact, the COVID-19 vaccines are as good at preventing serious illness and death in the majority of people with underlying health conditions as in the rest of the population.
• That’s why people previously identified as CEV are no longer considered to be at very high risk.
• The PHE study was supported by the preliminary findings of the OCTAVE trial which showed that the majority (60%) of clinically at-risk people have a strong immune response following two doses of a vaccine.
• The PHE study did find however that those who were immunosuppressed may not respond as well to COVID-19 vaccines as others. Protection against symptomatic disease for those who are immunosuppressed of all ages was 4% after one dose, however this increased to 74% after two doses.
• There are many reasons that cause immunosuppression and they affect the immune system in differing ways and amounts, so vaccine effectiveness may vary by specific condition and severity of that condition.
• The vaccine continues to be the best way to prevent serious illness and the spread of COVID-19 so we strongly urge you to take up the vaccination offer if you have not already done so.

• If you are immunosuppressed due to underlying health conditions or medical treatment, you may not have a full immune response to the vaccine and so might be less well protected than everyone else.
• As a result, you may want to take extra precautions to protect yourself and then discuss your risk with your NHS specialist at your next routine consultation.
• Third doses of the vaccine are being offered as part of the primary vaccination course to those over 12 years old who were severely immunosuppressed at the time of their first or second dose and may not have had a full response to vaccination – this includes those with leukaemia, advanced HIV and recent organ transplants.[1]
• If you fall into this category, you will be identified and invited for a vaccination by the hospital where you receive care under a consultant and/or your GP.
• If you already receive advice from your clinician on infection risk, you may wish to discuss your risk from COVID-19 at your next routine appointment.

https://www.gov.uk/government/news/jcvi-issues-advice-on-third-dose-vaccination-for-severely-immunosuppressed

• Shielding advice has not been in place since 1^st April 2021, when it was paused.
• Since 19^th July, people previously identified as CEV have been advised to follow the same guidance as everyone else.
• The decision to end shielding is based on the knowledge that for the majority of the CEV group, the risk of developing serious illness was reduced.
• We recognise that, despite advances in vaccination and treatments, there are people who remain at higher risk from COVID-19 and the decision has been taken because advising people to stay at home and limit all contact is no longer the best or most proportionate way of keeping them safe.

• A one-size fits all approach is no longer appropriate given that people can respond differently to the vaccine.
• Those who remain at higher risk after being vaccinated should discuss any necessary precautions with their NHS clinician as part of their routine engagement.https://www.gov.uk/government/news/jcvi-issues-advice-on-third-dose-vaccination-for-severely-immunosuppressed

• As a minimum, you should continue to follow the same guidance as everyone else, which can be found at gov.uk/coronavirus. However, people who are less well-protected by the vaccine may wish to consider taking extra precautions and discuss their risk with their NHS specialist at their next routine appointment. Extra precautions could include:
  • considering whether you and those you are meeting have been vaccinated – you might want to wait until 14 days after everyone’s second dose of a COVID-19 vaccine before being in close contact with others
  • considering continuing to practise social distancing if that feels right for you and your friends
  • asking friends and family to take a rapid lateral flow antigen test before visiting you
  • asking home visitors to wear face coverings
  • avoiding crowded spaces

• The Government is no longer telling anyone to work from home, however, employers still have a legal responsibility to protect their employees and others from risks to their health and safety.
• Your employer should be able to explain to you the measures they have in place to keep you safe at work. For example, some employers may ask employees to get tested regularly to identify people who are asymptomatic.
• Anyone who is worried about their risk and is unable to work from home should talk to their employer about their concerns.
• The Health and Safety Executive (HSE) has published guidance on protecting vulnerable workers, including advice for employers and employees on how to talk about reducing risks in the workplace.
• Access to Work can offer practical support to people who have a health condition that affects the way they work. The scheme can offer support including mental health support for people returning to work after a period of furlough or shielding, and travel-to-work support for those who may no longer be able to safely travel by public transport. For more information, please visit: gov.uk/access-to-work.

If you are struggling financially, you may also be eligible to apply for Universal Credit or Employment Support Allowance. For more information on benefits, please visit: www.gov.uk/financial-help-disabled

• Supermarkets stopped providing priority access to supermarket slots for people previously identified as CEV on the advice of government on 21^st
• Different supermarkets may have their own policies on priority access to supermarket slots.

• The NHS Volunteer Responders programme is still available to offer short-term help to those who need it. The NHS Volunteer Responders scheme can provide telephone support if people are feeling lonely, or help with collecting shopping, medication or other essential supplies. Patients can call 0808 196 3646 between 8am and 8pm, 7 days a week to self-refer, or visit NHS Volunteer Responders for further information.
• There may also be other voluntary or community services in your local area that you can access for support.
• All patients also can access a range of NHS services from home, including ordering repeat prescriptions or contacting their health professional through an online consultation. To find out more visit NHS Health at Home, or download the NHS App.
• The Every Mind Matters website offers advice and practical steps that people can take to support their wellbeing and manage their mental health. If they are feeling lonely, the Let’s Talk Loneliness website also has a variety of tips, advice and further resources that they may find helpful. The Hub of Hope can also be accessed to find local sources of mental health support and services, both from the NHS and from other organisations.

• The aim of the 2021 booster programme is to maintain protection against severe COVID-19 in those most vulnerable, and to protect the NHS.
• Whilst the Shielding Patient List (SPL) was created to help keep the most vulnerable safe at the start of the COVID-19 pandemic, we now have a better definition of the wide range of factors that may put someone at increased risk of serious illness from COVID-19.
• The effectiveness of the vaccine, the availability of evidence based effective treatments, and the reduction in transmission risk in those vaccinated mean that far fewer people are at serious risk of becoming seriously ill or being admitted to hospital with COVID-19.
• JCVI advises that for the 2021 COVID-19 booster vaccine programme, individuals who were vaccinated in Phase 1 of the COVID-19 vaccination programme (priority groups 1-9) should be offered a COVID-19 booster vaccine. This includes all adults over 50, and those aged 16-49 with underlying health conditions putting them at higher risk of severe COVID-19, as outlined in the Green Book.
• The vast majority of people who were on the SPL will therefore be eligible for a booster vaccine.
• Anyone who was on the SPL previously but no longer has a condition listed in the Green Book, is unlikely to need a booster.

• Third dose vaccinations are different to booster vaccinations as their aim is to increase protection levels for people who may not have had a strong vaccine response first time round.
• As per the preliminary results of the OCTAVE trial, most people previously considered CEV will be well protected by the vaccine.
• A third dose is therefore only being offered to people over 12 who were severely immunosuppressed at the time of their first or second dose, including those with leukaemia, advanced HIV and recent organ transplants.
• These people may not have had a full response to vaccination and so might be less protected than everyone else – offering a third dose may increase their protection levels.

• The Shielded Patient List will be maintained in its current form for some time as the information about those who were previously identified as CEV is used by health and social care services to provide care and treatment, to plan health and social care services and to carry out medical research.
• NHS Digital maintains the Shielded Patient List and information about how your personal data is used is available on their website here.

• During periods of shielding, patients may have registered their details with the National Shielding Service System to get support.
• The system has been closed to new registrations since 1^st April 2021.
• To find out more about your data, please see the privacy notice, which can be found here.

The ComFluCOV trial indicates that co-administration of the influenza and COVID-19 vaccines is generally well tolerated with no reduction in immune response to either vaccine. Therefore, the two vaccines may be co-administered where operationally practical.

The results of the OCTAVE study has lead to new guidance published on 1st September by the JVCI regarding a third dose of the Vaccine. You can see the full statement here.

Third dose of vaccine

Based on the JCVI recommendations, nearly all rheumatology patients (aside from those solely on hydroxychloroquine or sulfasalazine), should receive a third dose of the vaccine.

For those aged 18 years and over, JCVI advises a preference for mRNA (either the Moderna or Pfizer-BioNTech COVID-19 vaccines) vaccines for the third primary dose.

The JCVI will review whether this group requires a further booster at a later date, following completion of their 3-dose primary course.

A letter was sent by JVCI on 2nd September 2021 to:

• All GP practices
• All community pharmacy-led vaccination sites
• Vaccination centres
• All CCGs
• All directors of public health
• All directors of children’s services
• All NHS trust chief executives
• All ICS and STP leads

It contains updated information regarding the third primary dose of the COVID vaccine.

You can find the letter here.

Booster

The Joint Committee on Vaccination and Immunisation (JCVI) has updated its advice on the COVID-19 vaccine booster programme on the 14th September.

JCVI advises that for the 2021 COVID-19 booster vaccine programme individuals who received vaccination in Phase 1 of the COVID-19 vaccination programme (priority groups 1 to 9) should be offered a third dose COVID-19 booster vaccine.

They also advise that the booster vaccine dose is offered no earlier than 6 months after completion of the primary vaccine course, and that the booster programme should be deployed in the same order as during Phase 1.

Read the full Statement here.

There is no simple answer to these questions and you will need to make a personal judgement. Some useful information to consider: 

• Some people who are immunosuppressed, for example because of an underlying health condition or the medicines they are taking, may not have responded as well to their primary vaccines as those who are not immunosuppressed.
• The real take home message is that ‘some’ protection is certainly better than no protection and there is higher risk of serious consequences of COVID19 if disease is not well controlled. If you have any concerns you should speak to your treating clinician.  
• It is extremely difficult to know who will respond well to the vaccine, this is why the 3rd dose is being recommended to all people who are on medications for their RA (other than those on sulfasalazine and Hydroxychloroquine).

Some people are asking whether taking an antibodies blood test can tell them whether they have protection from COVID-19.

• We still don’t know how exactly how serology result (B cell response) correlates with protection from severe infection. Some recent experience is that most of the patients and the general population recently/currently infected despite double vaccinated had very mild disease. Virtually all OCTAVE participants had robust T cell response (even those with no/low B cell response) so while it is still unclear the significance of this response it is very encouraging.

  The most common form of antibody tests available only test for B cell response. Thus, having one may only cause unnecessary concern and expense.

Dr June Raine, MHRA Chief Executive says: “We ask anyone who suspects they have experienced a side effect linked with their COVID-19 vaccine to report it to the Coronavirus Yellow Card website.” 

There have been over 200,000 Yellow Card reports, most for mild side effects.  

You can read an article in Rheumatology on COVID-19 vaccination and antirheumatic therapies via the Oxford University Press here.  

The Mental Health Foundation has tracked the impact of the COVID-19 pandemic on our mental health and emotional wellbeing. They found that anxiety, worries and loneliness have been a feature of the pandemic for many of us.  

We have put together a page of resources to help you take care of your mental health.  

Being physically active can help with physical and mental fatigue and improve your feelings of emotional wellbeing and vitality. Levels of COVID-19 have now fallen to very low levels in all parts of the UK.  

You can find information about working safely during coronavirus (COVID-19) here: 

England: https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19?priority-taxon=5ebf285a-9165-476c-be90-66b9729f50da  

Northern Ireland: https://www.nibusinessinfo.co.uk/content/coronavirus-guide-making-workplaces-safer-and-priority-sector-list  

Scotland: https://www.gov.scot/publications/coronavirus-covid-19-returning-to-work/  

Wales: https://gov.wales/keep-wales-safe-work-html  

The Citizens Advice website has information on returning to work, including advice if you feel unsafe returning to work. They say: 

‘If you think your employer is treating you badly, you can talk to an adviser.’ 

Citizens Advice also says: 

• You have the right to be safe at work whether you work full time or have a zero-hours contract. 
• Your employer must take steps to protect you from coronavirus if they ask you to return to work. These include: 

• letting you travel to work at quieter times of the day 
• reducing how much face-to-face contact you have with the public 
• making sure that staff stay at least 2 metres apart in your workplace 

• If you can’t safely use public transport to get to work due to COVID-19, you may be eligible for the government’s Access to Work scheme to pay for a taxi to take you to work.  
• Your employer doesn’t have to make changes to protect people you live with, but you should still ask your employer what they can do to help. If you care for someone vulnerable, Citizens Advice says you should explain your situation to your employer as soon as possible. Government guidance says you can ask to be furloughed. 
• For the latest information about the furlough scheme, see here. The scheme has been extended until 30th September 2021. 

The government has produced 14 guides for working safely during COVID-19, which you can access here. 

If you are disabled, your employer may have to make ‘reasonable adjustments’. What is ‘reasonable’ will vary from employer to employer, varying on your situation and the size of the organisation. Together with other patient organisations, NRAS is asking the Vaccines Minister for more information on this and we will update this page if and when we have further information. 

(If you are not sure about the distinction between these types of medicines you can order, for free, our Medications in RA booklet or visit our medication section.)

It really depends if you are on mono-therapy biologic therapy or on combination therapy. Mono-therapy would be a biologic e.g. adalimumab without also taking methotrexate whereas combination is with another medication e.g. methotrexate. If you are on monotherapy and have no other underlying conditions or on high dose steroids you will NOT be in the ‘shielding’ group.

This level of data is not yet available however there is a Global Registry that has just launched and NRAS urges people with RA and JIA to participate. The Global #Rheumatology Alliance needs to understand how coronavirus affects rheumatic, autoimmune and autoinflammatory diseases in Europe. If you are an adult or child with RA or JIA please  join the registry at www.jarproject.org/covid.

There is also lots of other COVID19 research and data gathering happening very rapidly to find out more read the latest COVID-19 updates and COVID-19 research opportunities.

It is vitally important to keep your RA as well controlled as possible. If you come off your medication(s) you have a very high likelihood of going into RA Flare. Due to the massive impact of this virus on the health service you would more than likely be unable to get to see your GP or rheumatology team for any sort of speedy intervention. You may be advised to pause your medications if you are showing symptoms of COVID-19 but you should seek proper medical advice from speaking to 111 and ideally your rheumatology team.

This is a difficult question to answer because there is such a spectrum of expression of RA. But broadly speaking, RA does increase vulnerability and particularly if it is active. Again why it is so important to keep your RA as under control as possible by adhering to taking your medications AS prescribed. Most RA treatments are immunosuppressant, some more than others depending on dosage.

All people with RA should be encouraged to receive one of the COVID-19 vaccines. This is regardless of their treatment regimen or underlying diagnosis. The benefits of the COVID-19 vaccination outweigh the risks and by having the vaccine, this will reduce the risk of developing severe complications due to COVID-19. 

The guidance for those in doubt is to seek advice from the relevant health care practitioner. 

NHS England has vaccine in a number of different languages. You can access this information at https://www.england.nhs.uk/london/our-work/covid-19-vaccine-communication-materials/?priority-taxon=774cee22-d896-44c1-a611-e3109cce8eae

Patients should not stop their immunosuppression. Frequently, the immune response of people on immunosuppressants to these vaccine antigens is not as good as that of people who are not. However, a reduced response is safer than no response. People on rituximab need to speak to their rheumatology team to discuss the timings of the vaccination and your infusion of rituximab.

*This vaccine contains a live adenovirus vector but it is non-replicating so cannot cause infection and is therefore safe for people who are immunosuppressed. 

**Based on current evidence (May 2021) JCVI are advising a preference for a vaccine other than Oxford/AstraZeneca to be offered to healthy people aged 39 and under, including health and social care workers, unpaid carers and household contacts of immunosuppressed individuals. This advice may change if there is a change in the epidemiology or an interruption in the supply of the alternative vaccines. Within this age group, those who are older (over 30 years of age), male, from certain minority ethnic backgrounds, in certain occupations at high risk of exposure, and those who are obese, remain at high risk of COVID-19. In the absence of a suitable alternative, these individuals should still be offered the AstraZeneca vaccine and may choose to receive the AstraZeneca vaccine provided they have been informed and understand the relative risks and benefits. They should be given the latest version of the COVID-19 vaccination and blood clotting leaflet (https://www.gov.uk/ government/publications/covid-19-vaccination-and-blood-clotting). Those who have already received a dose of AstraZeneca vaccine should complete with the same vaccine. 

Yes – as to date we don’t know yet how long immunity will last after contracting coronavirus.

The COVID-19 vaccination will reduce the chance of you getting severe COVID-19 disease and therefore it is generally recommended that people with inflammatory arthritis should have the vaccine. It may take a week or two after the second dose for your body to build up protection. No vaccine is 100% effective – some people may still get COVID-19 after having a vaccination, but this should be less severe.

Advice may vary on a case-by-case basis.

In accordance with ARMA, it is advised that patients should not stop taking their immunosuppressant drugs for the vaccine. some drugs such as rituximab have been known to reduce the effectiveness of vaccines such as the seasonal flu jab. For this reason, it is expected that patients will experience the same effect from the covid vaccine. As per the update of the GOV green book on the 21st of January, there is not enough evidence to suggest that it would be disadvantages for patients on immunosuppressants to have the vaccine so should therefore receive it. However, this is general information only and any specific recommendations needs to include a conversation between the patient and their healthcare team, as the benefits and risks need to be considered on an individual basis.  

Please see the Government Green Book for additional guidance.  

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/998309/Greenbook_chapter_14a_1July2021.pdf 

Following close surveillance of the initial roll-out, the Medicines and Healthcare products Regulatory Agency (MHRA) has advised that individuals with a history of anaphylaxis to food, an identified drug or vaccine, or an insect sting CAN receive any COVID-19 vaccine, as long as they are not known to be allergic to any component (excipient) of the vaccine.  

If you have a known anaphylactic (severe allergic i.e. if you regularly carry an epipen) reaction to any of the components of the vaccine, please discuss this with you GP and notify the centre where you receive the vaccine. Generally, you should not be given the vaccine if you have had a previous systemic allergic reaction (including immediate-onset anaphylaxis) to:  

• a previous dose of the same COVID-19 vaccine
• any component (excipient) of the COVID-19 vaccine

You can find further information on the ARMA website here: http://arma.uk.net/covid-19-vaccination-and-msk/

The PETA UK website says, ‘The vaccines made by Pfizer/BioNTech, Oxford/AstraZeneca and Moderna that were recently approved for use in the UK do not contain any animal-derived ingredients.’ 

There is more information about vaccination on the NHS website here: https://www.nhs.uk/conditions/coronavirus-covid-19/coronavirus-vaccination/

The Arthritis and Musculoskeletal Alliance (ARMA) website gives further detail on some of the information above and you can read this here: http://arma.uk.net/covid-19-vaccination-and-msk/

The latest guidance for clinicians from the British Society for Rheumatology on this topic can be found here: https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

The Government website has the latest updates here: https://www.gov.uk/coronavirus.

In England, COVID-19 restrictions depend on what Tier your area is in. You can find this out using the postcode checker here: https://www.gov.uk/find-coronavirus-local-restrictions

The restrictions for each Tier are available to read here: https://www.gov.uk/guidance/local-restriction-tiers-what-you-need-to-know

The Scottish Government website has the latest updates here: https://www.gov.scot/coronavirus-covid-19/.

In Scotland, COVID-19 restrictions depend on the local protection level in your area. You can find this out using the postcode checker here: https://www.gov.scot/check-local-covid-level/

You can find out about the current restrictions in your area here: https://www.gov.scot/publications/coronavirus-covid-19-protection-levels/

The Welsh Government website has the latest updates here: https://gov.wales/coronavirus.

The Department of Health website has the latest updates here: https://www.health-ni.gov.uk/coronavirus.

You can see the latest restrictions in Northern Ireland here: https://www.nidirect.gov.uk/articles/coronavirus-covid-19-regulations-guidance-what-restrictions-mean-you.

This is the government’s key scheme to support employees who cannot work through Coronavirus pandemic.  The Chancellor has extended the scheme until 30 September 2021. 

‘If you and your employer both agree, your employer might be able to keep you on the payroll if they’re unable to operate or have no work for you to do because of coronavirus (COVID-19). This is known as being ‘on furlough’.’ – gov.uk

An employee on furlough leave is paid 80% of their usual wages, up to a monthly cap of £2,500. The Employer can if they are able and choose to do so, pay the 20% to bring pay up to the full 100%. For some lower-paid employees, if the remaining 20% is not covered by the employer, they may also be eligible for Universal Credit.

If you’re furloughed, you are allowed NOT allowed to work for your employer who is claiming this funding however you are allowed to work for and be paid by another company. You are also allowed to volunteer to support local help hubs etc.

The minimum time you can be on furlough leave is three weeks.

Employers can read more about furlough here: https://www.gov.uk/guidance/claim-for-wages-through-the-coronavirus-job-retention-scheme

People who need to stay home because of coronavirus can now get an online “isolation” note.

The notes mean people can provide evidence to their boss that they’ve been advised to self-isolate due to the virus and can’t work.

In an effort to reduce pressure on GP surgeries, the notes can be obtained without contacting a doctor or even leaving the house.

Anyone who claims Universal Credit or Employment and Support Allowance because of coronavirus will not be required to provide a fit note or isolation note.

The new isolation notes can be accessed through the NHS 111 online website. You can go straight to the isolation note page here: https://111.nhs.uk/isolation-note.

If your employer dismisses you as a result of you being unable to work due to you being the shielding group or high risk group with an isolation note, then you may have a claim for automatic unfair dismissal.