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COVID-19 vaccination for people who are severely immunosuppressed | Third primary dose

On 1 September 2021 the Joint Committee on Vaccination and Immunisation (JCVI) advised that a third dose of COVID-19 vaccine be offered to ‘severely immunosuppressed people’. The advice is based on preliminary evidence of poor vaccine effectiveness within these people.

This third dose is part of the primary vaccination schedule. It is separate from any potential booster vaccination.

The JCVI said that it expects that ‘severely immunosuppressed individuals will become eligible for a booster dose as part of a routine booster programme from around 6 months after their third primary dose, pending further advice.’ If advised, this will be coordinated through the NHS vaccination programme.

On 14 September 2021 the JCVI issued advice about booster vaccinations for some people. This advice is separate from, and does not supersede, the advice on a third primary dose for people who are severely immunosuppressed. The JCVI will review whether someone who is severely immunosuppressed requires a further booster at a later date, following completion of their three-dose primary course.

Flu vaccinations will form a separate programme to the COVID-19 primary vaccination courses and booster programmes. All eligible people will be offered the flu vaccine.

JCVI definitions

The JCVI defines severely immunosuppressed people as ‘aged 12 years and over with severe immunosuppression in proximity to their first or second COVID-19 vaccine doses in the primary schedule’. This is not the same cohort defined during the first lockdown as ‘clinically extremely vulnerable’ and advised to shield, but there is predictable overlap between the two groups.

The JCVI defines ‘severe immunosuppression at the time of vaccination’ using the guidance and timings in its 1 September 2021 advice on third primary dose vaccination.

For the most up-to-date advice, see COVID-19: the green book, chapter 14a.

JCVI advice on which vaccine to administer

The JCVI advises that the third primary dose should be an mRNA vaccine, with the option of the AstraZeneca/Oxford (Vaxzevria) vaccine for people who have received that vaccine previously, where this would facilitate delivery.

In exceptional circumstances, people who have received an mRNA COVID-19 vaccine previously may be offered a third primary dose of AstraZeneca/Oxford (Vaxzevria) vaccine following a decision by a health professional on a case-by-case basis.

For people aged 12 to 17 years, the Pfizer/BioNTech (BNT162b2) vaccine remains the preferred choice, as set out in JCVI advice of 4 August 2021.

Principles of care for people who are severely immunosuppressed

People who meet the JCVI definition of severely immunosuppressed should be assessed against more detailed specialty frameworks. They should only be offered a third primary dose following an individual risk assessment by their specialist.

Timing of the third primary dose will be determined by the specialist, taking into account the timing of the identification of immunosuppression, any immunosuppressive drug regime and time from the second primary dose. The third primary dose must be given at least 8 weeks after the second dose.

Identification of people who are severely immunosuppressed by specialty

The profile of people who will benefit from a third vaccine dose as part of their primary vaccination schedule may vary from specialty to specialty. The medical specialties of the RCP have devised detailed evidence-based frameworks to help determine whether someone is severely immunosuppressed.

These frameworks supplement a case-by-case assessment of people falling within the broad categories and criteria outlined by the JCVI. You must make an individual risk assessment before a third primary dose is recommended.

You may need to use the following sources to identify people who might exhibit impaired vaccination responses due to severe immunosuppression:

  • specialty databases and registries
  • pharmacy high-cost drugs databases
  • primary care records
  • trust data and subsets developed in 2020 to identify clinically extremely vulnerable people.

General practice will be identifying people using data held on GP IT systems. In broad terms, general practice can most easily identify people where there is a clear diagnosis in the IT system or immunosuppressive medication is prescribed within general practice.

General practice may or may not be able to identify people who receive their medication from a hospital source. It is unlikely to have information on the optimum timing of immunisation as part of a wider treatment course.

Letter confirming the need for a third primary dose

People who are severely immunosuppressed will not be able to self-refer for a third primary dose. They may be contacted via their specialist or GP and provided with a letter they can use to access vaccination. In England that will be via a hospital vaccination hub, a mass vaccination centre or a primary care network pharmacy site that is offering COVID-19 vaccination.

The letter should clearly state their need for a third primary dose of vaccine, as identified by the specialist team. In order to protect their confidentiality, it does not need to state the indication or underlying diagnosis.

Further information

You can download this statement as a PDF document below.

All JCVI publications and statements can be found here.

Please feel free to contact us via policy@rcp.ac.uk.

Specialty frameworks for identifying people who are severely immunosuppressed

We will add links to specialty frameworks as they become available. If the relevant one isn’t listed below, we suggest you contact your specialty society for advice.