'Severely immunosuppressed' people to be offered third dose of COVID-19 vaccine

The JCVI has recommended that people who are 'severely immunosuppressed' should have a third dose of the COVID-19 vaccine, at least 8 weeks after the second dose.

1. What is the JCVI's recommendation?
2. Is this part of the booster programme?
3. Why has this advice been issued?
4. Who is considered 'severely immunosuppressed'?
5. What do I need to do now?

1. What is the JCVI's recommendation?

The Joint Committee on Vaccination and Immunisation (JCVI) has issued advice that people who are 'severely immunosuppressed' should have a third 'top-up' dose of the COVID-19 vaccine as part of their primary vaccination schedule.

This third dose should be offered to people aged over 12 who were 'severely immunosuppressed' at the time of receiving their first or second dose of the vaccine.

The third dose should usually be offered at least 8 weeks after the second dose of the vaccine was received, though the decision on timing should be made by an individual’s specialist.

2. Is this part of the booster programme?

No, this offer is separate to any potential booster programme. The JCVI is still deliberating the potential benefits of booster vaccines for the rest of the population and is awaiting further evidence to inform this decision.

3. Why has this advice been issued?

The JCVI has made this recommendation as people who are 'severely immunosuppressed' may not mount a full response to vaccination and therefore may be less protected than the wider population. This is important as people with severe immunosuppression are at greater risk of becoming severely ill if they do catch COVID-19.

Preliminary data from the OCTAVE trial showed that almost everyone who was immunosuppressed mounted an immune response after 2 doses of the COVID-19 vaccine, as indicated by either antibodies or T cells. However, in around 40% of people, the levels of antibodies were low. It is not clear how much this may affect protection against COVID-19 as antibodies represent only part of a person’s immune response.

Studies are ongoing to see how effective a third dose is for immunosuppressed people, but it is very unlikely to cause any harm. Therefore, on balance, the JCVI’s view is that a third dose can be safely offered as it may increase their protection.

4. Who is considered 'severely immunosuppressed'?

Severe immunosuppression at the time of vaccination is defined using the guidance and timings stated below. People with psoriasis and psoriatic arthritis should pay particular attention to the criteria listed under points 2 and 3.

1. Individuals with primary or acquired immunodeficiency states at the time of vaccination due to conditions including:

• Acute and chronic leukaemias, and clinically aggressive lymphomas (including Hodgkin’s lymphoma) who were under treatment or within 12 months of achieving cure;
• Individuals under follow up for a chronic lymphoproliferative disorders including haematological malignancies such as indolent lymphoma, chronic lymphoid leukaemia, myeloma, Waldenstrom’s macroglobulinemia and other plasma cell dyscrasias (Note: this list is not exhaustive);
• Immunosuppression due to HIV/AIDS with a current CD4 count of <200 cells/µl for adults Primary or acquired cellular and combined immune deficiencies – those with lymphopaenia (<1,000 lymphocytes/ul) or with a functional lymphocyte disorder;
• Those who had received an allogeneic (cells from a donor) or an autologous (using their own cells) stem cell transplant in the previous 24 months;
• Those who had received a stem cell transplant more than 24 months ago but had ongoing immunosuppression or graft versus host disease (GVHD);
• Persistent agammaglobulinaemia (IgG < 3g/L) due to primary immunodeficiency (e.g. common variable immunodeficiency) or secondary to disease/therapy.


2. Individuals on immunosuppressive or immunomodulating therapy at the time of vaccination including:


• Those who were receiving or had received immunosuppressive therapy for a solid organ transplant in the previous 6 months;
• Those who were receiving or had received in the previous 3 months targeted therapy for autoimmune disease, such as JAK inhibitors or biologic immune modulators including B-cell targeted therapies (including rituximab but in this case the recipient would be considered immunosuppressed for a 6 month period), T-cell co-stimulation modulators, monoclonal tumour necrosis factor inhibitors (TNFi), soluble TNF receptors, interleukin (IL)-6 receptor inhibitors., IL-17 inhibitors, IL 12/23 inhibitors, IL 23 inhibitors. (N.B: this list is not exhaustive);
• Those who were receiving or had received in the previous 6 months immunosuppressive chemotherapy or radiotherapy for any indication.


3. Individuals with chronic immune-mediated inflammatory disease who were receiving or had received immunosuppressive therapy prior to vaccination including:

• High dose corticosteroids (equivalent ≥ 20mg prednisolone per day) for more than 10 days in the previous month;
• Long term moderate dose corticosteroids (equivalent to ≥10mg prednisolone per day for more than 4 weeks) in the previous 3 months;
• Non-biological oral immune modulating drugs e.g. methotrexate >20mg per week (oral and subcutaneous), azathioprine >3.0mg/kg/day; 6-mercaptopurine >1.5mg/kg/day, mycophenolate >1g/day) in the previous 3 months;
• Certain combination therapies at individual doses lower than above, including those on ≥5mg prednisolone per day in combination with other immunosuppressants (other than hydroxychloroquine or sulfasalazine) and those receiving methotrexate (any dose) with leflunomide in the previous 3 months.


4. Individuals who had received high dose steroids (equivalent to >40mg prednisolone per day for more than a week) for any reason in the month before vaccination.


Please note that not everybody who was on the 'clinically extremely vulnerable' (shielding) list will fall into the 'severely immunosuppressed' group and be eligible for a third dose of the COVID-19 vaccine. This group of ‘severely immunosuppressed’ people is smaller and is based on the latest data about how people with different levels of immunosuppression respond to the COVID-19 vaccine. People with lower levels of immunosuppression (who do not meet the criteria of ‘severely immunosuppressed’ specified above) will not be in this group, but are likely to be eligible for a ‘booster’ dose of the COVID-19 vaccine once that announcement is made.

It is also important to state that most individuals whose immunosuppression commenced at least two weeks after the second dose of vaccination do not require a third primary dose at this stage. Alongside those with lower levels of immunosuppression, they are likely to become eligible for a booster dose of the COVID-19 vaccine once that announcement is made.

5. What do I need to do now?

If you are considered 'severely immunosuppressed', based on the criteria above, you will be contacted as soon as possible to discuss your needs and arrange an appointment for your third dose of the COVID-19 vaccine.

If you do not fall into this group, you will not be offered a third dose of the COVID-19 vaccine and will not be contacted at this time.

If you have any concerns or you are unsure whether or not you fall into the 'severely immunosuppressed' group, we would recommend that you speak to your dermatologist or rheumatologist.