Guidance

Highest-risk patients eligible for new COVID-19 treatments: a guide for patients

Published 13 June 2022

An updated version of the report was published in March 2023: Higher-risk patients eligible for COVID-19 treatments: independent advisory group report (March 2023).

Background

As part of the government’s COVID-19 Enhanced Protection Programme, an independent advisory group (IAG) was commissioned by the Department of Health and Social Care to identify people who are at the highest risk of developing severe complications from COVID-19. These are mostly people whose immune system mean they are at higher risk of serious illness from COVID-19, despite vaccination.

Individuals within these defined groups are eligible to receive new COVID-19 treatments, such as neutralising monoclonal antibodies (nMABs) and antivirals, if they test positive for COVID-19 via a lateral flow test (reported via the report a COVID-19 rapid lateral flow test result page or 119) or PCR, and have not been admitted to hospital.

This document supplements the Higher-risk patients eligible for COVID-19 treatments: independent advisory group report published on 30 May 2022. It contains information on the following:

• the highest risk patient groups
• how some of these individuals will be identified and contacted automatically (or ‘digitally’) if they test positive for coronavirus
• details of which groups can be identified digitally and those that cannot
• guidance for accessing treatment for eligible people who cannot be identified digitally

You can find public-facing information about how to access COVID treatments on the NHS website. This page also provides information on accessing lateral flow test kits for people who are eligible to receive the new COVID-19 treatments.

The highest-risk patient groups

The IAG identified that people in the following groups may be eligible for COVID-19 treatments. Not all people within these groups are eligible for treatment. Rather, people within these groups will need to fulfil specific criteria relating to their condition (or treatments received for their condition) to be eligible for treatment.

These groups are regularly reviewed and currently include some people who have:

• chromosomal disorders affecting the immune system, including Down’s syndrome
• certain types of cancer or have received treatment for certain types of cancer
• sickle cell disease
• certain conditions affecting their blood
• chronic kidney disease (CKD) stage 4 or 5
• severe liver disease
• had an organ transplant
• certain autoimmune or inflammatory conditions (such as rheumatoid arthritis or inflammatory bowel disease)
• HIV or AIDS who have a weakened immune system
• inherited or acquired conditions affecting their immune system
• rare neurological conditions: multiple sclerosis, motor neurone disease, Huntington’s disease or myasthenia gravis

Additional criteria, including certain conditions not listed above, apply to children and young people (CYP) in order to be eligible to access these treatments. Families of potentially eligible CYP will be informed by their specialist clinician of their eligibility and provided with information on accessing treatment.

This list was developed based on clinical evidence of poorer outcomes from COVID-19 in the specified groups and expert agreement on the risk of poor outcomes from COVID-19 despite vaccination. It is important to note that this list is different from the list of health conditions that previously identified people as ‘clinically extremely vulnerable’ or those that were advised to shield.^{[footnote 1]}

It is also different from the list of health conditions that make someone eligible for:

• a third primary dose of the COVID-19 vaccine or a spring or autumn booster
• the COVID-19 Oximetry at home service

Digital identification process

The digital identification process allows people who are potentially eligible for treatment to be quickly identified after a positive COVID-19 test.

Conditions in the list above should be recorded in a patient’s electronic medical record, in the form of a code. The team at NHS Digital and NHS England have identified a list of codes which reflect some of the eligibility criteria to receive treatments for COVID-19.

When a person tests positive for COVID-19 (that is, they have registered a positive lateral flow or receive a positive PCR test result), nationally held data will be searched for the list of codes and/or rules to determine if they are potentially suitable for treatment for COVID-19. If they are found to have a code or fulfil a rule that means they are potentially suitable for treatment, their nearest COVID Medicine Delivery Unit (CMDU) will be alerted that they have tested positive and will contact the person to discuss potential treatment.

Patients identified by the digital identification process are only potentially suitable for treatment, and not all patients identified will go on to be offered treatment for COVID-19. This may be due to any of the following:

• not all individuals with their condition are considered to be at highest risk of severe illness from COVID-19
• the digital identification process was designed to identify as many patients as possible that may be eligible for treatment. Sometimes this means capturing individuals that fulfil some, but not all of the eligible criteria for COVID-19 treatments
• their symptoms may already be improving when assessed for suitability for treatment
• an individual’s nationally held data may be out of date. For example, they currently no longer have the condition that previously made them eligible for treatment, or are no longer on a medication or within a specified time frame from having received a medication that previously made them eligible for treatment
• there may be a delay updating nationally held data from the person’s medical record
• an individual’s clinical codes may not accurately reflect their conditions

The decision to offer treatment to potentially suitable individuals will be made by a clinician from the CMDU. On receiving an alert of a potentially suitable patient, the CMDU will contact them with a list of questions to decide whether or not treatment is beneficial.

Unlike the clinically extremely vulnerable (CEV) list, there is no nationally maintained ‘list’ of people who are potentially suitable to receive COVID-19 treatments. Every individual in the UK testing positive for COVID-19 will have nationally held data searched for the list of codes and/or rules to determine if they may be potentially suitable for treatment.

See full technical methodology on the NHS website

Guidance for people who cannot be identified digitally

Not all people who are potentially suitable for COVID-19 treatments will be identified digitally.^{[footnote 2]} This may be because:

• some conditions may not have associated codes in the nationally extracted data from an individual’s electronic medical record
• they have only recently been diagnosed so national data is not yet updated. For example, a new diagnosis of a disease can take months to update in the national data
• an individual’s clinical codes may not accurately reflect their conditions
• an individual’s conditions have not been recorded using clinical codes
• an individual is on hospital-only medication, that is not extracted nationally

These people will be identified through the non-digital route.

These people should be informed by their specialist of their potential suitability to receive treatment, with information on how to access treatment if they test positive for COVID-19.

If you are potentially suitable for COVID-19 treatments but have not been contacted about treatment within 24 hours of your positive test, you should contact your GP surgery, 111 or specialist. They will be able to make an urgent referral to a CMDU if needed.

The table below lists the patient groups that may be potentially suitable for COVID-19 treatments according to the following categories:

• conditions that are currently being picked up by the digital identification process
• conditions currently not picked up by the digital identification process, but will soon be added to the digital route
• conditions that cannot be picked up by the digital identification process

Digital patient groups

This table will be updated as NHS Digital further refines the list of codes and rules used to identify potentially eligible patients.

People who have conditions that are identified digitally and automatically referred for assessment are not guaranteed treatment.

Patient group	Currently identified digitally	Currently not identified digitally but will soon be added to the digital process	Cannot be identified digitally (non-digital route)
Down’s syndrome and chromosomal disorders known to affect immune competence	People with Down’s syndrome	Not applicable	People with other chromosomal disorders known to affect their immune systems
Cancer	Some people receiving chemotherapy in the last 0 to 3 months People receiving some types of chemotherapy in the last 3 to 12 months Some people receiving radiotherapy in the last 0 to 6 months	People receiving any chemotherapy in the last 12 months People receiving radiotherapy in the last 12 months People with metastatic or locally advanced inoperable cancer who have not received chemotherapy or radiotherapy People with lung cancer	People with a new diagnosis of cancer, or recent recipients of chemotherapy or radiotherapy, where the data has not yet been recorded or collected People who have had cancer resected within the last 12 months and have not had chemotherapy or radiotherapy
Sickle cell disease	People with sickle cell disease (not carriers)	Not applicable	People with a new diagnosis
Conditions affecting the blood	People who have received a stem cell transplant in the last 12 months People who have received a stem cell transplant with active graft versus host disease (regardless of time from transplant) People with blood cancers who have received chemotherapy in the last 12 months People with blood cancers who have received radiotherapy in the last 6 months People with chronic phase chronic myeloid leukaemia (who have received chemotherapy in the last 12 months) People with myelodysplastic syndrome People with: - myeloma (excluding MGUS) - chronic B-cell lymphoproliferative disorders (chronic lymphocytic leukaemia, follicular lymphoma) - chronic myelomonocytic leukaemia (CMML)	People with blood cancers who have received radiotherapy in the last 12 months People with AL amyloidosis People with thalassaemia (not carriers) or rare inherited anaemia [footnote 3] [footnote 4] People with myelofibrosis	People with a new diagnosis, where the data has not yet been recorded or collected People with blood cancers who have received CAR-T cell therapy in the last 24 months People with non-malignant conditions of the blood who have received B-cell depleting treatments within the last 12 months
Chronic kidney disease (CKD)	People with CKD stage 4 and 5, and/or on dialysis People with severe kidney disease on certain treatments to suppress their immune system (if the treatment is captured in their GP medical records)	Not applicable	People with a new diagnosis of CKD stage 4 and 5 or recently started on dialysis, where the data has not yet been recorded or collected People with severe kidney disease on treatments to suppress their immune system (if the treatment is recently started or only prescribed by their hospital)
Severe liver disease	People with cirrhosis of the liver People with liver disease on certain treatments to suppress their immune system (if the treatment is captured in their GP medical records)	Not applicable	People with a new diagnosis of cirrhosis of the liver, where the data has not yet been recorded or collected People with liver disease on treatments to suppress their immune system (if the treatment is recently started or only prescribed by their hospital and/or is not captured in their medical records)
Organ transplant	People who have received a solid organ transplant	Not applicable	All recent recipients of a solid organ transplant
Autoimmune or inflammatory conditions	People with an autoimmune or inflammatory condition are currently identified, but only those who are on the following treatments are eligible: [footnote 5] - corticosteroids [footnote 6] - cyclophosphamide - mycophenolate mofetil - tacrolimus - ciclosporin People with an autoimmune or inflammatory condition who are on the following treatments (if prescribed in the community): - azathioprine - mercaptopurine	People with an autoimmune or inflammatory condition who are on methotrexate (for interstitial lung disease only) [footnote 3]	People with an autoimmune or inflammatory condition who are treated with: - a qualifying immunosuppressive treatment that was newly started, where the data has not yet been recorded or collected - B-cell depleting therapy - immunosuppressive medication that is only prescribed by their hospital and/or is not captured in their medical records People with an autoimmune or inflammatory condition who have: - uncontrolled or clinically active disease - involvement or impairment of the kidneys, liver or lungs People with an autoimmune or inflammatory condition who are on the following treatments: - cyclophosphamide - JAK inhibitors - biologic therapies
Conditions affecting the immune system	People with the following: - common variable immunodeficiency (CVID) - undefined primary antibody deficiency on immunoglobulin (or eligible for Ig) - hyper-IgM syndromes - Good’s syndrome (thymoma plus B-cell deficiency) - severe combined immunodeficiency (SCID) - primary immunodeficiency associated with impaired type I interferon signalling - X-linked agammaglobulinaemia (and other primary agammaglobulinaemias) People with secondary immunodeficiency receiving, or eligible for, immunoglobulin replacement therapy	Not applicable	People with autoimmune polyglandular syndromes/autoimmune polyendocrinopathy, candidiasis, ectodermal dystrophy (APECED syndrome)
HIV/AIDS	People with HIV/AIDS [footnote 7]	Not applicable	People with a new diagnosis HIV/AIDS, where the data has not yet been recorded or collected People who have not listed their HIV status on GP records (if known)
Rare neurological conditions	All people with: - multiple sclerosis - motor neurone disease - myasthenia gravis - Huntington’s disease	Not applicable	People with a new diagnosis of any of the listed conditions, where the data has not yet been recorded or collected

1. The success of the COVID-19 vaccination programme has meant that the requirement for shielding and identifying people as clinically extremely vulnerable is no longer necessary. ↩

2. Patients with a new diagnosis within the last 0 to 3 months or newly commenced on qualifying treatments in the last 0 to 3 months may not have this data captured in the national extracts from their medical records and are therefore unlikely to be identified through the digital process. ↩

3. Further eligibility criteria concerning cardiac iron overload and co-morbidities apply which will be determined by the CMDU clinician at the time of assessment. ↩ ↩²

4. Pending further investigation by NHS Digital as to whether this will be possible. ↩

5. Patients will be asked by the triaging clinician if they are on one of the treatments listed below. ↩

6. All patients having received 4 prescriptions for corticosteroids in the 6 months before testing positive for COVID-19 will be identified, but only those on a high enough dose to render their immune system susceptible to severe infection will be offered treatment. ↩

7. Further eligibility criteria around level of immunosuppression and control of disease apply which will be determined by the CMDU clinician at the time of assessment. ↩