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Third dose covid vaccine for immunocomprimised patients

First Published 14th October 2021

Immunocomprimised patients are being offered a third dose. This must be given AT LEAST 8 weeks after the second dose. Immunocomprimised patients will most likely still be offered a booster, which will be six months after the third dose.

All non-immunocomprimised patients, including high risk patients, will be offered a booster 6 months after their 2nd dose.

We have sent a list of all our BHWC immunocomprimised patients to the covid vaccination centre and they will be contacting all our patients from 1st Nov 201 to offer you a third dose.

Call 0300 303 8060 to book in if you haven’t already received an invite.

These new guidelines were released recently and many of our patients found themselves in the situation they have already exceeded 8 weeks post 2nd dose. You can still have the 3rd dose upto 6 months after 2nd dose. If you are invited for your booster before your third dose invitation, you are advised to have your booster. 

What is the third COVID-19 vaccine third dose?

The JCVI has recommended that people aged 12 years and over who were immunosuppressed (have a weakened immune system) at the time of their first and second COVID vaccines (primary vaccination) should receive a third dose of COVID-19 vaccine. The JCVI is an independent committee that advises the government on vaccination schedules and vaccine safety.

What is the difference between this third dose and a booster dose?

This vaccination is being called a third dose as it is being recommended as part of your primary COVID-19 vaccination. The first two doses of the vaccine also make up your primary vaccination. This third dose is only being offered to people who are less likely to have had a strong immune response to the first two doses.

The booster programme is separate from the third dose. The booster vaccine dose is being offered to certain groups from September. The JCVI will review whether people who have had a third dose as part of their primary vaccination need a further booster vaccine, at a later date

What do I do if I am offered the booster before my third dose?

If you are eligible for both the third vaccine dose and booster dose, we recommend that you take whichever is offered to you first.

It is important that whoever is offering you a vaccine knows you are eligible for a third dose. This is because different vaccines are used for the third dose and the booster. So you need to tell the vaccination centre before they give you the injection.

Why is a third dose needed and who will get it?

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.

At the current time, JCVI advises that a third primary dose be offered to individuals aged 12 years and over with severe immunosuppression in proximity of their first or second COVID-19 vaccine doses in the primary schedule. Severe immunosuppression at the time of vaccination is defined using the guidance and timings stated below.

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 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/microL for adults or children
  • 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 (for example, 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 (note: 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 to > 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, such as 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 >7.5mg 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.

Individuals who had received brief immunosuppression (< 40mg prednisolone per day) for an acute episode (for example, asthma / COPD / COVID-19) and individuals on replacement corticosteroids for adrenal insufficiency are not considered severely immunosuppressed sufficient to have prevented response to the primary vaccination.

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

For those aged 18 years and over, JCVI advises a preference for mRNA vaccines for the third primary dose, with the option of the AstraZeneca Vaxzevria vaccine for individuals who have received this vaccine previously where this would facilitate delivery. In exceptional circumstances, persons who received a mRNA COVID-19 vaccine previously may be offered a third primary dose of AstraZeneca Vaxzevria vaccine following a decision by a health professional on a case-by-case, individualised basis. For those aged 12 to 17 years the Pfizer-BNT162b2 vaccine remains the preferred choice, as set out in JCVI advice of 4 August 2021.

The specialist involved should advise on whether the patient fulfils the eligibility criteria and on the timing of any third primary dose. In general, vaccines administered during periods of minimum immunosuppression (where possible) are more likely to generate better immune responses. The third primary dose should ideally be given at least 8 weeks after the second dose, with special attention paid to current or planned immunosuppressive therapies guided by the following principles:

  • where possible, the third primary dose should be delayed until 2 weeks after the period of immunosuppression, in addition to the time period for clearance of the therapeutic agent
  • if not possible, consideration should be given to vaccination during a treatment holiday or at a nadir of immunosuppression between doses of treatment

As with current advice in the green book (chapter 14a) JCVI has advised that:

individuals who have received a bone marrow transplant after vaccination should be considered for a re-immunisation programme for all routine vaccinations and for COVID-19.

Re-vaccination with a 2-dose schedule should be considered 3 to 6 months post autologous and allogeneic human stem cell transplant or CAR-T therapy. A third primary dose of vaccine should be administered at least 8 weeks after the second dose (in line with the advice above).

Most individuals whose immunosuppression commenced at least 2 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 as part of a routine booster programme from around 6 months after the second dose, pending further advice.

It is expected that severely immunosuppressed inviduals 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.

Will I need a booster dose if I have this third dose?

People who have had the third dose will also be eligible for a booster dose, this will be offered 6 months after the third dose.

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